What is THE HAVEN OF ARCOLA's CMS rating?

THE HAVEN OF ARCOLA has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does THE HAVEN OF ARCOLA have?

THE HAVEN OF ARCOLA has 37 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at THE HAVEN OF ARCOLA?

THE HAVEN OF ARCOLA has a one-star staffing rating from CMS with 0.14 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is THE HAVEN OF ARCOLA located?

THE HAVEN OF ARCOLA is located in ARCOLA, IL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does THE HAVEN OF ARCOLA have?

THE HAVEN OF ARCOLA has 100 certified beds.

Who owns THE HAVEN OF ARCOLA?

THE HAVEN OF ARCOLA is a for profit - corporation facility and is part of the HAVEN HEALTHCARE chain.

Is THE HAVEN OF ARCOLA safe?

THE HAVEN OF ARCOLA has documented safety concerns including a substantiated abuse finding on record. Families should ask about corrective actions taken.

Do nurses at THE HAVEN OF ARCOLA stick around?

THE HAVEN OF ARCOLA has average staff turnover at 50%, which is typical for the nursing home industry.

Was THE HAVEN OF ARCOLA ever fined?

No, THE HAVEN OF ARCOLA has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is THE HAVEN OF ARCOLA on any federal watch list?

No, THE HAVEN OF ARCOLA is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at THE HAVEN OF ARCOLA?

Medicare inspectors have found 37 deficiencies at THE HAVEN OF ARCOLA: 2 serious, 35 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting THE HAVEN OF ARCOLA?

Families visiting THE HAVEN OF ARCOLA should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does THE HAVEN OF ARCOLA compare to other nursing homes?

THE HAVEN OF ARCOLA has a 1-star overall rating, which is below average compared to other nursing homes in IL. Families should carefully review inspection findings and consider alternatives.

THE HAVEN OF ARCOLA | 15/100 (Grade F)

Aug 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect resident's right to privacy. This failure affected two of fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect resident's right to privacy. This failure affected two of four residents (R1, R2) reviewed for resident rights on the sample list of four. Findings Include:The facility's Resident Rights Guideline policy dated October 2023 documents the practice of this facility is to provide an environment in which residents may exercise their rights, each day. Residents have certain rights and protections under Federal law and the facility will always protect these rights through care and related services. One example of a resident's rights is Privacy and Confidentiality. R1's Medical Diagnoses List dated August 2025 documents R1 is diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R1's Behavior Tracking for July 2025 through August 2025 documents R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. R1 entered other resident's rooms or personal space 17 times in the last 30 days. R1's Care Plan dated 8/14/25 documents R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. Staff are to intervene as necessary to protect the rights and safety of others. R2's Medical Diagnoses List dated August 2025 documents R2 is diagnosed with Schizoaffective Disorder, Generalized Anxiety disorder, Depression, Insomnia, and Paranoid Personality Disorder. R2's Care Plan dated 6/6/25 documents R2 is cognitively impaired and has short term memory deficit. R2 requires substantial/dependent assistance with activities of daily living. R2 is incontinent and requires staff to provide perineal care at least every two hours. On 8/17/25 at 2:27 PM V9 Certified Nurses Assistant stated R1 has a lot of anxiety and needs constant attention and reassurance. R1 will follow staff into other resident's rooms and will not listen when you ask her not to do things. R1 will invade other resident's privacy and is hard to redirect. R1will get into staff or resident's faces when asking them repetitive questions. V9 stated R1 will often open the curtain to talk to staff while they are providing personal care for R1's roommate (R2). V9 stated staff will have to stop what they are doing to redirect R1 and she continues to invade R2's privacy. On 8/17/25 at 2:37 PM V7 Licensed Practical Nurse stated R1 is constantly invading others' privacy and personal space. On 8/17/25 at 2:51 PM V6 Licensed Practical Nurse stated R1 bothers other residents and invades their privacy. On 8/17/25 at 4:45 PM V2 Director of Nurses stated she was not aware of R1 continually opening R2's privacy curtain while staff are providing care and confirmed that is a violation of R2's right to privacy.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect resident's right to be free from verbal abuse. This failure ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect resident's right to be free from verbal abuse. This failure affected two of four residents (R1, R3) reviewed for resident rights on the sample list of four. Findings Include:The facility's undated Abuse policy documents Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident. R1's Medical Diagnoses List dated August 2025 documents R1 is diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R1's Behavior Tracking for July 2025 through August 2025 documents R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. R1's Care Plan dated 8/14/25 documents R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. Staff are to intervene as necessary to protect the rights and safety of others. R3's Medical Diagnoses List dated August 2025 documents R3 is diagnosed with Bipolar Disease, Anxiety, and a Mild Cognitive Impairment. R3's Minimum Data Set, dated [DATE] documents R3 is cognitively intact. R3's Care Plan dated 2/11/25 documents R3 exhibits behaviors caused by anxiousness with agitation which leads to verbal outbursts, mocking, yelling and demanding of others, sleep disturbances, refusal of care and false allegations. On 8/17/25 at 2:27 PM V9 Certified Nurses Assistant stated R1 has a lot of anxiety and needs constant attention and reassurance. R1 will follow staff into other resident's rooms and will not listen when you ask her not to do things. R1 will invade other resident's privacy and is hard to redirect. R1will get into staff or resident's faces when asking them repetitive questions. V9 stated R3 has verbally threatened R1. On 8/17/25 at 2:00 PM V5 Certified Nurses Assistant stated R3 yelled at R1 and stated R1 should get the f*** (expletive) out of here or she will break R1's hand. On 8/17/25 at 2:51 PM V9 Certified Nurses Assistant stated R3 is always telling R1 to shut up and go away. On 8/17/25 at 5:15 PM R3 stated R1 makes her very anxious and annoys her. R3 stated R1 follows staff around the entire shift. R3 stated there are times where she has gotten so annoyed with R1, that she has threatened her. R3 stated R1's behavior causes her great anxiety. It is hard for her to be around R1 and she is trying to be better. On 8/17/25 at 4:45 PM V1 Administrator confirmed that R3, threatening R1, could be considered verbal abuse. V1 also confirmed R1's behaviors and repetitive questions put her at risk for abuse.

Aug 2025 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse by anoth...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident with known physical behaviors for two of four residents (R1, R2) reviewed for abuse in the sample list of seven residents. This failure resulted in R2 experiencing physical trauma including a lacerated lip, swollen eye, and multiple scratches, and fear of R1 causing R2 to refuse emergency services due to fear of R1 attacking R2 in the hospital after R1 punched R2 multiple times. This past non-compliance occurred from 7/18/25-7/25/25.R2's Electronic Medical Record (EMR) documents medical diagnoses as Schizoaffective Disorder, Paranoid Personality Disorder, Dementia with Agitation, Extra Pyramidal and movement disorder and Paranoid Schizophrenia. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. This same MDS documents R2 requires supervision for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, transfers and walking up to 150 feet. R2's Nurse Progress Note dated 7/19/25 at 12:13 AM documents V4 Licensed Practical Nurse (LPN) was in R2's room administering medication to R2's roommate and noted R2 was laying in his bed laughing uncontrollably just prior to this incident. This same note documents A short time later, (R1) heard (R2's) laughter and entered (R2's) room. (R1) was verbally and physically aggressive. This same note documents (V5) Activity Assistant (AA) separated R1 and R2 and then R1 was assisted to R1's room across the hall. This same note states R2 stated R1 yelled at him to stop laughing. This same note documents R1 approached R2's bed where he was laying and hit R2 several times on the head. This same note documents R2 obtained a cut on his top lip and refused to go to the emergency room for medical care. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 requires supervision for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, transfers and walking up to 150 feet. R1's Nurse Progress Note dated 7/19/25 documents R1 was walking down the hallway towards his room, as R1 got closer to his room R1's verbally aggressive behavior became louder, then R1 dropped his linens that he was carrying for his shower and R1 entered R2's room. This same note documents (V4) LPN yelled and said NO do not go in there. (V5) Activity Assistant (AA) separated (R1, R2). (V5) AA took (R1) to his room across the hall. (R1) had a bloody nose. When the staff asked what happened (R1) stated (R2) was laughing and (R1) believed that (R2) was laughing at him. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact.R1 and R2's shared Final Incident Report to the State Agency dated 7/24/25 documents R1 believed R2 was laughing at him and entered R2's room where a physical altercation occurred. This same report documents staff were able to break up the altercation. This same report documents R2 obtained a cut to his upper lip and R1 was noted to have a bloody nose. On 8/9/25 at 9:45 AM R2 stated he was relaxing in his bed the night of 7/18/25 when R1 'came storming in my room and beat me up.' R2 stated he did not know why R1 was so mad. R2 stated R1 punched R2 with closed fists in the head, arms and face and repeatedly yelled 'Shut the f*** (expletive) up.' R2 stated he put his arms over his face in order to defend and protect himself. R2 stated R1 pulled him out of his bed onto the floor and continued to hit R2. R2 stated V5 Activity Assistant (AA) entered R2's room and had to 'pull' R1 off of R2. R2 stated I was so frightened that night. I didn't want to leave the room. I didn't want to go to the hospital because that is where (R1) was going. I just stayed in my room because I was afraid. It really hurt when (R1) was punching me. (R1) beat me up one other time on the smoking patio a long time ago. R2 stated V5 AA stayed with R1 until the police arrived to protect R2 from R1 in case R1 came back in R2's room.On 8/9/25 at 2:50 PM R6 stated he witnessed R1 hitting R2. R6 stated R2 was his roommate at the time and he never had any 'trouble' with R2. R6 stated R1 has a bad temper and stays away from R1 as much as possible. R6 stated he was sitting on his bed by the window when R1 'marched' into his room and started punching R2. R6 stated R2 was just laying in his bed and did not provoke R1. R6 stated he felt shocked that anyone would come into his room and just start beating someone up and felt scared of R1. R6 stated he was glad 'they' took R1 away so that R6 didn't have to worry about R1 returning to his room to 'get' R2. On 8/9/25 at 11:30 AM V2 Director of Nurses (DON) confirmed R1 walked into R2's room on 7/18/25 without provocation and hit and punched R2. V2 DON stated R2 has a behavior of laughing hysterically and believes that R1 thought R2 was laughing at R1. V2 DON stated the staff immediately responded when they heard the screaming and yelling coming from R2's room. On 8/9/25 at 1:15 PM V4 LPN stated the evening of 7/18/25 around 8:30-9:00 PM R1 was walking down the hall heading towards his room. V4 LPN stated R1 was carrying his towels and sheets he had gotten from the linen bin. V4 LPN stated R1 was talking loudly to himself and talking to the voices he hears in his head. V4 LPN stated R1 walked by R2's room. V4 LPN stated R2 has a medical disorder where he laughs uncontrollably. V4 LPN stated V4 had just been in R2's room administering medications to R2's roommate. V4 LPN stated R2 was laying in his bed with the blankets pulled up to his chest just prior to R1 entering R2's room. V4 LPN stated R1 walked by R2's room and then turned around, threw all of the linens in the hallway and walked into R2's room. V4 LPN stated at the same time as V4 was walking down the hall, V5 Activity Assistant was entering the hallway to see what all the yelling was about. V4 LPN stated V5 Activity Assistant was the first to arrive to R2's room. V4 LPN stated V5 had to pull R1 off of R2. V4 LPN stated she saw that R2 had a cut over his Right Upper Lip and R1 had blood coming out of the Left side of his nose. V4 LPN stated R1 stated R2 was laughing at him and it made him mad. V4 LPN stated R2 was visibly shaken up, had a shaky voice and stated to V4 'I don't want to leave my room.' V4 LPN stated R1 and R2 have had a previous altercation 'a few years ago' where R1 hit R2 on the smoking patio. On 8/9/25 at 1:40 PM V5 Activity Assistant (AA) stated he was working the evening of 7/18/25. V5 AA stated R1 had been yelling and talking loudly to himself and pacing up and down the hallway that evening. V5 stated R1 thinks he is the president of the United States and hears voices in his head that tell him to do bad things sometimes. V5 AA stated R1 and R2 have had prior history of R1 hitting R2. V5 AA stated R1 and R2 used to be roommates and had to be separated due to R1 hitting R2. V5 AA stated R2 was laying in his bed when R1 'stormed' into R2's room and began hitting R2. V5 AA stated V5 was the first staff member to get to R2's room. V5 AA stated he saw R1 hitting R2, saw R2 had scratches on both of his arms, a cup upper lip, swollen eye and R1 had a bloody nose. V5 AA stated R1 and R2 were separated. V5 AA stated R1 told V5 that R2 was laughing at R1 and it made him mad. V5 AA stated R2 was very visibly shaken up. The undated facility policy titled Abuse Prevention Policy documents the residents have the right to be free from abuse, neglect, exploitation, misappropriate of property, deprivation of goods and services by staff or mistreatment. This facility prohibits abuse, neglect, exploitation, misappropriate of property and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish to a resident. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. Prior to the survey date of 8/10/25, the facility had taken the following actions to correct the noncompliance: 1. The Quality Assurance Performance Improvement (QAPI) team including V1 Administrator, V15 [NAME] President of Operations (VPO) and V16 Regional Clinical Nurse (RCN) met on 7/22/25 to identify opportunities for improvement/deficient practice. 2. Immediate action consisted of: R1 and R2 were immediately separated. R1 was sent to the emergency room for evaluation and returned on continual monitoring (1:1) supervision. This continual monitoring was in place until R1 could be seen by psychiatry at which time, R1 was placed on 15 minute visual checks which have remained in place. 3. Actions completed and/or ongoing by 7/25/25: All staff were in serviced on behavioral intervention resources prior to the next shift; All behavioral care plans were reviewed to ensure interventions were in place; All Gradual Dose Reduction (GDR) requests and increases in behaviors within the last three months were reviewed; Behavioral Tracking and GDR audits were scheduled for three times the first week, twice the second week and then weekly for four weeks and were initiated and ongoing and; Resident care plans will be audited weekly for four weeks to ensure timely behavioral interventions are appropriate and effective with behavior tracking in place. Staff in-service on ‘Different ways to deescalate behaviors and put interventions in place' was completed on 7/25/25. Care plans and GDRs were reviewed by V1 Administrator, V2 DON and V16 Regional Clinical Nurse. Behavioral care plans and GDR audits were initiated on 7/22/25 and completed on 7/25/25. 4. V1 Administrator will report the findings to the QAPI meeting quarterly. V1 Administrator stated the facility has not had the next QAPI meeting but thus far there have been no new substantiated instances of abuse since 7/18/25.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident dignity for three of three residents (R4, R5, R6) re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident dignity for three of three residents (R4, R5, R6) reviewed for dignity in a sample list of seven residents.R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. This same MDS documents R4 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene and bed mobility. R4's Care plan documents medical diagnoses as Thoracic Scoliosis, Depression, Neuropathy, Thrombophlebitis of Lower Extremities, Unsteady on Feet, Muscle Wasting and Atrophy and Major Depressive disorder. This same care plan initiated 11/8/24 does not document a focus area, goal nor interventions for R4's behaviors of consensual sexual behavior with male peers prior to 7/29/25. This same care plan documents R4 requires a wheelchair for mobility. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. R4 and R5's shared Final Report to the State Agency dated 8/1/25 documents R4 stated R5 started rubbing her upper leg then moved up to touch her perineal area while she was sitting in the day room. This same report documents R4 moved away from R5 and that R5 did not actually touch R4's perineal area. R4's written statement dated 7/29/25 documents (R4) was sitting next to the ping pong table. (R5) got up off the couch and came towards me. (R5) was standing and bent down and started rubbing my leg. (R5) started at the knee moving up towards my (points to vagina). I backed away from (R5) and went to my room. I don't know what (R5) was thinking. On 8/9/25 at 12:10 PM V7 Licensed Practical Nurse (LPN) stated R5 touched R4 inappropriately in the hall next to the dayroom on the South unit on 7/29/25. V7 LPN stated R5 walked up to R4 who requires a wheelchair and touched R4's upper thigh and then moved his hand farther towards R4's genital area then R4 wheeled herself back away from R5. V7 LPN stated R4 told V7 that ‘(R5) touched my leg and tried to reach my vagina. I didn't like that.' V7 LPN stated R5 was sent to the emergency room for evaluation due to his behaviors. On 8/9/25 at 2:55 PM R6 stated R4 was sitting in the resident lounge in her wheelchair when R5 got up off of the couch (in the same room) and walked over to R4. R6 stated R5 put his hand on the inside of R4's lower thigh/knee area and squeezed lightly and then left his hand there for a few minutes. R6 stated R5 then moved his hand ‘clear up there' (R6 motioned to his perineal area). R6 stated he couldn't believe what he was seeing. R6 stated he was in shock. R6 stated he saw R4 move her wheelchair back away from R5. R6 stated he did not think R5 made contact with R4's perineal area but that ‘it wasn't for lack of trying.' On 8/10/25 at 10:00 AM V1 Administrator stated R4 and R5 both reside on a locked psychiatric unit. V1 Administrator stated both R4 and R5 are cognitively intact yet unable to make decisions for themselves and require constant supervision. V1 Administrator stated she thinks this incident is more of a resident rights issue than abuse due to R5 did not make contact with R4's perineal area. The facility policy titled Resident Rights Guideline revised October 2023 documents residents have the right to be treated with dignity and respect.

Feb 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by another...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by another resident. This failure affects two of four residents ( R2 and R7) reviewed for abuse in a sample list of eight residents. Findings include: The facility undated policy titled Abuse Prevention Policy documents abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again. 1. R2's undated Face Sheet documents medical diagnoses of Depression, Bipolar Disorder, Traumatic Brain Injury, Heart Failure, Prosthetic Heart Valve, Atrial Fibrillation and Cardiac Pacemaker. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 requires set up assistance for eating, dressing, toileting, oral hygiene, bathing and is independent in bed mobility and transfers. This same MDS documents R1 was able to walk 150 feet independently. R2's Final Report to State Agency dated 12/26/24 documents on 12/21/24 at 12:00 PM R1 was yelling out in the dining room. This same report documents (R1) began cussing and yelling in the dining room stating 'I'm going to kill all of you. (R2) stated she didn't know why (R1) was upset but that they (R1, R2) exchanged words. In conclusion, it was determined that the resident to resident (R1, R2) altercation did occur however, neither resident sustained any injuries. On 2/6/25 at 11:40 AM R2 stated R1 was mean to everyone. R2 stated R1 would yell and cuss and scare R2 and other residents. R2 stated R1 told R2 that he was going to kill her and then tried to throw a walker at another (unknown) resident so R2 got up and tapped R1 on the shoulder to remind R2 that he cannot act like that. R2 stated (R1) was cussing and scaring me and all the residents and the staff. (R1) should not act like that. (R1) was supposed to be nice. (R1) was not nice to anyone. On 2/6/25 at 11:30 AM V10 Licensed Practical Nurse (LPN) stated V10 sent R1 to the emergency room on [DATE] after an 'extreme outburst' in the dining room. V10 LPN stated the dining room was full of residents and a few staff and R1 was in the dining room threatening to kill everyone. V10 LPN stated R1 yelled at R2 I am going to kill you! V10 LPN stated R1 picked up his walker in his rage and almost hit another (unknown) resident in the head so R2 got up and said you mess with my friends, you mess with me and then R2 patted R1 twice in the shoulder/neck area. V10 stated (R1) was out of control that day. I don't know why (R1) was allowed to come back after that. V10 stated R1 was a very tall, large man who could easily cause damage to anyone around him. On 2/6/25 at 2:40 PM V1 Administrator stated R1 was mad on 12/21/24 due to R1 missed his snack pass and was not allowed to receive a snack. V1 Administrator stated R1's anger was directed towards R2. V1 Administrator stated R1 should have been given a snack if he asked for one so that may have appeased him and prevented R1's outburst. On 2/6/25 at 3:10 PM V14 Licensed Practical Nurse (LPN) stated It was supper time on 12/23/24 and the dining room was full of residents eating their supper. (R1) was mad because he couldn't have his bedtime medications early. I was standing behind my medication cart in the dining room at this time. (R1) became aggressive, demanding and violent. (R1) was gritting his teeth, his face and hands were shaking because he was so mad and he started lifting up his walker a foot off of the ground and pounding it on the floor multiple times. I repositioned my medication cart at an angle so if (R1) tried to throw his walker at me it might hit the medication cart first. All of the residents in the dining room were a witness to (R1's) behaviors. (R1) was yelling and cursing saying 'F*** (expletive) you! I am going to kill you while looking directly at (R2) and everyone in here and then kill myself'. I was so worried (R1) would hurt one of the residents. (R1) was out of control again. (R2) was sitting in a chair within a few feet of (R1) so I motioned for (R2) to move out of the way. (R2) was so scared, her face was white as a ghost. I talked to (R2) later and she said she was very scared and thanked me for keeping her safe. On 2/7/25 at 1:35 PM V1 Administrator stated she had heard R1 was upset about not being able to get his medications early but did not realize R1's outburst was in front of any other residents or was directed at R2. V1 Administrator stated after her investigating this incident on 2/7/24 R1 did in fact yell and curse at R2. 2. R7's undated Face Sheet documents medical diagnoses of Schizophrenia, Bipolar Disorder, Atrial Fibrillation, Ischemic Cardiomyopathy, Heart Failure and Chronic Kidney Disease. R7's Minimum Data Set (MDS) documents R7 as cognitively intact. R7's Nurse Progress Notes does not document an altercation with R1 on 12/21/24. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 requires set up assistance for eating, dressing, toileting, oral hygiene, bathing and is independent in bed mobility and transfers. This same MDS documents R1 as able to walk 150 feet independently. On 2/6/25 at 2:15 PM R8 stated R8 witnessed R1 yell at R7 on 12/21/24 just before lunch time in the facility community resident room on the South Unit. R8 stated R7 was sitting in a recliner chair when R1 approached R7 and yelled at R7 to get the f*** (expletive) out of my chair or else! On 2/6/25 at 4:30 PM R7 stated R1 yelled at him one day when R7 was sitting in the recliner chair in the community dayroom. R7 stated R1 yelled get the f*** (expletive) out of my chair or else! R7 stated R1 was'real mad at R7 for sitting in the recliner. R7 stated It scared me a little but (R1) is always yelling and carrying on. I think (R1) would kick my a** (expletive) since he is so big but you know what they say the bigger they are, the harder they fall. I'm not sure if I could do it but I'd sure give a try. On 2/7/24 at 1:40 PM V1 Administrator stated V1 was not aware that R1 yelled and cursed at R7 on 12/21/24. V1 Administrator stated R1 had a behavioral outburst in the dining room on 12/21/24 and after talking with V13 Social Service Assistant (SSA) found out that this incident between R1 and R7 had occurred just prior to R1's dining room incident. V1 Administrator stated after interviewing residents and staff on 2/7/24 it was determined that R1 did yell and curse at R7 in the community dayroom on 12/21/24. V1 Administrator stated V1 will be doing some educational inservicing on Abuse with her staff.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report allegations of verbal abuse to the Abuse Coordinator for thre...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report allegations of verbal abuse to the Abuse Coordinator for three of four residents (R1, R2, R7) reviewed for abuse in a sample list of eight residents. Findings include: The facility undated policy titled Abuse Prevention Policy documents Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. 1. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. The facility was unable to provide documentation a resident (R2) to resident (R1) verbal altercation on 12/23/24 was reported to the Abuse Coordinator. On 2/6/25 at 11:40 AM R2 stated R1 was mean to everyone. R2 stated R1 would yell and cuss and scare R2 and other residents. R2 stated (R1) yelled at me and it scared me. (V14 Licensed Practical Nurse) was there to help me get away from (R1). On 2/6/25 at 3:10 PM V14 Licensed Practical Nurse (LPN) stated R1 became aggressive, demanding and violent during supper on 12/23/24. V14 stated (R1) was yelling and cursing saying F*** (expletive) you! I am going to kill you (while looking at (R2)) and everyone in here and then kill myself. I talked to (R2) later and she said she was very scared and thanked me for keeping her safe. On 2/6/25 at 3:30 PM V14 Licensed Practical Nurse (LPN) stated V14 should have reported R1 verbally abusing and threatening multiple residents including R2 individually on 12/23/24. V14 LPN stated Word gets around quick here. I thought (V1) would have known about it. But, I should have told (V1) anyway. 2. R7's Minimum Data Set (MDS) documents R7 as cognitively intact. The facility was unable to provide documentation a resident (R1) to resident (R7) verbal altercation on 12/21/24 was reported to the State Agency. On 2/6/24 at 1:00 PM V13 Social Service Assistant (SSA) stated V13 stated she obtained R8's witness statement on 12/23/24 from the 12/21/24 incident between R1 and R2 but didn't think of it as a separate incident. V13 stated R8 told her that R1 and R7 got into it on 12/21/24 but thought it would have been investigated with all of the other things that happened that day with R1. On 2/6/25 at 4:30 PM R7 stated R1 yelled at him one day when R7 was sitting in the recliner chair in the community dayroom. R7 stated R1 yelled get the f*** (expletive) out of my chair or else! R7 stated R1 was real mad at R7 for sitting in the recliner. R7 stated It scared me a little but (R1) is always yelling and carrying on. I think (R1) would kick my a** (expletive) since he is so big but you know what they say the bigger they are, the harder they fall. I'm not sure if I could do it but I'd sure give a try. On 2/7/25 at 12:15 PM V1 Administrator stated staff should always report any allegation of abuse to V1 Administrator. V1 Administrator stated the staff did not follow the facility abuse policy by not reporting R1's verbal statements to R7 on 12/21/24 and R2 on 12/23/24.

Nov 2024 6 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to obtain a new Level 2 PASRR (Preadmission Screening and Resident Review) to evaluate a resident's need for specialized mental health service...

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Based on interview and record review, the facility failed to obtain a new Level 2 PASRR (Preadmission Screening and Resident Review) to evaluate a resident's need for specialized mental health services upon the expiration of the initial Level 2 evaluation. This failure affects one resident (R28) out of 11 reviewed for pre-admission screening on the sample list of 31. Findings include: R28's Level 2 PASRR to evaluate for the need of specialized mental health services dated 8/17/2015 documents R28 had a history of inpatient mental health hospitalizations, experienced delusions, irritability, and difficulty remaining on tasks related to her medical diagnosis of Paranoid Schizophrenia. This Level 2 screening had a determination date of 8/24/2015 and documented R28 required specialized services including mental health rehabilitation services, illness self-management, and community re-integration activities. This Level 2 screening documented this determination was valid for 90 days from the date of determination (11/22/2015), and a new determination should be obtained from the entity treating the individual on 11/22/2015. On 11/7/24 at 10:08 AM, V10, Business Office Manager, and V7, Social Services Director, stated they did not have any documentation more current than the Level 2 PASRR from 8/17/2015. At 10:31 AM, V10 stated, I called the (screening agency) and they did not have any records of a more recent screening. V10 further stated, The Level 1 screening is good for 30 days so the resident would have to be admitted to the facility within that 30 days, but the Level 2 can be limited to 90 days and then they would need another Level 2 in that 90 days.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a baseline careplan timely for one resident (R270) out of o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a baseline careplan timely for one resident (R270) out of one reviewed for careplans in a sample list of 31 residents. Findings include: The facility policy titled Baseline Care Planning policy revised 3/16/22 documents the following procedure shall be utilized in developing a baseline careplan (BCP). A BCP shall be developed to include instructions needed to provide effective person centered care to each resident, based on his/her initial assessment and the professional standards of quality of care, to serve as a functional guide in delivery of care until such time as a comprehensive careplan is developed. R270's undated Face Sheet documents R270 admitted to facility on 10/31/24 with medical diagnoses of Wedge Compression Fracture of T9-T10 Vertebrae, Dementia, and Hypertension. R270's admission assessment dated [DATE] documents R270 is alert and oriented to person only. R270's Nurse Progress Note dated 11/4/24 at 5:42 AM documents 4:25 AM (R270) fell. Full physical assessment done. Moves all extremities well ([NAME]). Alert and oriented x 1. (R270) complained of pain to ribs and underarms. This same note documents R270 was sent to the emergency room for evaluation. R270's Care plan does not include a focus area, goal nor interventions prior to R270's fall on 11/4/24. R270's baseline careplan was initiated on 11/6/24. On 11/8/24 at 12:10 PM V4 Care Plan Coordinator (CPC)/Licensed Practical Nurse (LPN) stated each department is responsible for entering their own component of the resident careplan. V4 stated V4 is responsible for the nursing portion of the resident careplan. V4 stated V4 completes the baseline resident careplan within the first week of the resident's admission. V4 stated V4 was not aware that there was any timeframe that baseline careplan had to be completed. On 11/8/24 at 12:30 PM V1 Administrator stated the resident's baseline careplan should be completed within 48 hours. V1 stated there is a baseline assessment that is completed upon admission but that assessment does not include goals or interventions for the staff to use to provide interventions.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to implement care planned post fall interventions for fall prevention. This failure affects one resident (R59) out of seven revi...

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Based on observation, interview, and record review, the facility failed to implement care planned post fall interventions for fall prevention. This failure affects one resident (R59) out of seven reviewed for falls on the sample list of 31. Findings include: On 11/6/24 at 10:43 AM, R59 was seated in her own room in a wheelchair. R59 had a power cord for a personal alarm hanging from the back of her wheelchair but the actual alarming module was not present. R59's Care Plan (undated) documents R59 experienced actual falls on 6/9/24 and 6/10/24. This care plan documents the post fall intervention from the fall on 6/9/24 was to provide an alarm on R59's wheelchair. R59's Nursing Progress Notes dated 6/9/24 documents R59 was seated in her wheelchair just prior to being noted on the floor sitting on her buttocks with her legs outstretched. R59's Nursing Progress Notes dated 6/10/24 documents R59 was sitting on her buttocks on the floor with her wheelchair next to her. On 11/6/24 at 11:00 AM, V4, Licensed Practical Nurse/ Care Plan Coordinator, reviewed R59's care plan and stated, Yes, (R59) is supposed to have an alarm on her bed and wheelchair. V4 accompanied (surveyor) to observe R59's alarms, V4 confirmed there was not an alarm present on R59's wheelchair, simply the power cord, then stated, I will have to fix this.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to maintain resident bed side rails in a safe condition. This failure affects one resident (R12) of five reviewed for bed side r...

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Based on observation, interview, and record review, the facility failed to maintain resident bed side rails in a safe condition. This failure affects one resident (R12) of five reviewed for bed side rails in the sample list of 31. Findings include: R12's medical diagnosis list (11/7/2024) documents R12's diagnoses include: Extrapyramidal and Movement Disorder, Left Knee Valgus Deformity (abnormal angle to the lower leg), and Dementia. R12's quarterly assessment (9/11/2024) documents R12 has impaired range of motion in both lower extremities. R12's Fall Risk Evaluation (9/11/2024) documents R12 has a recent history of falling in the facility. R12's Bed Rail Evaluation (9/11/2024) documents R12's bed side rail serves as an enabler to promote independence in entering and/or exiting R12's bed. R12's Care Plan (11/7/2024) documents R12 utilizes a bed side rail for mobility and staff should encourage R12 to use the side rail to promote R12's independence. On 11/6/2024 at 10:11AM, R12's half-length right side bed rail was in the upward position. The rail appeared loose and was leaning outwardly towards the center of R12's room. When lightly touched, the rail easily moved back and forth towards R12's mattress as well as left and right towards the floor. A five and one half inch gap was present between the side rail and mattress as measured by Illinois Department of Public Health measuring tape. R12 was present and reported using the rail to get up in bed and reported the side rail had been loose for a long time. On 11/7/2024 at 2:00PM, R12's right side bed rail remained in the upward position. When grasped, the entire bed rail easily moved back and forth towards the mattress a total distance of seven inches as measured by (State Agency) measuring tape. The rail also pivoted left and right about it's central point a distance of six inches towards the floor. R12 was present and stated it (the excessively loose side rail) is just hanging there and I'm worried about it. On 11/7/2024 at 2:03PM, V11 (Licensed Practical Nurse) observed the above rail and V11 reported the side rail needed replaced and was a concern since R12 uses the rail for transfers. The Food and Drug Administration Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment (3/10/2006) documents to reduce the risk of entrapment, injury, and death, the maximum safe spacing in a bed side rail system should not exceed 4 3/4.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review the facility failed to prevent cross contamination during medication administration for four residents (R13, R56, R51, R270) out of six reviewed for m...

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Based on observation, interview and record review the facility failed to prevent cross contamination during medication administration for four residents (R13, R56, R51, R270) out of six reviewed for medication administration in a sample list of 31 residents. Findings include: The facility policy titled Medication Administration revised 11/18/2017 documents appropriate hand washing is to be completed and/or alcohol based gel rub must be used throughout the medication pass. This should occur before and after medication pass and after touching an inanimate object possibly contaminated with microorganisms. Handwashing is not required per the Centers for Disease control (CDC) guidelines. It is acceptable to use alcohol based gel type solution between residents. The Facility Daily Midnight Census dated 11/6/2024 documents 69 residents reside in facility. On 11/7/24 at 7:22 AM V12 Licensed Practical Nurse (LPN) administered R56's medications. V12 LPN did not wash hands nor use an alcohol based hand rub (ABHR) prior to administering R56's medications. V12 LPN then proceeded to administer R270's medications without using ABHR nor washing her hands. V12 LPN then administered R13's medications without using ABHR nor washing her hands. V12 LPN then administered R51's medications without using ABHR nor washing her hands. A bottle of ABHR was sitting on top of V12 LPN's medication cart while V12 was passing medications to residents. V12 LPN touched dozens of medication cards, the top and front of the medication cart, the computer screen, the plastic medicine cups/water cups and the water pitcher when preparing each residents medications. V12 LPN also touched resident doors, privacy curtains and bedside tables when administering resident medications without washing her hands nor using ABHR when administering medications to the same four residents (R13, R51, R56 R270). On 11/7/24 at 7:30 AM V12 Licensed Practical Nurse (LPN) stated V12 should have used hand hygiene before administering medications and also in between administering medications to multiple residents, V12 LPN stated not using hand hygiene could result in bacteria being spread resident to resident. On 11/7/24 at 2:30 PM V2 Regional Director of Nursing (DON) stated facility nurses should use hand hygiene between every resident when administering medications.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to provide the services of a Registered Nurse for eight consecutive hours per day seven days per week. This failure has the potential to affec...

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Based on interview and record review, the facility failed to provide the services of a Registered Nurse for eight consecutive hours per day seven days per week. This failure has the potential to affect all 69 residents residing in the facility. Findings include: The facility's Nurses Schedule for October and November 2024 documents on 11/2/24, 11/5/24, and 10/29/24, there was not a registered nurse scheduled to work. The October Nurses Schedule documents on 10/27/24 there was a registered nurse working for four hours. On 11/8/24 at 9:15 AM, V1, Administrator, reviewed the Nurses Schedules and stated, I don't see an RN (Registered Nurse) on 11/3/(24), I don't see an RN on 11/5/(24), I don't see an RN on 10/29/(24). Correct on 10/27/(24) there was an RN for four hours. V1 further stated, We knew we would get this (citation), facilities are struggling with staffing. The facility's Form 802 Resident Matrix dated 11/6/24 documents 69 residents reside in the facility. The Department of Health and Human Services Center for Medicare and Medicaid Services Certification and Transmittal dated 10/4/23 documents all 100 beds in the facility are Certified Skilled Nursing Facility (SNF).

Aug 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure residents are free from significant medication errors, by failing to correctly identify a resident prior to medication administratio...

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Based on interview and record review, the facility failed to ensure residents are free from significant medication errors, by failing to correctly identify a resident prior to medication administration. This failure affects one resident (R1) out of seven reviewed for medication administration. Findings include: R1's Face Sheet (undated) electronic Census Detail documents R1 was admitted to the facility for this residency on 9/28/23. R1's (undated) electronic Diagnoses List documents R1 experienced medical conditions including Congestive Heart Failure, Atrial Fibrillation, History of Myocardial Infarction, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, Anxiety, Hypertension, Coronary Artery Disease, and major Depression. R1's emergency room After Discharge Instructions dated 8/8/24 documents R1 was treated at the emergency room for an accidental medication overdose, requiring intravenous fluids, administration of intravenous Vitamin K 5 milligrams (mg) to reverse the effects of Coumadin (anticoagulant, blood thinner), 1,000 milliliters of normal saline, and oral administration of Vitamin B-12 5 mg. On 8/15/24 at 10:30 AM, V2, Director of Nursing, stated, I was training a new nurse (V3, Licensed Practical Nurse), it was her second day working here. R1 had a room change the night before and his nameplate had not been moved to his new room where he became a roommate of (R2). V2 continued, (V3) got to the room of (R2) and prepared (R2's) medications. R2's name was the only one on the door but it was (R1) who was actually in the room at the time. V2 further stated, (V3) gave (R2's) medications to (R1), this was the HS (bedtime) medications and was around 2100 (9:00 PM). I did counsel (V3) that we don't just go by the name on the door, we have to look at the pictures in the charts, and that most of our residents can identify themselves by name. V2 continued, We did end up sending (R1) to the emergency room and they did give (R1) some Vitamin K, saline, and B-12. V2 concluded by stating, (R1) came back here in just a few hours. R1's (undated) Electronic Medical Record picture portrayed a standing, tall, thin, caucasian man with clean shaven face. R2's (undated) Electronic Medical Record picture portrayed a much shorter, rotund, african american man with a gray beard seated in a wheelchair. R2's (undated) current electronic Physician Order Sheet documented R2 receives HS medications including Coumadin 5.5 mg in a combination of a 3 mg tablet and a 2.5 mg tablet (anticoagulant), Trazadone 100 mg (antidepressant sedative), Lyrica (gabalin analogue, calms overactive nerves, nerve pain, muscle pain, seizures), Oxcarbazepine 300 mg (anticonvulsant, antiseizure), and Atorvastatin 20 mg (lowers cholesterol). These medications were confirmed with V2 as having been included in the medications incorrectly administered to R1. R1's (undated) electronic current Physician Order Sheet (POS) documented R1 did not have physician orders for any of the medications administered to R1 on 8/8/24. This same POS documents R1 does have physician orders for Apixaban (anticoagulant) 5 mg twice daily at 8:00 AM and 4:00 PM making a duplicitous medication therapy when given with R2's Coumadin at 9:00 PM. This same POS documents R1 does have physician orders to receive Sertraline 50 mg daily (antidepressant) also duplicitous when administered with R2's Trazadone. This POS documents R1 has physician orders to receive Buspirone (antianxiety) 5 mg twice daily at 8:00 AM and 4:00 PM having additive effects when administered with R2's Trazadone, Lyrica, and Oxcarbazepine. The facility Medication Administration Policy dated revised 11/18/17 documents, Medications must be identified by using the seven (7) rights of administration: Right resident, Right drug, Right dose, Right consistency, Right time, Right route, Right documentation. This same policy documents, Identify each resident prior to medication administration. Two methods of verification must be utilized prior to administration of a medication: Check photograph, Ask resident his/her full name, Verify resident's identity with another employee familiar with the resident, Call the resident by name and ask for confirmation.

Aug 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected multiple residents

Based on interview and record review the facility failed to operationalize their abuse prevention policy by failing to document identified interventions for five (R2, R3, R4, R5 and R6) of nine reside...

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Based on interview and record review the facility failed to operationalize their abuse prevention policy by failing to document identified interventions for five (R2, R3, R4, R5 and R6) of nine residents reviewed for abuse from a total sample list of nine residents reviewed. Findings include: The facility provided Abuse Prevention Program Policy dated 11/28/16 documents that the facility affirms the right of residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property by promptly and aggressively making the necessary changes to prevent future occurrences. Through the care planning process, staff will identify any problems, goals and approaches,which would reduce the changes of mistreatment, neglect and abuse of residents. R2, R3, R4, R5 and R6's medical records do not document interventions to address issues regarding behaviors with other residents. On 8/7/24 at 9:42AM, V1 Administrator said that the identified intervention after the 7/16/24 (resident to resident abuse) allegation involving R2 and R6 was to keep them separated and to prevent R2 from asking residents for hugs. V1 confirmed that these interventions were not documented. On 8/7/24 at 9:43AM, V1 Administrator said that intervention after the 7/16/24 (staff to resident abuse) allegation involving R3 was to remove the snack cart from reach without assistance. V1 confirmed that this intervention was not documented. On 8/7/24 at 9:44AM, V1 Administrator said that the intervention after the 7/15/24 (resident to resident abuse) allegation involving R4 and R5 was to place the activity cart in a less crowded area so that wheel chairs and ambulatory residents didn't bump into one another. V1 confirmed that this intervention was not documented. On 8/7/24 at 9:45AM, V1 Administrator said that all interventions identified during the investigations should have been documented in the residents medical record/care plan to ensure that all staff are aware of and implement these interventions to prevent further incidents.

Mar 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to protect the resident's right to be free of verbal and physical abuse by another resident for two of three residents (R8 and R9) reviewed for...

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Based on interview and record review the facility failed to protect the resident's right to be free of verbal and physical abuse by another resident for two of three residents (R8 and R9) reviewed for abuse in the sample of 22. Findings include: The facility's abuse report dated 2/10/24, documents an altercation between R8 and R9. This report also documents R9 called R8 a derogatory name and R8 got up from her table and walked to R9's table and R8 pinched R9 on the right forearm. R8's current Electronic Medical Record (EMR) documents R8's diagnoses as: personal history of a Traumatic Brain Injury, Bipolar Disorder, and Depression. R8's Psychosocial Evaluation dated 1/3/24, documents R8 is easily distracted, has difficulty utilizing coping skills, difficulty with impulse control, difficulty with problem solving, has poor judgement, makes inappropriate comments, is depressed, anxious, and suspicious, and is physically aggressive. R8's Care Plan dated 3/12/24, documents R8 displays manipulative behaviors, is impatient, and has verbal outbursts. R9's current EMR documents R9's diagnoses as: Schizoaffective Disorder, Autistic Disorder, and Mild Intellectual Disabilities. R9's Psychosocial Evaluation dated 12/21/23, documents R9 has difficulty responding appropriately, boisterous, difficulty with impulse control, difficulty making decisions, difficulty with problem solving, demonstrates poor judgement, makes inappropriate comments, socially inappropriate, angry/aggressive, and suspicious. R9's Care Plan dated 10/20/23, documents R9 displays impaired coping and can be verbally and physically aggressive. On 3/10/24 at 10:35 AM, R8 stated R9 called her a derogatory name so R8 pinched R9's arm. On 3/10/24 at 10:45 AM, R9 stated R9 did call R8 a derogatory name but does not know why she did. R9 stated then R8 scratched R9 on the arm but did not draw blood. On 3/21/24 at 10:00 AM, V1 Administrator confirmed abuse did occur between R8 and R9 due to R9 calling R8 a derogatory name and then R8 pinching R9's arm. The facility's Abuse Prevention Program Policy dated Revised 11/28/2016, documents this facility affirms the right of the residents to be free from abuse.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0659 (Tag F0659)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to follow physician discharge orders for two residents (R2, R3) of three residents reviewed for following physician discharge orders in the sa...

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Based on interview and record review, the facility failed to follow physician discharge orders for two residents (R2, R3) of three residents reviewed for following physician discharge orders in the sample list of 22. Findings include: 1.) R2's current Electronic Medical Record (EMR) documents R2's diagnoses as: Osteomyelitis, wedge Compression Fracture of T11-T12 Vertebra subsequent encounter for fracture with routine healing, and Anemia. R2's Physician Order Sheet (POS) dated 1/1/24-1/31/24, documents Aspirin 81 milligrams (mg) oral tablet chewable, give one tablet by mouth one time a day and Apixaban (Eliquis) (anticoagulant-blood thinner) oral tablet 5 mg give one tablet by mouth two times a day with a start date of 11/1/23. There are no documented orders on this same POS to stop Apixaban (Eliquis) (anticoagulant) at any time. R2's Care Plan dated 2/27/24, documents R2 is on an anticoagulant. The Health Status Note dated 1/9/24 documents R2 had an unwitnessed fall in R2's room with a head laceration and R2 was sent the the Emergency Department. R2's Emergency Documentation notes dated 1/9/24, document to hold Eliquis (Apixaban) (anticoagulant) until seen by primary care provide and follow-up with primary care provider in the next 24-28 hours. On 3/9/24 at 2:28 PM, V5 Nurse Practitioner (NP) stated R2 should have seen R2's primary care doctor within 24-48 hours after R2's emergency room (ER) visit as ordered by the ER physician. V5 stated R2 should have had Eliquis held as ordered and then followed up with the primary doctor within 24-48 hours as ordered. V5 stated the nurses did not inform V5 of R2's incident or he would have made sure they were holding Eliquis until seen by R2's primary care doctor. V5 stated not holding Eliquis could cause a brain bleed if R2 fell again. On 3/19/24 at 11:52 AM, V10 Licensed Practical Nurse (LPN) stated R2's Apixaban (Eliquis) (anticoagulant) should have been held until R2 saw R2's primary care provider within 24-48 hours. V10 LPN stated R2's medical record does not document R2 being seen by R2's primary care provider within 24-28 hours from R2's ER visit on 1/9/24. V10 LPN confirmed from the Medication Administration Record (MAR) that R2's Eliquis (Apixaban) (anticoagulant) had not been held at any time in January 2024. V10 confirmed R2 was not seen by R2's primary care provider until 2/6/24. V10 LPN stated by not holding R2's Apixaban (Eliquis) (anticoagulant) R2 could have had a brain bleed. On 3/20/24 at 10:01 AM, V11 LPN confirmed R2's Apixaban (Eliquis) (anticoagulant) was not held any time in January 2024. V11 LPN stated V11 was at the facility when R2 returned from the ER but must have been passing medications and not looked at the discharge orders. V11 confirmed R2 did not see R2's primary care provider within 24-24 hours after R2's ER visit. V11 LPN stated R2 could have a brain bleed from continuing to take the anticoagulant Eliquis (Apixaban). 2.) R3's current EMR documents R3's diagnoses as: age-related Osteoporosis, Parkinsonism, and Body Dysmorphic Disorder. R3's After Visit Summary dated 1/23/24, documents R3 was seen 1/23/24 for injury of head and Urinary Tract Infection. This same After Visit Summary documents to schedule an appointment with R3's Medical Doctor as soon as possible for a visit in 2 days. On 3/9/24 at 2:28 PM, V5 Nurse Practitioner (NP) stated R3 should have seen R3's primary doctors with 24-48 hours after R3's emergency room (ER) visit as ordered by the ER physician. On 3/19/24 at 11:52 AM, V10 LPN stated there is no documentation in R3's medical record of being seen by the primary care provider within 24-28 hours after emergency room visit. On 3/20/24 at 10:01 AM, V11 LPN confirmed R3 did not see R3's primary care provider within 24-24 hours after R3's ER visit as ordered. On 3/20/24 at 12:58 PM, V1 administrator stated the nurses should review discharge orders when a resident is returned to the facility, put the orders in the EMR and make a progress note and notify the doctor with any new orders. V1 stated any order from a physician for a resident should be followed. The facility's Conformance with Physician Medication Orders Policy date Reviewed 9/27/17, documents all medications shall be given as prescribed by the physician.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure therapy services were provided for six resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure therapy services were provided for six residents (R2, R4, R19, R20, R21, R22) of six residents reviewed for therapy services on the sample list of 22. Findings include: 1. On 3/21/24 at 1:00 PM, R2 stated they quit giving R2 therapy and R2 does not know if they are going to start it again. R2 stated, when asked if R2 wants therapy, oh yes, I need to have it, I felt tremendously better when getting it. R2's Physician Order Sheet (POS) dated 12/1/23, documents Physical Therapy (PT) and Occupational Therapy (OT) evaluate and treat. R2's Therapy Past Appointments Sheet dated 2/19/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. 2. On 3/21/24 at 12:42 PM, R4 stated R4 used to get therapy and then it just quit and R4 wants to resume therapy. R4 stated R4 needs that help because R4 has fallen and R4 has to get therapy. R4 stated they have not told R4 when therapy will start back up and that R4 has not done therapy in a while. R4's POS dated 1/31/24, documents skilled occupational therapy three times a week for 4 weeks to include therapeutic exercise, self care, neuromuscular re-education, therapeutic activities, wheelchair management, and safety awareness. R4's Therapy Past Appointments Sheet dated 2/19/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. 3. On 3/21/24 at 12:53 PM, R19 stated R19 was getting therapy and it just stopped and R19 does not know when it will start back again. R19 stated R19 needs that therapy. R19's POS dated 2/13/24, documents PT evaluate and treat for therapeutic exercise, therapeutic activities, therapeutic activities, 5 times a week for 4 weeks. R19's Therapy Past Appointments Sheet dated 2/19/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. 4. On 3/21/24 at 12:49 PM, R20 was asked about therapy but R20 is not able to hold a conversation due to low cognition. R20's Minimum Data Set (MDS) dated [DATE], documents R20 is not cognitively intact. R20's POS dated 1/23/24, documents OT clarification skilled OT three times a week for 4 weeks to include therapeutic exercise, self care, neuromuscular re-education, therapeutic activities, wheelchair management, and safety awareness. R20's Therapy Past Appointments Sheet dated 2/19/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. 5. On 3/21/24 at 12:57 PM, R21 stated R21 used to get therapy but they don't have it anymore. R21 stated no one has told R21 when therapy would start again but that R21 wants therapy again. R21's POS dated 2/6/24, documents PT/OT evaluation and treat. R21's Therapy Past Appointments Sheet dated 2/19/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. 6. On 3/21/24 at 12:45 PM, R22 was asked about therapy but R22 is not able to hold a conversation due to low cognition. R22's Minimum Data Set (MDS) dated [DATE], documents R22 is not cognitively intact. R22's POS dated 12/15/23, documents OT clarification 3 times a week for 4 weeks for therapeutic exercise, group therapy, OT evaluation med complex, and therapeutic activities and PT clarification 5 times a week for 4 weeks for therapeutic exercise, neuromuscular education, gait training, and group therapy. R22's Therapy Past Appointments Sheet dated 2/17/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. On 3/19/24 at 1:06 PM, V1 administrator stated the last therapy day here was 2/18/24 and therapy started back again on 3/19/24 with another company, but they only saw R20 on 3/19/24. V1 stated therapy left here due to non-payment from us. On 3/21/24 at 1:42 PM, V15 Regional Director of (Therapy Provider) stated they have not officially started therapy yet at this facility. V15 stated we saw one person on 3/19/24 for an evaluation but nothing else has been done. V15 stated we don't even have staff to cover that facility yet for therapy so we are looking for staff. V15 stated they have not even received a list from the facility for who needs to be seen by therapy. V15 stated there is no set start date at this time. On 3/21/24 at 1:55 PM, V16 Regional Director of Operations stated we do not have a policy for therapy. V16 stated when we accept residents into the facility we except all their care needs including therapy. On 3/19/24, 3/20/24, and 3/21/24, no therapists were seen working in the therapy room.

Dec 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from verbal and mental abus...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from verbal and mental abuse by staff for two of four residents (R1, R2) reviewed for abuse in a sample list of seven residents. Findings include: The facility policy titled 'Abuse Prevention Program' dated 11/28/2016 documents the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. Verbal abuse is the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. 1.) R1's undated Face Sheet documents R1 admitted to the facility on [DATE] with medical diagnoses of Major Depressive Disorder, Adjustment Disorder with mixed Anxiety and Depressed Mood, Borderline Personality Disorder, Trigeminal Autonomic Cephalgias, Malignant Neoplasm of Brain, and Post Traumatic Stress Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as independent in decision making. R1's undated Care Plan does not include a focus area, goal nor interventions for R1 being at risk for Abuse. R1's Nurse Progress Note dated 11/16/23 at 2:38 PM documents (R1) stated that she had suicidal ideations, she had a plan and stated how she was going to do it. (R1) was sent to emergency room (ER) department for evaluation and treatment per facility protocol. R1's Nurse Progress Note dated 11/16/23 at 8:25 PM documents R1 was admitted to psychiatric unit of the hospital. R1's Electronic Medical Record (EMR) documents R1 was hospitalized [DATE]-[DATE] for suicidal ideations. R1's Final Incident Report to the State Agency dated 11/16/23 documents R1 called the facility to report V3 Licensed Practical Nurse (LPN) stated to R1 that '(R1) made (V3's) life H***, (R1) is a known drug abuser and (R1) should take her S*** and go'. On 11/30/23 at 1:00 PM R1 stated That nurse (V3) wouldn't give me my pills. I left the dining room and (V3) was standing at the medication cart by the nurses station (South Unit). I walked by and asked (V3) for my pills. (V3) told me she had other residents to get pills for first and then would check to see if it was time for my pain medication. I was mad about that because if I wait too long the pain gets unbearable. I went back to my room when (V3) told me she would be down in a few minutes. When (V3) came down to my room, she brought (V4) Certified Nurse Aide (CNA) with her like (V3) was afraid I was going to jump her or something. (V3) told me 'We need to have a conversation. (V3) said 'you are a known drug abuser. You make my life a living H***. You should just pack your S*** and go. R1 stated R1 was verbally attacked by V3 to the point that R3 had mental health issues and thought about suicide later that same day. R1 stated They (facility) sent me back to the emergency room again that day because I said I wanted to commit suicide. R1 stated I called the facility as soon as (V3) left my room and reported (V3) to (V14) Office Manager. I was so sad after that. I was verbally attacked and traumatized, that my nurse (V3), who is supposed to take care of me would treat me so horribly. (V3) had no right as a professional or as a person to attack me like that. On 12/1/23 at 10:25 AM V3 Licensed Practical Nurse (LPN) stated V3 was R1's nurse on 11/16/23. V3 stated I said all of those things to (R1). I should not have said those things. I should not have raised my voice. I knew when (R1) asked me at the desk for her pain medication I was going to get agitated with (R1) and sure enough I did. I took (V4) with me because I knew I was going to be agitated with (R1). (R1) is drug seeking and a drug abuser. I was already extra stressed due to personal health problems. I got loud to make a point to (R1). I have been trained on interventions to use in exact situations like this. I not only didn't use those interventions to deescalate a resident with behaviors but I made things worse by yelling at (R1) and saying things I should not have said. This is not who I am. I feel awful about it. But, yes it did happen. As soon as (V1) Administrator called me, I said '(R1) got me. (R1) got me so agitated I yelled at her and said awful things. (R1) is right'. On 12/1/23 at 10:10 AM V4 Certified Nurse Aide (CNA) stated I witnessed the whole thing between (V3) and (R1). (V3) LPN asked me to come with her so she could give (R1) the pills. First thing (V3) said to (R1) was 'We need to have a conversation.' (V3) was not nice about that at all. I heard (V3) call (R1) a drug abuser. (V3) told (R1) that (R1) makes (V3's) life miserable and (R1) should just pack her stuff and leave. Normally (V3) is a very good nurse. I think (V3) was just scared and mad, so that whole scene was bad. I was just getting ready to stand in between (R1) and (V3) because it was getting heated. I didn't really know what to do but I didn't want anyone to get hurt. Then (V3) finally left (R1's) room. 2.) R2's undated Face Sheet documents R2 admitted to the facility on [DATE] with medical diagnoses of Orthopedic Aftercare following surgical Amputation of Right Foot above Right Ankle, Diabetes Mellitus Type II, Chronic Atrial Fibrillation, and Bipolar Disorder. The Brief Interview for Mental Status score dated 8/29/23 documents R2 as cognitively intact. R2's undated Care Plan does not include R2 being at risk for abuse. R2's Final Incident Report to the State Agency dated 10/20/23 documents On 10/16/23 (R2) self reported (V5) Certified Nurse Aide (CNA) called him a f****** (R2) stated he had not reported to anyone prior. (R2) reported he was up at the nurses' station getting a snack when (V5) CNA called him a f******, then (V6) Certified Nurse Aide (CNA) said 'he heard what you said.' (R2) states he is 99% sure (V5) was talking to him. (V7) Unit Aide stated (V5, V6) were talking on the phone to a male and heard (V5) start to say f****** but then stopped because she realized (R2) was there. On 12/1/23 at 1:30 PM R2 stated (V5) was on her personal cellular phone when I wheeled up to the nurses station (North Unit) where (V5) was standing on the phone. R2 stated (V5) knows I am gay. (V5) called me a f******. (V5) tried to cover it up by saying she was on the phone with her brother and that her brother called her a f****** and that she was just repeating that. R2 stated I am proud of who I am but do not like to be called names for my choices. Everybody has the right to be treated as humans. (V5) treated me like I am less than human. I have worked in healthcare a long time and know when I am being abused. (V5) verbally abused me that day. I cried for hours over that later that night by myself. It just mentally messed me up. I told (V1) about it the next day. I told (V1) on a Monday. I didn't tell anyone else (10/15/23) evening because I felt so bad. But (10/16/23) Monday morning, I just thought that should be reported to (V1) because there may be someone else here who (V5) says horrible things to also and can't report that for themselves. (V1) suspended (V5) CNA then. (V5) CNA worked the rest of that night (10/15/23). I shouldn't be called derogatory names for being who I am. On 12/1/23 at 10:10 AM V5 Certified Nurse Aide (CNA) stated V5 worked the evening of 10/15/23 until 1:00 AM early morning of 10/16/23 on the North unit. V5 stated I was on the phone with my brother. I wasn't on the buildings phone. I was using my personal cellular phone. My brother called me a f******. (R2) thought I was talking about him and calling him a f******. That was wrong. It doesn't matter if we said that to (R2) or if (R2) overheard it or what. We should not have said that word. On 12/1/23 at 11:00 AM V1 confirmed this incident did occur between R2 and V5. V1 Administrator stated V5 CNA was given a written warning for this behavior.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to timely report allegations of abuse to the abuse coordinator for two of four residents (R1, R2) reviewed for abuse in a sample list of seven ...

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Based on interview and record review the facility failed to timely report allegations of abuse to the abuse coordinator for two of four residents (R1, R2) reviewed for abuse in a sample list of seven residents. Findings include: The facility policy titled 'Abuse Prevention Program' dated 11/28/2016 documents the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. Verbal abuse is the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the Administrator. Supervisors should immediately inform the administrator and his/her designated representative of all reports of potential/alleged mistreatment, exploitation, neglect and abuse of residents and misappropriation of resident property. Upon learning of the report, the Administrator or designee shall initiate an investigation. 1.) R1's Final Incident Report to the State Agency dated 11/16/23 documents R1 called the facility to report V3 Licensed Practical Nurse (LPN) stated to R1 that '(R1) made (V3's) life h***, (R1) is a known drug abuser and (R1) should take her s*** and go.' On 12/1/23 at 10:25 AM V3 Licensed Practical Nurse (LPN) stated I did not directly report this incident to (V1). I knew (V1) would be at facility shortly because that was about the usual time (V1) arrived. I should have reported this immediately and did not. On 12/1/23 at 10:10 AM V4 Certified Nurse Aide (CNA) stated I witnessed the whole thing between (R1) and (V3). I did not report this incident myself but should have gone straight to the phone and called (V1). On 12/1/23 at 1:15 PM V1 Administrator stated V1 was just arriving at facility when V14 Office Manager called V1 to report that R1 had reported alleged abuse by V3 LPN. V1 stated As soon as I got to facility, I went straight to South Unit to talk to (R1) and (V3). I suspended (V3) immediately pending investigation. (V3) LPN nor (V4) CNA reported this incident. (R1) reported (V3's) behavior to the facility. (V3) and (V4) both should have called me immediately. They assumed I was on my way to the facility, but they did not know that for sure until I walked onto South Unit. 2.) R2's Final Incident Report to the State Agency dated 10/20/23 documents On 10/16/23 (R2) self reported (V5) Certified Nurse Aide (CNA) called him a f******. (R2) stated he had not reported to anyone prior. (R2) reported he was up at the nurses' station getting a snack when (V5) CNA called him a f******, then (V6) Certified Nurse Aide (CNA) said 'he heard what you said.' (R2) states he is 99% sure (V5) was talking to him. (V7) Unit Aide stated (V5, V6) were talking on the phone to a male and heard (V5) start to say f****** but then stopped because she realized (R2) was there. On 12/1/23 at 10:10 AM V5 Certified Nurse Aide (CNA) stated I called (V2) Director of Nurses (DON) later that night (10/15/23) but she didn't tell me I was suspended or anything. (V2) just told me she would report it to (V1). V5 stated (V1) Administrator called me that next morning (10/16/23) and told me I was suspended. I can see how (R2) was upset by that. I had to sign a write up for that and I agreed with being written up. I felt bad about it after (V1) explained it all to me. On 12/1/23 at 11:00 AM V1 stated R2 self reported the abuse on the morning of 10/16/23. V1 stated No one else ever reported this to me. (R2) self reported the allegation on the morning of 10/16/23. (V5, V6, V7) should have reported it that evening.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to ensure a staff member was removed from resident care after an allegation of staff to resident abuse for one of one residents (R2) reviewed f...

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Based on interview and record review the facility failed to ensure a staff member was removed from resident care after an allegation of staff to resident abuse for one of one residents (R2) reviewed for abuse on the sample list of seven. Findings include: R2's Final Incident Report to the State Agency dated 10/20/23 documents On 10/16/23 (R2) self reported (V5) Certified Nurse Aide (CNA) called him a f******. (R2) stated he had not reported to anyone prior. (R2) reported he was up at the nurses' station getting a snack when (V5) CNA called him a f******, then (V6) Certified Nurse Aide (CNA) said 'he heard what you said.' (R2) states he is 99% sure (V5) was talking to him. (V7) Unit Aide stated (V5, V6) were talking on the phone to a male and heard (V5) start to say f****** but then stopped because she realized (R2) was there. On 12/1/23 at 1:30 PM R2 stated (V5) was on her personal cellular phone when I wheeled up to the nurses station (North Unit) where (V5) was standing on the phone. R2 stated (V5) knows I am gay. (V5) called me a f******. (V5) tried to cover it up by saying she was on the phone with her brother and that her brother called her a f****** and that she was just repeating that. R2 stated I am proud of who I am but do not like to be called names for my choices. Everybody has the right to be treated as humans. (V5) treated me like I am less than human. I have worked in healthcare a long time and know when I am being abused. (V5) verbally abused me that day. I cried for hours over that later that night by myself. It just mentally messed me up. I told (V1) about it the next day. I told (V1) on a Monday. I didn't tell anyone else (10/15/23) evening because I felt so bad. But (10/16/23) Monday morning, I just thought that should be reported to (V1) because there may be someone else here who (V5) says horrible things to also and can't report that for themselves. (V1) suspended (V5) CNA then. (V5) CNA worked the rest of that night (10/15/23). I shouldn't be called derogatory names for being who I am. On 12/1/23 at 10:10 AM V5 Certified Nurse Aide (CNA) stated I called (V2) Director of Nurses (DON) later that night (10/15/23) but she didn't tell me I was suspended or anything. (V2) just told me she would report it to (V1). That happened right after supper on 10/15/23. I worked until 1:00 AM the morning of 10/16/23. V5 stated (V1) Administrator called me that next morning (10/16/23) and told me I was suspended. I can see how (R2) was upset by that. I had to sign a write up for that and I agreed with being written up. I felt bad about it after (V1) explained it all to me. On 12/1/23 at 11:00 AM V1 stated R2 self reported the abuse on the morning of 10/16/23. V1 stated No one else ever reported this to me. (R2) self reported the allegation on the morning of 10/16/23. (V5, V6, V7) should have reported it that evening. (V5) would have been suspended the night of 10/15/23 but that didn't happen until the morning of 10/16/23.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain a properly functioning call light system for f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain a properly functioning call light system for four (R1, R5, R6, R7) residents out of four residents reviewed for call lights in a sample list of seven residents. Findings include: 1. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as independent in decision making. On 11/30/23 at 1:20 PM R1's call light was activated by R1. R1's call light turned on a light above R1's door but was not audible. On 11/30/23 at 1:25 PM the Call Light System was not functioning as it was supposed to on the facility South Unit. South Unit call lights were observed with lights above the rooms but without sound. On 11/30/23 at 1:05 PM R1 stated What happens if I am in the shower or something and I fall. Who is going to come help me if they (staff) don't know the light is even on? We (residents) deserve to have it fixed. 2.) R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. On 11/30/23 at 11:38 PM R5's call light was activated. R5's call light did light up above R5's room door but was not audible. On 11/30/23 at 1:40 PM V9 Licensed Practical Nurse (LPN) stated the call light box at the nurses station doesn't work 'half the time'. V9 confirmed R5's call light did not show at the nurses desk. On 11/30/23 at 1:33 PM R5 stated I can get up on my own and take pretty good care of myself. But, when I need the staff I want them to be here quickly. I don't usually even use my call light but if I had an emergency I would want it work right! These things need fixed right away. 3.) R6 Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. On 11/30/23 at 1:32 PM R6 activated R6's call light. R6's call light did light up above R6's room door but was not audible. On 11/30/23 at 1:30 PM R6 stated Our call lights haven't worked for a few weeks now. They light up but there isn't any sound. They are broke. If I needed something I would have to wait for someone to see my light on. I don't know what I would do in the shower room if I fell. I use the shower across the hall. How do the staff even know if I am ok or not? You can't see the light above the room door or shower door from the other end of the hall. 4.) R7 Minimum Data Set (MDS) dated [DATE] documents R7 as cognitively intact. On 11/30/23 at 1:40 PM R7 activated R7's call light. R7's call light did light up above R7's room door but was not audible. On 11/30/23 at 1:35 PM R7 stated I agree with (R6). The call lights don't work right. It should have been fixed a long time ago. They (facility) are just waiting for somebody to get hurt. I had to wait 45 minutes a couple of days ago to get my light answered. The light comes on to the call light but there is no sound. It has been out for weeks. The staff have to actually look down the hall to see if there is a light on. They (facility) only allow one CNA down here (South Unit) so if that person is in a room then no one would see the call light come on. That box at the nurses station hasn't worked for awhile. The nurses pass their pills and then they sit there at the nurses station. If you want something, you have to walk up there before they notice you. On 12/1/23 at 7:20 AM V20 Maintenance Director stated V20 was made aware by residents on the South Unit 'about three weeks ago' that the sound did not work on all of the call lights on South Unit. V20 stated the facility called an outside company to assess the call light system not working properly. V20 stated the other company has not been to the facility yet and 'is supposed to come out 12/2/23'. V20 stated I don't know how to fix that kind of problem so I just have to wait on this guy to come out. I know it doesn't work right but I don't know what to do about it. On 12/1/23 at 2:15 PM V1 Administrator stated I was just made aware yesterday (11/30/23) that there was any kind of problem on South Unit with the call lights. The sound does not work and it should. We (facility) called a repair service and they are supposed to be out 12/2/23 to assess the situation. I agree this a problem that needs fixed as soon as possible. I don't know why I was not told about this weeks ago when it first malfunctioned.

Oct 2023 10 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to use a gait belt during a resident's transfer and ambula...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to use a gait belt during a resident's transfer and ambulation to prevent a fall for one (R40)of three residents reviewed for falls in the sample list of 44. The fall resulted in R40 sustaining a skin tear in the right arm. Findings include: The facility's Fall Prevention policy with a revised date of 11/10/18 documents, Policy: To provide for resident safety and to minimize injuries related to falls; decreases falls and still honor each resident's wishes/desires for maximum independence and mobility. Fall Prevention Interventions: 11. Transfer with proper number of assist and gait belt. R40's Fall Risk assessment dated [DATE] documents R40 is at risk for falls. The next Fall Risk Assessment was not completed until 9/27/23 which documents R40 is not at risk for falls even though R40 had falls on 9/6/23 and 9/27/23. On 10/2/23 at 11:00 AM, R40 was in R40's room in R40's wheelchair watching television. R40 stated that R40 fell in R40's room and hurt R40's back when R40 fell. R40's Nurse Progress notes dated 9/6/23 at 2:30 PM documents R40 fell in R40's room. This note documents R40 was in R40's wheelchair and stood up to try to hang up a sweater in the closet and R40's knees gave out and R40 fell. R40 sustained a skin tear to the right arm. The intervention developed for this fall was to educate R40 to ask for assistance. R40's Nurse Progress notes dated 9/27/23 at 5:42 AM documents at 4:30 AM, R40 lost R40's balance walking to the bathroom. This note documents V14 Certified Nursing Assistant (CNA) was with R40 but could not catch R40 because the privacy curtain got in the way. This note documents R40 complained of back pain, ambulance called and R40 transported to the hospital. R40's Minimum Data Set (MDS) dated [DATE] documents R40 requires extensive assistance of two staff for transfers and is not steady walking and moving from a seated to standing position. R40's Care Plan with a revision dated of 6/21/23 documents R40 had an actual fall with interventions to educate to ask for assistance dated 8/28/23 and to sit on the side of the bed until dizziness subsides dated 9/27/23. On 10/4/23 at 11:05 AM, V2 Director of Nursing stated that R40 should be walked with a gait belt and assistance of at least one staff member. V2 stated V2 does not know if R40 had a gait belt on during the fall on 9/27/23. On 10/4/23 at 1:51 PM, V14 CNA stated that V14 did not have a gait belt on R40 when R40 fell. V14 stated that R40 had gotten R40's self out of bed and had started walking to the bathroom when V14 came in R40's room. V14 stated V14 went to help R40 but did not put a gait belt on R40 and R40 lost R40's balance and V14 could not catch R40. V14 stated that R40 complained of back pain and the nurse assessed R40 and sent R40 to the Emergency Room. On 10/4/23 at 1:59 PM, V13 R40's Physician confirmed there was a fracture of the T12 vertebrae but it could not be determined if it was a new fracture or an old fracture. V13 stated that since R40 was not in excruciating pain and is back to R40's baseline it was most likely an old fracture that was irritated by the fall.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete comphrehensive minimum data set assessments within 14 days ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete comphrehensive minimum data set assessments within 14 days of admission and every 12 months for two (R27, R178) of 18 residents reviewed for Minimum Data Set assessments on the sample list of 44. Findings include: The facility's Comphrehensive Assessment/MDS (Minimum Data Set) policy with a revision date of 11/1/2017 documents, Each Resident residing in this facility for a full 14 days shall have a MDS initiated by the 13th day after admission, and a RAI (Resident Assessment Instrument) completed by the 14th day after admission. admission applies to: a. First admission to the facility, or b. Subsequent admissions to the facility. This policy also documents, The MDS shall be re-evaluated according to the following schedule. a. Quarterly-within 92 of previous ARD (Assessment Reference Date)/MDS b. Annually- within 366 days of previous Comprehensive ARD/MDS. 1. R27's Electronic Health Record documents R27's had an annual comphrehensive MDS assessment completed on 8/22/22. This screen documents that R27's comphrehensive assessment for 8/18/23 is in progress. 2. R178's Electronic Health Record documents R178's was admitted to the facility on [DATE]. R178's Electronic Health Record documents R178's admission assessment as having an assessment reference date of 9/11/23 and that this assessment is still in progress. On 10/4/23 at 11:43 AM, V4 MDS Coordinator confirmed R27 and R178's comphrehensive MDS assessments were not completed on time.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to develop a resident centered psychiatric treatment plan for serious mental illness for two (R70, R59) of three residents review...

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Based on observation, interview, and record review the facility failed to develop a resident centered psychiatric treatment plan for serious mental illness for two (R70, R59) of three residents reviewed for PASARR screens in a sample list of 44 residents. Findings Include: 1. On 10/2/23 at 12:06 PM, R70 was in R70's room which was on a locked unit designated for individuals with serious mental illness. R70's Pre-admission Screening and Resident Review (PASRR) dated 6/7/23 documents R70 suffers from Schizophrenia and requires specialized mental health care to treat this condition. R70's medical record does not document an interdisciplinary treatment plan to address R70's serious mental illness. On 10/4/23 at 10:00 AM V4, Care Plan Coordinator stated she was not aware individuals diagnosed with mental illness had to have a treatment plan. 2. On 10/2/23 at 10:00 AM, R59 was watching television in R59's room which was on a locked unit designated for individuals with serious mental illness. R59's Pre-admission Screening and Resident Review (PASRR) dated 7/31/23 documents R59 suffers from Schizophrenia and Bipolar Disease and requires specialized mental health care to treat this condition. R59's medical record does not document an interdisciplinary treatment plan to address R59's serious mental illness. On 10/4/23 at 10:00 AM, V4 Care Plan Coordinator stated she was not aware individuals diagnosed with mental illness had to have a treatment plan. On 10/4/23 at 1:00 PM, V1 Administrator stated the facility does not have a specific policy for psychiatric treatment plans.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop care plans with interventions for cigarette sm...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop care plans with interventions for cigarette smoking. This failure has the potential to affect two of two residents (R8, R54) reviewed for smoking in a sample list of 44 residents. Findings Include: 1. On 10/2/23 at 10:30AM R8 stated I am going out to smoke. R8 was observed receiving a cigarette which was to be lighted when he went to the smoking area. R8's Smoking evaluation dated 6/28/23 documents Smoking materials kept by staff and dispensed at designated times. R8's Care Plan updated 8/23/23 does not include interventions to address R8's smoking.2. On 10/02/23 at 10:50 AM, R54 was smoking cigarettes in the smoking area unsupervised. R54's smoking assessment dated [DATE] documents R54 requires supervision while smoking. R54's Electronic Health Record does not contain a care plan for smoking.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R24's Medication Administration Record (MAR) for October 2023 includes current physician's orders for 1. Clozapine (Antipsych...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R24's Medication Administration Record (MAR) for October 2023 includes current physician's orders for 1. Clozapine (Antipsychotic) 200 milligrams every morning and 600 Milligrams every evening. 2. Ativan (Antianxiety) 1 Milligram daily. 3. Divalproex EC (Neuroleptic) 750 Milligrams every morning. 4. Haldol 5 Milligrams every 24 hours PRN (As needed). The most recent Psychotropic medication assessment is dated 12/11/22. There is no documented psychotropic assessments documented for R24's Divalproex EC. There is no documentation of an assessment of Involuntary Movement Scale (AIMS) documented for R24. On 10/4/23 at 10:00 AM V4, Care Plan Coordinator stated I am responsible for psychotropic medication assessment, but I wasn't aware of that until today so they haven't been done in a while. Based on interview and record review the facility failed to complete psychotropic medication assessments for three (R49, R58, and R24) of five residents reviewed for psychotropic medications on the sample list of 44. Findings include: The facility's Psychotropic Medication policy with a revision date of 6/17/22 documents, 4. Initiate a Psychotropic Medication Quarterly Evaluation within 14 days of admission for those resident currently receiving psychotropic medication. 1. R49's Medication Administration Record (MAR) dated 10/1/23 through 10/31/23 documents R49 was admitted to the facility on [DATE]. This MAR documents R49 is receiving one 0.5 milligram (MG) tablet of Xanax (Antianxiety medication) three times a day, one 40 mg tablet of Paxil (Antidepressant one time a day, and one 100 mg tablet of Trazodone (antidepressant) at bedtime. This MAR documents R49's Xanax was ordered on 4/28/23, the Paxil was ordered on 4/29/23, and the Trazodone was ordered on 4/28/23. R49's medical record does not include an psychotropic medication assessments for the use of R49's psychotropic medications. On 10/4/23 at 8:50 AM, V1 Administrator stated there is not psychotropic medication assessments for R49. 2. R58's MAR dated 10/1/23 through 10/31/23 documents R58 was admitted to the facility on [DATE]. This MAR documents R58 is receiving 75 mg of Quetiapine Fumarate (Antipsychotic) two times and 10 mg of Escitalopram (antidepressant) once a day. This MAR documents the 75 mg of Quetiapine was ordered on 9/12/23 and the 10 mg of Escitalopram was ordered on 3/4/23. R58's medical record did not include psychotropic medication assessments for the use of R58's psychotropic medications. On 10/4/23 at 8:50 AM, V1 Administrator stated there is not psychotropic medication assessments for R58.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to initiate contact and droplet isolation and conduct a PCR (Polymerase chain reaction) test when respiratory symptoms were prese...

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Based on observation, interview, and record review the facility failed to initiate contact and droplet isolation and conduct a PCR (Polymerase chain reaction) test when respiratory symptoms were present and failed to post isolation signs for two of two (R67, R128) residents reviewed for isolation on the sample list of 44. Findings include: The facility's COVID-19 Control Measures policy with a revision date of 5/19/23 documents, 4. If a resident is displaying symptoms of COVID-19 and has an antigen test that is negative, the resident must be PCR (Polymerase chain reaction) tested and is to remain on TBP (transmission based precautions) until the test results are received. 1. On 10/3/23 from 9:00 AM to 3:00 PM, R67's bedroom door was open and R67 coughed forcefully all day long. R67's door room indicated that R67 was in isolation due to the cough. On 10/3/23 at 1:41 PM, V1 Administrator was notified that R67 had been coughing all day long. On 10/3/23 at 3:10 PM, a gown was hanging on the outside of R67's door. The door did not have a sign or indicate why a gown was hanging on the outside of the door. V16 X-ray technician walked up to R67's room and then walked up to the nurse's station and asked V15 Licensed Practical Nurse if R67 was in isolation. V15 stated he could wear a gown in there because R67 was having symptoms of a cough. On 10/4/23 at 8:30 AM, R67's door nor room indicated that R67 was in isolation. R67 continued to cough. On 10/4/23 at 1:00 PM, a Contact and Droplet isolation sign and PPE station was hanging on R67's door. On 10/4/23 at 1:10 PM, V2 Director of Nursing stated she did not know that R67 was coughing all day yesterday and stated that after finding out today she put him into contact and droplet precautions and asked them to do a PCR test per facility policy. V2 stated a rapid test was completed yesterday and was negative. V2 stated R67 should have been put into isolation yesterday and a PCR should have been completed also since symptoms were present. 2.) On 10/2/23 at 9:59 AM there was PPE (Personal Protective Equipment) hanging on the outside of R128's door. At this time, R128 was sitting outside of R128's room and confirmed that the PPE is for R128. R128 stated that R128 has an infection in R128's amputated leg (stump) and R128 pointed to R128's stump. There were no isolation signs posted on the door or outside of the room to indicate what type of PPE was required or what type of isolation R128 was on. On 10/4/23 at 9:51 AM, there was no isolation signs posted on R128's door or outside of R128's room and the PPE supplies were still hanging on the door. On 10/4/23 at 1:15 PM, V2 Director of Nursing confirmed R128 was on isolation and that there should be signs posted on the isolation rooms to indicate the type of isolation and PPE required.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to maintain resident rooms in a safe sanitary home like m...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to maintain resident rooms in a safe sanitary home like manner for five (R59, R53, R15, R42, R19) of 18 residents reviewed for environment in a sample list of 44 residents. Findings include: 1. On 10/2/23 at 10:00 AM, R15 and R19 were in their room watching TV. R15 was in the bed by the door. R19 was in the bed by the window. Between their beds was a third empty bed. This bed did not have a mattress and metal springs were exposed. A window type air conditioner was lying face down in the middle of the bed on top of the exposed springs. R19 stated That broken air conditioner has set there for weeks. I'm getting tired of looking at it. Would you want that in your bedroom? They put the new one in and just left it there. R19's Minimum Data Set, dated [DATE] documents R19 is cognitively intact. 2. On 10/2/23 at 10:00 AM, R42 and R59 were in their room watching TV. A small window unit air conditioner was in the window by R59's bed. The unit was not wide enough to fill the entire window. The empty space was approximately 24 inches by 12 inches. A piece of cardboard was taped to the window frame covering the empty space. The tape was coming loose leaving several two to three inch gaps to the outside, large enough for insects to enter. The cardboard was moist around the edges and smelled musty. R59 stated When the wind blows it comes right through that cardboard. It's been that way for a long time. 3. On 10/2/23 at 10:11 AM, R53 was sitting in the recliner in R53's room. There was a small window unit air conditioner in the window in R53's room. The unit was not wide enough to fill the entire window. The empty space was approximately 24 inches by 12 inches. A piece of cardboard was taped to the window frame covering the empty space. The tape was coming loose leaving several two to three inch gaps to the outside; large enough for insects to enter. The cardboard was moist around the edges and smelled musty. R53 stated, The rain comes in the room around that cardboard. You'd think they could fix it, but it's been that way since I got here in May. On 10/2/23 at 2:00 PM, V7 Maintenance Director stated, Those windows back on South need to be filled with some foam insulated boards. I just haven't had time to do that. It's been that way since about the first part of June. On 10/4/23 at 1:00 PM, V1 Administrator stated I wasn't aware those windows were patched with cardboard on (the hall in which R59, R53, R15, R42, R19 reside). I will talk to (V7). They should not have been left like that.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R24's Minimum Data Set summary with a print date of 10/4/23, documents R24's Assessment Reference Date (ARD) for R4's Minimum...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R24's Minimum Data Set summary with a print date of 10/4/23, documents R24's Assessment Reference Date (ARD) for R4's Minimum Data Set (MDS) was 9/19/23. This summary also documents sections A through Q are in progress. On 10/3/23 at 10:00 AM, V4 MDS Coordinator stated (R24's) MDS is late. I have been in this position for a short time and I have also been on maternity leave so I realize I am behind. Based on interview and record review the facility failed to complete quarterly Minimum Data Set assessments every three months for four (R53, R50, R11, R24) of 18 residents reviewed for Minimum Data Set assessments on the sample list of 44. Findings include: The facility's Comphrehensive Assessment/MDS (Minimum Data Set) policy with a revision dated of 11/1/2017 documents, The MDS shall be re-evaluated according to the following schedule. a. Quarterly-within 92 of previous ARD (Assessment Reference Date)/MDS. 1. R53's Electronic Health Record (EHR) documents an admission MDS was completed for R53 on 5/24/2023. R53's EHR documents R53's quarterly assessment was due on 8/23/23. This screen documents this annual assessment is still in progress. 2. R50's EHR documents an Annual MDS was completed for R50 on 5/25/23. R50's EHR documents a quarterly assessment was due on 8/24/23. This screen documents this annual assessment is still in progress. On 10/5/23 at 11:43 AM, V4 MDS Coordinator confirmed R53 and R50's quarterly MDS assessments as late. 3.) R11's EHR documents R11's last completed and submitted Quarterly Minimum Data Set is dated 6/8/23. R11's Quarterly Minimum Data Set, dated [DATE] documents it is still in progress and has not been completed and submitted. Sections B, C, D and Q are incomplete on this assessment.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0576 (Tag F0576)

Could have caused harm · This affected most or all residents

Based on record review and interview the facility failed to follow residents' rights by not allowing residents to receive their mail on Saturdays. This failure has the potential to affect all 77 resid...

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Based on record review and interview the facility failed to follow residents' rights by not allowing residents to receive their mail on Saturdays. This failure has the potential to affect all 77 residents residing in the facility. Findings include: Resident Council meeting held on 10/3/23 at 10:00 AM consisted of R72, R48, R21, and R10 (Resident Council President). All four residents stated they do not receive mail on Saturdays because there is no one from Activities here on the weekends to distribute it. On 10/4/23 at 9:00 AM, V12 Activity Director stated that they should be delivering mail on Saturdays. V12 stated that V12 is the only Activity person right now and V12 does not work on the weekends. On 10/04/23 at 9:04 AM, V1 Administrator stated that there is no one to pass out mail on the weekends so residents are not getting their mail on Saturdays. The Resident Census and Conditions of Residents report dated 10/2/23 documents 77 residents reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review the facility failed to post daily staffing. This failure has the potential to affect all 77 residents residing in facility. Findings include: The faci...

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Based on observation, interview and record review the facility failed to post daily staffing. This failure has the potential to affect all 77 residents residing in facility. Findings include: The facility's Resident Census and Conditions of Residents report dated 10/2/23 documents 77 residents reside in facility. On 10/2/23 upon entry into the facility there was no posted staffing located anywhere in the lobby or office areas. On 10/4/23 at 8:30 AM, there is still no posted staffing located anywhere in the lobby or office areas of the facility. On 10/4/23 at 8:49 AM, V1 Administrator confirmed the daily staffing is not posted. V1 stated that it should be posted outside of V1's office in the lobby area. V1 stated that the night nurse is responsible for completing and posting it.

Dec 2022 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a resident's representative of the deterioration of the resid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a resident's representative of the deterioration of the resident's wound. This failure affected one of three residents (R2) reviewed for Notification of Changes in the sample of five. Findings include: R2's Face Sheet dated 12/15/22 documents V11 is R2's Guardian. R2's Minimum Data Set, dated [DATE] documents R2 is severely cognitively impaired. R2's Wound Evaluation and Management Summary dated 12/2/22 documents R2's Stage Four Pressure Wound of the right lower back measured 4.5 x 2.5 x 1.2 centimeters and deteriorated since the week prior. The same summary also documents R2's Stage Four Pressure Wound of the right hip measured 4.5 x 5 x (not measurable) centimeters and deteriorated since the week prior. R2's Wound Evaluation and Management Summary dated 12/9/22 documents R2's Stage Four Pressure Wound of the right hip measured 4.5 x 5 x 2.8 centimeters and deteriorated since the week prior. On 12/14/22 at 1:50 PM V11 R2's Guardian stated the facility notified him of R2's wounds however did not notify him that the wounds were getting worse and he was not aware of how bad the wounds were. On 12/14/22 at 3:45 PM V6 Wound Nurse confirmed the facility should notify resident representatives when there is a deterioration in health (for example R2's wound deterioration) and V11 should have been made aware of the status of R2's back and hip wounds. The Notification for Change in Resident Condition or Status policy dated 12/7/17 documents the facility should promptly notify a residents representative of a resident's change in condition or status. This includes any symptom or sign that is a marked change (i.e. more severe).

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement a physician's order for a pressure reducing device (air ma...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement a physician's order for a pressure reducing device (air mattress). This failure affected one of three residents (R2) reviewed for Pressure Ulcers in the sample of five. Findings include: R2's Wound Evaluation and Management Summary dated 12/2/22 documents R2 had a Stage Four Pressure Wound of the right lower back and a Stage Four Pressure Wound of the right hip. V10 Wound Doctor wrote an order recommendation to apply an air mattress to R2's bed. On 12/14/22 at 3:45 PM V6 Wound Nurse confirmed the facility was not aware of V10's order for an air mattress for R2 and did not implement this pressure reducing intervention prior to R2's hospital admission on [DATE] (six days later). On 12/15/22 at 12:47 PM V10 confirmed the facility should have implemented the pressure reducing air mattress to R2's bed in an attempt to prevent further deterioration of R2's wounds. The Decubitus Care/Pressure Areas policy dated January 2018 documents when a pressure ulcer is identified additional interventions must be implemented in an effort to prevent worsening of the pressure ulcers.

Dec 2022 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to honor a resident (R208) request to have the call light ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to honor a resident (R208) request to have the call light answered. This failure affects one resident (R208) out of one resident reviewed for resident rights in a sample list of 21 residents. Findings include: R208's undated Face Sheet documents medical diagnoses of Pulmonary Hypertension, Moderate Persistent Asthma, Chronic Obstructive Pulmonary Disorder (COPD) and Chronic Respiratory Failure. R208's Cognitive assessment dated [DATE] documents R208's Brief Interview for Mental Status as cognitively intact. R208's Skilled Nursing Note dated 11/16/22 documents R208 as having an unsteady gait requiring supervision. This same Note documents R208 as having weakness and impaired balance. R208's Final Report to IDPH dated 11/16/22 documents (R208) came out of conference room and told (V16) Licensed Practical Nurse (LPN) she was going to (R208's) room and turning on call light to go to bed. (V16) stated 'Don't go turn your call light on they (staff) are all in the dining room. V16's Employee file includes disciplinary action dated 11/16/22 which documents Verbal education via phone. Do not tell any resident to not turn on their call light. It is every resident's right to use their call light. If Certified Nurse Aides (CNA) are unavailable to give care the nurse should provide care when asked. On 11/30/22 at 2:25 PM R208 was laying in bed with Oxygen in place at 3 Liters/Nasal Cannula. R208 was using accessory muscles to breathe while being interviewed. On 11/30/22 at 2:30 PM R208 stated I can get up and out of bed on my own but I like to have someone there. I do get short of breath due to my COPD. That nurse should have either helped me or had someone else help me. I think that would be the right thing to do. On 12/1/22 at 11:30 AM V1 stated (R208) is independent and does not need the assistance getting into bed but (V16) should not tell any resident to not turn on their call light. That could be considered against the resident's rights. We (facility) provided education to (V16) for that matter. Long Term Care Ombudsman Program Pamphlet titled Resident Rights revised July 2018 documents the following: Your facility must provide services to keep your physical and mental health, at their highest practical levels.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to protect the resident's right (R50) to be free from physical and verb...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to protect the resident's right (R50) to be free from physical and verbal abuse by another resident (158). R50 and R158 are two of six residents reviewed for abuse in a sample list of 21 residents. Findings include: R50's undated Face Sheet documents medical diagnoses of Paranoid Schizophrenia, Dementia and Paranoid Personality Disorder. R50's Minimum Data Set (MDS) dated [DATE] documents R50 as cognitively intact. This same MDS documents R50 requires supervision for walking in the corridor. R158's undated Face Sheet documents medical diagnoses of Schizoaffective Disorder, Anxiety with Psychosis, Panic Disorder and Agitation. R158's Minimum Data Set (MDS) dated [DATE] documents R158 as cognitively intact. This same MDS documents R158 as requiring supervision with walking in the corridor. R50's Final Report to Illinois Department of Public Health (IDPH) dated 11/3/22 documents Both residents (R50, R158) were hearing voices, (R158) shoved (R50) against the wall. This same report documents V17 Unit Aide stated 'I observed (R158) shoving (R50) up against the North wall and continue to restrain (R50) to the wall. While this was going on, (R158) was shouting, restraining (R50), using profanity and threatening to kick (R50's) a**. This same report documents V14 Certified Nurse Aide (CNA) stated 'I was in the other room and heard (R158) yelling. I could feel the wall shake. (R158) shoved (R50) in to the wall and was yelling at (R50). On 12/1/22 at 11:30 AM V1 stated The situation between (R158 and R50) was hands down abuse. One resident (R158) shoved (R50) into the wall. We (facility) sent (R158) out for (R158's) extreme behavior. It was unfortunate but that situation did happen. The facility policy titled 'Abuse Prevention Program' revised 11/28/2016 documents the following: Policy: The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property and exploitation as defined below. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to ensure the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. Definitions: The following definitions are based on federal and state laws, regulations and interpretive guidelines. Abuse is the willful injection of injury, unreasonable confinement, intimidation or punishment or punishment resulting in the physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury. Physical Abuse includes hitting, kicking, slapping, pinching and controlling behavior through corporal punishment. Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or families, or within hearing distance regardless of age, ability to comprehend or disability. Protection of Residents: Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to prevent cross-contamination during Stage 3 Pressure Ulc...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to prevent cross-contamination during Stage 3 Pressure Ulcer care for one (R17) of five residents reviewed for pressure ulcers in a sample list of 21 residents. Findings include: R17's Physician Order Sheet (POS) dated November 1-30, 2022 documents a physician order for a treatment of a Stage 3 Pressure Ulcer of the Right Hip to cleanse with wound cleanser, apply Calcium Alginate and cover with bordered foam dressing three times per week on Monday, Thursdays and Saturdays. R17's Minimum Data Set (MDS) dated [DATE] documents R17 as severely cognitively impaired. This same MDS documents R17 requires extensive assistance of one person for bed mobility. This same MDS documents R17 as requiring total assistance of two people with a mechanical lift for transfers. On 11/30/22 at 2:35 PM V13 Registered Nurse (RN) completed R17's Stage 3 Pressure Ulcer on Right Hip dressing change. V13 did not change gloves, wash hands nor use hand hygiene during the dressing change. R17's Stage 3 Pressure Ulcer had a pale center with dark purple surrounding skin and moderate yellow serous drainage. On 11/30/22 at 2:45 PM V13 RN stated I should have changed my gloves after removing (R17's) old dressing and before touching any of the new dressing supplies. I cross-contaminated by not changing my gloves. Anything that I touched would be considered contaminated and I used the new dressings that were contaminated to put right on (R17's) open wound. This could mean that (R17) could get an infection in (R17's) wound. On 12/1/22 at 3:30 PM V18 Regional Director of Operations stated (V13) RN should have changed gloves and washed (V13's) hands after removing (R17's) soiled dressing. Of course that cross-contamination could introduce germs into (R17's) Stage 3 Pressure Ulcer. The facility policy titled 'Dressing Change' revised July 2007 documents the following: Policy: to avoid introducing organisms into the wound. Procedure: 8. Wash your hands 9. Apply non-sterile gloves 10. Remove soiled dressing and place in bag 11. Observe for any signs of infection 12. Remove and discard soiled gloves 13. Wash your hands.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to complete quarterly psychotropic medication assessments. This failure affects two of seven residents (R48, R50) reviewed for unnecessary medi...

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Based on interview and record review the facility failed to complete quarterly psychotropic medication assessments. This failure affects two of seven residents (R48, R50) reviewed for unnecessary medications on the sample list of 21. Findings include: 1. R48's Physician Order Sheet dated December 2022 documents R48 is diagnosed with Alzheimer's Disease, Bipolar Disease, and Depression. R48 is prescribed Olanzapine (Antipsychotic) 5 milligrams in the morning and 20 milligrams at night, Lithium Carbonate Extended Release (Mood Stabilizer) 450 milligrams 1/2 tab in the morning and one tab in the evening, and Citalopram (Antidepressant) 40 milligrams once per day. R48's Olanzapine, Lithium Carbonate, and Citalopram Psychotropic Medication Quarterly Evaluations dated 9/7/21 were the last quarterly evaluations the facility completed. 2. R50's Physician Order Sheet dated December 2022 documents R50 is diagnosed with Anxiety, Bipolar Disease, and Depression. R50 is prescribed Caplyta (Antipsychotic) 42 milligrams once per day and Fluphenazine (Antipsychotic) 5 milligrams twice per day. R50's Caplyta and Fluphenazine Psychotropic Medication Quarterly Evaluations dated 12/27/21 and 8/20/22 were the only quarterly evaluations the facility completed. The facility's Psychotropic Medication Policy dated 6/17/22 documents any resident receiving psychotropic medications will have a Psychotropic Medication Assessment done at a minimum of every quarter. On 12/2/22 at 11:30 AM V1 Administrator confirmed the facility failed to assess R48's and R50's psychotropic medications quarterly.

THE HAVEN OF ARCOLA

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THE HAVEN OF ARCOLA

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