Accolade Healthcare of Peoria

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure a resident and resident's family was provided a notification of a room move, with rational for the move, prior to transferring the resident to a different room in the facility for one of three residents (R2) reviewed for resident rights in the sample of three.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to ensure a resident who is dependent for all turning and positioning, was safely positioned in bed during cares to avoid falling, conduct vital signs and a body assessment, initiate neurological checks, notify all appropriate parties, complete a fall assessment and update a residents care plan to adequately reflect their fall risk for three of three residents (R1, R2, R3) reviewed for falls in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable environment. This has the potential to affect all 132 residents living in the facility.

Inspectors wroteBased on record review and interview the facility failed to follow enhanced barrier precautions during wound care for one of eight residents reviewed for wound care (R3) in the sample of eight.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow its policy to use facial hair beard restraints while in the kitchen, and failed to ensure food items were labeled with identification and dates. This failure has the potential to affect 121 residents who reside at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise care plans for six (R9, R22, R94, R110, R265, and R415) of 24 residents reviewed for care plan revision in a sample of 59.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an appropriate indication for use of antipsychotic medications in seven residents (R22, R39, R70, R81, R102, R214, R415) with diagnosis of Dementia and failed to identify non-pharmacological interventions for two residents (R9, R110) receiving antidepressant medications of nine residents reviewed for unnecessary psychotropic medications in the sample of 59.

Inspectors wroteBased on interview and record review the facility failed to notify the appropriate State Agency of a new diagnosis of bipolar disorder for one resident (R81) of four residents reviewed for Preadmission Screening in the sample of 59.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe, assess, and document on a colostomy for one (R94) of one resident reviewed for colostomies in a sample of 59.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have specific dialysis orders related to the type of dialyzer, flow rate, and length of time; nephrologist; target weights; and care of the dialysis port for one (R265) of two residents reviewed for dialysis in a sample of 59.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left at a resident's bedside for one of 24 residents (R40) reviewed for medication storage in the sample of 59. Findings Include: The Facility's Administration of Medications policy dated 8/2023 documents Residents shall receive their medications on a timely basis in accordance with state and federal guidelines and within established facility policies. Self-administration of medications is permitted when approved by the interdisciplinary team, with a written order from the primary attending physician. On 9/6/24 at 9:30 AM, R40 was lying in bed with R40's bedside table over his bed. A clear medicine cup containing 11 pills was noted on R40's bedside table. The medication cup had been tipped over with approximately half of the pills spilled out onto the table. [...]

Inspectors wroteBased on observation, record review and interview, it was determined the facility failed to ensure call lights were answered in a timely manner and responded to accommodate the residents needs for 2 of 2 residents (R3, R4) with mobility restrictions observed for call light accessibility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure call lights were available for resident use for 1 of 2 residents (R3) reviewed with mobility restrictions observed for call lights.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide resident-centered care for one resident (R3) who required rehabilitation services status post-surgical fusion of the lumbar spine, as evidenced by lack of physician orders for spinal precautions; no care plan intervention related to spinal precautions or back brace use; improper use of mobility devices and inadequate assessment of medication management.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure interventions were implemented to prevent the development of pressure ulcers or worsening of wounds for 1 of 1 resident (R3) reviewed for wound and at high risk for a pressure ulcers.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff were competent to perform cares for a 1 of 1 resident (R3) reviewed for specialized equipment and spinal precautions.

Inspectors wroteBased on record review and interview the facility failed to ensure the right resident received IV (intravenous) access hydration, micronutrient therapy and failed to obtain a physician's order to administer IV hydration and micronutrient (vitamin and mineral therapy) for one of three residents (R1) reviewed for IV therapy in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to consistently offer/provide bedtime snacks to six residents (R8, R14, R27, R43, R63, R93) which include the Resident Council President (R8) of 16 residents reviewed for bedtime snacks in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident preferred television programs were displayed on the unit television viewing area for one (R84) of 45 residents reviewed for dignity in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan for a resident's anticoagulant and insulin medications (R359) and a resident's CPAP/continuous positive airway pressure machine (R309) for two of 25 residents (R309 and R359) reviewed for care plans in the sample of 45.

Inspectors wroteBased on record review and interview the facility failed to maintain an accurate Care Plan for one resident (R12) of 25 reviewed for care plan accuracy in a total sample of 45. Findings Include: The Facility's Care Plan policy dated 6/23 documents each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet the individual needs of the resident consonant with the physicians plan of care. On 10/10/23 at 10:30 AM, R12 stated (Staff) don't ever get me up. I would like to be out and about more. They say I refuse but I have never refused to get up. I have never refused anything. [...]

Inspectors wroteBased on interview and record review, the facility failed to perform recommended exercises for one (R12) of four residents reviewed for mobility in a total sample of 45. Findings Include: The Facility's Range of Motion dated 9/2018 documents the purpose of the policy is to provide resident with limited range of motion appropriate treatment and services to increase or prevent further decrease range of motion. Policy: all residents will be assessed on admission and quarterly, or more often as a change of condition warrants, for risk factors for development of contractures. A program will be developed based on the resident's unique risk factors and involving formalized therapy as applicable. Any ROM will be reflected in the interdisciplinary care plan and will be systematically and consistently followed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions were maintained for a resident with a Gastrostomy Tube/G-Tube and the facility failed to wear gloves while administering medications through a G-Tube for one of three residents (R359) reviewed for gastrostomy tubes in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain orders for a CPAP (Continuous Positive Airway Pressure) use for one (R309) of one residents reviewed for oxygen use in a sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician ordered narcotic medication for pain control was available on admission for one (R260) of three residents reviewed for pain in a sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an appropriate indication for use of an antipsychotic medication for one resident (R25) with a diagnosis of Dementia and failed to ensure prn (as needed) physician orders for an anti-anxiety medication did not exceed 90 days for one resident (R92) of five residents reviewed for unnecessary medications in the sample of 45.

Inspectors wroteBased on interview and record review, the facility failed to obtain physician ordered laboratory results for one of 25 residents (R359) reviewed for physician orders in the sample of 45.

Inspectors wroteBased on observation, interview and record review, the facility failed to post State Agency contact information. This failure has the potential to affect all 113 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their facility policy, and ensure that a resident had a physician order for medications that were stored at the bedside along with an assessment for self-administration of medications for two of four residents (R2 and R3) reviewed for self-administration of medication in a sample of four.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and obtain initial wound measurements, obtain physician orders for treatment of a skin impairment and to ensure a wound was monitored for one of three residents (R1) reviewed for wounds in the sample of four.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure a urinary drainage bag was placed in a privacy cover to maintain resident dignity for two of five residents (R18) and (R21) in a sample of 39. Findings Include: (R18's) Order Summary Report, dated 9/8/2022, documents Supra pubic catheter 16 French 10cc(Cubic Centimeters). (R21's) Order Summary Report, dated 9/8/2022, documents 16 French/10ml (Milliliter) Foley/catheter. On 9/6/2022, 9/7/2022 and 9/8/2022 (R18) and (R21's) urinary drainage bags were observed not to have a privacy cover over the urinary drainage bags. On 9/8/2022 at 10:30AM V10/LPN (Licensed Practical Nurse) stated, Yes, (R21's) urinary drainage bag should have a privacy cover on it. On 9/8/2022 at 10:40AM V11 (R21's) brother stated, I am here every day to visit, and I have never seen any kind of cover over (R21's) foley drainage bag. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident wheelchairs were clean for one (R13) of 39 residents reviewed for homelike environment in the sample of 39.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a resident with limited range of motion was provided appropriate treatment and services to maintain and/or prevent a further decrease for two of five residents (R36 and R106) reviewed for limited range of motion in the sample of 39.

Inspectors wroteBased on interview and record review, the facility failed to recognize a severe weight loss, develop a care plan, implement new interventions and notify a registered dietician or physician of a severe weight loss for one of three residents (R96) reviewed for weight loss in the sample of 39.