Addison Heights Health and Rehabilitation Center

Inspectors wroteBased on staff interview, resident interview, review of the medical record, review of the written staff statement and review of the facility policy, the facility failed to ensure the residents identified at risk for elopement did not elope from the facility. This affected one (#68) of one resident reviewed for elopement. The facility identified 18 (#24, #25, #41, #42, #44, #45, #46, #47, #65, #66, #67, #68, #69, #70, #71, #72, #73, and #74) residents at risk for elopement. The facility census was 71.

Inspectors wroteBased on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure the facility maintained comfortable and safe temperature levels. This affected all residents with the exception of 15 (#10, #12, #14, #15, #22, #26, #28, #35, #37, #43, #45, #48, #49, #50, and #51) residents whose room and common area were maintained at an appropriate temperature. The facility census was 74.

Inspectors wroteBased on medical record review, resident interview, staff interview, pest control vendor interview, review of pest control invoices, review of a staff statement and review of facility policy, the facility failed to maintain an effective pest control program. This affected one (#48) of three residents reviewed for pest control with the potential to affect all residents of the facility. The facility census was 72.

Inspectors wroteBased on observation, staff interview, resident interview, hospice staff interview, pest control vendor interview, medical record review, review of hospice documentation, review of a staff written statement and review of facility policy, the facility failed to ensure a dignified existence for a hospice resident when the resident was found with ants ants crawling all over her body. This affected one (#48) of three residents reviewed for dignity. The facility census was 72.

Inspectors wroteBased on observation, review of the medical record, staff interview, resident interview, and policy review, the facility failed to ensure there were effective procedures in place to protect the residents' personal belongings. This affected five (#80, #2, #11, #37, and #55) of seven residents reviewed for personal property and missing items. This had the potential to affect all residents except four residents (#6, #52, #64, #75) not receiving facility laundry services. The facility census was 74.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident representative was notified of change in condition. This affected one (#79) of three residents reviewed for changes in condition. The facility census was 74.

Inspectors wroteBased on review of the medical record, review of facility Self-Reported Incidents (SRIs), staff interview, and policy review, the facility failed to ensure an allegation of misappropriation was timely reported to the state agency. This affected one (#68) of four residents reviewed for abuse, neglect, and misappropriation. The facility census was 74.

Inspectors wroteBased on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure enhanced barriers precautions were implemented per physician orders. This affected one (#18) of three residents reviewed for infection control. The facility identified 14 residents on enhanced barrier precautions (EBPs). The facility census was 74.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure an accurate system for the dispensing, administration, reconciliation and destruction of controlled substances. The facility identified 34 residents receiving controlled pain medications. The facility census was 73.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure proper infection control practices were implemented regarding the use of personal protective equipment (PPE) during a SARS CoV-2 (COVID-19) outbreak. This had the potential to affect 54 residents not diagnosed with COVID-19 during the outbreak. The facility identified 14 residents with a COVID-19 infection (#17, #20, #34, #36, #37, #39, #41, #43, #46, #50, #56, #62, #67, and #73). The facility census was 68. Findings Include:Observation on 12/01/25 at 1:10 P.M., upon entrance to the facility, revealed staff and residents were wearing surgical masks. Interview on 12/01/25 at approximately 1:11 P.M. with Medical Records (MR) #362 revealed the facility was in a COVID-19 outbreak. Observations on 12/01/25 between 1:48 P.M. and 2:59 P.M. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure bed rails were in place to assist with bed mobility. This affected one (#58) resident of three reviewed for bed rail use. The facility census was 68. Findings Include:Review of the medical record for Resident #58 revealed an admission date of 05/02/25 with diagnoses of morbid obesity, muscle weakness, and Type II Diabetes Mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/25, revealed Resident #58 had intact cognition and was able to roll to the left and right with supervision and/or touching assistance. Review of the current care plan, initiated 05/02/25 and updated 06/24/25 revealed Resident #58 had impaired functional abilities, self-care and mobility deficits. [...]

Inspectors wroteBased on record review, review of the facility's investigation, review of Self-Reported Incident (SRI) #267064, staff interview, police report review, and facility policy review, the facility failed to provide adequate supervision which resulted in an incident of sexual abuse. This affected one (#36) of five residents reviewed for abuse. The facility census was 68.1. Review of the medical record for Resident #36 revealed an admission date of 06/27/25 with diagnoses of Alzheimer's disease, cerebral infarction, depression, anxiety, and cerebrovascular disease. Review of the comprehensive, significant change Minimum Data Set (MDS) assessment, dated 12/10/25, revealed Resident #36 had severely impaired cognition, used a wheelchair for mobility and was dependent on staff for all activities of daily life. [...]

Inspectors wroteBased on record review, staff interview, review of Self-Reported Incident #267064, and review of the facility policy, the facility failed to ensure an allegation of sexual abuse was reported timely to the State Agency. This affected one (Resident #36) of five residents reviewed for abuse. The facility census was 68. Review of the medical record for Resident #36 revealed an admission date of 06/27/25 with diagnoses of Alzheimer's disease, cerebral infarction, depression, anxiety, and cerebrovascular disease. Review of the comprehensive, significant change Minimum Data Set (MDS) assessment, dated 12/10/25, revealed Resident #36 had severely impaired cognition, used a wheelchair for mobility and was dependent on staff for all activities of daily life. [...]

Inspectors wroteBased on record review, observation, staff interview, and facility policy review, the facility failed to ensure medications were given per physician order. This affected two (#85 and #55) of seven residents reviewed for medication administration. The facility census was 68. Findings Include:1. Review of the medical record for Former Resident, Resident #85 revealed an admission date of 10/10/25. Resident #85 discharged home on [DATE]. Diagnoses included a fractured neck of right femur, osteoarthritis, anxiety, schizoaffective disorder, and venous thrombosis. Review of the 5-day Minimum Data Set (MDS) assessment, dated 10/17/25, revealed Resident #85 had impaired cognition. [...]

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to ensure food items were labeled with open dates and failed to ensure staff were knowledgeable regarding identifying expiration dates of packaged foods. This affected one (#16) resident identified to be on thickened liquids. The facility census was 68. Findings Include: Review of the medical record for Resident #16 revealed an admission date of 03/01/21 with diagnoses of hemiplegia/hemiparesis, cerebral infarction, and chronic obstructive pulmonary disease. Review of the 5-day Minimum Data Set (MDS) assessment, dated 11/23/25, revealed Resident #16 had impaired cognition. Review of a physician order dated 11/19/25 and discontinued 12/02/25 revealed Resident #16 was on nectar thick liquids. Review of a current physician order dated 12/02/25 revealed Resident #16 was on nectar thickened liquids. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure mattresses and bedframes were compatible. This affected one (#58) of three residents reviewed for mattress and bed frame compatibility. The facility census was 68. Findings Include:Review of the medical record for Resident #58 revealed an admission date of 05/02/25 with diagnoses of morbid obesity, muscle weakness, and Type II Diabetes Mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/25, revealed Resident #58 had intact cognition and was able to roll to the left and right with supervision and/or touching assistance. Review of the current physician order dated 05/07/25 revealed Resident #58 required a low air loss mattress at all times. Observation and interview on 12/01/25 at 1:50 P.M. [...]

Inspectors wroteBased on medical record review, staff interview, review of Self-Reported Incidents, review of witness statements, and review of facility policy, the facility failed to immediately report an allegation of staff to resident abuse to the State Survey Agency. This affected one (#27) of three residents reviewed for abuse. The facility census was 63.

Inspectors wroteBased on staff interview, and review of facility staffing documentation, the facility failed to ensure a Registered Nurse was scheduled eight consecutive hours when the facility exceeded a census of 60 residents. This affected all 60 residents residing in the facility. Review of facility staffing documentation and related schedules between 09/01/25 and 09/07/25. Facility census was 61 current residents on 09/04/25, 09/05/25, 09/06/25. The facility Director of Nursing was listed as the only Registered Nurse in the facility. On 09/11/25 at 1:07 P.M. interview with Scheduling Coordinator (SC) #466 during a review of facility schedules between 09/01/25 and 09/07/25 verified no additional Registered Nurse was scheduled in the facility on 09/04/25, 09/05/25, 09/06/25. SC #466 also confirmed the facility exceeded a resident census of 60 on each of the three days. [...]

Inspectors wroteBased on observation, staff interview, review of manufactures guidelines, review of pharmacy policy, and review of facility policy, the facility failed to store medications that require refrigeration. This affected Resident #13. The facility failed to ensure the freezer, located inside of the medication-storage refrigerator, was properly maintained. This affected eight residents (#10, #13, #33, #34, #37, #42, #60, and #68) that were identified by the facility as utilizing medications that required refrigeration. The facility also failed to ensure the medication-storage refrigerator maintained the correct temperature parameters to safely store medications that require refrigeration. This affected eight residents (#10, #13, #33, #34, #37, #42, #60, and #68) that were identified by the facility as utilizing medications that required refrigeration. [...]

Inspectors wroteBased on observation, staff interviews, resident interviews, and schedule reviews the facility failed to ensure adequate kitchen staff were available to provide timely meal service. This affected all residents. The facility census was 60. Observation of the kitchen staff on 09/08/25 at 8:00 A.M. revealed only Dietary Manager #504 was working in the kitchen and was preparing the breakfast meal. Review of the dietary staffing schedule dated 09/08/25 revealed one cook was scheduled from 6:00 A.M. to 2:00 P.M., and a dietary aide from 7:00 A.M. to 3:00 P.M. and a second aide from 10:00 A.M. to 8:00 P.M. There were two open shifts from 4:00 P.M. to 7:00 P.M. and 7:00 A.M. to 10:00 A.M.Interview with Dietary Manager #504 on 09/08/25 at 8:00 A.M. revealed two additional staff were scheduled, but failed to come into work. Observation at 12:45 P.M. [...]

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to dispose of expired foods and store foods properly. This had the ability to affect all residents. The facility census was 60. Kitchen observation on 09/08/25 at 7:57 A.M. revealed several foods were found expired in the walk in refrigerator. A plastic container of pears was dated 08/30/25 and marked to be used by 09/03/25. A large plastic container of jelly was dated 08/04/25 and use by date was 09/04/25. A plastic container was dated 09/07/25 and use by date was 09/07/25. Further observation revealed two five pound rolls of ground beef were sitting on a tray and had a red liquid substance on the tray. The meat failed to be labeled with dates. Observation of the walk-in freezer on 09/08/25 at 8:05 A.M. revealed a plastic bag of frozen chicken patties were left open to air. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to implement and monitor an effective water management program to minimize the risk for Legionella growth in the facilities building. This had the potential to affect all residents. The facility census was 60. Review of the facilities policy titled Legionella Infection Control Protocol, undated, revealed the facility will flush toilets and run sinks in resident's rooms daily to flush any standing water. The facilities protocol does not address flushing water in any other areas or a way to track and monitor areas that have been flushed. Interview on 09/09/25 at 12:11 P.M. with Director of Maintenance #458 revealed that maintenance runs water in all rooms and that water is tested with an instant read tester for Legionella randomly and a sample is sent out yearly for testing. [...]

Inspectors wroteBased on observation, resident interview, staff interview, review of medical record, and review of facility policy, the facility failed to ensure there was an adequate supply of linens to meet resident needs. This affected Resident #10. The facility also failed to ensure shower chairs were in good repair and functional in the 100-hall shower room. This affected 28 residents (#5, #6, #8, #10, #13, #17, #18, #20, #24, #25, #26, #28, #32, #33, #34, #38, #39, #41, #43, #44, #45, #46, #49, #52, #56, #58, and #63) identified by the facility as using this shower room and residing in the 100 and 200 halls. The facility failed to ensure a clean and homelike environment in resident rooms. This affected two residents (#10 and #17). The facility failed to ensure resident window shades were in functional working order. This affected two residents (#22 and #51). [...]

Inspectors wroteBased on observation, resident interview, staff interview, review of medical record, and review of facility policy, the facility failed to provide care and services in the area of personal hygiene. This affected four residents (#8, #20, #31, and #44) of five residents reviewed for activities of daily living. The facility census was 60.1. Review of the medical record for Resident #31 revealed an admission date of 06/27/25 with diagnoses of thyroid disorder, cerebrovascular accident (CVA), non-Alzheimer ' s dementia, and anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed moderate cognitive impairment and a requirement of substantial assistance with showering or bathing. Observation on 09/09/25 at 9:21 A.M. [...]

Inspectors wroteBased on observation, staff interview, and facility pest control documentation, the facility failed to ensure effective insect control was implemented. This affected 10 of 16 residents (#10, #17, #18, #20, #38, #44, #23, #45, #22, #51) reviewed for physical environmental conditions in a facility census of 60. 1.) Observation of Resident #38 on 09/09/25 at 10:36 A.M. revealed the resident was in bed with multiple black flying insects in room and landing on various surfaces. 2.) Observation of Resident #20 on 09/09/25 at 10:50 A.M. revealed black flying insects were observed in the room, landing on resident and bedside beverages sitting on the over bed table. Resident #20 stated insects were visible for an undescribed time and at times landed on food. 3.) Observation of Resident #44 on 09/10/25 at 12:01 P.M. revealed the resident was seated in room at the side of the bed. [...]

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to properly complete the Minimum Data Set (MDS). This affected one resident (#30) reviewed for vision. The facility census was 60. Review of Resident #30's medical record revealed an admission date of 02/03/25. Diagnoses included acute kidney failure, altered mental status, and malnutrition. Review of Resident #30's quarterly Minimum Data Set (MDS) dated [DATE] revealed he had an intact cognition. His vision was marked as adequate and no corrective lenses were required. Review of Resident #30's most recent care plan revealed the resident received optical services, but the record was absent to vision loss. Review of Resident #30's physician note dated 03/24/25 revealed previous to entering the facility he began loosing his vision and became nearly blind. [...]

Inspectors wroteBased on medical record review, staff interview and review of facility policy the facility failed to ensure the baseline care plan was individualized to meet resident needs. This affected one (#08) of one resident revealed for base line care plans. The facility census was 60. Review of the medical record for Resident #08 revealed an admission date of 07/02/25 with diagnoses of acute cystitis, cerebral infarction, heartburn, anorexia, personal history of transient ischemic attack (TIA), nicotine dependence, hypomagnesemia, other specified health status, major depressive disorder, adult failure to thrive, altered mental status (AMS), Alzheimer's disease, other acquired deformity of head, and unspecified protein-calorie malnutrition. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and resident interviews, the facility failed to ensure venous ulcer preventions were in place. This deficient practice affected one (#45) of one residents reviewed for venous ulcers. The facility census was 60. Review of Resident #45's medical record revealed an admission date of 05/02/25. Diagnoses included local infection of the skin and subcutaneous tissue, chronic venous hypertension with ulcer of the left and right lower extremity, non-pressure chronic ulcer of the left foot and right lower leg with fat layer exposed, pressure-induced deep tissue damage of the right buttock, pressure-induced deep tissue damage of the right sacral region, pressure-induced deep tissue damage of the left buttock, hypertension, and muscle wasting. [...]

Inspectors wroteBased on observation, resident interview, staff interview, review of facility medical record, and review of facility policy, the facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing. This affected two resident (#10 and #45) of two residents reviewed for pressure. The facility census was 60. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy, the facility failed to ensure fall prevention devices were implemented as indicated. This affected two of two residents (#38, #44) reviewed for fall prevention interventions in a facility census of 60. 1. Resident #38 admitted to the facility on [DATE] with the diagnosis including, bipolar disorder, dysphagia, epilepsy, disorder of psychological development, major depression, and acute and chronic respiratory failure with hypoxia. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy the facility failed to provide tracheostomy care and maintenance as ordered by the physician. This affected one of one residents (#6) reviewed for tracheostomy care in a facility census of 60. Resident #6 admitted to the facility on [DATE] with the diagnosis including, chronic respiratory failure with hypoxia, tracheostomy, acute kidney failure, atrial fibrillation, type 2 diabetes mellitus, hypertension, and anxiety disorder. According to the most current minimum data set assessment dated [DATE] assessed Resident #6 with intact cognition, no listed behaviors, dependent on staff for the completion of activities of daily living, received oxygen and tracheostomy treatments. [...]

Inspectors wroteBased on observation, staff interview, and review of a facility policy, the facility failed to provide a clean, well-maintained, and homelike environment. This affected 10 (#7, #9, #20, #30, #31, #32, #33, #34, #35, and #50) of 63 residents residing in the facility. The facility census was 63.

Inspectors wroteBased medical record review, review of care conference documentation, staff interview, and review of a facility policy, the facility failed to ensure care conferences were held for residents as required. This affected one (#1) of three residents reviewed for timely care planning conferences. The facility census was 63.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility clinical protocol, the facility failed to ensure interventions to prevent skin breakdown were implemented as ordered by the physician. This affected one (#3) of three residents reviewed for skin breakdown and pressure relieving interventions in a facility census of 63.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure residents were provided a comfortable and homelike environment. This affected three (#18, #27, #49) of six resident rooms observed and had the potential to affected all 26 residents (#39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, and #64) who resided in the memory care unit in a facility census of 64. Findings Include: 1. Observation on 04/30/25 at 6:50 A.M. revealed Resident #53 in the common area of the memory care (MC) unit seated in a wheelchair wearing a heavy winter coat with the hood pulled over her head. Concurrent observation revealed Resident #41 seated in a wheelchair wrapped in a blanket. Interview on 04/30/25 at 7:00 A.M. [...]

Inspectors wroteBased on observation, staff interview, review of Safety Data Sheets (SDS) documents, review of product labels, and policy review, the facility failed to ensure chemicals were stored in a safe and secure manner. This had the potential to affect four (#17, #21, #23, and #27) of four residents identified by the facility as being cognitively impaired and independently mobile who resided outside of the memory care (MC) unit. The facility census was 64. Findings Include: Observation on 04/29/25 at 12:53 P.M. of the linen cart located by Resident #12 and Resident #22's room revealed one canister of Sani-Cloth germicidal disposable wipes with a purple colored top and one canister of Sani-Cloth bleach germicidal disposable wipes with an orange colored top. Further observation revealed both canisters were open and accessible to residents. [...]

Inspectors wroteBased on observation, resident interview, resident representative interview, staff interview and review of facility policy, the facility failed to ensure the facility was free from pervasive odors. This had the potential to affect all residents in the facility except for 16 (#12, #13, #15, #16, #18, #19, #24, #26, #31, #37, #38, #41, #46, #57, #58, #75) residents identified by the facility as residing on the secured memory care unit. The facility census was 68.

Inspectors wroteBased on medical record review, staff interview, physician interview and review of facility policy, the facility failed to notify the physician timely of abnormal laboratory (lab) results. This affected one (#19) of three residents reviewed for notification of change. The facility census was 68.

Inspectors wroteBased on medical record review, staff interview, physician interview, Nephrology Nurse Practitioner (NNP) interview and review of facility policy, the facility failed to ensure the physician provided adequate and timely follow up for resident care needs. This affected one resident (#19) of three residents reviewed for physician services. The facility census was 68.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure facility air temperatures were maintained at a comfortable and acceptable level. This affected 18 (#2, #3, #5, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, and #29) of 68 residents residing in the facility observed for air temperatures. The facility census was 68.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure laboratory services were collected and completed according to the physician orders. This affected one (Resident #100) of one resident reviewed for laboratory services. The facility census was 70.

Inspectors wroteBased on wound care observation, medical record review, review of the Centers for Disease Control and Prevention (CDC), and review of facility policy, the facility failed to ensure infection control practices were followed during wound care. This affected one (#18) of one resident observed for wound care. The facility census was 70.

Inspectors wroteBased on observations, staff, resident and family interviews and review of a housekeeping checklist, the facility failed to ensure the facility was maintained in a clean and sanitary manner. This affected four (#3, #32, #33 and #44) out of six residents sampled for the environment. The facility census was 67.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and facility medication administration policy, the facility failed to ensure medications to treat migraine headaches were provided as ordered by the physician resulting in a significant medication error. This affected one resident (#12) reviewed for the administration of medications in a facility census of 69.

Inspectors wroteBased on record review, observations, staff and resident interview, and policy review, the facility failed to ensure residents were assessed for self-administration of prescription medications prior to maintaining them at bedside. This affected one (#50) of two residents reviewed for medication self-administration. The facility census was 71.

Inspectors wroteBased on observations, interviews, record reviews and review of the facility policy, the facility failed to ensure call lights were within reach for residents identified to use call lights to request care. This affected two (#36 and #37) of eleven residents observed for call lights within reach. The facility census was 71.

Inspectors wroteBased on family and staff interview, record review, review of the appointment calendar, review of Weather Underground website, and review of the facility policy, the facility failed to provide adequate assistance with dressing for a resident who was dependent on staff with activities of daily living. This affected one (#18) of three residents reviewed for outside appointments. The facility census was 71.

Inspectors wroteBased on resident interview, staff interview, and record review, the facility failed to ensure bariatric incontinence supplies were available to allow a resident to void in a dignified manner. This affected one (#80) of three residents reviewed for bariatric supplies.

Inspectors wroteBased on medical record review, family interview, staff interview, review of x-ray reports, and review of hospital documents, the facility failed to provide follow up assessments and failed to ensure potential abnormal x-ray results were reported to the facility and physician. This resulted in actual harm based on a reasonable person ' s response of experiencing pain due to the presence of a fracture that was not immobilized, when Resident #50, who had severe cognitive impairment and impairment in her ability to communicate, was identified with a swollen left wrist and pain in the hand. An x-ray was ordered to the hand with no x-ray ordered to the wrist. The hand x-ray captured an image of the wrist, which appeared abnormal. [...]

Inspectors wroteBased on review of the Payroll-Based Journal (PBJ) report, review of the daily posted staffing, review of employment dates, and staff interview, the facility failed to ensure Registered Nurse (RN) coverage eight hours each day. This had the potential to affect all 75 residents residing in the facility.

Inspectors wroteBased on observation, medical record review, staff interview the facility failed to ensure medications were securely stored on the memory care unit. This affected one (#29) of one residents reviewed for medication storage and had the potential to affect 13 (#3, #5, #6, #21, #32, #36, #50, #53, #58, #64, #65, #122, and #127) additional cognitively impaired and independently mobile residents identified by the facility residing on the secured memory care unit. Additionally, the facility failed to ensure fall interventions were implemented as care planned. This affected two (#8 and #172) of four residents reviewed for falls. The facility census was 75.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and review of pharmacy delivery manifest, the facility failed to obtain medications as prescribed by the physician for administration. This affected five (#17, #25, #59, #57, and #71) of six residents observed and reviewed for the provision of medications. Facility census was 75.

Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure the administration of medications with an error rate of less than five percent. A total of 15 errors were observed during 30 opportunities for a medication error rate of 50%. This affected five (#16, #17, #25, #17, #57, #59) of six residents observed during medication administration. The facility census was 75.

Inspectors wroteBased on observation, medical record review, staff interview, and review of facility policy, the facility failed to provide medications in accordance with physicians orders which resulted in medication significant medication errors. This affected four (#17, #25, #57, and #71) of six residents observed and reviewed for medication administration. Facility census was 75.

Inspectors wroteBased on medical record review, staff interview, review of Centers for Disease Control and Prevention (CDC) guidelines, and review of facility policy, the facility failed to ensure residents were offered pneumococcal vaccines per CDC guidelines. This affected five (#3, #9, #21 #30, and #32) of five residents reviewed for pneumococcal vaccinations. The facility census was 75.

Inspectors wroteBased on medical record review, family and resident interview, observation and staff interview, the facility failed to honor a resident's choice to get out of bed. This affected one (#8) out of four residents reviewed for activities of daily living The facility census was 75.

Inspectors wroteBased on staff interview, record review, and review of the facility policy, the facility failed to obtain written authorizations by the resident or representative to open a Resident Trust account. This affected two (#53, #16) of six residents reviewed for Resident Trust accounts. The facility census was 75.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure the current code status was present on both the electronic medical record (EMR) and the paper medical record (PMR) for two (#122 and #24) of two residents reviewed for advanced directives. The facility census was 75.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level 2 evaluation was completed for one (#27) of three residents reviewed for PASRR evaluations. The facility census was 75.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure dependent residents were provided with scheduled bathing and effective hygiene. This affected three (#16, #25, #61) of 29 residents reviewed for activities of daily living (ADL) and hygiene. Facility census 75.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure activities who were in bed were provided activities of interest. This affected two (#16 and #8) of two residents reviewed for the provision of activities in a facility census of 75.

Inspectors wroteBased on observation, family interview, staff interview, and review of the medical record, the facility failed to ensure interventions were in place to maintain range of motion (ROM). This affected one (#8) of one resident reviewed for range of motion. The facility census was 75.

Inspectors wroteBased on observation, staff interview, review of the medical record, and review of supply invoices, the facility failed to provide nutrition supplements as ordered by the physician. This affected one (#29) of one resident reviewed for nutrition supplements. The facility identified five residents who receive the nutrition supplement. Further, the facility failed to obtain weekly weights and ensure adequate water was provided to a resident with an enteral tube. This affected one (#8) of two residents reviewed for feeding tubes. The facility census was 75.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to ensure an abdominal binder was in place to secure a gastrostomy tube (Gtube) and prevent leakage for one (#16) out of two residents reviewed for Gtubes. The facility census was 75.

Inspectors wroteBased on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure supplemental oxygen was administered only with a physician's order and failed to ensure tracheostomy care was provided per physician orders. This affected two (#25, #46) of two residents reviewed for respiratory care and services. Facility census 75.

Inspectors wroteBased on observation, medical record review, staff interview, and pharmacy delivery manifest, the facility failed to place accurate documentation within the contents medical record. This affected three (#29, #45, and #71) of 23 residents reviewed for medical record entries in a facility census of 75.

Inspectors wroteBased on observation, family interview, and staff interview, the facility failed to ensure residents rooms were maintained in a clean, comfortable, and homelike environment. This affected four (#8, #27, #28, and #52) of five residents reviewed for a homelike environment. The facility census was 75.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to maintain an effective pest control program. This affected two (#28 and #29) of three residents reviewed for pest control with the potential to affect all residents of the facility. The facility census was 75.

Inspectors wroteBased on observation, medical record review, staff interview, resident interview, review of Centers for Medicare and Medicaid Services (CMS) guidance, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure two residents (#108 and #109) were not involuntary secluded to their rooms unnecessarily. Additionally, the facility failed to resume communal dining. This had the potential to affect all residents of the facility with the exception of three residents (#12, #20, and #39) who were identified as not receiving food from the kitchen. The facility census was 61.

Inspectors wroteBased on review of the scheduled meal times, observation and staff interview the facility failed to maintain adequate staffing in the kitchen to ensure meals were served in a timely manner. This affected all residents who eat their meals provided from the kitchen. The facility identified three residents (#12, #20, and #39) who did not receive food from the kitchen. The facility census was 61.

Inspectors wroteBased on medical record review, observation, staff interview, policy review, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to adhere to the following recommended infection control practices for preventing the spread of Coronavirus 2019 (COVID-19) related to ensuring new resident admissions were placed on transmission-based precautions for the recommended 14 days. This affected one resident (#46) of six new resident admissions. In addition, the facility failed to ensure a urinary collection device was properly stored for Resident #46. This had the potential to affect one resident (#39) who shared the same bathroom. Lastly, the facility failed to ensure a Coronavirus Disease 2019 (COVID-19) vaccine was offered to one resident (#12) of three reviewed for vaccine status. The facility census was 61. Findings Include: 1. [...]

Inspectors wroteBased on observation, medical record review, staff interview, resident interview, and facility policy review, the facility failed to properly assess and provide appropriately fitting, physically intact resident wheelchairs, chairs and bed. This deficient practice affected three residents (#41, #109, #12) of 24 reviewed for furniture and assistive devices. The facility census was 61.

Inspectors wroteBased on medical record review, staff interview, interview with resident's representative, and Centers for Disease Control and Prevention (CDC) Coronavirus Disease 2019 (COVID-19) Pandemic guidance, Centers for Medicare and Medicaid Services (CMS) recommendations, the facility failed to ensure residents were provided with in-person visitation opportunities. This deficient practice affected one resident (#25) of three reviewed for family visitation. The facility census was 61.

Inspectors wroteBased on observation, medical record review, staff interview, and review of facility resident smoking policy, the facility failed to complete accurate resident smoking assessments and monitor for smoking compliance for one resident (#43) to ensure resident safety. Additionally, the facility failed to ensure one resident (#44) had elopement prevention devices applied as ordered by the physician. This affected two residents (#43 and #44) of 24 residents reviewed for the potential for elopement and safe smoking in a facility census of 61.

Inspectors wroteBased on medical record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure a resident's access to dialysis (fistula) was assessed and documented daily. This affected one resident (#34) of one reviewed for dialysis. The facility was 61.

Inspectors wroteBased on medical record review, observation, staff interview, policy review, and manufacturer recommendations for use instructions the facility failed to ensure medications were administered as ordered. There were 27 opportunities were observed with eight medication errors for a calculated medication error rate of 29.63%. This affected two residents (#33, #41) of four residents reviewed for medication administration. The facility census was 61.

Inspectors wroteBased on medical record review, observation, staff interview, policy review, and manufacturer recommendations for use the facility failed to ensure the administration of insulin included the proper dosage which resulted in a significant medication error for one resident (#41) of four residents reviewed for medication administration. The facility census was 61.

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to ensure physician ordered laboratory testing was obtained in a timely manner. This affected two residents (#33 and #32) of 24 reviewed for laboratory testing. The facility census was 61.

Inspectors wroteBased on medical record review, observation, staff and resident interview, and policy review the facility failed to ensure residents received offered ancillary dental services. This affected one resident (#38) of one resident reviewed for dental services, who had poor oral health. The facility identified 42 residents who received dental services provided by the facility's ancillary dental service. The facility census was 61.

Inspectors wroteBased on medical record review, observation, and staff interview the facility failed to provide rehabilitation therapy to maintain functional abilities. This affected one resident (#109) of two residents reviewed for rehabilitation services and new admission. The facility census was 61.