Arc at Sangamon Valley

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to a clean environment for 1 of 5 (R25) residents reviewed for clean environment from a total sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to assist residents with showers. This applies to 2 of 4 (R17 and R34) residents reviewed for showers. 1. R17's Brief Interview for Mental Status dated 3/5/26 documents R17 is cognitively intact. R17's undated care plan documents R17 is to receive showers on Wednesdays and Saturdays. On 5/15/26 at 10:00 AM, R17 stated they missed my shower on Wednesday (5/13/26). R17's shower/bath log documents R17 did not receive a shower on 5/9/2026 or 5/13/26. R17's concern form dated 3/16/26 documents a concern that R17 did not receive a shower on Saturday 3/14/26. This form documents V3 Assistant Director of Nursing confirmed that R17 did not receive a shower on 3/14/26.2. R34's undated care plan documents R34 was admitted on [DATE] and has shower days scheduled for Mondays, Thursdays and as needed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement safety interventions to prevent falls. This applies to 2 of 4 (R7, R32) residents reviewed for falls from a sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent potential cross contamination during personal care for 1 of 3 (R16) reviewed for catheter care from a total sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic was given as ordered by the physician for one (R6) of six residents reviewed for medication administration in the sample of 34.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide sufficient staffing to provide safe and timely care for residents reviewed for sufficient staffing in the sample of 32. This failure has the potential to affect all 126 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for 2 of 5 (R2 and R38) residents, reviewed for wound care in a sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain enough batteries for the mechanical lifts for 1 of 4 residents (R154) reviewed for essential equipment in the sample of 32.

Inspectors wroteBased on interview, observation, and record review, the facility failed to safely transfer a resident to prevent falls in 1 of 4 residents (R2) reviewed for falls in the sample of 4. This failure resulted in R2 falling and receiving a laceration which required suture repair. Findings Include:On 10/16/25 at 9:17 AM, R2 was observed in her bed with an approximately 1 1/2 inch moon shaped scabbed, healing laceration to the right/center of her forehead. R2 is alert to self only. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a BIMS (Brief Interview for Mental Status Score) of 2, indicating R2 has severe cognitive impairment and is dependent with transfers. R2's Care Plan, dated 8/27/19, documents R2 is at risk for falls related to: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to prevent injury for 1 of 3 (R3) residents investigated for accidents in a sample of 3. R3's Undated Face sheet documents initial admission date 11/27/2023 diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, iron deficiency anemia unspecified, unspecified osteoarthritis, unspecified site and unspecified hearing loss, unspecified ear. R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R3's MDS dated [DATE] documents resident needs substantial/maximal assistance with sit to lying, lying to sitting onside of bed, assistance to sit to stand, chair/bed to chair transfer and toilet transfer. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to provide pain medications to a newly admitted resident for 1 of 3 (R2) residents investigated for medications in the sample of 20. R2's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE]. R2's EMR dated 4/18/25 documents a diagnosis of aftercare following joint replacement surgery and presence of right artificial hip joint. R2's Care Plan dated 5/18/25 documents The resident is at risk for pain r/t (related to) Osteoarthritis and RTHA (Reverse Total Hip Arthroplasty). R2's Physician Order dated 4/18/25 documents Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen); Give 1 tablet by mouth every 6 hours as needed for Pain. R2's Physician Order dated 4/18/25 documents tramadol HCl Oral Tablet 50 MG (Tramadol HCl); [...]

Inspectors wroteBased on interview and record review the facility failed to provide medication on admission on 1 of 3 (R2) residents investigated for quality of care in a sample of 20. R2's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE]. R2's EMR dated 4/18/25 documents a diagnosis of aftercare following joint replacement surgery and presence of right artificial hip joint. R2's EMR dated 4/18/25 documents a diagnoses of unspecified asthma and chronic obstructive pulmonary disease with acute exacerbation (COPD). R2's Care Plan dated 5/18/25 documents The resident is at risk for pain r/t Osteoarthritis and RTHAR2's Care Plan dated 5/18/25 documents The resident has altered respiratory status/difficulty breathing r/t COPD.R2's Physician Order dated 4/18/25 documents Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen); [...]

Inspectors wroteBased on record review and interview the facility failed to notify a resident's responsible party of a resident injury for 1 of 4 residents (R3) reviewed for notification in the sample of 6. Findings Include:R3's medical diagnosis sheet, print date of 7/23/25, documented R3 has diagnoses including unspecified severe dementia with agitation, dysphagia, osteoporosis, crest syndrome, anemia, and congestive heart failure. R3's MDS (Minimum Data Set), dated 6/23/25, documented R3 is severely cognitively impaired and is dependent on staff for ADLS (activities of daily living). R3's progress note, dated 7/10/25 at 11:57 PM, documented CNA (Certified Nurse Assistant) made writer aware that resident had smashed her finger in the door. 4th digit of right hand observed to have the door indention print, redness and what look like a bruise forming. POA/MD (Power of Attorney/Medical Doctor) updated. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to properly supervise 2 of 3 residents (R2, R3) reviewed for incidents and accidents in the sample of 6. This failure resulted in a resident (R2) to fall in an office rest room that was left unlocked after the office staff left for the day and R2 was not found for approximately 2.5 hours after staff noticed him missing. The facility also failed to complete an incident report per its policy after R3 sustained an injury when she got her hand stuck in a door and did not add an intervention to R3's care plan until 12 days after R3's incident. Findings Include:R3's medical diagnosis sheet, print date of 7/23/25, documented R3 has diagnoses including unspecified severe dementia with agitation, dysphagia, osteoporosis, crest syndrome, anemia, and congestive heart failure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wheelchairs were clean for 1 of 5 residents (R2), reviewed for safe/clean/comfortable/homelike environment in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall interventions were in place in 1 of 4 residents (R3), reviewed for falls in the sample of 5. Findings Include: R3's Face Sheet, undated, documents R3 has the following diagnoses: Dementia, History of Falling, and Chronic Kidney Disease. R3's Minimum Data Set, dated [DATE], documents R3 has moderate cognitive impairment, utilizes a wheelchair for mobility, and is dependent upon staff for chair/bed transfers. R3's Care Plan, dated 10/5/23, documents R3 is at risk for falls with the following interventions: [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to monitor a resident's enteral nutrition needs, monitor a resident's weight, identify severe weight loss of a resident, provide needed interventions to prevent further weight loss, and re-assess a resident's nutritional needs when the resident was not tolerating enteral nutrition for 1 (R11) of 3 residents reviewed for enteral nutrition. This failure resulted in R6 experiencing a 11.98% weight loss in 6 weeks of being admitted to the facility. Findings Include: R11's clinical census sheet, print date of 5/13/25, documented R11 was admitted to the facility on [DATE]. R11's medical diagnosis form, print date of 5/12/25, documented R11 has diagnoses including laceration of esophagus, history of anaphylaxis, gastrostomy status, hypertension, depression, anxiety, and anemia. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide enough nursing staff to adequately meet the needs for 4 of 4 (R2, R4, R7, and R11) residents reviewed for staffing in the sample of 16. These failures have the potential to affect all residents residing at the facility. Findings Include: 1. R2's diagnosis sheet, print date of 5/12/25, documented R2 has diagnoses including acute hematogenous osteomyelitis of left ankle and foot, type 2 diabetes mellitus, chronic kidney disease, hypertension, and heart disease. R2's MDS (Minimum Data Set), dated 4/18/25, documented R2 is cognitively intact and requires partial to moderate assistance with transfers to and from wheelchair. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within the first 48 hours of admission to the facility and failed to provide the baseline care plan to the resident within 48 hours of admission for 1 of 4 residents (R11) reviewed for baseline care plans in the sample of 16. Findings Include: R11's clinical census sheet, print date of 5/13/25, documented R11 was admitted to the facility on [DATE]. R11's medical diagnosis form, print date of 5/12/25, documented R11 has diagnoses including laceration of esophagus, history of anaphylaxis, gastrostomy status, hypertension, depression, anxiety, and anemia. R11's [NAME] Data Set/MDS, dated [DATE], documented R11 is cognitively intact and dependent on staff for all ADLS (activities of daily living). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who require assistance receive a shower or bath for 3 of 4 residents (R2, R11, R14) reviewed for Activities of Daily Living assistance in the sample of 16. This failure has the potential to affect all 126 residents residing at the facility. Findings Include: 1. R2's diagnosis sheet, print date of 5/12/25, documented R2 has diagnoses including acute hematogenous osteomyelitis of left ankle and foot, type 2 diabetes mellitus, chronic kidney disease, hypertension, and heart disease. R2's MDS (Minimum Data Set), dated 4/18/25, documented R2 is cognitively intact and requires partial to moderate assistance with transfers to and from wheelchair. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and identify a residents impaired skin integrity, failed to document weekly skin assessments, and failed to follow physician orders for pressure ulcer treatment for 3 of 4 residents (R7, R9, R14) reviewed for pressure ulcers in a sample of 29. This failure resulted in R7 developing pressure ulcer that upon identification was classified as an unstageable/stage 4, required significant debridement on multiple occasion, osteomyelitis and 7-day hospital stay. The Immediate Jeopardy began on 2/27/25 when the facility failed to assess and treat a high-risk resident who was readmitted on [DATE] without any pressure injuries, resulting in R7 developing a facility acquired unstageable/stage 4 pressure ulcer that was identified on 02/27/25 on her ischial tuberosity with infection present. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide consecutive 8-hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 122 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to report an injury of unknown origin to the administrator for 1 of 3 residents (R2) reviewed for reporting allegations of abuse in the sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to investigate an injury of unknown origin for 1 of 3 residents (R2) reviewed for abuse investigation in the sample of 29. Findings Include: R2's face sheet, print date of 4/1/25, documented R2 has diagnoses including unspecified dementia. R2's Minimum Data Set, MDS, dated [DATE], documented R2 is severely cognitively impaired and is dependent on staff for all ADLS (Activities of Daily Living). On 4/1/25 at 9:13 AM V15, R2's granddaughter, stated R2 developed a skin tear to her left upper arm and left hand during her two weeks stay at the facility. On 4/1/25 at 10:13 AM V16, daughter/POA (Power of Attorney), stated R2 developed a skin tear on her left upper arm around the middle of last week. V16 stated the skin tear was uncovered for a couple of days and then over the weekend it had a dressing over it. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to complete incident investigations, root cause analysis of skin tears, and failed to implement interventions as documented on resident care plans to reduce the risk of further skin tears and/or falls for 3 of 3 residents (R2, R10, R13) reviewed for supervision to prevent accidents in the sample of 29. Findings Include: 1. R2's face sheet, print date of 4/1/25, documented R2 has diagnoses including stage 4 pressure ulcer of sacral region, methicillin susceptible staphylococcus aureus infection, metabolic encephalopathy, unspecified dementia, stable burst fracture of T11-T12 vertebra, hyperlipidemia, hypertension, atrial fibrillation, hypoosmolality, and hyponatremia. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the residents' needs for 3 of 29 residents (R9, R16, R17) reviewed for staffing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with food that was served a palatable temperature for 3 of 5 residents (R16, R17, and R18) reviewed for food palatability in the sample of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to assess a resident's skin upon admission, failed to document weekly skin assessments, and failed to notify the physician for treatment orders when a pressure ulcer was documented for 1 of 4 residents (R1) in a sample of 10.

Inspectors wroteBased on interview and record review the facility failed to report and initiate investigation to determine cause of hematoma and skin tear for 1 of 3 residents (R2) reviewed for injury of unknown origin in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staff were available to provide needed care in a timely manner and supervision. This failure has the potential to effect all 109 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to educate residents on safety protocol and supervising dining for 6 of 7 residents (R2, R7, R8, R9, R10, R11) reviewed for accidents and supervision in the sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to answer call lights timely for 3 of 9 (R1, R13, R17) residents reviewed for dignity in the sample of 28.

Inspectors wroteBased on interview, observation, and record review, the facility failed to answer call lights in a timely manner for 3 of 10 residents (R17, R58, R102) reviewed for dignity in the sample of 51. This failure resulted in R58 feeling less than a person, R102 feeling humilated, and R17 felling terrible.

Inspectors wroteBased on interview, observation, and record review the facility failed to implement interventions to prevent weightloss, monitor weightloss, encourage resident eating for 2 of 7 residents (R7, R46) reviewed for weight loss in the sample of 51. This failure resulted in R7 and R46 both experiencing significant weight loss.

Inspectors wroteBased on interview, observation, and record review, the facility failed to serve food, dispose of outdated food, label and date food items to prevent food borne illness. This has the potential to affect all 116 residents residing in the facility.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to provide assistance with personal hygiene and feeding for 5 out of 32 residents, (R43, R46, R60, R7, R8), reviewed for assistance with activities of daily living (ADL) in a sample of 51.

Inspectors wroteBased on interview, observation, and record review, the facility failed to wear appropriate Personal Protective Equipment, perform hand hygiene between glove changes, and perform hand hygiene between resident contact to prevent cross contamination for 8 of 32 residents (R13, R25, R43, R45, R67, R86, R100, R106) reviewed for infection control in the sample of 51.

Inspectors wroteBased on record review and interview the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF/ABN) form CMS 1055 to residents prior to discharge from Medicare Part A services for 2 of 3 residents (R106, and R315) reviewed for Medicare Part A services in the sample of 51.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform complete incontinent care, for 2 of 5 (R6, R45) residents, reviewed for incontinence, in a sample of 51.

Inspectors wroteBased on interview and record review, the facility failed to address Pharmacy Recommendations in a timely manner for 1 of 5 residents (R87) reviewed for medication review in the sample of 5.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to review a urine culture and obtain a wound culture for 1 out of 6 residents, (R67), reviewed for antibiotic stewardship in a sample of 51.

Inspectors wroteBased on observation, interview and record review the facility failed to provide call light within reach for 1 of 7 residents (R4) reviewed for call lights in the sample of 8. Findings Include: On 8/13/2024 at 9:22 AM, R4 in bed. R4's call light was lying on the floor at the head of the bed out of R4's reach. On 8/13/2024 at 1:29 PM, R4's call light remains on the floor out of reach. R4's Care plan dated 6/30/2023 documents R4 attempts to self transfer with intervention to remind R4 to call for assist when needs help. On 8/14/2024 at 2:11 PM, V3, Executive Director stated call light should be within reach of residents. The facility policy Call Light System dated, revised December 20, 2011 documents it is the policy of the facility to provide a means of communication to meet the needs of each resident. The policy documents staff will: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to implement abuse policy for 1 of 3 residents (R4) reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse policy for 1 of 3 residents (R4) reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident is free from misappropriation of their property for 1 of 4 residents (R6) reviewed for misappropriation of property in the sample of 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow Nursing Standards of Practice while performing medication administration for 3 of 3 residents (R1, R3 and R4) reviewed for medications in the sample of 6.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure the current staffing record was posted. This failure has the potential to affect all 117 residents residing in the Facility.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure Resident's Rights and dignity were honored regarding timely assistance in order to prevent incontinence as well as ensure residents were not left in soiled linens for 4 of 5 residents (R2, R6, R9, R10) reviewed for dignity, in the sample of 12.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure there were enough staff available to meet the needs of residents safety for transfers and call light response time for 5 of 5 residents (R2, R6, R8, R10, R11) reviewed for Lack of Staff, in the sample of 12.

Inspectors wroteBased on observation, interview and record review, the Facility failed to follow their mechanical lift policy to ensure the safety of residents for 2 of 4 residents (R2,R6) reviewed for Resident Injuries, in the sample of 12.

Inspectors wroteBased on interview, observation, and record review, the facility failed to identify, monitor, provide education to resident and family, and implement interventions to prevent pressures ulcers for 2 of 3 residents (R2, R3), reviewed for pressure ulcers, in the sample of 6. This failure resulted in R2 and R3 sustaining facility acquired pressure ulcers while residing in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide complete incontinent care for 2 of 3 residents (R1, R3) reviewed for bowel and bladder incontinence, in the sample of 6.

Inspectors wroteBased on interviews, record reviews and observations the facility failed to notify doctor/family timely of change of condition for two of three residents (R2, R8) after R2 had an injury of unknown origin and R8 had facial bruising after an unwitnessed fall. This failure resulted in R2 being sent to the emergency room three days after the injury of unknown origin with a diagnosis of an odontoid fracture and R8 being taken to her primary doctor after family came into facility and saw R8 with facial bruising.

Inspectors wroteBased on interviews and record reviews the facility failed to treat and assess one of three residents (R2) after an injury of unknown origin to R2's head. This failure resulted in a delay in treatment for R2's odontoid fracture and significant bruising to face primarily around bilateral eyes.

Inspectors wroteBased on interviews and record review the facility failed to provide sufficient nursing staffing of Certified Nursing Assistants (CNA) for 30 residents on skilled unit. This failure has the potential to affect all 30 residents on this unit.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to report injury of unknown origin for one of three residents (R2) reviewed for abuse notification in the sample of 9.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to have fall interventions in place for one of three (R2) residents reviewed for accidents, in a sample of 9.

Inspectors wroteBased on record review and interviews the facility failed to investigate allegation of abuse for 1 of 5 residents (R3) reviewed for abuse investigation in the sample of 6.

Inspectors wroteBased on record review and interview the facility failed to assess R3 and determine a root cause related to a fall and implement interventions based upon this assessment/investigation for one of four residents (R3) reviewed for supervision to prevent accidents in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from neglect by not providing as needed monitoring/visual checks for 1 of 5 residents (R3), reviewed for neglect in the sample of 5. This failure resulted in R3 falling out of bed at an unknown time and being found deceased with face being disfigured and gash on the right side of his forehead. Findings Include: R3's Face Sheet, undated, documents R3 has the following diagnoses: Neurocognitive Disorder, COPD (Chronic Obstructive Pulmonary Disease), Atrial Fibrillation and Presence of a Cardiac Pacemaker. R3's Progress Note, dated [DATE] at 8:35 AM by V6, Licensed Practical Nurse (LPN), documents she was called to R3's room by a Certified Nurses Assistant (CNA). R3 was observed on the floor face down next to his bed. Resident had no response, pulse or respirations. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide timely monitoring/visual checks for 1 of 5 residents (R3), reviewed for changes in condition in the sample of 5. This failure resulted in R3 falling out of bed at an unknown time and being found deceased with face being disfigured and gash on the right side of his forehead. Findings Include: R3's Face Sheet, undated, documents R3 has the following diagnoses: Neurocognitive Disorder, COPD (Chronic Obstructive Pulmonary Disease), Atrial Fibrillation and Presence of a Cardiac Pacemaker. R3's Progress Note, dated [DATE] at 8:35 AM by V6, Licensed Practical Nurse (LPN), documents she was called to R3's room by a Certified Nurses Assistant (CNA). R3 was observed on the floor face down next to his bed. Resident had no response, pulse or respirations. Time of death was determined by two nurses at 8:20 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to determine if a resident had an advance directive in place upon admission or wanted to formulate an advanced directive for 1 of 5 residents (R1) reviewed for advanced directives in the sample of 5.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide ADL (Activities of Daily Living) care to 3 of 5 residents (R1, R4 and R5) reviewed for ADL care in the sample of 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide complete incontinent care for 1 of 3 residents (R2) reviewed for incontinent care in the sample of 12.

Inspectors wroteBased on interview, observation and record review, the facility failed to identify and monitor a rash for 1 of 4 residents (R4) reviewed for a skin condition in the sample of 13. The failure left R4 with a red rash with peeling skin on his scrotum and gluteal folds.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide hygiene after meals and oral care for 5 of 5 residents (R2, R3, R4, R5, R11) reviewed for assistance with Activities of Daily Living in the sample of 13.

Inspectors wroteBased on interview, observation and record review, the call light was not accessible for 2 of 9 residents (R1, R7) reviewed for call lights in the sample of 13.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the Administrator immediately for 1 of 13 residents (R10), reviewed for abuse in the sample of 13.

Inspectors wroteBased on interview and record review, the facility failed to do a complete and thorough investigation, into an allegation of abuse for 1 of 13 residents (R10) reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meals at palatable temperatures for one of five residents (R10) reviewed for palatable food in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely care for 1 of 7 residents (R44) reviewed for quality of care in the sample of 53. This failure resulted in delay in treatment for 27 hours after a fall before R44 was transferred to the local emergency room and determined to have sustained 6 rib fractures.

Inspectors wroteBased on interview and record review, the Facility failed to ensure residents were safely secured in the Facility vehicle prior to transport for 1 of 7 residents (R375) reviewed for accidents in the sample of 53. This failure resulted in R375 sustaining a right hip fracture and right tibia fibula (lower leg) fracture requiring surgical repair after falling to the floor on the bus.

Inspectors wroteBased on interview and record review the facility failed to assess a resident for pain for 1 of 7 residents (R44) in the sample of 53. This failure resulted in R44 receiving only one dose of Tylenol in the 27 hours after a fall until R44 was transported to the local emergency room and determined to have 6 rib fractures.

Inspectors wroteBased on observation and interview, the Facility failed to ensure refrigerated food was stored, labeled, and dated in a sanitary environment to prevent the risk of food borne illness. This has the potential to affect all 10 residents living in 500 Hall (R46, R389, R386, R222, R120, R104, R388, R385, R36, R390).

Inspectors wroteBased on observation, interview and record review the facility failed to perform complete incontinent care, catheter care and appropriate hand hygiene during care for 4 of 5 residents (R13, R16, R35, R40) reviewed for incontinent care/catheter care in the sample 45.