Arcadia Care Aledo

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure opened refrigerated and frozen food items were labeled with expiration dates, a kitchen food storage freezer was free from spills and the required meal food temperatures were obtained and recorded. This failure has the potential to affect all 43 residents residing in the facility. The facility policy, Food and Supplies: Storage, dated 01/2026 directs staff that food services will maintain clean food storage area. This same policy documents that all foods will be covered, labeled and dated. The facility policy, Monitoring Food Temperatures For Meal Service, dated 05/2026 directs staff that prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. [...]

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure resident and employee infections were monitored and tracked, residents were placed in isolation precautions when required, personal protective equipment (PPE) was available in isolation rooms, employees wore PPE during direct contact resident care and ensure glove removal and hand hygiene was completed during a resident's incontinence care. This failure has the potential to affect all 43 residents residing in the facility.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to ensure infection preventionist duties were implemented to provide infection surveillance and ensure that infection preventionist hours were adequate to oversee infection control and infection prevention policy and procedures. This failure has the potential to affect all 43 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a bedside table, toilet, bedspread, walls, baseboard trim, and window seals were kept clean and in good repair for three of 12 residents (R6, R23, and R40) reviewed for safe, clean, and homelike environment in the sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse from happening between residents (R5, and R7), who were reviewed for Abuse in a sample of 25. Findings Include:The facility's Abuse Prevention and Reporting-Illinois policy dated 09/2024 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident-sensitive and resident-secure environment. [...]

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to document a diagnosis and behaviors to warrant the use of scheduled injectable Haldol (antipsychotic medication), complete a psychotropic medication assessment when initiating Haldol, provide rational past the 14 day usage of PRN (as needed) injectable Haldol, and ensure that duplicate psychotropic mediations were not being provided for the same symptom for one of four residents (R4) reviewed for psychotropic medications in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess a resident's limitations in range of motion and develop and implement a restorative range of motion program for two of two residents (R4 and R21) reviewed for limitations in range of motion in the sample of 25. The facility's Restorative Nursing Program dated 12/25 documents, Policy: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Identify residents who currently have splints/braces or previous range of motion programs or those that have actual or potential limitations with ROM and/or pain. Develop an individualized program based on the resident's restorative needs and include the restorative program on the care plan. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fall precaution interventions were in place for R29, a resident with a history of falls and failed to assess and implement interventions for a resident with exit seeking behaviors (R6), for two of five residents reviewed for safety, in a sample of 25. The facility policy, Fall Prevention Program, dated 01/2026 directs staff at the time of admission and in accordance with the plan of care, the resident will be oriented to the use of the call device, and the nurse call device will be placed within the resident's reach at all times. The facility's Code Pink-Missing Resident/Elopement policy dated 4/2023 documents, The facility strives to promote resident safety and protect the rights and dignity of the residents. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and identify entrapment risks associated with the use of side rails, attempt alternatives prior to installing side rails, develop a plan of care to address side rail use along with the risks associated with side rail use, and obtain consent prior to the use of side rails for two of three residents (R21 and R40) reviewed for side rail use in a sample of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered by the physician for one of nine residents (R7), reviewed for medication administration, in a sample of 25. The facility policy, Medication Administration policy, dated 01/2026 directs staff medications must be administered in accordance with a physician's order, the right resident, right medication, right dosage, right route and right time. R7's facility admission Record documents that R7 was readmitted to the facility on [DATE] after a hospitalization for Metabolic Encephalopathy. R7's Nursing Progress Notes, dated 4/29/26 at 8:05 A.M. document that R7 was noted with left-sided weakness, altered mental status, unsteady gait and generalized weakness. R7 's physician was notified and R7 was sent to the local emergency room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure multi-dose injectable insulin pens were labeled with the date when opened for three of 12 residents (R22, R29, and R35) reviewed for storage and labeling of medications in a sample of 25.

Inspectors wroteBased on observation, interview, and record review failed to conduct regular maintenance inspections as part of a regular maintenance program to identify areas of possible entrapment for three of three residents (R21,R35, and R40) reviewed for side rail use in a sample of 25. The facility's Side Rails/Bed Rails Policy dated 12/25 documents, Purpose: To ensure the appropriate, safe, and correct installation, use, and maintenance of bed rails. Definitions: Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sized ranging from full to one-half, one-quarter, or one-eight lengths. Guidelines: The facility should ensure the bed is appropriate for the resident and that bed rails are properly installed and maintained. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from verbal abuse for 4 of 4 residents (R1-R4) reviewed for verbal abuse in the sample of 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was supervised in the dementia unit and away from the doors. This failure resulted in R1 being hit by the door for a second time, causing her to fall and fracture her hip. The facility failed to ensure a resident was safely transferred after a fall for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was assessed for injury after a fall and prior to being transferred for 1 of 3 residents (R1) reviewed for post-fall assessments in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to recognize an altercation between an employee and a resident as verbal abuse, failed to prevent access to all other facility residents by the same employee, resulting in this employee verbally abusing a second resident (R7) on a different occasion, failed to prevent resident to resident physical abuse for three of three residents (R2, R3 and R5) and failed to prevent employee to resident physical abuse (R8), for eight of eight residents reviewed for abuse, in a sample of 8. This failure has the potential to affect all 51 facility residents and resulted in R6 to feel fear, anxiety and shame. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 9/19/25 when V6/Former Employee Registered Nurse entered R6's room and verbally assaulted her within the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a resident's right to be treated with dignity for (R6), one of eight residents reviewed for resident rights, in a sample of 8. This failure resulted in R6 to suffer shame and embarrassment. The (State) Long-Term Care Ombudsman Program Residents' Rights for People In Long-Term care Facilities, provided to all new residents upon admission to the facility documents, As an individual living in a long-term care facility, you retain the same rights as every citizen of (State) and of the United States. The following regulations provide clarity on specific rights granted to residents living in long-term care facilities. Your rights to dignity and respect* Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures for the investigation of allegations of abuse, including identification of abuse, failed in the protection of residents during investigations, and failed taking corrective actions for allegations of abuse, for two of eight residents reviewed for abuse (R6 and R7), in a sample of 8. These failures resulted in this same employee verbally abusing a second resident (R8) on a different occasion. The facility Abuse Prevention and Reporting policy, dated 09/2024 directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. [...]

Inspectors wroteBased on interview and record review, facility staff refused to provide toileting assistance to two of two residents (R6 and R7), reviewed for Activities of Daily Living assistance, in a sample of 8. R6's Assessment Progress Note, dated 9/19/25 documents, 9/19/25 admitted from local hospital with diagnoses of Major Depressive Disorder and Acute Pain. R6's Nursing admission Assessment, dated 9/19/25, documents R6 as, Alert, oriented to person, place, time. Toileting assistance as requiring substantial/maximal assistance. R6's (facility) handwritten statement, dated 9/23/2025 documents, Friday I was admitted in to (facility). I had fallen asleep and when I woke up it was 6:12 P.M., I hit my call light, (I) was in need of using (the) bed pan. [...]

Inspectors wroteBased on record review and interview the facility failed to assess one resident (R1) of three reviewed for fall risk. R1 was admitted to the facility 12/28/23 with diagnoses to include, but not limited to: Major Depressive Disorder, Benign Prostatic Hyperplasia, Hypertension, Diabetes, and Cerebral Ischemia. R1 fell 10/28/25 at 5:05 AM resulting in R1 sustaining a right hip fracture. The facility's Fall Prevention Program policy dated 05/2025 documents, The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision. A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect 3 residents (R2, R4, R6) from physical abuse by another resident, and failed to protect a resident from abuse by a staff member for 1 resident (R7). These failures apply to 4 of 7 residents reviewed for abuse in the sample of 7.

Inspectors wrote3. The facility face sheet shows R5 was admitted to the facility with diagnoses to include cerebral infarction, hypertension and alcohol dependence. R5's facility assessment dated [DATE] shows him to be cognitively intact with no behaviors and requires standby assistance from staff for mobility. A nursing progress note dated 6/24/2025 shows R5 was in an incident with another resident. On 7/2/2025 at 12:30 PM, R5 said he was walking to his room from lunch and R6 came up to him and accused him of stealing his shirt and underwear. R5 said R6 hit him on his arm and continued yelling at him. R5 said a staff member came up to the situation right away and he was not physically harmed by R6. On 7/2/2025 at 1:24 PM, R6 said he does not remember the incident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the tops of stationary kitchen equipment, next to food preparation areas, are free of dirt/debris. This failure has the potential to effect all 38 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lids of trash dumpsters, located outside, are closed/secure to prohibit pests/animals from gaining access to discarded food/trash. This failure has the potential to effect all 38 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to use a set standard to determine the presence of an infection. This failure has the potential to affect all 38 residents who currently reside in the facility. Findings Include: The Facility's Antibiotic/Antimicrobial Stewardship Program policy dated 10/24 documents This facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the unnecessary use of antibiotics. This program helps ensure that our residents get the right antibiotics at the right time for the right duration, and can improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium Difficile Infections, and reduce healthcare costs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an appropriate indication for use for four residents (R2, R15, R29, R39) receiving psychotropic medications, failed to identify behaviors requiring the use of psychotropic medications and failed to attempt a Gradual Dose Reduction for (R2) of five residents reviewed for unnecessary medications in the sample of 28.

Inspectors wroteBased on record review and interview the facility failed to assess a new resident before transfering resident appropriately for one resident (R27) of 8 residents reviewed for accidents in a total sample of 28. This failure caused R27 to have a near fall that resulted in a broken toe. Findings Include: R27's admission nurse's notes dated 1/10/25 at 2:10 PM document resident is currently a (mechanical lift) for all transfers. On 3/11/25 at 9:00 AM R27 stated they (staff) got me up on a commode with two people and I did fine on the way to the commode but on the way back to the bed my legs did not work, and I stumbled. They used 5 people to get back to the commode and then used a (mechanical lift) to get me back in bed. When I stumbled my right foot got dragged across the floor. It started hurting the next day and then it started to bruise so we got an x-ray. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and identify triggers for one resident (R6) with a Primary Diagnosis of PTSD (Post Traumatic Stress Disorder) of two residents reviewed for Mood and Behavior in the sample of 28.

Inspectors wroteBased on observations, interview and record review the facility failed to prevent resident to resident physical abuse for one resident (R2) of three residents reviewed for abuse in the sample of three.

Inspectors wroteBased on observation, interview and record review the facility failed to initiate interventions to prevent resident to resident abuse for one resident (R2) of three residents reviewed for abuse in the sample of three.

Inspectors wroteBased on observation, record review and interview the facility failed to notify the doctor and obtain wound treatment orders for one resident (R1) and failed to investigate, monitor, and implement new fall interventions for two residents (R1, R2) of three residents reviewed for accidents and injuries in a total sample of three.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure nurse aides who provide direct patient care are not employed full time for more than four months without successfully completing a state approved training and competency evaluation program. This failure has the potential to affect 44 of 44 residents in the facility (R1-R44).

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to reduce a resident's risk of a fall (R2) and failed to provide adequate supervision to prevent falls (R1 and R2), for two of three residents reviewed for falls, in a sample of 3. These failures resulted in R1 sustaining a fall with a hematoma and R2 sustaining a fall with a right hip fracture, pubic rami fracture and a T12 compression fracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, notify the physician and obtain a treatment order for a newly identified pressure wound for one of three residents (R2), reviewed for pressure wounds, in a sample of 3. The facility policy, Decubitus Care/Pressure Area, dated (revised) 1/18 documents, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Upon notification of skin breakdown, the pressure area will be assessed and documented on the Treatment Administration record or the Wound Documentation Record. Document size, stage, site, depth, drainage, color, odor, and treatment (after obtaining from the physician). Notify the physician for treatment orders. The orders should include: [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain and administer physician- ordered medication for one of three residents (R1), reviewed for medications, in a sample of three. The facility policy, Medication Administration, dated (revised) 11/18/17 documents, Drug administration shall be defined as an act in which a single dose of prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. Document any medications not administered for any reason by circling initials and documenting on the back of the MAR (Medication Administration Record) the date, time, medication and dosage, reason for omission and initials. If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to administer a physician prescribed antibiotic medication to a resident with a diagnosis of lower extremity cellulitis for one of three residents (R1) reviewed for infections in the sample of three.

Inspectors wroteBased on interview and record review the facility failed to ensure physician ordered laboratory tests were collected as ordered for one of three residents (R1) reviewed for infections in the sample of three.

Inspectors wroteBased on interview and observation, the facility failed to ensure resident's clothing was labeled in a dignified manner. This failure has the potential to affect all 44 residents to reside at the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure grievances or recommendations are considered, addressed and acted upon. This failure has the potential to affect all 44 residents who reside at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the daily direct care staff hours and resident census. This has the potential to affect all 44 resident's residing in the facility. On 6/2/24 at 9:15 AM a tour was conducted of (the facility). No daily nursing hour data and census sheet was observed throughout the entire building. On 6/2/24 at 12:00 PM V2 (DON/Director of Nursing) stated, I was not aware that I was supposed to be filling out a sheet that includes the census for the day and the total number of staff and actual hours worked per shift for RN's (Registered Nurses), LPN's (Licensed Practical Nurses), and CNA's (Certified Nursing Assistants). V2/DON verified she has not posted the daily nursing staff data since she started as DON in March 2024. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure equipment in the facility kitchen was clean and free of debris, failed to date cooked food items to ensure use before expiration, and failed to monitor and record the required refrigerator, freezer temperatures, food temperatures of served foods and the required dishwasher sanitation levels. These failures have the potential to affect all 44 residents currently residing in the facility.

Inspectors wroteFacility failures resulted in two deficient practices. A. Based on record review, and observation, the facility failed to place signage in a conspicuous location to clearly identify the category of transmission-based precautions, instructions for PPE (Personal Protective Equipment) and/or instruction to see the nurse prior to entering the resident's room for 1 of 1 (R32) residents that required transmission-based precautions in a sample of 43 residents. B. Based on interview and record review the facility failed to have interventions in place to mitigate the growth and spread of legionella and failed to maintain logs of interventions. This has the potential to affect all 44 residents that reside at the facility.

Inspectors wroteBased on interview and record review the facility failed to: implement an antibiotic stewardship program that included assessing and monitoring residents for signs and symptoms of infections; ensure antibiotic usage was appropriate, and use of a nationally recognized surveillance criteria to define infections for 3 of 3 (R34, R57, R58) residents reviewed for the Antibiotic Stewardship Program in the sample of 43 residents. This failure has the potential to affect all 44 residents who reside at the facility.

Inspectors wroteBased on record review and interview, the facility failed to designate a qualified infection preventionist who is responsible for the facility's Infection Prevention and Control Plan. This failure has the potential to affect all 44 residents who reside at the facility.

Inspectors wroteBased on record review and interview, the facility failed to offer immunizations and vaccinations in 5 of 5 residents (R12, R14, R39, R40, R96) per policy. This failure has the potential to affect all 44 residents who reside at the facility.

Inspectors wroteBased on interview, observation and record review the facility failed to ensure the resident's memory care unit had warm water and was clean and free of odors for 19 of 42 residents (R2, R3, R4, R7, R8, R10, R11, R16, R20, R21, R22, R25, R27, R31, R33, R41, R42, R43, and R247) reviewed for safe clean and homelike environment in the sample of 43.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were kept stored in their original packaging with labels until administered for four of forty-three residents reviewed (R7, R20, R27, and R43) for medication administration, storage, and labeling in the sample of 43. The facility policy, Medication Administration dated (revised 7/3/13) directs staff, Medications must be prepared and administered as ordered (by the physician). All medications must be labeled with the resident's name, the medication, the dosage and instructions for administration. On 6/2/24 at 8:25 AM V17 (Agency Licensed Practical Nurse) was standing at her medication cart next to the dining room on the Dementia locked unit. V17 opened the top left drawer of her medication cart where there were four medication cups labeled with a first name all full of medications. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the facility Ombudsman monthly of a resident transfer to the hospital and failed to provide the resident and resident representative with a written notice of transfer, for one of two residents (R26) reviewed for hospitalizations, in a sample of 43. Findings Include: R26's medical record documents that R26 was transferred to a local hospital on 2/12/24. No evidence of a facility notification to R26 of a transfer/discharge was present on R26's chart. On 6/4/24 at 1:30 P.M., V18/Social Services Director verified that the facility did not provide R26 or his representative with a written notice of transfer. At that time, V18/Social Services Director also confirmed that she had not sent notification to the local Ombudsman of monthly facility transfers/discharges.

Inspectors wroteBased on interview and record review the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital, for one of two residents (R26), reviewed for bed holds, in the same of 43. Findings Include: R26's medical record documents that R26 was hospitalized on [DATE]. R26's medical record does not contain documentation of written notice to R26 or R26's resident representative, of the facility bed hold policy. On 6/4/24 at 1:30 P.M., V18/Social Services Director verified that the facility did not provide R26 or his representative with a a Bed Hold Policy or a written Notice of Transfer.

Inspectors wroteBased on interview and record review the facility failed to monitor a physician's order for self-catheterization and failed to update a resident's care plan to reflect self catherization needs for one of two residents (R18) reviewed for catheters, in a sample of 43.

Inspectors wroteF698 Based on observation, interview and record review the facility failed to obtain a physician's order for dialysis treatments, update a plan of care, for a resident receiving dialysis services and failed to assess a resident's dialysis fistula for hemorrhage post-dialysis for one of one residents (R26) reviewed for dialysis, in a sample of 43.

Inspectors wroteBased on record review and interview the facility failed to administer an IV (Intravenous) medication as ordered by the physician for one resident (R32) of 16 residents reviewed for medication administration, in a sample of 43. Findings Include: The facility policy, revised 7/3/2013, named Medication Administration, documents the following: Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. 22.) Notify the physician as soon as practical when a scheduled dose of a medication has not been administrated for any reason. R32's Cognitive Assessment, dated 2/7/2024, documents R32 has a BIMS (Brief Interviews for Mental Status) of 15. R32 is cognitively intact. [...]

Inspectors wroteBased on Interview and Record review the facility failed to prevent resident to resident sexual abuse for two of three residents (R1, R2) reviewed for Abuse in the sample of three.

Inspectors wroteBased on Interview and Record Review, the facility failed to revise a resident care plans to include an incident of resident to resident sexual abuse for two of three residents (R1, R2) reviewed for Abuse in the sample of three.

Inspectors wroteBased on observation, interview and record review the facility failed to notify the family of one resident (R1) of a condition change of three residents reviewed for falls. Findings Include: The facility's Notification for Change in Resident Condition or Status dated 7/1/2012 documents The facility and/or facility staff shall promptly notify appropriate individuals (i.e. Administrator, DON, Physician, Guardian, HCPOA, etc) of changes in the resident's medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the DON, physician, and unless otherwise instructed by the resident, the resident's next of kin or representative when the resident has any other afore mention situations. b. an accident or incident involving the residentg. Refusal of treatment or medications (i.e. three or more consecutive times. h. [...]

Inspectors wroteThese failures resulted in two deficient practices. A. Based on record review and interview the facility failed to monitor a resident after a fall and failed to initiate new interventions to prevent falls for two residents (R1 and R3) of three residents reviewed for falls with injury. B. Based on record review and interview the facility failed to assess one resident (R3) for the potential to harm himself after a suicidal statement of three residents reviewed for accidents and supervision. Findings Include: The Facility's Fall Prevention policy dated 08/2006 documents the policy is to provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an accurate shift-to-shift controlled medication inventory count, failed to ensure refrigerated controlled medications were immediately double locked, and failed to ensure controlled medication tracking sheets had accurate reconciliation. This failure has the potential to affect all 16 residents (R1 - R15) who have physician orders to receive controlled medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent misappropriation of narcotic medication for one resident (R1) of three residents reviewed for controlled medications.

Inspectors wroteBased on interview and record review the facility failed to check the nursing license status of a nurse prior to employment. This failure has the potential to affect all 48 residents who reside in the facility. Findings Include: The Facility's Nurse Staffing Policy dated 12/07/2017 documents No person may provide direct resident care without a certification and records check. The Facility's Administrator job description documents Personnel Functions: Ensure that appropriate identification documents are present prior to the employment of personnel and that and that appropriate documentation is filed in the employee's record in accordance with state and federal regulations. The Facility's Nursing Schedule for February and March 2024 documents V5 (Licensed Practical Nurse) worked the following days: [...]

Inspectors wroteBased on interview and record review the facility failed to have a licensed Administrator and failed to thoroughly investigate an incident of finding used needles and syringes. This failure has the potential to affect all 48 residents who currently reside in the facility. Findings Include: The Facility's undated Administrator job description documents Job Summary: The Administrator is responsible for directing the day to day functions of the facility in accordance with current local, state and federal standards and guidelines and regulations that govern long term care facilities to assure that appropriate care is provided in the facility. The Administrator is responsible for delegating the Administrative authority, responsibility necessary for carrying out duties. The Facility's Administrator job description also includes qualifications: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision for one of three residents (R8), reviewed for accidents/incidents, in a sample of 13. This failure resulted in R8 sustaining a second degree burn from unattended hot coffee.

Inspectors wroteBased on observation and record review, the facility failed to update a plan of care for one resident (R7) of three residents reviewed for wounds, in a sample of 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered therapy services were provided to residents for three of four residents (R2, R6, and R7) reviewed for therapy services in the sample of 13.

Inspectors wroteBased on record review and interview the facility failed to provide adequate heat in the dining room. This failure has the potential to affect 13 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, and R13 that eat in the dining room. Findings Include: The facility policy named, Disaster Plan/Policies and Procedures, dated 9/25/2012, documents the following: It is the policy of this facility to provide continuing safe, and comfortable care to its residents in the event the facility heating, and furnace systems fail during periods of unseasonably cold outside temperatures are present and such systems are required for resident safety and comfort. According to the weather graph on Google the temperature outside on 2/17/2024 at 9:52AM was 35 degrees. The facility Resident Council Agenda, dated 12/4/2023, documents the following: No heat in rooms. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a ureteral stent was removed for one resident (R2) of three residents reviewed for urinary catheters. This failure resulted in the ureteral stent becoming infected requiring removal after being transferred to the Emergency Department.

Inspectors wroteBased on observation, interview and record review the facility failed to assess, document and obtain treatment for sacral/buttock wounds, and failed to develop/revise a pressure ulcer wound care plan including initiating interventions for one of four residents (R2) reviewed for pressure ulcers in a sample of eight. This failure resulting in multiple pressure wounds across R2's buttocks and sacrum.

Inspectors wroteBased on interview and record review the facility failed to develop comprehensive care plans for four residents (R3, R4, R5, R8) of eight residents reviewed for care plans in a sample of eight.

Inspectors wroteBased on interview and record review the facility failed to convey resident funds within 30 days of discharge for one resident (R1) of three residents reviewed for discharge in a sample of eight.

Inspectors wroteBased on interview and record review the facility failed to administer a physician ordered antidepressant medication for one resident (R5) and failed to administer two physician ordered antibiotics for one resident (R2) of three residents reviewed for medications in a sample of eight.