Arcadia Care Havana

Inspectors wroteBased on observation, interview and record review the Facility failed to discontinue enteral feeding tube orders after an enteral gastrostomy feeding tube was removed and failed to assess, document and treat drainage and redness around a gastrostomy site for one of two Residents (R1) reviewed for gastrostomy care in a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for one (R3) of three residents reviewed for abuse, in a total sample of three. This failure resulted in R3 being verbally abused. This past noncompliance, which involved R3, occurred from 4/25/2026 to 6/03/2026. The facility Abuse Policy document: 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; Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents. The facility's Final Abuse Allegation Investigation, reported to the State Agency, dated 4/28/26, document: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to prevent physical abuse for five residents in the Alzheimer's Unit (R2,R3,R4,R8 and R16). The facility also failed to put any interventions to prevent further abuse of residents by R1 in place to protect all 16 other residents in the Alzheimer's Unit (R2-R17). This failure leaves the potential for abuse for all 16 residents who reside in the Alzheimer's Unit. The Immediate Jeopardy began on 3/4/2026 at 7:30 PM when R1 first abused another resident and had no intervention in place to stop further abuse. While the Immediacy was removed on 6/3/2026 the facility remains out of compliance at a Level 2 while the the facility assesses the effectiveness of their plan of removal and Quality Assurance program. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and treat pressure ulcers/wounds, failed to prevent pressure ulcers/wounds from worsening, failed to develop and implement pressure relieving interventions and a pressure ulcer care plan, failed to ensure pressure ulcer care and treatment was provided in accordance with professional standards of practice, failed to implement and maintain infection control practices during wound care, failed to maintain clean wound care supplies and treatment surfaces, and failed to ensure ordered dressing changes were completed as prescribed for three (R1, R11, and R12) of four residents reviewed for pressure ulcers in the sample of 41. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure allegations of abuse and injury of unknown origin were thoroughly investigated, documented, and reported timely for one (R11) of three residents reviewed for abuse in the sample list of 41.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse and injury of unknown origin were reported and thoroughly investigated timely for one (R11) of three residents reviewed for abuse in a sample list of 41.

Inspectors wroteBased on record review and interview the Facility failed to maintain safe/functioning locks on a bed and maintain a clear pathway to prevent two separate falls for one of seven Residents (R4) reviewed for Falls in a sample of seven.

Inspectors wroteBased on record review and interview the facility failed to obtain a physician ordered MRI (Magnetic Resonance Imaging) for one of seven residents (R1) reviewed for pain in the sample of seven.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control monitoring/surveillance and isolation precautions for Sarcoptes scabiei (scabies) were implemented for nine of 15 Residents (R4, R8, R9, R10, R11, R12, R13, R14 and R10) reviewed for Scabies in a sample of 16. This failure has the potential to affect all 59 Residents residing in the Facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers/bathing as scheduled for four (R1, R2, R3, and R16) of eight residents reviewed for showers/bathing in a sample of 16.

Inspectors wroteBased on interview and record review the facility failed to reasonably accommodate a resident's request to electronically monitor her own room for one resident (R1) and the facility failed to allow one resident (R3) to electronically monitor his own room of two residents reviewed who had requested electronically monitor their rooms. The State of Illinois Ombudsman Program Booklet documents You have a right to purchase and use an electronic monitoring device after providing notice to the facility using the Electronic Monitoring Notification Consent Form.1. R1's Medical Record documents that she was admitted on [DATE] with diagnosis to include but not limited to hemiplegia and hemiparesis following a cerebral infarction, anxiety and restless leg syndrome. R1's Medical Record documents that she is cognitively intact and makes all of her own decisions. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure seven residents (R1 through R7) were free from abuse of seven residents reviewed for abuse. This failure caused the residents to initially feel fear for their safety and has caused ongoing stress and anxiety.

Inspectors wroteBased on interview and record review the facility failed to recognize allegations of abuse as substantiated instances of abuse. This failure has the potential to affect all 56 residents who currently reside in the facility. The Facility's Abuse Prevention and Reporting policy dated 10/2022 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services by staff or mistreatment. The Facility's Abuse Prevention and Reporting policy documents Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental mean. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish to a resident. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all Certified Nurse Aides had 12 hours of required In-Service Training. This failure has the potential to affect all 56 residents who currently reside in the facility. The Facility's (Temporary Agency) Client Service Agreement dated 6/30/2023 documents (Facility) acknowledges that Professional Providers are independent contractors operating as self-employed individuals who use (Temporary Agency) to offer and provide healthcare services to (Facility). (Facility) acknowledges and agrees that (Temporary Agency) has no responsibility for, control over, or involvement in the scope, nature, quality, character, timing or location of any work or services performed by Professional Providers between (Facility) and Professional Providers. [...]

Inspectors wroteBased on observation, interview and record review the Facility failed to maintain a heating system, comfortable temperature ranges in the Facility's Dining Room and perform temperature checks/documentation following a faulty heating system. This failure has the potential to affect all 57 Residents that consume meals in the Dining Room.

Inspectors wroteBased on interview and record review the Facility failed to protect one of three Residents (R1) reviewed for Verbal Abuse from a Facility staff perpetrator.

Inspectors wroteBased on interview and record review, the Facility failed to provide a properly maintained transportation van causing safety risks for one of three Residents (R3) during transportation with weather risks (rain) and after sundown.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ and schedule sufficient maintenance, custodial, laundry, and housekeeping staff to ensure the facility was kept clean and free of odors, to ensure the facility had a sufficient amount of clean linens, mechanical lifts, mechanical lift slings, to ensure the facility's clean utility rooms and all resident rooms were cleaned at least daily, and to ensure the facility's walls, floors, mechanical lifts, lights, window coverings, and toilets were kept maintained and in good repair. These failures have the potential to affect all 58 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility assessment included the amount of direct care staff required daily to meet the needs of the residents, ensure there were an adequate amount of direct care staff to perform daily ADLs (Activities of Daily Living) to the residents, ensure residents received fresh ice water every shift, and ensure call lights were answered timely. These failures have the potential to affect all 58 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' toilets were clean and operable for four of ten residents (R4, R7, R8, R9) reviewed for safe, clean, comfortable, and homelike environment in the sample of 10.

Inspectors wroteBased on record review and interview the facility failed to protect R2 and R3 from financial exploitation from their guardians, after the facility was made aware, for two of three residents (R2 and R3) reviewed for misappropriation of funds in the sample of three. [...]

Inspectors wroteBased on record review and interview the facility failed to report allegations of exploitation of funds from residents' guardians immediately to the state agencies, local police, and Administrator, once the facility was made aware, for two of three residents (R2 and R3) reviewed for misappropriation of funds in the sample of three. These failures resulted in R2 and R3's guardians exploiting their monetary funds, even after the facility was made aware, and the Administrator, local police, State agency, Office of Inspector General, and Social Security Office not being made aware. [...]

Inspectors wroteBased on record review and interview the facility failed to protect residents from exploitation of funds from their guardians, once the facility suspected misappropriation of funds, and failed to immediately initiate an investigation of an allegation of misappropriation of funds for two of three residents (R2 and R3) reviewed for misappropriation of funds in the sample of three. These failures resulted in funds from R2's social security funds being transferred out of R2's checking account monthly into another account not associated with R2, even after the facility was made aware and no interviews, no bank record reviews, and no referrals sent to the state agencies. [...]

Inspectors wroteBased on record review and interview the facility failed to provide financial statements quarterly to residents and residents' representatives. This failure has the potential to affect all 44 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to promptly provide a copy of the updated admission agreement/contract to all residents and/or residents' representatives upon change of facility ownership. These failures have the potential to affect all 34 residents residing within the facility upon change of ownership on 11/1/24.

Inspectors wroteBased on record review and interview the facility failed to refund unused resident funds to a resident's representative within 30 days of the resident's death for one of three residents (R1) reviewed for resident funds in the sample of three.

Inspectors wroteBased on observation, interview and record review the Facility failed to maintain a sanitary and orderly environment for Residents by failing to stock disposable hand towels and/or cloth hand towels/wash clothes in Resident restrooms for nine of nine Residents (R2, R3, R4, R7, R8, R9, R10, R11 and R12) and maintain clean and orderly Resident restrooms for two Residents (R1 and R7) of nine reviewed for clean and homelike environment in a sample of 12.

Inspectors wroteBased on observation, interview and record review, the Facility failed to follow Physician Orders to apply bilateral lower extremity compression stockings and provide basic activity of daily living nail care for one of five Residents (R2) reviewed for cares in a sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse/RN for eight hours a day seven days a week. This has the potential to affect all 46 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a Certified Dietary Manager/CDM and failed to have certified staff. This has the potential to affect all 46 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient staff during the meal service. This has the potential to affect all 46 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a delivery, use-by date, or expiration date for Zucchini and loaves of bread. This has the potential to affect all 46 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a PASARR (Pre-admission Screening and Resident Review) Level I screening and/or Level II referral were completed for one (R2) of two residents reviewed for PASARR Screenings in the sample of 22.

Inspectors wroteBased on observation, interview and record review the Facility failed to provide activity of daily living/ADL assistance for hygiene/scheduled baths for one dependent resident (R4) of 16 resident's reviewed for Activity of Daily Living assistance in a sample of 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have orders for a BiPAP/Bilevel Positive Airway Pressure machine and failed to label and change oxygen and nebulizers per their policy and orders for three (R30, R191, and R192) of five residents reviewed for oxygen in a sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide specialized rehab services after an order for one (R191) of one resident reviewed for Rehab Services in a sample of 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the state survey book/binder readily accessible to the residents, family members, and legal representatives, and failed to have an accurate posting of the location of the state survey book/binder. This has the potential to affect all 46 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the required staffing information on a daily basis and failed to have the total number of actual hours worked for licensed and unlicensed nursing staff. This has the potential to affect all 46 residents in the facility.

Inspectors wroteBased on observation, interview and record review the Facility failed to initiate resident specific fall interventions for one of four Residents (R1) reviewed for falls in a sample of four. This failure resulted in R1 requiring laceration treatment and radiography testing, on two separate occasions, at the local hospital Emergency Department. Findings including: Facility Fall Prevention Program Policy, revised 5/2022, documents: to assure the safety of all Residents in the Facility when possible; 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 and assistive devices are utilized as necessary; methods to identity risk factors and identify Resident's at Risk; use and implementation of professional standards of practice; addresses each fall; [...]

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure that ongoing resident centered activity programs were being offered. This failure has the potential to affect all 40 Residents residing in the Facility.

Inspectors wroteBased on interview and record review, the facility failed to protect R1 through R74's right to be free from misappropriation of property from V4, Business Office Manager, for 74 of 75 residents (R1-R74) reviewed for misappropriation of funds in the sample of 75. These failures resulted in the facility failing to monitor the residents' pooled trust account monthly resulting in V4 stealing, over a period of eight months, $11,815.00/dollars of funds out of the residents' pooled facility trust fund account without residents' knowledge and resulted in V4 keeping R46's pre-paid social security card and making fraudulent charges, without R46's permission, on multiple occasions from April 2024 to September 2024 These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Abuse Policy to immediately report allegations of misappropriation of residents' funds to the local police department, the state agency, and the residents/residents' representatives for 75 (R1-R75) of 75 residents reviewed for reporting of allegations of abuse in the sample of 75. These failures resulted in R75 reporting to V3 (Prior Administrator-In-Training/AIT) on 6/20/24 that she suspected V4 (Business Office Manager/BOM) was making fraudulent charges from her debit card. This allegation was not reported to the state agency. On 7/22/24 V6 (Prior Administrator) was notified by V9 (Bank Manager) that she suspected V4 was making fraudulent withdrawals out of the resident's trust fund for personal use. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their Abuse Policy to thoroughly investigate all allegations of misappropriation of funds and to remove the alleged perpetrator V4 (Business Office Manager/BOM) from contact with residents and residents' funds while an investigation was occurring for 75 (R1-R75) of 75 residents reviewed for protection of abuse in the sample of 75. These failures resulted in R75 reporting on 6/20/24 to V3 (Prior Administrator-In-Training/AIT) that R75 suspected V4 was making fraudulent charges from R75's debit card. This allegation was not investigated, V4 was not suspended, and the residents' funds were not protected from V4. On 7/22/24 V6 (Prior Administrator) was notified by V9 (Bank Manager) that she suspected V4 was making fraudulent withdrawals out of the resident's trust fund for personal use. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions, develop a pressure ulcer care plan, and failed to perform daily skin checks for one of two residents (R36) reviewed for pressure ulcers in the sample of 29. These failures resulted in R35 developing a facility acquired unstageable pressure ulcer to the right heel that required surgical debridement and R35 developing a stage three pressure ulcer to the right buttock.

Inspectors wroteBased on interview and record review, the facility failed to have Resident Council Meetings for five of twelve meetings in the past year, this has the potential to affect all 36 residents who live in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility had an adequate amount of wash clothes and towels and maintained a clean shower curtain. This failure has the potential to affect all 36 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were aware of the process to submit grievances, and aware of who the facility grievance official is, and failed to develop and implement a resolution to monthly resident council complaints. This failure has the potential to affect all 36 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an ongoing program of activities daily on the day and evening shifts designated to meet the resident's physical, mental, and psychosocial well-being of each resident, failed to develop comprehensive activity care plans, and failed to assess resident activity interests and goals quarterly. These failures have the potential to affect all 36 residents residing within the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to employ a full-time Activity Director to plan, schedule, and implement an ongoing program of activities. This failure has the potential to affect all 36 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure there was enough nursing staff to provide nursing services. This failure has the potential to affect all 36 residents residing within the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide Registered Nurse/RN services eight hours daily and failed to employ a Director of Nursing (DON) to oversee the operation of the Nursing Department and ensure quality of care. This failure has the potential to affect all 36 residents residing within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to employ a Certified Dietary Manager. This has the potential to affect all 36 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to: keep meat in the refrigerator overnight; date and label food that has been opened in both cold food and pantry storage; discard outdated food; use proper storage containers to prevent foods from contamination; maintain a clean kitchen; replace and maintain floor tiles; clean overhead vents and returns in both food preparation and dish room areas; repair and maintain walls and corners that have paint and plaster chipped away; date and label all food brought in from the outside for residents; keep 50 pound bags of salt (softener) off of the kitchen floor; close spaces between ceiling tiles and around pipes; keep boxes of paper supplies off of the floor; and keep the door to the outside closed. This has the potential to affect all 36 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review the administration failed to ensure ongoing resident complaints were resolved, to ensure residents had an adequate amount of linens, to ensure an ongoing program of activities were provided to the residents daily, to ensure a full-time Director of Nursing, Activity Director, and Dietary Manager were employed to manage and oversee everyday nursing, activity, and dietary services, to ensure the facility had sufficient nursing staff, to ensure the most up-to-date infection control practices were implemented, to ensure resident council meetings were provided monthly, to ensure large dietary appliances were in good repair and working order, to ensure all required QAPI (Quality Assurance and Performance Improvement) members met monthly, to ensure plans were implemented to correct and/or improve identified areas of concern, and ensure all CNAs [...]

Inspectors wroteBased on observation, record review, and interview the governing body of the facility failed to employ a licensed administrator to oversee and manage the everyday operations of the facility. This failure has the potential to affect all 36 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement QAPI (Quality Assurance and Performance Improvement) plans to address the lack of follow-up to resident complaints, to address the lack of department heads including the Director of Nursing, Activity Director, and Dietary Manager, to address the lack of linens, to address the lack of an ongoing program of activities, to address the lack of sufficient nursing staff, to address the lack of education regarding QAPI, Dementia care and treatment, infection control practices, and abuse, to address the broken dietary equipment, to address the lack of resident council meetings, and the lack of required employees attending QAPI meetings. These failures have the potential to affect all 36 residents residing within the facility.

Inspectors wroteBased on Interview and Record Review the facility failed to have a Director of Nursing or the required number of members at the quarterly Quality Assurance Meetings. This has the potential to affect all 36 resident living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to make repairs to several large appliances: the reach-in refrigerator; range oven; convection oven; outside freezer door; steam table; large hood and baffles. This has the potential to affect all 36 residents living in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure direct care staff received annual Abuse and Prevention in-service training. This failure has the potential to affect all 36 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure direct care staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 36 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure direct care staff received annual Dementia Care in-service training. This failure has the potential to affect all 36 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement services to maintain and/or improve range of motion limitations for four of four residents (R6, R16, R24, R35) reviewed for limitations in range of motion in the sample of 29.

Inspectors wroteBased on observation and interview the facility failed to provide fresh water for four residents (R6, R7, R23, and R138) of 16 residents reviewed in a sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling urinary catheters for 11 of 12 residents (R3, R6, R7, R8, R15, R18, R24, R32, R33, R36, and R138) reviewed for EBP in the sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to cover a urinary catheter bag with a privacy bag and failed to provide a washcloth instead of a paper towel to use to wash the resident's face for two residents (R15, R23) of 16 residents reviewed for dignity in the sample of 29.

Inspectors wroteBased on record review and interview the facility failed to prevent resident (R35) to resident (R19) verbal abuse for one of two residents (R19) reviewed for abuse in the sample of 29.

Inspectors wroteBased on record review and interview the facility failed to report an allegation of resident (R35) to resident (R19) verbal abuse to the state agency for two of two residents (R19 and R35) reviewed for abuse in the sample of 29.

Inspectors wroteBased on record review and interview the facility failed to investigate an allegation of resident (R35) to resident (R19) verbal abuse for two of two residents (R19 and R35) reviewed for abuse in the sample of 29.

Inspectors wroteBased on interview and record review the facility failed to develop a PASRR (Pre-admission Screening and Resident Review) Recommendations Care Plan for one resident (R15) out of 16 reviewed for Care Plans in a sample of 29. Findings Include: The Comprehensive Care Plan dated 11/1/17, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person-centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on record review and interview the facility failed to obtain a level one PASRR (Pre-admission Screening and Resident Review) for one resident (R21) and failed to obtain a level II PASRR for two residents (R3 and R15). These failures have the potential to affect three of 16 residents (R3, R15, and R21) reviewed for pre-admission screenings in the sample of 29.

Inspectors wroteBased on interview and record review the facility failed to develop a Wound Care Plan for one resident (R24) out of 16 reviewed for Care Plans in a sample of 29. Findings Include: The Comprehensive Care Plan dated 11/1/17, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person-centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to document justifiable behaviors or diagnosis to warrant the use of an anti-psychotic medication for one of one resident (R27) reviewed for anti-psychotic medication use with the diagnosis of Alzheimer's Disease in the sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep copies of recent surveys in the survey book. This has the potential to affect all 36 residents living in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure physician ordered therapy services were provided for 1 resident (R1) of 3 residents reviewed for physical/occupational therapy.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities daily for the residents. This failure has the potential to affect all 40 residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide requested Medical Records for 1 resident (R1) of 3 residents reviewed for records requested in the sample of 13.

Inspectors wroteBased on record review and interview, the facility failed to provide the correct size (disposable briefs) for 3 residents (R3, R5, and R9) of 7 residents reviewed for supplies in the sample of 13.

Inspectors wroteBased on record review and interview, the facility failed to provide assistance for transportation to medical appointments for 1 residents (R8) of 6 residents reviewed for transportation needs in the sample of 13.

Inspectors wroteBased on record review and interview, the facility failed to provide assistance for transportation to dental appointments for 1 residents (R2) of 6 residents reviewed for dental service needs in the sample of 13.

Inspectors wroteBased on Interview and Record review the facility failed to provide Registered Nurse services eight hours daily. This failure has the potential to affect all 42 residents residing in the facility.

Inspectors wroteBased on Interview and Record Review, the facility failed to develop a comprehensive care plan for four of eight residents (R4, R7, R8, R9) reviewed for care plans in the sample of 10.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to respond to resident call lights in a timely manner for three of seven residents (R3, R10, R11) reviewed for call lights in the sample of 10.

Inspectors wroteBased on record review and interview the facility failed to provide Registered Nurse/RN services eight hours daily. This failure has the potential to affect all 38 residents within the facility.

Inspectors wroteBased on interview and record review the facility failed to follow a physician order and schedule a sonogram for 1 resident (R1) of 3 residents reviewed for diagnostic services. This failure resulted in the resident's treatment being delayed, causing him prolonged pain and a subsequent return visit to the emergency room for further treatment.

Inspectors wroteBased on interview and record review the facility failed to prevent misappropriation of resident property for 2 residents (R1 and R2) of 3 residents reviewed for abuse in a sample of four.

Inspectors wroteBased on Interview and Record Review the facility failed to report an allegation of misappropriation of resident property to the local law enforcement for 1 resident (R1) of 3 residents reviewed for abuse in a sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain blood glucose orders, failed to follow physician orders for obtaining blood glucose levels in a timely manner, and failed to document blood glucose orders, for one (R2) resident reviewed for physician orders in a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to follow its Fall Prevention Policy, failed to monitor, and failed to ensure fall prevention safety precautions were in place and followed to prevent a fall for one (R2) of three residents reviewed for falls; these failures resulted in R2 falling and sustaining a soft tissue hematoma to his forehead.

Inspectors wroteBased on interview and record review the facility failed to provide documented proof of 12 hours of Certified Nursing Assistants training in a twelve-month period. This includes Dementia Management, Abuse Prevention, and Impaired Cognition Training for Certified Nursing Assistants. This has the potential to affect all 40 residents living in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident's Practitioner Order for Life-Sustaining Treatment (POLST) was transferred to the current Physician order sheet for one of sixteen residents (R11) reviewed for advance directives in the sample of 29.

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to immediately report an allegation of misappropriation to the state agency and local law enforcement for one of sixteen residents (R7) reviewed for abuse in the sample of 29.

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to immediately report an allegation of misappropriation to the state agency and local law enforcement for one of sixteen residents (R7) reviewed for abuse in the sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident in COVID-19 isolation was offered an activities program to meet their assessed needs which affected two of 16 residents (R18, R33) reviewed for activities in a sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a wound treatment was applied as per physician's order, and hand hygiene was performed before applying a clean dressing for one of two residents (R3) reviewed for pressure ulcers in a sample of 16.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received individualized treatment and services based on their physician's order, comprehensive assessment, and Range of Motion Assessment to maintain, improve, or prevent further decrease in range of motion for three of four residents (R3, R33, R21) reviewed for range of motion in a sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the Care Plan and assist a resident while ambulating for one resident (R31) of two residents reviewed for falls in a sample of 29.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to ensure an oxygen humidity bottle contained liquid, complete physician ordered oxygen tubing and humidifier changes, clean an oxygen concentrator and CPAP (Continuous Positive Airway Pressure) equipment and care plan a CPAP for two of two residents (R4, R5) in the sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement in terms that the resident or resident's representative could understand. This had the potential to affect all 40 residents residing in the facility.