Arcadia Care Watseka

Inspectors wroteFailures at this level required more than one Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from sexual abuse by another resident, failed to identify repeated sexual predatory behaviors and implement interventions to address these behaviors for R9, resulting in psychosocial harm of R10 and R11, who voiced expressions of fear of R9, and resulted in R9 sexually abusing R5 and R15, for six (R5, R9, R10, R11, R15) of 14 residents reviewed for abuse in the sample list 20. These failures also put other residents in the facility at risk for psychosocial impact, including not limited to emotional harm, loss of dignity, and feeling afraid, as well as being at risk for further abuse from R9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (R1) was free from physical restraints applied for staff convenience; failed to assess for the use of physical restraints; failed to identify the specific medical symptoms justifying the use of a physical restraint; failed to notify the resident's representative; and failed to obtain a physician's order for physical restraints for one (R1) of three residents reviewed for restraints in the sample of 20. These failures put R1 at risk for psychosocial impact that includes but is not limited to emotional harm, dehumanization, pain, loss of dignity, self-respect, feeling of imprisonment, increased agitation and restlessness and at risk for serious physical injury. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from chemical restraints, failed to implement and document individualized non-pharmacological interventions prior to psychotropic medication administration, and failed to administer medications according to physician's orders for one of three residents (R1) reviewed for unnecessary medications in the sample list of 20. This failure resulted in R1 sustaining a fall resulting in an acute subdural hematoma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its abuse prevention policy by failing to ensure employee background checks were completed upon hire. This failure has the potential to affect 62 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a full-time qualified social worker. This failure has the potential to affect all 62 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement a Performance Improvement Plan (PIP) for identified problems with abuse, behavior monitoring, and falls. This failure has the potential to affect all 62 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely report an allegation of abuse to the Administrator and report abuse allegations to the State Survey Agency for six (R2, R5, R9, R10, R11, R15) of 14 residents reviewed for abuse in the sample list of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly document and thoroughly investigate abuse allegations, and implement appropriate corrective measures for seven (R1, R4, R5, R9, R10, R11, R15) of 14 residents reviewed for abuse in the sample list of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with eating for one of three residents (R16) reviewed for Activities of Daily Living on the sample list of 20. Findings Include: R16's Care Plan, dated 3/24/26, documents R16 is diagnosed with Activity Intolerance, Alzheimer's Disease, Dementia, Fatigue and has an Activity of Daily Living self-care performance deficit that requires one staff to assist with eating. R16 has a risk for weight loss and is under Hospice Care. R16 requires meal intake monitoring and has a goal to eat 50 percent or more of R16's meals. On 7/6/26 at 4:55 PM, R16 was sitting in R16's wheelchair in the television room by R16's self. R16 had a sandwich on R16's lap which R16 was tearing up into pieces but not eating. The sandwich had been torn apart but R16 was not eating it. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure post fall monitoring was completed timely and reflected ongoing assessment for one (R,6) of three residents reviewed for falls on a sample list of 20 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently implement wound prevention interventions and complete weekly skin/wound assessments for one of three residents (R16) reviewed for pressure ulcers on the sample list of 20 residents. Findings Include:The facility's Pressure Ulcer Prevention policy, dated December 2025, documents the policy's purpose is to prevent and treat pressure injuries. Staff are to use positioning devices, pads, pillows, etc. to reduce pressure from heels and toes as indicated. The facility's Pressure Injury and Skin Condition Assessment policy, dated December 2025, documents each pressure ulcer will be assessed and measured at least every seven days by a licensed nurse and documented in the resident's clinical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete thorough fall investigations following falls for two (R7, R1) residents and did not implement fall interventions for two (R7, R13) out of three residents reviewed for falls on a sample list of 20 residents. The Facility's Fall Prevention Program policy, revised May of 2022, documents safety interventions will be implemented for each resident identified as being at risk for falls. It further documents, all assigned nursing personnel are responsible for ensuring ongoing precautions are put into place and consistently maintained. 1. An Incidents by Incident Type Report, dated 6/29/26, documents R7 had unwitnessed falls on 4/10/26, 4/20/26, 4/25/26, 4/26/26, 5/17/26, and a witnessed fall on 4/26/26. R7's Minimum Data Set (MDS), dated [DATE], documents R7 is moderately cognitively impaired. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and document urinary catheter care for one of three residents (R13) reviewed for catheter care on the sample list of 20. Findings Include:The facility's Urinary Catheter Care policy, dated December 2025, documents in order to reduce the risk of or prevent infections in residents with indwelling catheters, urinary catheter care should be performed and documented on the Treatment Administration Record (TAR) at least daily. R13's Care Plan, dated 6/18/26, documents R16 has an indwelling urinary catheter related to Obstructive and Reflex Uropathy. R13's Treatment Administration Record for June 2026 does not document any urinary catheter care completed. On 7/6/26 at 4:30 PM, V49, Assistant Director of Nurses (ADON), confirmed R13 has a urinary catheter has had some recent urinary tract infections. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain resident equipment in a safe operable condition, failed to replace/repair equipment in disrepair after resident fall with injury and failed to implement new interventions post fall and an accident. These failures affected two of three residents (R2 and R3) reviewed for resident injury/injury of unknown origin on the sample list of seven.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free from abuse when (R1) struck (R2). This failure resulted in (R2) experiencing physical abuse and exposing other residents to potential harm. (R1) and (R2) are two residents reviewed for abuse in a sample of three residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage of at least eight consecutive hours per day, seven days a week. This failure has the potential to affect all 62 residents within the facility. Findings Include: Facility Midnight Census dated 2/21/26 documents 62 residents in house. The Facility Assessment Tool dated 11/2025-11/2026 Appendix 3 documents staffing information for units per shift. The facility has two shifts, shift one is 6:00am to 6:00pm and shift two is 6:00pm to 6:00am. Shift one requires one Registered Nurse (RN), two Licensed Practical Nurses (LPN), and six Certified Nursing Assistants (CNA). Shift two requires one RN, one LPN, and five CNAs. Daily Schedules dated 1/3/26, 1/4/26, 1/17/26, 1/18/26, 1/31/26, 2/1/26, 2/7/26, 2/8/26, 2/21/26, and 2/22/26 document no RN coverage for each 24-hour timeframe. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 62 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve diets as planned on the menu. These failures have the potential to affect all 62 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively sanitize dishes, failed to follow manufacturer's instructions for safe disinfectant use, failed to utilize appropriate sanitation test equipment, failed to ensure an ice machine drain line was was properly plumbed to prevent the potential for cross-contamination of ice, and failed to maintain sanitary floor surface areas. These failures have the potential to affect all 62 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to coordinate a Pre-admission Screening and Resident Review (PASARR) for residents with mental illness diagnoses during their residency at the facility. This failure affects two (R5, R23) of five residents reviewed for PASARR II completion in the sample list of 34.

Inspectors wroteBased on interview and record review the facility failed to complete weekly skin assessments for one of one resident (R8) reviewed for pressure sores on a sample list of 34. Findings Include:The Facility Skin Condition Assessment & Monitoring - Pressure and Non-Pressure Policy with no revision date documents Pressure and other Ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record. Resident identified will have a weekly skin assessment by a licensed nurse and each resident will be observed for skin breakdown daily during care and on the assigned bath day by the Certified Nursing Assistant. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly clean, store, change, and label oxygen tubing, and a nebulizer mask according to facility policy for one of four residents (R66) reviewed for respiratory care on the sample list of 34. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders to complete laboratory tests for two of two (R14, R16) residents reviewed for Laboratory Services on a sample list of 34. Findings Include:R14's admission Record dated 2/24/26 documents an admission date of 5/27/25 with medical diagnoses of Cerebral Infarction, Essential (Primary) Hypertension, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Aphasia Following Cerebral Infarction, Epilepsy, Major Depressive Disorder, Single Episode, Chronic Pain Syndrome, Hyperlipidemia, Nicotine Dependence, Cigarettes, Long Term (Current) Use Of Aspirin, Abnormalities Of Gait And Mobility, Unsteadiness On Feet, Difficulty In Walking, and Dysphagia. R14's Physician Order dated 2/5/26 documents an order to collect a Keppra (anti-epileptic drug) level. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect a residents (R1) right to be free from inappropriate touching and sexual comments by another resident (R2), for 1of 5 residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on nine of forty-four days reviewed for RN staffing. This failure has the potential to affect all 61 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the director of food services met the regulatory qualifications. The current Dietary manager was not a certified dietary manager, certified food service manager, or credentialed as required. This failure effects all 61 residents.

Inspectors wroteBased on interview and record review, the facility failed to coordinate a Pre-admission Screening and Resident Review (PASARR) for residents with mental illness diagnosis during their residency at the facility. This failure affects three (R4, R6, and R37) of five residents reviewed for PASARR II completion in the sample list of 29. 1. R4's Face Sheet dated 8/26/25 documents R4 was originally admitted to the facility on [DATE]. R4's Electronic Medical Record documents R4 had the following medical diagnoses Schizoaffective and Bi-polar (4/19/23). R4's PASARR Level I dated 5/12/22 documents a Level II screening is not indicated because there is no evidence of a serious behavioral health condition/SMI/ID/RC (Serious Mental Illness, Intellectual Disability and/or Related Condition). If changes occur or new information refutes these findings, a new screen must be submitted. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications according to physician's orders for one (R6) of three residents reviewed for medication administration in the sample list of 29. This failure resulted in five medication errors out of 25 opportunities, resulting in a 20% medication error rate. On 8/24/25 at 9:33am, V3 Licensed Practical Nurse (LPN) administered the following medications to R6: Fluticasone-Salmeterol (Advair) Inhaler 100-50 micrograms (mcg) 1 puff, Loratadine 10 milligrams (mg), Famotidine 40mg, Folic Acid 800mcg, Furosemide 40mg, Gabapentin 300mg, Losartan Potassium 50mg, Oxybutynin ER 10mg, Psyllium Husk Powder 1 tablespoon in water, Sennosides-Docusate Sodium (Senna) 8.6-50mg, and Oxycodone 5mg. R6's Physician Order Sheet (POS) dated 8/25/25 documents the following orders: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reweigh a resident (R3) for a documented significant weight gain, failed to accurately document meal intakes and provide nutritional supplementation as ordered for a nutritionally high-risk resident (R61), and failed to obtain weekly weights as ordered for two (R3 and R61) of four residents reviewed for nutrition in the sample list of 29.1. R61's Face Sheet dated 8/26/25 documents R61 has a diagnosis of Protein-Calorie Malnutrition. R61's Dietary Note dated 7/14/25 documents R61 has significant weight lost noted times six months and continue to monitor weights and intakes. Further documents R61 is on multiple supplements including fortified ice cream daily and nutritional shake three times a day. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from physical abuse and verbal abuse for three (R26, R24, R61) of four residents reviewed for abuse in a sample list of 35. Findings Include: The facility's Abuse Prevention and Reporting Policy dated September 2024 documents the facility affirms the right of the residents to be free from abuse. Physical Abuse is the infliction of injury on a resident that occurs other then by accidental means. Examples of physical abuse include hitting, slapping, and kicking. Verbal abuse may be considered a type of mental abuse and includes the use of oral communication to residents within hearing distance. Examples include harassing a resident, mocking, insulting, yelling at, and threatening residents. A resident to resident altercation should be reviewed as a potential situation of abuse. [...]

Inspectors wroteBased upon interview and record review, the facility failed to have a Registered Nurse (RN) providing services at least eight consecutive hours a day, seven days a week. This failure has the potential to affect all 62 residents currently residing in facility. Findings Include: The Facility Assessment Tool for Arcadia Care of Watseka dated November 2024 through November 2025 documents staffing should include one registered nurse (RN), two licensed practical nurses (LPN), and six certified nursing assistants (CNA's) for the 6:00 AM thru 6:00 PM shift and one registered nurse (RN), one licensed practical nurse (LPN), and five certified nursing assistants (CNA's) for the 6:00 PM thru 6:00 AM shift. The facility's March 2025 Nursing Schedule documents no Registered Nurses coverage on the following dates 3/8, 3/9, 3/13, 3/14, 3/17, and 3/18/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 62 residents in the facility. Findings Include: On 3/22/25, 3/23/25 and 3/24/25 V3 Dietary Manager was actively supervising dietary operations in the facility kitchen. On 3/11/25 at 11:04 AM V3 Dietary Manager stated that V3 was hired a couple of weeks ago as Dietary Manager. V3 stated that V3 is not currently a Certified Dietary Manger. V3 stated at this time V3 fails to meet the State of Illinois standards to be a food service manager/dietary manager. On 3/22/25 at 2:02 PM V1 Administrator confirmed that V3 Dietary Manager does not currently have a valid Food Safety/Dietary Manager Certificate as required. [...]

Inspectors wroteBased upon observation, interview and record review the facility failed to employ an Infection Prevention Nurse that physically works onsite in the facility at least part time. This failure has the potential to affect all 62 residents residing in the facility. Findings Include: Observations were made on 3/22/25, 3/23/25 and 3/24/25 between the hours of 8:30 AM and 4:00 PM. During these times, no certified Infection Preventionist nurse was in facility. On 3/24/25 at 2:00 PM, V7 Regional Registered Nurse stated the facility's Infection Preventionist is a Regional Infection Preventionist (V25) who works offsite. V7 stated V25 is responsible for all infection tracking and logs and that these are not kept/maintained in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility repeatedly failed to provide showers to residents according to their plans of care, physician orders, and preferences. This failure affects three residents (R17, R45, R61) out of five reviewed for activities of daily living on the sample list of 35. Findings Include: Facilities Bathing - Shower and Tub Bath Policy dated October 2024 documents: Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub bath or bed/sponge bath will be offered according to resident's preference, no less than once per week or according to the resident's preferred frequency and as needed or requested. 1. On 3/22/25 at 10:20 AM, R45 was seated in a tilt back wheelchair in R45's room. R45 was unshaven and had long nails. R45 Medical diagnoses; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and implement activities to meet the interest and needs of the residents. This failure affects four residents (R8, R55, R57, R63) of thirteen residents reviewed for activities in the sample list of 35. Findings Include: All four residents (R8, R55, R57, R63) reside on the facility's locked memory care unit/hallway. On 3/22/25 at 9:45 AM, 10:00 AM, 2:00 PM and 3/23/25 at 9:40 AM, and 11:00 AM. all four residents (R8, R55, R57, R63) were in their rooms asleep or sitting not engaged, with no structured activities. 1. R8's undated diagnoses list includes: Unspecified Dementia, unspecified severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse for one (R36) of four resident reviewed for abuse in the sample list of 35. Findings Include: On 3/23/25 at 11:39 AM V2 Director of Nursing (DON) stated R36 told V2 last week that the agency nurse V13 Licensed Practical Nurse (LPN) was very rough in her approach with him, her tone was harsh to him and that the nurse was talking about other residents to R36. V2 stated V2 did not tell V1 Administrator about it but stated she thought R36 told V1 himself. V2 stated she did not recognize R36's allegation as potential abuse at the time. V2 (DON) stated all potential abuse is supposed to be reported immediately to V1 Administrator. On 3/2/25 at 9:10 AM V1 Administrator stated R36 had not reported any abuse to V1 and no staff member reported any abuse regarding R36. [...]

Inspectors wroteBased on interview and record review the facility failed to coordinate a Pre-admission Screening and Resident Review (PASARR) level II evaluation for two (R21, R62) of three residents reviewed for PASARR II completion in the sample list of 35. Findings Include: 1. R21's Medical Diagnoses List dated March 2025 documents R21 was admitted to the facility on [DATE] and had a diagnoses of Schizoaffective Disorder: Bipolar Type and Anxiety Disorder. R21's Preadmission Screening and Resident Review (PASARR) Level I screening dated 10/9/23 documents a Level II screening is not indicated because there is no evidence of a serious behavioral health condition (Serious Mental Illness) however, if changes occur or new information refutes those findings a new screen must be submitted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an appropriate indwelling urinary catheter collection bag and failed to secure the bag in a safe and dignified manner for one of one resident (R63) reviewed for indwelling urinary catheters on the sample list of 35. Findings Include: R63's undated diagnoses list documents R63's diagnoses as: Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Chronic Kidney Disease Stage IV, Calculus of Ureter, and presence of Urogenital Implants. R63's Physician Order Sheet (POS) dated March 2025, documents an order for 16 (french)Fr/10 (cubic centimeters)cc related to other Obstructive and Reflux Uropathy. On 03/22/25 at 9:30 AM, R63's catheter bag was attached to R63's pants visible to all. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on six of fifteen days reviewed for RN staffing. This failure has the potential to affect all 66 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents (R1) right to be free from physical abuse by another resident (R2) for one of five residents (R1) reviewed for abuse in the sample list of 10.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan with intervention for behaviors. This failure affects one resident (R6) of four residents reviewed for behaviors in the sample list of ten.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide showers for four (R6, R7, R8 and R9) of four dependent residents reviewed for showers and failed to provide dental care for one (R9) of four residents reviewed for dental care from a total sample list of nine residents reviewed for dependent care.

Inspectors wroteBased on interview and record review, the facility failed to protect a residents right (R3) to be free from Abuse by another resident (R1), for two (R1, R3) out of three residents reviewed for abuse in the sample list of nine residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to use proper equipment to transport a resident (R1) resulting in R1 sustaining an impacted tibia fracture and associated proximal fibula fracture. The facility also failed to follow its incident/accident policy by failing to report a serious injury to the state survey agency and thoroughly investigate an injury to determine the root cause and develop interventions for one (R1) of three residents reviewed for accidents in the sample list of seven.

Inspectors wroteBased on observation, interview and record review the facility failed to staff a Registered Nurse (RN) for eight consecutive hours per day. This failure has the potential to affect all 68 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer insulin and diabetic medications timely and as ordered for four (R1, R2, R4, R7) of four residents reviewed for insulin in the sample list of seven.

Inspectors wroteBased on interview and record review the facility failed to routinely assess for pain and develop a care plan to address pain for one (R1) of five residents reviewed for accidents in the sample list of seven.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's (R2) right to be free from sexual abuse by another resident (R1). This failure resulted in R2, who is cognitively impaired, as a reasonable person that would not expect to be sexually abused in their own home or health care facility, causing them to feel fear, anxiety, and anger. The facility also failed to protect a resident's (R4) right to be free from physical abuse by another resident (R3) and protect a resident's (R6) right to be free from physical abuse by another resident (R4). These failures affected 5 (R1, R2, R3, R4, and R6) of 5 residents reviewed for abuse in a sample list of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement safety measures, failed to provide adequate supervision and toileting assistance to prevent falls (R2, R5); and failed to develop and implement fall interventions and thoroughly complete fall investigations (R1, R2, R5). These failures affected 3 (R1, R2, and R5) of 3 residents reviewed for falls in the sample list of 14. These failures resulted in R2 and R5 sustaining falls with lacerations that required emergency room treatment of medical glue closure.

Inspectors wroteBased on interview and record review the facility failed to develop and implement interventions to address behavioral disturbances associated with dementia for three (R3, R4, R6) of five residents reviewed for abuse in the sample list of 14.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident (R1) was free from misappropriation of funds by an employee (V3 (Business Office Manager/BOM). This failure resulted in psychosocial harm for R1. R1 is one of four residents reviewed for misappropriation of property in the sample list of six.

Inspectors wroteBased on interview and record review the facility failed provide quarterly statements for Resident Trust Funds for five (R1, R2, R3, R5, R6) of five residents reviewed for Trust Funds in the sample list of six.

Inspectors wroteBased on interview and record review the facility failed to ensure its Surety Bond provided adequate coverage of Resident Trust Funds. This failure affects five (R1, R2, R3, R5, R6) of five residents reviewed for Resident Trust Funds in the sample list of six.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of sexual abuse for one (R1) of four residents reviewed for abuse in the sample list of six.

Inspectors wroteBased on interview and record review the facility failed to provide dialysis services to one (R15) of two residents reviewed for dialysis services from a total sample list of 36. This failure resulted in R15 being hospitalized for Hypervolemia.

Inspectors wroteFailures at this level require more than one deficient practice statement. A. Based on record review and interview the facility failed to monitor potential exposure sites for Legionella. This failure has the potential to affect all 44 residents who reside in the facility. B.) Based on observation, interview and record review the facility failed to don PPE (Personal Protective Equipment) prior to entering a contact isolation room for one of one resident (R34) reviewed for transmission based precautions in the sample list of 36.

Inspectors wroteBased on interview and record review the facility failed to employ a certified Infection Preventionist. This failure has the potential to affect all 44 residents who reside at the facility. Findings Include: The Long-Term Care Facility Application For Medicare and Medicaid dated 8/25/24 documents 44 residents reside in the facility. The facility's Infection Control Surveillance and Monitoring Policy reviewed 12/7/18 states It is the policy of the facility to do routine surveillance and and monitoring of the facility to determine if compliance with work practices and care of protective clothing and equipment is maintained. Procedure: Monitoring the effectiveness of the facility work practices and protective equipment will be conducted by the Administrator, Infection Control Preventionist (ICP) and the Director of nursing (DON). This includes but is not limited to: a. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe, comfortable, and functional environment by failing to maintain the building structure to prevent roof leaks. This failure affects one (R12) of 16 residents reviewed for environment in the sample of 36. This failure has the potential to affect all 44 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to obtain laboratory tests as ordered and repeatedly failed to document blood glucose results for three of three residents (R4, R25, R46) reviewed for laboratory services in the sample list of 36.

Inspectors wroteBased on interview and record review the facility failed to ensure for the dignity of two (R5, R15) of 16 residents reviewed for dignity from a total sample list of 36 residents.

Inspectors wroteBased on interview and record review the facility failed to schedule a follow up cardiology appointment for one (R46) of two residents reviewed for dialysis in the sample list of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain treatment orders and implement pressure relieving interventions for three (R5, R14 and R4) of three residents reviewed for pressure ulcer wounds from a total sample list of 36 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse for one (R2) resident from another resident (R1) with known aggressive behaviors. This failure affects two (R1, R2) out of three residents reviewed for abuse in a sample list of three residents.

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by a staff member. This failure affected two of four residents (R2, R3) reviewed for abuse in the sample of four. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This failure affected three of five residents (R1, R2, R3) reviewed for abuse in the sample of nine. R1 pushed R2 who sustained skin tears to both elbows. R1 shoved R3 who fell into the wall, hit her head/back against the wall, then fell to the ground. R3 complained of back pain and was sent to the emergency room. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse can include such things as hitting, slapping, pinching, and kicking. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to adequately supervise and maintain a safe environment for residents, thoroughly investigate a fall, and failed to include a focus area, goal and interventions for a resident. These failures affect three residents (R2, R4, R6) out of three residents reviewed for falls in a sample list of nine residents. R6 sustained a dislocated Right Fourth finger and Left Foot Contusion as a result of an unwitnessed fall when the resident was found with dresser on top of him. Findings Include: 1. R6's Electronic Medical Record (EMR) documents R6's medical diagnoses as Dislocated Right Fourth Finger, Contusion to Left Foot, Moderate Dementia with Agitation, Delusional Disorder, Dysthymic Disorder and history of Embolism and Thrombosis of Deep Veins of Left Lower Extremity. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Director of Nurses (DON). This failure has the potential to affect all 47 residents in the facility. Findings Include: Upon survey entrance and throughout the survey (5/2/24- 5/3/24) there was no Director of Nurses present and employed by the facility. On 5/3/24 at 1:40 PM V1 Administrator confirmed the facility does not currently employ a full time Director of Nurses. There has not been a full time DON employed by the facility since March 2024. V1 confirmed the facility census is currently 47 residents. The facility's Facility assessment dated [DATE] documents a full time nursing supervisor (Director of Nurses) is required in order to meet the resident's needs and provide competent support and care for the facility's resident population.

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident by failing to follow the Abuse Prevention Program and remove an alleged perpetrator and implement interventions in order to keep others free from abuse. This failure affected three of five residents (R1, R2, R3) reviewed for abuse in the sample of nine. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse can include such things as hitting, slapping, pinching, and kicking. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on three of eight days reviewed for RN staffing. This failure has the potential to affect all 48 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on two of 18 days reviewed for RN staffing. This failure has the potential to affect all 49 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe and homelike environment for nine of nine (R1, R2, R3, R4, R5, R6, R7, R8, and R9) residents reviewed for their environment on the sample list of seven. This failure also has the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to protect residents' right to be free from abuse perpetrated by another resident. This failure affects two residents (R1 and R3) out of five reviewed for abuse allegations on the sample list of 24.

Inspectors wroteBased on interview and record review, the facility failed to provide therapy services as ordered by the physician for three of three residents (R17, R18, R19) out of seven reviewed for therapy on the sample list of 24. Findings Include: The Facility assessment dated [DATE] documents the facility provides therapy services through a contract agency. On 3/20/24 at 1:32 pm, V1 AIT (Administrator in Training) stated the facility currently does not have a therapy service and hasn't since 2/20/24. V1 stated the prior contracted therapy company walked out and stopped providing [NAME] due to non-payment by the facility's corporate ownership entity. V1 further stated a new company had been scheduled to begin providing services at the facility on 3/4/24 but had not yet come to the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify a resident's fall risk by inaccurately completing the admission fall risk assessment, develop an at risk for falls care plan and implement fall prevention interventions, provide appropriate supervision and assistance to prevent falls, investigate falls and implement appropriate post fall interventions for two of three residents (R1, R2) reviewed for falls on the sample list of three. This failure resulted in a newly admitted resident (R2) not being identified as a fall risk therefore not having any fall prevention interventions implemented. R2 experienced daily falls, including a fall on 1/26/24 in which R2 sustained a facial laceration requiring closure with adhesive glue and strips at the Emergency Room. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to employ a full time Director of Nursing. This failure has the potential to affect all 48 residents who reside at the facility. Findings Include: On 2/6/24 at 8:45 am, V2 AIT (Administrator in Training) stated the facility does not have a DON (Director of Nursing) or anyone serving as a DON full time explaining that the former DON quit on 1/19/24. The Facility assessment dated [DATE] documents the facility will have an RN with administrative duties 8-12 hours a day. The facility Nurses Midnight Census dated 2/5/24 documents 48 residents reside at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a Director of Nursing was working full time in the facility and failed to have a Registered Nurse working eight consecutive hours in a 24 hour period for five of 11 days reviewed. This has the potential to affect all 48 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to have a licensed administrator managing the facility. This failure has the potential to affect all 48 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to immediately report an allegation of abuse (R1) to the Abuse Coordinator. This failure affects 11 residents (R1, R2, R5, R6, R7, R8, R9, R10, R11, R12, R13) residing on the Dementia unit reviewed for abuse in the sample list of 13.

Inspectors wroteBased on interview and record review the facility failed to maintain a complete and accurate medical record for one of five residents (R1) reviewed for accuracy of medical records on the sample list of four.

Inspectors wroteBased on interview and record review, the facility failed to operationalize their Abuse Prevention Program by failing to complete pre-employment background screenings for an employee and failing to investigate and report allegations of misappropriation of property. This failure has the potential to affect four of four residents (R1, R2, R3 and R4) reviewed for abuse on the sample list of four. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility will implement systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively, and make necessary changes to prevent future occurrences. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free of misappropriation of property for one of four residents (R1) reviewed for abuse on the sample list of four. Findings Include: The facility Abuse Prevention Program dated 11/28/16 documents this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property and exploitation as defined below. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. R1's MDS (Minimum Data Set) dated 8/30/23 documents R1 is alert and oriented. R1's abuse folder contained a Facility Reported Incidents Smart Sheet Form dated 12/7/23 documents, R1 reported that R1's debit card was missing. [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of misappropriation of resident property to the State Survey Agency and local police for one of four residents (R1) reviewed for abuse on the sample list of four. Findings Include: The facility's Grievance Log contained the following grievance's from R1: 8/29/23 - R1 reported someone tried to use R1's card to pay a bill at Verizon. R1 asked to get more information. R1 called card company and they will refund the money to the card in 7-14 days. Police called and R1 was educated on not giving R1's card to anyone to use and R1 said R1 would work on it. 10/6/23 - R1 claims $105 is missing from R1's room and that the money was in a black sock. [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate allegations of misappropriation of resident property for one of four residents (R1) reviewed for abuse on the sample list of four. Findings Include: The facility's Grievance Log contained the following grievance's from R1: 8/29/23 - R1 reported someone tried to use R1's card to pay a bill at Verizon. R1 asked to get more information. R1 called card company and they will refund the money to the card in 7-14 days. Police called and R1 was educated on not giving R1's card to anyone to use and R1 said R1 would work on it. 10/6/23 - R1 claims $105 is missing from R1's room and that the money was in a black sock. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Infection Preventionist had completed required training on infection prevention and control. This failure has the potential to affect all 44 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain updated infection control logs, report a communicable disease to the local health department, label isolation linen containers, handle linens appropriately, and implement isolation for a resident (R2) with suspected Scabies (a highly contagious skin condition caused by a mite). These failures affect four (R1, R2, R3, R4) of four residents reviewed for infection control in the sample list of four.

Inspectors wroteBased on interview and record review the facility failed to provide showers as scheduled for one (R3) of three residents reviewed for showers in the sample list of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor a rash, document weekly skin assessments, and report a newly identified rash to the physician to obtain treatment orders. These failures affect two (R1, R3) of four residents reviewed for rashes in the sample list of four.