Axiom Healthcare of West Frankfort

Inspectors wroteBased on interview and record review, the facility failed to ensure the notifications and required reasons for transfer/discharge were adequately communicated and documented in the medical record and failed to permit a resident to return to the facility after hospitalization for two (R1 and R2) of three residents reviewed for inappropriate transfer and discharge in the sample of 32. This failure would cause a reasonable person to experience feelings of fear, agitation, anxiety, and distress as a result of being removed from their home and taken to an unfamiliar location with unfamiliar people, far away from family.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide enough staff to perform care duties timely. This failure has the potential to affect all 49 residents residing at the facility.

Inspectors wroteBased on interview, observation and record review the facility failed to discontinue using the kitchen for food preparation during a sewage backup affecting the kitchen. This failure has the ability to affect all 49 residents residing in the facility.

Inspectors wroteBased on interview, observation and record review the facility failed to treat residents with dignity, respond to residents quickly, and speak to residents respectively for 14 (R4, R5, R6, R8, R10, R13, R14, R16, R17, R23, R26, R28, R29, R32) of 14 residents reviewed for dignity in a sample of 32.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide working showers and toilets and failed to provide an environment free of sewage backup and odors for 17 (R4, R5, R10, R14, R16, R17, R18, R19, R21, R22, R23, R26, R27, R29, R30, R31, R32) of 17 residents reviewed for sanitary environment in a sample of 32.

Inspectors wroteBased on interview, observation and record review the facility failed to maintain free passage through exit doors in case of emergency procedures. This failure has the potential to affect the 31 residents residing on the 200 and 300 Halls.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide food at a palatable temperature for 5 (R10, R13, R14, R30, R31) of 5 residents reviewed for cold food in a sample of 32.

Inspectors wroteBased on interview and record review the facility failed to provide bed hold policy before/upon transfer from the facility for one (R1) of three residents reviewed for discharge process in the sample of 32.

Inspectors wroteBased on interview, observation, and record review, the facility failed to implement care plan fall interventions for 3 (R2, R4, and R13) of 5 residents reviewed for accidents in a sample of 46. This failure resulted in R2 being sent to the hospital after a fall and diagnosed with a closed fracture of left orbit and closed fracture of left side maxilla.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff were available to provide needed care in a timely manner. This failure has the potential to affect all 46 residents residing at this facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a full time Director of Nursing and to have a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 46 residents residing at this facility.

Inspectors wroteBased on interview, observation, and record review the facility failed to maintain an effective pest control program to rid the facility of gnats. This failure has the potential to affect all 46 resident currently residing in the facility.

Inspectors wroteBased on interview and observation the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 5 of 5 residents (R15, R22, R23, R32 and R38) reviewed for call light response times in a sample of 46.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide a method to call for assistance from the toilets and shower rooms for 36 (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R17, R19, R21, R22, R24, R25, R26, R28, R29, R30, R31, R32, R33, R36, R38, R39, R40, R41, R42, R43, R45, and R46) of 36 residents reviewed for accommodations of needs in a sample of 46.

Inspectors wroteBased on interview, observation, and record review the facility failed to maintain repairs to windows, floors, and radiators and keep resident floors, bathrooms, and shower areas clean for 36 (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R17, R19, R21, R22, R24, R25, R26, R28, R29, R30, R31, R32, R33, R36, R38, R39, R40, R41, R42, R43, R45, and R46) of 36 resident reviewed for safe clean, comfortable environment in a sample of 46.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide supplements as ordered to underweight residents for 4 (R1, R2, R3, and R15) of 6 residents reviewed for nutritional status in a sample of 46.

Inspectors wroteBased on interview, observation, and record review the facility failed to follow the menu provided for the residents receiving the mechanical soft diet for 6 (R9, R13, R16, R28, R31, and R37) of 6 residents reviewed portion sizes in a sample of 46.

Inspectors wroteBased on interview, observation and record review the facility failed to provide the mechanical soft diet as directed by the recipe for 6 (R9, R13, R16, R28, R31, and R37) of 6 resident reviewed for mechanical soft diets in a sample of 46.

Inspectors wroteBased on interviews, observations, and record review the facility failed to follow and maintain proper infection control practice for indwelling catheters and while providing indwelling catheter care and proper sanitation for glucometers for 6 (R2, R5, R19, R29, R31, and R34) of 12 residents reviewed for infection control in a sample of 46.

Inspectors wroteBased on interview and record review the facility failed to respond to a grievance in a timely manner for one (R3) of one resident reviewed for grievance responses in a sample of 46.

Inspectors wroteBased on record review and interview, the facility failed to ensure a level II Preadmission screening and Resident review (PASRR) was completed for a resident with a diagnosed mental disorder for 1 (R4) of 2 residents reviewed for PASRR screening in a sample of 46.

Inspectors wroteBased on interview, observation and record review the facility failed to follow the dietary preferences for 2 (R10 and R40) of 12 residents reviewed for dietary preferences in a sample of 46.

Inspectors wroteBased on interview and record review the facility failed to provide influenza and pneumococcal vaccinations after consent forms had been signed for 2 (R2 and R15) 5 residents reviewed for immunization in a sample of 46.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with dignity and respect when providing care to maintain or enhance his or her self-worth and value resident input for 13 (R1, R3, R4, R5, R6, R7, R8, R9, R11, R12, R13, R14, and R15) of 15 residents reviewed for resident rights.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide food in a manner that was palatable for 14 (R1, R2, R3, R4, R5, R6, R7, R8, R9, R11, R12, R13, R14, R15) of 15 residents reviewed for palatable food.

Inspectors wroteBased on observation, interview, record review the facility failed to provide supervision during smoking to prevent an accident and failed to provide an appropriate intervention to prevent future falls for 1 of 15 residents (R27) reviewed for accidents in a sample of 48. This failure resulted in R27 falling outside in the designated smoking area and then having to be sent out to the emergency room for laceration on her left and right arm and having to be seen by a wound care specialist.

Inspectors wroteBased on interview, and record review, the facility failed to ensure privacy was maintained for residents. This deficient practice has the potential to affect all 52 resident that reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to address a concern area discussed and documented in resident council. This failure has the potential to affect all 52 residents residing at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure all staff maintained the appropriate licenses while working at the facility. This failure has the potential to affect all 52 residents residing at the facility.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide beverages to residents. This failure has the potential to affect all 52 residents residing at the facility.

Inspectors wroteBased on interview and record review the facility failed to respect the resident rights to have an environment that promotes maintenance and enhancement of his or her quality of life for 40 of 40 residents (R1, R2, R3, R4, R5, R6, R7, R8, R10, R11, R12, R13, R15, R16, R17, R18, R19, R21, R23, R24, R25, R26, R27, R29, R30, R31, R32, R33, R35, R38, R39, R40, R41, R42, R43, R44, R45, R46, R47, R48) that live on the north and south halls reviewed for resident rights in a sample of 48.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a method for altering staff when resident's need assistance for 5 (R4, R7, R15, R17, R30) of 15 residents reviewed for call lights in reach in a sample of 48.

Inspectors wroteBased on interview and record review the facility failed to provide a smoke/vape free building for 5 of 5 residents (R2, R5, R6, R18, R23) reviewed for environment in a sample of 48. Findings Include:On 08/28/25 at 10:06AM, R2 who was alert and orientated stated that she has observed a staff member who was vaping in the hallway of the building. R2 stated that she doesn't know the staff name, but she is the one who looks like a boy. On 08/28/25 at 10:08AM, R6 who was alert and orientated stated that he has witnessed staff vaping in the hallway. R6 said that they vape in the hallway on day and evening shift. R6 said that it has been several staff and didn't want to name any names. On 08/28/25 at 11:23AM, R5 who was alert and orientated stated that she has witnessed staff vaping in the hallways and in some resident rooms. R5 said that they pull out their vapes often. [...]

Inspectors wroteBased on interview and record review the facility failed to follow the menu provided to the facility and correct portion sizes directed by the menu for 7 (R2, R3, R6, R9, R11, R13 and R27) of 15 residents reviewed for following the menu in a sample of 48.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide enough evening snacks so every resident may have a snack in the evening for 8 residents of 17 residents (R2, R3, R7, R11, R20, R27, R29, and R35) reviewed for evening snacks in a sample of 48.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from mental abuse for 1 of 15 residents (R34) reviewed for abuse in a sample of 48.

Inspectors wroteBased on interview and record review the facility failed to report and allegation of staff to resident abuse to the state agency (Illinois Department of Public Health) and failed to report an allegation of staff to resident abuse to the Administrator for 1 of 15 residents (R4) reviewed for abuse and neglect in the sample of 48.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly and timely investigate an allegation of staff to resident abuse for 1 of 15 residents (R4) reviewed for abuse in a sample of 32

Inspectors wroteBased on interview, and record review the facility failed to ensure they had RN (Registered Nurse) coverage 8 hours/day, 7 days/week. This failure has the potential to affect all 50 residents who reside at the facility. Findings Include:The undated facility Room Roster documents 50 residents currently reside at the facility. On 8/18/25 at 3:20 PM, V2 (Director of Nurses) stated she didn't have a Registered Nurse on staff. V2 stated she does have agency Registered Nurses that work at the facility at times. The facility schedules dated July 2025 and August 2025 documents the facility did not have RN coverage on 7/18, 7/19, 8/9, 8/10, and 8/23/25. On 8/18/25 at 4:25 PM, V2 confirmed in email the facility did not have RN coverage on the above listed dates.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered as ordered for 1 of 1 (R5) resident reviewed for medication administration in the sample of 9. Findings Include:R5's facility Transfer/Discharge Report with a print date of 8/18/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, delusional disorder, insomnia, and moderate intellectual disability. R5's MDS (Minimum Data Set) dated 6/30/2025 documents a Brief Interview for Mental Status score of 15, indicating R5 is cognitively intact. R5's Order Summary Report Active Orders as of: 04/19/2025 includes the following physician order with a start date of 04/18/2025, Preservision AREDS 2 Soft gel Give 1 capsule orally one time a day for Supplement Take 1 Capsule by Mouth Once Daily (Supplement). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were available to be administered as ordered for 1 of 1 (R5) resident reviewed for pharmacy services in the sample of 9. Findings Include:R5's facility Transfer/Discharge Report with a print date of 8/18/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, delusional disorder, insomnia, and moderate intellectual disability. R5's MDS (Minimum Data Set) dated 6/30/2025 documents a Brief Interview for Mental Status score of 15, indicating R5 is cognitively intact. R5's Order Summary Report Active Orders as of: 04/19/2025 includes the following physician order with a start date of 04/18/2025, Preservision AREDS 2 Softgel Give 1 capsule orally one time a day for Supplement Take 1 Capsule by Mouth Once Daily (Supplement). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident requiring dialysis received dialysis treatments for 1 of 2 residents (R1) reviewed for dialysis in the sample of 11. This failure resulted in R1 being admitted to the hospital to receive dialysis treatment and pulmonary venous congestion.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage 8 consecutive hours a day, 7 days per week. This failure has the potential to affect all 40 residents living in the facility. Findings Include: The facility's agency nursing time reports documented no RN was on shift for 11/10/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/7/2024, 12/8/2024, and 12/21/2024. On 3/13/2025 at 7:50 AM, V10 (Licensed Practical Nurse/LPN) stated there were some days in October 2024 - December 2024 that they did not have RN coverage for 8 consecutive hours a day. On 3/13/2025 at 10:05 AM, V2 (Director of Nursing) stated there were no RN punch times noted on the agency nursing reports for 11/10/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/7/2024, 12/8/2024, and 12/21/2024. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to properly maintain the hot water source to reach minimum washing temperatures in the dish machine and handle food properly to prevent cross contamination. These failures have the potential to affect all 40 residents residing in the facility. The Findings Include: 1. On 3/11/25 at 1:00 PM, the kitchen staff were in the process of washing the lunch dishes after the meal was served in the dish machine. When the temperature in the dish machine was checked with a kitchen provided calibrated thermometer, the water temperature was 80 degrees. At this time V5 (Dietary Manager) verified their dish machine was a low temperature dishwasher that uses chemical sanitization. V5 stated that they have trouble sometimes with the water temperatures because of the way the system works. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain documentation of holding quarterly Quality Assurance and Performance Improvement meetings (QAPI). This has the potential to affect all 40 residents residing in the facility. The Findings Include: During the investigation and review of facility records no evidence of quarterly QAPI meeting attendance or meeting information was found or produced by the facility. On 03/13/25 10:41 AM, V1 (Regional Director of Operations) stated the facility has been having quarterly QAPI meetings but she was unable to find any documentation of minutes or attendance sheets to show that the facility held quarterly QAPI meetings past 2/16/2024. The facility policy for Quality Assurance Performance Improvement Program with last revision date of 10/24/22 documents the following: Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that dietary supplements were provided to residents as ordered for 4 (R4, R13, R19, and R20) of 4 residents reviewed for nutrition status in the sample of 27. The Findings Include: 1. R4's admission Record documents an admission to the facility on 1/13/2025 and included the following diagnoses: dementia, Vitamin D deficiency and Vitamin B12 deficiency. R4's current Physician Orders for diet are as follows: regular diet and mighty shakes twice a day for low Body Mass Index (BMI). R4's Care Plan has a focus area of: I have a potential nutritional problem. A goal for this focus area included: I will maintain adequate nutritional status daily through the review date. The interventions include: provide diet as ordered. 2. [...]

Inspectors wroteBased on observation and record review, the facility failed to notify the proper authorities in an abuse investigation in 1 (R14) of 1 resident reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure behavioral interventions and procedures for suicide observation and prevention were provided to a resident with suicidal ideations for 1 (R23) of 1 resident reviewed for behavioral health services in the sample of 27.

Inspectors wroteBased on observation and interview, the facility failed to safeguard medical record information against loss/destruction and ensure records were readily accessible for 3 (R2, R33, R38) of 3 residents reviewed in the sample of 27. The Findings Include: 1. R33's Electronic Health Record (EHR) included an admission Record documenting R33 admitted to the facility on [DATE]. R33's EHR was missing records dated prior to 1/29/25 (such as progress notes, behavior tracking, physician orders, etc.). 2. R38's EHR included an admission Record documenting R38 admitted to the facility on [DATE]. R38's EHR included an Minimum Data Set (MDS) assessment dated [DATE] documenting a discharge with return not anticipated assessment an listed a discharge status of Nursing Home (long-term care facility). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from chemical restraints when staff administered an injectable anti-psychotic medication twice within an 8 hour time frame without the resident's consent and without a physician's order to include adequate indications for use, and failed to attempt less restrictive alternative treatments prior to administration of the medication for 1 (R1) of 3 residents reviewed for chemical restraints in the sample of 7. This failure resulted in R1 being sent to the emergency room for lethargy, facial swelling, and possible allergic reaction to the anti-psychotic medication administered. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to timely remove discontinued medication from the working stock for 1 of 3 residents (R1) reviewed for medication storage in a sample of 7.

Inspectors wroteBased on interview and record review the facility failed to ensure residents are free from physical and verbal abuse for 2 of 5 residents (R26, R44) reviewed for abuse in the sample of 14. This failure resulted in R26 experiencing incidents of mental anguish, fear, anxiety, and feeling unsafe as a result of V34's (Certified Nursing Assistant/CNA) mental and verbal abuse. The Immediate Jeopardy began on 5/7/24 at approximately 2:00 AM when V34 (Certified Nursing Assistant/ CNA) verbally and physically abused R26 by ripping R26's clothing while transferring R26 to the wheelchair and wheeling R26 to the dining room to wait for breakfast. V44 (Regional Director of Operations) was notified of the Immediate Jeopardy on 5/15/24 at 12:35 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly and timely investigate an allegation of staff to resident abuse, and failed to prevent further abuse from occurring while allowing staff to continue to have direct care with residents after allegations were made for 4 of 5 residents (R26, R44, R46, and R300) reviewed for abuse in a sample of 14 residents. Due to this failure R26 was verbally and physically abused by V34 (Certified Nursing Assistant/CNA) on 5/7/24 at approximately 2:00 AM. This also had the potential to affect all 47 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility administration knowingly failed to report abuse allegations, thoroughly and timely investigate abuse allegations, suspend staff pending facility abuse investigations, and inaccurately document resident assessments for 3 of 5 residents (R26, R46, and R300) reviewed for administration in a sample of 14. This failure has the potential to affect all 47 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to allow residents to choose to reside in the same room with their spouse and visit other residents for 2 out of 3 residents (R300 and R301) reviewed for resident rights in a sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to identify and report allegations of staff to resident verbal abuse immediately to the Administrator and failed to report and allegation of abuse to the Illinois Department of Public Health (IDPH) for 3 of 5 residents (R44, R46, and R300) reviewed for abuse in the sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage 8 hours a day, 7 days per week. This failure has the potential to affect all 44 residents who reside in the facility. Findings Include: The facility's nursing schedules for February and March 2024 documented the following dates were lacking 8 hours of Registered Nurse (RN) coverage: 2/4/2024, 2/5/2024, 2/11/2024, 2/25/2024, 3/9/2024, 3/10/2024, 3/16/2024 and 3/17/2024. On 3/19/24 at 2:40 PM, V2 (Director of Nursing/DON) confirmed that the facility's February and March 2024 nursing schedules were accurate. On 3/19/24 at 2:46 PM, V1 (Administrator) confirmed the lack of Registered Nursing coverage on the above listed dates. V1 stated the weekend dates are difficult for them to get RN coverage. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to date and label opened food items/leftovers. This failure has the potential to affect all residents residing in the facility who receive food from the kitchen. The Findings Include: On 3/19/24 at 9:00 AM, during the initial tour of the kitchen, items in the refrigerator were found to be opened without identifying and dating the food. Items found not dated and labeled after opening were salad dressing, corn, tortillas, shredded cheese and a container of meat. At this time, V3 (Dietary Manager) stated that she has new employees that maybe do not know they need to do this. V3 further stated she was unsure what was even in the one container that appeared to be a type of meat. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. This has the potential to affect all 44 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep resident care areas clean and in a good state of repair for 14 (R7, R18, R10, R16, R23, R21, R41, R45, R29, R22, R25, R35, R15, and R20) of 14 residents reviewed for homelike environment in the sample of 36. Findings Include: On 03/19/24 09:56 AM, R7's room was observed to have two brown stained ceiling tiles, a missing cover on the baseboard heater, and a brownish-orange discoloration to the floor near the baseboard under the sink. In R7's room and bathroom, chipped paint was noted on multiple areas of the walls as well as chipped wood on the door inside bathroom. On 03/19/24 at 10:17 AM, R18, R10 and R16's adjoining bathroom had missing baseboard with stained drywall exposed. On 03/19/24 10:21 AM, R23's room revealed the front cover was missing off the baseboard heater. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely completion of quarterly assessments for 4 (R5, R7, R26, R45) of 4 residents reviewed for quarterly assessments in the sample of 36. Findings Include: 1. R5's Profile Face Sheet documents an admission date of 5/21/19. This same document includes the following diagnoses: Schizoaffective Disorder, Major Depression Disorder, Anxiety, and Dementia. On 2/21/24 at 11:00 AM, V4 (Minimum Data Set/MDS Coordinator) stated that R5's quarterly MDS (Minimum Data Set) assessment was due on 2/7/24 and it was not completed and transmitted until 3/20/24. R5's current quarterly MDS Assessment Section Z was reviewed and noted to be signed by V4 and dated 3/20/24. 2. R7's Profile Face Sheet documents an admission date of 9/23/22. This same document includes the following diagnosrs: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Clinical Health Record for 2 (R8, R151) of 2 residents reviewed for Advanced Directives in the sample of 36. 1. Review of R8's Profile Face Sheet documented an original admission date to the facility of [DATE]. Diagnoses listed on this same sheet included but were not limited to: Rhabdomyolysis; Acute Kidney Failure, Unspecified; Type 2 Diabetes Mellitus without complications, etc . R8's Illinois Department of Public Health Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form dated [DATE] documented orders for patient in cardiac arrest as, No CPR (cardiopulmonary resuscitation): Do Not Attempt Resuscitation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive assessments were completed in accordance with required time frames for 3 (R32, R23 and R151) of 3 residents reviewed for comprehensive assessments and timing in the sample of 36. Findings Include: 1. R23's Profile Face Sheet documents an admission date of 4/3/20, and includes the following diagnoses: Major Depressive Disoder, Dementia, Muscle Weakness and Aphasia. R23's most recent completed Minimum Data Set (MDS) was dated 10/11/23 and coded as a quarterly assessment. On 3/21/24 at 11:30 AM, V4 (MDS Coordinator) stated that R23 was due for a comprehensive annual MDS 1/16/24, but this was not completed and transmitted until 3/14/24. R23's current comprehensive annual MDS Section Z was reviewed and noted to be signed by V4 and dated 3/14/24. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to implement a baseline care plan for 1 (R151) of 12 residents reviewed for baseline care plans in a sample of 36. Findings Include: R151's admission and Discharge Record documents an admission date of 1/31/24. This same document includes the following diagnoses: Spinal Stenosis, Physical Deconditioning, Anxiety, Memory Impairment and Depression. Review of R151's medical record revealed no care plan could be found. On 3/20/24 at 2:34 PM, V4 (Minimum Data Set [MDS]/Care Plan Coordinator) stated that she does not have a care plan (Comprehensive or Baseline) started. V4 further stated that usually the nurses start the baseline care plan on admission or within 24-48 hours of admission, and then she creates the comprehensive care plan. The Baseline Care Planning policy with a revision date of 3/16/22 documents 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise a comprehensive plan of care to meet current resident needs for 2 (R28 and R34) of 13 residents reviewed for care plan timing and revision in the sample of 36. Findings Include: 1. Review of R28's admission and Discharge Record documented an original admit date to the facility of 10/20/23. R28's Cumulative Diagnosis Log documented diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, Hyperglycemia, Weakness, Developmental Disorder, etc . R28's Nurse's Notes document on 11/13/23 at 2:00 PM, an entry detailing the onset of a new 1 centimeter by 1 centimeter open area on his left buttock. An additional entry on 3/20/24 at 6:00 PM, documented an evaluation was made by V11 (Wound Physician), in which the wound to R28's left buttock was determined to be resolved as of this date. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer pneumococcal and/or covid vaccinations in accordance with guidelines for 2 (R15 and R41) of 5 residents reviewed for immunizations in a sample of 36.