Belhaven Nursing & Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to supervise and assist one resident (R1) with feedings that required feeding assistance. This failure affected one resident (R1) out of three residents reviewed.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that one resident's (R13's) preferred diet was followed. This failure has affected one of 5 residents reviewed for dietary services.

Inspectors wroteBased on interview and record review, the facility failed to accommodate resident food preferences by not offering menu alternatives or substitutes during weekend meal service. These failures have the potential to affect all 188 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions during food delivery by not covering food/utensils during transport and by food service staff not wearing hair restraints during meal service and in the kitchen. These failures have the potential to affect all 188 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident call lights were responded to in a timely manner for one resident (R7) out of five reviewed for call lights.

Inspectors wroteBased on interview and record review, the facility failed to keep the residents free from abuse. This deficient practice affected one (R6) of three residents reviewed for abuse. Findings Include:Facility Reported Incident submitted to the IDPH (Illinois Department of Public Health) dated 12/09/25 documents in part, R1 reported V21 (Licensed Practical Nurse) snatched his cigarette out of his mouth and broke it on 12/07/25. R6's electronic health record (EHR) shows R6 admitted to the facility 02/13/24 and had a planned discharge from the facility on 03/05/25. [...]

Inspectors wroteBased on interview and record review the facility failed to submit the final investigation for staff to resident abuse to the Illinois Department of Public Health (IDPH) within the required five business days for (R6) out of three residents reviewed for abuse. Findings Include:Facility Reported Incident submitted to the IDPH (Illinois Department of Public Health) dated 12/09/25 documents in part, R1 reported V21 (Licensed Practical Nurse) snatched his cigarette out of his mouth and broke it on 12/07/25. R6's electronic health record (EHR) shows R6 admitted to the facility 02/13/24 and had a planned discharge from the facility on 03/05/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free of any significant medication error for one (R1) of four residents reviewed for improper nursing care.

Inspectors wroteBased on interviews and record reviews, the facility failed to prevent R1's fall, failed to care plan R1's need for mechanical lift transfers, failed to have two staff members during a mechanical lift transfer for R1, and failed to notify R1's representative of a fall for one of five residents reviewed for improper nursing care.

Inspectors wroteBased on review of records and interviews facility failed to maintain resident rights to be free from all forms of abuse for 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4. These failures are not in accordance with facility's abuse policy and affected 2 residents (R1, R2) both experiencing physical abuse.

Inspectors wroteBased on review of records and interview facility the failed to follow abuse reporting policy for 2 out of 4 residents (R1, R2) in a total sample of 4 residents reviewed. This failure has the potential to affect R1 and R2 in timely determination of abuse incidents and providing necessary interventions to prevent possible recurrence.

Inspectors wroteBased on observation, interview and record review, the facility failed to update the daily nurse staffing information. This failure affected all 199 residents residing in the facility.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to meet safe food temperatures for four residents (R48, R50, R83, and R182), sanitize food preparation table and clean kitchen environment. All has the potential to cause foodborne illnesses. This applies to 196 residents receiving oral nutrition.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to properly dispose of dietary trash in their garbage disposal bins. This applies to 199 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that Enhanced Barrier Precaution (EBP) sign was visibly posted; failed to provide Personal Protective Equipment (PPE) for a resident who requires EBP; failed to don PPE and perform hand hygiene in a contact isolation residents room; failed to follow infection control protocols by not tracking for legionella's; and failed to track antibiotic per facilities guidelines. These failures affected four residents (R140,R158 and R161,R197) and has the potential to affect all 199 residents reviewed for infection control.

Inspectors wroteBased on interview and record review the facility failed to maintain an adequate antibiotic stewardship program to prevent the spread of infectious Disease throughout the facility. This failure affected one resident (R140) and has the potential to affect all 199 residents residing in the facility. R140 has a diagnosis of but not limited to is currently a discharged resident but was admitted to facility on 10/17/2025-12/2/2025 with diagnosis documented in part: Neuralgia and neuritis, chronic pain, anxiety, abnormal liver function, personal history of COVID -19,anemia,benign prostatic hyperplasia with lower urinary tract symptoms, pressure ulcer of right buttock stage 4,pressure ulcer of right hip stage 4,neurogenic bowel. R140's record review of Order Summary Report displays that R140 in November 2025 R14o was on Doxycycline x 14 days from 11/20/25 -11/29/2025 . [...]

Inspectors wroteBased on interview and record review the facility failed to vaccinate eligible residents with the influenza and pneumococcal vaccine. The facility failed to document the declination and/or the benefits and side effects in the resident's electronic medical records. This deficient practice affected 6 residents (R4,R50,R114,R183,R197,R210) sampled in a total sample size of 72 and has the potential to affect all eligible residents that reside at the facility. Review of records for R4, R50, R114, R183, R197, R210, from admission dates to 12/16/25 have no findings of documentation of pneumococcal and or Influenza vaccine offering or education of the vaccine. Review of physician orders for R4, R50, R114, R183, R197, and R210 from admission to 12/16/25 show no orders of pneumococcal and or influenza vaccination. [...]

Inspectors wroteBased on Observation, interview, and record review, the facility failed to ensure that COVID vaccine was offered to residents and documented and failed to offer and provide education to staff regarding COVID vaccination. this failure has the potential to affect all 199 residents that reside in the facility. On 12/15/2025 at 11:09 am,V14 (Certified Nursing Assistant) stated that he was offered Influenza vaccine and declined the vaccine because he received the vaccine at his clinic on 11/19/25, V14 stated he gave human resource director a copy of his immunization records and signed the declination form. On 12/16/2025 at 12:10 pm,V11 ( Infection Control Nurse) stated that she has not offered the COVID vaccine to residents for 2025 and does not have any records to display that the residents consented or declined the vaccine and stated it was an oversight on her part. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to prevent insects from flying above and around food and food preparation areas. All has the potential to cause foodborne illnesses. This applies to 196 residents (census of 199 residents minus 3 residents with gastronomy tubes) receiving food from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to respect a resident's dignity by not maintaining a resident's urinary catheter drainage bag in a privacy bag for 1 of 1 (R209) reviewed for residents right in a sample of 72.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light device was within reach for one resident, (R67). This failure affected one resident (R67) and has the potential to affected all residents in the sample size of 72.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a code status physician's order was in a resident's electronic medical record (EMR). This failure affected one resident (R16) in a sample of 72 residents reviewed for advance directives.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that resident's equipment is clean for two residents (R4, R116) and the privacy curtains are clean and not tattered for one resident (R6). This failure affected 3 residents (R4, R6, R116) and has the potential to affect all 72 residents in the sample size.

Inspectors wroteBased on interview and record review the facility failed to refer one resident (R8) for rescreening to the state agency for Preadmission Screening and Resident Review (PASRR) before R8's Short Term Approval without Specialized Services determination had expired. This deficient practice affected one resident (R8) in a total sample size of 72 residents.

Inspectors wroteNumber of residents sampled:72Number of residents cited:1Based on Observation, interview, and record review, the facility failed to ensure that restorative rehabilitation program for splint device application was being thoroughly implemented as documented in plan of care. This failure affected one resident (R183) reviewed for splint devices in a sample of 72 residents. On 12/14/2025 at 11:00am, R183 was observed sitting in his wheelchair next to side of his bed, no leg rest were observed on the wheelchair and AFO splint was on shelf directly in front of where R183 was sitting, right lower extremity/foot was laying on the floor in an inward position. R183 stated that staff places the splint on sometimes but that they did not place the AFO on today and that he would like the AFO placed on. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to properly label oxygen nasal cannula tubing to ensure specialized care needs for the provision of respiratory care. This failure affected 1 of 1 resident (R44) reviewed for respiratory care in a sample of 72. R44's Face Sheet dated 12/17/2025, documents a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Acute and Chronic Respiratory Failure, Unspecified Whether with Hypoxia or Hypercapnia, Hypertensive Chronic Kidney Disease Stage 1 Through Stage 4 Chronic Kidney Disease, Chronic Bronchitis, and Dependence On Supplemental Oxygen. [...]

Inspectors wroteBased on observations, interviews, and record review, failed to ensure the narcotics accountability of controlled medication was accurate. This failure affected one resident (R196) and have the potential to affect all 64 residents on the third floor unit.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a residents had a privacy curtain which extended around the bed. This failure affected one residents (R78) residents in the total sample of 72 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a comfortable environment for one resident (R140). This failure affected one resident (R140) reviewed for environmental concerns.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received meal preferences and substitutes as requested. This failure affected 3 of 3 residents (R1, R2, R3) reviewed for meal preferences and substitutions. Findings Include:On 9/15/2025 at 1:46 pm, R1 stated he (R1) has informed staff several times that his dislikes should be noted on his meal ticket as ham, turkey, dressing, and oatmeal. R1 stated his meal ticket documents No Pork and he has informed staff that he eats pork but not ham. On 9/15/2025 at 1:31 pm, V7 (Certified Nurse's Assistant) stated residents are made aware of the meal substitutions every morning by the activity aide. V7 stated sometimes during mealtimes, a meal substitution will look appealing to a resident who has not requested a substitution meal, and the resident will make a request for that substitution. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were provided meals and snacks at appropriate times, in accordance with 42 CFRS483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. These failures have the potential to affect all 199 residents who receive oral meals from the facility's kitchen. Findings Include:On 08/25/2025 at 09:45 AM Surveyor was provided with facility census listing 199 residents residing in the facility. On 08/25/2025 at 1:00pm surveyor observed the Dining Rooms on the 2nd floor that revealed:Food Carts had been brought to the 2nd Floor Dining so staff could start the lunch meal service. [...]

Inspectors wroteBased on observations, interviews and record reviews, facility failed to administer resident's medications according to physician orders and instructions. This failure affected one out of three residents reviewed for medication administration and has the potential to affect all 26 residents on the second - floor unit receiving medications from the split medication cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement resident-directed care consistent with the resident's comprehensive assessment, professional standards of practice by a.) provide feeding assistance to two (R9, R10) residents b.) help a resident maintain their dignity during mealtime for one resident (R10) in a total sample of 10 residents. This failure places the resident at risk for more than minimal harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) ensure drinks consumed are in the appropriate form as ordered by the physician for one resident (R10) b.) provide the appropriate nutrient content as ordered by the physician order for two (R8, R9) out of ten residents reviewed for dietary services. This failure places the resident at risk for more than minimal harm.

Inspectors wroteBased on interview and record review, the facility failed to follow a physician order and monitor a resident's vital signs for one (R1) out of four residents reviewed for quality of care in a total sample of four. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. This failure places the resident at risk for more than minimal harm.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that the resident's call light system was working properly. This failure has the potential to affect 64 residents that reside on the second floor.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to maintain a safe, comfortable home like environment,[A] failed to maintain room temperatures for four [R4, R5, R6, R7] of seven [R1, R2, R3] residents reviewed for heating.

Inspectors wroteBased on interview and record review the facility failed to ensure that resident's medications are administered as ordered by the physician. This failure affected three residents (R1, R2 and R3) of three residents reviewed for quality of care.

Inspectors wroteBased on interviews, and record review, the facility failed to provide necessary treatment and services to promote healing of existing wounds for one (R1) of three residents reviewed. This failure has the potential for R1's wounds to get worse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident (R1) with a pressure ulcer, received the necessary treatment and services to promote wound healing and prevention of new wounds. This failure resulted in R1's wound worsening and requiring hospitalization for wound infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to respond to call lights used for staff assistance for 2 dependent residents (R5 and R6). This failure affected two of five residents reviewed for call light assistance.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy for scheduled medication administration time frame. This failure affected one resident (R2) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning call device for a dependent resident requiring assistance from staff. This failure affected 1 resident (R6) reviewed for resident call system.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident is free from physical assault from another resident. This failure affected one resident (R2) who was physically assaulted by another resident (R1) with a history of physical aggression toward others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) provide adequate supervision and monitoring for residents, b.) ensure medications were administered as ordered by the residents' physician, c.) ensure medications were given when the Medication Administration Record was signed, d.) notify physician of residents not receiving medications, e.) ensure medications were locked and secured while unattended, f.) provide sufficient nursing coverage to ensure adequate resident care and support, and g.) provide care and services that meet professional standards. These failures have the potential to affect 125 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy on abuse to protect residents' rights to be free from physical abuse. This failure resulted in: 1-R2 and R3 engaging in a verbal altercation that resulted in R2 pushing R3 causing R3 to fall while in the dining room. 2-R5 hitting R4, resulting in R4 sustaining a swollen lip and R4 was sent to the hospital. Findings Include: On 12/31/24, at 10:34 AM, R3 stated yes, R2 pushed R3 from the wheelchair in the dining room and R3 fell on R3's buttocks. On 12/31/24, at 10:54 AM, R2 stated that R2 has been in this facility for 3 years and R2 has a sitting spot in the dining room. R2 stated that R2 cannot remember the incident on 11/19/24 between R2 and R3, but R2 was sent to [NAME] Park Hospital for eight days. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate supervision to four (R2, R3, R4, and R5) residents while in the dining room out of four residents reviewed for supervision. This failure resulted in 1-R2 and R3 engaging in a verbal altercation that resulted in R2 pushing R3 causing R3 to fall. 2-R5 hitting R4, resulting in R4 sustaining a swollen lip and R4 was sent to the hospital. Findings Include: On 12/31/24, at 10:34 AM, R3 stated yes, R2 pushed R3 from the wheelchair in the dining room and R3 fell on R3's buttocks. On 12/31/24, at 10:54 AM, R2 stated that R2 has been in this facility for 3 years and R2 has a sitting spot in the dining room. R2 stated that R2 cannot remember the incident on 11/19/24 between R2 and R3. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to accurately log dish machine temperatures and failed to ensure that that the dish machine was functioning properly. This failure has the potential to affect 162 residents who receive meals from the facility kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident (R57) on enhanced barrier precaution (EBP) has an EBP sign posted by the resident's room, failed to ensure residents (R32, R57, R94, and R100) on enhanced barrier precautions have readily available PPE (personal protective equipment) for the staff, failed to ensure staff don appropriate PPE when performing ADL (Activities of Daily Living) care for 2 resident (R109 and R148, failed to ensure soiled linens coming out of laundry chute and soiled linens on laundry room floor were contained, and failed to monitor measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems that is based on nationally accepted standards. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice. The facility failed to vaccinate eligible residents with the pneumococcal vaccine. The facility failed to document the refusal and/or the benefits and side effects in the resident's electronic medical records. This deficient practice affected 9 residents (R40, R46, R55, R74, R104, R118, R132, R148 and R159) sampled in a total sample size of 74 and has the potential to affect all eligible residents that reside at the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications/substances during shift change. This failure affected 7 (R15, R41, R66, R82, R152, R158 and R164) residents taking controlled medications on 1-West and 5 (R16, R56, R135, R144, and R314) residents taking controlled medications on 2-East.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that four residents (R55, R104, R116 and R118) had psychotropic consents signed prior to administering antipsychotic medication. This failure has the potential to affect 85 other residents who have orders for psychotropic medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure multidose medications have open and discard dates and failed to ensure a multidose medication of a discharged resident was removed from the medication cart. These failures affected 4 (R14, R41, R154, and R165) residents reviewed for Medication Storage and Labeling in the total sample of 74 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the two wall heating unit vents in dining room and the hallway on the third floor are maintained in good repair and in a sanitary manner. This failure has the potential to affect all 50 residents on the third floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain and document the code status in the resident's electronic medical record which affected two residents (R9 and R41) reviewed for advanced directive in the sample of 74 residents.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that one resident's (R115) privacy curtain in his room was clean and free of a brown substance. This failure has affected one of five residents reviewed for nursing care.

Inspectors wroteBased on observation, interview and record review the facility failed to provide Activity of Daily Living (ADL) care to one resident seeking assistance with care (R109) in a total sample size of 74 resident. On 10/28/24 at 10:40am observed V33 (Certified Nursing Assistant/CNA) leaving R109's room with bag of soiled linen from R109's roommate. On 10/28/24 at 10:41am R109 observed laying in bed on R109's left side with incontinence brief exposed. R109 observed with stool draining from side of incontinence brief. On 10/28/24 at 10:41am R109 stated that he informed V33 (CNA) that he needed to be cleaned. R109 stated that his call light has been on for assistance to clean him. R109 stated that he has had two bowel movements in the incontinence brief and has been waiting to be cleaned since the first bowel movement was made. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions for residents at risk for pressure ulcers. This failure has the potential to affect two residents (R39 and R118), reviewed for wheelchair cushions as a pressure ulcer prevention intervention, in a total sample of 74 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the fall prevention interventions as stated in the care plans for residents with Dementia who are also at risk for falls. This failure has the potential to affect two residents, R132 and R215, reviewed for proper footwear as a fall prevention intervention, in a total sample of 74 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the urinary drainage bag was hanging below the bladder. This failure affected one resident (R9) reviewed in a sample of 74.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the nebulizer mask was contained and failed to post oxygen signage outside of the resident's room. These failures affected one resident (R159) reviewed for respiratory care in the total sample of 74 residents. Findings Include: R159's history documents in part, COPD, (Chronic Obstructive Pulmonary Disease) chronic respiratory failure, and shortness of breath. R159's Minimum Data Set (MDS), dated [DATE] documents in part, Section C. Brief Interview for Mental Status (BIMS) score of 15 which indicates that R159 is cognitively intact. Section J. Health Conditions: C. Shortness of Breath or trouble breathing when lying flat. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medications were safely locked up in the treatment cart when not in use to prevent tampering and accidental hazard; failed to ensure that resident medications were not left at bed side for two residents (R9 and R10); failed to ensure that adequate supervision is offered to one resident (R2) in the sample reviewed for falls. This failure affected R9 and R10 whose medications were left at bedside without physician order, and R2 who had a fall resulting in a laceration to the head. This has the potential to affect all 163 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that call lights are within reach for 7 of 7 residents reviewed for call lights in the sample. This failure affected R5, R7, R8, R9, R12, R13, and R14 whose call lights were not within reach while in bed.

Inspectors wroteBased on interview and record review the facility failed to report to IDPH (Illinois Department of Public Health) within required time unwitnessed fall incident with injury for one resident (R2) reviewed for falls in the sample. This failure affected R2 who had unwitnessed fall resulting in a laceration to the head and was sent to a local emergency room. This has the potential to affect all 163 residents residing in the facility.

Inspectors wroteBased on observation, interviews and record review the facility failed to follow Medical Doctor's orders for PRN (as needed) wound dressing change and wheel chair cushion to prevent the worsening of a wound for one patient (R1) who has a facility acquired stage four pressure wound. This failure has resulted in R1's facility acquired DTI (deep tissue injury) to progress to a Stage 4 pressure wound. And the facility failed to follow Medical Doctor's orders for PRN wound dressing change for one patient (R6) with a stage 4 pressure wound observed to be saturated with feces. This failure could result in worsening of R6's wound.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that one patient's (R6) pain was managed with prescribed medication every four hours as ordered. This failure has resulted in R6 experiencing pain of 10 on a scale of 1-10 during wound care and ADLs (Activities of daily living).

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that four patients (R2, R5, R6 and R8) were provided with incontinent care. This failure resulted in these four residents being soiled with urine and/ or feces for extended periods during the overnight shift.

Inspectors wroteBased on interview and record review the facility failed to ensure that resident's medications are administered as ordered by the physician. This failure affected three residents (R1, R2, and R3) out of the three resident reviewed for quality of care and administration of prescribed medications.

Inspectors wroteThe facility failed to follow provider orders and change the wound treatment plan for one resident (R4) out of a total sample of three residents (R4, R10, R11) for review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints imposed for three of three residents (R8, R9, R10) reviewed for restraints, resulting in the restriction of mobility and a potential for decline in physical functioning and psychosocial wellbeing. Findings Include: 5/23/2024 at 2:00 PM, R8, R9, R10 observed sitting in wheelchairs at Dining Room table; back wheels of each resident's wheelchair positioned up against the wall behind them, table positioned up against the armrests of resident's wheelchairs restricting residents' movements. R8, R9, and R10 were observed attempting to stand up multiple times. No meal or activity was in progress. R10 was eventually able to position legs over side of wheelchair allowing her to stand up and move from behind table. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents were free of abuse/physical assault. This affected two (R1, R3) of three residents reviewed for physical abuse with injuries. R4 hit R3 and R3 sustained injuries to the forehead and lips. As a result, R3 was sent to the hospital. And R2 physically attacked R1, R1 sustained injuries to the head and face and was hospitalized for 2 days.

Inspectors wroteBased on interview and record review, the facility failed to: adequately supervise and monitor a resident(R2) who has a history of physically assaulting other residents, and failed to provide the appropriate intervention when R2 refused to sleep and paced the hall all night on 2 consecutive days; and failed to supervise R1 who has weakness due to paralysis. As a result, R2 physically attacked R1, and R1 sustained injuries to the head and face and was hospitalized for 2 days.

Inspectors wroteBased on interview and record review the facility failed to recognize, evaluate, and address weight loss; and the facility failed to consistently implement interventions, monitor the effectiveness of interventions and revise them as necessary. These failures resulted in 1 resident [R3] of 4 [R5, R6, R10] residents sent to the emergency department with a diagnosis severe sepsis related to health care aspiration pneumonia, dehydration, low blood oxygen, and significant weight loss [ >10% change over 6 months]. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure radiological services were provided, as indicated by the physician's order, to a resident who sustained a fall with injury for 1 resident(R2) of 6 (R1, R4, R7, R8, R9) residents reviewed for falls. This failure resulted in R2 sustaining a Right Femur Fracture eight days prior to receiving an x-ray that indicated R1 had a questionable right sub capital fracture, was sent to the hospital for further evaluation and treatment and was admitted with a confirmed right sub capital fracture. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident (R7) remained free from abuse, in a sample of three residents reviewed. This failure resulted in R7 being verbally abused by R6.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the proper amount of fabric layers were used for one resident (R1) using a low air loss mattress out of three dependent residents with current pressure ulcers in a sample of three reviewed for pressure ulcer care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that Nurses documented weekly skin checks in the EMR (Electronic Medical Records), failed to ensure that shower/skin checks included skin integrity impairments, failed to document skin integrity impairments upon re-admission, failed to ensure accurate skin integrity impairment/ interventions were on the care plan, failed to timely notify the Physician of resident change in condition, and failed to ensure treatment orders were obtained for one of three residents (R2) reviewed for change in condition. These failures resulted in R2 sustaining lower extremity redness, edema, and pain for several days. On (11/3/23) a family member requested R2 be sent to the ER (Emergency Room) for evaluation and R2 was subsequently diagnosed with cellulitis, soft tissue infection, hypoglycemia, and pneumonia.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that sufficient nursing staff were available to meet the needs for three of four dependent residents (R1, R3, R4) reviewed for ADL (Activities of Daily Living) care, failed to ensure (R5's) blood sugar was obtained as scheduled, and failed to ensure (R5, R6) medications were administered as ordered. These failures have the potential to affect a total of 106 residents residing on 1st & 3rd floor.

Inspectors wroteBased on observation, interview and record review the facility failed to follow policy/procedures and failed to ensure that ADL (Activities of Daily Living) care was provided to three of four dependent residents (R1, R3, R4) reviewed for ADL care.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician orders, failed to ensure that medications were administered as ordered, failed to notify the physician regarding late medication administration, failed to document medication administration at the correct time for two of seven residents (R5, R6) in the sample, and the facility failed to ensure (R5's) blood sugar was obtained as scheduled (before meal).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure food trays and beverages were covered during transportation to residents' rooms to prevent contamination; failed to wear beard covering's in the kitchen and while serving food; failed to store knives under sanitary conditions; failed to maintain cookware condition to avoid chemicals contaminating the food; and failed to air dry the blender after staff washed it in the three-compartment sink. These failures have the potential to affect all 171 residents that receive nutrition from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure a Registered Nurse was on duty 8 consecutive hours 7 days a week. This has the potential to affect 175 of 175 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure food trays and beverages were covered during transportation to residents' rooms to prevent contamination; failed to wear beard covering in the kitchen and while serving food; failed to store knives under sanitary conditions; failed to maintain cookware condition to avoid chemicals contaminating the food; and failed to air dry the blender after staff washed it in the three-compartment sink. These failures have the potential to affect all 171 residents that receive nutrition from the kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their Garbage and Refuse policy by not disposing garbage in a sanitary manner. This has the potential to affect all 175 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy to ensure proper infection control protocols are followed such as performing hand hygiene while distributing food trays to 4 (R56, R66, R156, R473) residents and ensuring food trays on a food cart were covered to prevent contamination. The facility also failed to follow their policy to develop an infection prevention surveillance plan to decrease the risk of infection for the population served. This failure affects all 171 residents in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to have an effective pest control program. This has the potential to affect all 171 residents residing at the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy to ensure call lights are within reach for 1 resident (R373) out of three residents reviewed for call lights in a sample of 36.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their Guidelines for Cardiopulmonary Resuscitation-CPR by not clarifying and updating a resident's (R66) advanced directive for 1 out of a total sample of 36 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered by the physician for 1 (R43) of 2 (R105) residents reviewed for providing care according to professional standards during medication administration in a sample of 36. Findings Include: R43 has diagnosis not limited to Convulsions, Abnormal Levels Of Other Serum Enzymes, Vitamin D Deficiency, Anxiety Disorder, Folate Deficiency Anemia, Post-Traumatic Stress Disorder, Chronic, Anemia, Heart Failure, Epilepsy, Unspecified, Intractable, with Status Epilepticus, Acute Respiratory Failure, Type 2 Diabetes Mellitus, Schizophrenia, Major Depressive Disorder, Recurrent, Down Syndrome, Abnormalities Of Gait And Mobility, Dysphagia, Weakness, Lack of Coordination, Unsteadiness on Feet, Malaise, Morbid (Severe) Obesity, Metabolic Encephalopathy, Bipolar Disorder, Unspecified and Asthma. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow their policy and procedure on use of linen with an air loss mattress for 3 residents (R10, R87, and R104) of 8 residents reviewed for pressure wound treatment services out of a total sample of 36.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their Urinary Catheters policy by not placing a resident's (R38) urinary drainage bag in a privacy bag for 1 of 3 residents reviewed for urinary catheters out of a total sample of 36 residents.

Inspectors wroteBased on observation, interviews, and record review the facility failed to follow their midline intravenous catheter and peripherally inserted central catheter line policy for one [R92] of three [R10, R92, R159] residents to ensure their intravenous access was changed every seven days, in a sample of 36. R92's clinical record indicates but not limited to; R92 is a [AGE] year-old re-admitted back to the facility on [DATE] with medical diagnosis of infection and inflammation due to urinary catheter, bacteremia, and weakness. R92's physician orders: -10/14/23 IV-PICC [peripherally inserted central catheter line] right single lumen-change transparent dressing on admission then weekly and as needed [Dressing was to be changed on 10/14/23 then every 7 days] -10/14/23 -Micafungin Sodium intravenous Solution 100mg. Give one time per day for antifungal until 10/25/23. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their Oxygen Administration Guidelines by not following physician orders and changing oxygen tubing weekly for 1 (R66) out of 2 residents reviewed for oxygen out of a total sample of 36 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident (R15) was free from unnecessary anti-psychotic medications for 1 out of 5 residents reviewed for unnecessary medications out of a total sample of 36 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a medication error rate of less than 5% for 1 (R43) of 2 (R43, R105) residents observed during medication administration. Four errors were observed during 27 opportunities resulting in a 14.81% medication error rate. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from a significant medication error related to anticonvulsant medication administration for 1 (R43) of 2 (R43, R105) residents reviewed for medication administration in a sample of 36. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the two community shower rooms on the first floor and the only available shower room on the third floor were in a functional and sanitary condition. This failure has the potential to affect all 56 residents on the first floor and all 58 residents on the third floor of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a shower chair to accommodate a resident's need due to physical limitations. This affected one resident (R4) out of 2 residents reviewed for accommodation of needs. As a result, R4 did not receive showers as scheduled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care receive showers. This affected two residents (R4 and R8) out of 3 residents reviewed for ADL care.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the physician and failed to document the reasons for not administering medications as ordered. This failure affected one resident (R14) of two residents reviewed for medication administration and documentation of medications not given.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dressers for residents to keep personal clothing items. This failure affects two residents (R5 and R6), reviewed for availability of bedroom furniture.