Casey Rehab and Nursing

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview and record review the facility failed to supervise a resident during a shower for one of three residents (R1) reviewed for falls in the sample of three residents. This failure resulted in R1 falling from the wheelchair during a shower when staff turned away from R1 and R1 suffering from a left pelvic fracture. This past noncompliance occurred from 5/29/26-6/1/26. B. Based on interview and record review the facility failed to supervise a resident during meal time for one of three residents (R2) reviewed for falls on the sample list of three residents. This failure resulted in R2 falling when R2 was left unsupervised in the dining room and suffering a left posterior scalp laceration requiring three staples. This past noncompliance occurred from 6/5/26-6/6/26. [...]

Inspectors wroteBased on interview and record review the facility failed to provide necessary supervision of a safe transfer with the mechanical lift and to implement accident prevention interventions for one resident (R1) of four residents reviewed for Accidents in a sample list of four residents. This failure resulted in R1 sustaining a Nondisplaced Oblique Ankle Fracture requiring a visit to the local hospital emergency room. This past compliance occurred from 4/6/26 to 4/12/26.

Inspectors wroteBased on interview and record review, facility staff (V3 and V5, Certified Nursing Assistants, and V6 Registered Nurse) failed to report allegations of observed and known potential abuse in the required immediate, not more than 24 hour, time frame. This failure has the potential to affect three residents (R2, R3, and R4) out of twelve reviewed for abuse on the sample list of thirteen.

Inspectors wroteBased on interview and record review the facility failed to provide adequate pain control for one (R2) of three residents reviewed for pain on the sample list of seven. Findings Include: R2's Physician Order Sheet (POS) dated August 2025 documents R2 was admitted to the facility on [DATE]. R2 is diagnosed with Type II Diabetes Mellitus with Diabetic Polyneuropathy and Muscle Weakness among other medical diagnoses. R2's POS documents a physician order on 7/4/25 for Acetaminophen tablets 650 milligrams by mouth every six hours as needed for mild pain. If more than three doses given in 48 hours- staff are to notify the physician or advanced practice provider. R2's POS documents a physician order on 7/14/25 for Tramadol 50 milligrams by mouth as needed for pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate services for a resident with a diagnosis of dementia for one resident (R7) of three residents reviewed for dementia services on a sample list of seven.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall interventions were implemented for one (R2) of three residents reviewed for accidents on a sample list of three residents. Findings Include: R2's undated care plan documents R2's medical diagnoses include dementia with agitation, delusional disorders, essential hypertension, spinal stenosis, lumbar region without neurogenic claudication, vitamin B12 deficiency anemia, anxiety disorder, other malaise, urinary tract infection, depression, and psychotic disturbance. [...]

Inspectors wroteBased on interview and record review the facility failed to timely initiate antibiotic treatment for a urinary tract infection for one of three (R3) residents reviewed for falls in the sample list of three.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during wound care for one (R24) resident's left plantar heel open diabetic ulcer, failed to monitor R24's left heel diabetic ulcer and failed to follow physician orders for R24's left heel wound treatments for one of two residents (R24) reviewed for skin conditions in a sample list of 27 residents. R24 experienced the worsening of her left heel open wound due to dressing changes not being completed per physician order and not being provided timely incontinence care which led to R24's dressing to be fully saturated with wound drainage and urine which required antibiotics due to a Staphylococcus (Staph) infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain their survey results book in a manner accessible to residents. This failure has the potential to affect all 51 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a Level 2 screening for a resident newly diagnosed with severe mental illness to determine if there was a need for specialized mental health services. This failure effects one resident (R2) out of two residents reviewed for pre-admission screening on the sample list of 27.

Inspectors wroteBased on interview and record review the facility failed to complete a discharge summary for one (R48) resident out of one resident reviewed for discharge in a sample list of 27 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe storage of oxygen cylinders by failing to secure an oxygen tank to prevent being tipped over. This failure effects one resident (R23) out of six reviewed for accidents on the sample list of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to properly label medications and failed to monitor expiration dates on medications administered for one (R4) resident out of nine residents reviewed for medication administration in a sample list of 27 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident record was complete for one (R48) resident out of one resident reviewed for closed records in a sample list of 27 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to wear the proper Personal Protective Equipment (PPE) when providing feeding assistance and when administering medications to residents who are COVID-19 positive on Droplet and Contact Isolation Precautions for two of five residents (R38 and R20) reviewed for Infection Control in a sample list of 27 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide supervision of a severely cognitively impaired resident, with a history of elopement, to prevent the resident from leaving the facility unnoticed and unattended. Due to R1's frontal lobe dementia, V20 physician stated (R1) could have been hit by a car, fallen and obtained a fracture, or been injured in a multitude of ways. This failure affects one (R1) of three residents reviewed for supervision. The immediate jeopardy began on 7/28/24 when R1 was allowed to leave the alarmed Dementia unit unsupervised resulting in R1 eloping 0.9 miles away from the facility. V1 Administrator was notified of the Immediate Jeopardy on 8/8/24 at 9:26 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to provide in servicing to staff members on the facility Quality Assurance Performance Improvement (QAPI) program. This failure has the potential to affect all 44 residents residing in facility.

Inspectors wroteBased on interview and record review the facility failed to provide twelve hours of mandatory training for Certified Nurse Aides (CNA) yearly. This failure has the potential to affect all 44 residents residing in facility.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate fall interventions and keep equipment out of the hallways for one of three residents (R1) reviewed for falls on the sample list of 12 residents. Failing to ensure R1 was wearing appropriate footwear resulted in R1 falling and sustaining a laceration that required sutures.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free of physical abuse by another resident for three of three residents (R1, R7, R8) reviewed for physical abuse on the sample list of 12.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders to obtain a repeat Esophagogastroduodenoscopy (EGD) for one resident (R2) and failed to collect a urinalysis for one resident (R1). R1 and R2 are two of three residents reviewed for following physician orders in the sample list of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ the services of a full time Director of Nursing. This failure has the potential to affect all 48 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Director of Nursing. This failure has the potential to affect all 51 residents in the facility. Findings Include: On 12/5/2023 at 10:19 AM V1 Administrator confirmed the facility does not currently employ a Registered Nurse to serve as full time Director of Nursing. Upon survey entrance and throughout the survey (12/5/23- 12/8/23) there was no Director of Nursing present and employed by the facility. The facility's Facility assessment dated [DATE] documents a full time Director of Nursing is required in order to meet the resident's needs and provide competent support and care for the facility's resident population. The facility Long-Term Care Facility Application for Medicare and Medicaid dated 12/5/2023 documents 51 residents currently reside in the facility.

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 51 residents in the facility. Findings Include: On 12/07/2023 at 11:45 AM V6 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V6 reported being the full-time manager of the facility food service (person in charge) and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V6 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V6 reported the facility dietician only works in the facility one day per month. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the potential for physical cross-contamination of food and failed to ensure dietary staff donned required hair restraints. These failures have the potential to affect all 51 residents in the facility. Findings Include: 1. On 12/5/2023 at 10:16 AM V7 (Dietary Aide) was working in the food preparation area of the facility kitchen without any required hair restraint. 2. On 12/7/2023 at 11:32 AM a can opener was mounted on a food prep table in the kitchen. The opener was soiled with accumulations of metal shavings where the cutting blade contacts canned food items being opened. The cutting surfaces of the opener blade felt dull when touched. On 12/7/2023 at 11:50 AM V6 (Dietary Manager) observed the above can opener and stated the opener definitely needs cleaned. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure required personnel attended the required quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 51 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to map and identify high risk areas for Legionella growth, failed to formulate a prevention plan, failed to formulate a plan for any identified cases of Legionella, and failed to identify facility water outlets for testing samples. This failure has the potential to affect all 51 residents residing in the facility. Findings Include: On 12/7/23 at 1:53 PM V1 Administrator provided an undated Legionella Environmental Assessment Form. At 2:54 PM V12 Maintenance Director provided an undated floor plan map. The facility's floor plan map (undated) was a fire safety map showing the locations of fire walls, egress routes, smoke detectors, fire extinguishers, and sprinkler heads. V12 stated, I don't have a mapping to show the water distribution or high-risk areas for Legionella, I know where the city water comes into the building. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain corridor handrails in sound and stable condition. This failure has the potential to affect all 51 residents in the facility. Findings Include: On 12/7/23 at 2:54 PM there was a one-foot section of handrail at the intersection of the two 200 halls which was loose and easily moveable up and down as well as rotating. There was a section of handrail between resident rooms [ROOM NUMBERS] which moved up and both directions sideways one and one-half inches, being unscrewed from the mounting bracket, and having screws protruding from the brackets. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program by failing to exclude and prevent flying insects throughout the facility kitchen areas. This failure had the potential to affect all 51 residents in the facility. Findings Include: On 12/5/2023 at 10:28 AM three or more flies resembling fruit flies were flying around and resting on the kitchen dishwasher drainboard areas. On 12/7/2023 at 11:45 AM five or more flies resembling fruit flies were flying around and resting on the kitchen dishwasher drainboard areas. An additional fly surfaced and flew out of a nearby floor drain. The floor drain contained standing water and the interior pipe surface above the water was soiled with dark colored accumulations of debris. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue required quarterly account statements for a resident trust fund account. This failure affects one resident (R11) of one reviewed for trust funds on the sample list of 27. Findings Include: On 12/6/2023 at 11:56 AM, R11 reported having a resident trust fund account in the facility and not receiving any quarterly financial statements. On 12/6/2023 at 2:39 PM, V10 (Business Office Manager) reported starting employment in the facility during February 2023 and since that time not providing R11 with trust fund quarterly statements. V10 reported knowing V10 needs to learn how to produce the statements. V10 reported historically V10 just provided residents their account balances upon request. V10 reported R11 handles R11's own finances in the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to timely complete the Preadmission Screening and Resident Review (PASARR) Level-1 screening and failed to complete the recommended Level-2 screening for one of one residents (R47) reviewed for required screenings on the sample list of 27. Findings Include: R47's Physician Order Sheet (POS), dated December 2023, documents R47 was admitted into the facility on 4/26/23 and has medical diagnoses of Sever Bipolar Disorder with Psychotic Features and Dementia with Behavioral Disturbances. The undated Maximus computer screen-shot documents R47's Level-1 PASARR screen was submitted on 8/9/23. R47's Notice of PASARR Level-1 Screen Outcome documents R47's Level-1 Screening results were received by the facility on 12/6/23 and recommended R47 be referred for a Level-2 screening due to Mental Health Disability. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement physician ordered fall prevention interventions. This failure affects one resident (R8) out of six reviewed for falls on the sample list of 27. Findings Include: R8's current Physician Order Sheet, dated for December 2023 documents a physician order for R8 to have a bed and chair pressure alarm. On 12/5/23 at 10:31 AM, R8 was seated in a wheelchair in the facility Family Room. There was not any alarm on R8's wheelchair. V2 Assistant Director of Nursing stated, We are using a pommel cushion in (R8's) wheelchair so we don't have a double restraint. I think the chair alarm maybe refers to a recliner. On 12/5/23 at 10:58 AM, R8's room did not contain any kind of a chair, including a recliner. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly clean and maintain a Continuous Positive Airway Pressure (CPAP) machine and mask for one of one residents (R43) reviewed for respiratory care on the sample list of 27. Findings Include: The facility's Bilevel Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) policy dated 3/8/13 documents CPAP machines provide continuous positive pressure to the airways of spontaneously breathing residents. Machine circuits are to be cleaned every week and as needed. External filters should be cleaned once a week and as needed. R43's Physician Order Sheet (POS) dated December 2023 documents R43 is diagnosed with Aspiration Pneumonia, Quadriplegia, Seizures, Altered Mental Status, and Mild Cognitive Impairment. R43 has an order to use a Continuous Positive Airway Pressure (CPAP) machine at bedtime. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician's rationale for declining a Registered Pharmacist recommendation to reduce the dosage of an Anti-depressant/ sedative (Trazodone). This failure affects one resident (R35) out of five reviewed for psychotropic and unnecessary medications on the sample list of 27. Findings Include: R35's Pharmacist Consultation Report dated 7/26/23 documents the facility's Registered Pharmacist gave the facility a reminder that V13, Nurse Practitioner, had declined to accept the Pharmacist recommendation to decrease Trazodone on 6/22/23, but had not provided a rationale as a basis for disagreeing with the recommendation. On 12/7/23 at 2:09 PM, V1 Administrator stated, Here is the return form from V13. This return form with a rationale was dated 8/11/23, 46 days after the initial recommendation from the Pharmacist.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain resident bed side rails in a safe condition. This failure affects one resident (R2) of 12 reviewed for bed side rails in the sample list of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Director of Nurses. This failure has the potential to affect all 53 residents in the facility. Findings Include: Upon survey entrance and throughout the survey (10/31/23- 11/2/23) there was no Director of Nurses present and employed by the facility. On 11/2/23 at 12:00 PM V1 Administrator confirmed the facility does not currently employ a full time Director of Nurses. V1 confirmed the facility census is currently 53 residents. The facility's Facility assessment dated [DATE] documents a full time 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 observation, interview and record review the facility failed to ensure the dignity of one (R1) resident by leaving R1's soiled bedpan in plain view when not in use. This failure affects one (R1) resident out of three residents reviewed for dignity in a sample list of three residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident preferences were being honored for one (R1) resident by serving R1 red meats and not providing two baths per week. This failure affects one (R1) resident out of three residents reviewed for resident preferences in a sample list of three residents.

Inspectors wroteBased on observation, interview and record review the facility failed to follow a Physician order to timely obtain a Urinalysis (U/A) with Culture and Sensitivity (C&S) and failed to provide complete incontinence care for one (R1) resident out of three residents reviewed for Urinary Tract Infections (UTI) in a sample list of three residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to change the oxygen tubing and humidifier bottle for two of three residents (R2, R3) and failed to properly store a Bilevel Positive Airway Pressure (BiPap) mask for one of three residents (R1) reviewed for respiratory care on the sample list of three.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during wound care and perineal care for one (R1) resident out of three residents reviewed in a sample list of three residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R1) was not subjected to physical abuse from another resident (R5). This failure affects two residents. R1 is one of three residents reviewed for physical abuse in the sample list of three. R1 sustained a 2-centimeter occipital laceration to the top of the head with 3 staples.

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 41 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely thaw food, failed to store food at safe temperatures, failed to effectively sanitize dishes, failed to properly date and label food to prevent the potential for foodborne illness, and failed to maintain sanitary kitchen equipment. These failures have the potential to affect all 41 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility's Infection Preventionist was certified. This failure has the potential to affect all 41 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to offer the opportunity to formulate advanced directives in a timely manner to meet the resident choice and failed to accurately record resident choice for life sustaining measures in the medical record for two (R243 and R25) of two residents reviewed for advanced directives in a total sample list of 22.

Inspectors wroteBased on interview and record review, the facility failed to notify R22 of discontinuation of Medicare services. This failure affects one resident (R22) of three reviewed for beneficiary notifications in the sample list of 22.

Inspectors wroteBased on interview and record review, the facility failed to obtain and document required signatures to certify the accuracy of resident Minimum Data Set (MDS) assessments. This failure affects four residents (R15, R19, R20, R21) of five reviewed for MDS assessments in the sample list of 22.

Inspectors wroteBased on interview and record review the facility failed to justify the use of psychotropic medications by failing to track behaviors and complete assessments for the use of psychotropic medications in three (R13, R16 and R26) of five residents reviewed for psychotropic medication administration from total sample list of 22.