Complete Care at Margate Park

Inspectors wroteBased on interview and record review, the facility failed to follow the plan of care and provide verbal cues for one resident (R7) who was assessed as having a high risk for falls. This failure affected one of three residents reviewed for falls. This failure resulted in R7 falling to the ground and sustaining a hip fracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide physician ordered dressing changes to one resident (R2) with a history of pressure ulcers. This failure affected one resident (R2) out of three residents reviewed. R2's medical diagnoses include but are not limited to quadriplegia, essential hypertension, colostomy, acquired absence of left leg above knee. R2's [NAME] data set dated [DATE] has a Brief Interview for Mental Status score of 15, indicating R2's cognition is intact. On 06/12/26 at 10:31 am surveyor observed R2 with soiled, partially attached bandage to R2's left buttock and left ischium. On 06/12/26 at 10:31 am R2 stated that no one comes in to change his bandage. R2 stated he has requested a bandage change, but no one has come to change it. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (R13) resident of three in a sample of 22 residents had sufficient representation to advocate for their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent and protect resident's right to be free from misappropriation of resident property. This failure affects one (R9) resident out of five residents reviewed in a total sample of twenty-two residents. This failure places the resident at risk for more than minimal harm.

Inspectors wroteBased on interviews and record reviews, failed to follow their policy to ensure all special instructions and/or precautions such as treatment and devices (hospital bed, oxygen, implants, IVs, tubes/catheters) were in place prior to transfer to another facility for one (R7) out of three residents reviewed for discharge process in a sample of 22. Findings Include:On 05/12/2026 at 12:10 PM, R7 stated he transferred to a different facility. R7 stated his medications took a couple hours but was finally cleared up. R7 stated he was transferred with his CPAP (Continuous Positive Airway Pressure) machine. R7 stated he knows how to use his CPAP machine. R7 stated one of the items discussed during the meeting was that he needed a hospital bed. R7 stated his bed was never delivered. R7 stated he had to order his bed by himself. R7 stated it was very frustrating. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from resident-to-resident physical and verbal abuse; and failed to implement effective interventions to prevent recurrence of abuse resulting in repeated incidents between R1 and R2 resulting in (R1 and R2) engaging in multiple altercations involving derogatory remarks (racial slurs) and physical aggression (throwing coffee and hitting). The facility also failed to prevent and protect a resident (R3) from resident-to- resident abuse. These failures affected 3 of 3 residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure that allegations of resident-to-resident abuse were reported in accordance with facility policy and regulatory requirements. This failure affected 2 (R1, R2) out of 3 residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff in accordance with the facility assessment to meet the needs of residents residing in the facility. This deficient practice has the potential to affect all residents residing in the facility who require assistance with activities of daily living, supervision, and timely care. Findings Include:On 2/25/26 at 11:04 AM, a resident council meeting was held. Residents R23, R38, R61, R126, R148, R7, and R170 attended. All residents stated that staffing is insufficient to meet their needs. They reported ongoing staff shortages. R23 and R170 stated that call lights are not answered promptly due to inadequate staffing. R170 reported that on some nights there was no CNA assigned to the sixth floor. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to (a) post Enhanced Barrier Precautions (EBP) sign for two residents (15, R59); (b) ensure staff wore proper Personal Protective Equipment (PPE) upon entering a room for one (R13) resident on contact precautions; and (c) follow their 'General Immunization/Vaccination' policy. This has the potential to affect all the residents that reside in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to (a) follow their policy, (b) follow physicians' orders, and (c) have the correct settings on four residents' (R3, R41, R43, R80) air loss mattresses for four residents out of a total sample of 35 residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide feeding assistance as order by the physician for one resident (R15) with aspiration and swallowing precautions, and failed to follow their policy and procedure to ensure smoking materials were kept secured and out of residents' reach when unsupervised for four residents (R55, R118, R149, R162) out of a total sample of 35 residents. Findings Include: R15's diagnosis includes but is not limited to Chronic Obstructive Pulmonary Disease, Unspecified Protein-Calorie Malnutrition, Dysphagia, Cachexia, Adult Failure to Thrive, Unspecified Dementia, Esophageal Obstruction, Gastro-Esophageal Reflux Disease Without Esophagitis, Wernicke's Encephalopathy, Alcohol Abuse. R15's Speech Therapy Discharge summary dated [DATE] - 05/21/25 documents in part: [...]

Inspectors wroteF700Based on observation, interview and record review, the facility failed to follow their policy to obtain informed consent and physician's order for the use of bed rails. These failures could potentially affect four (R32, R47, R80 and R129) residents reviewed for Accidents in a sample of 35.

Inspectors wroteBased on observation, interview, record review, the facility failed to follow their policy to (a) properly date / label multi dose inhalers and nasal sprays after opening, (b) properly discard multi-dose inhalers and nasal sprays, (c) medications were separated from juices or other refreshments in the refrigerator. These failures could potentially affect all residents residing on 5th floor reviewed for medication storage and labeling in two of four medication carts and one of two medication storage rooms.

Inspectors wroteBased on interview and record review, the facility failed to ensure advance directive or code status is consistent with the comprehensive care plan of one (R10) out of eight residents reviewed for advance directive in a total sample of thirty-five. Findings Include: R10's Minimum Data Set (MDS) dated [DATE] noted he is cognitively intact. R10's Electronic Medical Record (EMR) noted he was admitted to the facility on [DATE]. He is [AGE] years old with diagnoses not limited to chronic viral hepatitis C, spinal stenosis, atherosclerotic heart disease of native coronary artery without angina pectoris, and non-pressure chronic ulcer of other part of left lower leg with necrosis of muscle, type 2 diabetes mellitus with other circulatory complications. Physician Order Sheet active/POS as of [DATE] noted Do Not Resuscitate/DNR dated [DATE]. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) re-assessments were completed upon expiration for two (R97, R162) out of nine residents reviewed for PASRR compliance in a total sample of 35 residents. Findings Include: R162's face sheet documents an original admission date of 7/9/24 with diagnoses not limited to Other Psychotic Disorder and Major Depressive Disorder. Review of R162's Notice of PASRR Level II Outcome dated 10/26/25 indicates a short-term approval without specialized services, with an approval end date of 1/25/26. The notice states the short-term approval allowed a limited number of days in a Medicaid-certified nursing facility and required submission of a new Level I screen to Maximus no later than 10 days prior to the short-term approval end date if continued stay was needed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive resident-centered care plan for one (R13) resident out of eight residents reviewed for comprehensive care plan in a total sample of thirty-five. Findings Include: R13's Minimum Data Set (MDS) dated [DATE] noted she is cognitively intact. R13's Electronic Medical Record (EMR) noted she was admitted to the facility on [DATE]. She is [AGE] years old with diagnoses not limited to chronic systolic congestive heart failure, unspecified asthma, chronic obstructive pulmonary disease, type 2 diabetes mellitus with unspecified complications. Physician Order Sheet (POS) active order as of 02/25/26 noted isolation; contact precautions related to Extended-Spectrum Beta Lactamase/ESBL from 02/14/26 until 02/28/26. On 02/25/26 at 12:09 PM, observed contact isolation sign on R13's door. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to obtain physician orders for oxygen administration and to place oxygen in use signage on the door of one (R75) resident out of two residents reviewed for respiratory care in a sample of 35.

Inspectors wroteF759Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5% for two (R23 and R164) of four residents reviewed for medication administration. There were 39 opportunities and 4 errors resulting in a 10.26% medication error rate.

Inspectors wroteBased on observation, interview and record review the facility failed to provide diet and supplement as ordered by the physician for one (R188) out of three residents reviewed during dining observation in a total sample of 35 residents. Findings Include:On 2/24/26 at 11:12 AM, R188 stated he does not receive his health shake twice a day. On 2/24/26 at 12:39 PM, R188's eating lunch in his room. R188 received one breaded fish patty, pasta noodles, squash, cup of coffee, glass of juice, and canned fruits. R188 did not receive his health shake. R188's meal ticket documents in part, NAS (No Added Salt) Doubled Portions at all meals. R188's meal ticket does not indicate health shake. R188 stated he usually only receives single portion with his meals, and he is supposed to receive double portions. R188 stated he should have received two pieces of fish patties. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that a resident (R185) completed their pneumonia vaccine series for one out of five residents reviewed for immunizations.

Inspectors wroteBased on interviews and record reviews, the facility failed to offer and administer the COVID-19 vaccine to a resident (R185) for one out of five residents reviewed for immunizations.

Inspectors wroteBased on interview and observations the facility failed to ensure that the dumpster lids were properly closed on two dumpsters, resulting in garbage hanging out of dumpster this failure has the potential to affect all 185 residents in the facility .

Inspectors wroteBased on observation, interviews, and record review, the facility failed to assess a resident's ability to safely self-administer medication, failed to obtain a doctor's order to self-administer medication, and failed to care plan self-administration of medication prior to initiating self-administration of medication. This failure affects 1 (R16) resident reviewed for self-administration of medication in the total sample of 21 residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain a resident's personal privacy. This failure affected 1 (R1) resident reviewed for personal privacy in the total sample of 21 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a physician order after administering inhaler sprays to a resident potentially placing a resident at risk for oral thrush. This failure affected 1 (R16) resident out of 5 residents reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for a resident while at the facility. This failure affected 1(R1) resident out of 5 residents reviewed for supervision. R1 incurred a full thickness burn on his left leg with a surface area of 136.90 cm^2 .

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's representative was notified of an injury of unknown source. This failure affected 1 (R1) resident reviewed for notification of representative in the total sample of 5 residents.

Inspectors wroteBased on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. This failure affected 1 (R1) resident out of 5 residents reviewed for reporting of injury of unknown source.

Inspectors wroteBased on interview and record review, the facility failed to ensure injury of unknown source was thoroughly investigated. This failure affected 1(R1) resident out of 5 residents reviewed for allegation abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents are free from abuse for one of three residents (R1) reviewed for abuse in the sample of nine. R1 suffered a head laceration after being pushed to the floor.

Inspectors wroteBased on interview and record review, the facility failed to assess and immediately start CPR (Cardiopulmonary Resuscitation) for resident found unresponsive on the floor for one of one resident (R3) reviewed for CPR in the sample of sample of nine. This failure resulted in R3 being without vital signs and not receiving immediate CPR.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident (R2) from abuse by another resident (R1), in one of three residents reviewed for abuse. As a result, R2 sustained discoloration of the left eye.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident had routine preventative screening for 1 resident (R3) out of 3 residents reviewed for routine screenings. This failure resulted in R3 not receiving recommended annual breast mammograms while residing in the facility, which resulted in R3 being diagnosed with stage 4 breast cancer which metastasized to other parts of her body. Findings Include:R3's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Neutropenia, malignant neoplasm of unspecified site of right female breast, secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes, secondary malignant neoplasm of mediastinum, secondary malignant neoplasm of other specified sites. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect one (R4) resident from resident-to-resident abuse out of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of physical abuse for one (R4) resident out of three residents reviewed for physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and monitoring for residents. As a result of these failures, R1 fell in the facility on 06/08/2025 and sustained a temporal laceration with sutures. This failure affects one (R1) out of three residents reviewed for supervision and monitoring.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents remain free from physical abuse and verbal abuse. These failures affected R1 who was physically hit by R2 in the arm and R3 who was verbally abused with derogatory words from a staff member in the sample of 7 residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to timely submit an initial abuse report to the state agency within 2 hours which affected one resident (R3) in the sample of 7 residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to post required staffing information in a high visibility area and failed to ensure the staffing posting included all required information. This failure has the potential to affect all 192 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure foods in the walk-in freezer were labeled with a date indicating when the items were placed in the freezer and labeled with a use by date to prevent expired foods from being served. This failure has the potential to affect all 188 residents in the facility who are receiving an oral diet.

Inspectors wroteBased on interview and record review, the facility failed to develop a QAPI (Quality Assurance Performance Improvement) plan that meets regulatory standards. This failure has the potential to affect all 192 residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop policies and procedures on how the facility obtains and uses feedback from residents, resident representatives, and staff to identify high-risk, high-volume, or problem prone issues as well as opportunities for improvement; Develop and implement policies and procedures which include how it ensures data is collected, used and monitored for all departments; Develop policies and procedures for how it will identify, report, and track, adverse events, and high risk, high volume, and/or problem-prone concerns; Establish priorities for its improvement activities, focus on high-risk, high- volume or problem-prone areas, as well as resident safety, choice, autonomy, and quality of care; Conduct at least one PIP annually focuses on high-risk or problem prone areas, identified by the facility, through data collection and analysis; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff were trained annually on the facility's QAPI program. This failure has the potential to affect all 192 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the 4th floor medication cart was locked while unattended. This failure has the potential to affect 51 residents on the 4th floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was not interrupted while eating for a scheduled blood glucose monitoring. This failure affected one resident (R88) reviewed in a sample of 62.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 resident's (R62) bed, with exposed wires, was repaired; failed to ensure 1 resident's (R85) missing closet door was replaced; and failed to repair 1 resident's (R180) leaky ceiling. These failures affected 3 residents (R62, R85 and R180), reviewed for resident's rights to enjoy a homelike environment, in a total sample of 62 residents.

Inspectors wroteBased on interview and record review, the facility failed to complete Minimum Data Set (MDS) assessments accurately in accordance with the Resident Assessment Instrument (RAI) guidelines. This failure affects 1 resident (R165) in a sample of 61.

Inspectors wroteBased upon interview and record review the facility failed to follow policy procedures, failed to ensure the vaccination consent form includes a refusal option, and failed to ensure staff provide informed consent prior to obtaining resident signature for one of five residents (R19) reviewed for immunization administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ADL (Activity of Daily Living) care to one resident (R138) reviewed for ADL care in a sample of 62.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the low air loss mattress was not layered with multiple linens. This failure affected 1 resident (R16) reviewed for pressure ulcer/injury prevention and treatment in a sample of 62 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to follow physician orders, failed to implement care plan interventions, failed to measure/record urine output, and failed to timely report hematuria to the physician for one of 62 residents (R19) in the sample reviewed for incontinence/catheter.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that enteral feed orders include daily total volume, failed to follow physician orders, and failed to provide enteral feedings as ordered for one of 62 residents (R122) in the sample reviewed for hydration/nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to discard expired medication. This failure has the potential to affect three residents (R64, R144, R189) in a sample size of 62. Findings Include: 1. On [DATE] at 10:05 am, the second-floor's medication cart had R189's Insulin Lispro Injection Solution 100 UNIT/ML labeled with an expiration date of [DATE]. R189's admission diagnosis includes but not limited to Type II Diabetes Mellitus, Hypertension, and Obesity. R189's Physician Order Sheet documents in part an active order for Insulin Lispro (Injection Solution 100 Unit/ML) with an order date of [DATE] and start date of [DATE]. R189's Medication Administration Record (MAR) documents in part Insulin Lispro Injection Solution had a check mark indicating administration dates of [DATE], [DATE], [DATE], [DATE] and [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff report maintenance concerns, failed document maintenance requests/repairs, and failed to repair malfunctioning equipment for one of 62 residents (R63) in the sample.

Inspectors wroteBased on review of records and interviews the facility failed to support requirements for petition to involuntary admit 1 resident (R2) out of 4 residents reviewed for transfer and discharge. These failures affected 1 resident (R2) who was twice petitioned to be transferred to the hospital and did not meet regulatory requirement or documentation during both transfers.

Inspectors wroteBased on interviews and records review the facility failed to accurately document on resident records for 2 (R1, R2) out of 4 residents reviewed. These failures affected 2 residents (R1, R2) on correct representation of their resident records. R1's physician order and medication administration have identified inconsistency. R2's petition for involuntary / judicial admission to the hospital documentation have identified inconsistency. These inconsistencies resulted to inaccurate representation of R1 and R2's records.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure individualized and appropriate fall interventions were identified and implemented to provide necessary supervision to prevent a resident from falling for 1 (R1) out of 4 residents reviewed for falls. Findings Include: R1's Fall note dated 2/28/25 at 9:00 PM documented by V4 (Licensed Practical Nurse) reads in part: Noted resident [R1] walking out of room with foley catheter in his hand. [R1] walked in front of the nursing station and fell and hit the back of his head. [R1] unable to give description. Full body assessment with no noted bruises or bumps. Emergency ambulance called and transferred R1 to the hospital. V4's (Licensed Practical Nurse/LPN) witness statement reads in part, Noted resident walking out of room and walk in front of nursing station and fall and hit his back of his head. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medication was administered as ordered by the physician. This failure affects 1 (R1) out of 3 residents reviewed for medication administration. Findings Include: R1's Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, Aphasia following cerebral infarction, Dysphagia following cerebral infarction, Essential Primary Hypertension, and Hyperlipidemia. On 2/25/25 at 11:05 AM, R1 is non-verbal and R1 uses a tablet (iPad) voice machine to communicate. R1 stated that he was ignored and was not provided morning medications including R1's blood pressure medication on 2/16/25 and today 2/25/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility is free of insect pests in one resident's (R2) room. This failure affects one resident (R2) reviewed for effective pest control program.

Inspectors wroteBased on interview and record review, the facility failed to follow their Fall Prevention Program policy and procedure to ensure residents fall care plan interventions were revised after each fall for 2 (R1, R2) out 3 residents reviewed for fall incidents. Findings Include: R1's clinical records revealed R1 had fall incidents on 12/15/24, 12/18/24, and 1/8/25. R1's progress notes dated 12/15/24 at 3:20 PM documents R1 fell going to the bathroom. R1's progress notes dated 12/18/24 at 3:20 AM documents R1 lost balance and fell trying to pick up [R1's] phone on the floor. R1's progress notes dated 1/8/25 documents R1 fell on [R1's] knees trying to go to the bathroom. R1's fall care plan date initiated on 4/10/24 do not show interventions were revised after R1's fall incidents on 12/15/24, 12/18/24, and 1/8/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Fall Prevention Program and a resident's comprehensive care plan by not providing appropriate staff assistance to the washroom to prevent a resident from falling for 1 (R2) of 3 residents reviewed for fall incidents. This failure resulted in R2's having a fall incident while using the washroom unassisted and was found on the washroom floor. Findings Include: On 1/14/25 at 1:08 PM, interviewed R2 regarding the fall that happened on 1/04/25. R2 was noted to be alert and oriented to person, place, time, and date. R2 stated that after lunch, [R2] was lying in bed. R2 stated that [R2] pressed the call light to ask for help to go to the washroom to brush [R2's] teeth. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to help a resident maintain their highest practical level by failing to a.) follow their restorative care policy b.) provide consistent restorative therapy for one (R10) resident out of three residents reviewed for quality of care. 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure there are enough restorative nurse aides to provide restorative care and respond to each individual needs as required by the resident's plan of care. This failure resulted in the resident (R10) missing restorative therapy several times in the past 90 days.

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (R4) was free from staff to resident physical abuse. This failure affected one resident (R4) in a total sample size of three residents (R1, R2 and R4) reviewed for abuse. This deficient practice resulted in harm for one resident (R4) experiencing physical pain and bruising.

Inspectors wroteBased on interview and record review, the facility failed to follow the Care Plan and failed to provide adequate supervision to one resident (R1) who was assessed as a high fall risk which resulted in multiple falls for one resident (R1) reviewed for resident injury, demonstrating inadequate care. This failure resulted in R1 falling on 10/12/2024 and sustaining a head injury which required R1 to be sent to the hospital where R1 received 3 staples to close the laceration to R1's head and again falling on 11/05/2024 which required R1 to be sent to the hospital for evaluation and testing.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent for psychotropic medication prior to administering the medication. This failure affects 1 resident (R2) in a sample of 3 residents (R2, R3, R5) reviewed for psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to report one allegation of abuse to the state survey agency. This failure has the potential to affect one resident (R4) reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an incident involving an allegation of injury of unknown origin. This failure affected one resident (R4) out of three residents reviewed for injury (R1, R2, and R4).

Inspectors wroteBased on interview and record review, the facility failed to accurately complete Fall Assessments for one resident (R1). This failure has the potential to affect one resident (R1) in a sample of 3 residents reviewed for resident injury.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and provide sufficient supervision to one (R8) resident out of three residents reviewed for improper nursing care. After interviewing staff, the surveyor identified that the facility did not have a physician pass privilege order in place the day the resident signed himself out to the community unaccompanied. Later that day, the resident got lost and the facility ordered the resident a transportation ride back to the facility. This failure has the potential to cause serious harm to a resident.

Inspectors wroteBased on interviews and record review, the facility failed to properly document one resident's (R9) personal belongings upon admission. This failure has resulted in R9 missing clothes.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a cataract surgery was scheduled for one resident (R13) as ordered resulting in R13 experiencing continued visual difficulties and failed to ensure two residents (R2 and R11) attended Doctor's appointment as scheduled.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one resident's (R1) psychotropic medication/ controlled substance was properly documented after administration. This failure has the potential to affect all residents who are currently prescribed controlled substances.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a policy to address strip/body searches of residents. This failure has the potential to affect two of three residents (R13, R4) reviewed for strip searches. This failure resulted in R13 feeling humiliated and ashamed; R4 feeling violated.

Inspectors wroteBased on interviews and records review, the facility failed to conduct interviews as appropriate to the allegations of abuse for one (R1) of four residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan to address a resident, with history of opioid dependence, for one of three residents (R1) reviewed for illegal drug use.

Inspectors wroteBased on interview and record review the facility failed to provide quality care to one resident (R5) of three residents reviewed by not scheduling a biopsy in a timely manner.

Inspectors wroteBased upon record review and interview the facility failed to follow the abuse policy procedures, failed to report abuse to IDPH (Illinois Department of Public Health) within regulatory requirements and failed to report actual time of occurrence for two of four residents (R5, R6) reviewed for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs of residents by failing to ensure call lights were within reach of two (R2, R3) of four residents reviewed.

Inspectors wroteBased on observation, interview and record review, facility failed to follow professional standards of practice and facility policy in documenting post-surgical wound assessment in two residents (R2, R5) out of 15 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide therapy services in a timely manner and failed to follow facility policy for two residents (R1, R5) out 15 residents in the sample. Findings 1. On 7/2/2024 at 10 AM the electronic health record of R1 was reviewed. R1 was admitted to the facility on [DATE]. An order for Physical Therapy to evaluate and treat was entered on 5/7/2024. An order for Speech Therapy to evaluate and treat was entered on 5/7/2024. An order for Occupational Therapy to evaluate and treat was entered on 5/7/2024. An order for Occupational Therapy evaluates and treat related to right hand limited range of motion was entered 5/31/2024. [...]

Inspectors wroteBased on interviews and record review the facility failed to give proper notice requirements per their policy to a resident was involuntarily transferred to the hospital for 1 (R1) out of 3 residents reviewed for admissions, transfers, and discharges. These failures affected 1 resident's (R1) right to be informed or notified of the reason for their transfer or discharge.

Inspectors wroteBased on interviews and review of records the facility failed to provide a copy of Bed Reserve Notification as per policy during involuntary transfer of 1 (R1) out of 3 residents reviewed for admissions, transfers, and discharges. This failure affected 1 resident (R1) on knowing the rights afforded to residents during transfers.

Inspectors wroteBased on interviews and review of records the facility failed to permit 1 (R1) out of 3 residents from returning back to the facility after hospitalization in accordance with their policy. This failure affected 1 resident (R1) to their right to return to the facility they considered as home.

Inspectors wroteBased on observation, review of records, and interviews the facility failed to document physician coordination of medications not received by resident per medication administration policy. Facility also failed to administer insulin as ordered by physician for 1 (R2) out of 3 residents reviewed for facility pharmaceutical services. These failures have the potential to affect 1 resident (R2) has history of stroke/cerebral infarction and diabetes mellitus in maintaining stable health condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 4 residents on the sixth floor (team 1) medication cart who are prescribed controlled substances, 4 residents on the fifth floor (team 1) medication cart who are prescribed controlled substances, 5 residents on the fourth floor (team 2) medication cart who are prescribed controlled substances, 7 residents on the fourth floor (team 1) medication cart who are prescribed controlled substances and 7 residents on the third floor medication cart who are prescribed controlled substances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the two community shower rooms on the sixth floor were in good repair. This failure has the potential to affect all 53 residents on the sixth floor of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the corridor handrails across from the nursing station on the sixth floor were firmly affixed to the wall. This failure has the potential to affect all 53 residents on the sixth floor of the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that R173's and R124's indwelling catheter drainage bags were covered. This failure affected two residents (R173 and R124) reviewed for dignity in the sample of 56 residents. Finding Include: 1. R173's admission record includes diagnoses of pressure ulcer, pleural effusion, cerebral infarction, diabetes, atrial fibrillation, venous insufficiency, and chronic kidney disease. On 2/26/24 at 11:10 am, surveyor observed (R173's) indwelling catheter drainage bag not covered on right side of bed facing the hallway. On 2/28/24 at 2:25 pm, V2 DON (Director of Nursing) stated the Indwelling catheter should be covered in a privacy bag, to provide dignity to the residents. R173's (Active orders as of 2/27/24) Order Summary Report documented, in part, Indwelling Catheter 16 F (French), 10 ml (milliliter) filled balloon. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide ADL (Activity of Daily Living) for 2 dependent residents (R77, R138). This failure has the potential to affect all 56 residents in the sample. Findings Include: R77 has a diagnosis of but not limited Encephalopathy, Quadriplegia, Interstitial Pulmonary Disease, Lack of Coordination, and Abnormal Posture. R77's Brief Interview of Mental Status score is 15. R138 has a diagnosis of but not limited Metabolic Encephalopathy, Acute Respiratory Failure, Type 2 Diabetes Mellitus and Need for Assistance with Personal Care. R138's Brief Interview of Mental Status score is blank. On 2/26/2024 at 12:30pm surveyor observed R77 with facial hair. R77 stated he would like to be shaved and that not being shaved makes him feel 'like a bum'. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide timely urinary catheter care for one resident (R111), who depends on staff for perineal care. This failure affected one resident reviewed for care from a sample 56 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a nasal cannula was changed weekly and secured when not in use for one resident (R45) and failed to administer oxygen for one resident (R156). This failure has the potential to affect all 31 resident who use oxygen therapy.

Inspectors wroteBased upon observation, interview and record review the facility failed to follow policies/ procedures, failed to ensure R1 was provided a wheelchair with functioning brakes, failed to ensure R1 and R4 belongings were inventoried, failed to ensure R2, R3 and R5 have clean clothing available, and failed to ensure that basic clothing requirements were met for two of five residents (R3, R5) in the sample. These failures have the potential to affect 212 residents residing in the facility.

Inspectors wroteBased upon record review and interview the facility failed to provide (R1, R2) timely services; failed to ensure R1's belongings were inventoried; failed to ensure R1 was provided a wheelchair with functioning brakes; and failed to provide adequate reimbursement to one of five residents (R2) reviewed for missing belongings.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's (POA) Power of Attorney for Healthcare of changes in condition/treatment which affected one (R1) resident reviewed for policy and procedure in a total sample of 7 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure serious bodily injury was reported to the State Agency within the mandated time frame and failed to develop policies and procedures which ensures reporting of serious bodily injury within the mandated time frame. These failures affected 1 (R3) resident reviewed for reporting of incident and accident in the total sample of 7 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the low air loss mattresses were set on appropriate setting for 2 residents (R4 and R5) reviewed for pressure ulcer prevention in the total sample of 7 residents.

Inspectors wroteBased on interview and record review, facility failed to follow their policy to be free from physical abuse by providing necessary care in services thus resulting in a male resident (R4) verbally and mentally abusing another female resident (R2) for two out of three residents reviewed for physical abuse.

Inspectors wroteBased on observations, interviews and record reviews, facility failed to ensure wound orders are followed in order to prevent the deterioration of pressure ulcers for one (R1) out of three residents review for pressure ulcer prevention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely care to three of five residents (R2, R3, R4). Two of these residents (R3, R4) had to hold their feces and/or urine for multiple hours before they were able to relieve themselves or receive care. This put residents at risk for harm due to holding their feces and/or urine. R3 had a swollen, distended stomach due to holding his feces, causing him severe pain. The failure affects three (R2, R3, R4) of five residents reviewed for neglect.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident safety by allowing a resident (R1) out on a community pass unsupervised. This failure resulted in staff not following the proper protocol procedures for residents with community pass privileges, which allowed R1, who can only go out on community pass supervised, to sign out on community pass on 8/31/23 unsupervised. R1 has not returned to the facility. This situation was identified as an immediate jeopardy. The Administrator was notified and presented with the immediate jeopardy template on 09/12/2023. The immediate jeopardy began on 8/31/2023 and removed on 9/15/2023. The facility presented an acceptable removal plan on 9/15/2023. However, the deficiency remains out of compliance at the second level of harm until the facility evaluates the effectiveness of the removal plan. Findings Include: [...]