Effingham Healthcare & Senior Living

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was available 7 days a week for 8 consecutive hours a day and failed to ensure a full time Director of Nursing (DON) was on staff. This failure has the potential to affect all 36 residents in the facility. The Findings Include:1. On 04/26/2026 at 10:40 AM, V1 (Administrator) stated the facility has not had a Director of Nursing (DON) since 3/13/26. V1 stated they are in the process of hiring a new one, but a start date has not yet been set. V1 stated in the interim, the facility staff have been doing the scheduling and if an issue arises, they contact a regional nurse with any questions or concerns. 2. On 4/26/2026 at 10:45 AM, V1 stated every other weekend, the facility does not have a Registered Nurse (RN) available to work the full 8-hour shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide alternative substitutes of similar nutritive value at mealtimes. This has the potential to affect all 36 residents residing in the facility. The Findings Include: On 4/26/26 at 12:00 PM, the meal served was observed to be roasted turkey, glazed carrots and stuffing. On this date and time, V15 (Cook) stated there was not a planned meal alternative for the residents. V15 stated that they have a planned menu signed off by the Dietitian. V15 said that if a resident does not like what is served, they will make them a cold cut sandwich, an egg salad sandwich or peanut butter and jelly after they are finished with all meals being served out. During the lunch meal at 12:45 PM, R21 stated that she does not like the stuffing, and carrots are not her favorite. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the privacy of 2 (R1 and R7) of 4 residents reviewed for resident rights in the sample of 27. Findings Include:1. R1's admission Record documented R1 was admitted to the facility on [DATE] with a diagnosis of pressure ulcer of sacral region. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 11, indicating R1 has moderate cognitive impairment. R1's current Care Plan documents a Focus area of Skin Integrity: Resident may be predisposed to develop skin impairment caused by pressure. R/T (related to) Moderate Risk per Braden Scale- Risk factors . This Focus area includes interventions of Braden/Skin risk assessment quarterly, pressure relieving devices, and apply incontinent barrier cream. [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of a missing item to the state agency (Illinois Department of Public Health) for 1 (R27) of 2 residents reviewed for abuse in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to ensure PASRR (Preadmission Screening and Resident Review) Level 2 screenings were completed for 1 (R4) of 5 residents reviewed for screenings in the sample of 27. Findings Include:R4's Transfer/Discharge Report dated 4/29/26 documented R4 was admitted to the facility on [DATE]. This same report includes diagnoses of bipolar disorder, cerebral infarction, dementia, brief psychosis episode, and major depressive disorder. R4's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 09, indicating R4 had moderate cognitive impairment. R4's current Care Plan documents a Focus area of, Anti-Psychotic: The resident uses anti-psychotic medications for brief psychotic disorder, paranoid delusions r/t (related to) MDD (major depressive disorder). Date Initiated: 09/25/2025. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure showers were provided as scheduled for 1 (R28) of 1 resident reviewed for ADLs (Activities of Daily Living) in the sample of 27. Findings Include:R28's admission Record documented an admission date of 10/31/25 and included diagnoses of complete lesion at C5 level and pressure ulcer of sacral region. R28's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R28 is cognitively intact. This same MDS documents R28 requires substantial/maximal assist with bathing. R28's current Care Plan includes a Focus area with a start date of 11/10/25 of, ADL: [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure care plan fall interventions were implemented for 1 (R16) of 3 residents reviewed for falls in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection control practices were implemented during medication administration and resident care for 2 (R7 and R35) of 13 residents in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe mechanical lift transfer for 1 (R1) of 3 residents reviewed for accidents in the sample of 5. This failure resulted in R1 acquiring a laceration to her head on the top left side resulting in 2 sutures being placed. This past noncompliance occurred between 11/26/25 and 12/1/25.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep resident rooms clean for 1 (R5) of 3 residents reviewed for homelike environment out of the sample of 7. Findings Include:R5's admission Record documented an admission date of 11/21/2025. This same record documented diagnosis including cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries, ST-elevation myocardial infarction of unspecified site, and presence of aortocoronary bypass graft. On 11/22/25 at 11:51 AM, an observation in R5's room revealed the following: 5 separate fecal matter smeared areas on the floor between bed 1 and bed 2. On 11/22/2025 at 12:00PM, an observation of 5 separate areas of fecal matter still smeared on the floor in R5' room between bed 1 and bed 2 after observing V3 (Housekeeping) clean R5's room including sweeping and mopping the floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain aseptic technique during bowel incontinence care and catheter care and apply Enhanced Barrier Precautions for 1(R1) of 3 residents reviewed for infection control in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure the services of a Registered Nurse for 8 consecutive hours per day, 7 days a week. This has the potential to affect all 32 residents living at this facility. The facility's Nursing schedule for August and September 2025 revealed the facility did not have 8 consecutive hours of RN (Registered Nurse) coverage for the dates of 9/7/25, 9/6/25, 8/24/25, 8/23/25 or 8/9/25. On 9/9/2025 at 8:50am, V1 (Administrator) said the facility did not have the required 8 hours of continuous RN coverage for the dates of 9/7/25, 9/6/25, 8/24/25, 8/23/25 or 8/9/25. On 9/8/2025 at 11:00am, V2 (Director of Nursing) said she realizes the facility does not have 8 continuous hours of RN coverage during the weekends. V2 said the facility is actively advertising to hire more Registered Nurses to meet the requirement. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide 8 hours per day, 7 days per week Registered Nursing (RN) coverage for the facility. This failure has the potential to affect all 37 residents residing in the facility. The facility's June 2025 Nurse Schedule documents on 06/01/25, 06/14/25, 06/15/25, 06/28/25 and 06/29/25 the facility did not have a Registered Nurse (RN) scheduled. On 06/04/25, 06/06/25, 06/09/25, 06/12/25, 06/20/25, and 06/26/25, V2 (Director of Nursing/DON) was the RN scheduled for 8 hours. The Employee Timecard Report for V2 documented on the dates of 06/04/25, 06/06/25, 06/09/25, 06/12/25, and 6/26/25, V2 worked 7.5 hours, and on 06/20/25, V2 worked 7 hours. The facility's July 2025 Nurse Schedule documents on 07/05/25, 07/06/25, 07/26/25 and 07/27/25, the facility did not have an RN scheduled for 8 hours. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 2 (R1 and R6) of 3 residents reviewed for abuse in the sample of 9.1. R1's admission Record documented an initial admission date to the facility on [DATE] and included diagnoses of hemiplegia affecting left nondominant side, chronic obstructive pulmonary disease, asthma, type 2 diabetes mellitus, morbid obesity, osteoarthritis, obstructive sleep apnea, disorder of prostate, generalized anxiety disorder, major depressive disorder, calculus of ureter, and abdominal pain. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to provide substantial evening snacks to residents. This failure has the potential to affect all 37 residents residing at the facility.

Inspectors wroteBased on interview, observation, and record review the facility failed to maintain floors, sinks and shower rooms in a clean, safe and sanitary condition for 20 of 20 (R2, R4, R6, R7, R8, R11, R12, R13, R14, R15, R16, R18, R19, R20, R21, R22, R23, R24, R26, and R27) residents reviewed for environment in a sample of 27.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the doctor and obtain treatment orders when a change to a pressure area was detected and failed to apply heel protectors to prevent further skin breakdown for 3 of 4 residents (R3, R4, R5) reviewed for pressure areas in the sample of 27.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely drain a full indwelling catheter bag, increasing the resident's risk for infection for 1 of 3 (R2) residents reviewed for catheters in the sample of 27. Findings Include:R2's admission record documents an admission date of 6/12/17 with the following diagnoses listed in part; cerebral infarction, retention of urine, neuromuscular dysfunction of bladder and urinary tract infection, site unspecified. R2's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) was not completed due to resident is rarely/never understood. R2's Order Summary Report documents an active order to replace bedside drainage bag with leg bag each morning. R2's care plan documents resident has an indwelling catheter. resident will show no s/sx (signs and symptoms) of Urinary infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage 8 consecutive hours per day, 7 days per week. This failure has the potential to affect all 34 residents residing in the facility. Findings Include: The facility's May 2025 Nurse Schedule documents on 05/03, 05/04, 05/17, 05/18, 05/26, and 05/31/25 the facility did not have a Registered Nurse scheduled. On 05/07, 05/08, 05/09, 05/12, 05/15, 05/20, 05/21, and 05/23/25, V2 (Director of Nursing/DON) was the RN Scheduled for 8 hours. The Employee Timecard Report for V2 documented on 05/07, V2 worked 7.5 hours, on 05/08, V2 worked 7.5 hours, on 05/09, V2 worked 5.25 hours, on 05/12, V2 worked 7.25 hours, on 05/15, V2 worked 7.25 hours, on 05/20, V2 worked 7.5 hours, on 05/21, V2 worked 7 hours, and on 05/23, V2 worked 7.5 hours. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assistance with hygiene care for 1 (R31) of 1 resident reviewed for dignity in the sample of 24. This failure resulted in R31 being left in urine-soaked clothing with urine dripping under his chair during mealtime, which would cause a reasonable person to feel discomfort, humiliation and frustration. The Findings Include: R31's Face Sheet documents an admission of 10/9/2023 and includes the following diagnosis: schizophrenia. R31's quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Section H of this same MDS documents R31 is frequently incontinent for urine. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a full time Registered Dietitian or full time Certified Dietary Manager on staff. This has the potential to affect all 34 residents residing in the facility. The Findings Include: On 9/17/24 on 9:00 AM, V4 (Cook) stated that they currently do not have anyone in the Dietary Manager role in the kitchen. V4 stated that there was someone, but they quit a couple days after she started. On 9/20/24 at 2:00 PM, V1 (Administrator) stated that she has not had anyone in the dietary manager role in the kitchen since June of 2024. V1 further stated that she is trying to find someone to fill that role but has not had any luck. V1 stated that they do have a Registered Dietitian come in once a month to review resident nutritional needs, but not full time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was clean and sanitary to prevent cross contamination. This has the potential to affect all 34 residents residing in the facility. The Findings Include: During the initial tour of the kitchen on 9/17/24 at 9:20 AM, the following observations were made: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide scheduled daily activities that met resident goals and preferences for six (R2, R3, R7, R12, R30 and R34) of six residents reviewed for activities in the sample of 24. Findings Include: 1. R2's admission Record documented an admission date of 3/1/24 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, and multiple sclerosis. R2's Minimum Data Set (MDS) assessment dated [DATE] under Interview for Activity Preferences documented that having books, newspapers, magazines, listening to music, being around animals, keeping up with the news, doing things with groups of people and doing favorite activities was somewhat important to R2, and going outside for fresh air when weather is good was very important to R2. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in the proper form of the diet order for 5 of 5 (R1, R16, R18, R19 and R30) residents reviewed for menus meeting resident needs in the sample of 24. The Findings Include: 1. R1's current order summary report lists diet order as: regular diet, pureed texture. 2. R16's current order summary report lists diet order as: regular diet, pureed texture. 3. R18's current order summary report lists diet order as: regular diet, mechanical soft texture. 4. R19's current order summary report lists diet order as: regular diet, mechanical soft texture. 5. R30's current order summary report lists diet order as: regular diet, mechanical soft texture. On 9/17/24 at 12:00 PM, during lunch meal observation, V4 (Cook) was preparing the altered diets for residents on mechanical soft and puree. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to follow Infection Control practices for 9 of 12 residents (R1, R2, R4, R6, R8, R9, R11, R12, and R17) reviewed for infection control in the sample of 24. The Findings Include: 1. On the initial tour of the facility on 09/17/2024 beginning at 9:30 AM, there were no resident rooms observed in the facility with signage on the doors indicating residents were on enhanced barrier precautions. On 09/17/2024 a Matrix for Providers (form CMS 802) was provided by the facility with no residents marked for transmission-based precautions. On 09/18/2024 at 08:30 AM, during screening of residents, there were no resident rooms observed in the facility with signage on the doors indicating residents were on isolation or enhanced barrier precautions. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify resident representatives in writing of hospital transfers for 1 (R3) of 1 resident reviewed for hospitalizations in a sample of 24. Findings Include: R3's admission Record documented an original admission date to the facility of 7/21/06. R3 was alert to person only. R3's Responsible Party was documented as being V22 (Guardian). R3's Progress Notes documented on 8/23/24, R3 was transported and admitted to the local hospital with a reddish/brown emesis throughout the day, along with unable to keep medication down. On 09/19/24 at 12:04 PM, V1 (Administrator) stated that the resident and/or their representative were notified of the hospital transfer and/or admission via phone. V1 confirmed that documentation is not provided to the resident representative in writing. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify resident representatives in writing of the bed hold policy during resident transfers for 1 (R3) of 1 resident reviewed for notice of bed hold policy upon transfer in the sample of 24. Findings Include: R3's admission Record documented an original admission date to the facility of 7/21/06. R3 was alert to person only. R3's Responsible Party was documented as being V22 (Guardian). R3's Progress Notes documented on 8/23/24, R3 was transported and admitted to the local hospital with a reddish/brown emesis throughout the day along with unable to keep medication down. On 09/19/24 at 12:04 PM, V1 (Administrator) stated that the resident representative was notified of the bed hold policy via phone and sent with the resident. V1 confirmed documentation was not provided to the resident representative in writing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for 3 (R8, R9, and R21) of 12 residents reviewed for accuracy of assessments in the sample of 24. Findings Include: 1. R9's admission Record documented an initial admission date of 08/02/2024. Diagnoses listed on this document include chronic obstructive pulmonary disease, cerebrovascular disease, spastic hemiplegia, chronic kidney disease, sleep apnea, unspecified dementia, gastro-esophageal reflux disease, bipolar disease, anxiety, and retention of urine. R9's Notice of PASRR Level II Outcome dated 07/22/2022 documented that You have a Level II PASRR Condition of Bipolar Disorder Level II Outcome: Level II - Approved No SS. R9's MDS with an Assessment Reference Date of 10/12/2013 documented this MDS as being an annual assessment. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide services of a Registered Nurse for eight consecutive hours per day, seven days a week. This has the potential to affect all 38 residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide an acceptable reason for discharge and failed to allow a resident to return to the facility for 1 (R1) of 3 residents reviewed for transfer/discharge in the sample of 19. This failure resulted in R1 remaining in the emergency room without placement from 12/12/23 to 12/18/23 and being admitted to a hospice room at the hospital due to not having a facility to be discharged to. This failure resulted in R1 having feelings of embarrassment, devastation, abandonment and fear of not knowing what was going to happen to him. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from mental abuse/mistreatment for 1 (R2) of 3 residents reviewed for abuse in the sample of 19. Findings Include: R2's admission Record with a print date of 1/4/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include early-onset cerebral ataxia, paraplegia, bipolar disorder, major depressive disorder, heart disease, muscle weakness, and anxiety. R2's MDS (Minimum Data Set) dated 10/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area of The resident (R2) has a communication problem r/t (related to) Expressive Aphasia with an initiation date of 11/20/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the facility abuse policy when they neglected to identify an allegation of abuse, and timely and thoroughly investigate an allegation of abuse for 1 (R2) of 3 residents reviewed for abuse in the sample of 19. Findings Include: The undated Final (Investigation) Report documents, .Summary: On the date of 1/3/2023, (State Survey Agency) surveyor was present in the building and reported to this writer verbal abuse allegedly occurring involving resident (R2) and Nurse, (V9/LPN-Licensed Practical Nurse). Throughout the investigation it was discovered that the alleged event occurred on 12/23/2023. This writer had not been notified of any allegations until 1/3/2023. (V9) was immediately placed on suspension pending investigation and ensuring of (R2's) safety was present Staff interviews: [...]

Inspectors wroteBased on interview and record review, the facility failed to timely report an allegation of abuse to the State Survey Agency for 1 of 1 (R2) resident reviewed for abuse in the sample of 19. Findings Include: The undated Final (Investigation) Report documents, .Summary: On the date of 1/3/2023, (State Survey Agency) surveyor was present in the building and reported to this writer verbal abuse allegedly occurring involving resident (R2) and Nurse, (V9/LPN-Licensed Practical Nurse). Throughout the investigation it was discovered that the alleged event occurred on 12/23/2023. This writer had not been notified of any allegations until 1/3/2023. (V9) was immediately placed on suspension pending investigation and ensuring of (R2's) safety was present .Conclusion: In conclusion, the accusation of abuse to (R2) cannot be substantiated. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely and thoroughly investigate an allegation of abuse for 1 of 3 (R2) residents reviewed for abuse in the sample of 19. Findings Include: R2's admission Record with a print date of 1/4/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include early-onset cerebral ataxia, paraplegia, bipolar disorder, major depressive disorder, heart disease, muscle weakness, and anxiety. R2's MDS (Minimum Data Set) dated 10/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area of The resident (R2) has a communication problem r/t (related to) Expressive Aphasia with an initiation date of 11/20/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a resident an advanced written notice of involuntary discharge with appeal rights for 1 (R1) of 3 residents reviewed for discharge in the sample of 19. Findings Include: R1's admission Record with a print date of 1/4/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include quadriplegia, adjustment disorder with anxiety, adjustment disorder with mixed disturbance of emotions and conduct, spastic hemiplegia, neurogenic bowel, and pressure ulcers. R1's BIMS (Brief Interview for Mental Status) dated 11/03/23 documents a score of 15, which indicates R1 is cognitively intact. R1's MDS (Minimum Data Set) dated 12/12/23 documents under Section G, R1 is dependent on staff for all Activities of Daily Living (ADL's). Under Section I, this same MDS documents a diagnosis of quadriplegia. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were safely transferred without injury for 1 (R3) of 3 residents reviewed for mechanical transfers in the sample of 12. The failure resulted in R3 suffering pain with left sided rib fractures, numbers 3 - 10 and a pneumothorax to the left lung. Findings Include: Review of R3's admission Record documented R3's initial admission date to the facility as 08/23/21. R3's date of birth is listed as 3/24/53. The same document lists diagnoses for R3 including but not limited to: Aphasia following Cerebral Infarction; Major Depressive Disorder; Essential Hypertension; Unspecified Atrial Fibrillation, etc. Review of R3's current Plan of Care documented an undated notation on the first page of the plan that stated, Special Instructions to include, Hoyer lift for transfers. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide services of a Registered Nurse for eight consecutive hours a day seven days a week. This has the potential to affect all 43 residents residing at the facility. Findings Include. The facility document dated November 2023 titled, Nurses Schedule documents V2, as the only registered nurse working 11/20, 11/21, and 11/22 with an X in the box for her name. The key under the schedule documents: x = 6a-6p or 6p - 6a. On 11/20/23 at 11:00 AM, V2 (Director of Nursing) was observed arriving at the facility. On 11/21/23 at 9:15 AM, V2 was observed arriving at the facility. At 9:20 AM, V2 was observed leaving the facility and returned at approximately 9:50 AM. On 11/21/23 at 1:50 PM, V2 stated, she had to leave today at approximately 2:00 PM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to serve meals at the facility's designated scheduled times. This has the potential to affect all 43 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide diets as ordered and failed to follow pre-planned menus and standardized recipes. This failure has the potential to affect all 37 residents who reside in the facility. Findings Include: 1. On 8/16/23 at 12:53 PM, R12 was observed being served a puree diet of tuna noodle casserole, mixed vegetables, apple sauce, and a (name brand) supplement cup. Review of R12's meal card documented R12 should receive double protein portions, which was not observed being served. On 8/16/22 at 12:55 PM, V4 (Cook) confirmed R12 was not served a double protein portion by mistake. At 1:00 PM, V4 was observed providing R12 an additional serving of tuna noodle casserole. On 08/17/23 at 09:33 AM, V1 stated that it her expectation that prescribed diets are followed as ordered. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to offer meal substitutes and honor resident preferences. This has the potential to affect all 37 residents residing in the facility. The Findings Include: 1. On 8/15/23 at 10:30 AM, R17 stated that he does not get options of alternate foods offered at mealtime. R17 stated that he does not know what is being served until he gets it delivered and most of the time the food is delivered late. R17 was alert to person, place and time. 2. On 8/16/23 at 1:00 PM, V11 (Family Member) stated that her husband R37 has been in the facility since January 2023 and hasn't been asked food preferences. During lunch mealtime on this day V11 stated that they sent R37 applesauce, and he does not like that. The menu for the lunch meal had German chocolate cake as the planned dessert. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to execute dietary services for timely meal distribution. The failure has the potential to affect all 37 residents residing in the facility. Findings Include: Mealtimes as provided by the facility documents lunch is at 12:00 PM. On 08/15/23 at 12:33 PM, the first meal tray was observed being served in the dining room. On 8/17/23 at 12:20 PM, R10 was observed placing her head on the dining room table while waiting for her meal and falling asleep. On 8/17/23 at 12:32 PM, the first meal tray was observed being served in the dining room. On 08/18/23 at 11:42 AM, staff were observed wheeling residents into the dining room, sitting them at tables for lunch. On 08/18/23 at 12:14 PM, resident hall trays were observed leaving the kitchen for delivery. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner. This has the potential to affect all 37 residents residing in the facility. The Findings Include: During the initial walk through of the kitchen on August 15th at 9:00 AM the following items were found: Raw beef was thawing on the rack above fresh produce in the refrigerator. V5 (Dietary Supervisor) was observed to have facial hair without being properly restrained. The countertop mixer was observed to have dried old food splatter in and around the mixer. The refrigerator unit next to the countertop where food is prepared was splattered with old, dried food. The oven top and side of oven was covered in old dried splattered food. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to serve foods at the desired palatable temperature for 33 (R2, R3, R4, R5, R7, R8, R9, R10, R11, R13, R14, R15, R16, R17, R18, R20, R21, R22, R23, R24, R25, R26, R27, R29, R31, R32, R33, R34, R35, R36, R38, R39, R40) of 33 residents reviewed for palatability in the sample of 42. Findings Include: On 08/15/23 at 10:30 AM, R17 stated that he eats his meals in his room and the food is normally cold. R17 is alert to person, place and time at this encounter. On 08/15/23 at 12:33 PM, R11 was observed being served Salisbury Steak, which she reported was, barely warm at best. R11 was observed as being alert and oriented to person, place, and time during this encounter. On 08/16/23 at 1:00 PM, V11 (Family Member) stated that she is here for every lunch meal. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 12 (R37) residents reviewed for assessments in a sample of 42. The Findings Include: A quarterly MDS assessment dated [DATE] documents in Section K0300 that R37 has not had weight loss of 5% or more in one month or 10% in six months and Section K0510 documents no indicating that R37 is not on a mechanically altered diet. R37's Physician's Order Sheet (POS) dated May 1st, 2023, to May 31st, 2023, documents a diet order of Regular, Pureed, thin liquids. R37's monthly weight grid documents a February weight of 153.6 pounds, March weight of 149.2 pounds, April weight of 138.8 pounds, and a May weight of 137 pounds. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered comprehensive care plan for 1 of 12 (R37) residents reviewed for weight loss in a sample of 42.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dining assistance to residents as needed for 2 of 11 residents (R26, R34) reviewed for dining in the sample of 42. Findings Include: On 08/16/23 at 12:41 PM, R34 and R26 were observed sitting at the same table in the dining room. No staff were observed as being present at the table. R34 and R26 had been served a regular diet of tuna noodle casserole, mixed vegetables, roll, and cup of applesauce as their meal. R34 was observed attempting to drink her applesauce out of the cup, with no success. R34 was then observed using her fork to scoop tuna noodle casserole off of her plate and into her full applesauce cup. On 8/16/23 at 12:45 PM, R34 was again attempting to drink her applesauce cup with tuna noodle casserole on top of it, with no success. No staff were present at table, intervening or assisting R34. [...]