Goldwater Care Clinton

Inspectors wroteBased on interview and record review the facility failed to ensure medications were administered as ordered to the correct resident for one of one resident (R3) reviewed for significant medication errors in the sample list of 23. This failure resulted in R3's blood pressure dropping to 60/30, feeling ill and being sent to the emergency room for evaluation and cardiac monitoring.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered and failed to ensure accurate documentation of controlled medication administration for three of seven residents (R3, R5, R7) reviewed for pharmacy services in the sample list of 23. 1. R7's admission Record documents an admission date of 07/31/2025 with diagnoses including Chronic Pain Syndrome, Generalized Anxiety Disorder, Essential Primary Hypertension, Major Depressive Disorder (Recurrent, Moderate), and Urinary Retention. R7's MDS (minimum data set) with an Assessment Reference Date (ARD) of 05/29/2026, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R7 is cognitively intact. On 7/13/2026 at 10:38 AM, R7 stated that on 7/4/2026 an unknown nurse was working the evening shift. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident's right to be free from physical abuse by failing to prevent a resident to resident altercation for two (R6 and R4) of four residents reviewed for abuse on the sample list of 15.

Inspectors wroteBased on observation, interview and record review the facility failed to implement fall interventions to prevent a fall for one resident (R12) and failed to adequately assess, monitor and evaluate residents post falls for three of three residents (R2, R12, R14) reviewed for falls in the sample list of 11. This failure resulted in R12 being sent to the hospital and receiving two sutures.

Inspectors wroteBased on interview, and record review the facility failed to ensure that residents and/or their designated financial powers of attorney received individual quarterly resident fund statements, as well as fund statements or receipts upon request for four of four residents (R4, R16, R18, R20) reviewed for personal funds in the sample list of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to exercise reasonable care in propelling a resident in a shower chair, causing a resident's foot to contact the wall. This failure affects one resident (R2) out of three reviewed for incidents on the sample list of five.

Inspectors wroteBased on interview and record review the facility failed to administer physician ordered medications during the morning medication administration pass on 5/10/26, which resulted in significant medication errors for eight of twelve residents (R1, R2, R3, R4, R5, R6, R7, and R8) reviewed for medications on the sample list of 16. This failure resulted in R5, R6 and R7 to endure and sustain pain and discomfort for an extended amount of time due to not receiving physician ordered narcotic pain medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure an adequate number of licensed nursing staff were in the facility to provide resident care and services. This failure has the potential to affect all 103 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete shift count of residents' narcotic medications and failed to maintain medication room/medication carts keys, in a safe manner to prevent residents, staff and visitors full access to medications, which included narcotic medications. These failures have the potential to affect all 103 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to notify resident family/representatives of missed administration of significant morning medications. This failure affects eight of twelve residents (R1, R2, R3, R4, R5, R6, R7, and R8) reviewed for notification/medications on the sample list of 16.

Inspectors wroteBased on interview and record review, the facility failed to provide eight hours of required Registered Nurse staffing coverage per 24-hour period for two of fourteen days reviewed for staffing. This failure has the potential to affect all 105 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain a resident's right to privacy while being assisted by staff. This failure affects one resident (R1) of three reviewed for privacy in the sample list of three residents.

Inspectors wroteBased on interview and record review, the facility failed to provide timely toileting assistance for three residents (R1, R2, R3) of three reviewed for Activities of Daily Living (ADLs) on the sample list of three residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident rights were protected when they failed to ensure Advanced Directives were obtained and/or documented for one (R2) of one resident reviewed for advance directives in the sample of nine residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical abuse for one (R5) of five residents. This failure affected two (R5 and R6) residents on the sample of seven residents.

Inspectors wroteFailures at this level required more than one deficient practice statementA. Based on interviews and record reviews the facility failed to ensure follow up medical appointments were scheduled for one (R3) of one resident reviewed for medical appointments in the sample of seven residents. B. Based on interview and record review the facility failed to ensure neurological assessments were completed for one (R5) of one resident reviewed for incidents involving a head injury in the sample of seven residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect residents (R1 & R5) from physical abuse from another resident (R2). This failure affected two (R1 & R5) of three residents reviewed for abuse in the sample list of five residents.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident-to-resident abuse to the State Agency for two (R2, R5) residents out of three residents reviewed for abuse, on a sample list of five residents.

Inspectors wroteBased on interview and record review the facility failed to investigate allegations of resident-to-resident physical abuse for two (R2, R5) out of three residents reviewed for abuse, on a sample list of five residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide supervision in a resident bathroom and the dining room and failed to remove a mechanical lift sling from the wheelchair to prevent falls, and failed to implement fall interventions, complete a fall assessment for five of six residents (R1, R17, R21, R23 and R112) reviewed for accidents on the sample list of 46. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately transcribe an order for Seroquel (antipsychotic), failed to administer an antiparkinsonian medication as recommended prior to meals and failed to ensure medications were taken by the resident for three of 46 residents (R7, R83 and R44) reviewed for medications in the sample list of 46 residents. This failure resulted in exacerbation of R7's behavioral symptoms related to dementia when R7 missed 13 days of R7's antipsychotic due to a transcription error. Findings Include:1. R7's Care Plan updated 11/6/25 documents the following diagnoses: Type II Diabetes, Alzheimer's Dementia, Repeated Falls, and Major Depression. R7's Minimum Data Set (MDS) dated [DATE] documents R7 has no behavioral symptoms. On 2/8/26 at 9:00AM R7 was in his bed watching television (TV). The Surveyor knocked on R7's open door. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide a registered nurse for eight consecutive hours daily. This failure has the potential to affect all 104 residents of the facility.

Inspectors wroteBased on interview, and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and to provide regular in-service education based on the outcome of these reviews. This failure has the potential to affect all 104 residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document food preparation temperatures on the food temperature log labeled for the main kitchen food preparation. This failure has the potential to affect all 104 residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure required staff members attended Quarterly Quality Assurance meetings. This failure has the potential to affect all 104 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper infection prevention and control practices related to oxygen administration for one (R73) of three residents reviewed for Respiratory Care out of a sample list of 45 and the facility failed to accurately document and analyze facility infections. This failure has the potential to affect all 104 residents currently residing at this facility.

Inspectors wroteBased on interview and record review the facility failed to designate one or more individuals as infection preventionist. This failure has the potential to affect all 104 residents currently residing at this facility.

Inspectors wroteBased on interviews and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training for staff. This failure has the potential to affect all residents residing in the facility.

Inspectors wroteBased on Interview and record review the facility failed to provide behavioral health training to all direct care staff. This deficiency has the potential to affect all resident who reside in the facility. Findings Include: The facility's Long-Term Care Application for Medicare and Medicaid dated 2/8/26 documents the census as 104 residents residing at the facility. On 2/17/26 at 10:00AM V1, Administrator and V14, Acting DON (Director of Nursing) verified they cannot provide documentation of Behavioral Health training for any staff was conducted in the 12 months previous to this survey.

Inspectors wroteBased on interviews and record review, the facility failed to honor residents' right to make choices regarding the timing of their showers. This failure affects three residents (R11, R23, and R45) out of three residents reviewed for personal care choices, from a total sample of 46. The facility's Bathing - Shower and Tub Bath Policy dated 11/28/12 with a revision on 1/31/18 documents that the purpose of this policy is to ensure resident's cleanliness to maintain proper hygiene and dignity. The policy requires that residents be offered a shower, tub bath, or bed/sponge bath according to their individual preferences for timing and frequency, at least twice per week, and additionally as requested or needed. R11's Electronic Medical Record (EMR) documents that R11 was admitted to the facility on [DATE] for aftercare following joint replacement surgery of the right hip on 12/01/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to date a multi dose insulin pen when opened for one (R56) of five residents reviewed for medication administration on the sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to ensure influenza and pneumococcal vaccinations was offered and documented in the medical record. This failure affected five of five (R15, R4, R2, R63, and R12) residents reviewed for Infection Control out of a sample list of 46.1. R15's undated Care Plan documents an admission date to the facility as 02/11/2025 with the following diagnosis: Iron Deficiency, Lipoprotein Deficiency, Vascular Dementia, Mild, With Anxiety, Depression, Restless Legs Syndrome, And Chronic Pain. R15's medical record does not document that a pneumococcal vaccine nor a influenza vaccine was offered to R15. R15's Minimal data set dated [DATE] documents R15 with a Brief Interview for Mental Status score of six indicating severe cognitive impairment. R15's medical record does not document that a pneumococcal nor an influenza vaccine was offered to R15. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure COVID-19 vaccinations are offered and documented. This failure affected five of five (R15, R4, R2, R63, and R12) residents reviewed for Infection Control out of a sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to obtain consents for psychotropic medications for one (R17) of five residents reviewed for unnecessary medications on the sample list of 46.

Inspectors wroteBased on Interview and record the facility failed to notify the physician and dietician of a significant weight loss for one (R112) of three residents reviewed for physician notification in the sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to ensure the right to be free from chemical restraints by failing to implement alternatives to psychotropic medications, failing to monitor for tardive dyskinesia, and failing to gradually reduce psychotropic medication for one (R17) of five residents reviewed for unnecessary medications on sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to accurately code a minimum data set assessment for one (R17) of 32 residents reviewed for assessments on the sample list of 46.

Inspectors wroteBased on interview and record review the facility failed to develop a care plan for constipation for two (R1, R17) of 32 residents reviewed for care plans on the sample list of 46.

Inspectors wroteBased on interview and record review the facility failed update a residents Care Plan to include a significant weight loss for one of 46 residents (R81) reviewed for Care Plans on the sample list of 46. Findings Include: R81's Census form dated 2/17/26 documents R81's admission date as 7/11/25. R81's weights are documented from 7/13/25 to 2/9/26 in the EMR (Electronic Medical Record). R81's weight on 7/13/25 was 175.0 pounds. R81's weight on 2/9/26 was 114.6 pounds which equals R81 losing 60.4 pounds. R81's care plan dated 2/4/26 does not address R81's weight loss. V15, Care Plan Coordinator stated on 2/12/26 at 2:30 PM I did not realize the care plan did not document the weight loss. I know we addressed (R81) needing a special diet, but we did not document anything about weight loss. [...]

Inspectors wroteBased on interview, and record review, the facility failed to complete neurological checks after an unwitnessed fall and a fall with a head injury for one (R112) of three residents reviewed for assessments in a sample list of 45.

Inspectors wroteBased on observation, interview and record review the facility failed to implement resident centered interventions for one resident with dementia (R7) of six residents reviewed for Dementia in a sample of 46. Findings Include: R7's Care Plan, updated 11/6/25, documents the following diagnoses: Type II Diabetes, Alzheimer's Dementia, Repeated Falls, and Major Depression. R7's Minimum Data Set (MDS) dated [DATE] documents that R7 has no behavioral symptoms. On 2/8/26 at 9:00 AM, R7 was in his bed watching TV. The Surveyor knocked on R7's open door. R7 shouted, What and who the H*** are you? The Surveyor introduced herself and explained to R7 that she was here from IDPH (Illinois Department of Public Health) to talk with residents about the care they receive at the facility. R7 seemed very agitated and shouted, Well, if you are from the F****** (expletive) state, get me out of here now. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered by the physician for one (R111) of five residents reviewed for medication administration on the sample list of 46. These failures resulted in two medication errors out of 29 opportunities resulting in a 6.9% medication error rate.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure liquids provided at the bedside were thickened as ordered by the physician for one (R107) of 32 residents reviewed for hydration on the sample list of 46.

Inspectors wroteFailures at this level required more than on deficient practice statement:A .Based on interview and record review the facility failed to complete a thorough admission process including greeting the resident within 15 minutes of arrival, providing access to the call light, notifying the pharmacy of resident's arrival, faxing prescriptions to the pharmacy within two hours, admission assessment including care plan focus, pain observation assessment, and fall assessment with transfer status. This failure affected one of five residents (R7) reviewed for quality of care on the sample list of 30. This failure resulted in R7 experiencing significant physical pain, severe anxiety and feelings of being disregarded by staff. B. [...]

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to effectively supervise a cognitively impaired resident to prevent repeat traumatic falls requiring emergency transfers to the hospital for evaluation and treatment. These falls resulted in R1 sustaining a large head hematoma, skin tear to the knee, and pain in R1's head, neck, back, and pelvis. These failures affect one resident (R1) of three reviewed for falls in the sample of three. B. Based on record review and interview the facility failed to complete a thorough fall investigation to determine root cause of a fall in order to implement a targeted intervention. [...]

Inspectors wroteBased on interview and record review the facility failed to address a resident's post-surgical pain. This failure affected one of five residents (R7) reviewed for pain on the sample list of 30. This failure resulted in R7 experiencing a significant increase of uncontrolled pain which required hospitalization. This past non compliance occurred from 11/19/25 to 12/19/25. Findings Include: R7's Hospital Discharge After Visit Summary documents R7 was discharged to the facility on [DATE], status post left total knee replacement surgery. Discharge orders included instructions to call the physician's office for any severe uncontrolled pain. R7's pain medication orders included hydrocodone 5/325 mg, take one to two tablets by mouth every four hours as needed for moderate to severe pain; hydromorphone 4 mg by mouth every four hours as needed for moderate to severe pain; [...]

Inspectors wroteBased on interview and record review the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a per day. This failure has the potential to affect all 107 residents in the facility. Findings Include: Facility Nursing Staff Schedules reviewed from 12/17/25 through 1/7/26 documented five days (12/20, 12/21, 12/26, 12/29, 12/30/25) that the facility failed to use the services of a Registered Nurse for at least eight consecutive hours. On 1/7/26 at 11:50 AM V2 Director of Nurses (DON) confirmed the facility did not have eight hours of Registered Nurse coverage every day and needed to hire more RNs in order to meet the requirement. V2 also confirmed the facility's current census was 107 residents. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure resident rights to dignified care for four of five residents (R5, R8, R9 and R10) reviewed for dignified care on the sample list of 30.

Inspectors wroteBased on observations, interviews and record review the facility repeatedly failed to honor residents' preference to choose the shift their showers would be scheduled, and repeatedly failed to provide dependent residents with showers. These failures affected five of five resident (R2, R3, R9, R24, and R26 ) resident reviewed for showers on the sample list of 30.

Inspectors wroteBased on interview and record review the facility failed to order, failed repeatedly to obtain medications from the pharmacy in a timely manner, and failed to administer a resident's pain medications. These failure affected three of five residents (R7, R9 and R24) reviewed for medications on the sample list of 30. Findings Include: 1. R7's Hospital Discharge After Visit Summary documents R7 was discharged to the facility on [DATE], status post left total knee replacement surgery. Discharge orders included instructions to follow physician orders for medications to control pain. R7's pain medication orders included hydrocodone 5/325 mg, take one to two tablets by mouth every four hours as needed for moderate to severe pain; hydromorphone 4 mg by mouth every four hours as needed for moderate to severe pain; morphine 15 mg by mouth every 12 hours; [...]

Inspectors wroteBased on record review and interview the facility failed repeatedly to administer muscle relaxer/pain/medication, resulting in a significant medication error for one of nine residents (R24) reviewed for medications administration on the sample list of 30.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident with an active, symptomatic pneumonia infection was placed on isolation precautions to prevent transmission of a bacterial infection, and repeatedly failed to ensure a second resident was not subjected to the exposure of the respiratory infection while treatment was delayed for four days, then while treatment was in progress for a total of 10 days. This failure affected two of six residents (R3 and R4) reviewed for transmittable infections on the sample list 30.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's physician of a significant change of condition (severe increase is pain). This failure affected one of five residents (R7) reviewed for pain on the sample list of 30. Findings Include: R7's Hospital Discharge After Visit Summary documents that R7 was discharged to the facility on [DATE], status post left total knee replacement surgery. Discharge orders included instructions to call the physician's office for any severe, uncontrolled pain. R7's pain medication orders included Hydrocodone 5/325 mg, take 1-2 tablets by mouth every four hours as needed for moderate or severe pain. Additional pain medication orders included Hydromorphone 4 mg by mouth every four hours as needed for moderate to severe pain; Morphine 15 mg by mouth every 12 hours; [...]

Inspectors wroteBased on interview and record review the facility failed to recognize an allegation of abuse and report the allegation to the State Agency. This failure affected one of eight residents (R8) review for abuse/misappropriation on the sample list of 30.

Inspectors wroteBased on interview and record review the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a per day. This failure has the potential to affect all 104 residents in the facility. Findings Include: Facility Nursing Hall Assignment Sheets reviewed from 8/27/25 through 9/15/25 documented nine days (8/27, 8/28, 9/2, 9/3, 9/4, 9/9, 9/11, 9/13, 9/14) that the facility failed to use the services of a Registered Nurse for at least eight consecutive hours. On 9/18/25 at 2:30 PM V1 Administrator confirmed there were days with no RN staffing available. V1 also confirmed the facility's average daily census was around its current census of 104 residents. The Bed Management sheet dated 9/10/25 documents a current census of 104 residents.

Inspectors wroteBased on interview and record review the facility failed to provide multiple scheduled showers for dependent residents. This failure affected three of three residents (R6, R8, R9) reviewed for showers on the sample list of 19. Findings Include: Facilities Bathing - Shower and Tub Bath Policy dated January 2018 documents: Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub bath or bed/sponge bath will be offered according to resident's preference, two times per week or according to the resident's preferred frequency and as needed or requested. Staff are to document bathing task and assistance provided in the electronic record, including pertinent observations. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to complete multiple wound dressing treatments and failed to address a residents repeated refusals for wound treatment. This failure affected one of three residents (R9) reviewed for wounds on the sample list of 19. Findings Include: The facility's Pressure Injury and Skin Condition assessment dated [DATE] documents the purpose of the policy is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown and assuring interventions are implemented. Dressing should be changed in accordance with physician orders and documented in the Treatment Administration Record (TAR). Physician ordered treatments shall be initialed by the staff on the electronic TAR after each administration. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right (R3) to be free of physical abuse from (R2) for two of six residents reviewed for abuse in the sample list of 19.

Inspectors wroteBased on interview and record review, the facility failed to conduct a fall investigation, develop a root cause, and implement relevant fall interventions for one resident (R4) of three residents reviewed for falls in the sample list 19. This past non-compliance occurred from 8/9/25 to 8/19/25.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records were accurately documented and maintained for five residents (R12, R13, R14, R15, R16) of five residents reviewed for documentation in the sample list of 19.

Inspectors wroteBased on interview and record review the facility failed to provide consistent quality care for five of eight residents (R1, R2, R5, R6, R7) reviewed for nursing care on the sample list of eight. Findings Include: The Facility assessment dated [DATE] documents all medical and non-medical supplies needed and ordered by the physician will be provided to the resident in a timely manner. If equipment is not in the facility, it will be ordered and provided, borrowed from a sister facility or rented to endure the needs of the residents are met. Staffing is adjusted based on resident census and acuity. Resident preferences and suggestions are elicited during resident council meetings and will be taken into consideration. Concerns will be addressed as appropriate and the need for additional staff will be considered to meet the needs of the residents in the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have linens and incontinence briefs for three of seven residents (R5, R6, R7) reviewed for resident preferences from a total sample list of seven residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide ordered dressing changes and failed to accurately document worsening pressure wound staging for three (R2, R3, and R4) of four residents reviewed for pressure wounds from a total sample list of seven residents.

Inspectors wroteBased on interview and record review the facility failed to administer medications as ordered resulting in repeated significant medication errors for two (R1, R2) of three residents reviewed for significant medication errors from a total sample list of seven.

Inspectors wroteBased on interview and record review the facility failed to ensure the dignity of one (R1) of three residents reviewed for dignity from a total sample list of seven residents.

Inspectors wroteBased on interview and record review the facility failed to administer medications according to physician orders for two of three residents (R1, R2) reviewed for medication administration in the sample list of seven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the services of a clinically qualified Director of Activities. This failure has the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide and implement activities to meet the interests and needs of the residents. This failure affects five (R1, R2, R3, R4, and R5) of five residents reviewed for activities on the sample list of five. Findings Include: On 1/28/25 intermittent observations were done between 10:05am and 2:20pm. R1 through R5 were observed between 10:05am and 10:20am sitting at tables in the dining/activity area participating in various activities (reading, puzzles, coloring, and folding). At 2:15pm, R2, R3, and R5 were observed sitting at the same tables they had been observed at 10:05am and 12:26pm in the dining/activity area with their empty lunch dishes still on the table. Residents were not observed in any group activities during these observations and no other individual activities observed while on the unit. [...]

Inspectors wroteBased on interview, and record review the facility failed to complete a thorough investigation and implement/develop post fall interventions for three of three residents (R26, R16, R15) reviewed for falls in the sample list of 43. These failures resulted in R26 sustaining a fall requiring sutures and/or staples. Findings Include: 1.) R26's electronic Progress Notes documents the following: 9/8/24 at 5:56 AM, R26 had an unwitnessed fall in his room and was found on the floor with a laceration above the left eye. R26 was sent to emergency room where they glued the laceration and applied adhesive strips to the laceration. 9/18/24 at 7:15 PM, R26 had an unwitnessed fall in his room and was found on the floor laying on his left side. This note by V26 Licensed Practical Nurse documents R26 stated he hit his head and had complaints of left shoulder and hip pain. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Resident Council grievances were resolved in a timely manner. This failure had the potential to affect all 90 residents who reside in facility.

Inspectors wroteBased on interview, and record review, the facility failed to document receiving registry verification that the employee has met eligibility requirements to work in the facility prior to start date. This failure has the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to conduct and document an accurate facility assessment. This failure has the potential to affect all 90 residents who reside at the facility. Finding Include: The facility census sheet dated 12/2/24 documents there are 90 residents who reside at the facility. 1. The facility assessment dated [DATE] Section A.1 states This facility has the following equipment to meet to meet the medical needs of the resident: Sit to stand or sling type mechanical lifts are not listed in this section. On 12/4/24 at 2:00PM V3, Assistant Director of Nursing provided a list of 18 residents who currently use mechanical lifts for mobility. V3 verified all of these residents use mechanical lifts for mobility. V3 verified it is possible that all residents who live at the facility could have to utilize a mechanical lift in the event of a fall. 2. [...]

Inspectors wroteFailures at this level require more than one deficient practice statement. A. Based on observation, record review and interview, the facility failed to maintain infection prevention procedures to provide a sanitary laundry service. This failure has the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to document education, offering the COVID-19 Vaccine, and the consent and/or declination of COVID-19 vaccines for staff. This failure has the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement accurate complete care plans to include fall prevention, pressure ulcer prevention, oxygen treatment, communication methods and medications for four of four residents (R15, R40, R54, R231) reviewed for care plans in a sample list of 43. Findings Include: 1.) R15's face sheet dated 12/04/24 documents medical diagnoses including Left Femur Fracture, Acute Kidney Failure, Pressure Ulcer of Buttock Stage 2, Major Depressive Disorder, and Anxiety. R15's Physician Wound Notes dated 10/23/24, 10/31/24, 11/6/24, 11/13/24, and 11/20/24 document unstageable, stage 4 and stage 3 pressure ulcers for R15. On 12/3/24 at 11:04 AM R15 had dressings to the right shin, left heel, and left great toe. R15's current Care Plan with admission date of 6/18/24 does not document any pressure ulcers or current interventions. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to assess the residents for eligibility, and ensure residents were offered and administered the pneumococcal and influenza vaccines. This failure affects four (R14, R43, R26, R54) of five residents reviewed for immunization in the sample list of 43.

Inspectors wroteBased on interview and record review the facility failed to submit the Minimum Data Set (MDS ) in a timely manner for one resident (R74) of 18 residents reviewed for MDS in a sample list of 43. Findings Include: The facility's Final Validation Report printed 12/4/24 at 8:52AM documents R74's MDS target Date 5/2/24 Care Plan Late. Care Areas Assessment (CAA) is more than 13 days after entry date. R74's MDS target Date 7/24/24 Assessment completed Late. Care Areas Assessment (CAA) is more than 14 days after assessment reference date. On 12/04/24 at 8:56 AM V16 Care Plan Coordinator and V17, Corporate Care Plan Consultant verified Assessment/Care Plan for R74 dated 5/2/24 and 7/24/24 were late. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete resident comprehensive assessments. This failure affects one resident (R14) of 3 residents reviewed for accuracy of assessments on the sample list of 43.

Inspectors wroteBased on interview, and record review, the facility failed to refer residents with newly diagnosed serious mental disorders for a level II PASARR (Pre-admission Screening and Resident Review) resident review upon a significant change in status assessment for two of two residents (R6, R14) reviewed for level II screening in the sample list of 43.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise care plans following falls with injury and new pressure ulcers for three of four residents (R26, R15, R181) reviewed for care plans in of a sample of 43. Findings Include: The facility's Care Plan Policy revised 6/1/22 states It is the policy of this facility to develop and implement a Base Line Care Plan, a comprehensive person-centered care plan and conduct care plan meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental, and psychological needs that are identified in the resident's comprehensive assessment. 1. R181's Treatment Administration Record (TAR) for December 2024 includes a treatment order for Coccyx wound -apply calcium alginate and silicone bordered foam dressing daily. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to administer insulin per manufacturer's directions and according to standards of practice for three residents (R25,R45, R47) of four residents reviewed for insulin administration in a sample list of 43 residents. Findings Include: 1. R25's Medication Administration Record (MAR) for December 2024 includes an active physician's order for Novolog (insulin) Flexpen U100. Subcutaneously per sliding scale before meals. The manufacturer's package insert for Novolog Flexpen U-100 documents Novolog starts acting fast. Eat a meal within 5 to 10 minutes after taking it. On 12/4/24 at 11:00AM V30 Licensed Practical Nurse (LPN) stated I have given all my insulin for 100 hall for lunch today. When asked when lunch would be served V30 stated about 12:00 Noon. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide an effective communication program for one resident (R40) of 18 residents reviewed for communication in a sample list of 43. Findings Include: R40's Continuity of Care Document printed 12/5/24 includes the following diagnoses: Amyotropic Lateral Sclerosis, Dysphasia, and Anxiety Disorder. On 12/02/24 at 2:18 PM R40 was in his room in a custom fitted wheelchair. R40 spoke very softly and deliberately but given time could be understood. R40 stated They don't take time to listen to me. They assume I can't talk to them, but I can. I have Amyotropic Lateral Sclerosis (Lou GehrigsDisease). I am 44 and I would like to be talked to. Sometimes I feel like I am not here. R40's Minimum Data Set (MDS) dated [DATE] documents R40 is cognitively intact and sometimes understood. [...]

Inspectors wroteFailures at this level require more than one deficient practice statement. A. Based on interview and record review, the facility failed to transcribe and implement physician orders to start a medication for one of one resident (R72) reviewed for medication orders on the sample list of 41. This failure resulted in a delay of medication administration for R72.

Inspectors wroteBased on observation, Interview, and record review the facility failed to assess, implement interventions and physician ordered treatments to prevent the development/worsening of pressure ulcers for two (R181, R15) of three residents reviewed for pressure ulcers in a sample list of 43 residents Findings Include: 1.) R181's Minimum Data Set (MDS) dated [DATE] documents R181 was cognitively intact and not at risk for pressure ulcers had any pressure ulcers. R181's Continuity of Care Document dated 12/5/24 includes the following diagnoses: Displaced Fracture Right Femur (10/30/24), Generalized Anxiety Disorder, Muscle Wasting/Atrophy, Parkinson's Disease, and Chronic Congestive Heart Failure. R181's Initial Wound Evaluation and Management Summary dated 11/27/24 documents (R181) has a stage II Pressure Ulcer on the coccyx measuring 1.2x0.7x0.1 Centimeters of greater that one days duration. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to properly date, label humidifier bottles and oxygen tubing when changed for three of three residents (R11, R20, R231) reviewed for respiratory services in the sample list of 43.

Inspectors wroteBased on interview and record review the facility failed to monitor one resident (R38) receiving opioid medication for bowel function for one resident reviewed for opioid medication in a sample list of 43.

Inspectors wroteBased on interview and record review the facility failed to obtain consent, assess/monitor residents receiving psychotropic medications and failed to document attempts to utilize nonpharmalogical interventions for two residents (R15, R38) reviewed for psychotropic medication in a sample list of 43.

Inspectors wroteBased on interview and record review, the facility failed to ensure the timeliness of laboratory services were completed as ordered by a physician for one (R28) of one resident reviewed for laboratory services on the sample list of 43.

Inspectors wroteBased on observation, interview, and record review the facility failed to report bed bugs and room change to a resident representative for one (R1) of five residents reviewed for bed bugs in the sample list of five.

Inspectors wroteBased on interview, and record review the facility failed to ensure medical records were complete and accurate for two (R1, R2) of five residents reviewed for bed bugs.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a resident's (R2) right to be free from physical abuse by another resident (R1). This failure resulted in R2 experiencing psychosocial harm and fear of R1, and a bruise on R2's arm. This failure affected two of two residents (R1, R2) reviewed for abuse on the sample list of 10.

Inspectors wroteBased on observation, interview, and record review that facility failed to revise comprehensive care plans appropriately for five of ten residents (R1, R3, R4, R5, R9) reviewed for care plan revision out of a sample list of ten.

Inspectors wroteBased on interview and record review the facility failed to timely report an allegation of resident to resident abuse to the state survey agency for two of four residents (R1, R2) reviewed for abuse in the sample list of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a baseline care plan for one of ten (R5) residents reviewed for comprehensive care plan out of a sample list of ten.

Inspectors wroteBased on observation, interview and record review the facility failed to document/monitor/track resident behaviors and failed to develop/implement non pharmacological behavioral interventions for one of four residents (R1) reviewed for abuse in the sample list of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain a stop date for a PRN (as needed) antipsychotic medication, failed to complete initial and quarterly psychotropic medication assessments, failed to document behaviors to warrant the use of an antipsychotic medication, failed to develop care plan with non-pharmacological interventions and failed to obtain psychotropic medication consents for two of three residents (R1, R9) reviewed for psychotropic medications in the sample list of 10.

Inspectors wroteBased on interview and record review the facility failed to ensure insulin was administered as ordered and failed to monitor blood glucose levels as ordered resulting in a significant medication error for one of three residents (R8) reviewed for medications in the sample list of 10.

Inspectors wroteBased on observation, interview, and record review the facility failed to answer call lights and care requests timely for four (R1, R2, R3, R8) of eight residents reviewed for call lights in the sample list of eight.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the use of a departure alert system was being used in the treatment of medical symptoms and not for staff convenience. This failure affects one (R1) of three reviewed for supervision on the sample list of six.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately complete R1's comprehensive assessment. This failure affects one (R1) of three residents reviewed for accuracy of assessments on the sample list of 6.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person centered comprehensive care plan for elopement (R2 and R3) for two of three residents reviewed for elopement in the sample list of 6.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's (R1) Health Care Power of Attorney of the delayed collection and results of an ordered urinalysis with subsequent bacteria growth, resulting in antibiotic treatment. R1 is one of three residents reviewed for family notifications of treatments and changes in conditions on the sample of eight.

Inspectors wroteBased on interview and record review, the facility failed to provide a routine bath and/or shower to one (R1) of three residents reviewed for bathing in the sample of eight.

Inspectors wroteBased on interview and record review, the facility failed to collect and send an ordered urine sample for a resident (R1) with a known history of Urinary Tract Infections in a timely manner. Thus, delaying treatment for a positive urinalysis and culture. R1 is one of three residents reviewed for Urinary Tract Infections and treatment in the sample of eight.

Inspectors wroteBased on interview and record review, the facility failed to follow medical doctor's medication administration orders for four residents (R5, R6, R7, R8) of four residents reviewed for medication administration/distribution in the sample list of four.

Inspectors wroteBased on interview and record review, the facility failed to administer significant medications (which can jeopardize resident's health and safety) for one of four residents (R8) reviewed for significant medications in the sample list of four.

Inspectors wroteBased on interview and record review, the facility failed to accurately document medication distribution times for three residents (R4, R6, R7) of four residents reviewed for accurate medication administration documentation in the sample list of four.

Inspectors wroteBased on interview and record review, the facility failed to have Registered Nurse coverage for at least 8 consecutive hours a day, 7 days a week for a total of 3 days in the 14 days reviewed. This failure has the potential to affect all 76 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a thorough and complete Quality Assessment & Assurance (QAA) of Policies and Procedures and a Quality Assurance Performance Improvement (QAPI) Program. The facility also failed to implement the QAA and QAPI Programs by failing to identify quality deficiencies, develop and implement appropriate plans of action to correct such deficiencies, and conduct distinct Performance Improvement Projects (PIPS). This failure has the potential to affect all 76 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure required personnel attended the Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 76 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to residents' requests for toileting assistance in a timely manner, resulting in residents experiencing episodes of incontinence, and failed to properly perform urinary catheter care. These failures affect four residents (R10, R11, R26, R67) out of four reviewed for incontinence and urinary catheter on the sample list of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their medication error rate was less than 5% during medication pass on 1/10/24. There were 26 opportunities, and total medication errors were 4. This gives the facility a 15.38% medication error rate. This failure affects four residents (R5, R26, R60, R229) out of 14 on the sample list of 31.

Inspectors wroteBased on interview and record review, the facility failed to obtain Level 2 PASARR (Pre-admission Screening and Record Review) for residents receiving a mental illness diagnosis during their residency at the facility. This failure affects three residents (R14, R35, R43) out of six reviewed for PASARR on the sample list of 31.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline Care Plan within 48 hours of resident's admission for one resident (R376) of one resident reviewed for Care Plans in the sample list of 31.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary for one resident (R73) who was discharged to another nursing facility. R73 is one of one resident reviewed for discharge in a sample list of 31. R73's closed Electronic Medical Record documents R73 initiated a discharge to another nursing facility. R73's historical Physician Order Sheet dated October 2023 documents the facility had received an order for R73 to be transferred to another nursing facility on 10/25/23. R73's care plan dated 9/7/23 does not contain any information concerning preparation for R73 and the impending discharge. The family of R73 came to the facility on [DATE] to transfer R73 to her new facility and the family was not given discharge information for R73 including a medication list or required levels of assistance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers to residents according to their plans of care, physician orders, and preferences. This failure affects two residents (R10, R26) out of four reviewed for activities of daily living on the sample list of 31.

Inspectors wroteBased on interview and record review, the facility failed to complete skin risk assessments, wound management daily reports, document weekly wound descriptions/measurements, and complete weekly skin checks for one resident (R67) of two residents reviewed for pressure ulcers in the sample list of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain humidification of supplemental oxygen, failed to change oxygen tubing, and failed to document physician orders for oxygen administration. These failures affect one resident (R26) out of one reviewed for oxygen on the sample list of 31.

Inspectors wroteBased on interview and record review, the facility failed to obtain physician responses, and failed to implement physician responses, for consultant pharmacist recommendations. This failure affects three residents (R14, R34, and R43) out of five reviewed for unnecessary medications on the sample list of 31.

Inspectors wroteBased observation, interview, and record review, the facility failed to follow basic infection control procedures during indwelling catheter care for one resident (R67) of one resident in the sample list of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of four residents (R4, R5) reviewed for abuse in a sample list of 7.

Inspectors wroteBased on interview and record review the facility failed to complete quarterly assessments for the risk of skin breakdown for two of three residents (R1, R2) reviewed for pressure sores in total sample of seven residents.