Goldwater Care Peoria Heights

Inspectors wroteBased on nterview and record review, the facility failed to prevent staff to resident theft of resident funds for one of three residents (R1) reviewed for misappropriation of property in the sample of four.

Inspectors wroteBased on interview and record review the facility failed to formulate a desired advanced directive for one resident (R2) of three residents reviewed for Advanced Directives. This failure resulted in R2 receiving CPR (Cardiopulmonary Resuscitation) when he did not wish to. This past non-compliance occurred [DATE] through [DATE]. The Facility's Advanced Directives policy dated [DATE] documents At the time of admission each resident will be asked if they have made advanced directives and provided educational information regarding state and federal law. The resident, the legal representative, or the individual who has been authorized as the resident's health care representative will be asked if an Advanced Directive, as recognized under the state law, has been executed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor, provide adaptive smoking materials, and a smoking apron for one resident (R3) of three residents reviewed for smoking in a sample of five. These failures resulted in R3 burning his second and third fingers resulting in third degree burns, which required the wound doctor to order treatment to the burned areas.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly screen a resident prior to admission for one (R1) of three residents reviewed for admission/discharge/transfers in a sample of five. This failure resulted in R1's behaviors not being properly controlled to where R1 was involuntarily discharged to the hospital, and currently waiting placement for a long term care facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely assessment, physician notification, documentation, and implementation of treatment interventions for pressure ulcers for one resident (R2) of five residents reviewed for pressure ulcers in the sample list of five. These failures resulted in delayed treatment implementation for pressure ulcers identified on admission and resulted in R2 developing two stage two pressure ulcers and one stage three pressure ulcer to the coccyx while residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow autonomy/freedom of choice, and failed to treat residents equally as compared to others for one (R28) resident; and failed to treat residents with dignity/respect when providing cares for one (R2) resident, and when assisting with feeding for ten (R6, R11, R17, R19, R30, R38, R48, R52, R53, and R57) of 40 residents reviewed for resident rights in a sample of 48. These failures resulted in R28 feeling embarrassed and becoming withdrawn from social interaction with staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received treatment as ordered for multiple pressure ulcers for one of two residents (R39) reviewed for pressure ulcers in a sample of 48. This failure resulted in R39's pressure ulcers worsening over time.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week. This failure has the potential to affect all 53 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare and serve food in accordance with professional standards for food service safety. These failures have the potential affect all 53 residents who live in the facility.

Inspectors wroteBased on interview and record review, the facility failed to keep linens in the hallway covered, and failed to include in their water management program the frequency for testing, testing protocols, acceptable ranges, and a system to document the testing and corrective actions for Legionella; failed to have any baseline testing performed to establish for their ranges or testing frequency; failed to do routine flushing of water lines; and failed to implement their policy following a water main break. These failures have the potential to affect all 53 residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to track antibiotic start and stop dates, labs/cultures drawn and what organism, and failed to use their infection assessment tool prior to administration of an antibiotic. These failures have the potential to affect all 53 residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff members are offered the COVID-19 vaccine, track staff member COVID-19 vaccinations, and provide staff education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. These failures have the potential to affect all 53 residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Advance Beneficiary Notice (ABN) CMS-10055 form was issued to Medicare Part A beneficiaries notifying the resident and/or resident's Power of Attorney, if applicable, the date Medicare Part A covered services will end for four of six residents (R4, R14, R30, R65) reviewed for ABN in a sample of 48.

Inspectors wroteBased on record review, observation, and interview the facility failed to provide a clean environment for five (R14, R20, R24, R32, R42) of five residents reviewed for the environment in a total sample of 48. R14's Electronic Health Record documents R14 was admitted to the facility on [DATE] with diagnoses to include Hypertension, Acute Kidney Failure, Diabetes, and Heart Failure. On 4/27/26 at 11:16 AM, V22 (R14's family member) reported R14 was transferred to a different facility on 4/20/26. V22 reported during R14's stay R14 had gotten another resident's feces on R14's pants while using the shared bathroom. V22 reported the bathroom had feces on the floor and toilet and R14 could not wait to go to the bathroom so he got the feces on his pants. On 4/29/26 at 9:06 AM, R45 reported he was R14's roommate prior to R14's discharge from the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations of abuse were reported immediately to the Administrator or designated official, and state agency for one (R46) of two residents reviewed for abuse in the sample list of 48.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were thoroughly investigated and that appropriate actions were taken to prevent further potential abuse for one (R46) of two residents reviewed for abuse in the sample list of 48.

Inspectors wroteBased on interview and record review the facility failed to notify the local Ombudsman of transfers and discharges, and the facility failed to notify one resident's family (R23) of three residents reviewed for transfers and discharges. These failures have the potential to affect all 53 residents that currently reside in the facility. The facility's Physician-Family Notification-Change of Condition policy, dated 11/13/2018, documents the purpose of the policy is to ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely. efficient, and effective manner. A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g. an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level I/II re-screen and/or referral was completed following a significant change in mental health status when a new mental illness diagnosis was added for a resident, implement and follow recommendations outlined in a Short-Term expired PASRR for three (R11, R28, and R35) of five residents reviewed for PASRR in the sample list of 48.

Inspectors wroteBased on interview and record review, the facility failed to implement a safety plan as identified on a Level II Preadmission Screening and Resident Review (PASSR) for one (R28) of five residents reviewed for PASSR in a total sample of 48.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident and representative were invited to participate in care plan meetings and failed to review and revise the comprehensive care plan on an ongoing basis for two (R11, R28) of five residents reviewed for care planning in the sample list of 48.

Inspectors wroteBased on observation, interview and record review the facility failed to provide activities to meet the needs of one (R28) of twenty four residents reviewed for activities in a total sample of 48.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate incontinence care and use of unauthorized incontinence products for one (R8) resident, and maintain dignity and hygiene of catheters for two (R2 and R3) of five residents reviewed for incontinence care and catheters in a sample of 48.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform tracheostomy care using aseptic technique for the tracheostomy site for one (R1) of two residents reviewed for tracheostomy care in a total sample of 48.

Inspectors wroteBased on interview and record review, the facility failed to identify PTSD (Post Traumatic Stress Disorder) triggers for one (R10) of two residents reviewed for PTSD in a total sample of 48.

Inspectors wroteBased on observation, interview and record review the facility failed to store medications in a safe manner for two of 22 residents (R30 and R58) reviewed for safe medication storage in the sample of 48.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was free from abuse by another resident, for one of five residents (R2), reviewed for abuse, in a sample of six. The facility policy, Abuse Prevention and Reporting, dated (revised) 10/24/22 directs staff that the facility prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. Abuse means any physical or mental injury, or sexual assault inflicted upon a resident other than by accidental means. The term willful means the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. [...]

Inspectors wroteBased on interview and record review the Facility failed to prevent a fall during a staff assisted transfer for one of three Residents (R4) reviewed for falls in a sample of five.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate administrative oversight to ensure the facility implemented policies for wound care, medication administration, treatment administration, quality assurance measures, and basic activities of daily resident care. These failures resulted in a facility-wide lack of supervision and care leading to residents experiencing worsening pressure ulcers, severe pain, a lack of resident care for gastrostomy tubes and pressure ulcer treatments with subsequent infections requiring hospitalization, untimely assistance with incontinent care and showers resulting in residents being left in soiled conditions for extended periods, missed medication administrations with significant medication errors, and not providing a functional, licensed and engaged leadership team. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, and treat a facility-acquired pressure ulcer, prevent a pressure ulcer from worsening, administer wound treatments as ordered, develop and implement pressure relieving interventions and a pressure ulcer care plan for two of three residents (R4, R9) reviewed for pressure ulcers in the sample of 16. This failure resulted in R4 developing a facility acquired pressure ulcer and R4 and R9's wounds worsening without adequate treatment and being transferred to the hospital with lethargy, high fever and requiring extensive hospitalization for diagnoses of sepsis and a stage four decubitus pressure ulcer with osteomyelitis. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/7/25 when R4 was identified at high risk of developing a pressure ulcer. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide physician ordered gastrostomy care including cleansing, laboratory monitoring, flushes, residual checks and tube insertion site assessments for a resident with an internal percutaneous endoscopic gastrostomy (PEG) tube for nutritional support for one of three residents (R9) reviewed for gastrostomy tubes (G-tube) in the sample of 16. This failure resulted in R9 transferring to the emergency room and being admitted to the hospital with fever, abdominal pain, diarrhea, nausea and vomiting, toxic appearance and a diagnosis of sepsis from multiple suspected sources including a g-tube site infection with pus filled drainage. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 11/22/25 when R9's scheduled gastrostomy tube cares were not completed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' call lights were answered promptly and residents received timely incontinence care for two of four residents (R2 and R15) reviewed for dignity in the sample of 16. These failures resulted in R2 and R15 lying in urine and feces for an extended period of time, causing R2 to feel pain, embarrassed, ashamed, disgusted, and R15 experiencing pain and burning to R15's buttocks causing R15 to feel like H*ll and disgusted.

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure a residents fecal collection system (rectal tube) was assessed and monitored, replaced after removal and care planned to ensure optimal outcome for one of one resident (R9) reviewed for rectal tubes in the sample of 16. This failure resulted in R9 going 17 days without proper fecal management collection and contributing to R9 developing infection in a stage four sacral pressure ulcer, requiring hospitalization with a diagnosis of sepsis and stage four sacral ulcer with osteomyelitis.

Inspectors wroteBased on interview and record review the facility failed to administer prescribed opioid medications to keep a residents' pain controlled, failed to perform pain assessments and implement pain relieving interventions while the resident was not receiving their prescribed pain relieving opioid medication, and failed to notify the physician of the need for a opioid medication refill order and complaints of increased pain for one of three residents (R2) reviewed for pain in the sample of 16. These failures resulted in R2 experiencing restlessness and unrelieved excruciating pain after five days of going without her prescribed pain medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities daily on the day and evening shifts designed to meet the resident's physical, mental, and psychosocial well-being of each resident. These failures have the potential to affect all 53 residents residing within the facility.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure sufficient staff were available to meet the needs of the residents. This failure has the potential to affect all 53 residents currently residing at the facility.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNAs) received 12 hours of mandatory in-service training as required. These failures have the potential to affect all 53 residents residing within the facility.

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure quarterly Quality Assurance (QA) meetings were held with facility administration and the facility's medical director. This failure has the potential to affect all 53 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure all staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 53 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure showers were completed as scheduled and hygiene assistance was provided to dependent residents for six of six residents (R1, R2, R5, R6, R7, and R9) reviewed for ADL (Activities of Daily Living) assistance in the sample of 16.

Inspectors wroteBased on interview and record review, the facility failed to ensure scheduled physician ordered medications were given for four of six residents (R1, R2, R7, and R9) reviewed for medications in the sample of 16.

Inspectors wroteBased on interview and record review the facility failed to refund money owed to a resident's representative timely after the resident left the facility for one of three residents (R3) reviewed for resident funds in the sample of 16.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to ensure resident falls were investigated and care planned, develop new interventions after falling, and ensure existing fall interventions were implemented for three of four residents (R1, R7, R9) reviewed for falls in the sample of 16.

Inspectors wroteBased on Interview and Record review, the facility failed to complete physician ordered weights for two of three residents (R1, R9) reviewed for nutrition in the sample of 16.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident was free of significant medication errors for two of three residents (R4 and R6) reviewed for significant medication errors in the sample of 16.

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure physician ordered laboratory (lab) monitoring was completed and processed for one of three residents (R9) reviewed for laboratory monitoring in the sample of 16.

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure a physician orbital x-ray (radiography imaging) was completed for one of three residents (R1) reviewed for x-ray imaging in the sample of 16.

Inspectors wroteBased on record review and interview, the facility failed to ensure their abuse policy was implemented when the facility failed to separate a visitor from a resident (R2) after an alleged altercation was reported for one of four residents (R2) reviewed for abuse in the sample of six.

Inspectors wroteBased on record review and interview the facility failed to report an allegation of visitor to resident verbal abuse to the state agency for one of four residents (R2) reviewed for abuse in the sample of six.

Inspectors wroteBased on interview and record review the facility failed to address concerns voiced by residents during their resident council meetings. This failure has the potential to affect all forty-six residents who reside in the facility. The facility's Grievances policy dated 9/25/2017 documents the policy's purpose as to ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay at this campus. All alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, will be immediately reported to the administrator and as required by state law. [...]

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of abuse for 2 residents (R10 and R11) of five residents reviewed for abuse in a sample of ten. The Facility's Abuse Prevention and Reporting policy dated 10/24/22 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and service by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident room temperatures were maintained at a safe and comfortable temperature of 71 degrees Fahrenheit or higher for 14 of 15 residents (R2-R15) reviewed for safe and comfortable environment in the sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to hold Quality Assurance (QA) and Improvement Committee Meetings. This failure has the potential to affect all 40 residents who currently reside in the facility. Findings Include: The Facility's Quality Assurance and Improvement Agenda dated 4/19/2019 documents that the following areas will be reviewed as a Quality Assurance Team at least every quarter: Resident Concerns, Consultant/Department Reports, Policy and Procedure Review and Updates, Nursing and Quality Improvement Information, Special Unit Report (if applicable), Dietary Report, Social Service Report, Activity Department, Housekeeping and Laundry, Quality Assurance Audits/Rounds, Surveys Compliance, Life Safety Concerns, Safety Issues/Risk Management, Personnel, Environmental Improvements Planned/Made during the Quarter, Census/marketing Recruitment. [...]

Inspectors wroteBased on record review and interview the facility failed to monitor infections. This failure has the potential to affect all 40 residents that currently reside in the facility. Findings Include: The Facility's Infection Control Surveillance and Monitoring policy dated 4/11/2022 documents It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained. Monitoring of the day-to-day operation of the Infection Control Program will be conducted by the DON/ICP (Director of Nursing/Infection Preventionist). Included in the duties are: Investigation and implementation of controls to prevent infections in the facility, determine and direct the correct procedures necessary for the prevention of infections. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an Antibiotic Stewardship Program. This failure has the potential to affect all 40 residents that currently reside in the facility. Findings Include: The facility's Antibiotic Stewardship Program Protocol dated 12/12/18 states, Purpose: To improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished using the Core Elements. Core Elements for Antibiotic Stewardship: 1. Leadership Commitment: Demonstrates support and commitment for safe and appropriate antibiotic use. Accountability: [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the local Office of the State Long-Term Care Ombudsman and Residents/Residents' Representative in writing of resident Hospital Transfer/Discharge for five (R2, R6, R30, R34 and R291) of five residents reviewed for transfers and hospitalizations in the sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to complete a new/updated PASARR (Preadmission Screening and Resident Review) Level II for one (R30) of two residents reviewed for PASARR screenings in a sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's prescribed medication was available for one (R1) of three residents reviewed for medication administration in a sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had fresh water available between meals for six of seven residents (R2-R7) reviewed for hydration in the sample of seven.

Inspectors wroteBased on record review and interview, the facility failed to ensure call lights were answered in a timely manner for one of three residents (R1) reviewed for call light response time in a sample of seven.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff provided care by assessing, evaluating, and providing immediate treatment of an acute condition for one of three residents (R1) reviewed for changes in condition in a sample of seven.

Inspectors wroteBased on record review and interview the facility failed to obtain scheduled physician prescribed medications from the pharmacy for one of three residents (R2) reviewed for medication availability in the sample of seven.

Inspectors wroteBased on record review and interview, the facility failed to ensure Physical Therapy/Occupational Therapy (PT/OT) was provided per physician order for one of three (R1) residents reviewed for therapy services in a sample of seven.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered by the physician for six residents (R5-R10) on the sample of residents reviewed for medication pass. This failure resulted in medication errors out of thirty-six opportunities for error, for a 22 percent medication error rate.

Inspectors wroteBased on interview and record review the facility failed to ensure physician ordered wound treatments and dressing changes were performed as ordered for 1 resident (R1) of 3 residents reviewed for wounds in a sample of 4. This failure resulted in R1 being admitted to the hospital for wound treatments.

Inspectors wroteBased on interview, and record review, the facility failed to provide required staff to assist and monitor residents during breakfast, failure to answer call lights timely, and failure to provide incontinent care for dependent residents. This failure has the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to complete their facility assessment to include the staffing requirements needed to care for the resident population and census. This failure has the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide incontinent care for 4 residents (R1, R2, R3, R4) reviewed for incontinent care in a sample of four. Findings Include: The Perennial Cleansing policy dated 12/2017 documents, To eliminate odor; to prevent irritation or infection and to enhance residents' self-esteem. The Certified Nurse's Aide policy not dated documents the CNA job summary, Working under the direction of the staff nurses, the Certified Nurse's Aide (CNA) provides personal care and assistance to residents to assure their safety and comfort. Carries out basic hygiene measures including but not limited to the following: grooming, shaving, applying makeup, oral hygiene/dental care, cuts/cleans nails, fingers and toes, foot care, skin care, bathing/showering and cleaning incontinent residence. [...]

Inspectors wroteThese failures resulted in three deficient practice statements. A. Based on interview and record review the facility failed to monitor laboratory tests results for a high-risk medication, Warfarin (anticoagulant) for one of two residents (R11) reviewed for anticoagulants in a sample of 42. This failure resulted in R11 being admitted to the hospital with a critical PT (Prothrombin level/normal 9.8-12.2 seconds) and INR (International Normalized Ratio/normal range 0.9-1.2 milligrams per deciliter). B. Based on interview and record review the facility failed to provide medications and discontinue a medication as ordered for 4 of 4 residents (R4, R8, R12 and R13) reviewed for medication administration. This failure resulted in R4 experiencing ongoing, unrelieved pain from 01/13/24 through 01/23/24. C. [...]

Inspectors wroteBased on interview and record review the facility failed to notify physician of abnormal laboratory results, a change in condition and a medication error for two of 13 residents (R11 and R13) reviewed for physician notification in a sample of 42. This failure resulted in R11 being admitted to the hospital with a critical PT (Prothrombin level/normal 9.8-12.2 seconds) and INR (International Normalized Ratio/normal range 0.9-1.2 milligrams per deciliter).

Inspectors wroteBased on interview and record review, the facility failed develop and maintain policies and procedures for monthly drug regimen review and failed to act timely on pharmacy recommendations for eleven of eleven residents (R4, R13, R19, R23, R28, R31, R38, R39, R40, R41 and R42) reviewed for pharmacy recommendations, in a sample of 42.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform the required nurse shift to shift controlled substance reconciliation for 31 of 31 residents, (R3, R4, R5, R8 and R11- R37) reviewed for controlled substances, in a sample of 42.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered by the physician for two residents (R5 and R12) on the sample of residents reviewed for medication pass. This failure resulted in two medication errors out of twenty- five opportunities for error, for an 8% medication error rate.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for three residents (R1, R2 and R4) of three residents reviewed for abuse in a sample of five. Findings Include: The Abuse Prevention policy dated 10/19/07, documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its resident, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure the facility is doing all is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide incontinent care for two residents (R3, R5) of three residents reviewed for incontinent care in a sample of five. Findings Include: Certified Nurse's Aide Job Summary (not dated) documents that the Certified Nursing Aide/CNA provides care and assistance to residents to assure their safety and comfort. The CNA carries out basic hygiene measures includes cleaning incontinent residents. On 1/6/24 at 3:15 PM, V1 stated the facility does not have a policy on incontinent care. The facility was hacked a few months ago and lost all the policies. 1. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to identify, assess, report and treat a facility-acquired pressure ulcer for one resident (R6); failed to administer wound treatment as ordered using proper infection control technique; failed to develop and implement pressure relieving interventions or care plan; failed to conduct a pressure ulcer development risk assessment for a resident identified as high risk for pressure ulcer development; and failed to develop a pressure ulcer care plan after a pressure ulcer developed for three of three residents (R1, R4, R6) reviewed for pressure ulcers in the sample of nine. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a fall risk assessment and implement fall interventions for two of three residents (R1 and R4) and failed to ensure a resident (R2) was properly transferred with a mechanical lift. This failure resulted in the mechanical lift tipped over while R2 was in the sling resulting in fracture of the right distal tibia and required a surgical repair.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure sufficient staff was available to meet the needs of residents. This failure has to potential to affect all 55 residents currently residing at the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide oversight and leadership to Administrator in Training and nursing staff to ensure implementation of its policy and procedures regarding pressure ulcers, staffing, assessments, care plans, and employee education. In addition, Administrator in Training is practicing without any type of license. These failures have the potential to affect all 55 residents residing at the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure call lights were answered in a timely manner for two of five residents (R5 and R9) reviewed for call lights in the sample of nine.

Inspectors wroteBased on interview, observation and record review, the facility failed to revise a care plan after a resident fall for one of three residents (R3) reviewed for falls in the sample of nine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure showers were completed as scheduled and hygiene assistance was provided to a dependent resident for one of four residents (R7) reviewed for ADL (Activities of Daily Living) assistance in the sample of nine.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a registered nurse, as required. This failure has the potential to affect all 59 residents currently in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to remove soiled PPE (Personal Protective Equipment) and apply clean PPE upon exiting the facility COVID-19 Unit, failed to apply the correct PPE upon entrance into the facility COVID-19 Unit and failed to ensure a COVID-19 positive resident exited the facility COVID-19 Unit with correct PPE. These failures have the potential to affect all 59 facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep medications secure for thirteen residents (R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15 and R16) of fifteen residents reviewed for medication storage, in a sample of 16.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered by the physician for three residents (R2, R6 and R7) on the sample of residents reviewed for medication pass. This failure resulted in four medication errors out of twenty- seven opportunities for error, for a 14.81% medication error rate.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure that sufficient staff was available to meet the needs of residents. This failure has to potential to affect all 54 residents currently residing at the facility.

Inspectors wroteBased on interview observation and record review, the facility failed to post signage with indication to maintain isolation precautions for a resident with suspected Shingles, failed to apply PPE (personal protective equipment) prior to entering a resident's room with isolation precautions in place for Shingles and a resident with Enhanced Barrier Precautions in place for two of six residents (R1 and R2) reviewed for improper nursing care in the sample of six. This failure has the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan with a new fall prevention intervention following a fall for one of three residents (R4) reviewed for falls in the sample of six.

Inspectors wroteBased on interview, observation and record review, the facility failed to conduct a fall risk assessment and ensure the assessment was thoroughly completed, as directed in their Fall Prevention policy, for one of three residents (R4) reviewed for falls in the sample of six.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities to meet the needs and interests of all the residents. This had the potential to affect all 45 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a full-time Activity Director. This failure had the potential to affect all 45 residents residing in the facility.

Inspectors wroteBased on record review, interview, and observation the facility failed to employ a full time Director of Nursing (DON) to oversee nursing services and failed to ensure a Registered Nurse (RN) worked at least eight hours daily. This failure has the potential to affect all 45 residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide food substitutions of equal nutritive value. This had the potential to affect all 45 residents residing in the facility.

Inspectors wroteBased on record review, interview, and observation the facility failed to label and date 21 containers of mixed fruit and 12 deli-meat sandwiches when prepared and stored in the refrigerator. These failures have the potential to affect all 45 residents who reside within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a full-time Administrator to manage, plan, organize, staff, direct, coordinate, report, and provide physical management to the facility. This failure has the potential to affect all 45 residents residing within the facility.

Inspectors wroteBased on observation, interview and record review the Governing Body failed to be consistently involved in the management and operation of the facility, failed to implement policies related to facility operations and resident care, including, Accommodation of Needs, Comfortable Homelike conditions, MDS (Minimum Data Set) assessments and care plans being completed timely and accurately, Psychotropics, Activities, Pressure Ulcers, Significant Weight Loss, Significant Medication Errors, Smoking supervision, Staffing, Medication storage, Incontinence Care, and Infection control. The Governing Body failed to ensure Director of Nursing and Activity Director responsibilities were completed. This failure has the potential to affect all 45 residents residing in the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement plans of action through their Quality Assurance and Assessment (QAA) Committee to address a lack in providing meaningful activities, providing equal nutritive value food substitutes, employing a full-time activity director and Director of Nursing, employing at least eight hour of registered nurses daily, and ensuring MDS (Minimum Data Set) Assessments were completed timely. These failures have the facility to affect all 45 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure the Infection Preventionist and Director of Nursing (DON) attended all quarterly QAA (Quality Assessment and Assurance) meetings. These failures have the potential to affect all 45 residents who reside within the facility.

Inspectors wroteThese failures resulted in two deficient practices. A. Based on record review and interview the facility to monitor and test for Legionella and other opportunistic waterborne pathogens within the facility's water system. This failure has the potential to affect all 45 residents residing within the facility. B. Based on observation, interview and record review, the facility failed to perform hand hygiene and a glove change between cares for one of 16 residents (R30) reviewed for infection control in the sample of 37.

Inspectors wroteBased on record review, interview, and observation the facility failed to follow their water temperature policy to maintain water temperatures between 100 to 110 degrees Fahrenheit for five of 37 residents (R5, R14, R33, R42, R96) reviewed for water temperature in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for a smoker, a resident receiving hospice services, and within 21 days of admission to the facility for four of 15 residents (R9, R23, R195, R196) reviewed for care plans in the sample of 37.

Inspectors wroteBased on record review, interview, and observation the facility failed to date multi-dose insulin pens once opened for four of eight residents (R2, R13, R39, R198) reviewed for insulin medication storage in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a wheelchair to a resident (R197) who was dependent on a wheelchair for mobility for one of two residents (R197) reviewed for accommodation of needs in the sample of 37.

Inspectors wroteBased on interview and record review, the facility failed to complete comprehensive admission and annual MDS (Minimum Data Set) assessments for 7 of 23 residents (R4, R11, R12, R18, R27, R195, R196) reviewed for MDS completion in the sample of 37.

Inspectors wroteBased on record review and interview, the facility failed to complete a significant change minimum data set assessment for a resident admitted to hospice for one of 23 residents (R9) reviewed for significant change in the sample of 37.

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly MDS (Minimum Data Set) assessment for three of 23 residents (R1, R23, R24) reviewed for MDS completion in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a baseline care plan within 24 hours of admission for one of one resident (R197) reviewed for baseline care plans in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a care plan for the use of an antipsychotic medication for one of four residents (R10) reviewed for antipsychotics in the sample of 37.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain an appropriate treatment order upon development and progression of a pressure ulcer for one of one resident (R30) reviewed for pressure ulcers in the sample of 37.

Inspectors wroteBased on observation, interview and record review the facility failed to supervise smoking residents and keep smoking materials in a safe place for three of three residents (R3, R23, R95) reviewed for smoking in the sample of 37.

Inspectors wroteBased on observation, interview and record review, the facility failed to cleanse a resident's perineal area during incontinence care for one of one resident (R30) reviewed for incontinence care in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a physician ordered supplement, obtain a weight upon admission, and obtain weekly weights following admission for one of two residents (R195) reviewed for weight loss in the sample of 37. These failures resulted in R195 having a significant weight loss of 11.2 lbs. (pounds)/6% in one month.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen tubing and oxygen humidity were dated for one of one resident (R30) reviewed for oxygen administration in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document justification to warrant the use of an antipsychotic, monitor for behaviors, perform a gradual dose reduction, and complete an AIMs (Abnormal Involuntary Movement) assessment for two of three residents (R10, R12) reviewed for antipsychotics in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for two of two residents (R9, R10) reviewed for medication errors in the sample of 37.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident understood the arbitration agreement and failed to inform a resident of their ability to rescind the agreement for one of three residents (R197) reviewed for arbitration in the sample of 37.

Inspectors wroteBased on interview, record review, and observation the facility failed to post nurse staffing for the last 18 months. This failure has the potential to affect all 45 residents residing within the facility.