La Bella of Danville

Inspectors wroteBased upon observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse for one (R2) of three residents reviewed for abuse on a sample list of three residents. According to the Electronic Health Record (EHR) R2 has diagnoses including Dementia with Agitation, Syphilis, HIV, Delirium, Paranoid Personality Disorder, Cognitive Impairment, and Restlessness and Agitation. R2's undated care plan documents R2 is at risk for wandering and elopement, is dependent on staff for Activities of Daily Living (ADL), is at risk for falls, takes psychotropic medications, has behavior of placing self on floor, and has a potential for mood problems. R2's Minimum Data Sheet (MDS) Section C, dated 5/6/26 documents R2 has severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide privacy curtains for five (R14, R15, R16, R17, R18) residents which also affected their roommates R19-R25 out of twelve residents reviewed for Physical Environment in a sample list of 35 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for residents by failing to remove hazardous extension cords and damaged electrical equipment from a resident room; maintain a clean community shower room; repair damaged walls and fixtures; and maintain common areas free of construction materials and disrepair. These deficient practices affected three residents (R11, R13, R18) out of seven residents reviewed for Physical Environment in a sample list of 35 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure fire system equipment was functioning properly and failed to complete a thorough fire watch for 10 (R5, R27-R35) residents residing in Zone 2 of the Dementia Unit out of 10 residents reviewed for Physical Environment in a sample list of 35 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide call lights for five (R14, R15, R16, R17, R18) residents out of 12 residents reviewed for Physical Environment in a sample list of 35 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect residents' right to be free from verbal and mental abuse by staff for two of three residents (R127, R138) reviewed for abuse in the sample list of 64. This failure resulted in psychosocial harm of R127.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain communication and collaboration with an offsite dialysis center, follow dialysis and physician's orders, complete assessments and monitoring for dialysis related complications, and report elevated blood pressures for one of two residents (R15) reviewed for dialysis in a sample list of 64. These failures resulted in R15 being hospitalized and admission to the intensive care unit.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure access to the state survey results for nine of nine (R1, R55, R89, R100, R102, R106, R109, R110 and R136) residents reviewed for resident council on the sample list of 64. This failure also has the potential to affect all 145 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to follow up on resident grievances reported in the resident council meetings and document the outcome of any actions taken to resolve the concern for nine of nine (R1, R55, R89, R100, R102, R106, R109, R110 and R136) residents reviewed for resident council on the sample list of 64. This failure also has the potential to affect all 145 residents residing in the facility. On 6/1/2026 at 1:30 PM during the resident council meeting, R1, R55, R89, R100, R102, R106, R109, R110 and R136 stated they do not feel that the facility always gives them a response to their grievances and if they do it is not timely. The facility's Resident Council Meeting minutes for the South building dated 12/30/25 document a concern that medications are not given on time. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food items were stored, labeled, and maintained in a sanitary manner. These failures have the potential to affect all 145 residents residing in the facility.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on interview and record review the facility failed to maintain infection control logs that identified infectious organisms to monitor for trends. This failure has the potential to affect all 145 residents in the facility. B. Based on observation, interview and record review the facility failed to develop and implement a Legionella water management plan that included identified risk areas and control measures. This failure has the potential to affect all 145 residents in the facility. C. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an effective pest control program was maintained to prevent rodent activity in the main kitchen dry storage area. This failure resulted in food items being contaminated by mice and created the potential for food borne illness for all 145 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are treated with dignity and respect for four of 29 residents (R2, R15, R10, R143) reviewed for resident rights in the sample list of 64.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain accurate accounting of resident trust fund accounts and provide quarterly statements for four of five residents (R15, R138, R92, R111) reviewed for personal funds in the sample list of 64.

Inspectors wroteBased on interview and record review the facility failed to ensure the surety bond exceeds the total resident trust fund balance. This failure affects three of five residents (R15, R92, R138) reviewed for resident trust funds in the sample list of 64.

Inspectors wroteBased on interview and record review the facility failed to follow their abuse prevention policy by failing to obtain employee background checks upon hire. This failure affects four of four residents (R127, R138, R15, and R2) reviewed for administration in the sample list of 64.

Inspectors wroteBased on observation, interview and record review the facility failed to report allegations of abuse to the administrator and state survey agency for three of three residents (R127, R138, R79) reviewed for abuse in the sample list of 64.

Inspectors wroteBased on observation, interview, and record review the facility failed develop and implement comprehensive care plans for discharge planning for four residents (R92, R127, R138, R154) of four residents reviewed for discharge planning in a sample list of 64.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to address a tripping hazard for two residents (R89, R100) of 18 residents reviewed for safety in a sample list of 64. B. Based on observation, interview, and record review the facility failed to provide supervision to prevent a fall, failed to implement post fall interventions, and failed to complete post fall neurological assessments for two of three residents (R17, R2) reviewed for falls in the sample list of 64. C. Based on observation, interview, and record review, the facility failed to provide required supervision during smoking for residents assessed as needing supervision while smoking for four (R64, R128, R130, R79) of four residents reviewed for smoking on of a sample list of 64.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were appropriately stored and labeled for five (R16, R29, R57, R82, R125) of ten residents reviewed for labeling and storage of medications from a total sample of 64 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to investigate an allegation of abuse and failed to remove the alleged perpetrator for three (R79, R127, R138) of three residents reviewed for abuse on the sample list of 64.

Inspectors wroteBased on interview and record review the facility failed to invite a resident and resident representative to care plan meetings for two of three residents (R92, R16) reviewed for care planning in the sample list of 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement wound treatments as ordered for one of three residents (R127) reviewed for skin conditions in the sample list of 64.

Inspectors wroteBased on observation, interview and record review the facility failed to arrange for vision services for one resident (R138) reviewed for vision in the sample list of 64.

Inspectors wroteBased on observation, interview and record review the facility failed to implement nutritional interventions for one of four residents (R10) reviewed for nutrition in the sample list of 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that prescribed medication was readily available for administration for one (R124) of five residents reviewed for medication administration from a total sample of 64 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications according to physician orders for two (R124 and R127) of five residents reviewed for medication administration on the sample list of 64. These failures resulted in two medication errors out of twenty-five opportunities resulting in an 8% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food in a form designed to meet individual resident needs for one (R97) of eighteen residents reviewed for dietary services from a total sample of 64 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that is palatable, attractive, and at an appetizing temperature for two (R1, R14) of 3 residents reviewed for Dietary Services. This failure has the potential to affect all 150 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely care for four (R8, R3, R13, R4) of four residents reviewed for change in condition in a sample list of 19.

Inspectors wroteBased on interview and record review the facility failed to return a credit balance and trust fund balance following discharge for one of three residents (R4) reviewed for billing in a sample list of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain fall interventions following falls with injury, accurately assess and document falls, timely notify physician and family of falls, and complete neurological assessments following fall with a head injury for 4 residents (R3, R4, R10, R8) of 6 residents reviewed for falls on a sample list of 19. These failures resulted in R3 sustaining an acute nondisplaced fracture at the medial and posterior malleoli.

Inspectors wroteBased upon interview, observation, and record review, the facility failed to promptly identify and intervene for an acute change in a resident's condition after a fall with a fracture; and failed to follow physician orders causing a delay in treatment that had the potential for harm for one (R4) of three residents reviewed on a sample list of seven residents. According to the Electronic Health Record (EHR) R4 has diagnoses including admission diagnosis of Urinary Tract Infection (UTI), Left Femur Fracture surgical aftercare, and repeated falls. R4's undated Care Plan documents R4 is high risk for falls with recent fall with fracture history (12/30/25); Interventions include adding scoop mattress on 1/26/26, offer to transfer R4 to wheelchair prior to dinner on 2/6/26, and non-skid strips placed by bed, and non-skid socks to replace slippers on 3/26/26. [...]

Inspectors wroteBased upon interview and record review the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for two residents (R3, R4) on a sample list of seven residents. 1) According to the Electronic Health Record (EHR) R3 has diagnoses including Cerebral Vascular Accident, Epilepsy, Vascular Dementia, Obstructive Uropathy, Severe Protein Malnutrition, Anxiety, and Autonomic Nervous System Disorder. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately transcribe an opioid analgesic medication order and failed to ensure nursing staff questioned and verified a large dose of a high-risk medication (Morphine 500 mg) before administration. This failure resulted in R5 experiencing drowsiness, respiratory depression, and memory loss. R5 was treated with Narcan (opioid antagonist) and later sent to the emergency room. These failures affected one of three residents (R5) reviewed for Pharmaceutical Services on the sample list of ten. The Immediate Jeopardy began on 3/10/26 when R5 was given an overdose of Morphine Sulfate (500 milligrams). V1 Administrator was notified of the Immediate Jeopardy on 3/31/26 at 2:50 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse (RN) providing services for at least eight consecutive hours a day, seven days a week. This failure has the potential to affect all 146 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents' right to be free from sexual abuse and assault perpetrated by another resident (R5) with known sexual behaviors. This failure affects two residents (R4 and R6) on the sample list of fourteen. This failure resulted in immediate jeopardy. The immediate jeopardy began on 2/2/26 at approximately 10:30 am when R5 made sexual contact with R4 and R6. V1, Facility Administrator, was notified of the immediate jeopardy on 2/13/26 at 11:15 am. The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on 2/16/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on interview, and record review, the facility failed to separate a resident (R5) from contact with other residents after an allegation of sexual abuse to prevent further sexual abuse and assault. This failure affects one resident (R6) out of six reviewed for sexual abuse on the sample list of fourteen. This failure resulted in immediate jeopardy. The immediate jeopardy began on 2/2/26 at approximately 10:30 am when R5 was left unsupervised after an allegation of sexual abuse towards R4, and sexually assaulted R6 while unsupervised. V1, Facility Administrator, was notified of the immediate jeopardy on 2/13/26 at 11:15 am. The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on 2/16/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to report an allegation of sexual abuse to the administrator. This failure has the potential to affect one resident (R4) out of six reviewed for sexual abuse on the sample list of fourteen.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient licensed nursing staff were present for each shift in each building. This failure has the potential to affect all 54 residents residing in the South Building.

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse (RN) providing services for at least eight consecutive hours a day, seven days a week. This failure has the potential to affect all 138 residents currently residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to submit the results of abuse and misappropriation of resident property investigations to the State Agency within five working days for three (R1, R2 and R3) of four allegations reviewed in the sample of 11 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of abuse/misappropriation of resident property were thoroughly investigated for three (R1, R2 and R3) of four allegations reviewed in the sample of 11 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify, report and investigate a fall; and failed to implement post fall interventions for one of three residents (R5) reviewed for injuries/accidents in the sample list of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right (R2) to be free from physical abuse by another resident (R1). This failure affects two (R1, R2) of four residents reviewed for abuse in the sample list of four residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement person centered activities and interventions for dementia care for one (R1) of four residents reviewed for abuse in the sample list of four.

Inspectors wroteBased on interview and record review the facility failed to protect resident's rights to be free from verbal and physical abuse from another resident. This failure affected three of five residents (R4, R5, R8) reviewed for abuse in the sample of eight. Findings Include: The facility's Abuse Prevention and Reporting- Illinois policy dated August 2023 documents the facility affirms the right of its residents to be free from abuse. The policy defines Abuse as the willful infliction of injury. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse as the infliction of injury on a resident. Physical abuse includes hitting, slapping, and other similar behaviors. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer five consecutive doses of ordered intravenous antibiotic medication. This failure affects one resident (R3) of one reviewed for medication administration in the sample of eight. Findings Include: R3's diagnosis list (printed 5/7/2025) documents diagnoses including: Cutaneous Abscess of Buttock and Encounter for Change or Removal of Non-surgical Wound Dressing. R3's Care Plan (printed 5/7/2025) documents R3 has a history of wound infection requiring antibiotic treatment. R3's wound treatment timeline (undated) documents R3 was to start antibiotic treatment for a wound infection on the morning of 4/19/2025. R3's Order Entry (4/18/2025 at 6:44PM) documents a medical order for R3 to begin antibiotic treatment with Unasyn, 1.5 grams, intravenously every eight hours. [...]

Inspectors wroteBased on interview and record review, the facility failed to effectively supervise R3 to prevent falls. This failure resulted in R3 falling from R3's wheelchair to the floor in R3's room. This failure affects one resident (R3) of three reviewed for accidents in the sample of eight. Findings Include: R3's diagnosis list (printed 5/7/2025) documents R3's diagnoses include: Cerebral Infarction (stroke), Personal History of Transient Ischemic Attack (temporary disruption of blood flow to the brain causing stroke-like symptoms), and Alzheimer's Disease. R3's admission Assessment (3/13/2025) documents R3 has severe cognitive impairment, uses a wheelchair, and is dependent on staff for mobility and transfers from the wheelchair to other surfaces. The facility fall log (April, 2025) documents R3 experienced falls in the facility on 4/1/2025, 4/12/2025, and 4/13/2025. [...]

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse involving two (R9, R10) residents out of four residents reviewed for abuse in a sample list of 11 residents.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders in arranging a referral for an outside resource for one (R1) resident out of three residents reviewed for physician orders in a sample list of 11 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 146 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program by failing to exclude and prevent flying insects in the facility food service areas resulting in direct cross-contamination of resident dishes. This failure has the potential to affect all 146 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to honor the resident rights for one (R100) resident out of one resident reviewed for resident rights in a sample list of 47 residents.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident and their representative in writing about a hospital transfer and failed to provide a bed hold notice for one of two residents (R82) reviewed for hospitalizations on the sample list of 38. Findings Include: On 04/8/25 at 11:00am, R82 stated R82 went to the hospital 2 times in the last 2 weeks. R82 stated the facility did not talk with R82 about a Bed Hold Policy nor was R82 provided a Bed Hold Policy upon going to the hospital. On 4/9/25 at 12:21 pm, V35 [NAME] President of Clinical Operations stated Bed Holds are to be filled out by the nurses when a resident is sent to the hospital; a copy should be sent with the resident, and the facility keeps a copy. V35 confirmed that R82 was sent to the hospital on 3/25/25 and 3/28/25 and a Bed Hold Policy was not given to R82. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a residents comprehensive assessment. This failure affects one (R119) of two residents reviewed for accuracy of assessments in the sample list of 47.

Inspectors wroteBased on observation, interview and record review the facility failed to enter in new wound dressing change orders and failed to provide wound care in accordance with professional standards. This failure affected one of three residents (R138) reviewed for wounds on the sample list of 47. Findings Include: The facility's Wound Care policy dated October 2010 documents staff should always verify the physician order and use the no-touch technique when cleaning a wound and if touching a wound is necessary, use sterile gloves. R138's Medical Diagnoses List dated April 2025 documents R138 is diagnosed with Idiopathic Aseptic Necrosis of the Right and Left foot and Peripheral Vascular Disease. On 4/11/25 at 10:25 AM V7 Wound Nurse performed R138's wound dressing changes. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during catheter care for one (R5) resident out of one resident reviewed for catheter care in a sample list of 47 residents.

Inspectors wroteBased on interview and record review the facility failed to accurately transcribe a physician order which resulted in a resident receiving nine inaccurate doses of a psychotropic medication (antidepressant). This failure affected one of five residents (R79) reviewed for Unnecessary Medications on the sample list of 47. Findings Include: The facility's Adverse Consequences and Medication Errors dated February 2023 documents a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medications errors include administering the wrong dose of a medication. [...]

Inspectors wroteBased on interview and record review the facility failed to offer, administer and/or obtain consent or declination of Influenza and Pneumococcal vaccinations for two (R57, R128) residents out of five residents reviewed for immunizations in a sample list of 47 residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain a functional bathroom ventilation fan. This failure affects one resident (R128) of one two reviewed for environment on the sample list of 47.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the safety of one (R1) resident by not implementing resident centered fall interventions and failed to thoroughly investigate one (R1) resident fall with injury out of four residents reviewed for falls in a sample list of four residents. R1 experienced pain and bleeding after her fall thus was transported to and evaluated at the emergency room, where she received three sutures to her forehead because of the fall.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision for a cognitively impaired resident, known to exit seek, and with a prior elopement history, to prevent an elopement. The facility also failed to complete a full body post-elopement assessment to determine injury, failed to develop an elopement care plan with interventions in a timely manner, and failed to ensure functional exit door alarms. These failures resulted in R1, a severely cognitively impaired resident at risk of falls and receiving anticoagulation therapy, exiting the facility without staff knowledge or supervision, walking approximately 0.4 miles in extreme cold weather down a busy street. R1's likely path included steep ditches and large rocks. These failures affect one of three residents (R1) reviewed for elopement on the sample list of 14. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean and comfortable environment for four (R1, R3, R10 and R11) of five residents reviewed for a safe, clean, comfortable, and home-like environment from a total sample list of 18 residents.

Inspectors wroteBased on interview and record review the facility failed to file a grievance for a known resident complaint for two (R1 and R3) of three residents reviewed for administration from a total sample list of 18 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were available to be given as ordered resulting in multiple missed doses of medications for three (R5, R6, R7) of six residents reviewed for medications in the sample list of 12.

Inspectors wroteBased on interview and record review the facility failed to administer insulin timely resulting in repeated significant medication errors for one (R6) of six residents reviewed for medications in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered for three (R4, R7, R5) of seven residents reviewed for medication administration in the sample list of 12. This failure resulted in three medication errors out of 25 opportunities, a 12 % medication error rate.

Inspectors wroteBased on observation, interview and record review the facility failed to complete wound dressing changes as ordered by the wound care physician. This failure affects one resident (R1) out of three residents reviewed for wound care on a sample list of nine. This failure resulted in R1's wounds becoming repetitively infested with parasitic fly larvae (maggots) requiring sanitation, causing pain and causing the wound to deteriorate.

Inspectors wroteBased on observation, interview and record review the facility failed to have an effective pest management program in place allowing flies to proliferate in the facility. This failure has the potential to affect all 141 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a diet as ordered for five (R1, R3, R6, R8 and R9) of five residents with diabetes reviewed for diabetic diet orders from a total sample list of nine residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from physical abuse for two of three residents (R1, R2) reviewed for abuse on the sample list of nine. This failure resulted in R2 experiencing discomfort and swelling to the face as well as being fearful of R1 after R1 hit R2. Findings Include: The facility's undated Preliminary 24 Hour Abuse Investigation Report documents on 6/3/24 at approximately 11:45 pm, V1 Administrator received an allegation that R1 struck R2 on the side of the face. R1 and R2's Physical Abuse Investigation Folder contained the following staff witness statements: V9 CNA's (Certified Nursing Assistant) statement documents R1 became very aggressive on Monday night (6/3/24). It started when R1 came back to the facility and just progressed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of residents by failing to accurately screen and assess a new resident upon admission and implement necessary safety interventions for two of three residents (R1, R2) reviewed for abuse on the sample of nine. This failure resulted in a newly admitted resident (R1) residing in a room with R2 and R1 being physically aggressive with R2, hitting R2 in the face with a closed fist. As a result of the physical abuse, R2 experienced facial discomfort and swelling along with psychosocial harm. Findings Include: [...]

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan for one of three residents (R1) reviewed for abuse on the sample list of nine. Findings Include: The facility's Identified Offender - admission Guidelines Policy dated May 2024 documents upon admission of an identified offender to a facility or a decision to retain an identified offender in the facility, the facility, in consultation with the medical doctor and law enforcement, must specifically address the resident's needs in an individualized plan of care that reflects the risk assessment of the individual. [...]

Inspectors wroteBased on observation and interview the facility failed to honor R4's breakfast meal preferences. This failure affects one of (R4) three residents reviewed for meal preferences in the sample list of nine. On 6/11/24 at 7:28 AM R4 showed the surveyor a picture of R4's 6/9/24 breakfast tray, which showed one fried egg only on the plate. R4 stated that is what R4 was served on 6/9/24 and 6/10/24. R4 explained R4 prefers fried eggs and about one month ago, talked with V16 Dietary Manager and requested two fried eggs, two pieces of toast and two sausages every day for breakfast and that the facility did it a couple of days but since then, R4 is only getting one slice of toast and then the past two days, didn't even get that, R4 only got one fried egg. On 6/11/24 at 7:28AM R4's breakfast tray consisted of two fried eggs, one slice of toast, oatmeal and a four ounce drink. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's right to be free from verbal abuse by staff. This failure affects one (R9) of three residents reviewed for verbal abuse on the sample list of nine residents.

Inspectors wroteBased on interview and record review the facility failed to facilitate interdisciplinary care plan meetings including residents for one (R2) of three residents reviewed for care plan meetings from a total sample list of nine residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide bathing, shaving and nail care for one (R2) of three residents reviewed for dependent activities of daily living from a total sample list of nine residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident's (R206) right to be free from sexual abuse and failed to protect a resident's (R208) right to be free from physical abuse from another resident. R206 and R208 are two of four residents reviewed for abuse in the sample list of 36.

Inspectors wroteBased on interview and record review, the facility failed to do complete a thorough investigation of an allegation of sexual abuse between two residents (R205) and (R206). R205 and R208 are two of four residents reviewed for abuse in the sample list of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify significant weight loss, timely report significant weight loss to the dietitian and physician, ensure weight loss was assessed/evaluated by a physician, notify the resident representative of weight loss, implement nutritional recommendations, and obtain weekly weights for five (R70, R39, R62, R60, R97) of nine residents reviewed for nutrition in the sample list of 54. These failures resulted in R70 experiencing a significant one month weight loss of 5.52% after experiencing a 10.77% weight loss the month prior, and a total weight loss of 24.25% in six months.

Inspectors wroteBased on interview and record review the facility failed to complete annual performance evaluations for three Certified Nursing Assistants (CNAs). This failure has the potential to affect all 139 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 139 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility to prevent the potential for physical cross-contamination of residents' food. This failure has the potential to affect all 139 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure the required Quality Assurance Performance Improvement (QAPI) meetings were being held quarterly and failed to ensure required members attended quarterly QAPI meetings. This failure has the potential to affect all 139 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure Certified Nursing Assistants (CNAs) received 12 hours of annual in-service training. This failure has the potential to affect all 139 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility repeatedly failed to provide written notifications of bed hold for one (R79) of two residents reviewed for hospitalizations in the sample list of 54.

Inspectors wroteBased on interview and record review the facility failed to identify specific targeted behaviors/interventions and attempt nonpharmacological interventions for five residents (R8, R57, R62, R13, R79) of six residents reviewed for psychotropic medication in a sample list of 54.

Inspectors wroteBased on observation, interview and record review the facility failed to label insulin upon opening (R114, R30), failed to ensure insulin was labeled with resident's name, failed to secure medications, and failed to ensure that a resident's medication card had the correct label with the correct dosage of medication (R97) for three of three residents reviewed for medication storage in the sample list of 54.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide feeding assistance in a dignified manner for one (R113) of 28 residents reviewed for dignity in the sample list of 54.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is cognitively impaired was provided a health care surrogate. This failure affects one resident (R7) reviewed for resident representative in a sample list of 54. Findings Include: R7'2 Order Summary printed 3/6/24 includes the following diagnoses: Altered Mental Status, Pseudobulbar Affect, Moderate Intellectual Disability, Intermittent Explosive Disorder, Downs Syndrome, Generalized Anxiety Disorder, Restlessness, Agitation, Seizures, Conduct Disorder, and Dementia. This summary documents R7's admission date as 12/21/21. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is severely cognitively impaired. R7's Care Plan revised 9/14/23 documents (R7) has explosive mood disorder & delusional disorder with behaviors of angry outburst & tearful episodes requiring meds. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain the signature of resident representative for a cognitively impaired resident on a Do Not Resuscitate order for one resident (R7) of five residents reviewed for Physician's Orders for Life Sustaining Treatment (POLST) in a sample list of 54. Findings Include: R7'2 Order Summary printed [DATE] includes the following diagnoses: Altered Mental Status, Pseudobulbar Affect, Moderate Intellectual Disability, Intermittent Explosive Disorder, Downs Syndrome, Generalized Anxiety Disorder, Restlessness, Agitation, Seizures, Conduct Disorder, and Dementia. This summary documents R7's admission date as [DATE]. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is severely cognitively impaired. R7's Care Plan documents, (R7) is a full code. Attempt resuscitation, CPR, including intubation and mechanical ventilation. Date Initiated: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to prevent misappropriation of resident's property for one of one resident (R138) reviewed for misappropriation of medication in the sample list of 54.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent a decline in Activities of Daily Living (ADLs) for one of three residents (R19) reviewed for ADLs in the sample list of 54.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dressing and shaving assistance for three (R70, R113, R94) of four residents reviewed for activities of daily living in the sample list of 54.

Inspectors wroteBased on interview and record review the facility failed to transcribe hospital discharge orders and obtain laboratory results as ordered for two (R79, R60) of 28 residents reviewed for physician's orders in the sample list of 54.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify a pressure ulcer, implement pressure relieving interventions, develop a pressure ulcer care plan, report pressure ulcers to the physician upon identification and wound decline, and routinely assess pressure ulcers for one (R113) of five residents reviewed for pressure ulcers in the sample list of 54.

Inspectors wroteBased on interview and record review the facility failed to safely transfer one (R131) of three residents reviewed for accidents from a total sample list of 54 residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a suprapubic catheter in a safe sanitary manner for one resident (R92) of three residents reviewed for catheter care in a sample list of 54. Findings Include: R92's Care Plan revised 1/29/24 documents, (R92) has a suprapubic catheter and history of recurrent Urinary Tract Infections, (UTI) is at risk for infection (UTI) related to complex Catheterization/Rectourethral fistula with colostomy placement. (R92) empties own urine without telling staff. (R92) has a diagnosis of obstructive uropathy. (R92) has times of pulling out catheter. (R92) removes dignity bag at times. (R92) moves catheter himself above the level of the bladder, even after education. Date Initiated: 03/25/2021 On 3/3/24 at 10:05AM V37, Certified Nurse's Aide was changing R92's pants and incontinence brief. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to check placement, with gastric residual, of a Gastrostomy tube prior to medication administration and prior to restarting a Gastrostomy feeding for one of two residents (R97) reviewed for Gastrostomy tube in the sample list 54.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications in accordance with Physician's Orders and manufacturer's recommendations for two of five residents (R2, R112) reviewed for medication administration in the sample list of 54. The facility had 2 medication errors out of 27 opportunities resulting in a 7.41% medication error rate.

Inspectors wroteBased on observation, interview and record review the facility failed to remove a roommate from an isolation room for two of two residents (R58, R60) reviewed for Infection Control in the sample list of 54.

Inspectors wroteBased on interview and record review the facility failed to obtain signed refusal of Flu vaccine for two residents (R7 and R92) of five residents reviewed for immunizations in a sample list of 54.

Inspectors wroteBased on interview and record review the facility failed to properly monitor a door alarm and failed to ensure a resident did not exit the facility unnoticed (elopement). This failure resulted in R4 leaving the facility alone and unsupervised for over 1 hour and 16 minutes. This failure affects one (R4) of three residents reviewed for elopement in the sample of 5. R4 had potential for serious injury and/or death due to the inclement winter weather and residents' poor safety awareness of walking in the street. R4's hands and face were exposed to dangerously cold temperatures increasing potential of frostbite. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/15/24 at 6:41pm when R4 left the facility unnoticed by staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R2) was not subjected to physical abuse by R3. This failure affects two (R2, R3) of 4 residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ dietary support staff with the appropriate competencies to carry out the functions of the food and nutrition service. This failure has the potential to affect all 139 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the supply of food to provide the quantity of food portions, according to the menu and resident preference. These failures have the potential to affect all 139 residents residing in the facility.

Inspectors wroteBased on observations, record review and interview the facility failed to properly maintain essential laundry equipment which resulted in one facility washing machine functioning to provide clean linen and clean personal laundry for all 139 residents residing in the facility.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure residents had access to their personal clothing. This failure affected five of ten resident (R1, R6, R8, R13 and R14) reviewed for access to personal possession/laundry on the sample list of 19.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dignity was maintained by talking to a resident (R2) in a condescending manner during dining. The facility also failed to respond to a call light in a timely manner to meet a resident's (R9) toileting needs. R2 and R9 are two of 16 residents reviewed for dignity on the sample list of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain non-pressure wound dressings and failed to report new skin impairment for one of four residents (R16) reviewed for skin impairment on the sample list of 19.

Inspectors wroteBased on observation interview and record review the facility failed to provide a diabetic diet, as ordered by the physician, for one of 13 residents (R1) reviewed for meals on the sample list of 19.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's(R2) right to be free from physical abuse by another resident (R1). This failure affects two residents (R1, R2) of six residents reviewed for abuse.

Inspectors wroteBased on record review and interview, the facility failed to notify a resident's guardian of an allegation of sexual abuse. This failure affects one resident (R2) out of three reviewed for notifications on a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from sexual abuse perpetrated by another resident. This failure affects one resident (R2) out of two reviewed for non-consensual sexual contact on a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse prevention policy by failing to notify local law enforcement of sexual abuse and inform the resident's representative of an allegation of sexual abuse and the results of the facility investigation. This failure affects one resident (R2) out of two reviewed for sexual abuse on the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse, and the final result of the facility investigation, to local law enforcement officials. This failure affects one resident (R2) out of two reviewed for sexual abuse on the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to complete pre-admission screening as required for a resident prior to admission to the to the Skilled Nursing part of the facility, when transferred to the Intermediate Care part of the facility, and when diagnosed with a new mental health diagnosis. This failure affects one resident (R1) out of three reviewed for pre-admission screening on the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to complete required pre-admission screening to determine the appropriateness for a resident who was expected to stay at the facility less than 30 days. This failure affects one resident (R2) on the sample of three reviewed for pre-admission screening on the sample of three.

Inspectors wroteBased on interview and record review the facility failed to protect the residents right to be free from physical abuse from another resident. This failure affects four of four (R4, R5, R6, R7) of eight residents reviewed for abuse in a sample list of 14.

Inspectors wroteBased on observation, interview and record review the facility failed to assist with activities of daily living for one (R4) of three residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review; the facility failed to identify, assess, and complete wound treatments as ordered for two (R3, R12) of four residents reviewed for wound care from the sample list of 14.