Menard Manor

Inspectors wroteBased on interview and record review the facility failed to immediately notify and consult with the resident's physician when a significant change in a resident physical, mental, or psychosocial status (that was a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 3 residents reviewed for change in condition. The facility failed to immediately inform MD on 3/13/2026 of Resident #1's change in condition after she had a fall on 3/13/2026. This failure could place residents at risk of serious decrease in health due to delayed treatment. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assure drugs and biologicals were stored properly in 1 of 1 medication room reviewed for expired medications and drug storage. The medication room contained 1 opened vial of insulin that was not dated when it was opened. The medication refrigerator contained 1 opened multi-use vial of Tuberculin PPD that had expired[PH1] . (Tuberculin is a sterile liquid containing the growth products of or specific substances extracted from the tubercle bacillus and used in intradermal skin tests for the diagnosis of tuberculosis). This deficient practice could place residents and staff at risk for not getting an accurate screening for Tuberculosis and at risk of not receiving the therapeutic dose of medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare, distribute and serve food under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. The ceiling fan located above the stove, dishwasher and prep table had lint and dust build up. The Maintenance Supervisor was not wearing a beard restraint when he entered the kitchen on several occasions and while food was present and open to air. [NAME] B coughed while preparing food without covering her mouth, failed to wash her hands correctly, put her bare hands into cooked food, and did not properly sanitize the thermometer while taking temperatures of food. These failures could place the residents that consumed food prepared in the kitchen at risk of food-borne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for two of four (Residents #1 and #26) residents reviewed for infection control, in that: The facility failed to ensure CNA E and CNA F donned PPE while performing personal care for Resident #26. The facility failed to provide PPE for residents in need of EBP for Resident #1 This failure could place residents at risk for spread of infectious diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accident hazards/supervision (Resident #26). The facility failed to ensure CNA E and CNA F demonstrated appropriate transfer techniques while using the mechanical lift for Resident #26. These failures could place residents at risk for injuries.

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #1 and Resident #2) reviewed for care plans. 1. The facility failed to have a care plan in place to accurately address Resident #1 diagnosis of diabetes. 2. The facility failed to ensure Resident #2's care plan accurately reflected her ½ side-rail use. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 2 of 4 residents (Resident #2 and Resident #3) reviewed for dietary services in that: The residents with puree diet did not receive consistent portion sizes of the puree desert. The facility served zero sugar pudding cups in place of the fortified pudding for lunch for Resident #2 and Resident #3. These failures could place residents at risk for poor food intake, weight loss, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure: Staff did not re-glove using the same single use glove. Staff did not cross contaminated the kitchen after touching the trash can lid and the did not immediately wash their hands. Staff did not handle food with their bare hands. Staff did not put food on cooking surfaces without ensuring they were covered. The walk-in refrigerator was maintained in a sanitary manner. These failures could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #32 and Resident #1) of 5 residents reviewed for infection control. CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #32. CNA's I & J failed to use enhanced barrier precautions (EBP) during transferring Resident #1 from his bed to his wheelchair. (EBP - refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent resident abuse for 1 of 4 (Resident #10) residents reviewed for abuse. The facility failed to ensure the housekeeping supervisor, per the facility's policy, immediately reported witnessed suspected roughness towards Resident #10 by CNA C on 09/07/24 to the Administrator, DON, or ADON. The housekeeper supervisor reported the allegation until 09/10/24. The housekeeper supervisor believed CNA C was rough with Resident #10 and wanted to see the video of the incident to see if CNA C was indeed abusive to the resident as she was not sure the incident occurred. Theses failures could place residents at risk for unsafe environment and further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported immediately, but not later than 2 hours after the allegation was made, or if the events that caused the allegation did not involve abuse or result in bodily injury not later than 24 hours, to Administrator for 1 of 4 residents (Resident #10 )reviewed for abuse in that: The housekeeper supervisor did not report that she thought she witnessed CNA C be rough with Resident #10 to the Administrator within 2 hours of the incident. This deficient practice could place residents at risk for not having all allegations of abuse and neglect reported to the State Survey Agency in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one Resident (Resident #32) of one reviewed for Percutaneous Endoscopic Gastrostomy - PEG (a tube inserted through the abdomen into the stomach for the purpose of administering liquid nutrition and medications) received the appropriate treatment and services to prevent complications and aspiration. LVN B failed to check PEG tube residual prior to administering Resident #32's medication as ordered by the physician. This failure could place residents receiving tube feedings at risk for aspiration pneumonia, dehydration, and metabolic abnormalities which could result in additional medical treatment and a decline in the resident's health.

Inspectors wroteBased on observations, interviews, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 1 of 4 (Resident #2) residents reviewed for bed rails. The facility failed to ensure Resident #2's ½ side rail was installed correctly. The facility failed to correctly care plan Resident #2's side rails. These failures could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. This failure could affect any resident in the facility, placing them at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents, hazards, and supervision. CNA A, CNA B, and CNA C failed to follow the plan of care which required a 2 person assist to transfer Resident #1 with the Hoyer Lift on 11/26/23. Resident #1 was transferred to a local hospital and an x-ray confirmed a proximal tibia and fibula fracture (break, in the shinbone just below the knee). The failure resulted in actual harm to Resident #1 on 11/28/2023. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. The failure placed residents at the facility who require the Hoyer lift at risk for pain or serious injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents, 1 of 1 Medication Carts and 1 of 1 Medication Storage Rooms reviewed for pharmacy services. - The facility failed to ensure the Medication Cart did not include two expired cards of Morphine Sulfate 15mg tablets. - The facility failed to ensure the Medication Storage Room did not contain one expired card of Baclofen 10 mg and one expired box of Albuterol Sulfate Inhalation Solution 1.25mg/3ml. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and worsening of symptoms of diseases. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a RN for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage (January 2023, February 2023, and March 2023). The facility did not have the required 8 consecutive hours of RN coverage during the months of January 2023 (4 days), February 2023 (3 days), and March 2023 (1 days). This failure could place residents at risk for not having their nursing care and medical needs met.