Nexus at Alton

Inspectors wroteBased on interview, observation, and record review the facility failed to provide daily dressing changes as ordered and to ensure they are following physician's orders for outside physician's appointments for 2 (R51 and R28) of 2 residents reviewed for quality of care in a sample of 46. Findings Include: 1. R28's Undated Face Sheet, documents he was initially admitted to the facility on [DATE]. R28's Quarterly Minimum Data Set (MDS) dated [DATE] documents R28 is cognitively intact. R28's Physician's Order Sheet (POS), dated 6/5/2026 documents a new physician's order need to see ENT (ear, nose and throat) specialist for ear and swallowing discomfort. R28's Acute Care Note, dated 6/13/2026 documents patient has had left ear pain since before entrance into the facility. The patient has not had it previously evaluated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain physician orders to provide tracheostomy care and suctioning for three of five residents (R5, R6, and R9) reviewed for tracheostomy care in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent potential cross contamination by failing to wear appropriate Personal Protective Equipment (PPE) to maintain enhanced barrier precautions and failing to perform appropriate hand hygiene and glove changes during care for three of three residents (R5, R6 and R7) reviewed for infection control in the sample list of 17.

Inspectors wroteBased on interview, observation and record review the facility failed to treat residents with dignity and respect for 3 of 4 residents; (R6, R7 and R8); reviewed for Resident Rights in a sample of 14. This failure caused R6 to have feelings of being unworthy of care and shamed and feeling worse about herself. This failure caused R7 to feel worse about himself and like he is a bother to staff. This failure caused R8 to feel insignificant.

Inspectors wroteBased on interview and record review the facility failed to provide pain management for 1 of 5 (R5) residents reviewed for medication administration in a sample of 15. This failure resulted in R5 experiencing excruciating and unbearable pain.

Inspectors wroteBased on record review, and interview, facility failed to ensure a nurse was appointed as charge nurse each shift and sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. This failure has the potential to affect all 82 residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 82 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide food at preferred temperature and palatable. This failure has the ability to affect all 82 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the environment in clean and good repair for 8 of 15 residents (R1, R3, R4, R5, R6, R9, R10, R14) rooms reviewed for environment in a sample of 15.

Inspectors wroteBased on interview and record review the facility failed to ensure medication was administered timely and as ordered for 4 of 4 (R1, R5, R6, R8) residents reviewed for medication administration in a sample of 14.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the call light system was in place and working properly for 5 of 15 residents (R2, R3, R4, R6, R10) reviewed for call lights.

Inspectors wroteBased on interview, observation and record review the facility failed to provide timely incontinent care for 1 of 4 residents (R8); reviewed for incontinent care in a sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to provide wound care services as ordered by the Physician for 1 of 7 residents (R3) reviewed for Abuse and Neglect, in the sample of 15. This failure resulted in R3 being hospitalized for wound infections. Findings Include:R3's Face Sheet, undated, documents R3 has the following diagnoses, in part: Need for Assistance with Personal Care, Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), Hypertension (HTN), ESRD (End Stage Renal Disease), Muscle Wasting/Atrophy, and Anemia. R3's MDS (Minimum Data Set), dated 4/6/26, documents R3 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R3 is cognitively intact. R3 requires substantial/maximal assist with toileting is always incontinent of urine, frequently incontinent of bowel, has two-foot ulcers, a diabetic foot ulcer, and a wound infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete pressure ulcer care and monitoring in 2 of 7 residents (R3, R4) reviewed for the Treatment/Services to Prevent/Heal pressure ulcers, in the sample of 15. This failure resulted in R3 being admitted to the hospital with wound infections. Findings Include:1) R3's Face Sheet, undated, documents R3 has the following diagnoses, in part: Need for Assistance with Personal Care, Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), Hypertension (HTN), ESRD (End Stage Renal Disease), Muscle Wasting/Atrophy, and Anemia. R3's MDS (Minimum Data Set), dated 4/6/26, documents R3 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R3 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to properly notify 4 (R5, R7, R12, and R14) of 6 residents prior to a room change reviewed for notification of room changes in a sample of 15. Findings Include:1.) R5's Undated Face Sheet documents R5 was originally admitted to the facility on [DATE] with diagnoses of Rheumatoid Arthritis of Left Hip, Post-Traumatic Stress Disorder, Unsteadiness on Feet, and Need for Assistance with Personal Care. R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact. On 5/26/26 at 8:46 AM R5 stated she is currently in room [ROOM NUMBER]xx. R5 stated she was not informed of her room change prior to moving, and the facility did not inform her family. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide showers to 4 of 6 residents (R2, R5, R7, R15) reviewed for Activities of Daily Living (ADL) care in a sample of 15. Findings Include:Findings Include:1.) R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has medical diagnoses of Aphasia, Hemiplegia, Weakness, Abnormal Posture, Contracture of the Right and Left Knee, Contracture of the Right and Left Ankle, and Dementia. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their Abuse Prevention Policy by not reporting an injury of unknown origin for 1 (R2) of 7 residents, reviewed for abuse, neglect, and injuries of unknown origin in the sample of 15. Findings Include:R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] with medical diagnoses of Aphasia, Hemiplegia, Weakness, Abnormal Posture, Contracture of the Right and Left Knee, Contracture of the Right and Left Ankle, and Dementia. R2's Care Plan Date Initiated 11/19/13 documents R2 has a communication problem related to Cerebrovascular Accident (CVA). [NAME] is nonverbal and only able to make unintelligible sounds and is unable to communicate effectively with verbal and non-verbal gestures. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin immediately to Administration for 1 (R2) of 7 residents reviewed for abuse in a sample of 15. Findings Include:R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a medical diagnosis of Aphasia, Hemiplegia, Weakness, Abnormal Posture, Contracture of the Right and Left Knee, Contracture of the Right and Left Ankle, and Dementia. R2's Care Plan Date Initiated 11/19/13 documents R2 has a communication problem related to Cerebrovascular Accident (CVA). [NAME] is nonverbal and only able to make unintelligible sounds and is unable to communicate effectively with verbal and non-verbal gestures. R2's Care Plan Date Initiated 3/2/17 documents R2 is considered at risk for abuse/neglect due to, mood cognition, weakness, behavioral/physical deficits. [...]

Inspectors wroteBased on interview and observation, the facility failed to supply a mechanism to alert staff that assistance is needed while residents are in their room, including a call light for 2 (R7, R12) of 6 residents in a sample of 15. Findings Include:1.) R7's Undated Face Sheet documents R7 was admitted to the facility on [DATE] with medical diagnoses of Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease, and Muscle Weakness. R7's Minimum Date Set (MDS) dated [DATE] documents R7 is cognitively intact, needs partial/moderate assistance with toileting hygiene, showering/bathing, needs supervision or touching assistance with chair/bed to chair transfers, and is occasionally incontinent of bladder. R7's Care Plan Date Initiated 1/27/26 documents Activities of Daily Living (ADL): R7 requires assist with daily care needs related to muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an adequate supply of towels and washcloths for 4 of 6 residents (R1, R3, R5, R8) reviewed for safe/clean/comfortable/homelike environment in the sample of 9. Findings Include:On 2/18/26 at 12:09 PM, there were no towels or washcloths on the 100, 300, or 400 hall linen cart. On the 200-hall linen cart there was 1 towel and no washcloths. On 2/18/26 at 2:32 PM, the clean linen room on the 100/200 hall was inspected. There were 3 towels and 8 washcloths. On 2/18/26 at 2:35 PM, the 100-hall linen cart was inspected and did not have any towels or washcloths. On 2/18/26 at 2:37 PM, the 200-hall linen cart was inspected and did not have any towels or washcloths. On 2/18/26 at 2:45 PM, the 300-hall linen cart was inspected and had 1 washcloth and no towels. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications within the specified time frame for 3 of 7 residents (R7, R8, R9) observed/reviewed for medication errors in the sample of 9. Findings Include:On 2/19/26 at 11:36 AM, V11, RN (Registered Nurse), was observed administering the following medications to R7: Loratadine, Nicotine Patch, Metformin, Atorvastatin, Buspirone, Famotidine, Hydrochlorothiazide (HCTZ), Lisinopril, Seroquel, and Mometasone Fureate Inhaler. On 2/19/26 at 12:10 PM, V7 stated sometimes she gets her medications late and sometimes at night she doesn't get her medications at all. R7's Medication Administration Record (MAR), dated 2/2026, documents the following physician orders: Loratadine 10mg (milligrams) PO (by mouth) Qd (daily) at 9:00 AM; [...]

Inspectors wroteBased on interview, observation, and record review, the Facility failed to serve appetizing food at palatable temperatures for 2 of 4 residents (R2, R3) reviewed for food and nutrition services in the sample of 9.

Inspectors wroteBased on interviews and record review the facility failed to provide hot water for bathing for 4 out of 4 residents (R4, R6, R7 and R8); reviewed for Resident Rights in a sample of 8.

Inspectors wroteBased on interviews and record review the facility failed to provide hot water for bathing for 4 out of 4 residents (R4, R6, R7 and R8); reviewed for Physical Environment in a sample of 8.

Inspectors wroteBased on interview and record review the facility failed to initiate the process to timely obtain prescription medication for 2 of 6 residents (R1, R3) reviewed for medications in the sample of 10. This failure resulted in R1 experiencing unnecessary severe pain and suffering. Findings Include:1. R1's admission Record, print date of 11/17/25, documented R1 has diagnoses including acquired absence of right leg above the knee, peripheral vascular disease, cellulitis of left lower limb, type 2 diabetes mellitus, COPD (chronic obstructive pulmonary disease), hereditary and idiopathic neuropathy, hyperlipidemia, anxiety disorder, depression, heart failure, and hypertension. R1's MDS (Minimum Data Set), dated 8/21/25, documented R1 is cognitively intact, and requires partial/moderate assistance with transfers. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide Physician prescribed medication for 2 of 7 (R2, R9) reviewed for medications in the sample of 20. This failure resulted in R9 missing 6 doses of pain medication leaving her in pain.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide Health Shakes for 5 of 5 residents (R14, R15, R16, R17, R20) reviewed for Dietary Supplements in the sample of 20.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide clean linens for 1 of 11 residents (R4) reviewed for linens in the sample of 20.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent Urinary Tract Infections for 2 of 3 residents (R7, R13) reviewed for incontinent care in the sample of 20.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide complete tracheostomy care and educate the resident on the proper way to provide tracheostomy care for 1 of 2 residents (R4) reviewed for tracheostomies in the sample of 20.

Inspectors wroteBased on interview, observation, and record review, the facility failed to wear a personal protective gown, wash hands when needed, change soiled gloves, encourage residents to wash hands, and clean multi-use equipment for 1of 5 residents (R4) reviewed for infection control in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to administer medications as ordered for 4 of 5 residents (R4, R6, R7, and R9) in a sample of 5. Finding Include:1. On 7/18/2025 at 12:06 PM R4 stated while admitted to the facility he did not always receive his medications daily. R4's Undated Face Sheet documents R4 was admitted to the facility on [DATE] and has a diagnosis of Pain in the Left Knee, Chronic Diastolic (Congestive) Heart Failure, Morbid Obesity, Epilepsy, Cortical Age-Related Cataract, Low-Tension Glaucoma, Cardiomegaly, Barrett's Esophagus, Hypothyroidism, and Hypertension. R4's Quarterly Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact, needed supervision/touching assistance with showering/bathing, lower body dressing, personal hygiene, rolling left and right, sitting to standing, and chair/bed to chair transfers. [...]

Inspectors wroteBased on interview and record review the facility failed to perform wound treatment as ordered for 3 or 3 residents (R4, R6, R9), reviewed for Quality of Care in a sample of 3. Finding Include:1. On 7/18/2025 at 12:06 PM R4 stated while admitted to the facility he did not always receive his dressing change to his left knee as ordered. R4's Undated Face Sheet documents R4 was admitted to the facility on [DATE] and has a diagnosis of Pain in the Left Knee, Morbid Obesity, Presence of Left Artificial Knee Joint, and Hypertension. R4's Quarterly Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact, needed supervision/touching assistance with showering/bathing, lower body dressing, personal hygiene, rolling left and right, sitting to standing, and chair/bed to chair transfers. [...]

Inspectors wroteBased on interview, observations, and record review, the facility failed to arrange a specialty Physician appointment for 1 of 3 residents (R2) reviewed for doctor appointments in the sample of 7. This failure resulted in R2 not receiving treatment for his poor vision, worsening vision, and only being able to see shadows.

Inspectors wroteBased on interview and record review the facility failed to answer call lights in a timely manner in 6 (R37, R14, R64, R18, R51, R61) of 6 residents reviewed for call lights in the sample of 33.

Inspectors wroteBased on interview, observation, and record review the facility failed to follow its Fall Prevention and Management policy and complete a root cause analysis after each fall, failed to implement interventions after each fall, and failed to implement fall interventions according to resident care plans for 3 of 4 residents (R2, R3, R6) reviewed for falls in the sample of 15. Findings Include: 1. R2's medical diagnosis form, print date of 5/21/25, documented R2 has diagnoses including aphasia following cerebral infarction, apraxia, cerebrovascular disease, hemiplegia, type 2 diabetes mellitus, depression, anxiety, hypertension, heart disease, contractures of lower extremities, and dementia. R2's MDS (Minimum Data Set), dated 2/24/25, documented R2 is severely cognitively impaired and dependent on staff for all ADLS (Activities of Daily Living). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were not asserting dominance over other residents for 2 of 6 residents (R1, R6) reviewed for abuse in the sample of 12. Due to this failure, R1 became tearful, scared, and embarrassed about a sexual abuse allegation, refusing to be seen by a provider due to being afraid of what may happen, refused therapy, and reported he lived in fear, confining himself to his room since (R6) resided across the hall from (R1).

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide residents with the correct diet as ordered by the physician for 4 of 4 residents (R3, R8, R11, R12) reviewed for residents receiving the correct diets in the sample of 12.

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations were thoroughly investigated for 2 of 6 residents (R1, R6) reviewed for abuse investigation in the sample of 12.

Inspectors wroteBased on record reviews and interviews the facility failed to transcribe medications to Physician Order Sheet, the Medication Administration Record, obtain medications from the pharmacy and administer medications as ordered by the physician according to standards of practice for 1 of 3 (R3) residents reviewed for significant medication errors. This failure resulted in R3 experiencing shortness of breath, heart palpitations, untreated Urinary Tract Infection and R3 feeling like he was going to die.

Inspectors wroteBased on record reviews and interviews the facility failed to complete the admission process and transcribe medications to Physician Order Sheet, the Medication Administration Record, obtain medications from the pharmacy and administer medications as ordered by the physician for 1 of 3 (R3) residents reviewed for significant medication errors. This failure resulted in R3 experiencing shortness of breath, heart palpitations, elevated blood glucose levels, untreated Urinary Tract Infection (UTI), R3 feeling like he was going to die, hospitalized and received critical care for untreated Urinary Tract Infection.

Inspectors wroteBased on record reviews and interviews the facility failed to transcribe medications to Physician Order Sheet, the Medication Administration Record, obtain medications from the pharmacy and administer medications as ordered by the physician for 1 of 3 (R3) residents reviewed for significant medication errors. This failure resulted in R3 experiencing shortness of breath, heart palpitations, untreated urinary tract infection and R3 feeling like he was going to die.

Inspectors wroteBased on record reviews and interviews the facility failed to transcribe medications to Physician Order Sheet, the Medication Administration Record, obtain medications from the pharmacy and administer medications as ordered by the physician for 1 of 3(R3) residents reviewed for providing care according to professional standards.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical and sexual abuse for 5 of 5 (R17, R18, R19, R20, R21) reviewed for abuse in the sample of 21. This failure resulted in R17 being sexually inappropriately touched by another resident. Findings Include: 1. R17's Face Sheet, print date of 3/24/25, documents R17 was admitted on [DATE] and has diagnoses of Type 2 Diabetes Mellitus, cocaine abuse, and mood disorder. R17's Minimum Data Set (MDS), dated [DATE], documents R17 is severely cognitively impaired. R17's Nurses Note, dated 3/18/2025 13:14, documents, This nurse was notified that this resident was inappropriately touched by another resident. Both residents involved were separated and (R16) put on 1:1 Upon investigation and questioning resident said nothing happened. Admin (Administrator) DON (Director of Nurses) and NP (Nurse Practitioner) notified. [...]

Inspectors wroteBased on interview and record review, the facility failed to send a resident for evaluation and treatment after multiple refusals for dialysis for 1 of 3 residents (R6) reviewed for change of condition in the sample of 21. This failure resulted in R6 being sent to the Emergency Room, being admitted to the Intensive Care Unit, and having a Central Line placed. Findings Include: R6's Face Sheet, print date of 3/20/25, documents R6 was admitted on [DATE] and has diagnoses of Schizophrenia, Dementia, Alzheimer's Disease, and Dependence on Renal Dialysis. R6's Minimum Data Set, dated [DATE], documents R6 is severely cognitively impaired. R6's Physician Order, dated 1/30/25, documents, Dialysis: 5 days a week. R6's Hemodialysis Treatment Times, dated 2/3/25 - 3/17/25, documents the last dialysis treatment was on 3/11/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the Physician prescribed pain medication for 1 of 5 residents (R5) reviewed for pain in the sample of 21. This failure resulted in R5 having pain requiring him to stay in bed all day, feeling frustrated, and enjoy his normal daily activities.

Inspectors wroteBased on interview and record review, the facility failed to provide the Physician prescribed pain medication for 1 of 5 residents (R5) reviewed for medications in the sample of 21. This failure resulted in R5 having pain requiring him to stay in bed all day, feel frustrated, and not enjoy his normal daily activities.

Inspectors wroteBased on interview and record review, the facility failed to offer a nighttime snack for 4 of 6 residents (R2, R3, R4, R5) reviewed for snacks in the sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to notify the Power of Attorney for the use of a narcotic and refusing therapy for 1 of 3 residents (R6) reviewed for notification in the sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to provide a final abuse investigation report for 2 of 5 residents (R19, R20) reviewed for abuse reporting in the sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to conduct an investigation for 2 of 5 residents (R19, R21) reviewed for abuse reporting in the sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to obtain a consent from a Power of Attorney for a psychotropic medication for 1 of 4 residents (R6) reviewed for psychotropic medications in the sample of 21.

Inspectors wroteBased on interview, observation, and record review, the facility failed to prevent verbal abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate and report allegations of sexual abuse for 1 of 3 residents (R2) reviewed for sexual abuse in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to initiate its Abuse Prevention policy for 1 (R2) of 3 three residents reviewed for sexual abuse in the sample of 11.

Inspectors wroteBased on interview, observation, and record review, the facility failed to measure, assess, monitor, and treat wounds when identified and obtain orders to treat wounds for 1 of 1 (R4) reviewed for wounds in the sample of 11.

Inspectors wroteBased on interview, observation, and record review, the facility failed to assess and monitor pressure ulcers, provide Physician prescribed treatment, and maintain clean dressings for 2 of 3 residents (R1, R11) reviewed for pressure ulcers in the sample of 11.

Inspectors wroteBased on interview, observation, and record review, the facility failed to replace a loose dressing for 1 of 2 residents (R4) reviewed for Peripherally Inserted Central Catheter (PICC) lines in the sample of 11.

Inspectors wroteBased on interview and record review the Facility failed to support the resident's right for the Power of Attorney (POA) to access their family's personal medical records and honor their written request for records for 1 of 3 residents (R2) reviewed for medical records in the sample of 6.

Inspectors wroteBased on interview and record review the Facility failed to provide and document sufficient preparation and orientation for a safe and orderly discharge from the facility for 1 of 3 residents (R1) reviewed for discharge in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide toileting to promote resident's dignity for 1 of 3 residents (R3) reviewed for dignity in a sample of 8. This failure caused R3 to be incontinent and feel helpless, ashamed, embarrassed, depressed, and demeaned.

Inspectors wroteBased on interview and record review the facility failed to obtain consent for an antipsychotic medication prior to administering antipsychotic and antidepressant medication for 2 of 3 residents (R3, R4) reviewed for informed treatment/treatment decisions in a sample of 8.

Inspectors wroteBased on interview and record review the facility failed to provide tracheostomy (trach) care for 1 of 1 resident (R3) reviewed for trach care in a sample of 8.

Inspectors wroteBased on interview and record review the facility failed to arrange a medically necessary appointment transport for 1 of 3 (R16) residents reviewed for dialysis in the sample of 18. This failure resulted in R16 missing his appointment to treat a clogged dialysis shunt, which in turn created ineffective dialysis procedures.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food was served in the appropriate portions for 8 of 13 (R2, R7, R8, R9, R10, R11, R12, and R13) residents reviewed for food services.

Inspectors wroteBased on interview and record review, the facility failed to obtain and properly document code status for 5 of 6 residents (R58, R261, R264, R265, R266) reviewed for advanced directives, in the sample of 43.

Inspectors wroteBased on interview and record review, the Facility failed to ensure palatable and appetizing meals for 5 of 5 residents (R18, R13, R24, R33, R267) reviewed for food palatability and temperature in the sample of 43.

Inspectors wroteBased on interview and record review, the Facility failed to follow their alternative menu for 6 of 6 residents reviewed for alternative food choices in the sample of 43.

Inspectors wroteBased on Observation, Interview, and Record Review, the facility failed to maintain infection control during dialysis treatment on 7 residents (R266, R41, R10, R30, R261, R53, R32) in the sample of 43. Findings Include: R266's Face sheet documents an admission date of 5/1/2024 and diagnosis includes Encephalopathy, Cirrhosis of the Liver, End Stage Renal Disease, Ascites. R266's order sheets dated 4/1/2024 document Hemodialysis in house with dialysis company. R41's Face sheet documents an admission date of 9/20/2022 and diagnosis includes End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, Vascular Prosthetic, Type 2 Diabetes, Bacteremia. R41's order sheets dated 4/1/2024 document Hemodialysis in house with dialysis company. [...]

Inspectors wroteBased on interview and record review, the facility failed to transcribe and carry out a physician order for a specialist appointment for 1 of 1 resident (R57) reviewed for quality care, in the sample of 43. Findings Include: R57's admission Record, dated 3/28/24, documented that R57 had a diagnosis of unspecified cirrhosis of liver, malignant neoplasm of the colon, ascites, thrombocytopenia unspecified and decreased white blood cell count unspecified that were added to the diagnosis list on 4/19/24. R57 Minimum Data Set (MDS), dated [DATE], documented that R57 was moderately cognitively impaired. R57's Physician Order Sheets, (POS), dated 4/19/24, documented, Refer to the hematologist diagnoses Leukopenia and Thrombocytopenia one time only related to decreased white blood cell count and unspecified Thrombocytopenia. [...]

Inspectors wroteBased on Interview and Record Review, the facility failed to provide timely access to medical records, for 2 of 2 (R3, R4) residents, reviewed for rights to access medical records, in a sample of 12. Findings Include: R3's Face sheet, undated, documented an admission date of 12/16/2023. On 4/18/2024 at 3:00PM, V10, R3's daughter, stated I have asked for (R3's) medical records and still have not received anything. I emailed (V5, Medical Records) worker, all the required documents on 2/9/2024. I then followed up with (V5) on 2/15/2024 and needed to send another proof of identification. I sent that proof in the same day and have not heard anything. I sent (V5) an email in March to see if (V5) had heard anything about (R3's) medical records, and she emailed back that she sent everything to the corporate office and knew nothing else. I still have none of (R3's) medical records. [...]

Inspectors wroteBased on interview and record review, the Facility failed to ensure residents were free from mental abuse for 2 of 7 (R1, R2) residents reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to notify the physician of residents continued leg pain for 1 of 3 residents (R3) reviewed for physician notification in the sample of 4. This failure resulted in R3 having unrelieved pain and a delay in treatment for a right femur fracture that required surgical intervention.

Inspectors wroteBased on interview and record review the facility failed to timely assess, timely notify physician of resident's increased pain, and timely treat a fracture for of 1 of 3 residents (R3) reviewed for quality of care in the sample of 4. This failure resulted in R3 having leg pain from at least 1/23 through 1/28/24 and being admitted to hospital for right femur fracture requiring surgery.

Inspectors wroteBased on interview and record review the facility failed to safely transfer a resident per plan of care for 1 of 3 residents (R3) reviewed for supervision to prevent accidents in the sample of 4. This failure resulted in R3's sustaining a right femur fracture which required surgical repairment.

Inspectors wroteBased on interview, observation and record review, the facility failed to adequately supervise a resident to prevent an elopement of 1 of 3 residents (R2) reviewed for supervision. This failure resulted in R2 eloping from the facility. R2 was gone from the facility for approximately 14 hours and sustained a fractured right tibia while out of the facility. On 11/07/23 at 2:50pm V1 Administrator and V2 [NAME] was in room when V1 signed IJ Template. The Immediate Jeopardy began on 10/10/23 approximately 11:00 PM-12:00AM, When R2 eloped from the facility, and was found out in the rain under a tree with a broken leg. The staff was unaware of R2 had exited the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide feeding assistance with meals for 2 of 3 residents (R3, and R7) reviewed for ADL (activities of daily living) assistance in the sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to prevent sexual abuse by a male resident for 1 of 3 residents (R12) reviewed for abuse on the sample list of 27. This deficient practice resulted in R27 having inappropriate sexual contact with R12.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there were sufficient Nursing Staff in the facility to provide adequate care and assistance for residents, resulting in residents not gotten out of bed for meals and residents not receiving showers. This failure has the potential to affect all 64 residents in the living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain walls and floors in good repair for 11 of 27 residents (R11, R15, R14, R16, R17, R18's, R19's, R20, R21, R22's and R23's) reviewed for Physical Environment on the sample list of 27.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to submit an initial resident abuse allegation to the state agency within the 2-hour time frame for allegation of abuse for 1 of 3 resident (R13) reviewed for abuse on the sample of 27.

Inspectors wroteBased on observation, interview and record review, the facility failed to store medication, label insulin and Tubersol in accordance with standards of practice. This has the potential to affect all 76 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with bathing, grooming, and hygiene to dependent residents for 4 of 8 residents (R8, R24, R25, R43) observed for activities of daily living (ADL) in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe transfer for 4 of 4 residents (R8, R33, R40, R43) reviewed for safe transfers in the sample of 37.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely and complete incontinence care and catheter care for 4 of 4 residents (R28, R40, R43, R53) residents reviewed for incontinent care/catheter care in a sample of 37.

Inspectors wrote4. R8's Face Sheet, dated 4/5/23, documents that R8 was admitted to the facility on [DATE]. R8's Electronic Medical Record, documents that R8's diagnoses include Malnutrition, Asthma, Morbid Obesity, Dysphagia, End Stage Renal Disease (ESRD), COVID-19, Dependence on Renal Dialysis, Obstructive and reflux uropathy, Anemia, Seizures, Transient Ischemic Attack (TIA), Schizoaffective Disorder, Major Depressive Disorder, Psychosis, Polyosteoarthritis, Atherosclerotic Heart Disease, Spinal Muscular Atrophy. R8's Care Plan, dated 3/21/23, documents (R8) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness, ESRD, and spinal muscular atrophy. She primarily uses a wheelchair, is incontinent of B&B (bowel and bladder). Interventions: BATHING: R8 requires total care with bathing. PERSONAL HYGIENE: R8 requires extensive assistance with personal hygiene. [...]

Inspectors wroteBased on interview and record review, the Facility failed to provide tube feedings as ordered by the physician for 1 of 1 resident (R29) reviewed for tube feedings in the sample of 37.

Inspectors wroteBased on interview, and record review, the facility failed to employ a Registered Nurse (RN), 8 hours per day, 7 days per week. This has the potential to affect all 71 residents living in the facility. Findings Include: On 1/4/2022 at 4:34 PM, V1, Administrator, stated, I have been here since October 2021 and we have had corporate in the building working. I am not aware of any issues with not having a RN. We have not had an RN every day consecutively working the floor but we have had an RN working in the building. (V8) was working as the RN. We do not have a full time Director of Nursing (DON) but (V2) is working as the interim DON. On 1/04/2022 at 4:13 AM, V8, Corporate Regional Nurse, stated, I am aware we have been struggling to find an RN full time and meeting 8 hours a day seven days a week. We have been using agency, but it has been difficult. I have not been working the floor. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 71 residents living in the facility.

Inspectors wroteBased on interview and record review the facility failed to develop an ongoing infection control program that collects data to calculate and analyze infection rates and failed to implement infection control procedures that prevents the spread of COVID-19 and other infections. This has the potential to affect all 71 residents living in the facility. Findings Include: 1. On 1/5/2022 at 9:01 AM, documentation regarding how the facility identifies, analyzes data, and provides surveillance of infections within the facility was requested for the past year including pathogens and organisms. The October 2021 infection and antimicrobial log/surveillance Log provided by the facility only documented 6 residents with one urinary tract infection documented. 2. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to clean the CPAP (continuous positive airway pressure) as ordered for 5 of 5 residents (R2, R3, R10, R14, R39) reviewed for respiratory care in the sample 48.

Inspectors wroteBased on observation, interview and record review, the facility failed to date opened insulin pens and to ensure physician's orders have the appropriate route for 4 of 4 residents (R54, R12, R22, R27) reviewed for medications in the sample of 48.

Inspectors wroteBased on interview and record review the Facility failed to provide residents with food according to their food plan/preferences for 4 of 25 residents (R29, R30, R39, R106) reviewed for food choices in the sample of 48.

Inspectors wroteBased on interview and record review, the Facility failed to provide residents with flavorful and properly cooked food for 5 of 25 residents (R29, R34, R39, R108 and R157) reviewed for palatable food in the sample of 48.

Inspectors wroteBased on interview and record review, the facility failed to secure medications to ensure residents do not have access for one of one resident (R9) reviewed for 1 of 1 accident investigations in a sample of 48.

Inspectors wroteBased on interview and record review the facility failed to monitor and assess the hemodialysis shunt sites for 2 of 4 residents (R12, R21) reviewed for dialysis in the sample of 48. Findings Include: 1. R12's Minimum Data Set (MDS) dated [DATE] documents R12 is moderately cognitively impaired. R12's Hemodialysis Care Plan documents dated 1/7/22 documents observe access site for infection redness, drainage, swelling, and pain every shift. R12's December 2021 Treatment Administration Record (TAR) documents that R12's hemodialysis access site was only assessed 30 times for 3 shifts for the month of December (should have been 90 times). On 1/6/22 at 3:00 PM, R12 stated, I don't know if they check it or not. 2. R21's MDS dated [DATE] documents R21 is moderately cognitively impaired. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were given as ordered. There were 25 opportunities with 2 errors resulting in an 8% medication error rate. The errors involved 2 residents (R54, R108) in the sample of 48 out of 3 residents observed during the medication administration.

Inspectors wroteBased on interview and record review the facility failed to accurately document in the medical record a resident's change in condition which required emergency care for one of one resident (R255) reviewed for documentation in a sample of 48.

Inspectors wroteBased on observation, interview and record review the Facility failed to post an updated Ombudsman Information with the correct name and telephone number for the Ombudsman. This has the potential to affect all 71 residents living in the facility.