Nexus Pavilion at Belleville

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure that medication was ordered and available in a timely manner for 6 of 6 (R5, R58, R84, R77, R101, R113), residents in a sample of 42. This failure resulted in R84 not receiving his pain medication and experiencing increased and excruciating pain, R5 not receiving a muscle relaxer and experiencing phantom cramps and pain in left lower extremity amputation. It also resulted in R58 not receiving is clonazepam and experiencing increased anxiety and chest pain resulting in transportation to hospital.

Inspectors wroteBased on observation, interview and record review the facility failed to administer pain medications for 3 of 4 residents (R5, R84 and R101) reviewed for pain in the sample of 42. This failure resulted in R5 experiencing phantom pain, R84 experiencing excruciating pain in wrist and back, and R101's pain being elevated to a level 8 on a scale of 1-10 for 2 days.

Inspectors wroteBased on interview, observation, and record review the facility failed to maintain resident dignity while eating in the dining room for 3 of 25 residents (R12, R77, R126) reviewed for resident dignity in the sample of 42.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide a safe resident environment and protect residents from abuse for 1 of 10 residents (R2) reviewed for resident abuse in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired medications on the medication cart when reviewed for pharmacy services in the sample of 9. This failure has the potential to affect all 29 residents residing on the 500 hall. Findings Include:On 5/13/26 at 10:20 AM, the 500-hall medications care was observed with the following expired medications noted: Oyster Shell Calcium with an expiration date of 12/11/23; Acetaminophen 325mg (milligrams) with an expiration date of 6/2025; Bisacodyl 5mg with an expiration date of 12/2024; Vitamin C 250mg with an expiration date of 3/2026; Vitamin B12 500mcg (micrograms) with an expiration date of 4/2026; Simethicone 125mg with an expiration date of 2/2026; Loperamide Hydrochloride Oral Solution 1mg/7.5ml (milliliter) with an expiration date of 10/2025; Aspirin 81mg with an expiration date of 3/2026. [...]

Inspectors wroteBased on interview and record review, the Facility failed to provide adequate supervision for a resident with a history of substance abuse in 1 of 4 residents (R2) reviewed for accidents and hazards in the sample of 9.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program related to bed bugs in the facility. This has the potential to affect all 123 residents residing in facility.

Inspectors wroteBased on observation interview and record review the facility failed to initiate Enhanced Barrier Precautions and provide personal protective equipment for 4 of 4 (R21, R23, R24, R25) residents reviewed for infection control in the sample list of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent abuse for 1 (R3) of 9 residents reviewed for abuse in the sample of 9.

Inspectors wroteBased on observation, interview and record review the facility failed to investigate abuse for 1 (R3) of 9 residents investigated for abuse in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pest control services for bed bugs when reviewed for physical environment. This failure has the potential to affect all 107 residents residing in the facility. Findings Include:On 1/6/26 at 1:58 PM, room [ROOM NUMBER] was observed, no residents reside in this room. Approximately seven dead bed bugs were noted on a glue board, one live bed bug noted on the mattress by the door. On 1/8/26 at 8:40 AM, room [ROOM NUMBER] was observed, this room does not house any residents, one live bed bug observed on the baseboard and one live bed bug on the mattress sheet. On 1/8/26 at 8:43 AM, room [ROOM NUMBER] was observed, this room does not house any residents, several dead bed bugs observed on the baseboards. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents resided in a safe environment, free from actual and potential abuse. This failure resulted in R3 who has a diagnosis of Schizophrenia, Bipolar Disorder and Depression, experience physical abuse from a staff member, injury to left eye and feeling fear, anger, and ashamed.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide supervision to prevent elopement for 1 (R7) of 3 reviewed for elopement in the sample of 13. This failure resulted in R7, a resident with known desire and attempts to leave the facility, eloping from the facility and found 12 miles away approximately 8 hours later by police. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 7/25/25 when the R7 eloped from the facility. V1, Administrator, V2, Director of Nursing (DON), V3, Regional Nurse Consultant (RNC), and V19, Regional Director of Clinical and Operations, were notified of the Immediate Jeopardy on 7/30/25 at 4:08 PM. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide pain medication to 1 of 3 residents (R3) reviewed for pain control in the sample of 8. This failure resulted in R3 having excruciating pain and having trouble functioning during that time in pain. The Findings Include:R3's admission Record, dated 7/21/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Diabetes Mellitus (DM), Pneumonia, Bacteremia, and a Lung Abscess with Methicillin Resistant Staphylococcus Aureus (MRSA) infection. R3's Care Plan, dated 7/9/25, documents R3 Is Independent with Activities of Daily Living (ADLs). R3 has an alteration in comfort with interventions including administer pain meds and treatments as ordered, assess pain characteristics: [...]

Inspectors wroteBased on interview, observations, and record review, the facility failed to provide an antibiotic for 1 of 1 resident (R3) reviewed for medication administration in the sample of 6. This failure resulted in R3 not receiving his antibiotic as ordered, his Vancomycin Trough levels subtherapeutic therefore not sufficient in treating R3's Methicillin Resistant Staphylococcus Aureus (MRSA) infection in his lungs. The Findings Include:R3's admission Record, dated 7/21/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Diabetes Mellitus Type 2 (DM2), Pneumonia, Bacteremia, and a Lung Abscess with Methicillin Resistant Staphylococcus Aureus (MRSA) infection. R3's Care Plan, dated 7/9/25, documents R3 Is Independent with Activities of Daily Living (ADLs). [...]

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure residents were being monitored and supervised to prevent elopement for 1 of 3 residents (R2) reviewed for supervision to prevent elopement in the sample of 11. This failure resulted in R2 attempting to exit the facility around 2 AM on 6/10/2025. R2 was redirected but no other interventions were implemented and R2 then later eloped from the Facility on 6/10/2025 at 5:49 AM and was sent out to the hospital for six days with a diagnosis of Paranoid Schizophrenia and behaviors. The Immediate Jeopardy began on 6/10/25 when the facility failed to implement resident-centered interventions after R2 previously displayed exit seeking behaviors to prevent R2 from eloping the facility again the same day. [...]

Inspectors wroteBased on interview, and record review the facility failed to maintain an effective pest control system to eradicate bed bugs. This has the potential to affect all 113 residents living in the facility.

Inspectors wroteBased on observation, interview and record review the Facility failed to pass medications according to physician's orders for 5 of 7 residents (R2, R6, R8, R9, R10) reviewed for medication in the sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate nursing staff to provide nursing and related services to meet the residents' needs safely and to administer their medications for 4 out of 4 residents (R4, R5, R6, R7) reviewed for medications in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to ensure the administration of scheduled morning and afternoon medications for 4 out of 4 residents (R4, R5, R6 and R7) reviewed for medication administration in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's right to privacy when privacy curtains were not present in their rooms for 4 of 4 residents (R1, R2, R4, and R12) observed in a sample of 23 residents observed for privacy curtains.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinent/colostomy care in 1 of 1 resident (R2) reviewed for ADL (Activities of Daily Living) care in the sample of 6. This failure resulted in R2 developing painful, red excoriation around his colostomy site extending down to the abdomen, perineal area and buttocks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide colostomy care to 1 of 1 resident (R2) reviewed for ostomy care in the sample of 6. This failure resulted in R2 developing painful, red excoriation around the colostomy site extending down to the abdomen and perineal area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify pain and provide pain relief to 1 of 1 resident (R2) reviewed for pain management in the sample of 6. This failure resulted in R2 having pain and discomfort related to excoriation around his colostomy site extending down to the abdomen and perineal area and that is not being treated or recognized.

Inspectors wroteBased on Interview, Observation, and Record Review, the facility failed to maintain a pest free environment for 4 of 5 residents (R1, R2, R3, R4) reviewed for pest control in the sample of 5. The Findings Include: 1. R1's admission Record, dated 4/3/25, documents R1 was admitted to the facility on [DATE] with diagnosis of Asthma, Type 1 Diabetes Mellitus (DM), Obesity, and Schizoaffective Disorder. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. On 4/3/25 at 9:35 AM, R1 stated I see bugs in my room at least once a week, and they are usually coming from around the wall and then sometimes in my bed. R1 pulled her sheets back and one bug was seen in her bed. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent physical abuse for 3 of 4 residents (R5, R6, R10) reviewed for Freedom from Abuse and Neglect in a sample of 16. This failure resulted in R6 acquiring a subarachnoid hemorrhage and left orbital wall fracture.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to prevent development of additional pressure injuries for 1 of 3 residents, (R1) reviewed for treatment/services to prevent/heal pressure ulcers in a sample of 16. This failure resulted in R1 developing two new Stage 2 pressure injuries.

Inspectors wroteBased on interview and record review the Facility failed to ensure abuse investigations were thoroughly investigated for 2 of 5 residents (R401, R402) reviewed for abuse investigations in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to prevent abuse for 3 of 7 (R20, R30, R62) residents investigated for resident-to-resident abuse in a sample of 39.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and document a head to toe skin assessment upon readmission to the facility for 1 (R44) of 1 resident reviewed for pressure wounds in the sample of 39. This failure resulted in the deterioration of the pressure ulcer from a stage II to a stage III. R44's Undated Face Sheet documents initial admission date 4/17/2020 diagnoses of spina bifida and pressure ulcer of sacral region unspecified stage. R44's Annual Minimum Data Set (MDS) dated [DATE] documents she is alert and no pressure ulcers, not at risk for pressure ulcers, no unhealed pressure ulcers. R44's Care Plan, addresses resident at risk for skin complications r/t (related to) skin spina bifida. Goal: area to right buttock will remain stable/heal. Interventions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to employ a full-time Director of Nurses DON to oversee the facility's nursing department. This failure has the potential to affect all 126 residents residing in the facility.

Inspectors wroteBased on observation, interviews, and records review, it was determined that the facility failed to ensure garbage in the facility dumpster was covered. This has the potential to affect all 126 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to send a medical record request in a timely manner for 1 (R174) of 3 residents reviewed for medical records in the sample of 39. R174's Undated Face Sheet documents she was initially admitted to the facility on [DATE]. R174's Nurse Progress Note, dated 8/13/2024 at 11:52 PM documents upon during rounds this nurse noted labored breathing. Vital signs 104/69, heartrate 60, oxygen saturation 77%, respirations 18, temperature 97.6 degrees. Secretions noted to the back of throat. PRN (when needed) nebulizer given as ordered. Suction administered to clear airway. Oxygen saturation now at 80%. Nurse practitioner called and gave orders to send to ED (emergency department) to eval (evaluate) and TX (treatment). POA (Power of Attorney) called and VM (voicemail) left. DON (Director of Nurses) called and VM left. [...]

Inspectors wroteBased on interview and record review the Facility failed to ensure abuse investigations were thoroughly investigated for 2 of 5 residents (R401, R402) reviewed for abuse investigations in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 4 residents (R2) was protected from another resident with known sexually inappropriate behaviors resulting in the sexual abuse of R2. This failure has the potential to affect all 123 residents residing at the facility. The Immediate Jeopardy began on 01/07/25 at 2:12 PM, when R3 was admitted back into the facility and the facility failed to initiation a plan of care and interventions to address how residents would be kept safe and free from sexual abuse, resulting in R2 being sexually abused by R3. V2, Director of Nursing (DON) and V7, Minimum Data Set (MDS) Coordinator were notified of the Immediate Jeopardy on 01/17/25 at 09:36 AM. The Immediacy was removed on 01/17/25, but noncompliance remains at Level II due to time needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician visits were completed at least every 60 days for 4 residents (R2, R11, R12, and R13) reviewed for frequency of physician visits in a sample of 13. Findings Include: 1. R2's face sheet, undated, documented R2 has diagnoses including schizoaffective disorder, bipolar type, COPD (chronic obstructive pulmonary disease), myelodysplastic syndrome, hypotension, and pancreatic cancer. R2's MDS (Minimum Data Set), dated 12/13/24, documented R2's cognition is moderately impaired and dependent on staff for all ADLS (activities of daily living). R2's care plan, dated 12/26/24, documented R2 requires healthcare monitoring related to diagnosis of pancreatic cancer. She is at risk for pain, disturbed body image, fear, impaired skin integrity, and infection. [...]

Inspectors wroteBased on interview and record review the facility failed to monitor and supervise 1 of 3 residents (R4) reviewed for elopement in a sample of 10. This failure resulted in R4 leaving the facility unattended, on 12/20/2024 from 2:00 AM to 3:30 AM, falling outside the facility, sustaining multiple abrasions to both lower extremities, a dislocated left wrist, and a laceration to R4's forehead and left cheek that required sutures. The Immediate Jeopardy began on 12/20/2024 when R4 eloped from the facility without staff knowledge. R4 was last seen in the facility on 12/20/2024 2:00 AM and was found outside the facility on the ground. Due to R4 physical and cognitive vulnerabilities, R4 had the likelihood of serious harm and injury when R4 eloped. V1, Administrator, and V30, Regional Clinical Nurse, were notified of the Immediate Jeopardy on 1/3/2025 at 2:50 PM. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program related to bed bugs in the facility for 1 of 2 units observed.

Inspectors wroteBased on interview and record review, the facility failed to report verbal abuse allegations to Illinois Department of Public Health for 1 of 3 residents (R2) reviewed for abuse. This failure resulted in R2 becoming upset, crying, refusing medications and refusing to eat.

Inspectors wroteBased on interview and record review, the facility failed to investigate verbal abuse allegations for 1 of 3 residents (R2) reviewed for abuse. This failure resulted in R2 becoming upset, crying, refusing medications and refusing to eat.

Inspectors wroteBased on interviews and record reviews the facility failed to secure a resident's medication, for 1 out of 3 residents, (R2), reviewed for misappropriation of resident's property in a sample of 4.

Inspectors wroteBased on interview and record review, the Facility failed to ensure residents receive requested, prescribed pain medications for 2 of 3 residents (R1, R2) reviewed for narcotic use in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to provide the necessary physician-prescribed supervision to prevent elopement and falls for 3 of 4 residents (R3, R1, R7) reviewed for one-on-one supervision in the sample of 7.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure wound treatments were consistently provided for 1 of 3 residents (R2) reviewed for wound care. This failure resulted in R2 requiring transfer to the hospital, maggots developing in R2's wound, a diagnosis of osteomyelitis and needing IV antibiotics therapy.

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure adequately equipped call lights were in place to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 14 of 15 (R1-14) residents reviewed for call lights in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from verbal abuse by an employee for 1 of 5 residents (R28) reviewed for abuse in the sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents do not have access to chemicals for 1 of 3 residents (R3) reviewed for supervision to prevent accidents in the sample of 5. This failure resulted in R3 drinking a liquid containing bleach, being transported to the hospital for evaluation and medical treatment. R3, as a person with altered mental status and Schizophrenia would be afraid and apprehensive of being sent to the hospital.

Inspectors wroteA. Based on interview and record review, the facility failed to ensure residents were free from abuse for 9 of 25 residents (R30, R35, R36, R39, R50, R63, R64, R85 and R88) reviewed for abuse, in the sample of 59. This failure resulted in R30 biting R50 and R50 being treated for a human bite and seeing the wound nurse for treatment. This failure also resulted in R85 being thrown out of wheelchair by R39, and R39 attempting to smash R85's head with the wheelchair causing an abrasion to R85's left ear, upper left arm, and face.

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to ensure resident's coffee was served at temperatures that would not burn aresident for 1 of 12 residents (R30) reviewed for accidents in the sample of 59. This failure resulted in hot coffee being spilled on R30 and R30 sustaining burns to thigh and abdomen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide interventions to address weight loss for 1of 9 residents (R108) reviewed for weight loss in the sample of 59. This failure resulted in R108 losing 45.5 pounds (#s), a 16.98% loss of body weight in less than 2 months.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure allegations of abuse, neglect, or mistreatment were thoroughly investigated and interventions were put into place to prevent further potential abuse, neglect exploitation or mistreatment for 7 of 25 residents (R30, R36, R39, R50, R63, R85 and R88) reviewed for abuse in the sample of 59. This failure had the potential to affect all 112 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was working in the facility seven days a week, for 8 consecutive hours. This failure has the potential to affect all 112 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food is stored, prepared and held in a manner which prevents potential contamination and potential food-borne illness. This has the potential to affect all 112 residents living in the facility.

Inspectors wroteBased on interview and record review the facility failed to identify the causative organism for infections to track and trend current infections and to prevent further infections in the facility. This has the potential to affect all 112 residents living in the facility. Findings Include: 1. The facility's Infection Surveillance Monthly Report for the month of December 2023 documents R20 had a urinary tract infection (UTI) and altered mental status and he was on Macrobid 100mg. (R20) was seen and treated in the ER (Emergency Room) called lab about UA (urinalysis) culture results had been disregarded. Lab tech (technician) stated increased WBC (white blood cells) usually treat as such. The facility's Infection Surveillance Monthly Report for December did not document the organism causing R20's UTI. 2. [...]

Inspectors wroteBased on interview and record review the Facility failed to ensure the Facility had an Infection Preventionist working in the building at least part time. This has the potential to affect all 112 residents living in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide proof of continuing education of nursing assistants. This has the potential to affect all 112 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure behavioral health training for all employees. This has the potential to affect all 112 residents living in the facility.

Inspectors wroteBased on interview and record review the Facility failed to ensure there was sufficient qualified nursing staff available at all times to ensure timely medication administration for five of five residents (R27, R61, R63, R64, R102) reviewed for sufficient staffing in the sample of 59.

Inspectors wroteBased on interview and record review, the facility failed to administer medications and perform blood glucose monitoring as ordered by the physician for 5 of 5 residents (R27, R61, R63, R64 and R102) reviewed for Pharmacy Services in the sample of 59.

Inspectors wroteBased on interview and record review the facility failed to ensure the residents were given the correct antibiotics for the organism causing infection for 4 of 4 residents (R20, R58, R67, R78) reviewed for antibiotic stewardship in the sample of 59. Findings Include: 1. R20's Physician Order Sheet (POS) dated 12/24/23 documents R20 received Macrobid 100 milligrams (mg) twice daily (BID) for Urinary Tract Infection (UTI) until 12/30/23. The facility's Infection Surveillance Monthly Report for December 2023 did not document the organism causing R20's UTI (Urinary Tract Infection). R20's medical record was reviewed and there was no culture and sensitivity (C&S: a lab test to attempt to grow bacteria, viruses, or fungi and then test which medications will effectively work to stop the infection) conducted to ensure that R20 was receiving the appropriate antibiotic to treat R20's UTI. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat a pressure ulcer per physician's order for 1 of 3 residents(R14) reviewed for pressure ulcers in the sample of 59.

Inspectors wroteBased on interview and record review, the facility failed to locate and or replace missing clothing for 5 of 5 residents (R13, R64, R70, R100, R103) reviewed for loss of property in the sample of 59 Findings Include: 1. R13's Minimum Data Set (MDS), dated [DATE], documented that R13 was moderately cognitively impaired. On 8/9/24 at 9:00 AM, R13 stated, I'm missing all my underwear. R13's Grievance form, dated 3/28/24, documented, (R13) was losing her clothes down to her last three underwear. Moving forward making sure all clothes are properly labeled and legible. On 4/11/24 at 3:00 PM, V28, Housekeeping Supervisor, stated, We go and talk to them and asked them what is the item that is missing. The Psych Social will do a grievance and I basically follow up I let them know (psych social) if I can't find them (the clothes) in one week. We ask them to reimburse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure progressive fall interventions were in place for 1 of 3 residents (R3) reviewed for falls in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to provide antibiotics as prescribed by a physician for the treatment of urinary tract infections in 1 of 3 residents (R5) reviewed for infection in the sample of 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician prescribed diet and nutritional supplement orders in 1 of 3 residents (R4) reviewed for nutrition in the sample of 5.

Inspectors wroteBased on interview and record review the Facility failed to monitor/assess and treat a wound and monitor the resident's overall condition related to wound infection for 1 of 3 residents (R4) reviewed for wounds in the sample of 9. This failure resulted in R4 developing a swollen leg on [DATE] with V22, Physician/Medical Director, prescribing an antibiotic on [DATE] which was not given for 5 days. There was no documented monitoring of R4's leg until [DATE] at which time, R4 had an infected necrotic left leg wound measuring 20 centimeters (cm) by (x) 12 cm x .6 cm and a necrotic left foot wound measuring 10 cm x 8 cm x diameter 0.9 cm requiring surgical debridement by V31, Wound Physician. Subsequently, there was no monitoring of R4's medical condition while receiving antibiotics for his wound infection including vital signs from 10/2 through [DATE]. [...]

Inspectors wroteBased on interviews, and record reviews the facility failed notify the physician of changes related wound infections including failure to give medications and treatments as ordered for 1 of 3 residents (R4) reviewed for notification in the sample of 13. This failure resulted on [DATE], R4 was sent to the hospital and admitted with sepsis and expired on [DATE] from septic shock and bacteremia.

Inspectors wroteBased on interview and record review the facility neglected to ensure residents were receiving timely assessment, monitoring, and treatment to address wounds and wound infections for one of three residents (R4) reviewed for neglect in the sample of 13. This failure resulted in R4 not receiving an antibiotic as ordered on [DATE] which delayed treatment of an infection, not receiving ordered wound treatments, not having timely assessments, and monitoring of his left leg which resulted in the development of two large infected necrotic wounds, and not monitoring the overall condition of R4 during his treatment of the infection. On [DATE], R4 was sent to the hospital and admitted with sepsis and expired on [DATE] from septic shock and bacteremia.

Inspectors wroteBased on interview and record review the Facility failed to ensure Care Plans were revised to address residents' current needs for 1 of 6 residents (R4) reviewed for revision of Care Plans in the sample of 13.

Inspectors wroteBased on interview, and record review the facility failed to ensure abuse did not occur for 1 of 3 residents (R2) reviewed for abuse in the sample of 6.

Inspectors wrote2. R34's Face Sheet, undated, documents that R34 has diagnoses of difficulty in walking, other abnormalities of gait and mobility, muscle weakness, lack of coordination, syncope, and collapse. R34's Physician Order (PO) dated 04/04/22 documents other abnormalities of gait and mobility. R34's PO dated 07/28/21 documents other lack of coordination. R34's PO dated 07/28/21 documents muscle weakness (generalized). R34's Fall Risk Evaluation dated 12/14/22 documents a score of 17.0. R34's Care Plan dated 12/21/22 documents (R34) is at high risk for falls related to use of psychotropic medication, some visual loss and DX (diagnosis): Seizure Disorder and Syncope. 12/14/2022 - fall while going to restroom. R34's Care Plan Interventions document the following: 11/29/22 Education done with (R34) on taking his time while he is up walking. [...]

Inspectors wroteBased on interview and record review the Facility failed to ensure they had sufficient staff for supervision of residents. This has the potential to affect all 123 residents living in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food is stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 123 residents living in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide a comfortable environment for 4 of 4 residents (R2, R26, R99, R125) reviewed for safe, comfortable environment in the sample of 75.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of abuse, theft, misappropriation for 3 of 9 residents, (R45, R56 and R125), reviewed for abuse in the sample of 75.

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly review assessment in 1 of 1 resident (R93) reviewed for assessments in the sample of 75. Findings Include: R93's Minimum Data Set, (MDS), documents R93 has not had a quarterly review assessment completed since 10/22/2022. On 3/14/23 at 8:30 AM, V47, Licensed Practical Nurse/MDS, confirmed R93 has not had an MDS assessment since 10/22/2022. V45 stated, she would get one opened up on R93 today. The MDS policy, dated 6/2015, documents an MDS is completed on each new admission, quarterly, annually, upon discharge and with a significant change of condition.

Inspectors wroteBased on interview, observation, and record review the facility failed to update and revise care plans for 1 of 1 (R34) resident reviewed in a sample of 75.

Inspectors wroteBased on interview, observation, and record review, the facility failed to assess and monitor a rash for 1 of 5 residents (R101) reviewed for skin conditions in the sample of 75.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide supplements as ordered, to prevent and/or treat weight loss is 1 of 3, residents (R113) reviewed for nutrition in the sample of 75.