Palm Garden of Mattoon

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right to be free from misappropriation of property for one resident (R1) of three residents reviewed for misappropriation of property/abuse in the sample list of four residents.

Inspectors wroteBased on interview and record review the facility failed to protect and promote the residents' rights and ensure dignity was maintained for six residents (R1, R3, R4, R9, R10, R11) out of six residents reviewed for dignity in a sample list of 25 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a clean, homelike environment for five (R2, R16, R23, R24, R25) residents and failed to maintain clean resident community areas out of five residents reviewed for physical environment in a sample list of 25 residents.

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by another resident (R2) for two residents (R1, R19) out of seven residents reviewed for abuse in a sample list of 25 residents.

Inspectors wroteBased on interview and record review the facility failed to immediately report verbal abuse to the Abuse Coordinator for one (R19) resident by another resident (R2) out of seven residents reviewed for abuse in a sample list of 25 residents.

Inspectors wroteBased on interview and record review the facility failed to accurately document behaviors for three (R1, R2, R6) residents out of three residents reviewed for behavioral health in a sample list of 25 residents.

Inspectors wroteBased on interview and record review the facility failed to protect one (R6) resident's right to be free from verbal and physical abuse from another (R7) resident with R9-R13 witnessing this incident. The facility failed to protect one resident (R5) from verbal abuse by another resident (R8). These failures affect nine residents (R5, R6, R7, R8, R9, R10, R11, R12, R13) out of nine residents reviewed for abuse in a sample list of 33 residents.

Inspectors wroteBased on observation, interview and record review the facility repeatedly failed to ensure medications and narcotics were locked and stored properly for 16 (R5, R8, R14, R19-R31) residents out of 16 residents reviewed for medication storage in a sample list of 33 residents.

Inspectors wroteBased on interview and record review the facility failed to treat a resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one resident (R8) out of three residents reviewed for dignity in a sample list of 33 residents.

Inspectors wroteBased on interview and record review the facility repeatedly failed to administer two medications to one (R2) resident causing significant medication errors out of eight residents reviewed for medication administration in a sample list of 33 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during medication administration for three (R15, R16, R17) residents out of seven residents reviewed for Infection Control in a sample list of 33 residents.

Inspectors wroteBased on interview and record review the facility failed to protect resident's right to be free from resident-to-resident verbal abuse. This failure affected one of six residents (R1) reviewed for abuse on the sample list of six. Findings Include:The facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program Policy, dated April 2021, documents that each resident has the right to be free from abuse, including but not limited to verbal abuse. R2's Medical Diagnoses list, dated April 2026, documents that R2 is diagnosed with Major Depressive Disorder and Generalized Anxiety. R2's Minimum Data Set (MDS), dated [DATE], documents that R4 is cognitively intact, has bilateral lower extremity impairment, and uses an electric wheelchair for mobility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision and ensure a door alarm was audible to staff to prevent a cognitively impaired resident with exit seeking behaviors from eloping from the facility for one of four residents (R4) reviewed for elopement in the sample list of 40 residents. R4 was found eight blocks from the facility by a citizen who called emergency services when they saw R4 wandering in the road. These failures resulted in R4 falling and suffering abrasions to R4's palm and knee and R4 being exposed to significant danger including road hazards, uneven terrain and railroad tracks.

Inspectors wroteBased on interview and record review the facility failed to initiate an elopement care plan for three (R37, R39, R40) residents out of four residents reviewed for elopement in a sample list of 40 residents.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's right to be free from staff to resident physical and emotional abuse which caused skin tears to the resident's arm and severe emotional distress. This failure affected one of three residents (R93) reviewed for abuse on the sample list of 39. Findings Include: The facility's Abuse Prevention Program dated February 2021 documents that the facility affirms residents' rights to be free from abuse. This includes freedom from physical restraint, mistreatment, or abuse of any resident. Abuse is defined as the willful infliction of injury, intimidation, or punishment resulting in harm, pain, or mental anguish. Willful means the individual acted deliberately; it does not require intent to inflict injury or harm. [...]

Inspectors wroteBased on interview and record review the facility failed to implement pressure relieving measures timely, failed to complete a thorough skin assessment weekly and failed to prevent one (R107) resident's right heel pressure ulcer from worsening to a stage IV out of three residents reviewed for pressure ulcers in a sample list of 39 residents. R107 obtained a Stage IV pressure ulcer to her right heel at the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement fall prevention interventions and failed to maintain a safe environment for two residents (R7 and R107) out of six residents reviewed for falls in a sample of 39 residents. R107 experienced pain and fear as a result of falling, as well as a closed head injury and multiple contusions following a fall on 1/1/25. R107 required further evaluation of her injuries in an emergency room following falls on 1/1/25 and 1/8/25 due to having a physician order for Xarelto (anticoagulant therapy).

Inspectors wroteBased on interview and record review the facility failed to provide a sufficient number of Licensed Nurses and Certified Nursing Assistants staff to meet the residents' needs for safety and quality of care. This failure has the potential to affect all 94 residents residing in the facility. Findings Include: The Facility assessment dated [DATE] documents an average daily census of 80-85 residents. The facility's goal is to maintain sufficient staffing to ensure an adequate number of qualified staff are available to meet each resident's needs. The Daily Nursing Schedule for 1/24/26 and 1/25/26 documents that on the night shift of 1/24/26 there was one nurse and one Certified Nursing Assistant (CNA) assigned to the front half of the building. On the day shift of 1/25/26, there was only one nurse in the building until 11:00 AM, when a second nurse arrived. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to employ a full time Certified Dietary Manager (CDM). This failure has the potential to affect all 94 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain sanitary conditions during food preparation by dietary staff not wearing gloves and improperly applied hairnet during meal service. This failure has the potential to affect all 94 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a clean, homelike environment for four (R2, R52, R56, R77) out of five reviewed for physical environment in a sample list of 39 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to protect resident dignity by leaving a urinary collection device uncovered in public view. This failure affects one resident (R88) out of five reviewed for urinary catheters on the sample list of 39.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident (R81) from misappropriation of personal property by another resident (R74). This failure affects two residents (R74 and R81) out of six reviewed for misappropriation on the sample list of 39.

Inspectors wroteBased on interview and record review, the facility failed to report all allegations of misappropriation of resident's personal property to the state surveying agency. This failure affects two residents (R74 and R81) out of six reviewed for misappropriation on the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to allow one (R11) resident the opportunity to choose a destination facility in his involuntary discharge process out of three residents reviewed for discharges in a sample list of 39 residents.

Inspectors wroteBased on interview and record review the facility failed to complete an accurate Minimum Data Set (MDS) assessment for three of four residents (R7, R10, R93) reviewed for Resident Assessments on the sample list of 39. Findings Include: 1. R7's MDS dated [DATE], Section N documents R7 receives insulin. R7's Physician Order Sheet (POS) dated December 2025 does not include insulin. 2. R10's MDS dated [DATE], Section N documents R10 receives insulin. R10's Physician Order Sheet (POS) dated December 2025 does not include insulin. 3. R93's MDS dated [DATE], Section N documents R93 receives insulin. R93's Physician Order Sheet (POS) dated December 2025 does not include insulin. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain or renew short-term Pre-admission Screening and Record Review (PASRR) prior to the expiration date (R9 and R81), and failed to obtain a revised PASRR for a resident diagnosed with severe mental illnesses whose PASRR did not include mental health diagnoses (R31). This failure affects three residents (R9, R31, and R81) out of nine reviewed for Pre-admission Screening on the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services to maintain or increase a resident's range of motion. This failure affected one of three residents (R10) reviewed for Range of Motion on the sample list of 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one resident's (R88) respiratory mask from potential cross-contamination, and failed to obtain appropriate physician orders for two residents (R9 and R10) to include required pressures for operation. This failure affects three residents (R9, R10, and R88) out of three reviewed for respiratory equipment on the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain informed consent for use of bilateral bed rails. The facility also failed to safely and securely install bed rails and failed to maintain safe and secure bed rails for one of six residents (R7) reviewed for accident hazards on the sample list of 39. Findings Include: The facility's Bed Safety and Bed Rails policy dated August 2022 documents that bed rails must be properly installed. To use bed rails, the facility must obtain informed consent. R7's Medical Diagnoses List dated January 2026 documents R7 is diagnosed with Chronic Obstructive Pulmonary Disease, Fractured Left Tibia, Disorder of Muscles, Lack of Coordination, Gait Abnormalities, Muscle Wasting, Phantom Limb Syndrome, and Right Above-the-Knee Amputation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide needed behavioral health services for community re-integration. This failure affects one resident (R74) out of one reviewed for behavioral health services on the sample list of 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a qualified Psychiatric Rehabilitation Services Director (PRSD). This failure affects one resident (R74) out of one reviewed for behavioral health services on the sample list of 39.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate portion sizes and failed to provide food that is palatable for three (R11, R81, R93) out of three residents reviewed for dining services in a sample list of 39 residents.

Inspectors wroteBased on interview and record review the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a per day. This failure has the potential to affect all 98 residents in the facility. Findings Include: Facility Nursing Staff Daily Assignment Sheets reviewed from 11/1/25 through 11/28/25 documented seven days (11/1, 11/2, 11/8, 11/9, 11/15, 11/22, 11/23) that the facility failed to use the services of a Registered Nurse for at least eight consecutive hours. On 11/28/25 at 2:34 PM V2 (Director of Nurses) confirmed the facility did not have eight hours of Registered Nurse coverage every day, especially on the weekends when administration staff aren't at the facility to cover. V2 also confirmed the facility's current census was 98 residents. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide food that accommodates resident preferences and failed to provide appealing options to residents who choose not to eat food that is initially served. These failures have the potential to affect all 98 residents residing in the facility. Findings Include: R2's Medical Diagnoses List dated November 2025 documents R2 is diagnosed with Chronic Obstructive Pulmonary Disease, Lymphedema, Cellulitis, Congestive Heart Failure, Chronic Ulcers of the Feet, Bipolar Disorder, and Depression. R2's Minimum Diagnoses Sheet dated 10/6/25 documents R2 is cognitively intact. R2's Physician Order Sheet documents R2 is prescribed a no added salt, regular diet. R2's undated Dietary Card documents R2 dislikes fish, chicken, beets, or squash. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the nursing staff consistently completed and signed controlled substance count sheets at the end of each shift. This failure has the potential to affect two of four residents (R1, R2) reviewed for controlled substance count sheets in the sample of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement interventions to address behaviors to prevent a reoccurring injury following a fall that resulted in a partial finger amputation (R1). The facility also failed to supervise, implement fall interventions, and thoroughly investigate a fall (R3) for two of four residents (R1, R3) reviewed for falls in the sample list of four. This failure resulted in R3 experiencing an unwitnessed fall and coccyx fracture.

Inspectors wroteBased on observation, interview, and record review the facility failed to update a care plan to accurately include transfer/walking status and assistive devices for one of four residents (R2) reviewed for falls in the sample list of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for oxygen therapy (R4), failed to administer oxygen according to physician orders (R11), and failed to change oxygen humidifier bottles and tubing according to physician orders (R4 and R11). These failures affect two residents (R4 and R11) out of five reviewed for specialized services on a sample of eleven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately record provided services by documenting incomplete treatments as completed. This failure affects two residents (R4 and R11) out of five reviewed for specialty services and treatments on the sample list of eleven.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dignity was provided during incontinence care and mealtime for five of five residents (R3, R4, R5, R6, R7) reviewed for dignity in a sample list of seven residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely and complete incontinence care for one (R3) dependent resident out of three residents reviewed for incontinence care in a sample list of seven residents.

Inspectors wroteBased on interview and record review the facility failed to notify one (R1) residents court appointed Guardian of changes in medications and laboratory orders out of three residents reviewed for notifications in a sample list of four residents. Findings Include:R1's Electronic Medical Record (EMR) documents R1's primary diagnosis is the medical management of Paranoid Schizophrenia. Other medical diagnoses include Thyrotoxicosis, Noncompliance with medication regimen, Cannabis abuse with Psychotic Disorder with Hallucinations, Major Depressive Disorder, Anxiety and Insomnia. R1's Letters of Office-Guardianship filed 11/18/2024 documents R1 as a 'Disabled Adult' and that V4 has been appointed R1's Court Appointed Guardian. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to administer one (R1) resident's psychotropic medication per physician order causing R1 to miss ten doses. This failure affected one (R1) out of three residents reviewed in a sample list of four residents. Findings Include:R1's Electronic Medical Record (EMR) documents R1's primary diagnosis is the medical management of Paranoid Schizophrenia. Other medical diagnoses include Thyrotoxicosis, Noncompliance with medication regimen, Cannabis abuse with Psychotic Disorder with Hallucinations, Major Depressive Disorder, Anxiety and Insomnia. R1's Physician Order Set (POS) dated August 2025 documents a physician order starting 4/7/25 for Ativan 0.5 milligrams (mg) twice daily for Anxiety. R1's Pharmacy packing slip dated 6/8/25 documents 30 tablets of Ativan 0.5 milligrams (mg) were delivered to the facility on 6/8/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean, homelike environment in four of the facility's community shower rooms for two residents (R1, R2) out of three residents reviewed for physical environment in a sample list of three residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect one (R4) resident's right to be free from verbal and mental abuse and being physically threatened by another resident (R5) which was witnessed by a resident (R6) out of nine residents reviewed for abuse in a sample list of 12 residents. R4 was made to cry, feel sad and scared causing her to be fearful of being physically abused.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect one (R4) resident from being repeatedly verbally and mentally abused by another resident (R5) throughout an entire day while the staff were aware of R4 being abused. Two residents (R4, R5) were affected by this failure out of nine residents reviewed for abuse in a sample list of 12 residents. R4 felt scared causing her to change her activity routine in fear of being further abused by R5.

Inspectors wroteBased on interview and record review the facility failed to report allegations of verbal and/or mental abuse to the Abuse Coordinator timely on three separate occasions involving R5 verbally and mentally abusing R4 on 4/22/25, R8 verbally abusing R7 on 4/6/25 and R9 verbally abusing R10 on 4/7/25. These failures affect six residents out of nine residents reviewed for abuse in a sample list of 12 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate Certified Nursing Assistant (CNA) staffing for eight out of 14 days reviewed for staffing. This failure has the potential to affect all 83 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a medication error rate under five percent for one (R3) resident out of four residents reviewed for medications in a sample list of seven residents. A medication administration pass was completed with three errors out of 28 opportunities resulting in a 10.7% medication error rate.

Inspectors wroteBased on observation, interview, and record review the facility failed to timely report decreased urination and abdominal distention (R1). The facility also failed to perform hand hygiene after toileting assistance (R5) for two (R1, R5) of four residents reviewed for urinary tract infections (UTIs) in the sample list of six. This failure resulted in R1 being hospitalized for a UTI, urinary retention, and acute kidney injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there is a sufficient number of certified nursing assistants to provide care and respond to resident's basic individual needs. This failure has the potential to affect all 82 residents currently residing at facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure there is a full time Director of Nursing (this was corrected during the survey). Facility also failed to ensure a Registered Nurse (RN) is providing services to residents at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 82 residents currently residing at facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and resident's representative of the transfer or discharge, including the reason, in writing to 4 (R1, R2, R4, and R5) residents out 4 reviewed for hospitalization in a sample size of 6.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and resident's representative at the time of transfer to hospital in writing of the bed-hold policy to 3 (R1, R2, and R4) residents out 3 reviewed for hospitalization in a sample size of 6.

Inspectors wroteBased on interview and record review the facility failed to provide a safe transfer and thoroughly investigate a fall to identify root cause for one (R1) of three residents reviewed for falls in the sample list of six.

Inspectors wroteBased on interview and record review the facility failed to ensure appropriate prescribing of antibiotics for one (R4) of four residents reviewed for urinary tract infections (UTIs) in the sample list of six.

Inspectors wroteBased on interview and record review the facility failed to ensure that a current copy of one (R3) resident's advance directive of three reviewed was accessible and in the resident's medical record during a medical emergency resulting in the facility staff delaying cardiopulmonary resuscitation.

Inspectors wroteBased on interview and record review the facility failed to ensure that all nursing personnel were certified in cardiopulmonary resuscitation. This failure has the potential to affect all 86 residents who currently reside in the facility.

Inspectors wroteFailures at this level require more than one Deficient Practice Statement. A. Based on observation, interview, and record review the facility failed to supervise a resident after providing the resident with a hot pureed food. This failure affects one (R31) of six residents reviewed for accidents in the sample of 33. This failure resulted in R31 spilling hot liquid on R31's lap sustaining redness and 3 blistered areas to R31's bilateral lower extremities requiring subsequent treatment which is ongoing. B. Based on observation, interview, and record review the facility failed to remove a tripping hazard to prevent a fall and failed to implement fall interventions and complete a root cause analysis for two residents (R133, R20) of six residents reviewed for accidents in the sample of 33. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a full time Director of Nurses (DON). This failure has the potential to affect all 83 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to report injuries of unknown origin to the State Agency for one (R22) out of one resident reviewed for abuse in a sample list of 33 residents.

Inspectors wroteBased on interview and record review the facility failed to obtain a level II PASARR (Preadmission Screening and Record Review) for one resident (R31) of four residents reviewed for PASARR screenings identified as not having a diagnosis of serious mental Illness by the Level I PASARR but later was diagnosed with a serious mental illness in a sample of 33. Findings Include: R31's Care Plan dated 12/17/24 includes the following diagnoses: Psychotic Disorder, Cerebral Infarction with Dominant Right sided Hemiparesis/Hemiplegia, Anxiety, Major Depression, Dysphagia, Muscle Weakness, and Reduced Mobility. R31's Level I PASARR obtained prior to R31's admission on [DATE] documents no under the category History of Severe Mental Illness. However, the diagnoses Psychotic Disorder with Hallucinations was added to R31's diagnoses list on 7/24/21. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain a level II PASARR (Preadmission Screening and Record Review) for one resident (R3) of four residents reviewed for PASARR screenings identified as having a diagnosis of serious mental Illness by the Level I PASARR in a sample of 33. Findings Include: R3's Care Plan reviewed 11/13/24 include the following diagnoses: Schizophrenia, History of Traumatic Brain Injury, and Major Depression. R3's Level I PASARR obtained prior to R3's admission on [DATE] documents yes under the category History of Severe Mental Illness. The facility did not provide documentation a Level II PASARR was obtained. On 1/24/25 at 10:00 AM V14 (Admissions and Marketing Coordinator) stated We do not have a Level II PASARR for (R3). I have arranged to have one completed as soon as the screener is available. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent cross contamination during wound treatment and failed to assess, monitor, obtain treatment orders and implement care plan interventions for pressure sores for one (R75) of three residents reviewed for pressure sore in a sample list of 33 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent cross contamination during incontinence care. The facility also failed to maintain a urinary catheter drainage bag off the floor and in a dignity bag for two of three residents (R54, R1) residents reviewed for incontinence care and urinary catheters in a sample list of 33 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to identify/track resident specific targeted behaviors and failed to initiate resident centered interventions for one resident (R31) of five residents reviewed for Psychotropic medications in a sample list of 33. Findings Include: R31's Care Plan dated 12/17/24 includes the following diagnoses: Psychotic Disorder, Cerebral Infarction with Dominant Right sided Hemiparesis/Hemiplegia, Anxiety, Major Depression. Dysphagia, Muscle Weakness, Reduced Mobility. R31's Medication Administration Record for January 1, 2025 thru January 31, 2025 includes the following current physician's orders for psychotropic medications: 1. Lorazepam (antianxiety) Oral Concentrate 2 MG/ML Give 0.25 ml by mouth every 4 hours as needed for anxiety. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to adequately supervise a resident with a history of falls and complete a thorough fall investigation for one of three residents (R3) reviewed for falls on the sample list of 14. Failing to supervise R3 resulted in R3 falling and suffering fractures.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a full-time Director of Nurses (DON) and failed to have Registered Nurse (RN) coverage eight consecutive hours per day seven days a week for four of 14 days in a two week period. These failures have the potential to affect all 86 residents in the facility. Findings Include: Upon survey entrance and throughout the survey (12/27/24- 01/02/25) there was no Director of Nurses working in the facility. On 12/27/24 at 1:10 PM V2 (Registered Nurse) stated the facility has not employed a full time Director of Nurse for months. On 12/27/24 at 3:20 PM V1 (Administrator) confirmed the facility has not employed a Director of Nursing for several months. On 01/02/25 at 11:40 am V24 (Nurse Scheduler/ Human Resources) confirmed the schedule for the past two weeks. V24 stated the following: (V2 RN) does not work the floor. [...]

Inspectors wroteBased on record review and interview the facility failed to protect a resident's right to be free from physical abuse by another resident. This failure affects one of four residents (R2) reviewed for abuse on the sample list of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a dependent resident assistance with dressing and hygiene needs. This failure affects one of three residents (R4) reviewed for assistance with activities of daily living on the sample list of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete skin assessments after skin impairment was identified (12/09/24), failed to measure new skin impairment, failed to obtain wound treatment orders in a timely manner, and failed to obtain a physician order prior to applying medication to a resident's skin impairment. These failures affect one of four (R4) residents reviewed for skin impairment/treatments on the sample list of 14.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a skin assessment with measurements and accurate description, obtain a pressure ulcer treatment order in a timely manner, and obtain a physician order before applying medication to a pressure ulcer. These failures affect one of four residents (R4) reviewed for skin impairment/treatments on the sample list of 14.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely incontinence care for one of three residents (R4) reviewed for incontinence care on the sample list of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure qualified licensed staff apply Nystatin (medication antifungal powder) for one of four residents (R4) reviewed for skin impairment/treatments on the sample list of 14.

Inspectors wroteBased on interview and record review the facility failed to maintain complete and accurate medical records for a resident that was out of the facility at a doctor's appointment. This failure affects one of eight residents (R4) reviewed for complete/accurate medical records on the sample list of 14.

Inspectors wroteBased on interview and record review the facility failed to follow its grievance policy by failing to complete a grievance form for one (R2) of five residents reviewed for abuse in the sample list of five.

Inspectors wroteBased on interview and record review the facility failed to timely report an allegation of physical abuse to the state survey agency for one (R1) of five residents reviewed for abuse in the sample list of five.

Inspectors wroteBased on interview and record review the facility failed to sufficiently staff Certified Nursing Assistants during the night shift in order to provide services to meet the residents' needs in a manner that promotes each resident's rights and well-being. This failure affects four residents (R1, R2, R3, R4) of four reviewed for staffing in the sample list of four and has the potential to affect all 79 residents residing in the facility. Findings Include: The Facility Assessment Tool dated 8/2/24 documents the facility has an average daily census of 80-85 residents. The same tool documents on average the facility have around 35 residents who require one to two staff to assist them with toileting and around 16 residents that are completely dependent on staff for toileting. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct pressure ulcer risk assessments according to the facility policy and failed to complete physician ordered weekly skin checks. This failure affects two residents (R1 and R3) out of three reviewed for pressure ulcers on a sample of three.

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

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from restraint and the least restrictive fall intervention was implemented. This failure affects one (R3) of three residents reviewed for restraints.

Inspectors wroteBased on observation, interview, and record review the facility failed to investigate injuries of unknown origin for one (R1) of three residents reviewed for injuries of unknown origin from a total sample list of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide targeted interventions to prevent falls that resulted in injury in one (R2) of three residents reviewed for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 88 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary food storage and service areas. These failures have the potential to affect all 88 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to follow its Legionella Policy and Procedure by failing to have the water system inspected annually and failed to have the boiler and thermostatic mixing valves serviced. This failure has the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the dignity of five residents (R1, R11, R27, R37, R64) out of five residents reviewed for dignity in a sample list of 41 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote the right to a safe, clean, comfortable homelike environment for 30 (R59, R37, R45, R51, R11, R43, R80, R73, R19, R1, R30, R56, R62, R28, R32, R61, R27, R10, R82, R77, R78, R79, R47, R24, R83, R75, R89, R87, R64, R66) of 88 residents reviewed for environment on the sample list of 41.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by a staff member for four residents (R75, R78, R79, R89) out of five residents reviewed for abuse in a sample list of 41 residents.

Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown origin for one (R27) resident and failed to report an allegation of verbal abuse by a staff member for four residents (R75, R78, R79, R89). These failures affect five residents out of five residents reviewed for abuse in a sample list of 41 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a Continuous Positive Airway Pressure (C-PAP) was applied, ensure the C-PAP mask fit, and ensure respiratory equipment was dated, changed, clean, and kept off the floor to prevent contamination for four (R59, R10, R73, and R62) of four residents reviewed for respiratory on the sample list of 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide skilled rehabilitation services to residents with physician orders to receive such services. This failure affects five residents (R15, R31, R34, R39, and R90) out of six residents reviewed for therapy services on the sample list of 41.

Inspectors wroteBased on observation and interview the facility failed to ensure that bathroom call light cords were attached to the call light pull station and were able to be reached from the floor for six (R62, R43, R30, R55, R59, and R56) of 24 residents reviewed for call lights on the sample list of 41.

Inspectors wroteBased on interview and record review, the facility failed ensure resident rights were maintained by failing to include a resident's family representative in R83's care plan conference. This failure affected one of one resident (R83) reviewed for care plan attendance/resident rights on the sample list of 41.

Inspectors wroteBased on record review and interview, the facility failed to document ongoing generally accepted accounting principles to account for residents' personal funds, failed to provide a quarterly financial report to a resident (R62) and a resident (R83) family representative. These failures affected two of two residents (R62 and R83) reviewed for resident funds on the sample list of 41.

Inspectors wroteBased on interview and record review, the facility failed to complete Minimum Data Sets (MDS) Resident Assessment Instrument (RAI) in the required time frame, failed to complete Care Area Assessments (CAAs) in the required time frame, and failed to complete care planning processes in the required time frame. This failure affects three residents (R12, R19, and R80) out of three reviewed for MDS completion on the sample list of 41.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination and follow wound treatment order during pressure ulcer wound care for one (R64) out of two residents reviewed for pressure ulcers in a sample list of 41 residents.

Inspectors wroteBased on interview and record review the facility failed to implement fall interventions for one (R64) resident resulting in a fall with injury out of eight residents reviewed for Accidents in a sample list of 41 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure catheter collection bags and tubing were positioned up off the floor to prevent contamination for three (R1, R37, and R31) of four residents reviewed for catheters on the sample list of 41.

Inspectors wroteBased on interview and record review, the facility failed to implement recommendations made by the Registered Pharmacist. This failure affects one resident (R87) out of five reviewed for unnecessary medications on the sample list of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow pharmacy instruction for the administration of medication, in accordance with facility policy and pharmacy protocol, for 2 of 8 residents (R75 and R78) reviewed during medication observation. The facility had 2 medication errors out of 25 opportunities resulting in an 8 percent medication error rate.

Inspectors wroteBased on observation, interview and record review the facility failed to label a resident's eye drop bottle with the resident's name, and the date the bottle was opened. This failure affected one of eight residents (R78) reviewed during medication administration on the sample list of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a bed rail was affixed firmly to the bed frame for two of two (R1, R62) residents reviewed for bed rails on the sample list of 41.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all residents have access to the State survey results. This failure has the potential to affect all 88 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to post nursing staffing for all residents to see. This failures has the potential to affect all 88 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's (R2, R3) rights to be free from physical abuse by another resident (R1). This failure affects three (R1, R2 and R3) of three residents reviewed for abuse in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to implement their Abuse Prohibition Policy by not thoroughly investigation allegations of resident abuse. This failure affects two (R1, R3) of three residents reviewed for abuse allegations in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse between two residents (R1, R3) in an appropriate time frame. R1 and R3 are two of three residents reviewed for abuse in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse for 8 consecutive hours, 7 days per week. This failure has the potential to affect all 92 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike, clean, and comfortable environment related to sewage backflow issues rendering showers and toilets inoperable, interruptions in hot water supply, and intermittent inadequate heating. This failure affects 15 residents (R1, R2, R10, R11, and R17 through R27) out of 15 reviewed for physical plant problems on the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication cart in a locked or supervised condition, allowing potential access to an independently mobile cognitively impaired resident in the direct vicinity to the medication cart on the covid-19 isolation unit. This failure affects one resident (R20) out of three reviewed for mobility and cognitive status residing on the covid isolation unit, on the total sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent the misappropriation of resident smoking materials/funds. This failure affects nine of twelve residents (R6, R8, R9, R10, R11, R12, R14, R15 and R16) reviewed for smoking on the sample list of 18.

Inspectors wroteBased on interview and record review the facility failed to follow their abuse policy to report allegations of misappropriation of resident smoking materials/funds to resident families for nine of twelve residents (R6, R8, R9, R10, R11, R12, R14, R15 and R16) reviewed for misappropriation on the sample list of 18 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain a consent for bedrails, failed to assess the use of physical restraints timely, failed to include physical restraints on the care plan and failed to provide medical reasoning for physical restraints for one (R3) resident out of three residents reviewed for accidents in a sample list of three residents.

Inspectors wroteBased on interview and record review, the facility failed to report and notify the Abuse Coordinator/Administrator of alleged abuse for one resident (R1) of three residents reviewed for abuse in the sample of nine.