Pekin Manor

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions to prevent pressure ulcer development, conduct a pressure ulcer risk assessment once a week for four weeks after admission and then quarterly thereafter, update pressure ulcer care plans with pressure relieving interventions, and failed to provide a treatment as ordered by the physician for three of three residents (R1, R2, and R3) reviewed for facility acquired pressure ulcers in the sample of four. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement enhanced barrier precautions and contact precautions during wound and incontinence cares for four of four residents (R1-R4) reviewed for infection control practices in the sample of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to answer a call light timely to provide timely incontinence cares and dressing, failed to maintain a resident's dignity for one of four residents (R4) reviewed for resident rights in the sample of four.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure the floor was free and clear of trip hazards for one of three residents (R1) reviewed for falls with injury in a sample of four. On 01/05/25, R1 fell at the facility after a cord on the floor of the walkway entering her room became trapped in the wheel of her walker. R1 sustained a laceration to her forehead requiring placement of nine sutures, a skin tear and bruising to her right third finger, and fractures to C1 (first cervical vertebrae) and C2 (second cervical vertebrae), requiring R1 to wear a hard cervical collar at all times.

Inspectors wroteBased on observation, interview, and record review, the facility failed to cover a urinary catheter bag with a privacy bag for one of 24 residents (R18) reviewed for dignity in the sample of 33

Inspectors wroteBased on interview and record review, the facility failed to notify the facility Ombudsman of Facility Discharges/Transfers, monthly, for two residents (R26 and R67) of 7 reviewed for discharges in the sample of 33.

Inspectors wroteBased on interview and record review the facility failed to develop a Person Centered Care Plan for one resident (R67) out of 24 reviewed for Care Plans in a sample of 33. Findings Include: The Care Plan Policy, dated 6/1/22, documents, It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meter resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 6. The comprehensive care plan will be developed within 7 (seven) days after the completion of the comprehensive MDS (Minimum Data Set) assessment as outlined in the RAI (Resident Assessment Instrument) manual guidelines. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to change an oxygen tubing/humidifier bottle for one resident (R2) of two residents reviewed for oxygen therapy in the sample of 33. Findings Include: The Oxygen Therapy policy, dated 3/16/17, documents, To provide a source of oxygen to persons experiencing an insufficient supply of same. Procedure: 7. Oxygen set-up (cannula/mask, tubing) must be exchanged every 7 (seven) days. R2's current Medical Record documents R2 was admitted to the facility on [DATE], with diagnoses which included Acute Respiratory Failure with Hypoxia (Primary), Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure with Hypercapnia, and Shortness of Breath. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document a diagnosis and monitor for specific adverse behaviors to warrant the use of an antipsychotic medications for one of five residents (R249) reviewed for unnecessary medications in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent misappropriation of property for 1 resident (R1) of 3 residents reviewed for misappropriation of property in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care to 1 resident (R1) of 3 residents reviewed for nail care in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform indwelling urinary catheter care according to facility policy and failed to keep the urinary bag below the bladder and off the floor for one (R7) of two residents reviewed for indwelling catheters in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove Personal Protective Equipment/PPE and perform hand hygiene upon exiting a COVID-19 positive resident room to prevent cross-contamination; failed to follow their COVID-19 policy regarding wearing masks for one resident (R79); and failed to perform hand hygiene during incontinence care for one resident (R7) of 19 residents reviewed for infection control in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean kitchen including can openers, refrigerators, ovens and fans; failed to label and or discard food items as needed, and failed to keep scoops out of food bins. This has the potential to affect all 90 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all staff was wearing required Personal Protective Equipment (PPE) according to Centers for Disease Control (CDC)guidelines. This failure has the potential to affect all 90 residents in the building.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan with interventions to address significant weight loss (R67), psychotropic medication use (R81), and proper transfer status (R135), for three of 18 residents reviewed for comprehensive care planning, in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a pressure ulcer dressing/packing was not soiled with feces prior to covering it with a dressing for one of two residents (R12) reviewed for pressure ulcers in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a gait belt was used during a transfer with a stand aid, for one of six residents (R135) reviewed for transfer assistance in a sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to follow the Registered Dietitian's dietary recommendations in a timely manner for a resident that experienced a significant weight loss, for one of two residents (R67) reviewed for nutrition, in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document clinically indicated diagnoses and behaviors to justify the use of an antipsychotic, failed to initiate an antipsychotic at the lowest dose, failed to implement non-pharmacological interventions, failed to perform a GDR (Gradual Dose Reduction), and failed to complete an AIMs (Abnormal Involuntary Movements) assessment for three of six residents (R18, R46, R49) reviewed for antipsycotic medication use, in the sample of 32.