Richland Nursing & Rehab

Inspectors wroteBased on observation, interview, and record review, the facility failed implement PROM (Passive Range of Motion) exercises per COTA (Certified Occupational Therapy Assistant) recommendations for 1 of 3 (R1) residents reviewed for range of motion in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide urinary catheter care according to professional standards of practice to prevent a Urinary Tract Infection for 1 of 3 residents (R1) reviewed for catheter care in a sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were free from medication errors for 2 (R6, R63) of 13 residents reviewed for medication errors in the sample of 51. This failure resulted in R63, after receiving monthly doses of injectable atypical antipsychotic on 1/31/26 and 2/5/26, experiencing extrapyramidal symptoms and sedation. These symptoms resulted in R63 being sent to the local ER (Emergency Room) and poison control being contacted.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate CNA (Certified Nursing Assistants) staff to meet residents needs. This has the ability to affect all 76 residents living at the facility. Facility Grievance/Concern documents documented the following:On 10/15/26: No one answered call light from 2am or maybe 3am until 6am. On 12/23/26: Call lights not being answered timely. On 1/19/26: Had to wait 45 minutes with light on to get put on the toilet. Then had to wait 45 minutes to get off the toilet. On 04/14/2026 at 12:16 PM, R25 was alert and oriented. R25 stated when there is only one CNA (Certified Nursing Assistant) working, there have been times she has been left on the toilet over an hour. R25's Face Sheet documented an admission Date of 2/15/24. On 04/14/2026 at 2:20 PM, R14 was alert and oriented. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain infection prevention and control practices. This has the potential to affect all 76 residents living in the facility. The Findings Include: 1. R35's face sheet documents an admission date to the facility of 02/27/2026. The diagnoses listed include spinal stenosis, type 2 diabetes mellitus, generalized anxiety disorder, bipolar disorder, atherosclerotic heart disease if coronary artery, seizures, chronic diastolic heart failure, acute kidney failure, chronic obstructive pulmonary disease, and gastro -esophageal reflux disease. R35's care plan with a start date of 03/10/2026 documents a focus area of resident is frequently incontinent of bowel and bladder. Interventions listed include provide incontinent care as needed and toilet as scheduled and as needed. On 04/14/2026 at 12:10 P.M. [...]

Inspectors wroteBased on interview and record review the facility failed to establish an antibiotic stewardship program that includes protocols to ensure appropriate antibiotic use, and systems to monitor antibiotic outcomes. This failure has the potential to affect all 76 residents who reside at the facility. The Findings IncludeOn 04/16/2026 an infection control log was presented by V2 (Director of Nursing). The log contained a floor plan for the months of January 2026 - April 2026 that were color coated to differentiate between the different types of infections that residents were experiencing. The log contained a monthly summary of antibiotics that were utilized for the months of January 2026 - April 2026. That log had a print date of 04/16/2026 at 12:48 P.M. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to employ an Infection Preventionist who remains on site. This failure has the potential to affect all 76 residents who reside at the facility. The Findings IncludeOn 04/17/2026 at 11:23 A.M. V7 (Regional Nurse) stated she is responsible for the role of infection preventionist until V2 completes the course. V7 stated she is not sure how often she is actually at the facility. V7 stated she logs in remotely and reviews infections for the facility. On 04/17/2026 at 12:10 P.M. V2 (Director of Nursing) stated she has not completed the course, but she will be taking it to be the infection preventionist for the facility. On 04/17/2026 at 12:23 P.M. V1 (Administrator) stated V26 (Former Employee) was the infection preventionist for the facility. V1 stated that V26 quit without notice. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly assessments were completed within the required time frames for 7 (R2, R20, R48, R57, R68, R72, and R81) of 7 residents reviewed for quarterly MDS (Minimum Data Set) assessments in the sample of 51. The Findings Include:1. R2's face sheet documents R2 has an admission date to the facility of 11/22/2023. Diagnoses listed include retention of urine, unspecified dementia, major depressive disorder, unilateral primary osteoarthritis, anemia, obstructive sleep apnea, anxiety disorder, and hypothyroidism. On 04/15/2026 at 12:33 P.M. V7 (Regional Nurse) stated R2's quarterly MDS with an ARD (Assessment Reference Date) of 03/12/2026 has not been completed yet.2. R20's face sheet documents R20 has an admission date to the facility of 11/06/2019. [...]

Inspectors wroteBased on interview and record review the facility failed to complete timely quarterly MDS (Minimum Data Set) for 4 (R8, R13, R51, and R56) of 4 residents reviewed for quarterly MDS assessments completed timely in the sample 51. The Findings Include:1. R8's face sheet documents an admission date to the facility of 10/01/2025. The diagnoses listed include metabolic encephalopathy, acute kidney failure, dementia, type 2 diabetes mellitus, anxiety disorder, essential hypertension, hyperlipidemia, gastro esophageal reflux disease, and mood disorder. A final validation report dated 04/14/2026, provided by V1 (Administrator) documents that R8's quarterly MDS (Minimum Data Set) was submitted on 4/14/26 and had a target/ due date of 03/03/2026. The same document had a warning message of assessment completed late: more than 14 days after the assessment reference date.2. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure that residents were offered activities who chose to stay in their room for 4 of 4 residents (R22, R64, R66 and R80) reviewed for activities in a sample of 51. The Findings Include:1. R64's face sheet documents an admission date of 1/11/24 and includes the following diagnosis: chronic respiratory failure, major depression disorder, heart failure, anxiety, and morbid obesity. On 4/14/26 at 11:00 AM, R64 who is alert and oriented to person, place and time stated that she has not gotten any activities given to her since she can remember. R64 stated that due to her being bed bound she chooses to spend her time in her room rather than being transferred to a chair and out to the dining room for activities and meals. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide an environment free of hazards, implement appropriate interventions for falls, and provide a safe transfer with a mechanical lift for 4 (R2, R12, R22, and R81) of 4 residents reviewed for accidents in a sample of 51.

Inspectors wroteBased on observation, interview and record review the facility failed to offer residents food alternatives per personal preferences for 4 of 4 residents (R22, R64, R66, and R80) reviewed for meal alternatives in a sample of 51. The Findings Include:1. R80's face sheet documents an admission date of 2/20/2023. R80's April Physician's Order sheet documents R80 has a regular diet ordered. On 4/14/26 at 12:00 PM, R80 was observed in his room with his lunch tray on his bedside table. R80 who was alert to person, place and time, stated that he will not eat the carrots because they serve them too often. R80 stated that he ate the baked pasta but threw out the rock-hard garlic bread that was in his trash can next to his recliner. R80 stated he never gets to make food choices prior to his meal; he just finds out what is being served when it is delivered. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide Pneumococcal Immunizations for 4 (R18, R47, R62, and R64) of 9 residents reviewed for Immunizations in the sample of 51. The Findings Include1. R18's face sheet documents R18's date of birth as 10/22/1944 (over [AGE] years of age) and an admission date to the facility of 07/31/2019. The diagnoses listed include polyosteoarthritis, unspecified dementia, psychotic disorder with delusions, major depressive disorder, anxiety disorder, hypothyroidism, essential hypertension, and acute upper respiratory infection. R18's I-Care (Illinois Comprehensive Automated Immunization Registry Exchange) documented that R18 has not had any pneumonia vaccines. R18's vaccine consent release only dated year 2026, documented R18 agreed to the Pneumococcal vaccination. [...]

Inspectors wroteBased on interview and record review the facility failed to sign and complete an IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life Sustaining Treatment (POLST) form for 1 (R87) of 1 residents reviewed for Advanced Directives in the sample of 51.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a clean homelike environment for 2 of 2 (R8 and R62) residents reviewed for cleanliness in a sample of 51. The Findings Include: 1. R8's admission Record documented an admission date of 6/03/2004 and included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R8's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99, which indicates severe cognitive impairment. Under section GG0120. Mobility Devices documented R6 used a wheelchair for mobility. R8's Care Plan documented a focus area of difficulty with communicating needs due to unclear speech and difficulty finding words to complete thoughts with interventions that included observing closely and anticipating needs as needed. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the resident or the resident's representative of the transfer/discharge/bed hold in writing for 3 (R2, R6, and R7) of 3 residents reviewed for discharge notification/bed hold in the sample of 51. The Findings Include: 1. R6's admission Record documented an admission date of 10/01/2025 and included diagnoses of metabolic encephalopathy, acute kidney failure, unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, type 2 diabetes mellitus without complications, anxiety disorder, unspecified, depression, unspecified, mood disorder due to known physiological condition with major depressive-like episode. R6's Progress Note by V12 (LPN/Licensed Practical Nurse) dated 4/1/2026 at 12:40 PM documented resident returned from the local emergency by ambulance at 12:30 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to complete a comprehensive assessment annually and submit it timely for 1 (R73) of 1 resident reviewed for comprehensive assessments in the sample of 51. The Findings Include:R73's face sheet documents an admission date to the facility of 03/03/2025. The diagnoses listed include Alzheimer's disease, unspecified dementia, chronic kidney disease stage 4, paroxysmal atrial fibrillation, unspecified systolic heart failure, and essential hypertension. A final validation report dated 04/14/2026, provided by V1 (administrator) documents that R73's annual MDS (Minimum Data Set) had a target/ due date of 03/04/2026 and was not completed until 4/14/26. The same document had a warning message of assessment completed late: more than 14 days after the assessment reference date. On 04/15/2026 at 12:33 P.M. [...]

Inspectors wroteBased on record review and interview, the facility failed to refer a resident for a PASARR (Preadmission Screening and Resident Review) screening following the addition of a diagnosis of Schizoaffective Disorder for one resident (R28) of two residents reviewed for PASARR screening in the sample of 51.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician orders for dating/labeling when changing oxygen tubing and humidifier bottles for 3 of 3 (R64, R66 and R80) residents reviewed for oxygen tubing in a sample 51. The Findings Include: 1. R66's face sheet documents an admission date of 2/6/19. This same document includes the following diagnosis: chronic obstructive pulmonary disease and centrilobular emphysema. R66's April physician orders include an order to change oxygen tubing and humidifier bottle weekly, initial and date once a day on Saturday. R66's Medication Administration Report (MAR) dated 3/21/26-4/20/26 documents that R66's oxygen tubing was changed every Saturday. On 4/15/26 at 1:30 PM, R66 who was alert to person, place and time stated that he does not know when they change his tubing or how often it happens. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from resident to resident physical abuse for 3 (R2, R7 and R8) of 3 residents reviewed for abuse in the sample of 9. This failure resulted in R2 being woken up to R1 having R1's hands over R2's mouth and nose while pushing down and with R2 yelling out she was trying to kill me., R7 being kicked in the leg above the knee by R5 and R8 being hit in the back by R5 a few hours later. A reasonable person being held down and potentially suffocated, kicked and slapped would feel fearful, intimidated, and threatened while residing in their home. Findings Include: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the physician was notified with a change in condition for 1 of 3 (R1) residents reviewed for physician notification in the sample of 15. Findings Include:R1's Resident Face Sheet with a print date of 2/5/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease. R1's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status of 09, indicating a moderate cognitive deficit. R1's Care Plan documents a Problem area of, I am at risk for impaired nutrition and hydration related to: I am on a regular DIET with a start date if 10/1/25. This Problem area includes the intervention of, Monitor weight and notify provider of significant weight changes .Date Created: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 3 (R1) residents reviewed for medication administration in the sample of 15. Findings Include: R1's Resident Face Sheet with a print date of 2/5/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease. R1's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status of 09, indicating a moderate cognitive deficit. R1's Care Plan does not document a Problem area related to medication administration. [...]

Inspectors wroteBased on interview and record review the facility failed to initiate Cardiopulmonary Resuscitation (CPR) for 1 of 3 (R1) residents reviewed for death in the sample of 13. This failure resulted in facility staff not initiating CPR for R1 when R1 was found unresponsive on [DATE]. R1 was found unresponsive by V7 (Certified Nurse Assistant/CNA) and V8 (CNA). V8 notified V4 (Registered Nurse) that R1 was unresponsive. V8 asked V4 if R1 was a Full Code or DNR (Do Not Resuscitate), and V4 responded she did not know. V4 stated she did not initiate CPR because there was nothing in her chart saying R1 was a Full Code or DNR. R1's progress note dated [DATE] documents R1 was a full code. R1 was pronounced dead at the facility by V4 and V6 (Licensed Practical Nurse). [...]

Inspectors wroteBased on interview and record review, the facility failed to formulate or offer to formulate an Advanced Directive for 1 of 11 residents (R1) reviewed for Advance Directives in the sample of 13. The past non-compliance occurred on [DATE].

Inspectors wroteBased on interview and record review the facility failed to prevent resident to resident abuse for 3 of 6 (R1, R3 and R4) residents reviewed for abuse in a sample of 6. This failure resulted in R3 being bit on the wrist by R4, leaving a bruise, and R4 being grabbed by the shirt and slapped on the face by R3. A reasonable person being bit and slapped would feel fearful, intimidated, and threatened.

Inspectors wroteBased on interview and record review, the facility failed to provide proper resident supervision during ambulation for 1 (R1) of 3 residents reviewed for accidents in the sample of 6. This failure resulted in R1 falling and sustaining a fracture to the right arm and elbow.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were assisted with activities of daily living (ADL's) and call lights were answered in a timely manner promoting dignity for 3 of 5 (R3, R4, R5, R10 and R13) residents reviewed for dignity in the sample of 26. This failure resulted in R13 asking for assistance to toilet for at least 35 minutes while in the dining room and common area and subsequently having an episode of incontinence. R13 was visibly upset and crying out for help during this 35-minute time frame. This would cause any reasonable person to feel embarrassed and humiliated.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient staff to monitor and provide timely care for 4 of 7 (R8, R13, R14, and R15) residents, reviewed for staffing in the sample of 26. This failure has the potential to affect all 79 residents currently residing at the facility. Findings Include: The facility Daily Census Report dated 5/5/25 documents there are 79 residents currently residing at the facility. 1. On 5/6/25 from 12:25 PM until 12:58 PM this surveyor conducted continuous observation of the common area/dining room on the Alzheimer's unit. At 12:25 PM, when this surveyor entered this area, R13 was sitting in the dining room in her wheelchair talking with V25 (Patient Aid/PA). R13 asked V25 to take her to the bathroom. V25 responded to R13 that she couldn't but they (Certified Nursing Assistants/CNA's) would take her as soon as they could. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the Dining Room floor in a clean and sanitary condition for 14 of 14 residents (R3, R4, R5, R7, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25) reviewed for a clean homelike environment in a sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were assisted with activities of daily living (ADL's) in a timely manner for 2 of 5 (R2 and R13) residents reviewed for ADL's in the sample of 26. Findings Include: 1. R13's Resident Face Sheet with a print date of 5/6/25 documents R13 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia, moderate, with anxiety. R13's MDS (Minimum Data Set) dated 2/5/25 documents a BIMS (Brief Interview for Mental Status) score of 01, indicating R13 has a severe cognitive deficit. This same MDS documents R13 is frequently incontinent of urine and bowel and requires substantial/maximal assistance with toileting hygiene and partial/moderate assistance with toilet transfer. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with dementia received the necessary person-centered care and services consistent with the resident's goals and symptomology for 3 of 3 (R13, R14, and R15) residents reviewed for dementia care in the sample of 26. Findings Include: On 5/6/25 from 12:25 PM until 12:58 PM this surveyor conducted continuous observation of the common area/dining room on the Alzheimer's unit. At 12:25 PM, when this surveyor entered this area, R13 was sitting in the dining room in her wheelchair talking with V25 (Patient Aid/PA). R13 asked V25 to take her to the bathroom. V25 responded to R13 that she couldn't but they (Certified Nursing Assistants/CNA's) would take her as soon as they could. V25 told R13, They can't stop feeding residents to take you. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to prevent a cognitively impaired ambulatory resident (R1) from exiting the facility unwitnessed and without staff supervision for 1 of 3 residents reviewed for elopement in the sample of 3. This failure resulted in R1, unknown to staff, exiting the facility and walking approximately one block away, falling and sustaining a skin tear over his left temporal region and scattered abrasions over both hands, wrists, and elbows, and then entering a private citizens unlocked vehicle. R1 was treated at the local ER (Emergency Room) for the skin tears and released later that evening. [...]

Inspectors wroteBased on interview and record review, the facility failed to adequately staff the Dementia Care Unit. This has the ability to affect all 25 residents living on that unit.

Inspectors wroteBased on interview and record review, the facility failed to timely contact a residents Power of Attorney (POA) and provide a comprehensive report of an elopement for one resident (R1) of three residents reviewed for POA notification in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to safely transfer residents according to Transfer Assessments and Care Plans for three residents (R2, R3, R4) of four residents reviewed for falls in the sample of six. This failure resulted in R2, on 1/27/25, falling during a transfer and fracturing his 8th left rib and dislocating his left shoulder.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient staff to provide care for Activities of Daily Living (ADL) and provide supervision and assistance during meals. This failure has the potential to affect all 78 residents residing in the facility.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide dignified dining services while maintaining resident's rights for 4 (R28, R66, R74, R79) of 21 residents reviewed for dining in a sample of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that dependent residents receive eating and bathing assistance for 4 of 5 residents (R55, R63, R71 and R52) reviewed for Activities of Daily Living in the sample of 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify specific medical conditions or symptoms necessitating the use of physical restraint and failed to release the restraint per the plan of care for 1 (R71) of 1 resident reviewed for restraints in a sample of 50.

Inspectors wroteBased on interview and record review, the facility failed to ensure an individual admitted with a mental illness diagnosis was referred to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination of need for any specialized services for 1 of 3 residents (R48) reviewed for PASARR requirements in a sample of 50.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide adequate supervision to residents during mealtime to ensure resident safety for 1 of 21 residents (R28) reviewed for dining in a sample of 50.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the diet as ordered for 3 (R28, R66, and R71) of 21 residents reviewed for dining in a sample of 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control practices during resident care for 4 of 9 (R1, R22, R26, R78) residents reviewed for resident care observations in a sample of 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to residents' requests for assistance in a timely manner to ensure dignity and respect for quality of life for 3 (R3, R6 and R7) of 7 residents reviewed for dignity. This failure resulted in care not being provided timely, causing R3, R6 and R7 to experience discomfort/pain, and caused R3 to feel humiliation and anxiousness from sitting in urine and/or feces for extended periods of time, not knowing how long it will take for her to receive necessary assistance. Findings Include: 1. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure sufficient staff were scheduled/available to provide timely care to meet residents' needs. This failure has the potential to affect all 85 residents currently residing at the facility. Findings Include: 1. R3's Resident Face Sheet with a print date of 12/27/2024, documented R3 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, heart failure, secondary pulmonary arterial hypertension, major depressive disorder, type 2 diabetes mellitus, and anxiety disorder. R3's Physician Order Summary with date range from 11/27/2024 - 12/27/2024 documented an order to apply zinc cream to gluteal fold and buttocks twice daily and as needed with incontinence. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the kitchen in a clean, sanitary and pest free condition. This has the potential to affect all 85 residents living in the facility. Findings Include: During a tour of the kitchen on 12/26/2024 at 9:07 AM, the following items were observed: 1. There were no paper towels at the handwashing sink in the kitchen. 2. The storeroom was noted to have jelly packets on the floor and pieces of cereal on the floor under the shelving. 3. There were specs of food particles all over the floor along with dust, dirt and debris. 4. There was a paper bait trap noted in between two shelving units that had dead bugs on it, along with dead bugs noted behind the oven. Some of the dead bugs were noted to be roaches. 5. Two bones were noted on the floor directly under a metal table in the center of the room. 6. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain an effective pest control program to rid the facility of roaches and bed bugs. This failure has the potential to affect all 85 residents currently residing in the facility. Findings Include: 1. On 12/26/2024 at 8:58 AM, V1 (Temporary Administrator/Social Service Director/SSD) stated they recently had a resident admitted with bed bugs. V1 stated that R1 was admitted from the hospital on [DATE]. V1 stated that R1's family brought in clothes on 12/07/2024 and staff found bed bugs in the clothes. V1 stated that R1 lives in an apartment in town, and she notified the housing authority of the bed bugs that were on R1's clothes. V1 stated that R2 was R1's roommate and R2 was moved to a different room. R1 was admitted to the hospital for other issues on 12/14/24. [...]

Inspectors wroteBased on interview and record review the facility failed to prevent physical abuse of a resident from another resident with a known history of aggression towards other residents in 1 of 3 residents (R1) reviewed for abuse in the sample of 33. This failure resulted in R1 being slapped, choked, and hit in the stomach by R2. These actions would cause a reasonable person to have feelings of fear and insecurity while living in their home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a safe transfer to a wheelchair for 1 of 3 resident (R2) reviewed for safety in a sample of 5. This failure resulted in R2, during a transfer, receiving a laceration to her leg requiring an emergency room visit and a total of 16 stitches to the wound.

Inspectors wroteBased on interview and record review, the facility failed to assess for risk of dehydration, to contact a medical provider to report lack of food and fluid intake, and to implement in a timely manner orders for labs to identify dehydration for 1 of 3 residents (R1) reviewed for hydration in the sample of 5. This failure resulted in R1 requiring hospitalization from 2/4/24 through 2/14/24 for a diagnosis of dehydration and requiring IV (Intravenous) fluid replacement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a functional call light system for 2 of 4 residents (R3 and R4) reviewed for call lights in a sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to provide anti-anxiety medications as prescribed for 1 (R47) of 3 residents reviewed for behavior in the sample of 40. This failure resulted in R47 engaging in severe behaviors, including self-injurious behavior, and R47 was transferred to the local hospital for evaluation and treatment, requiring 6 staples to a head laceration. Findings Include: R47's Face sheet documented an admission date to the facility of 11/6/19. Diagnoses on this same form include, but are not limited to Major Depressive Disorder; Undifferentiated Schizophrenia; Schizoid Personality Disorder; Dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance; Anxiety Disorder; and Suicidal Ideations. V9 (Physician) is documented as being R47's physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: (1) ensure updated education was provided regarding the benefits and potential side effects of all available pneumococcal vaccines; (2) offer and/or administer the pneumococcal vaccine in accordance with current standards of practice to residents eligible to receive the vaccine for 4 (R4, R52, R76, R79) of 5 residents reviewed for immunizations in the sample of 40; and (3) update the facility's Immunization policy and Pneumonia Vaccination Informed Consent form to include Vaccination Timing for Adults following the most recent recommendations from the Centers for Disease Control and Prevention (CDC). This had the potential to affect any residents eligible to receive the Pneumococcal vaccines. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident dignity by ensuring residents are appropriately dressed for one (R71) of one resident reviewed for resident rights in the sample of 40.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident for a Level II (2) Preadmission Screening and Resident Review (PASRR) for 1 (R14) of 2 residents reviewed for coordination of PASRR assessments in the sample of 40. The Findings Include: R14's face sheet documents an admission date of 8/20/19, and includes the following diagnoses: major depressive disorder with diagnosis date of 8/19/22, unspecified psychosis not due to a substance or known physiological condition with diagnosis date of 5/7/20, and generalized anxiety with diagnosis date of 8/19/22. R14's current Level 1 PASRR, dated 2/22/11, from the previous facility that R14 was transferred from, documents long term care placement was appropriate. On 1/18/23 at 2:00 PM, when asked if R14 had a Level 2 PASRR, V7 (Social Services) stated she would immediately refer R14 for a Level 2 PASARR review. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a PASRR (Preadmission Screening and Resident Review) Level II screening for 1 (R73) of 3 residents reviewed for PASRR Screening in the sample of 40. Findings Include: R73's Face Sheet documented an admission date to the facility of 3/28/23. This same face sheet documented R73 has diagnoses including but not limited to Schizophrenia and Bipolar Disorder. R73's PASRR Level 1 screening, dated 3/28/23, documented no mental health diagnosis is known or suspected. Due to this inaccurate entry, no level II PASRR screening was indicated. On 01/18/24 at 12:52 PM, V7 (Social Services) stated she recognized the 3/28/23 Level I screening was incorrectly marked that R73 does not have a serious mental illness. V7 stated she will make the referral for a Level II to be completed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate greater than 5%, with two medication errors out of 25 opportunities for error, resulting in an 8% error rate. This deficient practice affected one (R5) of four residents observed for medication administration in the sample of 40.