The Haven of Farmer City

Inspectors wroteBased on interview and record review the facility failed to adequately assess, monitor, document, and respond to a significant change in condition for one of three residents (R5) reviewed for quality of care in the sample list of five. This failure resulted in R5 experiencing a delay in treatment for respiratory symptoms and increased lethargy. Findings Include: The Facility's Change in Resident's Condition or Status Policy revised on August 2008 documents, the Director of Nursing or designee will notify the resident attending physician or On-Call Physician when there has been, a significant change in the resident's physical/emotional/mental condition. This document also states that the Director of Nursing or designee will notify the resident/legal representative when there is a significant change in the resident's physical, mental, or psychosocial status. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability and reconciliation of a controlled substance medication for one (R5) of three residents reviewed for medication administration in the sample list of five.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 48 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively sanitize dishes and failed to prevent physical cross-contamination of ice. These failures have the potential to affect all 48 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide physician ordered therapeutic supplements and diets. These failures affected 21 residents (R1, R2, R3, R4, R5, R9, R10, R12, R15, R18, R24, R26, R27, R35, R38, R39, R40, R41, R44, R45, R47) of 21 reviewed for therapeutic diets on the sample list of 34.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident's right to dignity while dining, for three of 15 (R9, R17, and R47) residents reviewed for dignity while dining on the sample list of 34. On 3/17/26 between 12:30 pm and 1:00 pm 15 residents were fed by staff in the assisted dining room. During this time period, V6 (Certified Nursing Assistant/CNA), V7 (CNA) and V8 (CNA) intermittently engaged in extensive personal conversations about what other facilities are getting paid out of town for CNAs working for agency. The same three CNAs discussed other numerous other topics some of which included relatives birthday activities, and a staff member's two year old's behaviors. V6, V7, and V8 (CNAs) talked to each other while feeding R9, R17 and R47. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document resident advance directives in the resident's medical record. This failure has the potential to affect two (R10 and R41) of 16 residents reviewed for advanced directives in the sample list of 34.

Inspectors wroteBased on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage upon a resident discharge from Medicare Part A services. This failure affects one resident (R16) of three reviewed for beneficiary notifications in the sample list of 34.

Inspectors wroteBased on interview and record review the facility failed to arrange for the required Preadmission Screening and Resident Review (PASRR) assessment to determine a resident need for nursing home and specialized services for a serious mental illness, post the thirty 30 days exempt admission PASRR status screening. This failure affects one of two resident (R38) reviewed for PASRR screening on the sample list of 34.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for insulin and anticoagulant use and monitoring. This failure affects one (R5) of five residents reviewed for unnecessary medications in the sample list of 34.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an indwelling urinary catheter drainage bag and tubing, in a clean sanitary manner, off the floor. This failure affects one of one resident (R6), reviewed for urinary indwelling catheters/infection on the sample list of 34.

Inspectors wroteBased on observation, interview and record review, the facility repeatedly failed to maintain Bilevel Positive Airway Pressure (BIPAP) ventilation mask, and tubing, Nebulizer (Neb) medication inhalation mask and tubing, oxygen humidification water bottles, oxygen administration tubing and nasal cannula equipment in a clean sanitary condition and according to the facility policy. These failures affect two of two residents (R1 and R38) reviewed for oxygen therapy on the sample list of 34.

Inspectors wroteBased on interview and record review, the facility failed to offer and administer an influenza vaccine to ensure a resident was up to date for vaccines for one (R6) of five residents reviewed for immunizations in the sample list of 34.

Inspectors wroteBased on interview and record review, the facility failed to offer and administer a COVID-19 vaccine to ensure a resident was up to date for vaccines for one (R6) of five residents reviewed for immunizations in the sample list of 34.

Inspectors wroteBased on interview and record review the facility failed to allow a resident to refuse a blood glucose check and failed to provide privacy for blood glucose monitoring and insulin administration for one (R1) of three residents reviewed for resident rights on the sample list of five.

Inspectors wroteBased on interview and record review, the facility failed to safely transfer a resident (R1) from the bed to the wheelchair. This failure resulted in R1 sustaining a broken arm requiring emergency evaluation and treatment at the hospital. R1 is one of three residents reviewed for accidents in the sample list of four. This past non-compliance occurred from 8/13/25 to 8/14/25. Findings Include: The facility Safe Lifting and Movement of Residents Policy (revised August 2008) documents the following: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses mechanical lifting devices for the lifting and movement of residents. Mechanical lifting devices shall be used for any resident needing a two person assist. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a discharge plan for administration of diabetic medications and wound care for one of three residents (R2) reviewed for discharge in the sample list of six.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor walk-in refrigerator and freezer temperatures and failed to prevent food contamination by storing utensils in bulk food containers. These failures have the potential to affect all 44 residents residing in the facility. Findings Include: The facility's Storage policy dated October 2020 documents Food should be stored at the proper temperature and utensils or tools should not be left in food containers. The facility's Equipment Temperatures policy dated September 2008 documents all refrigerators and freezers shall be monitored regularly to ensure that they are working properly and to correct any mechanical difficulties quickly to prevent food spoilage. The temperatures should be recorded on the corresponding Temperature Charts. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a new pressure ulcer and nausea/stomach pain for two residents (R5, R247) of two residents reviewed for reporting changes in status in the sample list of 25.

Inspectors wroteBased on observation, interview, and record review the facility to ensure the least restrictive restraint was used for the least amount of time for one resident (R8) of one resident reviewed for restraints in a sample list of 25. Findings Include: The facility's Physical Restraint/Enabler policy revised 7/24/18 states Policy: To allow residents to be free of physical restraints which are not required to treat medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience. It is recognized that there may be emergency situations in which restraints may be required. Under the heading Procedures the policy also states Place physical restraint problem on the resident's Care Plan. The Care Plan must address the duration, type, and circumstances under which the restraint can be used. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently maintain good personal and oral hygiene for one of three residents (R26) reviewed for Activities of Daily Living on the sample list of 25. Findings Include: The facility A.M. Care policy dated 3/20/23 documents A.M. Care will be given to all residents daily. Nursing assistants are responsible for providing daily A.M. care to all residents which includes providing oral hygiene including the brushing of teeth, washing of the face, underarms, and perineal areas, applying deodorant, dressing in clean clothing, and providing nail care. R26's Physician Order Sheet dated December 2024 documents R26 is diagnosed with Epileptic Syndrome with Seizures and Mild Neurocognitive Disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control standards for catheter irrigation for one resident (R2) of one resident reviewed for catheter care in the sample list of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to change, date and store oxygen tubing and humidifier bottles in a sanitary manner for two of two residents (R3, R14) reviewed for respiratory care in the sample list of 25. Findings Include: 1. R3's Medical Diagnoses list dated December 2024 documents R3 is diagnosed with Congestive Heart Failure and Atrial Fibrillation. R3's Physician Order Sheet (POS) dated December 2024 documents R3 is prescribed oxygen at two liters per nasal cannula continuously. Nursing is to change oxygen tubing weekly. On 12/15/24 at 10:43 AM R3's oxygen tubing was laying on the ground. The nasal cannula was attached to the concentrator which was running at two liters per minute. The humidifier bottle was empty and both tubing and humidifier bottle were undated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Trauma Informed Care for one resident (R27) of one resident reviewed for Post Traumatic Stress Disorder in a sample of 25. Findings Include: The facility's Trauma Informed Care Policy dated [DATE] states Purpose: To ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. The third bullet point under Types of trauma survivors is Survivors of abuse. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe and secure bed rail for one of one resident (R14) reviewed for bed rails on the sample list of 25. Findings Include: R14's Medical Diagnoses list dated December 2024 documents R14 is diagnosed with History of Falling, Mixed Alzheimer's Vascular Dementia with Behavioral Disturbances, Insomnia, Anxiety, Psychotic Disorder, Bipolar Disorder with Psychotic Features, Attention Concentration Deficit, and Chronic Obstructive Pulmonary Disease. R14's Physician Order Sheet (POS) dated December 2024 documents R14 is prescribed the use of a right 1/2 side transfer bar for physical function of bed mobility. On 12/15/24 at 10:30 AM R14's side rail was extremely loose and moved from side to side and front and back leaving a big gap between the bed mattress and side rail. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to properly dispose of a medication for one of six residents (R197) reviewed for medication administration in a sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered to keep the medication error rate below five percent (5%). There were three medication errors out of 25 opportunities resulting in a 12% error rate. This failure affected one resident (R19) of six residents reviewed for medications on the sample list of 25. Findings Include: The facility's Medication Administration policy revised 11/18/17 states Medications must be prepared and administered within one hour of the designated time or as ordered. (i.e. Medication time is 9:00AM the medication can be administered as early as 8:00AM or as late as 10:00AM.) Medication is ordered Daily then medication can be given during the day at residents preference. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dental services for one of two residents (R26) reviewed for Dental Services on the sample list of 25. Findings Include: R26's Physician Order Sheet (POS) dated December 2024 documents R26 is diagnosed with Epileptic Syndrome with Seizures and Mild Neurocognitive Disorder. The same POS documents an order for dental services to be provided as needed. R26's Care Plan Summary dated 10/25/24 does not address R26's need for dental services and broken teeth. R26's Minimum Data Set (MDS) dated [DATE] documents R26 is cognitively intact. On 12/15/24 at 10:06 AM R26 stated staff never offer to set him up or assist him with brushing his teeth. R26 stated he has had multiple teeth break off and has not seen a dentist since he has been in the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide and/or assist the resident in arranging dental services for a resident with broken dentures for one resident (R24) of two residents reviewed for dental issues in a sample list of 25. Findings Include: R24's Care Plan dated 4/19/24 Documents R24 requires oral/dental health maintenance related to (R24) is edentulous. Coordinate arrangements for dental care and transportation as needed/as ordered. On 12/15/24 at 10:00AM V20 (R24's family member) stated (R24) hasn't got any dentures. They were broken at the nursing home (R24) was in before (R24) came to (the facility). I have asked for (R24) to be taken to the dentist over and over to get some new teeth. I have even spoken to the administrator, but they just grind (R24's) food. (R24) does not like the ground food. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a communication process in place with the Hospice service provider and failed to have an up to date Hospice Plan of Care for one (R36) of one residents reviewed for Hospice Services on the sample list of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to have the survey results readily accessible to the residents. This failure has the potential to affect all 44 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the services of a qualified director of food and nutrition services. This failure affects all 44 residents residing in the facility. Findings Include: On 12/15/24 at 9:15 AM V1 (Administrator) stated the facility has not had a qualified Dietary Manager since the last one quit. The facility hired V17 (Dietary Manager) who is starting work on 12/16/24 and would work on getting V17 trained and qualified. On 12/16/24 at 11:45 AM V17 was actively supervising and directing the meal service for lunch. The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/16/24 documents 44 residents reside in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure therapy services were provided for two (R1 and R3) of three residents reviewed for therapy services on the sample list of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 44 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify repeated episodes of verbal abuse of R28 by V11 (R28's Spouse) and failed to protect the resident's right to be free from verbal, mental, and physical abuse by V11. These failures resulted in V11 being allowed unsupervised visits with R28, subjecting R28 to repeated incidents of verbal and mental abuse by V11, and R28 being hit in the mouth by V11 resulting in psychosocial harm. R28 is one of five residents reviewed for abuse in the sample list of 33. The Immediate Jeopardy began on 10/26/23 at 6:50 PM when V11 was witnessed hitting R28 in the mouth. V1 (Administrator) was notified of the Immediate Jeopardy on 11/8/23 at 9:30 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure repetitive allegations of verbal and mental abuse and an injury of unknown origin were reported to the administrator, and timely report an allegation of abuse to the state survey agency. These failures affect two (R28, R45) of five residents reviewed for abuse in the sample list of 33. These failures resulted in R28 being subjected to repeated incidents of verbal/mental abuse, and physical abuse by V11 (R28's Spouse) resulting in psychosocial harm for R28.

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient dietary staff to timely serve meals. This failure has the potential to affect all 44 residents who reside at the facility. Findings Include: On 11/5/23 at 10:31 AM, R24 stated the facility food/meals are always served late. On 11/6/23 at 11:22 AM, V12 (Cook) and V13 (Dietary Aide) were the only two staff working in the kitchen preparing food for lunch. On 11/6/23 at 12:06 PM, V12 served the first meal tray and stated, lunch is supposed to be served at 11:30 am however, it is hard because of only having two people in the kitchen. V12 explained there is always only two staff in the kitchen, a cook, and the aide and that the facility really needs an extra person. V12 also stated that V12 is taking over as Dietary Manager and as soon as V12 can find someone to take V12's spot as the cook. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper food storage, cleanliness of the kitchen and prevent potential food contamination by not ensuring facial hair was covered while preparing and serving food. This failure has the potential to affect all 44 residents who reside at the facility. Findings Include: The facility Kitchen Sanitation Policy dated October 2020 documents the Food Service Manager will monitor sanitation of the Dietary Department on a daily basis. The Dietary Sanitation QA (Quality Assurance) Review shall be used as a tool to monitor compliance with sanitation standards and identify which areas need corrective action. The Food Service Manager will develop a cleaning schedule for the department and ensure that dietary employees complete cleaning tasks as scheduled. [...]

Inspectors wroteBased on interview and record review, the facility failed to give residents and their representatives an option of not signing an arbitration agreement as a condition of admission. This failure has the potential to affect all 44 residents who reside at the facility.

Inspectors wroteBased on interview and record review the facility failed to have timely quarterly Quality Assurance (QA) meetings. This failure has the potential to affect all 44 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement their Infection Control Surveillance and Monitoring Policy by failing to thoroughly complete infection control logs, analyze the data, identify trends, and implement the appropriate isolation precautions for shingles. This failure has the potential to affect all 44 residents who reside at the facility. Findings Include: The facility Infection Control Surveillance and Monitoring Policy dated 3/10/22 documents the facility will do routine surveillance and monitoring of the facility to determine if compliance with work practices. Monitoring of the day-to-day operation of the Infection Control Program will be conducted by the DON (Director of Nursing). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their antibiotic stewardship program. This failure has the potential to affect all 44 residents who reside at the facility. Findings Include: The facility Antibiotic Stewardship Program dated 11/1/17 documents this program is used to improve the use of antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished utilizing the Core Elements: [...]

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of abuse. This failure affects one (R28) of five residents reviewed for abuse in the sample list of 33.

Inspectors wroteBased on interview and record review the facility failed to ensure a Level II PASARR (Preadmission Screening and Resident Review) was completed for one of one resident (R35) reviewed for PASARR in the sample list of 33.

Inspectors wroteBased on interview and record review the facility failed to develop a baseline care plan to include fall risk and interventions for one (R28) of 13 residents reviewed for care plans in the sample list of 33.

Inspectors wroteBased on observation, interview and record the facility failed to initiate care plans to include resident centered problems, goals, and interventions for four residents (R11, R15, R28) of 12 residents reviewed for care plans in a sample list of 33.

Inspectors wroteBased on observation, interview and record review the facility failed to update a care plan to include a significant weight loss for two residents (R26, R45) of 12 residents reviewed for care plans in a sample list of 30. Findings Include: 1. R45's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Dementia with Behavioral Disturbance, Depression, Anxiety, Insomnia, and History of Fall with Hip Fracture. The facility's Weight flow sheet for the preceding 12 months documents on 08/01/2023, R45 weighed 127 pounds (lbs.) and on 10/01/2023 R45 weighed 112 lbs. which is an 11.81 % Loss. On 11/6/23 from 11:30AM to 12:15PM R45 was observed sitting in the dining room and attempting to leave the table. When table mates were served before R45, R45 attempted to take food and drink off another resident's tray. [...]

Inspectors wroteBased on interview and record review the facility failed to provide Restorative Nursing Programs for one resident (R24) of one resident reviewed for positioning and mobility in a sample list of 33 residents. Findings Include: R24's Physician's Order Sheet (POS) for November includes the following diagnoses: Cerebral Infarct, Emphysema, Chronic Kidney Disease Stage III, Malignant Neoplasm of the Spinal Cord, Type II Diabetes, and Depression. On 11/6/23 at 11:00AM R24 stated After I finished therapy, they were supposed to start Restorative programs, but I don't get them. R24's Minimum Data Set (MDS) dated [DATE] documents R24 is to receive Passive Range of Motion, Active Assisted Range of Motion, Bed Mobility, Transfer, dressing, and grooming restorative programs. [...]

Inspectors wroteBased on interview and record review the facility failed to complete a fall risk assessment and thoroughly investigate falls for one (R28) of four residents reviewed for accidents in a sample list of 33 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to correctly perform incontinence care for one (R6) of four residents reviewed for Urinary Tract Infections in the sample list of 33.

Inspectors wroteBased on interview and record review the facility failed to report significant weight loss to the resident representative and physician, timely implement nutritional recommendations, and record amount of intake for nutritional supplements for one (R26) of two residents reviewed for nutrition in the sample list of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify the risk for entrapment for one (R11) of one resident reviewed for bed rails in a sample list of 33 residents. Findings Include: R11's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Parkinson's Disease, Depression, Anxiety and Chronic Fatigue Syndrome. R11's Minimum Data Set, dated [DATE] documents R11 is cognitively intact and requires staff assistance or is dependent on staff for Activities of Daily Living (ADL's). On 11/05/23 at 11:55 AM R11 was lying in her bed. There is a 1/2 length side rail in place to both sides of R11's bed. On the end of the rail toward R11's legs there is a gap in the rail approximately 5 by 10. R11 is very thin, and her left foot is against the rail. When comparing R11's foot with the rail it could easily fit into the gap. [...]

Inspectors wroteBased on interview and record review the facility failed to provide physician visits at least every 60 days alternating with an advanced practice nurse for three of four residents (R11, R15,R45) reviewed for physician's visits in the sample list of 33. Findings Include: The facility's Policy Physician's Services (not dated) documents After the first 90 days a resident must be seen by a physician at least every 60 days. The physician may schedule alternate visits by a Physician's Assistant or a Nurse Practitioner. 1. R11's Nurse Practitioner Progress note dated 8/31/23 documents R11 has been a resident since 2015. V24 (Nurse Practitioner) documented assessments for R11 on 8/31/23. There is no documentation to indicate a physician has evaluated R11 in July, August, September, or October 2023. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to track targeted behaviors for one (R15) of five residents reviewed for psychotropic medications in a sample list of 33 residents. Findings Include: R15's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Mixed Alzheimer's Disease, Vascular Dementia with behavioral disturbances, Anxiety, and Major Depression. This POS also documents current physician's orders for the following psychotropic medications: 1. Alprazolam (antianxiety) 0.25 milligrams (MG) in the AM and 0.5 mg at Bedtime. 2. Quetiapine (antipsychotic) 12.5 mg every morning. 3. Buspar (Antianxiety) 15 mg twice daily. 3. Remeron (antidepressant) 7.5 mg at bedtime. 4. Melatonin (sleep aide) 10 mg at bedtime. The only behavior tracking sheet documented for R15 is for November 2023 and the sheet is blank. [...]

Inspectors wroteBased on interview and record review the facility failed to administer insulin per orders, have parameters for notifying the physician of blood glucose results, and coordinate times for glucose monitoring and insulin administration. These failures resulted in significant medication errors for one (R28) of five residents reviewed for medications in the sample list of 33.

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal vaccinations per resident/resident representative request for two of five residents (R27, R31) reviewed for vaccinations on the sample list of 33. Findings Include: 1.) R27's Consent for vaccinations dated 12/28/22 documents R27 wishes to have the PPSV23 (Pneumococcal Polysaccharide Vaccination) and/or PCV13 (Pneumococcal Conjugate Vaccination), whichever vaccination R27 is able to receive. R27's medical record does not document that R27 has historically received a Pneumococcal vaccination or that the facility administered the PPSV23 or PCV13 vaccination as requested. 2.) R31's Consent for vaccinations dated 8/12/22 documents R31 wishes to have the PPSV23 and/or PCV13, whichever vaccination R31 is able to receive. [...]

Inspectors wroteBased on record review and interview the facility failed to deliver unopened mail to all residents. This failure has the potential to affect all 44 residents residing at the facility.