Winning Wheels

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure hot liquids were safely served and failed to ensure a process was in place for hot liquids for 1 of 3 residents (R5) reviewed for safety in the sample of 8. This failure resulted in R5 spilling his coffee on his lap and sustaining two partial thickness burns to his left inner knee causing R5 pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement it's pest control policy. This failure has the protentional to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to check placement of a narcotic pain patch as ordered for 1 of 3 residents (R1) reviewed for patch placement and administration.

Inspectors wroteBased on interview and record review, the facility failed to protect 6 residents (R1,R2,R3,R4,R5,R6) from misappropriation of medications. This applies to 6 of 6 residents reviewed for misappropriation in the sample of 14.

Inspectors wroteBased on interview and record review, failed to report alleged violations of misappropriation for 6 residents (R1, R2, R3, R4, R5, R6) to IDPH (Illinois Department of Public Health) within 24 hours, failed to implement policies and procedures for reporting the possible crime to law enforcement. These failures apply to 6 of 6 residents reviewed for misappropriation in the sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered per physician's orders for 4 of 6 residents (R4, R5, R6, R14) reviewed for pharmacy services in the sample of 14.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a meal was served in a sanitary manner and failed to ensure the temperature of resident refrigerators were monitored. This has the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the pureed diet menu for 4 of 4 residents (R4, R16, R38 and R42) reviewed for menus in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents on a pureed diet were served a meal in a form that meet their needs for 4 of 4 residents (R4, R16, R38 and R42) reviewed for pureed diets in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure psychotropic medications were prescribed for a defined duration for 1 of 5 residents (R12) reviewed for unnecessary medications in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level 2 screen after a resident that was diagnosed with schizoaffective disorder diagnoses which applies to 1 of 18 residents (R7) reviewed for PASARR assessments in a sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dressing was in place for a resident with a stage 4 pressure injury for one of one resident (R71) reviewed for pressure injuries in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was transferred in a safe manner for 1 of 18 residents (R73) in the sample of 18 reviewed for safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date and time liquid nutrition when it was initiated for 1 of 4 residents (R34) reviewed for tube feeding in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to administer a medication as ordered by the physician for one of 18 residents (R3) reviewed for pharmacy services in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a multidose insulin pen was discarded 28 days after being opened for 1 of 18 residents (R3) reviewed for medication storage in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dental services for a resident which applies to 1 of 1 resident (R49) reviewed for dental services in a sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change their gloves and perform hand hygiene in a manner to prevent cross contamination for one of 18 residents (R34) reviewed for infection control in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents rooms were free from pests which applies to 2 of 18 residents (R46, R54) reviewed for pest control is a sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safety measures were implemented for three residents (R1, R2, R3) who fell during cares and/or transfers of three residents reviewed for falls. This failure resulted in R1 sustaining a fractured left humerus.

Inspectors wroteBased on interview and record review, the facility failed to treat a residents (R1) urinary tract infection (UTI) for nearly 48 hours. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure controlled medications were signed off in the electronic narcotic inventory system at the time the controlled medications were administered for 7 of 10 residents (R4-R10) in the sample of 10.

Inspectors wroteBased on observation, interview, and record review the facility failed to utilize a glucose monitoring sensor per physician orders for 1 of 3 residents (R1) reviewed for physician orders in the sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received assistance with activities of daily living for 2 of 4 residents (R1, R2) reviewed for activities of daily living (ADL) in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure orders were in place for a resident with non-pressure skin injuries and failed to ensure a resident's central venous catheter dressing was changed weekly. This applies to 2 of 3 residents reviewed for nursing care in the sample 4.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and serve food in a clean, sanitary manner. This failure has the potential to affect all of the residents in the facility.

Inspectors wrote2. R23's order summary sheet for June 2024 shows an order for enhanced barrier precautions related to history of MDRO (Multiple Drug Resistant Organism) with indwelling devices every day and night shift for infection control management. The order was not started until 6/12/24. On 6/12/24 at 2:00 PM, V3 entered R23's room to complete his dressing change. He had no sign on the door to indicate enhanced barrier precautions, and V3 did not don a gown before performing the dressing change. R23 was observed to have open wounds on his buttocks, an indwelling catheter, and a feeding tube. On 6/13/24 at 8:05 AM, V3 said R23 should be on enhanced barrier precautions due to having a MDRO in his blood and multiple indwelling devices such as his tracheotomy, feeding tube and catheter. He should have signage up on his door and PPE available for staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal care for a resident in a manner to promote dignity for 1 of 1 resident (R49) in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's right to be free from abuse for 2 of 3 residents (R38, R44) reviewed for abuse in the sample of 20 and 1 resident (R25) outside the sample.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of abuse for 2 of 3 residents (R38, R44) reviewed for abuse in the sample of 20 and 1 resident (R25) outside the sample.

Inspectors wroteBased on interview and record review, the facility failed to obtain a Level 2 PASRR (Pre-admission Screening and Resident Review) for 2 of 5 residents (R61,R67) reviewed for PASRR screening in the sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to provide feeding assistance to 1 of 1 residents (R37) reviewed for activities of daily living (ADL's) in the sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify a resident's skin concern, assess the area, and start a treatment for 1 of 1 resident (R49) reviewed for skin concerns in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a medical device related pressure injury and failed to identify an area of pressure prior to becoming a Stage 3 for 2 of 4 residents (R32, R23) reviewed for pressure in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's splint was applied to prevent further limited range of motion for 2 of 4 residents (R19, R30) reviewed for limited range of motion in the sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to safely transfer a hospice resident using a gait belt for 1 of 1 resident (R76) reviewed for transfers in the sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep a urinary drainage bag below the level of the bladder and failed to prevent a urinary drainage bag from contact with the floor for 1 of 2 residents (R28) reviewed for catheters in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to supervise a resident with exit-seeking behaviors to prevent her from eloping from the building unsupervised. This failure resulted in R1 eloping from the facility and being able to reach a heavily traveled highway. This applies to one of three residents (R1) reviewed for the safety in the sample of 8. The Immediate Jeopardy began on 4/24/24 when R1 was able to elope from the facility. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 4/30/24 at 12:50 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 5/1/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident (R4) was free from sexual abuse (by R5) for 1 of 8 residents reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse. This applies to one of three residents (R1) reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of abuse. This applies to one of three residents (R1) reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to administer a resident's pain medication as ordered, failed to manage a resident's pain at a comfortable level, and failed to obtain emergency doses of a resident's pain medication when it was unavailable. These failures resulted in R12's Norco supply becoming depleted, R12 missing 16 doses of a prescribed narcotic pain medication, and R12 experiencing increased pain levels.

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of medications for 13 of 13 residents (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14) reviewed for misappropriation in the sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to ensure a nurse was removed from resident care after an allegation of misappropriation of controlled medications and failed to immediately investigate an allegation of misappropriation of medication. These failures apply to 6 of 13 residents (R1, R6, R8, R10, R12, R13) reviewed for misappropriation in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify an excessive amount of narcotic medication usage for 16 residents (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17), failed to ensure an accurate count of narcotic medications for 3 residents (R15, R16, R17), and failed to dispose of a narcotic medication after it was removed from its original packaging for 1 resident (R3).

Inspectors wroteBased on observation. interview and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, and failed to cover prepared food. This applies to all residents who reside in the facility that consume food prepared in the facility's kitchen.

Inspectors wroteBased on observation. interview and record review, the facility failed to control the fly infestation throughout the facility. This applies to all residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a urinary catheter remained below the level of the bladder, failed to ensure the drainage tubing was covered, failed to have a physicians order for a Texas catheter, and failed to provide incontinence care in a manner to prevent cross contamination for a resident with a catheter for 4 of 7 residents (R17, R31, R41, R79) reviewed for urinary catheters in the sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the confidentiality of a resident's electronic medical record was protected for 1 of 1 residents (R13) reviewed for privacy and confidentiality in the sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure interventions were in place for a resident with skin shearing for one of one resident (R30) reviewed for non-pressure wounds in the sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's call light system was in working order for 1 of 1 resident (R68) reviewed for call lights in the sample of 22.