Inspection Report
Plan of Correction
Deficiencies: 0
Apr 21, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility will be certified in compliance with health requirements effective April 21, 2025, based on acceptance of the Plan of Correction and substantial compliance.
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 2
Mar 24, 2025
Visit Reason
The inspection was conducted as the facility's Annual Recertification Survey from March 24, 2025 to March 27, 2025.
Findings
The facility failed to follow recommended infection control precautions during catheter care for one resident and failed to offer the recommended pneumococcal vaccine to eligible residents. Staff education on transmission-based precautions was provided, and audits were planned to ensure compliance.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow recommended infection control precautions during catheter care for Resident #13. | Level D |
| Failure to offer the recommended pneumococcal vaccine to eligible residents (Resident #11 and Resident #13). | Level D |
Report Facts
Census: 22
Residents reviewed for pneumococcal vaccine: 5
Residents not offered pneumococcal vaccine: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Observed performing catheter care and infection control procedures |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding infection control expectations and vaccine monitoring |
| Administrator | Provided statements regarding vaccine information and facility policies |
Inspection Report
Plan of Correction
Deficiencies: 0
May 14, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification effective May 10, 2024.
Inspection Report
Annual Inspection
Census: 25
Deficiencies: 1
Apr 24, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #115175-C and #115552-C.
Findings
The facility failed to properly secure medications to minimize loss or access for one medication cart, which was left unlocked and unattended for 6 minutes. Staff were re-educated and a plan for ongoing audits was established.
Complaint Details
Complaint #115175-C and #115552-C were investigated and both were not substantiated.
Deficiencies (1)
| Description |
|---|
| Facility failed to properly secure medications to minimize loss or access for 1 of 1 medication carts; med cart was left unlocked and unattended for 6 minutes. |
Report Facts
Census: 25
Audit frequency: 10
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Staff A observed leaving medication cart unlocked | |
| Director of Nursing | Interviewed regarding expectation that med cart be locked | |
| Certified Nursing Assistant | Staff B observed walking past medication cart |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 10, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance certification.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective June 10, 2023.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 9, 2023
Visit Reason
Investigation of a Facility Reported Incident #111613-M conducted from May 17, 2023 to June 9, 2023 to determine compliance with abuse and neglect policies.
Findings
The facility failed to ensure that a contracted staffing agency completed the entire criminal background check screening process for one agency staff member, Staff A, who had multiple misdemeanor convictions. The staffing agency did not provide required documentation from the Department of Human Services, and Staff A worked in the facility despite this incomplete screening.
Complaint Details
Investigation was triggered by a facility reported incident #111613-M. The complaint was substantiated as the facility failed to ensure proper background checks were completed for agency staff.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to assure a contracted staffing agency completed the entire criminal background check screening process for one agency staff member with multiple misdemeanor convictions. | SS=D |
Report Facts
Number of arrests for Staff A: 3
Date range of investigation: Investigation conducted from May 17, 2023 to June 9, 2023.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Agency staff member with incomplete criminal background check and multiple arrests. |
| Associate Executive Director | Confirmed staffing agency had not provided required documentation from DHS. |
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 9, 2023
Visit Reason
An annual recertification survey and investigation of complaint #109396-C and facility reported incident #109400-I were conducted from March 6, 2023 to March 9, 2023.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation of complaint #109396-C was included in the survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 13, 2023
Visit Reason
An on-site revisit of the complaint survey ending December 15, 2022 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective January 17, 2023. Denial of Payment for New Admits (DPNA) was not effectuated.
Complaint Details
This visit was a follow-up to a complaint survey ending December 15, 2022. All deficiencies were corrected.
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 3
Dec 15, 2022
Visit Reason
The inspection was conducted as a result of investigations of complaints #106701-C and #108711-C, both of which were substantiated.
Findings
The facility failed to follow physician orders for medication administration, failed to provide necessary assessments for a resident with a condition change, and failed to appropriately monitor and respond to abnormal PT/INR lab results for residents on anticoagulant therapy, resulting in serious adverse outcomes including a resident's death.
Complaint Details
Complaints #106701-C and #108711-C were substantiated. An Immediate Jeopardy was identified on 12/14/22 related to failure to respond to abnormal INR levels, which was removed after corrective actions were implemented.
Severity Breakdown
Level D: 2
Level J: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to follow physician orders for medication administration, specifically sertraline for Resident #1. | Level D |
| Failure to provide necessary assessments for Resident #1 with a condition change, including monitoring for anticoagulant complications. | Level D |
| Failure to appropriately monitor and respond to abnormal PT/INR lab results for Residents #1 and #4 on anticoagulant therapy, leading to an Immediate Jeopardy that was later lowered to Level D. | Level J |
Report Facts
Resident census: 22
Deficiency severity level: 3
Date survey completed: Dec 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Mentioned in relation to interview and education of staff on following physician orders and PT/INR monitoring. |
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 25, 2022
Visit Reason
A revisit of the survey ending March 14, 2022 and investigation of complaint #101191 were conducted April 20 - 25, 2022.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective March 28, 2022. Complaint #101191-C was not substantiated.
Complaint Details
Complaint #101191-C was not substantiated.
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Mar 14, 2022
Visit Reason
The inspection was conducted as an investigation of Facility Reported Incident #102958-I from March 8 - 14, 2022, related to a substantiated incident involving a resident burn injury.
Findings
The facility failed to complete safety and skin assessments and did not provide adequate supervision to prevent a burn injury to Resident #1, who sustained second degree burns from spilling hot coffee on her thighs. The investigation revealed gaps in communication and assessment processes related to the incident.
Complaint Details
Facility Reported Incident #102958 was substantiated following investigation conducted March 8-14, 2022.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete safety and skin assessments and provide adequate supervision to prevent accidents, resulting in a burn injury to a resident. | SS=G |
Report Facts
Resident census: 25
MDS date: Feb 8, 2022
Assessment dates: Mar 9, 2022
Incident report date: Feb 19, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Registered Nurse | Reported discovery of blisters on Resident #1 and information about the incident |
| Staff B | Licensed Practicing Nurse | Reported communication and investigation details regarding Resident #1's injuries |
| Staff C | Certified Nurse Aide | Observed blisters on Resident #1 and reported to day shift |
| Staff D | Certified Nurse Aide | Discovered blisters on Resident #1 and reported shift information |
| Director of Nursing | Director of Nursing | Provided statements about assessment schedules and investigation findings |
Inspection Report
Annual Inspection
Census: 23
Deficiencies: 4
Oct 7, 2021
Visit Reason
The inspection was conducted as the facility's annual health survey from October 4 to October 7, 2021.
Findings
The facility was found deficient in developing baseline care plans within 48 hours of admission for residents, ensuring staff were trained and certified in CPR, following physician orders for wound care, and maintaining infection prevention and control practices including eye protection and hand hygiene during COVID-19. The facility reported a census of 23 residents during the survey.
Deficiencies (4)
| Description |
|---|
| Failure to develop baseline care plans within 48 hours of admission for 3 of 3 residents reviewed. |
| Failure to ensure staff trained in cardiopulmonary resuscitation (CPR) were on duty at all times for six residents requiring CPR. |
| Failure to follow physician's orders for wound care for 1 of 12 residents sampled. |
| Failure to establish and maintain an infection prevention and control program including proper use of personal protective equipment and eye protection during COVID-19. |
Report Facts
Census: 23
Residents reviewed for baseline care plans: 3
Residents requiring CPR: 6
Residents sampled for wound care: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Acknowledged baseline care plans were not being done on admissions since August 2021 and stated facility planned to recertify staff in CPR. |
| Staff A | Licensed Practical Nurse (LPN) | Documented wound dressing care and noted no signs of infection. |
| Staff D | Dietary Aide | Observed failing to wear eye protection during meal delivery. |
| Staff B | Registered Nurse (RN) | Observed entering resident rooms without eye protection. |
| Staff C | Certified Nurse Aide (CNA) | Observed entering resident rooms without eye protection and failing to wear eye protection during incontinence care. |
| Staff H | Certified Nurse Aide (CNA) | Observed washing hands and applying gloves but failing to wear eye protection. |
| Staff I | Certified Nurse Aide (CNA) | Observed wearing masks but no eye protection during resident care. |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
May 12, 2021
Visit Reason
The inspection was conducted to investigate Facility Reported Incidents #90414 and #93207 and Complaint #91252 from May 4, 2021 to May 12, 2021.
Findings
The facility failed to follow appropriate infection control techniques during incontinence care for one sampled resident and failed to follow CDC guidelines related to the COVID-19 pandemic. Observations revealed staff not wearing masks properly and not performing hand hygiene after mask adjustments. The resident required extensive assistance due to severe cognitive impairment and was occasionally incontinent of urine.
Complaint Details
Facility Reported Incident #90414-1 was not substantiated. Complaint #91252-C was not substantiated. Facility Reported Incident #93207-1 was not substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to follow appropriate infection control techniques during incontinence care and failure to follow CDC guidelines related to COVID-19 pandemic. |
Report Facts
Census: 27
MDS assessment score: 3
Date of MDS assessment: Jan 25, 2021
Date of Care Plan problem: Jan 19, 2021
Date of Infection Control Program policy: Sep 9, 2020
Date of CDC update: Feb 23, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nurse Aide | Observed removing wet brief, adjusting mask, sanitizing hands, and failing to perform hand hygiene properly |
| Staff F | Registered Nurse | Observed with mask below chin, failing to perform hand hygiene after mask adjustments |
| Staff C | Observed reentering resident's room and sanitizing hands | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff mask and glove use policies |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 25, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on August 24-25, 2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 22
Deficiencies: 0
Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Annual Inspection
Census: 28
Deficiencies: 3
Feb 13, 2020
Visit Reason
The inspection was conducted as part of the annual health survey of Deerfield Retirement Community Inc.
Findings
The facility was found deficient in coordination of PASARR and assessments, quality of care, and infection prevention and control. Specific issues included failure to resubmit PASARR after diagnosis changes, failure to follow physician orders for a resident, and failure to follow infection control standards for two sampled residents.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to coordinate assessments with the PASARR program for a resident after a change in diagnosis. | SS=D |
| Failure to follow physician orders for treatment and care for a resident, including wound care. | SS=D |
| Failure to establish and maintain an infection prevention and control program meeting federal standards, including failure to follow infection control standards for sampled residents. | SS=D |
Report Facts
Census: 28
Deficiencies cited: 3
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