AUTUMN MEADOWS OF CAHOKIA
For profit - Partnership
150 Beds
Independent
Data: November 2025
6 Immediate Jeopardy citations
Trust Grade
0/100
#452 of 665 in IL
Last Inspection: April 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Autumn Meadows of Cahokia has received a Trust Grade of F, indicating significant concerns about the facility's quality and care. Ranking #452 out of 665 facilities in Illinois places it in the bottom half, while its county rank of #4 out of 15 suggests only three local options are better. The facility's trend appears stable, with 19 issues reported in both 2024 and 2025. Staffing is rated at 2 out of 5 stars, with a turnover rate of 49%, which is about average for the state but still concerning. Notably, the facility has incurred $347,886 in fines, which is troubling compared to most Illinois facilities, and it has less RN coverage than 85% of the state's homes. Specific incidents raised serious alarms, including a failure to monitor a resident who requires continuous oxygen while smoking, putting both the resident and others at risk. Additionally, there was an incident of mental abuse when a group of men entered the facility, harassed residents, and filmed a music video without consent, leading to residents feeling unsafe. Furthermore, the facility failed to adhere to advanced directives for a resident, resulting in unwanted lifesaving measures that ultimately led to the resident's death. While there are some strengths, such as having a number of staff, the significant weaknesses in care and safety make this facility a concerning option for families.
- Trust Score
- F
- In Illinois
- #452/665
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ⚠ Watch
- 49% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $347,886 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 55 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 33%
Review needed
19 → 19 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 19 issues
2025: 19 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 49%
Near Illinois avg (46%)
Higher turnover may affect care consistency
Federal Fines: $347,886
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 55 deficiencies on record
6 life-threatening 8 actual harm
Sept 2025
3 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to 1) develop and implement a person-centered plan of car...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to 1) develop and implement a person-centered plan of care for fall prevention; 2) ensure proper working order of R2's bed for 1 of 3 residents reviewed for falls in the sample of 11. This failure resulted in R2 who was post right below the knee amputation attempting to self-transfer, R2's bed rolled away from him due to a malfunctioning locking mechanism, and with R2 falling to the floor. The impact and trauma from the fall, re-opened the amputation surgical incision site, requiring urgent hospital treatment and surgical revision of the surgical site. Findings Include:R2's admission Sheet, with admission date of 07/25/25, documented R2 has diagnoses of but not limited to Peripheral vascular disease, Type II Diabetes Mellitus (DM), complete traumatic amputation at knee level, right lower leg, subsequent encounter, need for assistance with personal care, acquired absence of right leg below knee, and difficulty in walking. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and he requires assistance of one with transfers. R2's Morse Fall Scale, dated 07/25/25 at 2:29 PM, documented R2 was a high risk for falling with a score of 50. Morse Fall Scoring is as follows: High Risk 45 and higher, moderate risk 25-44, and low risk 0-24. R2's Care Plan, date initiated for falls 08/19/25, documented R2 is at risk for falls. Gait/balance problems d/t (due to) a recent BKA (below the knee amputation). 08/17/25 Unwitnessed fall, reopened surgical BKA. Goal: The resident will be free of injury (r/t related to) falls. Interventions include but not limited to anticipate and meet the residents needs as needed, ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed, and follow facility fall protocol. R2's Progress Notes, dated 8/9/2025 at 10:13 PM, Administration Note: documented R2 had his staples removed from his right BKA. R2's Progress Notes, dated 8/16/2025 at 11:21 AM, Administration Note: documented R2's areas to his right BKA had healed over. R2's Progress Notes, Effective date: 08/17/2025 at 22:45 (10:45 PM), Created by: V23, Assistant Director of Nursing, created date: 09/16/2025 at 13:46 (1:46 PM), documented Late Entry:Resident laying on floor in hallway his feet legs pointing into the doorway to his room with his head more centered towards the hallway. He was holding his recent surgical BKA. His surgical wound had opened up measuring 15 cm (centimeters) in length and 3 cm in height. A pain assessment as well as a complete body assessment were completed Resident was placed back into his W/C (wheelchair) after assessments completed. The open laceration was covered with ABD (abdominal) pads then wrapped to stop the bleeding. This was effective. Local ambulance service was notified of our need for transport to local hospital. POA (Power of Attorney)/Physician/DON (Director of Nursing) notified. Report called to local hospital. Nurses Note from V24, Licensed Practical Nurse (LPN) R2' Progress Notes, dated 8/18/2025 at 5:16 AM, documented *Transfer to Hospital Summary Resident admitted to Local Hospital Admitting diagnosis (Dx): wound Dehiscence. R2's Operative Note, dated 08/20/25 at 10:18 AM, documented R2 had depleted (used up) venous (vein) access and a suitable IV (Intravenous) could not be started. Instead, they had to place a triple lumen-catheter (a type of central venous catheter in his right femoral vein (in his right groin area) to be able to administer the general anesthesia. Under general anesthesia the right leg was prepped and draped. The patient had a complete dehiscence (is a surgical complication where a closed incision reopens, exposing internal tissues and potentially organs) of the right BKA closure site. There was a hematoma present. The incision was made along the previous closure site and the entire below-knee flap was taken down. There was evidence of some nonviable (incapable of life or living) muscle and traumatized muscle from the fall as well as a hematoma (localized collection of blood that pools outside of blood vessels) which was evacuated (removed). There was a large amount of fibrous tissue in the posterior flap. An excisional debridement was preformed of these fibrous tissues. A portion of the tibial bone was exposed in the wound. Proximally a cm of tibial bone was then excised using a power saw. All the posterior flap was viable with no evidence of necrosis or ischemia. The wound was irrigated with an antibiotic solution, the posterior flap was brought anteriorly, and the previous skin incision was reapproximated using interrupted vertical sutures. The leg was dressed with Adaptic gaze, fluff gauze, kerlix wraps and an ace wrap. R2's Progress Notes, dated 08/22/2025 at 4:00 PM, documented R2 returned to the facility at this time.R2's Illinois Department of Public Health (IDPH) Final Report, dated 08/25/25, documented Diagnosis: Attention and concentration deficit, moderate protein-calorie malnutrition, peripheral vascular disease, unspecified, cognitive communication deficit, complete traumatic amputation at knee level, right lower leg, subsequent encounter, muscle weakness (generalized), need for assistance with personal care, acquired absence of right leg below knee. Nursing reported a fall with injury. The fall took place on 8/17 at 22:30. Resident was sent out to the hospital for further evaluation. Resident was a new admission that came to the facility on 7/25/25, brand new amputee on right lower leg. Resident was found lying on the floor that resulted from a fall. Resident was trying to complete a self-transfer. Resident is a brand-new amputee and has a diagnosis deficit. Resident lack safety awareness and has not come to terms with his most recent amputation. Resident has difficulty with asking for assistance or using his call light because he is in denial about losing his independence. Resident was interviewed and stated he had to poop. Resident didn't want to ask for help, so he initiated a self-transfer and fell. The resident had a laceration, but he also caused his surgical wound to reopen resulting in a hematoma. Resident was sent out for further evaluation. Resident returned on 8/22 after the hospital completed a revision of his right BKA closure site. The hospital didn't come back with any new wound treatments. Our wound nurse was able to assess and obtain orders from out Nurse Practitioner to do the following: resident returned with sutures, apply wet to dry dressing with ABD pad and Kerlix/ace wraps daily. Resident care plan has been updated with new interventions regarding his recent fall and will continue therapy to build his upper body strength to conduct safe transfers. Will continue to monitor resident at this time. On 09/11/25 at 1:25 PM, R2 said his bed was broke and his wheels on the bed wouldn't lock. He said he had his wheelchair beside the bed and when he was trying to get out of bed and into his wheelchair the bed rolled away from him, and he fell on the floor and busted his stump open. R2 said he put his call light on to get some help, but no one ever came so he crawled out into the hallway and yelled for help. R2 said two certified nursing assistants (CNAs) finally came down and helped him up off the floor, they put him in his wheelchair and wheeled him up to the nurse's station (NS) so the nurse could check him out. R2 said they sent him out to the hospital, and they put the sutures back in his leg and then sent him home on Sunday. On 09/16/25 at 11:57 AM, V14, Maintenance Director said he isn't sure if R2 got a new bed or not and he would have to look it up. He then asked V15, Maintenance who was standing next to V14 if he remembered if R2 had gotten a new bed and V15 said yes, he did. This surveyor asked V14 and V15 if they could tell me why R2 received a new bed. V15 said because R2 complained his bed wouldn't lock. V14 then stated the locking mechanism on the bed wasn't working and when it doesn't work it will cause the bed to slide. On 09/17/25 at 2:41 PM, Follow up interview with R2. R2 said the incident happened around eight or nine in the evening. He said he went to get up on his own and the bed slid, he fell, and he put his call light after he fell. R2 said he waited for a long time, and no one came to assist him, so he crawled out into the hallway and yelled for help, and it still took the CNAs a while to come and help him. R2 stated the CNAs finally came and got him in his wheelchair and took him to the nurse's station for the nurse to assess. R2 said he was bleeding all over the place. There was a trail of blood from the bed to the hallway. He said there was so much blood they had to take towels and put on it to stop it from bleeding. R2 said it hurt bad, on a scale of 0-10 with 10 being the worst he said it was an 11. On 09/17/25 at 3:07 PM, V14, Maintenance Director stated he believes he found out R2's bed was broken from a work order then he stated, no he made a note in the meeting about the bed. He said they have a meeting every morning with the department directors, and he made a note about the bed. He said he would have to look for the notes from that day because he wasn't sure what day it was on. V14 said they had to replace R2's bed because the locking mechanism did not work correctly, and the bed wouldn't lock, and was still able to move. On 09/18/25 at 10:40 AM, V1, Administrator stated she can't put a date on it when she was made aware of R2's bed not working properly. She said R2 came in and then he had the fall, and it was sometime during that time frame that she was made aware. V1 was questioned if was before or after the fall and she said she was unable to remember and that is why she can't put a date on it. V1 said she would expect staff to fix it themselves if it was something they were able to fix if not she would expect them to put in a work order or report it to one of the nurse managers, and between maintenance and nursing they would get it fixed. On 09/17/25 at 11:45 AM, V19, Medical Director said he would deem R2 a fall risk and there should be a fall plan of care in place for him. V19 stated the fall R2 had has the potential to cause harm and he is sorry it happened. V19 said he thinks the facility failed in preventing R2's fall. He said no one was answering his call light, and his bed was broke that's a lot. He said yes, this incident has the potential for the resident to experience harm or death. He said it's unacceptable and he absolutely agrees the facility failed. The facility's Fall Prevention Protocol, reviewed dated of 03/2025, documented Standard: This facility is committed to establishing guidelines and procedures to minimize falls and their effects so as to maximize every resident's well being. It is established that it is impossible to prevent all falls due to their multi factorial nature, however this standard dictates a mode of action that attempt to identify, assess and implement interventions for each resident at risk and the facilitates an environment that is as safe as possible. It further documents Policy: I. Fall Prevention/Risk Assessment A comprehensive fall risk assessment will be completed for every resident within 48-72 hours of admission/readmission and in conjunction with each required MDS assessment period and/or whenever the resident has a fall that is not consistent with previously identified risk factors. This assessment shall include a review of the resident's physical status, cognitive function, functional status, environment and device use. Residents identified through the fall risk assessment as being at risk for falls shall have in place an interdisciplinary care plan that will address their risk by directing interventions towards the identified, modifiable etiologies or risk factors. Care plans will be revised and/or updated in conjunction with scheduled MDS assessments and repeat fall risk assessments.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Room Equipment
(Tag F0908)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure essential resident equipment was in good working condition fo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure essential resident equipment was in good working condition for 1 of 1 resident reviewed for physical environment in a sample of 11. This failure resulted in R2 who was post right below the knee amputation attempting to self-transfer, R2's bed rolled away from him due to a malfunctioning locking mechanism, and with R2 falling to the floor. The impact and trauma from the fall, re-opened the amputation surgical incision site, requiring urgent hospital treatment and surgical revision of the surgical site. Findings Include: R2's admission Sheet, with admission date of 07/25/25, documented R2 has diagnoses of but not limited to Peripheral vascular disease, Type II Diabetes Mellitus (DM), complete traumatic amputation at knee level, right lower leg, subsequent encounter, need for assistance with personal care, acquired absence of right leg below knee, and difficulty in walking. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and he requires assistance of one with transfers. R2's Progress Notes, Effective date: 08/17/2025 at 22:45 (10:45 PM), Created by: V23, Assistant Director of Nursing, created date: 09/16/2025 at 13:46 (1:46 PM), documented Late Entry:Resident laying on floor in hallway his feet legs pointing into the doorway to his room with his head more centered towards the hallway. He was holding his recent surgical BKA. His surgical wound had opened up measuring 15 cm (centimeters) in length and 3 cm in height. A pain assessment as well as a complete body assessment were completed Resident was placed back into his W/C (wheelchair) after assessments completed. The open laceration was covered with ABD (abdominal) pads then wrapped to stop the bleeding. This was effective. Local ambulance service was notified of our need for transport to local hospital. POA (Power of Attorney)/Physician/DON (Director of Nursing) notified. Report called to local hospital. Nurses Note from V24, Licensed Practical Nurse (LPN). The facility's Work Order/Maintenance request form, dated 08/18/25, documented V14, Maintenance Director per: Morning meeting that R2 needed his bed replaced due to bed/lock on old bed defective. On 09/11/25 at 1:25 PM, R2 said his bed was broke and his wheels on the bed wouldn't lock. He said he had his wheelchair beside the bed and when he was trying to get out of bed and into his wheelchair the bed rolled away from him, and he fell on the floor and busted his stump open. R2 said he put his call light on to get some help, but no one ever came so he crawled out into the hallway and yelled for help. R2 said two certified nursing assistants (CNAs) finally came down and helped him up off the floor, they put him in his wheelchair and wheeled him up to the nurse's station (NS) so the nurse could check him out. R2 said they sent him out to the hospital, and they put the sutures back in his leg and then sent him home on Sunday. On 09/16/25 at 11:52 AM, V16, Housekeeping said R2 did complain that his bed slides and he fell because of it. On 09/16/25 at 11:57 AM, V14, Maintenance Director said he isn't sure if R2 got a new bed or not and he would have to look it up. He then asked V15, Maintenance who was standing next to V14 if he remembered if R2 had gotten a new bed and V15 said yes, he did. This surveyor asked V14 and V15 if they could tell me why R2 received a new bed. V15 said because R2 complained his bed wouldn't lock. V14 then stated the locking mechanism on the bed wasn't working and when it doesn't work it will cause the bed to slide. On 09/17/25 at 2:41 PM, Follow up interview with R2. R2 said the incident happened around eight or nine in the evening. He said he went to get up on his own and the bed slid, he fell, and he put his call light after he fell. R2 said he waited for a long time, and no one came to assist him, so he crawled out into the hallway and yelled for help, and it still took the CNAs a while to come and help him. R2 stated the CNAs finally came and got him in his wheelchair and took him to the nurse's station for the nurse to assess. R2 said he was bleeding all over the place. There was a trail of blood from the bed to the hallway. He said there was so much blood they had to take towels and put on it to stop it from bleeding. R2 said it hurt bad, on a scale of 0-10 with 10 being the worst he said it was an 11. On 09/17/25 at 3:07 PM, V14, Maintenance Director stated he believes he found out R2's bed was broken from a work order then he stated no he made a note in the meeting about the bed. He said they have a meeting every morning with the department directors, and he made a note about the bed. He said he would have to look for the notes from that day because he wasn't sure what day it was on. V14 said they had to replace R2's bed because the locking mechanism did not work correctly, and the bed wouldn't lock, and was still able to move. On 09/18/25 at 10:40 AM, V1, Administrator stated she can't put a date on it when she was made aware of R2's bed not working properly. She said R2 came in and then he had the fall, and it was sometime during that time frame that she was made aware. V1 was questioned if was before or after the fall and she said she was unable to remember and that is why she can't put a date on it. V1 said she would expect staff to fix it themselves if it was something they were able to fix if not she would expect them to put in a work order or report it to one of the nurse managers, and between maintenance and nursing they would get it fixed.V25, Regional Director stated the facility doesn't have an updated policy for maintenance as they are transitioning to a new system.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a person-centered plan of care for fall preven...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a person-centered plan of care for fall prevention for 1 of 3 residents reviewed for falls in a sample of 11. This failure resulted in R2 who was post right below the knee amputation attempting to self-transfer and R2 falling to the floor. The impact and trauma from the fall, re-opened the amputation surgical incision site, requiring urgent hospital treatment and surgical revision of the surgical site. Findings Include: R2's admission Sheet, with admission date of 07/25/25, documented R2 has diagnoses of but not limited to Peripheral vascular disease, Type II Diabetes Mellitus (DM), complete traumatic amputation at knee level, right lower leg, subsequent encounter, need for assistance with personal care, acquired absence of right leg below knee, and difficulty in walking. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and he requires assistance of one with transfers. R2's Morse Fall Scale, dated 07/25/25 at 2:29 PM, documented R2 was a high risk for falling with a score of 50. Morse Fall Scoring is as follows: High Risk 45 and higher, moderate risk 25-44, and low risk 0-24. R2's Care Plan, date initiated for falls 08/19/25, documented R2 is at risk for falls. Gait/balance problems d/t (due to) a recent BKA (below the knee amputation). 08/17/25 Unwitnessed fall, reopened surgical BKA. Goal: The resident will be free of injury (r/t related to) falls. Interventions include but not limited to anticipate and meet the residents needs as needed, ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed, and follow facility fall protocol. R2's Progress Notes, Effective date: 08/17/2025 at 22:45 (10:45 PM), Created by: V23, Assistant Director of Nursing, created date: 09/16/2025 at 13:46 (1:46 PM), documented Late Entry:Resident laying on floor in hallway his feet legs pointing into the doorway to his room with his head more centered towards the hallway. He was holding his recent surgical BKA. His surgical wound had opened up measuring 15 cm (centimeters) in length and 3 cm in height. A pain assessment as well as a complete body assessment were completed Resident was placed back into his W/C (wheelchair) after assessments completed. The open laceration was covered with ABD (abdominal) pads then wrapped to stop the bleeding. This was effective. Local ambulance service was notified of our need for transport to local hospital. POA (Power of Attorney)/Physician/DON (Director of Nursing) notified. Report called to local hospital. Nurses Note from V24, Licensed Practical Nurse (LPN). R2's Operative Note, dated 08/20/25 at 10:18 AM, documented R2 had depleted (used up) venous (vein) access and a suitable IV (Intravenous) could not be started. Instead, they had to place a triple lumen-catheter (a type of central venous catheter in his right femoral vein (in his right groin area) to be able to administer the general anesthesia. Under general anesthesia the right leg was prepped and draped. The patient had a complete dehiscence (is a surgical complication where a closed incision reopens, exposing internal tissues and potentially organs) of the right BKA closure site. There was a hematoma present. The incision was made along the previous closure site and the entire below-knee flap was taken down. There was evidence of some nonviable (incapable of life or living) muscle and traumatized muscle from the fall as well as a hematoma (localized collection of blood that pools outside of blood vessels) which was evacuated (removed). There was a large amount of fibrous tissue in the posterior flap. An excisional debridement was preformed of these fibrous tissues. A portion of the tibial bone was exposed in the wound. Proximally a cm of tibial bone was then excised using a power saw. All the posterior flap was viable with no evidence of necrosis or ischemia. The wound was irrigated with an antibiotic solution, the posterior flap was brought anteriorly, and the previous skin incision was reapproximated using interrupted vertical sutures. The leg was dressed with Adaptic gaze, fluff gauze, kerlix wraps and an ace wrap. R2's Progress Notes, dated 08/22/2025 at 4:00 PM, documented R2 returned to the facility at this time. On 09/17/25 at 11:45 AM, V19, Medical Director said he would deem R2 a fall risk and there should be a fall plan of care in place for him. V19 stated the fall R2 had has the potential to cause harm and he is sorry it happened. V19 said he thinks the facility failed in preventing R2's fall. He said no one was answering his call light, and his bed was broke that's a lot. He said yes, this incident has the potential for the resident to experience harm or death. He said it's unacceptable and he absolutely agrees the facility failed. The facility's Care Planning policy, effective date of 05/02/07, documented Comprehensive Care Plans The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS/RAI). Each care plan will be dated indicating the date in which it was implemented. Each resident's comprehensive care plan should be designed to: o Incorporate identified problem areas; o Incorporate risk factors associated with identified problems; o Reflect goals and objectives in measurable outcomes; o Identify the professional services that are responsible for each element of care; o Aid in preventing or reducing declines in the resident's functional status and/or functional levels;o Enhance the optimal functioning of the resident and;o Build upon the strengths of the resident. The facility's Fall Prevention Protocol, reviewed dated of 03/2025, documented Standard: This facility is committed to establishing guidelines and procedures to minimize falls and their effects so as to maximize every resident's well-being. It is established that it is impossible to prevent all falls due to their multi factorial nature, however this standard dictates a mode of action that attempt to identify, assess and implement interventions for each resident at risk and the facilitates an environment that is as safe as possible. It further documents Policy: I. Fall Prevention/Risk Assessment A comprehensive fall risk assessment will be completed for every resident within 48-72 hours of admission/readmission and in conjunction with each required MDS assessment period and/or whenever the resident has a fall that is not consistent with previously identified risk factors. This assessment shall include a review of the resident's physical status, cognitive function, functional status, environment and device use. Residents identified through the fall risk assessment as being at risk for falls shall have in place an interdisciplinary care plan that will address their risk by directing interventions towards the identified, modifiable etiologies or risk factors. Care plans will be revised and/or updated in conjunction with scheduled MDS assessments and repeat fall risk assessments.
Aug 2025
1 deficiency
1 IJ (1 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide monitoring of a resident requiring continues o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide monitoring of a resident requiring continues oxygen with a known history of having smoking materials in the room and failed to implement interventions to ensure a safe environment for 1 of 3 residents (R3) reviewed for smoking. This failure resulted in (R3) continuing to smoke inside room while wearing oxygen placing self and others at risk for safety concerns. Findings include:This failure resulted in an Immediate Jeopardy began on 8/5/2025 when R3 who requires continuous oxygen and suffers from Chronic Obstructive Pulmonary Disease and Dyspnea was found to have odors of smoke of mind altering substances in his room. The survey team validated the abatement on 8/26/25 at 3:27pm. The facility remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of policies and procedures and the in-service training.R3's Care Plan, dated 8/10/2025, documents that (R3) at for safety concerns r/t (related to) possession of smoking substance and using it in his room. The resident will not suffer injury from unsafe smoking practices. (R3) is instructed to get up every 2 hours to sit in his chair to have his room searched for drugs hidden. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. It also documents (R3) is at risk for safety concerns r/t having possession of smoking substances in his room while in use of O2 and not being supervised. The resident will not smoke without supervision. The resident will not suffer injury from unsafe smoking practices. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Observe clothing and skin for signs of cigarette burns.R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is cognitively intact.R3's Physician Order Sheet (POS), dated 5/20/2025, documents Oxygen 2LPM (liter per minute) per NC (nasal canula) continuous every shift.R3's progress Notes, dated 8/5/2025 at 3:24 AM, documents that Nursing Note (HC), Note Text: Writer has noted that resident was noted to have mind altering substance in his room. The smell of THC. Resident states he is aware of facility policy and will not do it again. Attendee to see resident today on rounds.R3's Progress Notes, dated 8/10/2025 at 10:34 AM, documents that Nursing Note (HC), Note Text: Day shift aide stated resident was in his room with door closed, when they opened resident door very strong smoke smell released from the room. Nurse educated resident on safety concerns while on oxygen and while in building as well facility smoking policies.On 8/11/2025 15:57 Nursing Note (HC) Note Text: room searched, sweep complete on room for smoking supplies. resident given copy of smoking policy, verbalized understanding of policy and verbalized understanding of education given by nurse V5 at time of smoking incident. will continue to f/u.On 8/20/2025 a review of R3's electronic health record documents no smoking assessment or contract. R3's Behavior Monitoring & Interventions, dated 8/5/2025 to 8/25/2025, and MONITOR - Behavior Symptoms documents, dated 8/5/2025 to 8/25/2025, documents no refusals of care.On 8/21/2025 at 11:00 AM R3's Electronic Health Record (EHR) reviewed. R3's EHR documents no smoking assessment and no contract. At that time R3's smoking assessments and contracts requested. R3's EHR documents no monitoring of R3 for smoking in room from 8/5/2025 to 8/10/2025. R3's EHR documents no refusal to transfer from bed to chair from 8/12/2025 to 8/19/2025, 8/21/25 to 8/24/2025. As of 8/25/2025 at 3:00 PM the facility hadn't provided R3's smoking assessments or smoking contract.On 8/20/2025 at 10:01 AM V2, Director of Nurses, stated that the midnight CNA upon entering R3's room, noticed the smell. V2 stated that they asked if he was smoking and R3 denied. V2 stated that they did not complete an incident report or complete an investigation. V2 stated that they put in place to get R3 up during the day. V2 stated that R3 has behaviors of yelling and cursing the staff out. V2 stated that when this occurs the staff leaves the room and then he goes down to the room and talk with R3. V2 stated that they completed a room search of R3's drawers and did not find anything. V2 stated that they were not able to search R3's bed or person because R3 would not get out of the bed.On 8/20/2025 at 11:32 AM V5, LPN, stated that she was notified of the strong smoke smell coming from room by V16, CNA, and that R3 had offered to sell V16 some marijuana. V5 stated that V16 identified the smell as marijuana. V5 stated that she entered R3's room. V5 stated that she did not see R3 smoking but was able to smell the aroma. V5 stated that she spoke with R3 about smoking in his room and he said he wouldn't do it anymore.On 8/20/2025 at approximately 11:00 AM V1, Administrator, stated that she was aware of R3 smoking and the care plan had been updated to reflect interventions put in place. V1 stated that this is not a new problem for R3. V1 stated that this has been going on prior to V1 date of hire in March. V1 stated that she inherited this problem.On 8/20/2025 at 2:15 PM V13, MDS Coordinator, stated that she was made aware of R3's smoking in his room on a Sunday. V13 stated that the facility addressed, provided education, and put interventions in place. V13 stated that the interventions are not working due to R3 refusing to get up. V13 stated that they continue to educate R3, and interventions are in place.On 8/20/2025 at 2:30 PM V10, Wound Nurse, stated that she was present on August 10 when R3 was noted to have smoked. V10 stated that she was alerted by staff that there was an odor coming from R3's room. V10 stated that upon entering V10 smelled the smoke. V10 stated that R3 was lying in bed with oxygen on and in place. V10 stated that she informed R3 that he could not smoke in his room because it was dangerous. V10 stated that she educated him on the risk of smoking with his oxygen. V10 stated that R3's oxygen was on and in place. V10 stated that she was able to get the lighter from R3. V10 stated that she didn't find any smoking supplies. V10 stated that she asked R3 where it was? R3 stated that he didn't have any more he smoked it all. V10 stated that she educated R3 on not smoking and R3 stated that he would not do it anymore. V10 stated that she was concerned because R3 has oxygen, and it could ignite. V10 stated that she started working at the facility in April. V10 stated that she was told that this was a problem prior to her employment.On 8/21/2025 at 2:04 PM V17, Nurse Practitioner (NP), stated that it is a big concern of any resident to smoke when using oxygen. V17 stated that the concern would be causing fire, harm to the resident and others. V17 stated that she would expect herself or the rounding physician to be notified. V17 stated that it is dangerous, and she would expect the resident to be assessed, interventions put in place, an investigation to be conducted, and ongoing monitoring.On 8/21/2025 at 3:00 PM V15, NP, stated that it was a fire hazard for R3 to be smoking in his room. V15 stated that it is dangerous for R3 to smoke in his room. V15 stated that R3 is on continuous oxygen and that could ignite causing harm and injury to R3 and his roommate if he has one. V15 stated that she would expect to be notified of the incident. V15 stated that she was not aware and not been notified of these incidents prior to this conversation. V15 stated that she would expect an investigation to be performed to find out how is R3 getting the items as he does not get out of the bed or leave his room. V15 stated that R3 health concerns could be a problem as well due to his COPD.On 8/25/2025 at 12:40 PM V16, CNA, stated that R3 showed her a small amount of substance in a bag. V16 stated that R3 identified it as marijuana and offered to sell it to her. V16 stated that she declined and reported it to her supervisor. V16 stated that she is unsure of the date. V16 stated that on a Sunday she came onto the hall and smelled a strong odor. V16 stated that she noticed that R3's door was closed. V16 stated that when she entered R3's room a cloud of smoke came out of the room. V16 stated that R3 was lying in bed with his oxygen on and in place. V16 stated that she asked R3 what was going on and R3 became upset and started cursing at V16. V16 stated that she explained to R3 that he can't smoke in his room because it is dangerous. V16 stated that she explained that he is putting her and all the residents on oxygen at risk for blowing up and catching on fire. V16 stated that R3 told her that he would not do it again. V16 stated that she texted V1 and informed her of what she found. V16 stated that V1 notified V10, and a room search was performed. V16 stated that interventions were put in place at that time. V16 stated that they were notified to get R3 out of the bed. V16 stated that R3 does not want to get out of bed and curses her and threatens to hit her in the head if she tries.On 8/25/2025 at 4:10 PM V1 stated that she was only aware of 1 incident of R3 smoking.On 8/26/2025 at 3:23 PM V18, Primary Physician, stated that it is a big concern with R3 smoking in his room with oxygen. V18 stated that R3 could blow the place up. V18 stated that he would expect that the facility would monitor this behavior.The facility Smoker's List 2025 documents All Cigarettes and Lighters must be returned into activity staff. All Smoking activities must be done in the designated area and with supervision. All residents that smoke must have a signed contract on file. No exceptions.The facility's Smoking Policy, dated 5/22/2017, This is a smoke free facility for staff. This facility allows direct supervised smoking by resident outside on patio in rear of facility. All resident cigarettes and smoking paraphernalia will be maintained in a locked box. No resident shall have possession of these materials. Smoking is prohibited in front of the facility in resident rooms or compartment where flammable liquids, combustible gases or oxygen is in use or stored. It continues Oxygen containers are not allowed in smoking areas at any time.The facility's Drug and Alcohol Behavioral Contract, not dated, documents for any resident who appears to be under the influence of any illegal substance or alcohol, the physician will be notified and the resident will be tested immediately. 1. First offense: responsible party/guardian will be notified of the offense. Staff will discuss behavior with the resident and attempt to define why the action occurred. Care plan will be updated as indicated. Nursing will check room daily, at random times, for illegal substances or alcohol for an unspecified amount of time. 2. Second offense: responsible party/guardian will be notified of the offense. Staff will discuss behavior with the resident and attempt to define why the action occurred. Care plan will be updated as indicated. Nursing will check room daily, at random times, for illegal substances or alcohol for an unspecified amount of time. The resident will be sent to a chemical dependency/alcohol abuse program within or outside of the facility.The Immediate Jeopardy that began on 8/5/25 was removed on 8/26/25, when the facility took the following actions to remove the immediacy: All smoking materials and paraphernalia were removed from R3's room on 8/10/25. This action was completed by nurse (V19).Resident room audit every 2 hours initiated 8/10/2025. Will be changed to Nursing to complete room audit with resident consent every shift due to R3 refusal of every 2 hours 8/25/2025.Smoking assessment completed for R3 on 8/25/2025 by MDS nurse.Installed smoke alarm in R3's room; placed oxygen safety signage 8/25/2025 by Maintenance Director.Initiated a every 15-minute safety check on R3 by nursing staff on 8/25/2025.Director of Nursing or designee completed re- education on smoking policy and safety on 8/5/25, 8/10/2025 and 8/25/25.Admin, DON/ADON, and CNA Supervisor educated all staff on smoking policy, oxygen/fire safety, monitoring procedures, and procedures for reporting noncompliance. Initiated on 8/25/2025 to all staff present and remaining staff will be educated prior to next shift.Smoking policy will be reviewed for implementation of additional interventions for safety of residents with oxygen. Completed by Regional Nurse on 8/25/25.Actions to prevent re-occurrence:On 8/25/2025, smoke detectors to be placed in resident rooms who smoke and are on oxygen. This will be completed by the maintenance Director.All residents with oxygen orders will receive a smoking risk assessment within 24 hours on all re-admissions starting on 8/25/2025 by charge nurse. All care plans will be updated by the MDS nurse to include individualized interventions by 8/25/2025.All residents who smoke and/or are on oxygen will be educated on facility smoking policy, fire hazards, and oxygen safety by 8/25/25.Education will be documented in resident records and completed by the maintenance director.Ongoing quality assurance:DON/designee will complete daily audits for 14 days to ensure 15-minute checks and compliance with interventions for R3 starting on 8/25/25.Admin or Activity director will conduct weekly audits for 8 weeks, then monthly audits for 6 months starting 8/25/2025.Results reviewed in monthly QAPI meetings by IDT with corrective actions implemented as needed starting on 8/25/2025.On 8/20/2025 V4, Social Service Director, provided the facility resident roster identifying 89 residents residing in the facility.
Jul 2025
4 deficiencies
1 IJ (1 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent mental abuse by denying access to visitors wh...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent mental abuse by denying access to visitors who abuse, exploits and harasses the residents residing in the facility. This failure has the potential to affect all 91 residents residing in the facility. This failure resulted in a Immediate Jeopardy when on 6/18/25, the facility failed to prevent a group of men from entering the facility, smoking marijuana, saying/singing obscenities such as sit your old a** down, f*** you n****, and swinging a leather belt around, while shooting a music video which included two residents (R1, R4), without their permission, that was posted on social media, now showing over 67,000 viewers. This failure has caused mental and psychosocial harm, leading to residents feeling unsafe in the facility, which is their home. Due to the unknown reason of the men's intrusion into the facility, this could have caused physical, mental, and psychosocial harm to all residents, due to the incident that occurred and not knowing if the men had deadly weapons or what their intentions were. This failure has caused residents to feel unsafe in the facility.
The Immediate Jeopardy began on 6/18/25 at 6:00 PM, when the group of men entered the facility. On 7/7/25, at 1:43 PM, V1, Administrator, V2, Director of Nurses (DON), and V27, Assistant Director of Nursing (ADON), were notified of the Immediate Jeopardy. On 7/9/25, the surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 7/8/25 but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of policies and procedures and the in-service training.
Findings include:
On 6/18/25, at approximately 6:00 PM, the facility failed to prevent a group of men from entering the facility, smoking marijuana, saying/singing obscenities such as sit your old a** down, f*** you n****, and swinging a leather belt around, while shooting a music video and included two residents (R1, R4), without their permission, in this video that was posted on social media, now showing over 67,000 viewers.
On 7/2/25 at 9:30 AM, R4 was observed in the hallway in his wheelchair. R4 stated he found out he was in a video without his permission. R4 stated he was in his room and must have fallen asleep because he was awoken by a loud noise, not a normal noise, and he saw a group of guys cursing, smelling like marijuana, yelling F*** old people. R4 stated the lady at the front desk (V11, Receptionist) didn't try to stop them from coming in the building. R4 stated he called the police because he didn't know what the men were doing. R4 stated a couple of days later he was shown a video posted on social media and he saw CNAs (Certified Nursing Assistants) in the video just walk by these guys and didn't say anything to them. R4 stated he isn't sure why this was allowed to happen and doesn't feel safe in the facility. R4 stated I can't defend myself and neither can any of the other people that live here, they are sick and that is why they are here, these hooligans, I didn't know if they came in with guns, knives, or what their intentions were. R4 appeared anxious, nervous, and fearful when talking about the incident.
R4's Face Sheet, undated, documents R4 has the following diagnoses: Type 1 Diabetes, Neuropathy, Chronic Kidney Disease, Heart Disease, Traumatic Amputation of the Right Foot, Need for Assistance with Personal Care, and Traction Detachment of the Left Eye Retina.
R4's Minimum Data Set (MDS), dated [DATE], documents R4 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R4 is cognitively intact.
R4's Care Plan, dated 7/14/25, documents R4 has Activities of Daily Living (ADL) self-care performance deficit and requires assistance with daily care needs.
On 7/3/25 at 2:35 PM, R1 stated he did not give permission to be videotaped or have the video posted on social media.
R1's Face Sheet, undated, documents R1 has the following diagnoses: Altered Mental Status, Schizophrenia, Type 2 DM, Pulmonary Hypertension, and Heart Disease.
R1's MDS, dated [DATE], documents R1 has a BIMS score of 10, indicating R1 has moderate cognitive impairment.
R1's Care Plan, dated 4/12/24, documents R1 has an ADL self-care performance deficit and requires assistance with daily care needs.
R1's Care Plan, dated 6/25/25, documents on 6/25/25, it was brought to staff's attention that R1 was in a video going around on social media that illegally recorded on the premises, violating R1's privacy. R1 will be removed from the common areas if door lock system fails. The facility doors will be locked 24/7 and will require either a code or staff permission to enter the facility, approved visitors only.
R1's Progress Note, dated 6/25/25 at 4:32 PM, documents the following: About 12:00 PM, writer received notification from staff that a video was circulating on social media posted by a civilian. Apparently, the video had a glimpse of the resident in it. The facility was unaware of the video being recorded. Police were notified and took a report. Writer spoke with R1's POA (Power of Attorney) and made her aware of the video and advised the preventative measures that would be put into place moving forward.
R1's Progress Note, dated 6/27/25 at 11:16 AM, documents the following: Resident is alert with periods of confusion. Resident has a diagnosis of Schizophrenia, Wandering, and Insomnia. Resident likes to hang out in the common areas. Resident witnessed an incident regarding some men running in the building. R1 stated he saw the event take place. He stated they were just young and confused.
The facility's Final Investigation Report, dated 6/27/25, documents the following: On June 18th, 2025, a group of men entered into the building behind some employees. The receptionist asked them to sign in because they stated they were here to see their granny. Then the men proceeded to laugh and say they were just playing, then a few more men rushed behind him and ran through 100 halls. (V13 and V16) from the dietary department had asked the men to leave once they got down the hall. The men left and exited out the front door. Witnesses say they did have their phone in their hand but wasn't sure at the moment what they were doing or what they were possibly recording. Other staff and residents did witness the phone in their hand, and it seemed like they were recording themselves. Our resident (R4) called the police first and told the receptionist (V11) he called. The men were still hanging out in the parking lot. The DON and the police arrived simultaneously, and the men exited the parking lot. After the video surfaced on 6/25/25, staff notified the administrator that one of the residents (R1) appeared in the video. The video didn't mention any names or identify who theses residents were. They saw a small glimpse of (R4), but he claims he was telling the civilians to exit and stop causing commotion. (R4) is alert and oriented x 4 and he is his own POA. Administrator notified the police again and called R1's family about the event. MD (Medical Doctor) is aware of the event. Residents were interviewed on the 100-hall, they had no concerns and advised they all feel safe. Social Service Assistant ensured them that their safety is our priority. Activity Director is conducting a resident council meeting advising all the residents that the doors will now be locked 24/7 and visitors must put in a code to enter, or the receptionist will have to manually let them in the building. Our HR (Human Resources) director also sent out a voice alert notifying families and staff our interventions. There was no harm done and no abuse substantiated, all residents have continued their daily routine with no mental anguish. (R1) has continued his daily routine as well with no mental anguish.
The QAPI (Quality Assurance Performance Improvement) Action Plan, dated 6/27/25, documents the concern was video recording and invasion. The root cause analysis was unlocked doors, possible people hanging around parking lot, and ensure proper screening. Goals/Objectives are to keep the doors locked 24/7. Action items are to lock the doors 24/7, pending new cameras with a possible buzz in option, and spot checks of the parking lot.
On 7/2/25 at 8:30 AM, V4, CNA (Certified Nursing Assistant), stated she saw a video that was circulating, some guys came in rapping, unsure of the date, the video was inappropriate, the men in the video kept saying sit your old a** down.
On 7/2/25 at 8:32 AM, V5, LPN (Licensed Practical Nurse), stated she saw the video on social media, it was inappropriate, there were young men rapping, she was unable to watch it fully and she is unsure of who's social media site it came from.
On 7/2/25 at 8:35 AM, V6, CNA, stated she wasn't here when the video was made but it was all over social media, the video was inappropriate, there were young men running around singing sit you old ass down.
On 7/2/25 at 8:37 AM, V7, CNA, stated there was a video shot in the facility and that was inappropriate. V7 stated she isn't sure of who's social media page it was shared from. V7 stated it was from a gentleman that made the video, they were in the parking lot and facility, there were residents in the video.
On 7/2/25 at 8:40 AM, V9, RN (Registered Nurse), stated there was a video on social media, it was inappropriate, the individuals in the video don't work at the facility, it was disrespectful and not safe. V9 stated she didn't think there were any residents or staff that were affiliated with or knew the men in the video, it could be local people, but she isn't sure of who they were or any of their names. V9 stated she only saw it because someone else posted it, but she was unable to tell the surveyor who posted it.
On 7/2/25 at 8:50 AM, V10, Dietary Manager, stated she was gone for the day when the incident with the video occurred on 6/18/25, but her evening dietary staff were here and wrote statements. V10 stated the video crossed the line and violated HIPAA (Health Insurance Portability and Accountability Act), the men were walking through the facility, she thinks there was one resident in the video.
On 7/2/25 at 9:00 AM, V2, Director of Nurses (DON), there was a video of about 6-7 black men in the facility. V2 stated he got a call from the facility on 6/18/25 in the evening about it and came immediately, when he arrived the men were standing outside of the facility, he is unsure of their names and doesn't believe they were affiliated or knew any of the staff or residents. V2 stated he asked the men what they were doing at the facility and what was their purpose of being there, one of the men, V14, Unidentified Male, told him that he had came in, gave the receptionist a phony name to distract her, while the other men snuck in the front door.
On 7/2/25 at 10:15 AM, V12, R3's Family, stated R3 was in the hospital but has been transferred to another nursing home. V12 stated R3 didn't want to return because she didn't feel safe in the building because of the video that was made in the facility.
On 7/2/25 at 10:37 AM, R7 stated he doesn't feel safe in the facility with those men coming through the door like that, smoking marijuana.
On 7/2/25 at 10:40 AM, R8 stated he doesn't feel safe in the facility since the incident occurred.
On 7/2/25 at 3:35 PM, V18, CNA, stated she was here when the video incident occurred on 6/18/25. V18 stated she didn't see the men with the camera, but they were rapping in the hallway, there were a few residents in the hallway, can't recall who they were. V18 stated when this happened, she didn't feel safe because she didn't know who they were or why they were there.
On 7/2/25 at 4:19 PM, V13, Dietary Aide, stated she was here when the incident with the video occurred on 6/18/25, she was clocking out and noticed a group of men in the parking lot, she went to tell the receptionist, who was outside, then she went to the nurses station to let the staff know what was going on and then the men came through the front door and were coming down the hallway, so she told them to leave because nobody else would. V13 stated this made her feel unsafe, the men came in smoking and doing all kinds of stuff.
On 7/2/25 at 4:25 PM, V17, CNA. stated on 6/18/25 she was on the 100-hall doing her rounds, she went to the nurse's station and noticed a group of men coming down the 100-hall, she thought it was a resident's family, but it wasn't. V17 stated a few of the other aides walked down the hallway, doesn't recall who the aides were, to see what was going on. V17 stated there were residents saying it made them feel uncomfortable, unable to recall who, just that there were a few.
On 7/2/25 at 4:50 PM, V11, Receptionist, stated on 6/18/25 around 6:00 PM, she was in the parking lot talking with a resident's family member and noticed a group of men in the parking lot, they were talking loudly, and she didn't think anything of it. V11 stated about that time a couple of the kitchen staff came from around the building and told her about the men. V11 stated she came back into the facility and 1 man came to the desk and about 6 or 7 men came in after the first male and proceeded to walk down the hallway, she asked them what they were doing and told them if they weren't here to see a loved one, they needed to leave. V11 stated the other men kept walking and the one man said they were there to film a video, and she told them they needed to leave, they could not do that here. V11 stated she didn't call the police while the man was at her desk because she leaves the facility at 9 at night and didn't want to get shot, you'll get shot, I'm [AGE] years old. V11 stated one of the residents saw it and called the police. V11 stated the men did eventually leave the facility and were outside talking to V2, DON. V11 again stated she felt very unsafe, she was afraid she would get shot because they will do that to you. V11 stated now the doors are kept locked and any visitors have to be let in. V11 stated she will feel much safer when they get the new things in place, they are supposed to install a camera at the receptionist desk and any visitors will have to be buzzed in. So, when a visitor comes, she will be able to see who it is, ask why they are here, and they won't be let in until it is verified who they are and that they are visiting a resident. V11 appeared upset and visibly shaken when talking about the incident and what could have happened.
On 7/3/25 at 2:40 PM, V1, Administrator, stated on 6/18/25, she received a phone call that some men were in the facility, one of the men distracted the receptionist by telling her he was here to see his granny, while the other men came into the facility and proceeded down the 100-hall. V1 stated staff did tell the men to leave and they did eventually. V1 stated R1 was the main resident in the video, he and his POA (Power of Attorney) were not concerned for him or his safety. V1 stated she isn't sure who the men were, but the word is that the one singing could be a rapper with local connections. V1 stated there were no staff or residents that knew the men, and no one had given them permission to videotape in or outside the facility. V1 stated since the incident, they are keeping the front door locked at all times and anyone entering through that door has to be let in by the receptionist or staff.
On 7/8/25 at 10:25 AM, V29, Paramedic/Clinical Team Member for V28, FNP (Family Nurse Practitioner), stated an incident like this could cause mental and psychosocial harm. V28 stated staff needed to observe R4 for any signs of increased anxiety, acting out towards stimulation like what had occurred with the incident that could resemble PTSD (Post Traumatic Stress Disorder).
The Abuse Prevention Program policy, dated 6/2008, documents the facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical), neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. It is the policy of this facility to develop a mechanism to reduce the risk of abuse, neglect, misappropriation of resident property and/or crimes from being committed against the residents of this facility. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Examples include abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings of any manner that would demean or humiliate residents.
The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 7/8/25, documents there are 91 residents residing in the facility.
The Immediate Jeopardy that began on 6/18/25 was removed on 7/8/25, when the facility took the following actions to remove the immediacy:
On 6/18/2025, Dietary staff demanded for the group of men to exit the facility. Then men exited to the parking lot.
On 6/18/2025, local authorities were called, and they took report and immediately made the group of men exit the premises.
On 6/18/2025, the doors were programmed to lock at 6:00 PM which requires a code upon entry, or the receptionist has to manually open the door for all visitors.
When the facility was notified, an unauthorized video surfaced the internet, the Administrator, V1, immediately reported the recording and called the local authorities on 6/25/2025.
On 6/25/2025, Maintenance Director reprogrammed the door to lock 24/7.
On 6/27/2025, Activity Director, V40, conducted a resident council and ensured the residents they safety is our first priority. All residents were invited, the ones who desired to come, attended the meeting.
On 6/27/2025, Human Resources (HR), V38, sent out a voice alert to residents' families and staff advising the new safety measures that were implemented.
On 6/27/2025, V1, conducted a QAPI meeting with all department heads analyzing the following: receptionist must spot check front premises to ensure no civilians are lingering around, if so call 911, lock doors 24/7 and don't pass out code, ensure proper screening for visitors.
a.
The screening process requires the following: the receptionist or designee is required to ask the purpose of their visit. Vendors must identify themselves and the purpose of their visit. All families and friends that are here for residents must identify the residents name and the purpose of their visit.
b.
b.
The receptionist or designee will be required to fill out the spot check form daily, and the checks are ongoing between 8:00 AM-9:00 PM. Spot checks are completed every two hours. A CNA or a Nurse will check the lobby every two hours between 9:00 PM-8:00 PM. No other doors are accessible to the public from the outside; you must use a code. By locking the doors, it does not interfere or override our fire alarm system. In the case of an emergency, the doors are still programmed to open, and residents and staff will still have an exit to egress.
On 6/27/2025 an in-service was conducted by the Business Office Manager, V43.
a.
Front doors will be locked 24/7.
b.
Must conduct proper screening, ensure they have purpose for their visit.
On 6/27/2025, the Administrator, V1, called the local authorities and made a second report to (V25, Local Police Officer), case number 2025-05942. He advised he will now escalate this matter to (V26, Local Police Detective) for charges of disorderly conduct and property invasion.
On 7/7/2025, Maintenance Director, V37, reached out to the (local) police department for a consult regarding a plan or a preventative measure for unwanted visitors. (V41, Local Police Officer) advised he will check with the sheriff and give us an update.
On 7/7/2025, QAPI team created a code for possible weapon/invasion. DON, V2, ADON, V27, initiated an in-service regarding the following:
a.
All unwanted visitors, immediately call 911 and demand them to exit the premises.
b.
If intruders bypass front doors/ force entry call 911 and yell code Silver
c.
Once the Silver code is activated, all available staff will move residents to a safe zone, or behind a barrier such as a locked door. If possible, they can evacuate to an alternate door if there is no potential harm.
d.
Any suspicion of weapons, foreign objects, violence, disorderly conduct, unauthorized recordings, suspicious activity, drug utilization, yell the code Silver and call 911
e.
Any concealed clothing, face coverings, disguises, yell code Silver.
f.
After a code Silver has been activated, any designated person that can go into a locked room will initial the 911 call. Locked rooms are utility closets, storage rooms, manager offices, and the medication room.
g.
After a code Silver is activated, all staff will have residents go in their room and hide or move them to a safe zone.
h.
Staff will help our residents exit, they will proceed to evacuate if safe.
i.
In-serviced staff to create a barrier between themselves/residents and the perpetrators.
Starting 7/7/2025, and continuing until further addressed in a plan of correction, the IDT team will have a monthly QAPI to review any concerns and make necessary changes and review the following:
a.
Going forward, receptionist will have a form to complete daily, indicating they completed a spot check of the front premises.
b.
Implementing name tags, ensuring everyone can be identified. Vendors must have a visitor pass/badge indicated they were allowed in the building.
c.
On 7/8/2025, All CNAs completed a Safety questionnaire with all the residents. The CNAs will be directed by Social Services to ask questions for a screening and any resident who responds affirmatively will be referred to Social Services for further assessment, physician/psychiatrist notification and recommendation as to further services and supports. The questionnaire focused on, fears of their surroundings, safety concerns, mood state, and providing education with the new interventions that were implemented for their safety.
d.
On 7/8/2028, Social Services, V39, initiated a whole house in-service regarding the abuse policy and will be completed by night shift.
e.
On 7/8/2028, our abuse policy is being reviewed and modified to focus on key components such as Psychosocial and mental abuse. The policy was updated by (V42, Regional Operational Support).
Date of Removal/Abatement Completion: 7/8/2025
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect residents' privacy for 2 of 4 residents (R1, ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect residents' privacy for 2 of 4 residents (R1, R4) reviewed for privacy/confidentiality in the sample of 8.
Findings include:
1. On 6/18/25, at approximately 6:00 PM, the facility failed to prevent a group of men from entering the facility, smoking marijuana, saying/singing obscenities such as sit your old a** down, f*** you n****, and swinging a leather belt around, while shooting a music video and including two residents (R1, R4), without their permission, that was posted on social media, now showing over 67,000 viewers.
On 7/2/25 at 9:30 AM, R4 was observed in the hallway in his wheelchair. R4 stated he found out he was in a video without his permission. R4 stated he was in his room and must have fallen asleep because he was awoken by a loud noise, not a normal noise, and he saw a group of guys cursing, smelling like marijuana, yelling F*** old people. R4 stated the lady at the front desk (V11, Receptionist) didn't try to stop them from coming in the building. R4 stated he called the police because he didn't know what the men were doing. R4 stated a couple of days later he was shown a video posted on social media and he saw CNAs (Certified Nursing Assistants) in the video just walk by these guys and didn't say anything to them. R4 stated his privacy, and rights were violated by these men. R4 appeared anxious, nervous, and fearful when talking about the incident.
R4's Face Sheet, undated, documents R4 has the following diagnoses: Type 1 Diabetes, Neuropathy, Chronic Kidney Disease, Heart Disease, Traumatic Amputation of the Right Foot, Need for Assistance with Personal Care, and Traction Detachment of the Left Eye Retina.
R4's Minimum Data Set, MDS, dated [DATE], documents R4 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R4 is cognitively intact.
2. On 7/3/25 at 2:35 PM, R1 stated he did not give permission to be videotaped or have the video posted on social media.
R1's Face Sheet, undated, documents R1 has the following diagnoses: Altered Mental Status, Schizophrenia, Type 2 DM, Pulmonary Hypertension, and Heart Disease.
R1's MDS, dated [DATE], documents R1 has a BIMS score of 10, indicating R1 has moderate cognitive impairment.
R1's Care Plan, dated 6/25/25, documents on 6/25/25, it was brought to staff's attention that R1 was in a video going around on social media that illegally recorded on the premises, violating R1's privacy.
R1's Progress Note, dated 6/25/25 at 4:32 PM, documents the following: About 12:00 PM, writer received notification from staff that a video was circulating on social media posted by a civilian. Apparently, the video had a glimpse of the resident in it. The facility was unaware of the video being recorded. Police were notified and took a report. Writer spoke with R1's POA (Power of Attorney) and made her aware of the video and advised the preventative measures that would be put into place moving forward.
On 7/2/25 at 9:00 AM, V2, DON (Director of Nurses), there was a video of about 6-7 black men in the facility. V2 stated he got a call from the facility 6/18/25 in the evening about it and came immediately, when he arrived the men were standing outside of the facility, he is unsure of their names and doesn't believe they were affiliated or knew any of the staff or residents. V2 stated he asked the men what they were doing at the facility and what their purpose of being there was, one of the men, V14, Unidentified Male, told him that he had came in, gave the receptionist a phony name to distract her, while the other men snuck in the front door.
On 7/2/25 at 4:50 PM, V11, Receptionist, stated on 6/18/25 at approximately 6:00 PM, she was in the parking lot talking with a resident's family member and noticed a group of men in the parking lot, they were talking loudly, and she didn't think anything of it. V11 stated about that time a couple of the kitchen staff came from around the building and told her about the men. V11 stated she came back into the facility and 1 man came to the desk and about 6 or 7 men came in after the first male and proceeded to walk down the hallway, she asked them what they were doing and told them if they weren't here to see a loved one, they needed to leave. V11 stated the other men kept walking and the one man said they were there to film a video, and she told them they needed to leave, they could not do that here. V11 stated she didn't call the police while the man was at her desk because she leaves the facility at 9 at night and didn't want to get shot, you'll get shot, I'm [AGE] years old. V11 stated one of the residents saw it and called the police.
On 7/3/25 at 2:40 PM, V1, Administrator, stated on 6/18/25, she received a phone call that some men were in the facility, one of the men distracted the receptionist by telling her he was here to see his granny, while the other men came into the facility and proceeded down the 100-hall. V1 stated staff did tell the men to leave and they did eventually. V1 stated R1 was the main resident in the video, he and his POA (Power of Attorney) were not concerned for him or his safety.
On 7/8/25 at 10:25 AM, V29, Paramedic/Clinical Team Member for V28, FNP (Family Nurse Practitioner), stated an incident like this could cause mental and psychosocial harm. V28 stated staff needed to observe R4 for any signs of increased anxiety, acting out towards stimulation like what had occurred with the incident that could resemble PTSD (Post Traumatic Stress Disorder).
The Resident Rights Policy, undated, documents the residents have the right to privacy and confidentiality.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to recognize potential abuse and immediately report an al...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to recognize potential abuse and immediately report an allegation of abuse to the Department. This has the potential to affect all 91 residents in the facility.
Findings include:
On 6/18/25, at approximately 6:00 PM, the facility failed to prevent a group of men from entering the facility, smoking marijuana, saying/singing obscenities such as sit your old a** down, f*** you n****, and swinging a leather belt around, while shooting a music video and including two residents (R1, R4), without their permission, in this video that was posted on social media, now showing over 67,000 viewers.
On 7/2/25 at 9:30 AM, R4 was observed in the hallway in his wheelchair. R4 stated he found out he was in a video without his permission. R4 stated he was in his room and must have fallen asleep because he was awoken by a loud noise, not a normal noise, and he saw a group of guys cursing, smelling like marijuana, yelling F*** old people. R4 stated the lady at the front desk (V11, Receptionist) didn't try to stop them from coming in the building. R4 stated he called the police because he didn't know what the men were doing. R4 stated a couple of days later he was shown a video posted on social media and he saw CNAs (Certified Nursing Assistants) in the video just walk by these guys and didn't say anything to them. R4 stated he isn't sure why this was allowed to happen and doesn't feel safe in the facility. R4 stated I can't defend myself and neither can any of the other people that live here, they are sick and that is why they are here, these hooligans, I didn't know if they came in with guns, knives, or what their intentions were. R4 appeared anxious, nervous, and fearful when talking about the incident.
R4's Minimum Data Set, MDS, dated [DATE], documents R4 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R4 is cognitively intact.
The facility's Final Investigation Report, dated 6/27/25, documents the following: The initial report was submitted on 6/25/25 which was 7 days after the incident occurred. On June 18th, 2025, a group of men entered into the building behind some employees. The receptionist asked them to sign in because they stated they were here to see their granny. Then the men proceeded to laugh and say they were just playing, then a few more men rushed behind him and ran through 100-hall. (V13 and V16) from the dietary department had asked the men to leave once they got down the hall. The men left and exited out the front door. Witnesses say they did have their phone in their hand but wasn't sure at the moment what they were doing or what they were possibly recording. Other staff and residents did witness the phone in their hand, and it seemed like they were recording themselves. Our resident (R4) called the police first and told the receptionist (V11) he called. The men were still hanging out in the parking lot. The DON and the police arrived simultaneously, and the men exited the parking lot. After the video surfaced on 6/25/25, staff notified the administrator that one of the residents (R1) appeared in the video. The video didn't mention any names or identify who theses residents were. They saw a small glimpse of (R4), but he claims he was telling the civilians to exit and stop causing commotion. (R4) is alert and oriented x 4 and he is his own POA. Administrator notified the police again and called R1's family about the event. MD (Medical Doctor) is aware of the event. Residents were interviewed on the 100-hall, they had no concerns and advised they all feel safe. Social Service Assistant ensured them that their safety is our priority. Activity Director is conducting a resident council meeting advising all the residents that the doors will now be locked 24/7 and visitors must put in a code to enter, or the receptionist will have to manually let them in the building. Our HR (Human Resources) director also sent out a voice alert notifying families and staff our interventions. There was no harm done and no abuse substantiated, all residents have continued their daily routine with no mental anguish. (R1) has continued his daily routine as well with no mental anguish.
On 7/2/25 at 9:00 AM, V2, Director of Nurses, DON, there was a video of about 6-7 black men in the facility. V2 stated he got a call from the facility on 6/18/25 in the evening about it and came immediately, when he arrived the men were standing outside of the facility, he is unsure of their names and doesn't believe they were affiliated or knew any of the staff or residents. V2 stated he asked the men what they were doing at the facility and what was their purpose of being there, one of the men, V14, Unidentified Male, told him that he had come in, gave the receptionist a phony name to distract her, while the other men snuck in the front door.
On 7/2/25 at 3:35 PM, V18, Certified Nurse's Aide, CNA, stated she was here when the video incident occurred on 6/18/25. V18 stated she didn't see the men with the camera, but they were rapping in the hallway, there were a few residents in the hallway, can't recall who they were. V18 stated when this happened, she didn't feel safe because she didn't know who they were or why they were there.
On 7/2/25 at 4:19 PM, V13, Dietary Aide, stated she was here when the incident with the video occurred on 6/18/25, she was clocking out and noticed a group of men in the parking lot, she went to tell the receptionist, who was outside, then she went to the nurses station to let the staff know what was going on and then the men came through the front door and were coming down the hallway, so she told them to leave because nobody else would. V13 stated this made her feel unsafe, the men came in smoking and doing all kinds of stuff.
On 7/2/25 at 4:25 PM, V17, CNA. stated on 6/18/25 she was on the 100-hall doing her rounds, she went to the nurse's station and noticed a group of men coming down the 100-hall, she thought it was a resident's family, but it wasn't. V17 stated a few of the other aides walked down the hallway, doesn't recall who the aides were, to see what was going on. V17 stated there were residents saying it made them feel uncomfortable, unable to recall who, just that there were a few.
On 7/2/25 at 4:50 PM, V11, Receptionist, stated on 6/18/25 around 6:00 PM, she was in the parking lot talking with a resident's family member and noticed a group of men in the parking lot, they were talking loudly, and she didn't think anything of it. V11 stated about that time a couple of the kitchen staff came from around the building and told her about the men. V11 stated she came back into the facility and 1 man came to the desk and about 6 or 7 men came in after the first male and proceeded to walk down the hallway, she asked them what they were doing and told them if they weren't here to see a loved one, they needed to leave. V11 stated the other men kept walking and the one man said they were there to film a video, and she told them they needed to leave, they could not do that here. V11 stated she didn't call the police while the man was at her desk because she leaves the facility at 9 at night and didn't want to get shot, you'll get shot, I'm [AGE] years old. V11 stated one of the residents saw it and called the police. V11 stated the men did eventually leave the facility and were outside talking to V2, DON. V11 again stated she felt very unsafe, she was afraid she would get shot because they will do that to you. V11 stated now the doors are kept locked and any visitors have to be let in. V11 stated she will feel much safer when they get the new things in place, they are supposed to install a camera at the receptionist desk and any visitors will have to be buzzed in. So, when a visitor comes, she will be able to see who it is, ask why they are here, and they won't be let in until it is verified who they are and that they are visiting a resident. V11 appeared upset and visibly shaken when talking about the incident and what could have happened.
On 7/3/25 at 2:40 PM, V1, Administrator, stated on 6/18/25, she received a phone call that some men were in the facility, one of the men distracted the receptionist by telling her he was here to see his granny, while the other men came into the facility and proceeded down the 100-hall. V1 stated staff did tell the men to leave and they did eventually. V1 stated there were no staff or residents that knew the men, and no one had given them permission to videotape in or outside the facility. V1 stated since the incident, they are keeping the front door locked at all times and anyone entering through that door has to be let in by the receptionist or staff. V1 stated she reported the incident after she became aware of the video.
The Abuse Prevention Program policy, dated 6/2008, documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. The facility will develop and implement policies and procedures to assist in the identification and reporting of events, trends and patterns that may constitute abuse or that may require further investigation. Facility staff will investigate and report any allegations of abuse within timeframe required by Federal Law. Any allegation of abuse will be reported to the facility Administrator or his/her designee, who will follow Federal requirements for reporting to the following entities: State licensing agency responsible for licensure of the facility, law enforcement officials, the resident's representative, and the resident's primary physician.
The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 7/8/25, documents there are 91 residents residing in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse. This has the potenti...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse. This has the potential to affect all 91 residents in the facility.
Findings include:
On 6/18/25, at approximately 6:00 PM, the facility failed to prevent a group of men from entering the facility, smoking marijuana, saying/singing obscenities such as sit your old a** down, f*** you n****, and swinging a leather belt around, while shooting a music video and including two residents (R1, R4), without their permission, in this video that was posted on social media, now showing over 67,000 viewers.
On 7/2/25 at 9:30 AM, R4 was observed in the hallway in his wheelchair. R4 stated he found out he was in a video without his permission. R4 stated he was in his room and must have fallen asleep because he was awoken by a loud noise, not a normal noise, and he saw a group of guys cursing, smelling like marijuana, yelling F*** old people. R4 stated the lady at the front desk (V11, Receptionist) didn't try to stop them from coming in the building. R4 stated he called the police because he didn't know what the men were doing. R4 stated a couple of days later he was shown a video posted on social media and he saw CNAs (Certified Nursing Assistants) in the video just walk by these guys and didn't say anything to them. R4 stated he isn't sure why this was allowed to happen and doesn't feel safe in the facility. R4 stated I can't defend myself and neither can any of the other people that live here, they are sick and that is why they are here, these hooligans, I didn't know if they came in with guns, knives, or what their intentions were. R4 appeared anxious, nervous, and fearful when talking about the incident.
R4's Minimum Data Set (MDS), dated [DATE], documents R4 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R4 is cognitively intact.
On 7/2/25 at 9:00 AM, V2, Director of Nurses, DON, stated there was a video of about 6-7 black men in the facility. V2 stated he got a call from the facility on 6/18/25 in the evening about it and came immediately, when he arrived the men were standing outside of the facility, he is unsure of their names and doesn't believe they were affiliated or knew any of the staff or residents. V2 stated he asked the men what they were doing at the facility and what was their purpose of being there, one of the men, V14, Unidentified Male, told him that he had come in, gave the receptionist a phony name to distract her, while the other men snuck in the front door.
On 7/2/25 at 3:35 PM, V18, Certified Nurse's Aide, CNA, stated she was here when the video incident occurred on 6/18/25. V18 stated she didn't see the men with the camera, but they were rapping in the hallway, there were a few residents in the hallway, can't recall who they were. V18 stated when this happened, she didn't feel safe because she didn't know who they were or why they were there.
On 7/2/25 at 4:19 PM, V13, Dietary Aide, stated she was here when the incident with the video occurred on 6/18/25, she was clocking out and noticed a group of men in the parking lot, she went to tell the receptionist, who was outside, then she went to the nurses station to let the staff know what was going on and then the men came through the front door and were coming down the hallway, so she told them to leave because nobody else would. V13 stated this made her feel unsafe, the men came in smoking and doing all kinds of stuff.
On 7/2/25 at 4:25 PM, V17, CNA. stated on 6/18/25 she was on the 100-hall doing her rounds, she went to the nurse's station and noticed a group of men coming down the 100-hall, she thought it was a resident's family, but it wasn't. V17 stated a few of the other aides walked down the hallway, doesn't recall who the aides were, to see what was going on. V17 stated there were residents saying it made them feel uncomfortable, unable to recall who, just that there were a few.
On 7/2/25 at 4:50 PM, V11, Receptionist, stated on 6/18/25 around 6:00 PM, she was in the parking lot talking with a resident's family member and noticed a group of men in the parking lot, they were talking loudly, and she didn't think anything of it. V11 stated about that time a couple of the kitchen staff came from around the building and told her about the men. V11 stated she came back into the facility and 1 man came to the desk and about 6 or 7 men came in after the first male and proceeded to walk down the hallway, she asked them what they were doing and told them if they weren't here to see a loved one, they needed to leave. V11 stated the other men kept walking and the one man said they were there to film a video, and she told them they needed to leave, they could not do that here. V11 stated she didn't call the police while the man was at her desk because she leaves the facility at 9 at night and didn't want to get shot, you'll get shot, I'm [AGE] years old. V11 stated one of the residents saw it and called the police. V11 stated the men did eventually leave the facility and were outside talking to V2, DON. V11 again stated she felt very unsafe, she was afraid she would get shot because they will do that to you. V11 stated now the doors are kept locked and any visitors have to be let in. V11 stated she will feel much safer when they get the new things in place, they are supposed to install a camera at the receptionist desk and any visitors will have to be buzzed in. So, when a visitor comes, she will be able to see who it is, ask why they are here, and they won't be let in until it is verified who they are and that they are visiting a resident. V11 appeared upset and visibly shaken when talking about the incident and what could have happened.
On 7/3/25 at 2:40 PM, V1, Administrator, stated on 6/18/25, she received a phone call that some men were in the facility, one of the men distracted the receptionist by telling her he was here to see his granny, while the other men came into the facility and proceeded down the 100-hall. V1 stated staff did tell the men to leave and they did eventually. V1 stated R1 was the main resident in the video, he and his POA (Power of Attorney) were not concerned for him or his safety. V1 stated she isn't sure who the men were, but the word is that the one singing could be a rapper with local connections. V1 stated there were no staff or residents that knew the men, and no one had given them permission to videotape in or outside the facility. V1 state she reported the incident after the video surfaced.
The facility's Final Investigation Report, dated 6/27/25, documents the following: The initial report was submitted on 6/25/25. The report documented On June 18th, 2025, a group of men entered into the building behind some employees. The receptionist asked them to sign in because they stated they were here to see their granny. Then the men proceeded to laugh and say they were just playing, then a few more men rushed behind him and ran through 100-halls. (V13 and V16) from the dietary department had asked the men to leave once they got down the hall. The men left and exited out the front door. Witnesses say they did have their phone in their hand but wasn't sure at the moment what they were doing or what they were possibly recording. Other staff and residents did witness the phone in their hand, and it seemed like they were recording themselves. Our resident (R4) called the police first and told the receptionist (V11) he called. The men were still hanging out in the parking lot. The DON and the police arrived simultaneously, and the men exited the parking lot. After the video surfaced on 6/25/25, staff notified the administrator that one of the residents (R1) appeared in the video. The video didn't mention any names or identify who theses residents were. They saw a small glimpse of (R4), but he claims he was telling the civilians to exit and stop causing commotion. (R4) is alert and oriented x 4 and he is his own POA. Administrator notified the police again and called R1's family about the event. MD (Medical Doctor) is aware of the event. Residents were interviewed on the 100-hall, they had no concerns and advised they all feel safe. Social Service Assistant ensured them that their safety is our priority. Activity Director is conducting a resident council meeting advising all the residents that the doors will now be locked 24/7 and visitors must put in a code to enter, or the receptionist will have to manually let them in the building. Our HR (Human Resources) director also sent out a voice alert notifying families and staff our interventions. There was no harm done and no abuse substantiated, all residents have continued their daily routine with no mental anguish. (R1) has continued his daily routine as well with no mental anguish.
The abuse investigation for this incident was reviewed. V1 interviewed all alert and oriented residents on 100-hall but did not interview any other residents in the facility regarding this incident.
The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 7/8/25, documents there are 91 residents residing in the facility.
The Abuse Prevention Program policy, dated 6/2008, documents the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. The facility will develop and implement policies and procedures to assist in the identification and reporting of events, trends and patterns that may constitute abuse or that may require further investigation. The Policy documents Facility staff will investigate and report any allegations of abuse within timeframe required by Federal Law.
Jun 2025
8 deficiencies
3 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0578
(Tag F0578)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow advanced directives for 1 of 4 (R89) residents reviewed for ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow advanced directives for 1 of 4 (R89) residents reviewed for advanced directives in the sample of 67. This failure resulted in an Immediate Jeopardy on [DATE] when R89 was transferred to the hospital with lifesaving measures, against the documented DNR (do not resuscitate) advanced directive status. R89 ultimately expired at the hospital after being subjected to CPR, Mechanical Ventilation and the use of an AED (automated external defibrillator) which subsequently re-started his heart for a period of time. On [DATE] at 2:28 PM V1, Administrator, V2 DON and V3 ADON were notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on [DATE], after abatement reviews dated [DATE] at 3:05 PM and 3:17 PM, [DATE] at 12:11 PM and [DATE] at 10:57 AM but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training.
Findings include:
R89's Undated Face Sheet, documents R89 was initially admitted to the facility on [DATE].
R89's admission Minimum Data Set (MDS) dated [DATE] documents he was cognitively intact.
R89's Social Services Note, dated [DATE] at 4:18 PM documents R89 was admitted from a local hospital on [DATE]. He signed the POLST to be DNR. POLST will need to be signed by NP or Doctor. Order needs to be entered in PCC (Point Click Care).
On [DATE] at 11:53 AM V7, Director of Social Services stated she documented the wrong year on the social service note dated [DATE] should be documented [DATE]. V7 confirmed (R89's) code status was DNR because she spoke to him herself about it and he definitely didn't want anyone pounding on his chest or being electrically shocked to restart his heart, he'd rather die peacefully.
R89's POLST Form, dated [DATE] documents do not resuscitate, comfort-focused treatment. Primary goal is maximizing comfort through symptom management. Allow natural death. Do not use treatments listed in full and selective treatment. Full treatment: mechanical ventilation and cardioversion (use of an AED shocking the heart.) Selective treatment: do not use invasive mechanical ventilation.
R89's Care Plan dated [DATE], documents resident chose to be a DNR per POLST. No CPR in the event that patient has no pulse, do not attempt resuscitation/DNR. Comfort focused treatment if patient is not in cardiac arrest. Follow if patient has a pulse.
On [DATE] at 2:59 PM, V27, Medical Records stated she uploaded (R89's) POLST form on [DATE] and although she stated it wasn't a good and clear copy to scan into the resident's medical record, she could still read the form after it was uploaded to (R89's) medical record.
R89's Nursing Note, dated [DATE] at 8:00 AM documents nurse alerted by staff that resident showing a change in condition. Resident observed with a thready, faint pulse. Patient assessed and treated until EMS arrived.
R89's Nursing Note, dated [DATE] at 8:50 AM documents hospital notified facility patient expired at 8:48 AM. Arrangements made from hospital to be transported to funeral home.
R89's Health Status Note, dated [DATE] at 10:37 AM documents EMS arrived at 8:09 AM and departed at 8:21 AM.
On [DATE] at 2:00 PM V11, CNA stated she recalled (R89) he was alert and oriented and was able to make his needs know. On [DATE] V14, CNA was assigned to (R89) and she recalled they both reported to V15, RN that (R89) was out of it that morning and the resident was really spacy. A while later she entered (R89's) room and observed V14 transferring (R89) with a gait belt from his bed to wheelchair and (R89) stated, I can't stand, I'm dizzy! and V14 lowered (R89) to the floor. V11 stated she ran down the hall and yelled for a nurse and grabbed the crash cart. V11 stated staff (names unknown) laid (R89) on the floor and started CPR and continued CPR until EMS arrived to the facility. V11 stated she was really concerned for (R89) because he was slow to respond earlier that morning but when she reported it to V15 she was receiving nurse report from the night shift nurse and she waived her away.
On [DATE] at 2:15 PM V12, LPN stated she recalled (R89) and the day he was transferred to the hospital on [DATE]. V12 stated she wasn't assigned to the resident that day but at around 6:30 AM, at the beginning of the shift she overheard V11, CNA report to V15 that (R89) wasn't acting himself, she didn't know if V15 assessed (R89) or not because she was assigned to another hall. A while later, V12 heard staff yelling down the hall they need a nurse. She entered (R89's) room and observed V17, LPN and V16, LPN was on the floor administering CPR compressions to (R89) she relieved V16 from doing CPR compressions and checked (R89's) pulse and she didn't feel a pulse at that time. She didn't know (R89's) code status was but she did CPR because the other nurses were doing it. V12 stated after the code was over and (R89) was transferred to the hospital V15 told her that she was very upset because (R89) was a DNR and they did CPR on him and shouldn't have. She was concerned for her nursing license at that time and V12 didn't know what V15 documented as to what occurred when (R89) coded. V12 stated she didn't see V15 in the room during this time, V15 may have been outside at that time.
R89's Medical Record dated [DATE] documents no vital signs documented.
On [DATE] at 3:45 PM V17, LPN stated on [DATE] she was assigned to the 500 hall and during nurse report she overheard V11, CNA and V14, CNA report to V15, RN that (R89) was not himself and something was wrong with him. V17 didn't know if V15 went to assess (R89) or anything because she was assigned to the 500 hall and (R89) resided on 300 hall. Sometime in the morning (time unknown) V15 asked her, We don't do CPR on a resident that's still breathing, right? V17 responded, No, we only do CPR if the resident's not breathing. V17 didn't know what was going on or if V15 assessed (R89) at that time. A while later (time unknown) V17 heard staff yelling, CODE and she ran to (R89's) room and noted (R89) was sitting on the edge of the bed as V14 was holding him up and she assisted V14 to placed (R89) on the floor. V16, LPN arrived to (R89's) room and they started doing CPR at that time. V17 stated she didn't know (R89's) code status if he was a DNR or a full code but she went with performing CPR because that was her nurse intuition. After the EMS left the facility V17 stated V15 looked at (R89's) medical record she told her (R89) was supposed to be a DNR not a full code so staff shouldn't have done CPR on (R89) and they were nervous about it and didn't want to get in trouble. V17 stated she doesn't know what V15 documented in (R89's) medical record but she told her she wasn't going to document that staff did CPR because she didn't want to get in trouble or lose her nursing license.
On [DATE] at 10:45 AM V14, CNA was assigned to (R89) on [DATE] and he recalled what occurred. V14 stated this was the first day he was assigned to (R89) and didn't know him at all. V14 stated he asked V11 if she could help him and she went into (R89's) and told V14 that (R89) wasn't acting himself and she left the room and reported to a nurse (name unknown) that (R89) wasn't right and V11 came back to (R89's) room and said she told the nurse about it. Over an hour later V14 stated (R89) was laying in bed and was yelling, Get me up! I want to get up! No nurse came to (R89's) room V14 and V11 transferred (R89) to his wheelchair and as they did (R89) fainted/passed out and wasn't responsive. V14 and V11 got (R89) back to bed and he wasn't talking and his eyes were closed. V11 left (R89's) room and yelled down the hall that they need a nurse and V12, V16, V17 responded to (R89's) room immediately. They told them to put (R89) on the floor and the nurses started CPR. V14 stated he's a CNA and didn't know (R89's) code status. V14 recalled when EMS arrived to the facility he saw they used a mechanical ventilator to pump (R89's) chest and used an AED to shock (R89's) heart. EMS stated they got a heartbeat back on (R89) and he was transported to the hospital. V15 entered (R89's) and finally assessed him, 911 was called and he was transported to the hospital.
On [DATE] at 11:14 AM V15, RN stated she was assigned to (R89) on [DATE] and she was familiar with him and was assigned to him often. V15 stated (R89's) baseline was he was alert and able to make his needs known and was a 1-2 person transfer. On [DATE] she recalled she got to work around 6:30 AM and got report from the night shift nurses (names unknown) and no issues or concerns was expressed for (R89.) No staff reported that he wasn't acting right during nurse report. It wasn't until around 8:00 AM that V11 reported that (R89) was not acting himself and she immediately went to his room and laid eyes on him. At that time (R89) was in bed and he stated he didn't want to get up out of bed. V15 stated (R89) was lethargic at that time and was very slow to respond to her and while she was assessing his vital signs including blood pressure, heart rate, pulse oxygenation and respirations and he was rapidly declining right in front of her. V15 recalled (R89's) pulse was faint and the oxygen saturation machine didn't register on his finger and she tried different fingers but it still would register a reading. She instructed V11 and V14 to put (R89) on the floor and she ran and got the crash cart and yelled, Code blue! She looked up (R89's) code status in the computer but she stated it was grayed out and she couldn't read it so she errored on the side of caution and instructed staff to start CPR. V12, V16 and V17 helped with CPR compressions and bagged (R89) until EMS arrived to the facility. V15 reported to EMS that (R89) was a full code and they continued CPR using a mechanical ventilator and also shocked (R89's) heart with an AED. (R89) heartbeat came back and EMS transferred him to the hospital. Hospital staff called back a few minutes later and stated (R89) was deceased . V15 stated she didn't ask other staff if a resident was breathing if you should start CPR because she is an RN and knows if the resident is breathing you don't start CPR. V15 stated she documented the entire change in condition regarding (R89) in the nurse progress notes in the computer including his vital signs and how staff provided CPR that day, she didn't know why the assessment wasn't documented in (R89's) medical record because she knows if you don't document it it wasn't done and she definitely wanted to protect her nursing license. After (R89) was transferred to the hospital the medical records staff showed her a code status book at the nurse's station and she read (R89's) code status and it showed he was a DNR. She was really upset because of everything staff did to save his life including mechanical ventilation and using the AED to shock his heart when they weren't supposed to do any of that.
On [DATE] at 12:25 PM V15 called back and stated she recalled when she got the crash cart to (R89's) room staff (name unknown) was on the phone with V2 and he told staff to start CPR on (R89) immediately and that's why staff did CPR.
On [DATE] at 9:45 AM V34, Former Therapy Program Manger stated she worked with (R89) and provided occupational therapy, she noted (R89) was alert and able to make his needs known. V34 stated she got to the facility at 5:00 AM on [DATE] and noted (R89) was in bed around 6:30 AM and observed V11 and V14 were transferring (R89) from his bed to wheelchair and he was yelling out that he didn't want to get up. V34 entered (R89's) room and told the CNAs to sit him back on the bed and they did. V15, RN entered (R89's) room and asked what he's yelling about and at that time V34 noted (R89) took a gasp for breath which she thought was odd. V15 instructed the CNAs to lay him in bed and raise the head of the bed and that he'd be fine V15 then left (R89's) room. V34 stated she was gravely concerned about (R89) but that V15 was an RN and she trusted her nurse judgement. Around 8:00 AM she went to (R89's) room to check on him and V11, CNA was in his room and told V34 that she reported to V15, RN that (R89) was not responsive but that no one was doing anything about it. V34 stated she went to get a blood pressure cuff and a pulse ox and put it on (R89), neither the blood pressure or pulse ox would register a reading at that time and from what she could tell (R89) wasn't breathing. V34 stated she called V2, DON at that time on her cell phone and V2 stated he wasn't at the facility but if (R89) wasn't breathing that she needed to call a code blue and start doing CPR. V11, CNA yelled code blue down the hall and V12, LPN and V17, LPN entered (R89's) room and started doing CPR on him. V34 stated (R89) was transferred to the hospital after EMS got a heartbeat and she was informed he passed away shortly after arriving to the emergency room. V34 stated she found out from staff on [DATE] that (R89) was supposed to be a DNR, not a full code.
On [DATE] at 3:00 PM V16, LPN stated she worked night shift and arrived to the facility at 10:30 on [DATE] and also worked day shift on [DATE] as well. V16 stated she was assigned to (R89) night shift and administered a medication, (medication name and dose unknown) to him at 6:00 AM on [DATE], V16 stated he was sleeping and she woke him up and he was at baseline at that time he took the medication and went back to sleep. He didn't complain of shortness of breath or pain at that time. V16 gave nurse report to the day shift nurses V12, V15 and V17 and V15 was (R89's) day shift assigned nurse. V16 didn't recall any staff reporting (R89) was having any changes during nurse report. A while later she was at the nurse's station and V11 came to the nurse's station and reported to V15 several times that (R89) wasn't acting right and was slow to respond to them. V16 stated V11 is assigned to (R89's) hall and knows him well so she knew something must be wrong if she kept saying something was wrong with (R89.) A few minutes went by and V15 was still on the computer at the nurse's station at that time and wasn't going to assess (R89) so her and V12 went to assess (R89.) V16 stated she was halfway down the hall when a therapy employee (name unknown) came out of (R89's) and stated he's no longer responsive. V16 stated when she entered (R89's) he was in bed and eyes were closed. Her and V12 assessed (R89) by doing a sternal rub which he had no response to and the pulse oximetry machine wasn't displaying a reading at that time. We called for a crash cart at that time and an unknown staff told them he is a full code. She instructed staff to put (R89) on the floor and she, R12 and V17 started CPR. When EMS arrived they used a mechanical ventilator and an AED to shock his heart a few times. After (R89) was transferred to the hospital she recalled a staff said (R89) was supposed to be a DNR and she didn't know that and she knew if a resident is a DNR they aren't supposed to do CPR on them.
On [DATE] at 2:20 PM V27, Medical Records stated she recalled on [DATE] when (R89) was transferred to the hospital. V27 stated she told the nurse (name unknown) that was on the phone with EMS that she has a binder with resident information in it and that they could use the binder information if needed and she would replace whatever documents they use from the binder after (R89) was transferred to the hospital. V27 stated she didn't recall telling a nurse that the resident's code status was in the binder.
R89's Hospital Medical Record, dated [DATE] documents History of Present Illness patient presents to the ER by EMS in cardiac arrest. Per EMS 10 minutes of downtime with bystander CPR. When EMS arrived 3 shocks were advised. EMS was a BLS crew, no medications give. No other history obtained. ACLS was continued on arrival to the ER. Pt airway was intubated on arrival, ACLS was continued. On arrival was initially given epinephrine, calcium bicarb. On pulse check, was in V Fib was shocked and provided with 300 mg of amiodarone. On next pulse, was V-Tach was provided with 150 of amiodarone and shock. Next pulse check was also V-Tach was provided with 100 of lidocaine and shock. At next pulse check, PE, AA was given epinephrine next couple pulse checks 2, still PE with cardiac standstill. Eventually time of death was called at 8:48 AM.
On [DATE] at 12:45 PM V2, DON stated when a resident has a change in condition he expects staff to obtain vital signs including blood pressure, heart rate, oxygen saturation and respirations. He also expects the nurse to assess the resident from head to toe noting any abnormalities. The nurse should talk to the resident and see what their orientation status is to see if there is a change in baseline. The nurse should also assess the resident for pain and dizziness. and to notify the physician of what the assessment was and to obtain orders from the physician. V2 stated the full change in medical condition assessment including vital signs is expected to be documented in the resident's nurse progress notes. V2 recalled R89 and stated he was sent to the emergency room for his catheter at one point but he was readmitted to the facility the same day and he didn't recall any specifics of what occurred on [DATE].
On [DATE] on 12:12 PM V2, DON stated if staff call him and notify him of a resident having a change in condition he would tell staff to get the resident's vital signs and have a nurse assess the resident and to notify the resident's physician of the change in condition to get physician's orders but he would never tell staff to initiate or start CPR because he doesn't know residents' code status and denied telling staff to initiate or start CPR on (R89) when he coded on [DATE]. He doesn't know why staff would say that he said that.
On [DATE] at 11:25 AM V2, DON stated when a resident is initially admitted to the facility he expects staff to assess the resident's code status and document it on the POLST form. He expects the POLST form to be scanned into the computer in the resident's medical record and expects staff to upload a readable POLST form so staff can view it in an emergency situation. V2 stated he noted (R89's) POLST appeared [NAME] and it was poor quality and he couldn't read what (R89's) code preference was on the form. V2 stated (R89) was a DNR and staff should have provided comfort measures only and shouldn't have done CPR or had an AED used on him to restart his heart. A DNR comfort measures only means staff should still assess the resident, obtain vital signs, apply oxygen to the resident and ensure the resident is pain free and stabilize the resident to the best of the nurse's ability. V2 expected staff to honor the resident's POLST form wishes.
On [DATE] at 11:40 AM V1, Administrator stated the facility doesn't have an advanced directive policy and they probably should so staff would know what it is and to follow it. V1 expects the POLST form in resident's medical records to be readable to ensure in an emergency the licensed nurse can read the POLST form and abide by the resident's documented POLST form code decision.
On [DATE] at 9:50 AM, V21 Nurse Practitioner stated staff including the assigned nurse should know the resident's code status and should most definitely follow it because that is the resident's wishes which are usually documented upon admission to the facility. V21 stated if (R89's) comfort measures only then staff shouldn't have done CPR including mechanical ventilation or using an AED to shock his heart. The only thing staff should have offered (R89) should be oxygen if his signed POLST form documents comfort measures only.
Identified opportunity for improvement/deficient practice:
Improving nursing skill sets for conducting a code blue status and executing physician orders timely and efficiently.
Immediate Corrective Action for those affected by the deficient practice:
-V22, Wound Nurse from hospital held a CPR class that was completed for nurses on [DATE].
-Code Blue status in-service completed on [DATE]. The in-service outlines reviewing the POLST before performing CPR or when a Code Blue is active. Completed by DON and ADON.
-Physician Orders for Life sustaining treatments inservice and Change in Medical Condition policy inservice completed on [DATE]. Completed by DON and ADON.
-Medical order that outlines patients specifics wishes for end of life-sustaining procedures in-service completed on 4/25. Completed by DON and ADON and LNHA.
-Night shift charge nurse currently audits Crash Carts daily. Inservice completed by DON and ADON on [DATE].
-Performing CPR on a resident with no pulse return demonstration, initiated [DATE] and will be ongoing. Completed on [DATE] by DON and ADON.
-Immediate DNR and Full Code Status Audit completed on [DATE]. Completed by SSD.
-Ordered AED Machine, pending delivery Date, Order placed on [DATE] by Medical Records on [DATE]. Pending tracking number.
-Inserviced Medical Record [NAME] and [NAME] SSD to ensure all POLST forms are readable. Completed by LNHA on [DATE].
2. Process/Steps to identify others having the potential to be impacted by the same deficient practice:
-All residents have the potential to be affected. R89 expired on [DATE].
3. Measures put into place/systematic changes to ensure the deficient practice does not reoccur.
-DON/ADON or designee will review physician's orders (e.g., code status) daily for the next 4 weeks.
-DON/ADON or designee will review Review laboratory or radiology results pertinent to the resident's death when a death occurs for the next 4 weeks.
DON/ADON will pull three random charts twice a week for the next 4 weeks and do the following:Review progress notes to determine what interventions were put into place to address the change or decline in condition (e.g., first aid measures, glucose monitoring, cardiopulmonary resuscitation [CPR], and immediate transfer)?
4. Plan to monitor performance to ensure solutions are sustained.
Beginning [DATE] and continuing until further addressed in the plan of correction, the DON or Designee will conduct a chart review, 3 random charts twice a week for 4 weeks to ensure chart is the following:
-Evaluate interventions to determine was intervention appropriate, monitored and modified as needed
-Was pain assessed and treatment measures documented.
-Ensure care was consistent with the resident advance directive or goals for care
-If concerns are identified, review facility policies and procedures with regard to factors that led to the resident's death.
-Review resident sig change and compare it to their baseline.
-Ensure resident decisions were honored and executed.
-Communicate changes with family/POA.
-Do a complete audit on chart, after death.
-Medical Records or SSD is responsible for auditing the POLST form in PCC, Emergency Response book on Wednesday weekly for the next 4 weeks.
Surveyors validated the removal of abatement by reviewing medical records for change in medical condition. R89 was deceased and therefor his medical record was not further reviewed. Surveyors reviewed additional sampled residents medical records to ensure the facility's following notification changes in condition policy. The facility documented inservices of staff which the surveyors reviewed. Employees including (V1, V2, V3, V19, V29 and V29) were interviewed regarding the inservices. R48's does not have a POLST but does have a state guardianship paperwork that documents he is a DNR. V1 stated all staff have been inserviced on the facility's advanced directive policy and if they haven't been they will be inserviced on the policy prior to working on the floor with residents.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R240's Electronic Medical Record (EMR) Medical Diagnoses Sheet, documented his code status was Do Not Resuscitate (DNR) with ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R240's Electronic Medical Record (EMR) Medical Diagnoses Sheet, documented his code status was Do Not Resuscitate (DNR) with comfort focused measures. The Sheet documented R240 had the following diagnoses: Acute Kidney Failure, Type 2 Diabetes Mellitus, Essential Hypertension, Chronic Kidney Disease stage 2, Congestive Heart Failure, muscle weakness, sepsis, severe sepsis with septic shock, vascular dementia.
R240's Physician's Orders (PO), dated 5/13/25, documented R240 was receiving Bactrim DS Oral, tablet 800-160 mg (milligram), Give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 7 days.
R240's Progress Note, dated 5/13/25, at 17:17 PM, documented Resident on antibiotic therapy due to UTI. Resident remains afebrile, vital signs WNL (within normal limits), no adverse reactions noted. Will continue to monitor.
R240's Vital Summary, dated 5/15/25, at 9:38 PM, documented his blood pressure was 114/70 mmHg (millimeters of mercury); oxygen (O2) saturation level (sats) was at 98% at room air; temperature was 97.8 degrees Fahrenheit (F), and respirations 18 breaths/minute.
There were no vital signs documented on 5/16/25 in R240's medical record.
R240's Vital Summary, dated 5/17/25, at 12:24 PM, documented R240's temperature was 97.2 degrees F; at 12:26 PM respirations of 18 breaths/minute; and blood pressure of 135/72 mmHg ; and no O2 sats documented.
No further vital signs were documented in R240's medical record.
R240's Nursing Note, dated 5/18/25, at 1:37 PM, documented Resident has had a change in condition. Resident is refusing to eat, drink, or take noon meds. Resident is non-compliant with care. Writer reached out to resident POA (Power of Attorney), (V81) to make aware of changes and was sent to voicemail. There is no documentation R240's medical practitioner, V50 (Nurse Practitioner) was notified.
R240's Nursing Note, dated 5/18/25, at 9:28 PM, documented Residents POA (V81) came up to facility to see resident. Writer informed POA of residents decrease in appetite and fluid intake. Writer also made POA aware of resident's resistance when it came to allowing staff to provide peri care, showers, and assistance with feeding. POA stated she noticed a change in resident as well. Writer suggested hospice POA stated she would talk with residents' sons, and will the facility know when they make their decision. There was no documentation R240's medical provider, including V50, Nurse Practitioner, was notified.
R240's Nursing Note, dated 5/19/25, at 6:46 AM, documented Resident observed to be declining. No food or drinks consumed during a 24-hour period due to resident consistent refusal. Resident appears to be less responsive than baseline. Appropriate staff have been notified. There was no documentation R240's medical provider, including V50 was notified.
On 5/27/25 2:44 PM V80, LPN stated she was the night shift nurse that had come in on 5/18/25. Stated that she recalls being notified by the off going nurse that day that R240 hadn't been himself that day and wasn't wanting to eat/drink/take meds. Stated they told her to keep an eye on him and they had talked to his family about initiating hospice. Stated that night she can't recall if she took any vital signs, stated the electronic medical record system prompts the nurses if vital signs are needed are needed per a schedule or with meds. V80 stated that night he slept well and displayed no emergent needs. Stated she had given report to the oncoming shift of the previous day expressed concerns and that he had no occurrences over the night.
R240's Nursing Note, dated 5/19/25, at 7:25 AM, documented Residents conts (continues)to decline in condition. Resident is having shallow breathing, only responds to physical stimuli. Writer notified residents POA (V81) and stated she would be up today to visit resident. There was no documentation R240's medical provider, including V50, was notified.
R240's Nursing Note, dated 5/19/25, at 9:00 AM, documented Writer got report resident health is declining. Writer got vitals, O2 (oxygen) was low, O2 was administered at 2L (Liters). Resident son is present, POA notified of changes in condition. POA and son requested resident be sent out to (out of state hospital) per POA. (Ambulance Service) EMS (Emergency Medical Service) called, ambulance arrived resident transported to (out of state hospital).
R240s's Nursing Note, dated 5/19/25, at 2:07 PM, documented Writer called (out of state) ED (Emergency Department) to get report on resident, nurse stated resident was changed to full code and was intubated and sent to ICU (Intensive Care Unit).
R240's Nursing Note, dated 5/19/25, at 5:23 PM, documented This nurse called (out of state hospital) ED for report on (R24). I spoke with charge nurse (name of charge nurse) who states that resident expired at 3:35 PM this afternoon.
R240's Hospital Emergency Department (ED) Records, dated 5/19/25, documented R240 arrived at the hospital at 9:54 AM. The Hospital Records documented EMS (Emergency Medical Service) states that when they arrived pt (patient) was very lethargic and cool to touch, blood sugar read low. EMS gave Glucagon. Upon arrival pt still only responsive to pain and blood sugar read low.
R240's Emergency Medicine Resident Note, in the hospital record dated 5/19/25, documented Patient was brought in by EMS from nursing home after he was found to be unresponsive. Patient had low blood sugars to below 40s per EMS. EMS was unable to establish any venous access, patient was given glucagon instead. Per EMS, patient has not been eating for the past several days, and patient was recently hospitalized (at out of state hospital) for an unknown sickness. Initial vital signs for normal on presentation aside from hypothermia to 88.9 Degree F. Patient was responsive to pain but was not alert to self or place.
R240's Attending Physician Supervisory Note, dated, 5/19/25, documented The patient is a [AGE] year-old male that comes from a nursing home initially for hypoglycemia. The patient is paperwork demonstrated that is patient status was DNR DNI with more so an emphasis on comfort measures. An ultrasound IV was placed by myself and during this time the patient continued to decline. We started the patient on pressors since the patient did not have any paperwork stating that he would not want this. Also, during this time, we attempted to contact the family after several attempts we finally were able to get a hold of the patient's son. At this point they completely changed the patient 's code status and made him a full code. The note continued We had multiple discussions with the family. Therefore, at this point the patient was CPR. The patient subsequently declared dead at 1525 by myself.
On 5/23/25, at 11:36 AM, V24, LPN stated she took care of R240 on Monday, 5/19/25. She stated she was given report that he had a change of condition. V24 stated R240 had stopped eating and was being non-compliant with care. V24 stated R240's breathing was shallow, and his O2 sats were low. V24 stated she put oxygen on R240 for comfort. V24 stated R240's son, V82, was at the bedside while she took R240's vitals and was asking if there was something they could do. V24 stated that there was a conversation between V82 and V81 on the phone. V24 stated V81 and V82 decided to send him out. V24 stated V83 was R240's physician but the facility was notifying V50, as she was in the facility Monday through Friday. When questioned where this notification would be documented, V24 responded it would be documented the Progress Notes. V24 stated that on the weekend, the facility did have an on-call doctor that they could notify, but they were calling V50, as they had her direct number and could call her. V24 stated that the on-call service would be notified from 1:00 PM on Friday until 7:00 AM the following Monday. When asked what V50 directed them to do regarding R240, she stated nothing. V24 stated she notified V50 when the family requested R240 be sent to hospital as she needed V50's permission to send R240 out.
On 5/23/25, at 11:50 PM, V10, LPN, stated that V50 was in the facility routinely and followed R240's care. V10 stated R240 wasn't eating or drinking. She said it all started on Tuesday of the previous week. V10 stated V50 was at the facility on Tuesday, and she notified V50 at that time. V10 stated it wasn't like R240 to not eat or drink. V10 said that he was not letting them care for him. She said that she came in on Saturday or Sunday and it was the same thing, he was not eating or drinking. She said that she called V81 and discussed possible Hospice. She said that was the family's choice. She encouraged V81 and the family come in as she thought they may be able to help or get him to eat. V10 stated said they notified V81 that needed to get in and see him. She said the son, V82, came in and was at the bedside. V10 stated she attempted to R240's blood pressure using the wrist cuff, and it was reading low, she thought 96/52. V10 stated it was up to the family as to what they wanted to. V24 stated V82 was at the bedside and V81 was talking to him, and they decided to send him out to the hospital. When asked if V50 was notified of his blood pressure and changes of condition, she said that she initially told V50 of the change but after that, he didn't have a big change it just continued. V10 stated she did not notify V50 because she was already aware of R240's change.
On 5/23/25, at 10:28 AM, V50 stated that she was R240's medical practitioner and she was the one who saw him in the facility. V50 stated that she had not been notified on 5/18/25 of R240's change of condition as she does not take weekend call. She stated that the on-call service takes over at 1:00 PM on Friday and extends until 7:00 AM on Monday. V50 stated that she was not aware R240 had been sent to the hospital until Tuesday (5/20/25), at which time she was told he expired. She stated that notification of medical practitioner would have been documented in the Progress Notes. V50 stated that per standards of practice, vital signs would be taken if the initial vitals were abnormal. V50 stated that for example if a O2 sat was below 90%, the nurses should contact the medical practitioner and the medical practitioner would make the decision as if they wanted to send the resident to the hospital, continue to monitor vitals or get laboratory work.
On 5/23/25, at 12:00 PM, during a follow-up call with V50, she stated that V10 did notify her of R240's change of condition on Tuesday, 5/13/25. She stated she was not notified on 5/18/25, that there was a change in R240's baseline. V50 stated she was not called regarding R240 being sent to the hospital, and she did not give that order. V50 stated she did not become aware of R240's change of condition until after he passed away. She stated that she was not sure if the outcome would have changed if she had been notified, but she said it would have allowed her to have a conversation with the family regarding how they wanted to proceed. She said they would have discussed possible medications to stimulate appetite, tube feeding and possible Hospice. She again stated that R240 had chosen Do Not Resuscitate with Comfort Measures.
The facility took the following actions to remove the Immediacy:
Identification of Residents Affected or Likely to be Affected:
Improving nursing skill sets for conducting a complete assessment on residents who has acute change in condition and non-urgent change in condition.
1.Immediate Corrective Action for those affected by the deficient practice:
DON, V2 and V3, ADON completed an in-service on 4/29/2025 on our Notification Changes in Condition policy.
The policy includes the following:
Upon identification of any change in condition licensed nursing personnel will contact the resident's attending physician/on-call physician/practitioner to notify him/her of the change. Acute changes in condition should occur immediately upon recognition while non-urgent changes should occur no later than 72 hours from the noted change.
All notifications should be documented and should include; The date and time of the notification;
a)
The name of the individual contacted;
b)
The specific reason for the notification;
c)
And any specific responses that were given by the person contacted.
All changes of condition require an immediate assessment and documentation of resident condition which should include, at a minimum:
a)
Pain
b)
Orientation
c)
Any change from baseline status
d)
Status of any pending labs/diagnostics
e)
Vital signs
All changes of condition require a follow up assessment with proper documentation that will include the following: pain, orientation, baseline status and current status, updates on results from labs/diagnostics and vital signs. Nursing will continue to update MD/NP on the status of the resident.
2. Process/Steps to identity others having the potential to be impacted by the same deficient practice:
-All resident have the potential to be affected. R89 expired on 2/25/2025.
3. Beginning April 29, 2025, measures were put into place/systematic changes to ensure the deficient practice does not recur.
-DON/ADON or designee will review physician's orders (e.g., code status) daily for the next 4 weeks.
-DON/ADON or designee will review laboratory or radiology results pertinent to the resident's change in condition for the next 4 weeks.
-DON/ADON will pull three random charts twice a week for the next 4 weeks and do the following: Review progress notes to determine what interventions were put into place to address the change or decline in condition (e.g., first aid measures, glucose monitoring, cardiopulmonary resuscitation [CPR], and immediate transfer)?
4. Plan to monitor performance to ensure solutions are sustained.
-Beginning April 29, 2025 and continuing until further addressed in the plan of correction, the DON or Designee will conduct a chart review, 3 random charts twice a week for 4 weeks to ensure chart is the following:
-Evaluate interventions to determine was intervention appropriate, monitored and modified as needed
-Was pain assessed and treatment measures documented.
-Ensure care was consistent with the resident advance directive or goals for care
-If concerns are identified, review facility policies and procedures with regard to factors that led to the resident's change in condition.
-Review resident significant change and compare it to their baseline.
-Communicate changes with family/POA.
Surveyors validated the removal of abatement by reviewing medical records to ensure residents had readable POLST forms uploaded and a physician's order for code status, verification of code status documented in medical. R89 was deceased and therefor his medical record was not further reviewed. Surveyors reviewed POLST forms and physician's orders for code status. R48 didn't have an updated POLST form and this was brought to the attention of V7, Social Services Director. The facility submitted an advanced directive policy dated 4/30/2025 and they inserviced staff that day on the policy. V1, Administrator stated all staff will be inserviced before they start working, including agency staff. Employees including (V1, V2, V3, V7, V19, V27, V29 and V49.) Surveyors conducted a review of all facility inservices. Were interviewed to ensure they were aware of current policies and procedures and had been inserviced. The completion date was changed from 4/29/2025 to 4/30/2025 due to V1, DON and V2 ADON inservicing staff on the new advanced directive policy. V1 stated all staff have been inserviced on the facility's notification changes in condition policy and if they haven't been they will be inserviced on the policy prior to working on the floor with residents.
Based on interview and record review, the facility failed to properly assess, monitor residents experiencing a change in condition for 3 of 5 residents (R89, R193, R240) reviewed for change in medical condition in the sample of 67. This failure resulted in R89's delay in medical treatment for a change in condition and R89 was pronounced deceased at the hospital on 2/25/2025.
This failure resulted in Immediate Jeopardy on 2/25/202 when R89, he had a change in condition and the facility failed to timely assess R89 which resulted in R89 being transferred to the hospital with lifesaving measures. R89 ultimately expired at the hospital. On 4/29/2025 at 9:15 AM V1, Administrator, V2 DON and V3 ADON were notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on 4/30/2025, after abatement reviews dated 4/29/2025 at 1:18 PM, 2:00 PM and 2:29 PM but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training.
Findings include:
1.R89's Undated Face Sheet, documents R89 was initially admitted to the facility on [DATE].
R89's admission Minimum Data Set (MDS) dated [DATE] documents he was cognitively intact.
R89's Nursing Note, dated 2/25/2025 at 8:00 AM documents nurse alerted by staff that resident showing a change in condition. Resident observed with a thready faint pulse. Patient assessed and treated until EMS arrived.
R89's Nursing Note, dated 2/25/2025 at 8:50 documents hospital notified facility patient expired @ 8:48 AM. Arrangements made from hospital to be transported to funeral home.
R89's Health Status Note, dated 2/25/2025 at 10:37 AM documents EMS arrived at 8:09 AM and departed at 8:21 AM.
On 4/23/2025 at 2:00 PM V11, CNA stated she recalled (R89) he was alert and oriented and was able to make his needs know. On 2/25/2025 V14, CNA was assigned to (R89) and she recalled they both reported to V15, RN that (R89) was out of it that morning and the resident was really spacy. A while later she entered (R89's) room and observed V14 transferring (R89) with a gait belt from his bed to wheelchair and (R89) stated, I can't stand, I'm dizzy! V14 lowered (R89) to the floor. V11 stated she ran down the hall and yelled for a nurse. V11 stated she was really concerned for (R89) because he was slow to respond earlier that morning but when she reported it to V15 she was receiving nurse report from the night shift nurse, and she waived her away.
On 4/23/2025 at 2:15 PM V12, LPN stated she recalled (R89) the day he had a change in medical condition and was transferred to the hospital on 2/25/2025. V12 stated she wasn't assigned to (R89) that day but at around 6:30 AM, at the beginning of the shift she overheard V11, CNA report to V15 that (R89) wasn't acting himself, she didn't know if V15 assessed (R89) or not because she was assigned to another hall. A while later V12 heard staff yelling down the hall they need a nurse that (R89) had a change in medical condition.
R89's Medical Record dated 2/25/2025 documents no vital signs documented.
On 4/23/2025 at 3:45 PM V17, LPN stated on 2/25/2025 she was assigned to the 500 hall and during nurse report she overheard V11, CNA and V14, CNA report to V15, RN that (R89) was not himself and something was wrong with him. V17 didn't know if V15 went to assess (R89) or anything because she was assigned to the 500 hall and (R89) resided on 300 hall. Sometime later that morning (time unknown) staff announced (R89) wasn't responsive and 911 was called and he was transferred to the hospital.
On 4/24/2025 at 10:45 AM V14, CNA was assigned to (R89) on 2/25/2025 and he recalled what occurred. V14 stated this was the first day he was assigned to (R89) and didn't know him at all. V14 stated he asked V11 if she could help him and she went into (R89's) and told V14 that (R89) wasn't acting himself and she left the room and reported to a nurse (name unknown) that (R89) wasn't right and V11 came back to (R89's) room and said she told the nurse about it. Over an hour later, V14 stated (R89) was laying in bed and was yelling, Get me up! I want to get up! No nurse came to (R89's) room V14 and V11 transferred (R89) to his wheelchair and as they did (R89) fainted/passed out and wasn't responsive. V14 and V11 got (R89) back to bed and he wasn't talking and his eyes were closed. V11 left (R89's) room and yelled down the hall that they need a nurse and V12, V16, V17 responded to (R89's) room immediately. V15 entered (R89's) and finally assessed him, 911 was called and he was transported to the hospital.
On 4/23/2025 at 11:14 AM V15, RN stated she was assigned to (R89) on 2/25/2025 and she was familiar with him and was assigned to him often. V15 stated (R89's) baseline was he was alert and able to make his needs known. On 2/25/2025 she recalled she got to work around 6:30 AM and got report from the night shift nurses (names unknown) and no issues or concerns was expressed for (R89.) No staff reported that (R89) wasn't acting right during nurse report. It wasn't until around 8:00 AM that V11 reported that (R89) was not acting himself and she immediately went to his room and laid eyes on him. At that time (R89) was in bed and he stated he didn't want to get up out of bed. V15 stated (R89) was lethargic at that time and was very slow to respond to her and while she was assessing his vital signs including blood pressure, heart rate, pulse oxygenation and respirations and he was rapidly declining right in front of her. V15 recalled (R89's) pulse was faint and the oxygen saturation machine didn't register on his finger and she tried different fingers but it still wouldn't register a reading. V15 also reiterated that no staff reported to her that (R89) was having an issues or any concerns prior to after nurse report and she started administering medications to residents. V15 stated she documented the entire change in condition regarding (R89) in the nurse progress notes in the computer including his vital signs, she didn't know why the assessment wasn't documented in (R89's) medical record because she knows if you don't document it it wasn't done and she definitely wanted to protect her nursing license. V15 stated (R89) was transferred to the hospital via EMS and he died shortly after arriving to the hospital.
On 4/25/2025 at 9:45 AM V34, Former Therapy Program Manger stated she worked with (R89) and provided occupational therapy, she noted (R89) was alert and able to make his needs known. V34 stated she got to the facility at 5:00 AM on 2/25/2025 and noted (R89) was in bed around 6:30 AM and observed V11 and V14 were transferring (R89) from his bed to wheel chair and he was yelling out that he didn't want to get up. V34 entered (R89's) room and told the CNAs to sit him back on the bed and they did. V15, RN entered (R89's) room and asked what he's yelling about and at that time V34 noted (R89) took a gasp for breath which she thought was odd. V15 instructed the CNAs to lay him in bed and raise the head of the bed and that he'd be fine V15 then left (R89's) room. V34 stated she was gravely concerned about (R89) but that V15 was an RN and she trusted her nurse judgement. Around 8:00 AM she went to (R89's) room to check on him and V11, CNA was in his room and told V34 that she reported to V15, RN that (R89) was not responsive but that no one was doing anything about it. V34 stated she went to get a blood pressure cuff and a pulse ox and put it on (R89), neither the blood pressure or pulse ox would register a reading at that time and from she could tell (R89) wasn't breathing. V34 stated (R89) was transferred to the hospital and she was informed he passed away shortly after arriving to the emergency room.
On 4/23/2025 at 3:00 PM V16, LPN stated she worked night shift and arrived to the facility at 10:30 PM on 2/24/2025 and also worked day shift on 2/25/2025 as well. V16 stated she was assigned to (R89) night shift and administered a medication, (medication name and dose unknown) to him at 6:00 AM on 2/25/2025, V16 stated he was sleeping and she woke him up and he was at baseline at that time he took the medication and went back to sleep. He didn't complain of shortness of breath or pain at that time. V16 gave nurse report to the day shift nurse V15 was (R89's) day shift assigned nurse. V16 didn't recall any staff reporting (R89) was having any changes during nurse report. A while later she was at the nurse's station and V11 came to the nurse's station and reported to V15 several times that (R89) wasn't acting right and was slow to respond to them. V16 stated V11 is assigned to (R89's) hall and knows him well so she knew something must be wrong if she kept saying something was wrong with (R89.) A few minutes went by and V15 was still on the computer at the nurse's station at that time and wasn't going to assess (R89) so her and V12 went to assess (R89.) V16 stated she was halfway down the hall when a therapy employee (name unknown) came out of (R89's) and stated he's no longer responsive. V16 stated when she entered (R89's) he was in bed and eyes were closed. Her and V12 assessed (R89) by doing a sternal rub which he had no response to and the pulse oximetry machine wasn't displaying a reading at that time.
R89's POS and MAR dated 2/2025, documents no 6:00 AM medication was ordered for that time. No medications were signed out by staffing including V16.
On 4/25/2025 at 8:35 AM V2 stated he looked into (R89's) POS and MAR dated 2/2025 he didn't see any physician ordered medications due at 6:00 AM and wasn't sure what medication V16 would have administered to (R89.)
On 4/23/2025 at 12:45 PM V2, DON stated when a resident has a change in condition he expects staff to obtain vital signs including blood pressure, heart rate, oxygen saturation and respirations. He also expects the nurse to assess the resident from head to toe noting any abnormalities. The nurse should talk to the resident and see what their orientation status is to see if there is a change in baseline. The nurse should also assess the resident for pain and dizziness and to notify the physician of what the assessment was and to obtain orders from the physician. V2 stated the full change in medical condition assessment including vital signs is expected to be documented in the resident's nurse progress notes. V2 recalled (R89) and stated he was sent to the emergency room for his catheter at one point but he was readmitted to the facility the same day and he didn't recall any specifics of what occurred on 2/25/2025.
On 4/23/2025 on 12:12 PM V2, DON stated if staff call him and notify him of a resident having a change in condition he would tell staff to get the resident's vital signs and have a nurse assess the resident and to notify the resident's physician of the change in condition to get physician's orders.
On 4/25/2025 at 11:40 AM V1, Administrator stated she expects staff to follow facility policies and procedures for when a resident experiences a change in medical condition.
On 4/23/2025 at 9:50 AM, V21 Nurse Practitioner stated she assessed (R89) on 2/21/2025 at the facility and he was sitting up in bed and was alert and oriented to person, time, place and situation and he told her he was struggling to walk but should be getting therapy soon so he hoped he gets better so he can go home. V21 assessed (R89's) and noted his lower extremities and left arm were swollen at that time. She ordered the following labs: CBC, CMP, BMP and a doppler to his left arm at that time and doesn't know if the facility got the order completed or not, she hasn't seen the blood work or the doppler results in (R89's) medical record. V21 stated although she didn't order the labs and doppler STAT (immediately) she expected staff to order the blood work and doppler the same day and to get the results as soon as possible. When staff report to a nurse that a resident isn't acting himself or is out of it she expects the assigned nurse to assess the resident immediately and to obtain vital signs including blood pressure, heart rate, respirations and pulse oxygenation and to check on the orientation of the resident at that time to see if he's had a change in medical condition. After the nurse assesses the resident they should call the physician and report the findings to see what if any interventions or new physician's orders are applicable. After the nurse completes the assessment on the resident if she thinks the resident should be 911 be transported to the emergency room then she can do that without a physician's order but after the resident is transferred to the hospital the nurse should call the physician's office and give them an update on the resident's medical status. V21 stated there is no documentation in the physician's medical record that (R89's) nurse notified the physician's office of the resident's change in medical condition.
2. R193's Undated Face Sheet, documents he was initially admitted to the facility on [DATE] with diagnoses included Stage 3 pressure ulcer of left hip.
R193's POLST form, signed 2/16/2024 documents R193 was a full code.
R193's Significant Change MDS, dated [DATE] documents R193 was severely cognitively impaired.
R193'2 Nursing Note, dated 6/15/2025 at 11:20 AM, documents writer went into resident's room to perform wound care and found resident unresponsive. Writer called for assistance from staff. CPR administered 911 called CPR performed until ambulance arrived. Paramedics arrived and took over CPR. Writer notified Hospice along with POA and physician and DON. Paramedics continued to work on patient while they escorted him out the building to local hospital. No vitals signs or thorough assessment documented.
The Facility's Notification Changes in Condition Policy, revised 2/20/2023 documents it is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental or psychosocial status. Upon identification of any changes in condition licensed nursing personnel will contact the resident's physician/on call-physician/practitioner to notify him/her of the change. Acute changes in condition should occur immediately upon recognition. All notifications should be preceded by an appropriate physical assessment to enable the physician to make adequate and appropriate treatment and/or transfer decisions. For acute changes in condition this should occur immediately when practicable and after addressing the resident's immediate needs. All notifications should be documented and should include the date and time of the notification, the name of the individual contacted, the specific reason for the notification and any specific responses that were given by the person contacted. All changes of condition require follow-up assessment and documentation of resident condition which include at a minimum, vital signs, pain, orientation any change from baseline status.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Pressure Ulcer Prevention
(Tag F0686)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R66's Face Sheet, print date of 5/21/25, documented diagnoses of Alzheimer's Disease with late onset, muscle weakness, diffic...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R66's Face Sheet, print date of 5/21/25, documented diagnoses of Alzheimer's Disease with late onset, muscle weakness, difficulty walking,
R66's Care Plan, revision dated of 3/6/25, documented left heel 'mushy'. R66's Care Plan intervention, initiated on 3/7/25, documented Left multipodus boot to be worn at all times.
R66's MDS, dated [DATE], documented she was not at risk for pressure ulcer and did not have any pressure ulcers at that time.
On 5/21/25, at 10:06 AM, R66 was seated in a wheelchair (w/c) at the nurse's station near the bird cage. R66 was wearing blue colored crocs with fur-type lining and pink socks. She was not wearing a pressure relieving boot on her left foot.
On 5/21/25, from 10:07 AM until 12:06 PM, R66 remained in the small dining room for activities and then for lunch. She continued to wear crocs on both feet and was not wearing a pressure relieving boot on her left foot.
At 1:05 PM, V41, CNA, was coming out of R66's room. R66 was sitting in her room in her w/c wearing crocs and socks. After asking R66 if I could see her heels, and she agreed, V41 assisted by removing R66's shoes off the left and right feet and removed R66's socks. R66's left heel was darkened, and she said it was sore. V41 placed R66's socks on both her feet and then placed a blue pressure relieving boot onto R66's left foot. V41 stated to R66, That will make it feel better.
On 5/27/25, V22, Wound Nurse, stated that R66 should have skin prep to her left heel and the use of the boot for pressure relieving measure. V22 stated that the goal of the interventions is to prevent breakdown. V22 stated that R66's boot should be worn while out of bed and while also in bed if the heels are not being floated.
Based on observation, interview, and record review, the facility failed to assess, timely treat pressure ulcer infection, and provide pressure relief, to prevent pressure ulcer development and worsening of pressure ulcers for 3 of 6 residents (R6, R29, R66) reviewed for pressure ulcers in the sample of 67. On 12/27/2024, R6 acquired a deep tissue injury from pressure to his left shoulder which opened to a Stage IV, exposing tendon. On 1/10/2025, (R6) acquired another deep tissue injury, unstageable, from pressure to right hip which opened to Stage IV pressure ulcer exposing hardware on his right hip. Subsequently, (R6's) pressure ulcers worsened and (R6) was admitted to the hospital with pressure ulcer infection from 2/28/2025 - 3/14/2025 with osteomyelitis.
This failure resulted in Immediate Jeopardy on 12/13/2024 when R6, who is severely contracted and in fetal position, has a history of pressure ulcers and is at high risk for pressure injuries. (R6's) low air loss mattress malfunctioned on 12/13/2024, which caused him to lay on the metal frame with no pressure reducing device for the prevention of bedsore. On 12/27/2024, (R6) acquired a deep tissue injury which Wound Nurse Practitioner, V13, stated was from the facility not providing adequate pressure relief and from the low air loss mattress malfunctioning. From 12/27/2025 until 1/17/25, the facility did not follow the order from wound consultant for the left shoulder pressure ulcer. On 1/10/2025, (R6's) acquired an additional deep tissue injury, unstageable, to his right hip from pressure. (R6) was seen by Wound Nurse with pressure ulcers worsening and opening to Stage IV pressure ulcers, exposing tendon on his left shoulder and hip hardware on his right hip. On 2/28/2025, due to the decline in (R6's) pressure ulcer and possible infection in (R6's) left shoulder, V13 ordered (R6) be sent to hospital. (R6) remained in the hospital from [DATE] through 3/14/2025 and diagnosed with osteomyelitis. (R6) returned to the facility on 3/14/25 and had an order for IV antibiotic to be administered for 7 days. The MAR documented R6 did not receive the antibiotic for 3 of the 7 days prescribed. On 4/9/25, V50, Nurse Practitioner, concerned with possible infection in (R6's) pressure ulcer, ordered a culture. This culture was not obtained until 4/17 and not reported to V50 until 4/24/25 at which time, the lab indicated infection. V50 ordered PICC line placement for (R6) to administer antibiotics. The facility failed to gain venous access until 4/29/25, at which time antibiotic was started. V50, NP, stated the delay in treatment of the wound infection could cause R6 sepsis which could result in organ shutdown resulting in death. On 5/9/2025 at 10:44 AM V1, Administrator, V2 Director of Nursing DON and V3 Assistant Director of Nursing ADON were notified of the Immediate Jeopardy.
The surveyors confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 5/20/25, after the team attempted to validate abatement on 5/13 and 5/14/25, and 5/20/25, and observed that residents (R6, R51, and R59) at high risk for skin breakdown were lying on low air loss mattresses that were not set to the appropriate weight setting of each resident. On 5/20/25, at 12:10 PM, the survey team validated the facility's abatement but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the facility's in-service training, ongoing assessment, monitoring of pressure relieving equipment and pressure ulcer monitoring.
Findings include:
1. R6's Undated Face Sheet, documents he was initially admitted to the facility on [DATE] with diagnoses including osteomyelitis, stage IV pressure ulcer to sacrum, stage IV left upper back pressure ulcer, stage IV right hip pressure ulcer, pressure induced deep tissue damage, paraplegia, hyperglycemia and contractures of both knees.
R6's Physician's Order Sheet (POS) dated 10/10/2024 documents pressure relieving low air loss mattress to bed and pressure relieving cushion to wheelchair every shift for pressure relieving devices to protect skin.
R6's Annual MDS, dated [DATE], documents severely cognitively impaired, dependent with toileting hygiene, shower/bathe self, personal hygiene, dependent with rolling left and right and chair/bed-to-chair transfers, incontinent of bowel and bladder, at risk for developing pressure ulcers, one stage III pressure ulcers, pressure reducing device for chair and bed, pressure ulcer/injury care treatment, application of nonsurgical dressings, applications of ointments/medications other than to feet.
R6's POS, dated 12/1/2024 documents the following active physician's orders: 10/12/2023 document weekly skin assessment every Monday day shift and 7/9/2024 waffle boots on when in bed every shift pressure release. 6/11/2024 apply pillows between left and right legs and thighs every shift for positioning. 10/10/2024 pressure relieving low air loss mattress to bed and pressure relieving cushion to wheelchair every shift for pressure relieving devices to protect skin. Notify MD/DON/Wound Nurse if he has or c/o (complaint of) any excoriated and/or open areas.
R6's Undated Care Plan, documents resident is at risk for decline in wound impairment to skin integrity r/t (related to) poor PO (by mouth) intake, incontinence and decreased mobility. 12/31/2023 left shoulder stage IV pressure ulcer -nosocomial (acquired in house) and right hip pressure ulcer stage IV pressure ulcer. Goal: resident will have a decline in wound status through next review date. Interventions: pressure relief techniques, left to right side to side t/p (turn and reposition) every hour and PRN (when needed), use positioning devices as indicated. Multipodus boots on when in bed. Use positioning devices when in bed to maintain positioning when in bed. Use pillows between legs when in bed. Educate staff on the importance of maintaining left to right t/p schedule to promote healing and reduce the risk for skin breakdown. Apply padding to bony areas (such as pillows, boots, heel protectors etc.) as indicated. Low air loss, pressure relieving mattress to bed. He uses a pressure relieving cushion to protect the skin while up in chair. Notify nurse of any redness areas, s/s (signs or symptoms) of infection, excoriation or skin breakdown immediately, treatments as ordered (see physician's order sheet/TAR), notify PCP (primary care provider) DON (Director of Nursing) if decline noticed in wound status, monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal. s/s of infection, maceration etc. to MD (physician.)
R6's POS dated 12/13/2024, documents late entry: d/c (discontinue) low air loss mattress until replaced, due to it not functioning properly, per wound consultation company CNAs moved resident from broken low air loss mattress today and put on regular mattress until replacement mattress is available.
R6's Wound Nurse Practitioner Progress Note, dated 12/13/2025 stage 3 coccyx pressure ulcer measured 2.3 cm x 2.3 cm x 0.6 cm, 50% slough, granulation tissue 30%, skin intact 20%, exposed structure: blank. Pressure ulcer length, width, depth and tissue status deteriorated as compared to previous visits conclusion. Visit specific information: patient now has a regular mattress and appears to be able to turn and reposition much better. This was the only pressure ulcer R6 had as of 12/13/2024.
R6's Nursing Progress Note, dated 12/18/2024 at 3:14 PM documents, Upon doing daily treatment to coccyx, this nurse noticed an area to the right hip which appears to be consistent with an abrasion. Area measures 5.5 x 4.5 x 0.1 cm. (whole reddened area.) with a small open area to the middle measuring 2 x 2 x 0.1 cm. Area bright red in color, small amount of clear yellowish drainage noted. No odor, not warm to touch. Area surrounding open area intact, yet bright (whole reddened area.) with a small open area to the middle measuring 2 x 2 x 0.1 cm. Area bright red in color, small amount of clear yellowish drainage noted. No odor, not warm to touch. Area surrounding open area intact, yet bright red. Facial grimacing noted when area cleansed. This nurse also noted an area to the Right shoulder/deltoid measures; 8 x 3.5 x 0.1 cm (whole reddened area) with a small open area to the middle measuring; 2 x 0.5 x0.1 cm small amount of clear yellowish drainage noted. No odor, not warm to touch. Area surrounding open area intact, yet, bright red in color. Facial grimacing noted when area cleansed. Area consistent with an abrasion as well. This nurse reported findings to the Administrator as well as DON and ADON. Message left with POA to return call. MD made aware as well as well as V13- new orders redc'd to Cleanse areas with soap and water, pat dry. Apply skin prep to periwound apply TAO and cover with dry protective dressing daily and PRN. Education provided to staff regarding turning and repositions q2. Resident also provided with more offloading devices such as pillows and wedges. Spoke with maintenance regarding status of the replacement low air loss mattress, maintenance states that one came in today he was going to check and see if it belonged to him or not.
On 5/2/2025 at 2:55 PM, V63, LPN stated she was assigned to R6 on 12/18/2025 and stated she observed (R6) laying on the air loss mattress but all the air was in the foot of the mattress, no air was at the head of the bed and the (R6) lay directly on the bedframe. V63 stated she spoke to the maintenance man regarding (R6's) air loss mattress malfunctioning but he said it was working just fine and he wouldn't switch the bed out or change (R6's) bed. V63 stated there were numerous times that she observed (R6) laying on the air loss mattress with no air in the head of the bed and she spoke to V13, Wound Consultant about her concerns but (R6) continue to lay in the broken air mattress bed.
R6's Wound Nurse Practitioner Progress Note, dated 12/19/2024, documents (R6) was removed off the low air loss mattress last week due to his wound continuing to decline. Patient is contracted and lies on fetal position and on the low air loss mattress this potentially place him on the frame depending on the level of inflation that the bed is set to. We placed them on a regular mattress so he would stop sinking into the bed however this week he now has two new wounds. I did discuss with V2, DON that maybe we could place a thinner foam on the bed frame and then a low air loss mattress which would help reduce pressure to the area if the mattress deflated enough to where he's putting pressure on the frame. Also discuss with V2 the need for frequent turning and repositioning. Stage 3 pressure ulcer to right trochanter wound 3 initial assessment measured 3.5 cm x 2.1 cm x 0.2 cm wound bed 60% granulation and 40% slough. Stage 3 pressure ulcer to right shoulder wound 4 initial assessment measured 1.5 cm x 5.5 cm x 0.2 cm wound bed 30% granulation and 70% skin intact.
5/1/2025 at 3:25 PM V32, Maintenance Director stated there was a situation with R6's low air loss mattress and he wasn't here at that time but he recalled it was in December 2024 that maintenance staff reported to him that the resident's air loss mattress was found to be faulty, all the air was out of the mattress and the resident lay in a concave hole in the middle of the bed and the resident was laying on bedframe. Staff told him the mattress needs to be replaced and it was replaced the same day. He replaced several low air loss mattresses for the resident due to staff not pushing the static mode button to the off position when the resident is in the prone position. Observation showed at that time that the static mode button was in the on position, and it should have been off, V32 turned it to the off position. V32 stated when the resident's head of bed is elevated the static mode should be in the ON position because if not it doesn't distribute the air in the air loss mattress properly. V32 stated he has replaced R6's low air loss mattress at least 4 times in the last 2 years because it just wears out after time.
On 5/8/2025 at 9:30 AM V32, Maintenance Director stated they don't document work orders when they change out resident's bed even if they are faulty. V32 didn't know what dates (R6's) air loss mattress was malfunctioning or when (R6) had a regular pressure relieving mattress.
On 5/8/2025 at 9:45 AM V22, Wound Nurse stated she doesn't know what dates (R6's) air loss mattress wasn't working properly or when he lay on a regular mattress.
R6's Wound Nurse Practitioner Progress Note, dated 12/27/2024 documents a new Unstageable pressure ulcer on left shoulder measured 0.9 cm x 1.5 cm x 0.1 cm. Treatment: skin prep, paint wound edges and surrounding skin. Visit specific information: Patient is still on a regular mattress and his wounds are improving this week. This was the suspicion that patient just needed better off flowing and not necessarily the low air loss mattress which was sinking him into the frame of the bed. Due to patient's falling (means balling) up in the fetal position it is highly likely that he needs offloading more frequently.
R6's POS dated 12/27/24 through 12/31/20242024 documents no physician's order for skin prep.
R6's TAR, dated 12/27/2025 through 12/31/2025 no documentation staff administered skin prep to (R6's) unstageable left shoulder pressure ulcer.
R6's Wound Nurse Practitioner Progress Note, dated 1/3/2025 documents a initial/new assessment an unstageable pressure ulcer on left shoulder/wound 5 measured 3.0 cm x 2.5 cm x 0.1 cm. Wound assessment documents the pressure ulcer was facility acquired. Treatment: skin prep, paint wound edges and surrounding skin. Right trochanter wound 3 and right shoulder wound 4 documented healed.
R6's POS, dated 1/1/2025 through 1/9/2025 physician's order for skin prep to (R6's) unstageable left shoulder pressure ulcer.
R6's TAR, dated 1/3/2025 through 1/9/2025 no documentation staff administered skin prep to (R6's) unstageable left shoulder pressure ulcer.
R6's Wound Nurse Practitioner Progress Note, dated 1/10/2025 documents left shoulder unstageable pressure ulcer/wound 5 treatment: cleanse with soap and water, skin prep to periwound, apply calcium alginate to wound base and cover with bordered gauze. New pressure ulcer assessed unstageable right trochanter wound 6 measured 2.0 cm x 2.5 cm x 0.1 cm, 100% skin intact treatment: skin prep.
R6's Wound Nurse Practitioner Progress Note, dated 1/10/2025 documents wound 5 unstageable left shoulder pressure ulcer/wound 5 measured 3.1 cm x 3.8 cm x 0.2 with 30% slough and documents pressure ulcer deteriorated compared to previous visit. New unstageable pressure ulcer right trochanter (hip) wound 6 measured 2.0 cm x 2.5 cm x 0.1 cm wound bed 100% intact. Treatment: paint surround skin with skin prep.
R6's POS dated 1/10/2025 no physician's order for (R6's) unstageable left shoulder pressure ulcer/wound 5 treatment of calcium alginate to wound base and cover with bordered gauze per wound nurse practitioner documentation dated 1/10/2025 and no physician's order for skin prep to right trochanter wound 6 unstageable pressure ulcer per the wound nurse practitioner's documentation dated 1/10/2025.
R6's Braden, dated 1/16/2025 at 1:08 PM documents moderate risk for skin breakdown.
R6's Annual MDS, dated [DATE], documents severely cognitively impaired, dependent with toileting hygiene, shower/bathe self, personal hygiene, dependent with rolling left and right and chair/bed-to-chair transfers, incontinent of bowel and bladder, at risk for developing pressure ulcers, two stage III pressure ulcers, pressure reducing device for chair and bed, pressure ulcer/injury care treatment, application of nonsurgical dressings, applications of ointments/medications other than to feet.
R6's Wound Nurse Practitioner Progress Note, dated 1/17/2025 documents left shoulder unstageable pressure ulcer/wound 5 and unstageable right trochanter pressure ulcer/wound 6 treatment changed to cleanse with soap and water, skin prep to periwound, calcium alginate to wound bed and cover with bordered gauze. It was documented both pressure ulcers had deteriorated compared to the conclusion of the previous visit.
R6's TAR dated 1/1/2025 through 1/16/2025 no documentation staff administered skin prep to (R6's) left shoulder of right trochanter.
R6's POS dated 1/17/2025 and discontinued on 1/21/2025 documents a new physician's order for skin prep to both shoulders and right hip daily. (The wound nurse practitioner initially ordered skin prep to left shoulder daily on 12/27/2024 and right hip on 1/10/2025 this is the first physician's order for skin prep.) No new physician's order from the wound nurse practitioner progress note, dated 1/17/2025 documented both left shoulder and right trochanter pressure ulcer treatments to soap and water, skin prep to periwound, calcium alginate to wound bed and cover with bordered gauze.
R6's POS dated 1/21/2025, documents a new physician's order left shoulder and right trochanter pressure ulcer cleanse with soap and water, pat dry, apply skin prep periwound, apply Santyl to wound bed, calcium alginate to wound bed and cover with bordered gauze.
R6's POS dated 1/17/2025 documents pressure relieving mattress to bed and a pressure relieving cushion to wheelchair every shift for pressure relieving devices to protect skin.
R6's TAR dated 1/2025 documents blank boxes dated 1/22/2025, 1/29/2025 and 1/30/2025 for the left shoulder and right trochanter pressure ulcer treatment.
R6's Braden, dated 2/10/2025 at 4:18 PM documents high risk for skin breakdown.
R6's Quarterly MDS, dated [DATE], documents R6 was severely cognitively impaired, dependent with toileting hygiene, shower/bathe self, personal hygiene, dependent with rolling left and right and chair/bed-to-chair transfers, incontinent of bowel and bladder, two stage III pressure ulcers, two unstageable pressure ulcers, pressure reducing device for chair and bed, pressure ulcer/injury care treatment, application of nonsurgical dressings, applications of ointments/medications other than to feet.
R6's Wound Nurse Practitioner Progress Note, dated 2/12/2025 documents visit specific information: patient now has a low air loss mattress.
R6's Wound Nurse Practitioner Progress Note, dated 2/21/2025 documents wound 5 left shoulder pressure ulcer is now documented as a Stage IV measured 10.0 cm x 6.0 cm x 0.8 cm with tunneling and wound bed was covered with 80% slough, with exposed tendon, serosanguineous drainage. Wound 6 right trochanter pressure ulcer is now documented a stage IV measured 5.8 cm x 6.3 cm x 0.6 cm with tunneling no exposed structure documented. Both pressure ulcers per wound nurse practitioner documentation had deteriorated compared to the conclusion of the previous visit.
R6's TAR dated 2/2025 blank boxes for left shoulder and right trochanter pressure ulcer treatments on 2/3/2025, 2/4/2025, 2/10/2025, 2/12/2025, 2/18/2025, 2/20/2025 and 2/26/2025.
R6's Wound Nurse Practitioner Progress Note, dated 2/28/2025 documents wound 5 left shoulder pressure ulcer stage IV measured 8.5 cm x 6.2 cm x 0.8 cm, wound bed 80% slough, 10% granulation and 10% exposed structures, exposed structure: tendon and serosanguineious exudate. Wound 6 right trochanter pressure ulcer stage IV measured 6.5 cm x 6.5 cm x 0.7 cm with tunneling tissue type: 10% granulation and 10% exposed structures (no specific exposed structures documented) with purulent exudate. Both pressure ulcers per wound nurse practitioner documentation had deteriorated compared to the conclusion of the previous visit. Visit specific information: recommend culture to left shoulder and right trochanter today and if it is not completed today patient needs to go to the hospital.
R6's POS, dated 3/2/2025 discontinue pillows between left and right legs and thighs every shift for positioning. Physician's order discontinued: pressure relieving mattress to bed and a pressure relieving cushion to wheelchair every shift for pressure relieving devices to protect skin.
R6's Nursing Note, date 3/3/2025 at 9:27 AM documents R6 was admitted to the hospital for osteomyelitis.
R6's POS dated 3/12/2025 a new physician's order pillows between left and right legs and thighs every shift for positioning related to contracture, left and right knee. A new physician's order pressure relieving low air loss mattress to bed and wheelchair every shift for pressure relieving devices to protect skin. A new physician's order weekly skin assessment on day shift every Monday and pressure relieving mattress to bed and chair.
R6's Braden, dated 3/14/2025 at 7:11 PM documents moderate risk for skin breakdown.
R6's Hospital After Summary dated 3/14/2025, documents Ertapenem 1 gram into a venous catheter daily last given on 3/14/2025 at 10:14 AM. Pressure ulcer treatment documented Santyl apply topically daily to left shoulder and right trochanter.
R6's readmission assessment dated [DATE] at 6:54 PM no documentation of a readmission skin assessment.
R6's Nurse Progress Note, dated 3/14/2025 no documentation of skin upon readmission to the facility.
R6's Weekly Observation Note, dated 3/17/2025 at 12:44 PM documents (R6) was admitted on [DATE]. Skin color is pale. Skin temperature is warm. Skin turgor shows tenting due to a delay in return of skin. Skin issues present. Refer to assessment for more information. Recent readmit with wound vac in place. Refer to full assessment for more information.
R6's Medical Record, dated 3/17/2025 no documentation of (R6's) skin or wounds.
R6's POS dated 3/14/2025 documents Ertapenem 1 gram IV every 24 hours for infection for 7 days until finished. End date 3/19/2025. On 3/19/2025 new physician's order Ertapenem 1 gram IV every 24 hours for infection until 3/21/2025. No pressure ulcer treatment to coccyx on POS.
R6's MAR dated 3/2025 documents new physician's order on 3/14/2025 documents Ertapenem 1 gram IV every 24 hours for 7 days for infection. No documentation Ertapenem was administered on the following days: 3/15/205, 3/17/2025, 3/19/2025 was blank on the MAR and 3/21/2025 had an X on the MAR.
R6's Medical Record no documentation of reason why staff didn't administer Ertapenem IV antibiotic medication per physician's orders.
R6's Weekly Skin Observation Note, dated 3/17/2025 at 12:44 PM documents (R6) was admitted on [DATE], skin color is pale, skin temperature is warm, skin turgor shows tenting due to delay in return of skin, skin issues present refer to assessment for more information. No additional skin/wound assessment was documented in (R6's) medical record.
R6's Significant change MDS, dated [DATE], documents severely cognitively impaired, dependent with toileting hygiene, shower/bathe self, personal hygiene, dependent with rolling left and right and chair/bed-to-chair transfers, incontinent of bowel, indwelling urinary catheter, at risk for developing pressure ulcers, three stage IV pressure ulcers, 2 unstageable pressure ulcers, pressure reducing device for chair and bed, pressure ulcer/injury care treatment, application of nonsurgical dressings, applications of ointments/medications other than to feet.
R6's Wound Nurse Practitioner Progress Note, dated 3/19/2025 documents wound 5 left shoulder stage IV pressure ulcer measured 7.6 cm x 6.5 cm x 0.9 cm with tunneling, wound bed 70% covered with slough with tendon exposed. Right trochanter wound 6 stage IV pressure ulcer measured 8.5 cm x 6.5 cm x 0.7 cm with tunneling. Wound bed was covered with 50% slough, with exposed hardware, purulent drainage. Both pressure ulcers documented to have deteriorated compared to the conclusion of the previous visit.
R6's Braden, dated 3/21/2025 at 8:36 AM documents moderate risk for skin breakdown.
R6's Weekly Skin Observation Note, dated 3/21/2025 at 9:05 AM documents skin color is normal, skin temperature is dry, skin turgor is normal as skin returns promptly, skin issues present refer to assessment for more information.
R6's POS, dated 3/25/2025 a new physician's order prevalon boots on at all times every shift for pressure relieving device.
R6's Wound Nurse Practitioner Progress Note, dated 3/26/2025 documents a new treatment order for (R6's) stage IV right trochanter pressure ulcer was cleanse with soap and water, skin prep to periwound, calcium alginate to wound base, santyl to wound bed and cover with bordered gauze daily.
R6's Braden, dated 3/28/2025 at 8:38 AM documents moderate risk for skin breakdown.
R6's Skin/Wound Note dated 4/4/2025 at 11:23 AM documents wound care provided. Treatment applied per treatment orders. Resident's wound is red a bright red beefy color with white slough present on wound bed. Resident tolerated wound care well with no s/s (signs or symptoms) of pain or discomfort noted during treatment.
R6's Medical Record no documentation of wound nurse practitioner weekly wound assessment dated [DATE] through 4/8/2025.
R6's Wound Nurse Practitioner Progress Note, dated 4/9/2025 documents stage IV left shoulder pressure ulcer wound 5 treatment: wash with soap and water, skin prep, calcium alginate, Bactroban and bordered gauze dressing change twice a day (BID.) Wound nurse practitioner documented pressure ulcer deteriorated compared to the conclusion of the previous visit.
R6's POS dated 4/15/2025 documents Bactroban apply to left shoulder topically everyday shift for wound healing, cleanse wound with w/s apply Bactroban and calcium alginate and dry dressing every day and PRN. There was no physician's order to change the dressing BID per the wound nurse consultant's recommendation, dated 4/9/2025.
R6's TAR, dated 4/2025 Bactroban apply to left shoulder topically everyday shift for wound healing, cleanse with w/s apply Bactroban and calcium alginate and dry dressing every day and PRN. Blank boxes on the TAR for the following dates that R6 did not recieve treatments: 4/15/2025, 4/16/2025, 4/25/2025, 4/28/2025 and 4/29/2025.
R6's POS, dated 4/9/2025 documents a new physician's order obtain wound culture from (R6's) left shoulder related to possible infection.
R6's Wound/Skin Note, dated 4/9/2025 at 2:39 PM, documents
NP stated to obtain cultures form area due to discoloration of wound related to possible infection.
R6's Lab Result, documents specimen collected 4/22/2025 documents organisms present. Moderate growth organism growth for two and rare growth for one organism. (No documentation of which pressure ulcer/wound was cultured.)
On 5/6/2025 at 3:07 PM V64, Lab Client Solutions Representative stated a specimen was collected from the facility on 4/14/2025 but it was tossed out by the lab due to missing resident identification information. A second specimen was collected from the facility on 4/22/2025 and arrived to the out of state lab on 4/23/2025.
R6's POS, dated 4/24/2025 documents a new physician's order for Meropenem 1 gram IV every 12 hours for 7 days for wound infection, wound location not documented.
R6's MAR, dated 4/2025 documents evening dose on 4/24/2025, both morning and evening doses on 4/25/2025 and 4/26/2025, morning dose on 4/27/2025, evening dose on 4/27/2025 staff documented administered, morning dose on 4/28/2025 staff documented 9/other, then physician's order was discontinued.
On 5/1/2025 at 3:34 PM V58, LPN stated he did not give (R6) the IV dose of Meropenem 1 GM on the morning of 4/28/2025. V58, LPN, stated if his initials are on (R6's) MAR it is by accident and he is not allowed to give IV medication because he is an LPN.
R6's POS dated 4/28/2025 documents a new physician to discontinue the IV antibiotic Meropenem 1 gram and reordered it on 4/29/2025.
On 5/7/2025 at 11:40 AM V3, ADON stated she was aware the V50, NP ordered a wound culture (wound location unknown) at the beginning of 4/2025 and the first wound culture was sent to the lab (date unknown) and it was thrown out from the lab due to not have appropriate resident labeling/identification on it. The second wound culture was obtained at the facility a few days later and sent to the lab. V22, Wound Nurse reported the wound culture results to V50, NP on 4/24/2025 and she spoke to V50 on 4/25/2025 regarding (R6's) wound culture report results showing there was an infection. V50 ordered 7 days of IV antibiotics at that time and ordered (R6) to have a PICC line placed or to have a mobile PICC line company come to the facility and insert a PICC line. V3 stated she discussed PICC line placement with V22, wound nurse and she was told (R6) needed an appointment to have the PICC line placed and the facility doesn't have a mobile PICC line company service. V3 stated on 4/28/2025 she attempt multiple times to insert an IV peripherally and (R6's) veins were not cooperating so she was not able to get IV access. She notified V50 of no IV access and V50 put the IV antibiotics on hold and (R6) got an appointment and had the PICC line placed on 4/30/2025 and since then the IV antibiotics were reordered and (R6) has received the IV antibiotics were administered per physician's orders. When staff administer medications, including IV antibiotics they are expected to sign off the medication was administered as soon as they administer it.
On 5/7/2025 at 3:22 PM V22, Wound Nurse stated she looked up the wound culture results from the lab in the computer on 4/24/2025 and notified (V50), NP of the lab results. (V50) called her back on 4/25/2025 and gave a physician's order for (R6) to get a PICC line inserted and to have IV antibiotics for 7 days for a wound infection. V22 stated she couldn't just send (R6) to the hospital for PICC line placement and the facility didn't have a mobile company to come place the PICC line in the facility. V22 stated V3, ADON attempted multiple times to place a peripheral IV in (R6) but it was unsuccessful. An appointment was made for (R6) on 4/29/2025 and the PICC was placed at an outside office on 4/30/2025. V22 stated (R6) has received the IV antibiotics since they had PICC line access on 4/30/2025. V22 stated IV antibiotics were put on hold by (V50) because (R6) didn't have [TRUNCATED]
SERIOUS
(H)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
6. R31's Diagnoses Report, print date of 5/27/25, documents he has diagnoses of need for assistance with personal care, hemiple...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
6. R31's Diagnoses Report, print date of 5/27/25, documents he has diagnoses of need for assistance with personal care, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, and cerebral infarction.
R31's Care Plan, with revisions dated 12/21/21, documented (R31) has an ADL (Activities of Daily Living) self-care deficiency r/t (related to) CVA (stroke with left sided weakness, activity intolerance, confusion and fatigue. The Care Plan, interventions with revision on 8/16/23 documented Toilet Use: x2 extensive assist with toileting. Assist with dressing change and peri care after all toileting and incontinent episodes. The interventions documented Transfer x2 extensive assist with transfers.
R31's MDS, dated [DATE], documented he has impairment on one side of lower extremities (hip, knee, ankle, foot). The MDS documents that R31 is dependent for toilet transfer as helper does ALL of the effort, Resident does none of the effort to complete the activity.
On 5/14/25, at 12:50 PM, V6, CNA, stated that she was going to assist R31 to the toilet. V6 entered R31's room. R31 was seated in his wheelchair. V6 pushed R31 into the bathroom. She placed a gait belt around R31's waist. V6 directed R31 to stand up and he did so independently without assistance. She told him to grab both handicap rails on the wall to each side of the toilet. He did this. At this time, his right leg began to shake, as he faced the toilet. She cued him to grab the handicap bar to the right of the toilet, which he did. R31 was having difficulty moving his right and left legs to pivot to the right to sit on the toilet. V6 verbally cued him multiple times. He finally pivoted enough and then he fell heavy onto the toilet seat and sighed.
On 5/27/25, at 12:57 PM, V2, DON, stated that he was unsure of R31's transfer status.
Based on interview and record review the facility failed to properly supervise, develop and implement progressive intervention to prevent falls and provide safe transfers for 6 of 6 residents (R22, R31, R43, R46, R69, R72) reviewed for accidents in a sample of 67. This failure led to R69 having multiple visits to the emergency room and receiving a closed non-displaced fracture of right ilium, 0.5 cm laceration to right eyebrow, a laceration to the forehead, and bruising to face on 3 separate occasions.
Findings include:
1. R69's EMR (Electronic Medical Records) undated documents that resident was admitted to the facility on [DATE].
R69's EMR dated 11/22/23 documents a diagnosis of epilepsy, history of falling, and unspecified convulsions.
R69's MDS (Minimum Data Set) dated 1/30/25 documents a BIMS score of 11 out of 15. The MDS documents that the resident is independent with roll left and right. The MDS documents that the resident requires supervision or touching assistance for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer.
R69's Care Plan dated 11/23/23 documents (R69) is at risk for falls and/or injury r/t weakness, impaired gait, unsteadiness on feet and poor safety awareness. He will get self-up off the floor without notifying staff. The resident had 8 interventions for 24 falls from 4/19/24 until 4/19/25.
R69's Nursing Note dated 4/19/24 at 8:07 PM documents This nurse was notified by staff members that resident fell out of his wc (wheelchair) while smoking and then started to have a seizure. This nurse and second nurse went to patio area. Resident noted to be on the ground on his back having tonic clonic seizure. This nurse came back into building called 911 and began printing paperwork for resident to be sent to (local hospital). Second nurse stayed outside with resident for assistance. Resident noted to be combative when staff tried to assist resident to his chair. Resident finally let staff assist him into wc. This nurse informed resident once inside building that he would be taking to the hospital for eval. Resident stated I don't agree with that. I don't take medicine. Resident then wheeled himself to his room.
No intervention documented on the care plan for this fall.
R69's Health Status Note dated 5/25/24 at 5:40 PM documents Summoned to room. Resident lying on floor, face down next to bed. Resident non-verbal. Blowing respiration noted. Eyes open and fixed. Upper and lower extremities jerking. Head moving in an up and down motion Resident not responding to verbal stimuli. Staff at side to prevent injury. V/S (vital signs) 97.8 108 22 O2 sat (oxygen saturation) 96.
No intervention documented on the care plan for this fall.
R69's Nursing Note dated 6/26/24 at 7:18 AM documents CNA (Certified Nursing Assistant) notified writer that resident was in his room on the floor. Writer went into residents' room and found resident lying on his rt side on the floor. ROM (Range of Motion) performed resident is able to move all limbs without any pain or discomfort. Limbs are equal in length no injuries or bruising present at this time Neuro Check performed. Staff assisted resident up into his wheelchair. MD (Medical Director) notified of fall along with POA (Power of Attorney).
No intervention documented on the care plan for this fall.
R69's Nursing Note dated 7/19/24 at 9:28 AM documents the aid answered the resident call light and noticed he was on the floor asked was he ok and after he stated yes the aid alerted the nurse. this nurse went into the resident ' s room to assess the resident while on the floor. he is alert and oriented x4. the resident stated he was on the floor because he tried to get in his wheelchair and did not make it so he got on the floor to keep from falling. the resident stated he did not hit his head nor hurt himself he just needed help getting back up into his wheelchair. no new s/s no c/o pain or discomfort. this nurse and the aid assisted him back into his wheelchair and will check on him throughout the day and f/u.
No intervention documented on the care plan for this fall.
R69's Nursing Note dated 7/26/24 at 8:21 PM documents Resident noted on the floor in his room. Resident stated he wants to go to the hospital so he can get out of here. But needs help getting up. Resident states he is cold. Resident is spitting on the floor. Resident VS WNL (within normal limits). (Local Ambulance Service) called to transport Res to hospital. Psych MD Notified and a message was left.
R69's Nursing Note dated 8/2/24 at 4:14 PM documents res was transported back to facility after x-rays r/t (related to) to large abd (abdomen) bruise on R side patients was diagnosed at ED (Emergency Department) w/ a closed nondisplaced fracture of R ilium resident has no recollection of fall or incident that would have caused fracture will cont to f/u (follow up) res is in bed resting quietly no outward c/o pain or discomfort at this time.
No intervention documented on the care plan for this fall.
R69's Nursing Note dated 8/11/24 at 9:15 AM documents Resident noted on the floor in his room next to AC (air conditioning) unit. Resident states he does not know what he was doing before or during time he was noted on floor. Resident is conscious and breathing. Resident's wheelchair was Parallel to his body and clothes were Neatley folded on the seat of the wheelchair. Resident refused to let staff check vital signs, Resident offered pain medication and declined it. Resident asked staff if he could smoke a cigarette. No apparent injuries noted, (local ambulance service) called to transport Resident to ER (Emergency Room) for further assessment. MD Notified and Aware. Resident's Guardian (V36) Notified via phone call he did not answer, A voicemail message was left with call back number.
No intervention documented on the care plan for this fall.
R69's Health Status Note dated 10/6/24 at 8:49 AM documents Resident was found on the floor this morning covered in wet having a hard time breathing lying on his left side. Resident asked what happened and how did he get on the floor? he stated he didn't know. he was assisted into chair and immediately started leaning to the left unable to stay conscious, when asked if he was in pain, he stated he was having pain to back. He was very lethargic, hard to keep eyes open. sent to (metro hospital) for evaluation via ems (Emergency Medical System). vitals 147/70 72 95 98.0 18. pupils slow to react.
No intervention documented on the care plan for this fall.
R69's Nursing Note dated 10/10/24 at 1:30 PM documents Resident had a fall in the dining room he was found bottom down, and wheelchair flipped over on the left side of him. Resident had no injuries, and he could not explain what he was doing. He refused vitals to be taken. No neuro initiated. Left voicemail for (V36). Md was notified.
No intervention documented on the care plan for this fall.
R69's Nursing Note dated 11/21/24 at 4:19 PM documents (R69) had possible seizure, unwitnessed fall with AMS (Altered Mental Status) and difficulty breathing. He is lying on the floor, wheelchair alongside him, tipped onto its side. (R69) is struggling to inhale through his trach stoma. He is refusing supplemental O2/Nursing care and being combative with care. Guardian notified that he will most likely be sent to the closest ER, (local hospital) and that bed hold policy is being sent with him. MD notified he is being sent out to the ER via *911. Face sheet, POS (Physician Orders), Code Status, Guardianship papers and Bed hold policy in folder to be sent with him.
No intervention documented on the care plan for this fall.
R69's Nursing Note dated 11/26/24 at 8:04 AM documents Resident had a seizure in the dining room. Resident was sitting up in his chair in dining room when he fell to the floor and began seizing. Seizure began at 753am and ended at 758am resident is alert per his usual baseline. Staff assisted resident up off floor and back into chair after seizing end no injuries noted at this time. MD notified.
No intervention documented on the care plan for this fall.
R69's Nursing Note dated 12/11/24 at 7:46 AM documents the halls CNA alerted the writer that the resident was on the floor so the writer went into the residents room and the resident was also covered in blood across his face, as the writer assessed the resident she noticed a gash across the residents right eye and scratches on his right leg that had an open wound where the blood was flowing from but was dried up. there is blood on the resident ' s pillow on his bed and blood on numerous items and the floor of the resident ' s room. the writer asked the resident was he experiencing any pain and the resident stated he was not in any pain, and he could not pull his WC close enough or push his self-back on the bed, so he eased his self to the floor. the resident was assisted back into his WC by two CNAS the writer attempted to wash his face, but he refused and stated he would do it his self the writer alerted the administrator and called the ambulance, and the writer will f/u.
R69's Nursing Note dated 12/12/24 at 8:13 AM documents Per ER notes: (R69) has 0.5 cm (centimeter) laceration to right eyebrow, with bruising. (x2) absorbable sutures to right eyebrow. He received his Tdap (BOOSTRIX) while in ER.
Intervention: 12/11/24 - educate on importance of medication compliance and possible consequences of not taking. Encourage him to taking medication to prevent consequences more frequent checks throughout the night.
R69's Nursing Note dated 12/25/24 at 10:40 PM documents Resident had a seizure in the dining room and had an unwitnessed fall. Ambulance was called and resident refused to be transported. His vital were 98.1, 76, 18 149/88 patient is back at his current baseline. He refused all vital thereafter stating that he didn't fall.
Intervention: 12/25/24 - fall due to seizure activity. Educate on need for and importance of taking all medications as prescribed. Notify MD of continued refusal of medications and seizure activity with fall.
R69's Nursing Note dated 1/14/25 at 9:43 AM documents Writer observed a laceration to residents' forehead he also had a bruise on his nose that was reddish in color, he was also noted to have a discoloration on his right inner eye. Resident stated that he fell and didn't notify anyone. Resident will be sent out to (local hospital) for an evaluation. Md, DON (Director of Nursing) and there was a message left for (V36) to contact the facility at their earliest convenient.
No intervention documented on the care plan for this fall.
R69's Nursing Note dated 1/20/25 at 9:55 PM documents Writer was notified by staff that resident was on the floor in his room. Upon evaluation of resident, he was lying on the floor on side trying to get to the door. His isn't complaining of any pain or discomfort. He couldn't stat what happened. His vitals are 98.1,76,18,163/94, 96 % room air. Neuro checks where initiated, but the resident denied any further vitals. Md, (V36) where notified.
No intervention noted on the care plan for this fall.
R69's Nursing Note dated 1/29/25 at 4:45 AM documents 4:30am (R69) was found sitting on the floor. He says he rolled out of bed face first, no pain, redness in his face, ROM wnl, no other bumps or bruises, he says he feels fine, vitals wnl. Physician and DON notified. Will notify POA and continue to monitor.
R69's Nursing Note dated 1/30/25 at 2:27 PM documents Resident noted to have an area protruding from right above the right eye. It is black and purple. Resident stated he has no pain. There is an open tiger text awaiting an answer from the MD.
Intervention: 1/29/25 - increase nighttime checks, assist with getting out of bed as indicated.
R69's Nursing Note dated 2/17/25 at 12:34 PM documents Writer was alerted to the dining room where patient had fallen out of the chair during a seizure. He denied falling or having a seizure and denied vitals. He agreed to go to the hospital and when the ambulance arrived, he declined to go. His family member was notified, and she knows he denied being assessed at the hospital. Resident is back at his current baseline.
Intervention: 2/17/25 - Notify MD of continued refusal of medications and seizure activity with fall. educate on importance of medication compliance and possible consequences of not taking. Encourage him in taking medication to prevent consequences. more frequent checks throughout the night.
R69's Health Status Note dated 2/27/25 at 5:05 AM documents Alerted to the resident's room, (R69) noted on floor near bedside laying on his left side in fetal position. Upon assessment for pain resident complaint of lower back and buttock pain. No c/o hitting head, resident noted with redness to left hip. Will transport to E.R. for exam related to lower back and buttock pain.
Intervention: 2/27/25 - ask if he has to toilet of if he wants to get out of bed if noted to be awake.
R69's Nursing Note dated 3/7/25 at 8:54 PM documents Resident found lying on ground in smoking area actively seizing and vomiting. Placed on left side, head protection provided by staff hand. 02 85% on room air. Seizure activity continued x5 minutes. Resident sat upright in wheelchair. Alert and oriented x2able to make needs known. Refusing vital signs and care at this time. CNA unable to clean vomit from resident. Remains non-compliant with all medication. On call Np contacted and notified of condition. Skin intact, no injuries noted related to fall.
No intervention documented on the care plan for this fall.
R69's Health Status Note dated 3/27/25 at 5:01 AM documents call placed to this pt's (V36) his p.o.a. to notify him of this pt having fallen, no answer, brief message left.
Intervention: 3/27/25 - Educate (R69) to ask for assistance prior to attempting to stand up. staff to increase rounding on (R69).
R69's Nursing Note dated 4/01/25 at 3:05 AM documents Resident noted to be on the floor during rounds. resident noted to have seizure like activities. pupils fixed. extremities rigid. Resident legs lowered to the floor. resident not responding to verbal or painful stimuli. loss of bodily fluid. blue tinged lips. 911 initiated approx 0150. Resident monitored until ems arrival. resident began to respond back to stimuli approx 0212. EMS arrival 0220. Attempted to change resident clothing and assist to stretcher. resident required 3x assist.
No intervention documented on the care plan for this fall.
R69's Nursing Note dated 4/09/25 at 11:51 AM documents Resident was found in his room on the floor between the doorway and hallway. When asked if resident fell, he stated no and then when asked if he placed himself on the door he stated, he didn't know. Resident was placed on neuro checks as protocol. Resident A&Ox2, VS: 134/82, 98.0, 91, 18 with pupils equal and reactive to light. Will cont. to monitor.
Intervention: 4/09/25 - Psych to eval.
R69's Nursing Note dated 4/19/25 at 2:01 PM document Writer was notified by several staff members that resident was on the floor in the dining room having a seizure. Seizure lasted about 3 mins while resident was lying on his left side with head elevated by writer. When asked any of the witnesses if he hit his head, other alert and oriented residents gave full account of resident falling and hitting his head om another resident's chair. Neuro checks have been implemented. Assessment at baseline.
Intervention: 4/19/25 - staff to assist (R69) to the floor if seizure activity is present.
2. R43's EMR undated documents that the resident was admitted to the facility on [DATE].
R43's EMR dated 5/6/22 documents a diagnosis of Dementia.
R43's EMR dated 10/14/24 documents a diagnosis of history of Falling.
R43's EMR dated 1/1/25 documents a diagnosis of muscle weakness (generalized) and difficulty in walking.
R43's MDS dated [DATE] documents a BIMS score of 11 out of 15. The MDS documents that the resident is independent with roll left and right. The MDS documents that the resident requires supervision or touching assistance for sit to lying and lying to sitting on side of bed. The MDS documents that the resident requires partial/moderate assistance for sit to stand, chair/bed to chair transfer, and toilet transfer.
R43's Care Plan dated 10/15/24 documents (R43) is at risk for falls r/t impaired Gait/balance, Psychoactive drug use, weakness, Poor safety awareness.
R43's Nursing Note dated 10/15/24 at 5:43 PM documents Resident had a fall at 5:05pm. I was a couple doors down at my cart when I heard him fall. I walked into the room to find him laying on his right side. Resident was assesed and neuro vitals started. Resident denied any pain or discomfort. Resident did receive a skin tear to the back of his left arm. He stated that he was trying to get to the bathroom. Resident teaching provided on call light use.
No intervention noted on the care plan for this fall. The intervention was noted in the nursing note that the resident was educated on call light use.
R43's Nursing Note dated 10/19/24 at 8:46 AM documents CNA notified writer that resident was in his room on the floor. Writer went into residents' room and found resident was in his room on floor on fall mat on his hands and knees. Staff assisted resident up off floor and onto bed range of motion performed. Resident has no c/o of pain limbs equal in length. Writer asked resident what caused him to fall resident stated he was attempting to get into wheelchair unassisted. Writer educated resident on the importance of using call light to ask for assistance when attempting to get into wheelchair. Resident sister notified along with MD.
No intervention documented on the care plan for this fall. Intervention noted in the nursing note that the resident was educated on call light to ask for assistance when attempting to get into wheelchair.
R43's Nursing Note dated 11/14/24 at 1:34 PM documents Resident was found in room on his knees in staff assisted resident up off his knees and into his wheelchair. Rom (Range of Motion) performed no c/o pain or discomfort noted. MD notified along with family.
No intervention documented on the care plan for this fall.
R43's Nursing Note dated 11/25/24 at 9:36 AM documents Staff notified writer that resident was on the floor in the bathroom. Writer went into bathroom saw resident lying face first on floor. Staff assisted resident up off floor into wheelchair resident denied pain during transfer. Rom performed resident denied pain limbs are equal in length. Writer asked resident how fall occurred. Resident stated he was attempting to transfer himself on to toilet and lost his balance. Writer educated resident on the importance of using call light when needing to use restroom to get assistance from staff.
No intervention documented on the care plan for this fall. Intervention noted in the nursing note that resident was again educated on call light use. This intervention was previously used twice and not progressive.
R43's Nursing Note dated 11/30/24 at 6:45 PM documents Staff notified writer that resident was in dining area lying on floor. Writer went into dining room and found resident lying face first on floor. Staff assisted resident up off floor and into chair. Rom performed no c/o of pain noted all limbs equal in length. No injuries or bruising noted at this time. MD notified along with sister.
No intervention documented on the care plan for this fall.
R43's Nursing Note dated 12/05/24 at 11:49 AM documents Resident was attempting to get out of his wheelchair and into a regular chair at nurses station. Resident lost his footing and fell on to the floor. Resident denies hitting his head. Writer and another nurse assisted resident up off floor. No injuries noted no c/o of pain Rom performed all limbs equal in length no c/o pain. Residents' sister (V40) notified along with MD. Resident was educated to ask for assistance when attempting to ambulate.
No intervention documented on the care plan for this fall. Intervention noted in the nursing note that resident was educated to ask for assistance when attempting to ambulate.
R43's Nursing Note dated 12/07/24 at 11:36 AM documents CNA alerted this nurse that resident was on the ground this nurse upon assessment noted resident lying on floor in room, face up with head sticking out of doorway with legs towards bed. VS immediately taken, noted WNL limits. Resident is noted to be pleasantly confused and alert. ROM WNL. [NAME] without difficulty. Noted floor is dry, lighting is adequate and resident had on regular socks with shoes noted to be on floor at end of bed. Resident states that he was in his bed and wanted to get up so he got up and tried to get in my wheelchair but doesn't remember falling. No injury noted. Denies pain or discomfort. Noted call light on bedding. Resident assisted to wheelchair from floor with 2 staff assist and gait belt without difficulty or incident. Resident educated, reminded and encouraged to utilize call light for assistance. Resident voiced understanding. Up in wheelchair at this time, propelled by staff to dining room for lunch. MD/POA updated to fall.
No intervention documented on the care plan for this fall. Intervention noted in the nursing note that the resident was educated, reminded, and encourage to use call light.
R43 ' s Health Status Note dated 12/19/24 at 2:25 PM documents nurse alerted to resident on the floor in room, resident was lying on floor besides bed on his chest with legs lying on the side. resident stated he was trying to get into bed or into chair he couldn't specify which one he was attempting to do prior to fall. resident was assessed for pain and injury. He has a laceration to top of head, it was cleaned and tao (triple antibiotic ointment) applied. resident perrla (Pupils equal, round, reactive to light and accommodation) prom performed resident assisted off of floor into bed, vital taken b/p (Blood Pressure) 120/79 97.6 84 18 90. md and poa adon, notified.
No intervention documented on the care plan for this fall.
R43's Nursing Note dated 12/24/24 at 7:13 AM documents Observed laying on floor near bed, laying on face down with head propped up on folded arms, pt stated he tried to get out of bed without assistance, pt stated he did not hit his head, floor dry and free of clutter, bed in low position improper footwear on, pt alert and orientated x1, able to answer simple question and follow simple commands, some bouts of confusion observed, skin assessed, no apparent injuries, some redness to bilateral knees, ROM WNL, denies pain and discomfort, VS 97.8, 20,113/73,76, 97% RA, MD and POA notified, 72hr monitoring, neuro checks in place, encouraged pt to use call light for assistance. understanding verbalized, resting in bed eating candy, HOB elevated, call light in reach and grip socks on feet.
No intervention documented on the care plan for this fall. Intervention noted in the nursing note was educated resident on using the call light assistance.
R43's Health Status Note dated 12/30/24 at 3:45 AM documents Alerted to the resident's room by staff. Resident noted on floor, sitting on buttocks near the bathroom. Resident denies pain and denies hitting head. Head-to-toe assessment performed. Resident's vital signs WNL. Transferred from floor to bed with 2 assists and gait belt.
No intervention documented on the care plan for this fall.
R43's Nursing Note dated 1/5/25 at 3:21 AM documents 3:15am resident called out for help. CNA went to see what resident needed, he was on the floor. When asked what happened resident stated that he was trying to get to the bathroom and fell. Resident was assessed by this nurse. The only thing found on him was a red spot to the right hip where he fell. Resident denies pain or discomfort. ROM WNL. Vital signs taken and stable T 97.3 BP 124/69 P 85 R 18. Resident was assisted by two CNAs back into the bed and reminded to use his call light when assistance is needed. He agreed. He is currently resting in bed with call light in reach. Will continue to monitor.
No intervention documented on the care plan for this fall. Intervention noted in the nursing note to remind resident to use call light.
R43's Nursing Note dated 1/22/25 at 6:50 PM documents Noting the resident was observed lying on left side on the floor in dining room area. There were no liquids or obstacles in the area of the fall. The resident stated, he was trying to get up out of the w/c and suddenly went forward to the floor landing on left side and bi-lateral arm. A head-to-toe assessment was completed with no c/o pain or discomfort voiced or observed at this time. When questioned on rather he hit his head, the resident stated, I didn't hit my head.1mm brisk, PERRLA, A & O x2, Vitals: 145/60 B/P ,90P, 97.9T, 20R with glucose 277, ROM in bi-lateral arm area observed equal with raise, and grip. A 72-neurological observation has been started. (V30) and POA will be notified of the above note.
No intervention documented on the care plan for this fall.
R43's Health Status Note dated 2/16/25 at 11:09 AM documents resident found on the floor in the hallway of 500 hall outside of resident's room. Resident was lying on his right side with head on the floor his legs and feet under his wheelchair. with a small skin tear to his r elbow. resident states he did hit the front of his head. resident states he just fell forward. Resident was assessed for injury and pain, prom performed, perrla, assisted off of floor and into wheelchair. md and poa (V40) notified.
Intervention: 02/16/2024 When assisting him to his wheelchair, staff to ensure it is HIS wheelchair, NOT anyone else's. Treatment to right elbow skin tear as ordered.
R43's Nursing Note dated 3/15/25 at 1:56 PM documents CNA alerted this nurse that resident had fallen. Upon visualizing resident, noted wheelchair to be in resident doorway, resident is lying face down on floor with head turned to the right and legs straight out. Resident states I peed this nurse and CNA noted that resident was not incontinent of urine but of bowel. Noted small BM, brown and soft in adult brief. Peri care provided. VS 97.1 76 120/80 18 97%RA 118bs. Resident pleasant and cooperative with care and staff. Resident assisted via 2 assist and gait belt from floor to bed. ROM WNL. [NAME] without difficulty or complaint. MD aware, no new orders. POA made aware.
Intervention: 03/17/2025 When noted to be going to his room, staff to cue him through mobility task while going through his doorway.
Practitioner Note dated 4/4/25 at 8:38 AM documents Patient was found sitting on the floor in the restroom around 8:40. Notified staff who then got him up. Also discussed with nurse. Upon examination patient appears alert. No bruises noted. Good ROM to both upper and lower extremities. Denies hitting his head also does not appear to have hit his head. No erythema noted to head arms or legs at this time. Patient denies dizziness, shortness of breath, or any pain. Reports that he thinks therapy is going well he just can't get to the bathroom . Continues to work in therapy on strength for independence with ADLs.
Intervention: 4/4/25: Staff to increase rounding on (R43). Take (R43) out of room when he is up.
3. On 4/22/2025 at 8:58 AM a Call don't fall sign was observed on R22's wall by R22's television, along with a sign stating Do not get out of bed by yourself sign on R22's side wall by bed. R22 observed sitting in wheelchair in the middle of the room and call light pinned to R22's bedsheets.
04/25/25 9:38 AM, R22 observed standing up in the room by self in front of the sink. R22's wheelchair noted in the middle of the room and call light on R22's bedsheets.
04/25/25 10:32 AM R22 observed sitting in chair watching television, call light observed noted on R22's bed.
4/25/25 at 11:08 AM, V35, Certified Nursing Assistant (CNA), stated See he is trying to get up now on his own. R22 observed trying to get out of chair by himself, call light was observed to be on R22's bedsheets. V35, CNA, helped R22 get up and get into his wheelchair.
R22's Care Plan reviewed/revised on 12/5/2024 documents R22 has an Activities of Daily Living (ADL) self-care performance deficit related to activity intolerance, weakness, hypotension, anemia, polyneuropathy, and shortness of breath (SOB) with exertion. Interventions include mobility/ambulation x1 supervision to limited assist with mobility. R22 uses a wheelchair without bilateral leg rests. Partial/Moderate to Substantial/Maximum assist with ambulation utilizing a wheeled walker. Partial/Moderate to Substantial/Maximum assist with transfers. Ensure he has on non-skid footwear (non-skid socks or shoes) when out of bed. Notify nurse if he complains of weakness, pain and/or shortness of breath.
R22's Care Plan revised on 10/9/2022, documents R22 is at risk for falls related to syncope, hypotension, weakness, poor safety awareness. Care Plan documents intervention on 12/27/2024, ensure that he has on proper footwear, encouraged him to use call light for assistance with transfers and ADL's. If noted to be awake with rounds, ask if he needs to toilet. Intervention added on 03/12/2025, documents encourage him to request assist with weight bearing tasks/ADL's due to weakness and SOB with exertion/sitting/lying flat. Refer to therapy. Intervention a[TRUNCATED]
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to respect a residents privacy and dignity during a social...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to respect a residents privacy and dignity during a social media post for 1 (R46) of 3 residents reviewed for dignity in a sample of 67.
Findings Include:
R46's Undated Face Sheet, documents R46 was initially admitted to the facility on [DATE] with diagnoses including Parkinson's Disease with Dyskinesia, History of Falling, Hypertension, and Aphasia.
R46's Minimum Data Set (MDS) dated [DATE] documents R46 is severely cognitively impaired.
R46's Resident Consent to Photograph and Authorization for Use or Disclosure of Protected Health Information dated 4/7/2025 documents an illegible signature for consent.
Unknown dated Social Media Post documents, a photo of R46 with V48, Restorative Nurse/QA. The photo documents R46 in his wheelchair with V48, Restorative Nurse/Quality Assurance, posing next to R46 with a sign taped her V48, Restorative Nurse/QA's buttock stating, R46's First Initial and Last Name, Fall Risk.
On 5/13/2025 at 10:09 AM R46 denied knowing if the facility had him sign a consent allowing the facility to take his photo and post the photo on social media.
On 5/13/2025 at 2:11 PM V73, R46's POA stated she was unaware that a picture of R46 had been taken and posted on social media. V73 stated R46 does not know much about social media, and she is sure R46 would not want his pictures posted on it. V73 stated the facility has never reached out to her to consent for R46's picture to be taken and posted on social media. V73 stated it is hard to say if R46 could write his name to consent to have his photo taken and posted on social media due to his Parkinson's. V73 stated R46 does not care for his picture to be taken and she knows he would not want his picture to be posted on social media.
On 5/13/2025 at 2:22 PM R46 stated he just found out about a photo being taken of him and posted social media from a friend. R46 was shown the photos there were posted and confirmed that it is him in the photograph and R46 could not say who the employee was in the photo with him. R46 stated he cannot say what the context of the photo was. R46 stated he does not recall giving consent for his photo to be taken. R46 stated he feels fair about his picture being taken and does not like the photo. R46 stated he would like the picture to be taken down from social media and for the facility to not post his picture. R46 could tell this surveyor his name but is unable to recall what year it is currently, stating the year is 2022.
On 5/13/2025 at 2:35 PM V1, Administrator, stated regarding the photo of R46, it was Twin/ Day at the facility and staff were to pick a resident to dress alike and coordinate with.
On 5/13/2025 at 2:39 PM V48, Restorative Nurse/ QA, stated she did not write the sign that is in the picture, that another co-worker wrote the sign and posted it on social media. V48 stated she dressed like R46 for Twin Day and was bringing awareness because R46 falls all the time. V48 stated it was just a joke between herself and R46. V48 stated R46 was okay with the picture, and he was able to give consent and R46 is not confused at all.
On 5/20/2025 at 11:00 AM, V1, Administrator, stated the facility does not have an actual social media policy and every resident signs a consent for their picture to be taken and used on any social media when they sign their admission paperwork. V1, Administrator, stated a consent to photograph is included in the facility's admission paperwork. V1, Administrator, stated the facility follows the Illinois Long Term Care Ombudsman Program Resident Rights document for their resident rights policy.
On 5/27/2025 at 1:25 PM, V2, DON, stated the facility's admission Contract does include a consent to photograph each resident and photos can be used for advertising their services and on social media. V2, DON, stated R46 is fully aware of what is happening and is alert and oriented x 3. V2, DON, stated R46 could give verbal consent for his photograph to be taken and thinks R46 could sign his name on a consent form. V2, DON, stated he is unsure who took the picture of R46 and the staff member in the photo, who took the picture with R46 in it, or who took the photo down from social media. V2, DON, stated R46 and the staff member present in the picture both gave verbal consent for their picture to be taken. V2, DON, stated regarding the content of the photograph, R46 was asked if R46 was okay with it and R46 said it was okay for the photograph to be taken.
The Illinois Long Term Care Ombudsman Program Resident Rights pamphlet last revised 11/18 documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure availability and working order of a personal wheelchair for 1 of 3 (R6) residents reviewed for accommodation of needs in...
Read full inspector narrative →
Based on observation, interview and record review the facility failed to ensure availability and working order of a personal wheelchair for 1 of 3 (R6) residents reviewed for accommodation of needs in the sample of 67.
Findings Include:
R6's Occupational therapy Progress Report, dated 2/13/2023 to 2/23/2023 documents patient currently unable to utilize personal tilt and space wheelchair with ROHO due to missing cushion and chair in disrepair.
R6's Occupational Therapy Progress Note, dated during certification period of 3/14/2023 through 4/12/2023, documents patient tilt and space chair still in disrepair. Patient has assessment for new chair 3/23/2023.
R6's Occupational Therapy Treatment Encounter Note, dated 2/28/2024, documents skilled occupational therapist assessment indicates need for a tilt and space wheelchair with a hybrid ROHO cushion, adjustable headrest, pommel and fix leg rest.
R6's Wound Nurse Practitioner Progress Note, dated 4/23/2025 V13 documented visit specific information: patients broda chair was found and I do recommend that he gets up for short periods of time. Recommend discussing with therapy for best option of offloading cushion for chair.
A Typed Statement, dated 4/24/2025 signed by V18, documents (R6) was seen by skilled OT (Occupational Therapy) at this facility from 3/28/2025 to 4/22/2025 during that POC (plan of care) this therapist recommended patient utilize a tilt and space wheelchair with adjustable leg rest and a ROHO cushion (hybrid select or enhancer) when out of bed to maximize offloading and pressure relief. As of 4/24/2025 there had been no documented change in function or medical status that would change this recommendation. From a therapy perspective, when properly inflated a ROHO remains the gold standard for pressure relief and the aforementioned cushions provide the versatility to customize weight distribution to the patient's needs. Unless, due to the severity of the wounds, a wound care specialist has an alternative cushion recommendation that would provide comparable or superior pressure relief this would be the best option for patient's comfort and wound healing.
Periodic observation of R6 throughout the annual survey, dated 4/22/2025 through 5/20/2025 noted him sitting in a high back wheelchair. His personal tilt and space wheelchair was in a storage room at the facility.
On 4/24/2025 at 8:23 AM V18, OT stated (R6) had a specialty tilt and space wheelchair order years ago he got the wheelchair then he was admitted to hospice, he was discharged from hospice on 1/30/2023 and he never got his specialty wheelchair back. V18 recently assessed (R6) in OT from 3/28/2025 through 4/22/205 and it was her professional recommendation that he have his specialty tilt and space wheelchair with specialty wheelchair cushion with leg rests. The cushion she recommended was a special cushion for him because she could air up and deflate different cells of the cushion to assist with offloading his coccyx pressure ulcer and to ensure he had proper pressure relief. V18 stated she asked the former therapy manager many times about (R6's) wheelchair but it fell on deaf ears, she didn't know where (R6's) wheelchair or cushion was and she stated the facility never planned on replacing or even tried to locate R6's wheelchair.
On 5/1/2025 at 2:15 PM V13, Wound Nurse Practitioner stated she would follow therapy's recommendations for what wheelchair (R6) should be using and whatever chair he is up in should have a pressure relieving cushion to offload pressure on his coccyx pressure ulcer, if the pressure ulcer isn't offloaded properly is could potentially lead to the worsening of the pressure ulcer.
A facility policy regarding accomodation of needs was requested multiple times throughout the survey to V1 (administrator), but never provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to completely investigate an allegation of sexual abuse for 1 of 3 resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to completely investigate an allegation of sexual abuse for 1 of 3 residents (R40), reviewed for abuse in the sample of 67.
Findings Include:
On 5/29/25 at 2:10 PM, R40 was observed in room in wheelchair, with a calm, flat affect, and is alert and oriented to person, place, and time. R40 stated R8 is a friendly guy, and he touched her. When asked where, she pointed to her breasts and abdomen. R40 stated she doesn't recall where it happened or if anyone saw it, but it happened a few weeks ago and she reported it to her nurse, unsure of name. R40 stated she doesn't remember if anything like this has happened before, but it hasn't happened since. R40 stated she isn't afraid of R8. R40 stated she feels safe in the facility.
R40's Face Sheet, undated, documents she has the following diagnoses, in part: Mild Cognitive Impairment, Unspecified Mood Disorder, and Cerebral Infarction.
R40's MDS (Minimum Data Set), dated 5/14/25, documents R40 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R40 is cognitively intact and doesn't have any indicators of Psychosis or Delirium.
R40's Care Plan, dated 5/7/25 and 5/13/25, that she has a behavior problem of making false accusations of staff and other residents. On 5/11/25, R40 accused another resident of groping her in the dining room.
R40's Progress Note, dated 5/11/25 at 12:25 PM, documents the following: Reported per staff that a male resident was in mdr (main dining room) attempting to touch this resident in private areas. Staff did intervene immediately, and male resident was removed from area. This resident said that male did not touch her. She did not have any s/s (signs or symptoms) fear/fright. Resident was assessed and had no redness or bruising noted. ED (Emergency Department), NP (Nurse Practitioner), PD (Local Police Department) made aware, and report filed. Resident to be referred to psych as well upon next visit.
On 5/29/25 at 2:30 PM, R8 was observed in room in bed, calm, cooperative, alert to self and place only. R8 had no recollection of the alleged abuse involving R40 and denied any inappropriate touching of the female residents or staff.
R8's Face Sheet, undated, documents R8 has the following diagnoses, in part: Diffuse Traumatic Brain Injury, Altered Mental Status, Bipolar Disorder, Anxiety, and Post-Traumatic Stress Disorder.
R8's MDS, dated [DATE], documents R8 has a BIMS score of 12, indicating R8 has moderate cognitive impairment, has disorganized thinking, has physical, verbal, and other behavioral symptoms that put him at risk for significant risk of physical illness or injury.
R8's Care Plan, dated 4/7/25 and 5/6/25, documents R8 is at risk of being physically aggressive towards others related to impaired cognition, poor impulse control, and anger. R8 has a behavior problem of making sexual inappropriate comments and groping staff.
R8's Progress Note, dated 3/8/25 at 6:35 PM, documents the following: Resident continues to be sexually hyperactive, approaching women, he also needs constant redirection. He will be sent to hospital for psych evaluation.
R8's Progress Note, dated 3/9/25 at 3:30 AM, documents the following: Received call regarding increased behaviors, nurse attempt to send to ER (Emergency Room) for eval (evaluation), once EMT (Emergency Medical Technician) arrived resident refused.
R8's Progress Note, dated 3/30/25 at 5:01PM, documents the following: Grabbing at staff, touching buttocks and attempting to touch breasts. Trying to get in RNs (Registered Nurse) med (Medication) cart. Explaining to him he can't touch med cart. Slapped RN across face. Administrator called, to send out for Psych eval.
R8's Progress Note, dated 5/6/25 at 11:27 AM, documents the following: Resident conts. (continues) to displays inappropriate sexual behavior towards female staff. Resident attempted to grab writer's vagina during morning med pass. Writer informed resident that what he was doing was inappropriate. Resident told writer to shut up and give him some p****. Writer tried to administer morning meds resident refused. Writer reached out to Dr (Doctor), NP and left voicemail to call facility.
R8's Progress Note, dated 5/8/25 at 9:53 AM, documents the following: It has been reported from several employees about (R8's) inappropriate behaviors. Staff reported that he makes inappropriate comments to them. The latest comment that he made to a staff member was Come here so I can grab your fat p****. Within minutes of being spoken to about his behavior he reached over and rub another employee down her leg. The nurse on 500 hall reported that (R8) touched her between the legs. SSD (Social Service Director) spoke with him and, called his POA (Power of Attorney) to see if she can speak to him about his behavior. Nurse notified.
R8's Progress Note, dated 5/11/25 at 1:27 PM, documents the following: Resident up per w/c (wheelchair) propelling self around facility. Was observed in common areas attempting to touch female counterparts and staff inappropriately. Did not witness resident making contact and no female resident voiced concern. No resident displayed s/s fear or fright. Was redirected and taken to low stimulus environment for calming. Did notify NP and resident to be seen by psych upon next visit for consult r/t (related to) sexual aggression. POA made aware of behaviors. Behavior tracking initiated. (Local) police phoned, and report made.
R8's Progress Note, dated 5/12/25 at 3:03 PM, documents the following: On May 8, 2025, at 9:53am SSD sent a message to RN Clinical Director for Long Term Psychiatric and Medical Management requesting that (R8) be seen by Psych on next visit. She asked what type of behaviors that he is displaying. SSD told her about several of the things that (R8) has done that was sexual inappropriate towards the staff.
R8's Progress Noted, dated 5/20/25 at 6:22 PM, documents the following: Resident sexually inappropriate with nurse verbally and attempted to grab at private areas. Multiple attempts at redirection.
R8's Progress Note, dated 5/25/25 at 6:55 PM, documents the following: Resident attempting to reach for staff members butts and private areas. Multiple staff members attempting to redirect him and tell him this is inappropriate behavior. Resident ignores staff and continues trying to grab us inappropriately.
The Abuse Investigation Final Report, dated, 5/14/25, documents there is insufficient evidence to declare there was intentional abuse. There was no interview with R8 in the investigation. In the final report there is mention that staff and residents interviewed, however there were no notes in the investigation file of who, when and by whom these interviews were conducted, other than V28, RN, V75, CNA (Certified Nursing Assistant), R40, and R71, to reach the conclusion. There is insufficient evidence in the investigation file provided by V1, Administrator, on 5/29/25 at 1:20PM, to validate that a complete and thorough investigation was completed due to a lack of interviews with other staff and residents.
The Local Police Department Incident Report, dated 5/11/25 by V83, Local Police Officer, documents R8 was interviewed and R8 denied putting his hands on R40 and stated he did not know what the officer was talking about. R40 was interviewed and stated she was in the dining room with other people and R8 grabbed her by her breast and vagina.
On 5/29/25 at 2:20 PM, V28, RN, stated she did not witness the alleged abuse involving R8 and R40. V28 stated she was the nurse for both residents and (V75) reported stopped her in the hallway and told her that R8 touched or attempted to touch R40. V28 stated when she initially talked to R40, she said nothing happened but then she told the police that R8 touched her inappropriately. V28 stated she notified V1, Administrator, the local police department, R8's family and the MD. V28 stated R40 had no s/s of fear or fright, so they monitored her for 3 days. V28 stated it has been reported that R8 will try to touch female staff or make inappropriate comments to them, but not the female residents.
On 5/30/25 at 8:29 AM, V1, Administrator, stated she only talked to the witnesses of the alleged incident between R8 and R40. V1 stated since there were no other witnesses, she didn't interview other staff or residents, she only interviewed V28, V75, R40, and R71.
On 5/30/25 at 10:57 AM, V75, CNA, stated he did not witness R8 touch R40. R40 had reported it to him and there were no other staff or residents around when it was reported to him. V75 stated he reported it to the nurse, V28, and she took it from there.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to provide adequate heating and ensure roof and utility ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to provide adequate heating and ensure roof and utility hoppers were leak-free. This has the potential to affect all 90 residents living in the Facility.
Findings include:
On 4/24/25 at 10:38 AM, R22 stated the activity dining area has been cool in the mornings.
On 4/24/25 at 10:45 AM, R15 stated the activity dining area has been cool in the mornings.
On 4/24/2025 at 10:58 AM, V25, Licensed Practical Nurse (LPN), stated the activity dining area is a little chilly some days.
On 4/24/25 at 2:30 PM, V32, Maintenance Supervisor, stated the heat does not work in the activity dining room and has not worked at all during the two years he has worked here. He stated the surrounding heaters help warm the room, so it might get up to 60 degrees (Fahrenheit) in there even when it is 0 degrees (F) outside. He stated, You can try to turn the heat on, but it just won't work.
On 4/24/2025 at 11:05 AM, V26, Certified Nursing Assistant (CNA) Coordinator, went to the soiled utility room between the 200 and 300 halls and tried to flush the hopper multiple times. The water in the basin would flush partially, but did not fully empty. V26 stated the hopper must be clogged, and she will make sure maintenance is aware. V26 then went to the soiled utility room between the 500 and 600 halls where water was dripping from the faucet into the hopper. V26 stated V32 was aware of the leak.
On 4/24/25 at 2:30 PM, V32 entered the soiled utility room between the 200 and 300 halls. V32 flushed the hopper, and most of the water in the basin went down the drain, but not all of it. He stated all of the liquid should go down the drain because it is basically a toilet. He flushed several more times for a total of five flushes. There was a drip of water coming out of the faucet. V32 stated he needed to work on it, and the other hopper usually works better. V32 then walked to the soiled utility room between the 500 and 600 halls. V32 flushed the hopper, and there was a drip of water coming from the faucet. He stated he needed to put a seal on the cold water faucet handle.
On 4/24/25 at 2:30 PM, V32 stated there are leaks in the roof and they probably need a new roof, but they are out of warranty and it probably comes down to money. He pointed to the ceiling outside room [ROOM NUMBER]. The ceiling was peeling off in places with brown water stains measuring approximately two square feet. V32 stated the roof leaks with heavy rain which is about five times per year. V32 then went to the mechanical room where there was peeling tape across the ceiling above the hot water heater which he said is due to the roof leaking.
On 4/29/2025 at 10:34 AM, the shower in R45's room did not have a shower head. The faucet was turned on, but no water came out.
On 4/29/2025 at 12:45 PM, V45, R45's Family, stated the shower in R45's room does not work and have never worked since R45 was been admitted to the facility.
On 4/29/25 at 9:26 AM, V32 stated nothing has been done with the hoppers, the roof or the activity dining room heat since we toured the Facility last week. He stated there are a lot of bigger issues that he has to take care first.
On 4/30/25 at 9:26 AM, V1, Administrator, stated she was aware the heat in the activity room was not working, but just did not know how long it had been a problem. She was notified of the leaking roof by V32 on 4/29/25.
On 4/29/25 at 2:58 PM, V1 stated the Facility does not have a policy regarding functionality of equipment.
The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 4/22/25 documents there are 90 residents living in the Facility.
Mar 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to provide oxygen therapy as ordered for 1 of 3 residents (R2) reviewe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to provide oxygen therapy as ordered for 1 of 3 residents (R2) reviewed for respiratory care in the sample of 4.
Findings include:
1. R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and chronic respiratory failure with hypoxia.
On 3/19/25 at 8:34 AM, R2 stated the power went out on 3/14/25 and she had to go without oxygen for a couple of hours. She stated she begged for portable oxygen, but they never brought it. She was starting to feel a little short of breath before the power kicked back on.
R2's 8/26/24 Physician Order documents if resident complains of or has signs and symptoms of shortness of breath when lying flat, ensure the head of bed is elevated and/or assist her with propping up pillows when in bed (except while providing care) at every shift.
R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, dependent with bed mobility and transfer, and received oxygen therapy.
R2's Care Plan revised 1/16/24 documents R2 is at risk for impaired oxygenation, weakness, shortness of breath, fatigue, skin pallor (paleness), lightheadedness, dizziness and a fast heartbeat related to diagnosis of COPD and OSA.
R2's March 2025 Medication Administration Record (MAR) documents blanks in the rows labeled SOB (Short of Breath) (Yes or No) and Administered for the evening shift on 3/14/25.
R2's 10/2/24 Physician Order documents oxygen at 2 liters/minute per nasal cannula continuously and as needed while in bed for chest pain/shortness of breath.
R2's March 2025 MAR does not document oxygen was provided on evening shift on 3/14/25.
On 3/19/25 at 10:15 AM, V6, Registered Nurse (RN), stated R2 only uses oxygen as needed.
On 3/19/25 at 3:05 PM, V9, Nurse Practitioner (NP), stated R2 is cognitively intact and is able to determine when she needs supplemental oxygen.
On 3/19/25 at 2:30 PM, V1, Administrator, stated she does not have a policy regarding respiratory care, but she expects oxygen to be provided as ordered and documented in the MAR.
Mar 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to prevent the reoccurance of a pressure ulcer for a resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to prevent the reoccurance of a pressure ulcer for a resident with a history of wounds and risk factors, as well as initiate a timely and appropriate treatment for 1 of 3 residents (R3) reviewed for pressure ulcers, in the sample of 7.
Findings include:
On 3/13/2025 at approximately 8:45 AM, V8, Certified Nursing Assistant (CNA) stated R3 has a new open area, about the size of a dime, to her coccyx (buttocks). At this time, R3 also confirmed she had a wound to her bottom.
On 3/13/2025 at approximately 10 AM, the facility provided their Resident Matrix. R3 is not listed as having a pressure ulcer.
R3's Face Sheet dated 3/13/2025 documents R3 has multiple diagnoses include Diabetes Mellitus, atherosclerosis of bilateral legs, mixed incontinence, muscle weakness, and contractures of the right and left knees.
R3's Skin Attention Form dated 3/10/2025 documents a Xon the diagram of a body. This form continues to document, Indicate the area with an 'X' where you notice abnormality or change in color, moisture, temperature, integrity or turgor and answer the questions. If you are not sure if area is a real problem, mark it down anyway. The nurse should assess all areas where the CNA had indicated change.
R3's Minimum Data Set (MDS) dated [DATE] documents R3 has a functional limitation in range of motion on both sides of her lower extremities as well as R3 is dependent on staff for rolling from left to right and for transfers from chair/bed to chair.
R3's current Care Plan was requested and documents, (R3) is at risk for development and/or decline in current pressure ulcers related to decreased mobility and incontinence. The goal includes, She (R3) will have no new development of pressure ulcers through the next review. It further documents, 3/10/2025- re-opened area to coccyx. and 3/13/2025 WCP (Wound Care Plus) to eval and treat as indicated.
On 3/13/2025 at 10:15 AM, V2, Director of Nursing (DON) provided a list titled, Pressure Wound Log. This document was dated 3/13/2025 and does not include R3 on it. This Wound Log does not include stage, measurements, or locations of the pressure wounds. At this time, V2 stated currently there is no wound nurse, so he has assumed the responsiblities of wounds in the absense of the wound nurse position. V2 stated he would look and see if R3's pressure ulcer had been assessed/measured.
On 3/13/2025 at 10:20 AM, V5, Licensed Practical Nurse (LPN) was observed initiating a treatment to R3's left buttocks. R3 did not have any type of dressing or cream to her buttocks. In the crease of R3's left buttocks was an approximately 1 cm open area. At this time V5 stated she, Just got the order 'fixed' because they just put gauze and tape on it but it needed (the special foam gel dressing).
On 3/13/2025 at 11:04 AM, the Pressure Ulcer Log was reviewed with V2. At this time, V2 stated he needed to add R3 to the list. V2 confimed the open area was first identified on 3/10/2025. V2 stated it was an old healed area and had opened back up. V2 confirmed treatment was not intiated until 3/13/2025 and should have been done when it was first reported (3/10/2025).
On 3/13/2025 at 11:24 AM, V16, Registered Nurse (RN) stated when an open area is first identified, she would do a whole body skin assessment, measure the wound, call the doctor and get a treatment order in place. V16 stated she would absolutely not just put gauze and tape on the open area.
On 3/13/2025 at 11:58 AM, V2 stated he had just obtained measurements on R3's wound to R3's left buttock and it measured 0.5 centimeters (cm) by 1 cm.
R3's Physician's Orders dated 3/13/2025 documents, WCP (Wound Care Plus- an outside agency) to eval (evaluate) and treat as indicated. It further documents an order for a gel formula dressing was ordered on 3/13/2025. It continues, Apply to left buttock topically every 72 hours for open area to left buttock. Cleanse area with wound spray, apply wound prep around the outside of the wound and apply (dressing). Change Q (Every) 72 hrs (hours) and prn (as needed).
R3's Progress Notes dated 3/10/2025 at 2:03 PM documents, CNA notified me of a new sore area on the lower left thigh (back) on resident. Pink and about 1/2 centimeter in length, pink in color, no bleeding noted. Cleansed with wound cleanser and covered with tape and gauze. Nurse Practitioner notified, will continue to monitor.
R3's Progress Notes dated 3/13/2025 at 11:26 AM documents, Np (Nurse Practitioner) gave orders to cleanse area with wound spray, apply skin prep around the outside of wound and (dressing) change Q 72 hrs and prn.
The Facility's Skin-Ulcer-Wound Policy dated 10/12/2023 documents, All caregivers are responsible for preventing, caring for, and providing treatment for skin ulcerations. It further documents the purpose of the policy is, To prevent breakdown of tissue or ulcerations and To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations. It continues to document risk factors as impaired/decreased mobility, co-morbidities such as diabetes, exposure of skin to urinary or fecal incontinence and history of a healed ulcer makes pressure ulcers more likely to have recurrent breakdown. This policy documents all orders must be approved by the physician within 24 hours. It also documents, At the time a skin issue is discovered it must be measured. Wounds are 3 dimensional, therefore length, width and depth must be documented if using a measuring instrument.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to perform Range of Motion (ROM) exercises to a resident ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to perform Range of Motion (ROM) exercises to a resident with contractures for 1 of 3 residents (R3) reviewed for Restorative Programs/Physical Therapy, in the sample of 7.
Findings include:
R3's Face Sheet dated 3/13/2025 documents R3 has multiple diagnoses include Diabetes Mellitus, atherosclerosis of bilateral legs, mixed incontinence, muscle weakness, and contractures of the right and left knees.
R3's Minimum Data Set (MDS) dated [DATE] documents R3 has a functional limitation in range of motion on both sides of her lower extremities as well as R3 is dependent on staff for rolling from left to right and for transfers from chair/bed to chair.
R3's current Care Plan was requested and documents, (R3) is at risk for pain (joints), stiffness, edema, redness, decreased ROM, weakness, physical deformity and skin breakdown r/t (related to) diagnosis of arthritis and BLE (bilateral Lower Extremities) contractures. It further documents to provide ROM exercises with daily care as tolerated. It continues to document R3 has self care deficit due to weakness and poor trunk control. It continues to document R3 is at risk for falls, pain and decreased mobility related to bilateral knee contractures and should be receiving a restorative ROM program.
R3's Current Physician's Orders were requested and do not include an order ROM to be performed.
On 3/13/2025 at approximately 12:10 PM, R3 was observed sitting in a chair, with her bilateral legs bent at both knees. At this time, V8, Certified Nursing Assistant (CNA) stated R3 does have contractures to both her legs and there were no interventions in place for them. V8 stated she does not perform any kind of exercises on R3. At this time, R3 confirmed no one does any exercises on her legs, but she would participate if they did.
On 3/13/2025 at 12:13 PM, V2, Director of Nursing (DON) stated the Facility is working on starting a restorative program back up. V2 stated in the meantime, the CNAs assigned to the hall are responsible for completing ROM exercises. V2 stated R3 does have contractures and should be receiving ROM to stretch it out. V2 confirmed R3 was not enrolled in any therapy services at the moment. V2 stated the restorative program is a step below physical therapy. V2 stated the Facility has been without a restorative program for a month or two. V2 stated any resident with contractures should be receiving ROM exercises.
On 3/13/2025 at 12:39 PM, V1, Administrator, stated the Facility does not currently have a restorative nurse, but has one starting next week. V1 stated residents with contractures can be referred to therapy services. V1 stated she will get R3 a referral for therapy services.
On 3/13/2025 at 12:52 PM, V7, CNA coordinator, stated the Facility did have a restorative program with 4 CNAs that would perform ROM, but they have not had it for months. V7 stated the CNAs assigned to the resident should be performing ROM.
On 3/13/2025 at 1:17 PM, V1, Administrator, stated she called and got R3 an order for therapy services for positioning and her contractures.
On 3/13/2025 at 2:00 PM, V1, Administrator, stated the Facility does not have a policy for contracture prevention/ROM.
Dec 2024
6 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess, monitor, and provide timely treatment for R2's knee pain. Th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess, monitor, and provide timely treatment for R2's knee pain. This failure resulted in when R2 had continued pain and swelling from 11/15/24 until 12/7/24 at which time her femur bone was protruding through her skin. R2 was hospitalized with an open femur fracture requiring surgical intervention which caused pain and suffering, with an increased risk for infection, vascular issues, and subsequently could have resulted in death. The failure to provide ongoing assessment, monitoring, and treatment for R2's ongoing knee pain led to R2's undiagnosed femur fracture to develop into an open fracture.
The Immediate Jeopardy began on 11/15/24 when R2's right foot injury was noted, and the facility failed provide ongoing assessment, monitoring, and timely treatment for R2's ongoing symptoms including an increase in swelling and pain. The facility did not seek treatment for R2's ongoing symptoms until R2's femur fracture penetrated through her skin on 12/7/24. On 12/13/24 at 12:40 PM V1, Administrator, was notified of the Immediate Jeopardy. The surveyors confirmed through interview and record review that the Immediate Jeopardy was removed on 12/15/24, but noncompliance remains at Level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and quality assurance.
Findings include:
R2's Face Sheet, print date of 12/16/24, documented R2 has diagnoses of unspecified fracture of right femur, unspecified severe protein-calorie malnutrition, Alzheimer's disease, atherosclerosis, paranoid schizophrenia, drug induced dyskinesia, contractures, history of cerebral infarction, cognitive communication deficit, osteoporosis, and functional quadriplegia.
R2's Minimum Data Set, MDS, dated [DATE], documented R2 is moderately cognitively impaired, is non-ambulatory, and is dependent on staff for transfers.
R2's Care Plan, undated, documented R2 requires a mechanical lift for all transfers.
R2's Resident Care Flow Sheet, undated, documented R2 is assist of 1 for transfers.
R2's Electronic Medical Record, EMR, Progress Note dated 11/15/24 at 10:16 AM documented slight discoloration to right posterior foot observed, appears to be injury, green in color and edema to right foot, origin unknown, no incident reported, facial grimacing observed when palpated, NP (Nurse Practitioner) notified, and hospice nurse notified.
R2's Incident Report, dated 11/15/24 at 10:06 AM, documented incident description: slight discoloration to R (right) posterior foot, appears to be injury green in color and edema to R foot. Resident unable to give description. Predisposing Situation Factors: during transfer.
R2's EMR Progress Note, dated 11/15/24 at 12:35 PM documented call return for the hospice nurse, made aware that NP (Nurse Practitioner) would give an order for x-ray to foot if hospice approved, V13 hospice Registered Nurse, RN agreed to x-ray.
R2's hospice aide visit note, dated 11/15/24 at 8:45 AM, documented patient's right foot swollen and bruised. Case manager updated on new concerns.
R2's radiology results report, dated 11/16/24, documented reason for study: pain, right foot. Findings: There is mild osteopenia. There is mild degenerative joint disease seen. There is no fracture, dislocation, or soft tissue swelling. No osteomyelitis is seen. There is a plantar heel. Conclusion: Mild degenerative joint disease; otherwise, no fracture or dislocation seen.
R2's radiology results report, dated 11/17/24, documented reason for study: localized swelling, mass and lump, right lower limb. Findings: views of the knee show mild joint space loss and subchondral sclerosis compatible with osteoarthritis. No acute fracture or dislocation is seen. No significant joint effusion is noted. Conclusion: Mild osteoarthritis, without fracture.
R2's EMR Progress Note, dated 11/20/24 at 8:48 AM documented writer was notified that resident's knee was very swollen, and she has a black bruise on her left and right coccyx. Wound nurse was notified to take a look at the area. MD (Medical Doctor) is already aware of the situation, there was an x-ray performed.
R2's EMR Progress Note, dated 11/22/24 at 3:12 AM, documented patient right knee is very swollen and c/o (complaint of) pain. Medicated for pain.
R2's EMR Progress Note, dated 11/22/24 at 2:19 PM, documented writer was notified by CNA that resident only ate about 20% of her meal. CNA stated that she is having difficulty eating and drinking.
R2's EMR Progress Note, dated 11/26/24 at 10:26 PM, documented resident remains on hospice. No s/s of distress. She is complaining of pain in her knee and foot.
R2's hospice aide visit note, dated 11/29/24 at 8:30 AM, documented right leg, knee, and foot swollen. Case Manager and in house nurse updated on new concern and visit.
R2's hospice nurse visit note, dated 11/29/24 at 10:30 AM, documented patient continues to have some increased swelling to her right foot and leg up to her knee at a +2 edema.
There are no Progress Notes in R2's medical record from the facility from 11/26/24 through 12/1/24 regarding the condition or further assessment of R2's knee.
R2's hospice nurse triage notes, dated 12/1/24 at 7:43 AM, documented patient's right knee is swollen and painful to touch. Advised to give patient pain medication. It continues, patient's right knee is more swollen than a week ago.
R2's EMR Progress Note dated 12/1/24 at 11:13 AM documented aide notified nurse of resident right knee looking abnormal. Upon assessment resident knee was swollen with minimal pain to touch. MD notified and stated to refer resident to orthopedic surgeon as outpatient f/u (follow up). DON (Director of Nursing) notified, and hospice nurse will leave message for regular nurse to follow up with resident.
R2's EMR Progress Note, dated 12/4/24 at 11:33 AM documented per nursing documentation R2 had c/o right knee pain during look back. 11/29 NOR (new order received) for Tylenol TID (3 times per day).
R2's hospice nurse notes, dated 12/6/24 at 12:20 PM, documented our HHA (hospice health aide) found a small blister on her right knee today while bathing. It continues, treatment orders - cover blister with 3x3 foam dressing daily and prn (as needed). Increased pain related to blister. New orders received: tramadol 25mg BID (two times a day) and q4hrs PRN. Education provided to sign on the new order that was giving in order to help control R2's pain better.
R2's EMR Progress Note dated 12/6/24 at 1:45 PM documented resident knee continues to be monitored; hospice nurse was consulted to look at patient knee. Upon evaluation the knee swollen, and red. Writer asked hospice nurse for an order for pain medication for her pain. Tramadol was ordered TID and PRN (as needed).
R2's hospice aide visit note, dated 12/6/24 at 9:00 AM, documented patient has blister on right knee. Case Manager and in house nurse updated.
R2's EMR progress note dated 12/7/24 at 1:40 PM documented this nurse was informed by nursing that resident was noted to have something sticking out of her knee. Upon assessment this nurse noted an area to her right knee to look like bone sticking out of knee with clear and red fluid flowing from area. Vitals WNL (within normal limits). Emergency services contacted. MD/hospice made aware. Phoned POA to inform. No answer. Admin notified. Ambulance in route.
R2's hospice progress note, dated 12/7/24 at 1:43 PM documented patient bones popped through skin. Facility MD sent patient out.
R2's EMR Progress Note dated 12/7/24 at 1:56 PM documented EMS (Emergency Medical Services) here to transport resident to hospital.
R2's EMR Progress Note dated 12/9/24 at 5:27 PM documented writer received an update on resident, she was admitted for a right femur fracture. Administrator, DON, and MD notified.
R2's Regional Hospital Emergency Medicine Notes dated 12/7/24, documented R2 presents to ED (Emergency Department) for evaluation of right leg deformity. Per EMS, patient was found in bed at her nursing home when staff found blood on her sheets and on further investigation noticed a deformity to the patients right distal femur with a poke hole oozing blood. Nursing home staff is unaware of any fall or when the trauma may have occurred. Patient has dementia so further history is limited secondary to patient mental acuity. Imaging notable for open fracture of the right distal femur. Orthopedics consulted. Given fracture and belief that had the patient fallen she would not have been able to get herself back into bed without staff being aware of her injury, will consult social work for concern of elder abuse. Will also get trauma scans and consult trauma surgery.
R2's regional hospital orthopedic trauma surgery notes, dated 12/7/24, documented x-rays of right femur knee and tib-fib taken in the ED reviewed by me demonstrates right distal femur fracture with significant lateral displacement of the right proximal femur fragment. CT scan of the right knee taken in the ED and reviewed by me demonstrates right distal femur fracture with lateral displacement of the proximal femur fragment, appears to have significant callus formation around the fracture site indicating a nonacute fracture. There is gas tracking from open wound. It continues, given CT scan imaging showing callus formation around the fracture would lean towards this not being an acute fracture. Per son she has had no injury and was found in her bed today by nursing facility staff with open wound. Given also none reported injury to the right ankle 2 to 3 weeks ago cannot rule out NAT (Non-Accidental Trauma).
R2's trauma admission history and physical dated 12/7/24 documented this is an [AGE] year-old female presenting as a level 3 - consult trauma following suspected fall/elder abuse. Concerns with safety at NH (nursing home). Son open to finding new establishment.
R2's regional hospital x-ray results of right knee and right femur, dated 12/7/24, documented open fracture distal femoral shaft.
R2's regional hospital trauma surgery progress notes, dated 12/8/24, documented right ankle pain, right knee pain, (moans to pain) right lower extremity in ace wrap to knee.
R2's regional hospital physician progress note, dated 12/9/24, documented femoral shaft fracture, chronic - spoke to nursing home who stated swelling was first noted to leg/knee on 11/15/24 and this worsened along with surrounding erythema in the last few days leading up to admission. When noticed, hospice was notified prompting x-ray.
R2's regional hospital operative progress notes, dated 12/9/24, documented this is an elderly woman who is very infirm and demented. Recently, the nursing home noted a small gradual ulcer and sore over the anterolateral distal femur, which actually was an open fracture. She apparently had a fracture of the distal femur, which was unrecognized; however, on presentation to regional hospital with the open wound, x-rays and CAT scan noted a significantly displaced comminuted but healed distal third femur fracture with significant malunion. Distal lateral spike from proximal segment was quite sharp and prominent and had eroded the skin and now was protruding approximately a center through the skin with skin breakdown, essentially an open delayed fracture.
On 12/10/24 at 2:20 PM V2, Director of Nursing, DON, stated that he does not manage the resident incidents for the facility. V2 stated that the previous nurse who was in charge of investigating resident incidents and unknown injury investigations was terminated a while back and V4 (Licensed Practical Nurse, LPN)/Restorative Nurse/QA (Quality Assurance) is now in charge of incidents. V2 stated V4 started in this position 2 weeks ago.
On 12/10/24 at 2:24 PM V4 stated she just started in this position a little over a week ago and is now following up on falls in the facility's risk management EMR. V4 stated she is not aware of any unknown injuries occurring since she started in this position.
On 12/10/24 at 2:33 PM V1, Administrator, stated she is the one that is in charge of reporting and investigating unknown injuries. V1 stated R2 was admitted to the hospital this past Saturday, 12/7/24 with a femur fracture. V1 stated she spoke to R2's family and they told her the hospital physician stated that R2's femur fracture is 3-4 weeks old. V1 stated R2's knee was x-rayed in November and the x-ray was negative for any fracture. V1 stated she is still investigating R2's unknown injury/femur fracture.
On 12/10/24 at 3:09 PM V5, Care Plan Coordinator, CPC, stated that she was putting interventions in for the resident falls/incidents in the time frame when the facility did not have a QA Nurse but that she did not investigate the fall/incidents during this time.
On 12/10/24 at 3:30 PM V6, Certified Nurse Assistant, CNA, stated she is not aware of how R2 sustained the femur fracture. V6 stated she did report to R2's nurse that R2 as having a lot of leg pain and that it was swollen. V6 stated she does not recall when this was and that she does recall a nurse looking at R2's leg when she informed the nurse of R2's pain. V6 stated R2 is transferred via a mechanical lift with 2 assists.
On 12/10/24 at 3:38 PM V7, Licensed Practical Nurse, LPN stated that she had been off work a week back in November and when she returned to work the CNAs told her R2's knee was swollen, bruised, warm, and red. V7 stated she thinks maybe R2's leg was broken around 11/17/24. V7 stated she told V2 that the in-house x-ray company they use may have missed the fracture on the x-ray.
On 12/10/24 at 3:45 PM V8 stated she took care of R2 last Thursday, 12/5/24, and that she told the nurses that R2's bone was broken in her leg because you could see the bone poking through the skin. V8 then demonstrated how the bone looked under the skin by sticking her hand partially in a disposable glove and pressing a finger tightly up and out against the glove. V8 stated R2 was in severe pain and R2's knee was warm and swollen. V8 stated she reported this to R2's nurse, V7, and to another nurse on 12/5/24 and that they both said it was arthritis according to the x-ray. V8 stated that R2 should be transferred with a mechanical lift but staff just pick her up because she is 90 pounds and that is why she thinks someone dropped R2. V8 then presented a resident care flow sheet with a list of the residents' names on the hall that R2 resides on and stated look at this, it says R2 is to be transferred with an assist of one.
On 12/11/24 at 9:37 AM Surveyor requested incident investigation from V1 for R2's injury that was documented in R2's progress notes on 11/15/24. V1 replied I don't see any incidents for that date, oh there is an incident report for that date in risk management, I am responsible for investigating and reporting incidents, but I didn't, and I don't know why it was not done. V1 stated that the facility does not have any staff statements nor any investigation notes for R2's unknown injury that was documented on R2's 11/15/24 incident report form. V1 stated that she does consider R2's injury that was documented on R2's 11/15/24 incident report to be an unknown injury. V1 stated that no staff notified her of R2's injury that was documented on 11/15/24 and that if she would have known about it then she would have investigated it. Surveyor asked V1 for more information regarding the statement V1 documented on R2's injury investigation that was initiated on 12/9/24, V1 documented V9 CNA usually works the front half of 600 so hasn't cared for her in some time but stated when she did work the back half of 600 1 time, she left R2 in bed due to the swelling. She stated that another CNA had spoken to her and told her that R2 had a fall. Surveyor asked V1 if she identified who the staff member was that told V9 that R2 had a fall and V1 stated I don't know who the CNA was because V9 could not recall the CNAS name. V1 stated she became aware of R2's injury on Saturday, 12/7/24 and reported the incident/unknown injury to IDPH on 12/9/24 after she was told by one of the facility's nurses that R2 had a femur fracture. V1 stated that she is the one who usually investigates the incidents since the facility terminated the QA nurse back in September of this year. V1 stated R2's injury to her right foot that was documented on 11/15/24 should have been investigated. V1 stated the Therapy Department determines how residents should be transferred and then the Medical Records staff update the transfer flow sheets at the nurse's station. V1 stated the CNAs transfer the residents according to the flow sheets.
On 12/11/24 at 11:35 AM V9 stated she believes another CNA mishandled R2 during a transfer. V9 stated when she came in last week on day shift, maybe on Wednesday but not for sure, a night shift CNA told me R2's leg was swollen when she was giving me report that morning and this CNA said she was told that someone dropped R2 causing the leg injury. V9 stated she could not recall the name of the CNA that told her this nor did the CNA name the employee who allegedly dropped R2. V9 stated R2's leg was 3 times the size of her other leg last week. V9 stated R2 is very small so the CNAS can transfer R2 with one assist with the mechanical lift. V9 stated she assumes that is why the facility's care sheet has R2 down as a 1 assist with transfers.
On 12/11/24 at 11:42 AM V7 LPN stated she thought one of the CNAs did tell her last week that R2's bone looked like it was popping through the skin, so she went and looked at R2's leg and did not think it looked like the bone was coming through. V7 stated she did call hospice at this time and got an order to increase R2's tramadol for her increase in pain.
On 12/11/24 at 11:50 AM V10 LPN stated when she worked two weekends ago an agency nurse asked her to go down and look at R2's leg because the agency nurse thought the leg appeared fractured. V10 stated R2 grimaced when she touched R2's leg. R2 stated that the agency nurse informed her she called R2's hospice nurse and updated hospice on R2's leg but that she does not recall what hospice did about the nurse's concerns.
On 12/11/24 at 11:57 AM V11 LPN stated she has been R2's nurse a few times over the past few weeks and that R2's right leg was red and swollen.
On 12/11/24 at 12:20 PM V12 (R2's son) stated he received a call from R2's hospice nurse last Saturday on 12/7/24 and told him that the nursing home was sending his mom to the emergency room because she had a bone coming out of her right leg. V12 stated R2 then was transferred to a regional hospital and that the orthopedic surgeon told him R2's right leg was fractured approximately 3 weeks ago and that R2 had to of been dropped to cause this type of fracture. V12 stated this surgeon told him not to take R2 back to that nursing home. V12 stated the surgeon was unable to fix the fracture but did shave the bone off, cleaned out the injury, and then stitched the leg back up. V12 stated that he has not received any notifications from the nursing home about R2's leg and that the only information he has received about R2 in the past two months has been from the hospice nurse. V12 stated R2 is going to a different facility when she is discharged from the hospital.
On 12/11/24 at 1:00 PM V13, Hospice RN, stated Oh my God, a few days prior, she (R2) had a small blister that had formed that looked like a pressure injury. V13 stated he was notified by V14 Hospice CNA, around 11/15/24, that R2 had bruising to the bottom of her ankle with swelling, the facility ordered an x-ray. V13 stated he notified V12, R2's son and he (V13) and V12 thought it was weird that she would have bruises and swelling since R2 barely moved and was either in the reclining wheelchair or her bed. V13 stated he assessed R2, and Tylenol and Lasix were ordered, the next week when V13 returned the leg was swollen, going up the calf and towards the knee and the knee had started to swell. V13 stated he reported this to the facility and V14, reported that she had also notified the facility. V13 stated the following week, there was a small area of redness that appeared to be a pressure injury from R2 being contracted and her knees rubbing together. V13 stated skin prep was ordered. The next time he was notified he was told that R2's bone was sticking out of her leg. V13 stated in his opinion, that type of an injury could have only occurred during a transfer or something of that nature because R2 didn't move, and she was either in the reclining wheelchair of the bed. V13 stated he was never notified of any of the changes in R2 by the facility only by V14.
On 12/11/24 at 1:55 PM V14, Hospice CNA, stated approximately 3 weeks ago, and she noticed bruising from the bottom R2's heel and swelling in the foot. V14 stated when she would touch the heel, leg, or foot, R2 would jump, make noises and grimace. V14 stated she told V10, LPN, and she took V14 along with two other nurses, unsure of names, to look at R2's foot. When V14 stated she comes to bathe R2 on Thursdays, except the week of Thanksgiving and she came that Friday. V14 stated when she came the week of Thanksgiving, R2's entire leg and knee was huge, swollen, and went up the entire leg. V13 stated she notified R2's nurse, unsure of name. V13 stated there was a blistered area to the knee that was white in the center, and it looked like bone. V13 stated she then called V13 to notify him.
On 12/11/24 at 3:11 PM V16 LPN stated she is the nurse that completed the incident report on R2 on 11/15/24. V16 stated that R2's hospice CNA was giving R2 a bed bath and that the hospice CNA reported to her that R2 had bruises on her right lower extremity. V16 stated she assessed R2, gave R2 pain medicine because R2 had facial grimacing. V16 stated she did notify V1, V2, and R2's doctor of the injury of unknown injury on 11/15/24. V16 stated that she was concerned something may have happened during a transfer causing R2's injury. V16 stated the nursing staff are supposed to transfer residents according to the resident care flow sheets that are in a book at the nurse's station.
On 12/12/24 at 8:26 AM V18 LPN stated she was R2's nurse on 11/17/24 and that she contacted V19 R2's primary physician because R2's right knee was swollen. V18 stated she did not notice any bruising nor an increase in R2's pain symptoms V18 stated she notified V19 through the secure message system in (electronic medical record system). V18 stated she is an agency nurse, so she does not work regularly and when she worked on 12/1/24 the CNAS informed her they were not getting R2 out of bed because it looked like something was protruding from the side of R2's knee and it was hard. V18 stated she looked at R2's knee and the protrusion were hard. V18 stated she reported this to the DON, and he instructed her to get an order for x-rays of R2's knee. V18 stated she notified V19, R2's Physician, through the secure messenger system and sent V19 a photo of R2's knee. V18 said V19 replied that it looked like water under the knee, no x-ray ordered but did order a referral to an outpatient orthopedic doctor. V18 stated this occurred on a Sunday and she thinks she put in an order for the referral and passed it on in report, but she does not know if the appointment was ever set up. V18 stated she called the hospice nurse on 12/1/24 about R2 and that hospice said don't send R2 to the hospital and just keep her comfortable. V18 stated outpatient referral need to be approved by hospice but she did not inform the hospice nurse about V19 ordering the outpatient orthopedic referral. V18 stated she does not know if V19 was informed of the ongoing issues with R2's knee because she is just agency. V19 stated she messaged him on 11/17/24 and 12/1/24. R2's progress notes do not document any physician notification on 11/17/24.
On 12/12/24 at 8:53 AM V1 stated she is not able to pull the secure messages for R2 from the EMR because they only save for two weeks, and the nurses are supposed to document the messages in the resident's progress notes.
On 12/12/24 at 9:06 AM V1 stated no order for the outpatient orthopedic consultation was put into R2's record nor did the facility arrange an appointment for R2 to see an orthopedic surgeon.
On 12/12/24 at 9:25 AM V19 stated he had received notifications from the facility regarding R2's edema via the secure message system. V19 stated he would have to check his records to see when and how many times he was notified. V19 stated he was notified from time to time on her. V19 stated he was not aware that the facility did not put in an order in the EMR for the orthopedic referral he gave on 12/1/24 nor was he aware of the facility not setting up this appointment. V19 stated that for R2's bone to come through her skin it had to be caused by trauma and that a pathological fracture would not cause this. V19 stated he would have expected the facility to immediately initiate an investigation on 11/15/24 when the EMR documented an injury to R2's right foot.
On 12/12/24 at 11:19 AM, V19 stated he is not able to view secure messages from the facility nurses beyond 12/4/24 because the system deletes them after a week. On 12/7/24 he was notified bone was sticking through the skin and he had R2 sent to the ER. V19 stated the facility contacted him again on 12/9/24 that R2 was admitted to the hospital with a femur fracture and that he requested more information from the facility of how the fracture happened, and he has not heard back from the facility. V19 stated he does not recall being told by the nurse on 12/1/24 that R2's bone appeared to be protruding under the skin.
On 12/16/24 at 11:25 AM V1 stated the facility should have reported and investigated R2's right leg injury when it was first found on 11/15/24. V1 stated the facility nurses should have been closely assessing R2's leg and should have updated R2's primary physician of R2's right leg condition changes.
On 12/16/24 at 11:27 AM V20 Regional Director stated R2's leg injury should have been investigated when it was first noted on 11/15/24, R2's leg should have been closely monitored, and that R2's attending physician should have been updated of the ongoing changes of R2's condition.
The Hospice Services Agreement dated January 2009 states, The services provided by (Hospice Provider Name) and Nursing Facility under the terms of this Agreement shall be in addition to, and not a substitute for, the services routinely provided to residents by Nursing Facility according to its agreements with residents and applicable state and federal laws and regulations.
The facility's Notification Changes in Condition, dated 2/20/23, documented it is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental, or psychosocial status. Definitions: 1. Acute change in condition is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status that, without intervention, may result in complications or death. 2. Non-urgent change in condition is a deviation from a patient's baseline in physical, cognitive, behavioral, or functional status that is not reasonable expected to result in complications or death may be a persistent or intermittent result of the patient's diagnosed disease state. Policy guidelines and interpretation: 1. Upon identification of any change in condition licensed nursing personnel will contact the resident's attending physician/on-call physician/practitioner to notify him/her of the change. Acute changes in condition should occur immediately upon recognition while non-urgent changes should occur no later than 72 hours from the noted change. 2. All notifications should be preceded by an appropriate physical, mental, or psychosocial assessment to enable the physician to make adequate and appropriate treatment and/or transfer decisions. 3. Following notification of the physician, licensed nursing personnel will contact the resident's responsible party/emergency contact/family member/POA or Guardian to inform him/her of the change. For acute changes in condition this should occur immediately when practicable and after addressing the resident's immediate needs and for non-urgent changes in condition the notification should occur within 72 hours of the noted change. 4. All notifications should be documented and should include; a. The date and time of the notification; b. The name of the individual contacted; c. The specific reason for the notification; d. And any specific responses that were given by the person contacted. 5. All changes of condition require follow-up assessment and documentation of resident condition which should include, at a minimum: a. Vital signs b. Pain c. Orientation d. Any change from baseline status e. Status of any pending labs/diagnostics.
The Immediate Jeopardy that began on 11/15/24 was removed on 12/15/24 when the facility took the following actions to remove the immediacy:
A.
Identification of Residents Affected or Likely to be Affected:
1.
R2 was transferred to a hospital for treatment. R2 is no longer a resident of the facility. The facility has conducted an ongoing investigation into R2's injuries.
2.
V2, Director of Nursing, or designee has assessed all residents, completed on 12/14/24, to identify any pain or injury of unknown origin not previously identified, assessed, reported, and treated. For any findings identified, the facility would follow its policy to ensure the pain/injury is reported, assessed, monitored, and treated timely. No residents with unreported/untreated pain or injuries identified.
B.
Actions to Prevent Occurrence/Reoccurrence:
1.
On 12/13/24 V1 Administrator, V2 Director of Nursing, and V20 Regional Director and Facility Governing Body reviewed the facility's policies for Incidents/Accidents and Significant change to confirm policies provide a system for identifying, assessing, monitoring, and treating injuries and pain, as well as investigating the cause. No updates required, but Governing Body recommended retraining on policy requirements.
2.
V2, Director of Nursing, or designee have provided in-service training to all direct care staff and nursing staff on facility policy for: Significant changes, with an emphasis on ensuring timely reporting, assessment, and follow-up when a resident demonstrates a significant change; and Incidents and Accidents, with an emphasis on policy section addressing injuries of unknown origin including the process for identifying, reporting, assessing, and facilitating treatment, as well as investigating the cause of any unknown injury. Any staff or agency who have not received the in-service training(s) by the Removal/Abatement date will receive the training before starting their next shift.
3.
V2, Director of Nursing or designee will conduct random observations daily of at least 5 residents for 3 weeks then 5 residents monthly to determine if there is any pain or injuries of unknown origin that have been addressed per policy. V1, Administrator/designee will conduct daily review of PCC 24-hour Communication and Incident reports to ensure any change of condition/injury is monitored, assessed, investigated, reported, and treated. Any identified failures will be immediately addressed. Results will be documented and shared with QAPI for review, analysis and follow-up as needed.
Date Facility Asserts Completion of Abatement: 12/15/24.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide services per current standards of practice, rising to the le...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide services per current standards of practice, rising to the level of neglect with R2 sustaining a femur fracture on an unknown date, with the femur bone ultimately penetrating through the skin after 15 days of documented continued pain and extremity abnormality. This failure resulted in R2 being hospitalized with an open femur fracture requiring surgical intervention which caused pain and suffering.
Findings include:
R2's face sheet, print date of 12/16/24, documented R2 has diagnoses of unspecified fracture of right femur, unspecified severe protein-calorie malnutrition, Alzheimer's disease, atherosclerosis, paranoid schizophrenia, drug induced dyskinesia, contractures, history of cerebral infarction, cognitive communication deficit, osteoporosis, and functional quadriplegia.
R2's MDS (Minimum Data Set), dated 12/4/24, documented R2 is moderately cognitively impaired, is non-ambulatory, and is dependent on staff for transfers.
R2's hospice aide visit note, dated 11/15/24 at 8:45 AM, documented patient's right foot swollen and bruised. Case manager updated on new concerns.
R2's radiology results report, dated 11/17/24, documented reason for study: localized swelling, mass and lump, right lower limb. Findings: views of the knee show mild joint space loss and subchondral sclerosis compatible with osteoarthritis. No acute fracture or dislocation is seen. No significant joint effusion is noted. Conclusion: Mild osteoarthritis, without fracture.
R2's EMR (Electronic Medical Record) progress note dated 11/22/24 at 3:12 AM documented patient right knee is very swollen and c/o (complaining of) pain. Medicated for pain.
R2's EMR progress note dated 11/26/24 at 10:26 PM documented .she is complaining of pain in her knee and foot.
R2's hospice aide visit note, dated 11/29/24 at 8:30 AM, documented right leg, knee, and foot swollen. Case Manager and in house nurse updated on new concern and visit.
R2's hospice nurse visit note, dated 11/29/24 at 10:30 AM, documented patient continues to have some increased swelling to her right foot and leg up to her knee at a +2 edema.
R2's hospice nurse triage notes, dated 12/1/24 at 7:43 AM, documented patient's right knee is swollen and painful to touch. Advised to give patient pain medication. It continues, patient's right knee is more swollen than a week ago.
R2's EMR progress note dated 12/1/24 at 11:13 AM documented aide notified nurse of resident right knee looking abnormal. Upon assessment resident knee was swollen with minimal pain to touch. MD notified and stated to refer resident to orthopedic surgeon as outpatient f/u (follow up). DON (Director of Nursing) notified, and hospice nurse will leave message for regular nurse to follow up with resident.
R2's EMR progress note dated 12/4/24 at 11:33 AM documented per nursing documentation R2 had c/o right knee pain during look back. 11/29 NOR (new order received) for Tylenol TID (3 times per day).
R2's hospice aide visit note, dated 12/6/24 at 9:00 AM, documented patient has blister on right knee. Case Manager and in house nurse updated.
R2's hospice nurse notes, dated 12/6/24 at 12:20 PM, documented our HHA (hospice health aide) found a small blister on her right knee today while bathing. It continues, treatment orders - cover blister with 3x3 foam dressing daily and prn (as needed). Increased pain related to blister. New orders received: tramadol 25mg BID (two times a day) and q4hrs PRN. Education provided to sign on the new order that was giving in order to help control R2's pain better.
R2's EMR progress note dated 12/6/24 at 1:45 PM documented resident knee continues to be monitored; hospice nurse was consulted to look at patient knee. Upon evaluation the knee swollen, and red. Writer asked hospice nurse for an order for pain medication for her pain. Tramadol was ordered TID and PRN (as needed).
On 12/16/24 at 11:35 AM V21 CNA (Certified Nurse Assistant) stated she was assigned to R2's hall on 12/7/24 and that she made her first rounds at 6:30 AM, checked on R2 and could see R2's bone tightly up against the skin near right knee. Stated she informed day nurse V11 LPN and the night nurse. V21 stated these two nurses went and looked at R2's knee shortly after she told them. V21 stated when she checked on R2 around lunch time the bone was through the skin and there was blood on the sheets.
On 12/16/24 at 11:50 AM V11 LPN (Licensed Practical Nurse) stated she was R2's nurse on 12/7/24 on the day shift. V11 stated she and the night nurse went and looked at R2's leg at approximately 6:30 AM on 12/7/24 and R2's right leg was swollen, red, and it appeared bone was up against the skin. R2 stated the night nurse had given R2 pain medication. V11 stated she did not notify R2's doctor at this time because prior x-rays were negative and that she did send her out once the bone came through the skin around noon.
R2's EMR progress note dated 12/7/24 at 1:40 PM documented this nurse was informed by nursing that resident was noted to have something sticking out of her knee. Upon assessment this nurse noted an area to her right knee to look like bone sticking out of knee with clear and red fluid flowing from area. Vitals WNL (within normal limits). Emergency services contacted. MD/hospice made aware. Phoned POA (power of attorney) to inform. No answer. Admin notified. Ambulance in route.
R2's hospice progress note, dated 12/7/24 at 1:43 PM documented patient bones popped through skin. Facility MD sent patient out.
R2's EMR progress note dated 12/7/24 at 1:56 PM documented EMS (Emergency Medical Services) here to transport resident to hospital.
R2's regional hospital emergency medicine notes dated 12/7/24, documented R2 presents to ED (Emergency Department) for evaluation of right leg deformity. Per EMS, patient was found in bed at her nursing home when staff found blood on her sheets and on further investigation noticed a deformity to the patients right distal femur with a poke hole oozing blood. Nursing home staff is unaware of any fall or when the trauma may have occurred. Patient has dementia so further history is limited secondary to patient mental acuity. Imaging notable for open fracture of the right distal femur. Orthopedics consulted. Given fracture and belief that had the patient fallen she would not have been able to get herself back into bed without staff being aware of her injury, will consult social work for concern of elder abuse. Will also get trauma scans and consult trauma surgery.
R2's regional hospital orthopedic trauma surgery notes, dated 12/7/24, documented x-rays of right femur knee and tib-fib taken in the ED reviewed by me demonstrates right distal femur fracture with significant lateral displacement of the right proximal femur fragment. CT scan of the right knee taken in the ED and reviewed by me demonstrates right distal femur fracture with lateral displacement of the proximal femur fragment, appears to have significant callus formation around the fracture site indicating a nonacute fracture. There is gas tracking from open wound. It continues, given CT scan imaging showing callus formation around the fracture would lean towards this not being an acute fracture. Per son she has had no injury and was found in her bed today by nursing facility staff with open wound. Given also none reported injury to the right ankle 2 to 3 weeks ago cannot rule out NAT (Non-Accidental Trauma).
R2's trauma admission history and physical dated 12/7/24 documented this is an [AGE] year-old female presenting as a level 3 - consult trauma following suspected fall/elder abuse. Concerns with safety at NH (nursing home). Son open to finding new establishment.
R2's regional hospital operative progress notes, dated 12/9/24, documented this is an elderly woman who is very infirm and demented. Recently, the nursing home noted a small gradual ulcer and sore over the anterolateral distal femur, which actually was an open fracture. She apparently had a fracture of the distal femur, which was unrecognized; however, on presentation to regional hospital with the open wound, x-rays and CT (computed tomography) scan noted a significantly displaced comminuted but healed distal third femur fracture with significant malunion. Distal lateral spike from proximal segment was quite sharp and prominent and had eroded the skin and now was protruding approximately a center through the skin with skin breakdown, essentially an open delayed fracture.
On 12/10/24 at 3:38 PM V7 LPN stated that she had been off work a week back in November and when she returned to work the CNAS told her R2's knee was swollen, bruised, warm, and red. V7 stated she thinks maybe R2's leg was broken around 11/17/24. V7 stated she told V2 DON that the in-house x-ray company they use may have missed the fracture on the x-ray.
On 12/10/24 at 3:45 PM V8 CNA stated she took care of R2 last Thursday, 12/5/24, and that she told the nurses that R2's bone was broken in her leg because you could see the bone poking through the skin. V8 then demonstrated how the bone looked under the skin by sticking her hand partially in a disposable glove and pressing a finger tightly up and out against the glove. V8 stated R2 was in severe pain and R2's knee was warm and swollen. V8 stated she reported this to R2's nurse V7 and to another nurse on 12/5/24 and that they both said it was arthritis according to the x-ray.
On 12/11/24 at 11:42 AM V7 LPN stated I think one of the CNAS did tell me last week that R2's bone looked like it was popping through the skin, so she went and looked at R2's leg and did not think it looked like the bone was coming through. V7 stated she did call hospice at this time and got an order to increase R2's tramadol for her increase in pain.
On 12/11/24 at 11:50 AM V10 LPN stated when she worked two weekends ago an agency nurse asked her to go down and look at R2's leg because the agency nurse thought the leg appeared fractured. V10 stated R2 grimaced when she touched R2's leg. R2 stated that the agency nurse informed her she called R2's hospice nurse and updated hospice on R2's leg but that she does not recall what hospice did about the nurse's concerns.
On 12/11/24 at 11:57 AM V11 LPN stated she has been R2's nurse a few times over the past few weeks and that R2's right leg was red and swollen.
On 12/11/24 at 1:00 PM V13, Hospice RN, stated Oh my God, a few days prior, she (R2) had a small blister that had formed that looked like a pressure injury. V13 stated he was notified by V14 Hospice CNA, around 11/15/24, that R2 had bruising to the bottom of her ankle with swelling, the facility ordered an x-ray. V13 stated he notified V12, R2's son and he (V13) and V12 thought it was weird that she would have bruises and swelling since R2 barely moved and was either in the reclining wheelchair or her bed. V13 stated he assessed R2, and Tylenol and Lasix were ordered, the next week when V13 returned the leg was swollen, going up the calf and towards the knee and the knee had started to swell. V13 stated he reported this to the facility and V14, reported that she had also notified the facility. V13 stated the following week, there was a small area of redness that appeared to be a pressure injury from R2 being contracted and her knees rubbing together. V13 stated skin prep was ordered. The next time he was notified he was told that R2's bone was sticking out of her leg. V13 stated in his opinion, that type of an injury could have only occurred during a transfer or something of that nature because R2 didn't move, and she was either in the reclining wheelchair of the bed. V13 stated he was never notified of any of the changes in R2 by the facility only by V14.
On 12/11/24 at 1:55 PM V14, Hospice CNA, stated approximately 3 weeks ago, she noticed bruising from the bottom R2's heel and swelling in the foot. V14 stated when she would touch the heel, leg or foot, R2 would jump, make noises and grimace. V14 stated she told V10, LPN, and she took V14 along with two other nurses, unsure of names, to look at R2's foot. When V14 stated she comes to bathe R2 on Thursdays, except the week of Thanksgiving and she came that Friday. V14 stated when she came the week of Thanksgiving, R2's entire leg and knee was huge, swollen, and went up the entire leg. V13, stated she notified R2's nurse, unsure of name. V13 stated there was a blistered area to the knee that was white in the center, and it looked like bone. V13 stated she then called V13 to notify him.
On 12/12/24 at 8:26 AM V18 LPN stated she was R2's nurse on 11/17/24 and that she contacted V19 R2's primary physician because R2's right knee was swollen. V18 stated she did not notice any bruising nor an increase in R2's pain symptoms V18 stated she notified V19 through the secure message system in PCC. V18 stated she is an agency nurse, so she does not work regularly and when she worked on 12/1/24 the CNAS informed her they were not getting R2 out of bed because it looked like something was protruding from the side of R2's knee and it was hard. V18 stated she looked at R2's knee and the protrusion was hard. V18 stated she reported this to the DON (Director of Nursing) V2, and he instructed her to get an order for x-rays of R2's knee. V18 stated she notified V19 through the secure messenger system and sent V19 a photo of R2's knee. V18 said V19 replied that it looked like water under the knee, no x-ray ordered but did order a referral to an outpatient orthopedic doctor. V18 stated this occurred on a Sunday and she thinks she put in an order for the referral and passed it on in report, but she does not know if the appointment was ever set up. V18 stated she called the hospice nurse on 12/1/24 about R2 and that hospice said don't send R2 to the hospital and just keep her comfortable. V18 stated outpatient referral need to be approved by hospice but she did not inform the hospice nurse about V19 ordering the outpatient orthopedic referral. V18 stated she does not know if V19 was informed of the ongoing issues with R2's knee because she is just agency. V19 stated she messaged him on 11/17/24 and 12/1/24. R2's progress notes do not document any physician notification on 11/17/24.
On 12/12/24 at 9:06 AM V1 (Administrator) stated no order for the outpatient orthopedic consultation was put into R2's record nor did the facility arrange an appointment for R2 to see an orthopedic surgeon, although acknowledging a referral had been made.
On 12/12/24 at 9:25 AM V19 R2's primary physician stated he had received notifications from the facility regarding R2's edema via the secure message system. V19 stated he would have to check his records to see when and how many times he was notified. V19 stated he was notified from time to time on her. V19 stated he was not aware that the facility did not put in an order in the EMR for the orthopedic referral he gave on 12/1/24 nor was he aware of the facility not setting up this appointment. V19 stated that for R2's bone to come through her skin it had to be caused by trauma and that a pathological fracture would not cause this. V19 stated he would have expected the facility to immediately initiate an investigation on 11/15/24 when the EMR documented an injury to R2's right foot.
On 12/12/24 at 11:19 V19 (R2's physician and facility Medical Director) stated he is not able to view secure messages from the facility nurses beyond 12/4/24 because the system deletes them after a week. On 12/7/24 he was notified bone was sticking through the skin and he had R2 sent to the ER. V19 stated the facility contacted him again on 12/9/24 that R2 was admitted to the hospital with a femur fracture and that he requested more information from the facility of how the fracture happened, and he has not heard back from the facility. V19 stated he does not recall being told by the nurse on 12/1/24 that R2's bone appeared to be protruding under the skin.
On 12/16/24 at 11:25 AM V1 stated the facility should have reported and investigated R2's right leg injury when it was first found on 11/15/24. V1 stated the facility nurses should have been closely assessing R2's leg and should have updated R2's primary physician of R2's right leg condition changes.
On 12/16/24 at 11:27 AM V20 Regional Director stated R2's leg injury should have been investigated when it was first noted on 11/15/24, R2's leg should have been closely monitored, and that R2's attending physician should have been updated of the ongoing changes of R2's condition.
Review of R2's Clinical Record documented despite multiple continued reports of pain, abnormal extremity presentation without signs of healing, and specific reports of a bone appearing the facility initiated no further diagnostic testing to evaluate and treat. R2's Clinical Record documents the only x-ray's R2 received following the initial bruising, in which a possible injury was suspected was on 11/16/24 and 11/17/24, both in the facility.
The facility Abuse Prevention Program policy, revision date of 2/2023, documented this facility affirms the right of our residents to be free from abuse (verbal, mental, sexual, or physical), neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. This facility therefore prohibits acts of mistreatment, neglect, abuse and/or crimes from being committed against its residents. This facility desires to establish a resident sensitive and resident secure environment. It is the policy of this facility to develop a mechanism to reduce the risk of abuse, neglect, misappropriation of resident property and/or crimes from being committed against the residents of this facility. It continues, neglect as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately investigate a resident injury of unknown origin for 1 o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately investigate a resident injury of unknown origin for 1 of 4 residents (R2) reviewed for injuries of unknown origin and abuse. This failure resulted in R2 experiencing increased pain and swelling from 11/15/24 until 12/7/24 when R2 was admitted to a regional hospital. R2's leg injury of unknown origin was first documented on 11/15/24 and R2's unknown injury investigation was not initiated until 12/9/24 two days after R2's fracture femur penetrated through her skin. This failure has the potential to affect all 88 residents residing in the facility.
Findings include:
R2's face sheet, print date of 12/16/24, documented R2 has diagnoses of unspecified fracture of right femur, unspecified severe protein-calorie malnutrition, Alzheimer's disease, atherosclerosis, paranoid schizophrenia, drug induced dyskinesia, contractures, history of cerebral infarction, cognitive communication deficit, osteoporosis, and functional quadriplegia.
R2's MDS, dated [DATE], documented R2 is moderately cognitively impaired, is non-ambulatory, and is dependent on staff for transfers.
R2's care plan, undated, documented R2 requires a mechanical lift for all transfers.
R2's resident care flow sheet, undated, documented R2 is assist of 1 for transfers.
R2's EMR (Electronic Medical Record) progress note dated 11/15/24 at 10:16 AM documented slight discoloration to right posterior foot observed, appears to be injury, green in color and edema to right foot, origin unknown, no incident reported, facial grimacing observed when palpated, NP (Nurse Practitioner) notified, and hospice nurse notified.
R2's incident report, dated 11/15/24 at 10:06 AM, documented incident description: slight discoloration to R (right) posterior foot, appears to be injury green in color and edema to R foot. Resident unable to give description. Predisposing Situation Factors: during transfer.
R2's EMR progress note dated 11/20/24 at 8:48 AM documented writer was notified that resident's knee was very swollen, and she has a black bruise on her left and right coccyx. Wound nurse was notified to take a look at the area. MD (Medical Doctor) is already aware of the situation, there was an x-ray performed.
On 12/11/24 at 9:37 AM Surveyor requested incident investigation from V1 for R2's injury that was documented in R2's progress notes on 11/15/24. V1 replied I don't see any incidents for that date, oh there is an incident report for that date in risk management, I am responsible for investigating and reporting incidents, but I didn't, and I don't know why it was not done. V1 stated that the facility does not have any staff statements nor any investigation notes for R2's unknown injury that was documented on R2's 11/15/24 incident report form. V1 stated that she does consider R2's injury that was documented on R2's 11/15/24 incident report to be an unknown injury. V1 stated that no staff notified her of R2's injury that was documented on 11/15/24 and that if she would have known about it then she would have investigated it. Surveyor asked V1 for more information regarding the statement V1 documented on R2's injury investigation that was initiated on 12/9/24, V1 documented V9 CNA usually works the front half of 600 so hasn't cared for her in some time but stated when she did work the back half of 600 1 time, she left R2 in bed due to the swelling. She stated that another CNA had spoken to her and told her that R2 had a fall. Surveyor asked V1 if she identified who the staff member was that told V9 that R2 had a fall and V1 stated I don't know who the CNA was because V9 could not recall the CNAS name. V1 stated she became aware of R2's injury on Saturday, 12/7/24 and reported the incident/unknown injury to IDPH on 12/9/24 after she was told by one of the facility's nurses that R2 had a femur fracture. V1 stated that she is the one who usually investigates the incidents since the facility terminated the QA nurse back in September of this year. V1 stated R2's injury to her right foot that was documented on 11/15/24 should have been investigated.
R2's EMR progress note dated 12/7/24 at 1:40 PM documented this nurse was informed by nursing that resident was noted to have something sticking out of her knee. Upon assessment this nurse noted an area to her right knee to look like bone sticking out of knee with clear and red fluid flowing from area. Vitals WNL (within normal limits). Emergency services contacted. MD/hospice made aware. Phoned POA to inform. No answer. Admin notified. Ambulance in route.
R2's regional hospital emergency medicine notes dated 12/7/24, documented R2 presents to ED (Emergency Department) for evaluation of right leg deformity. Per EMS, patient was found in bed at her nursing home when staff found blood on her sheets and on further investigation noticed a deformity to the patients right distal femur with a poke hole oozing blood. Nursing home staff is unaware of any fall or when the trauma may have occurred. Patient has dementia so further history is limited secondary to patient mental acuity. Imaging notable for open fracture of the right distal femur. Orthopedics consulted. Given fracture and belief that had the patient fallen she would not have been able to get herself back into bed without staff being aware of her injury, will consult social work for concern of elder abuse. Will also get trauma scans and consult trauma surgery.
The facility's investigation notes of R2's right leg injury, dated 12/7/24, documented V1 Administrator was informed of R2 being sent to the ER (Emergency Room) on 12/7/24 for evaluation of a possible knee injury. It continues, 12/9/24 I (V1) was informed by V7 LPN (Licensed Practical Nurse) this AM at approximately 8:45 AM that R2 had a femur fx (fracture). I submitted the reportable injury.
On 12/16/24 at 11:25 AM V1 stated the facility should have reported and investigated R2's right leg injury when it was first found on 11/15/24. V1 stated the facility nurses should have been closely assessing R2's leg and should have updated R2's primary physician of R2's right leg condition changes.
On 12/16/24 at 11:27 AM V20 Regional Director stated R2's leg injury should have been investigated when it was first noted on 11/15/24, R2's leg should have been closely monitored, and that R2's attending physician should have been updated of the ongoing changes of R2's condition.
On 12/17/24 at 9:40 AM V1 Administrator stated she did not investigate R2's coccyx bruising that was documented in R2's progress notes on 11/20/24. V1 stated that she was notified by R2's nurse on Saturday, 12/7/24 that R2's right leg bone came through her skin. V1 stated she did not initiate an investigation on 12/7/24 because she was out of town, nor did she delegate any members of the facility management team to go into the facility and initiate the investigation. V1 stated she started the investigation on Monday 12/9/24.
The facility Abuse Prevention Program policy, revision date of 2/2023, documented this facility affirms the right of our residents to be free from abuse (verbal, mental, sexual, or physical), neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. This facility therefore prohibits acts of mistreatment, neglect, abuse and/or crimes from being committed against its residents. This facility desires to establish a resident sensitive and resident secure environment. Policy: It is the policy of this facility to develop a mechanism to reduce the risk of abuse, neglect, misappropriation of resident property and/or crimes from being committed against the residents of this facility. This will be done by implementing the following systems and/or practices: It continues; Injuries of Unknown Source are defined by as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the sources of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury. It continues, Serious Bodily Injury is defined by the Elder Justice Act 2011(19)(A) as an injury involving extreme physical pain; involving substantial risk for death; involving protracted loss or impairment of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation. It continues, 5. Facility staff will investigate and report any allegations of abuse within timeframes required by Federal law.
The facility's Reporting of Abuse, Neglect, Theft and Crimes policy, dated 2/23, documented It is the policy of this facility to establish internal reporting guidelines for facility staff in the event they become aware or formulate a reasonable suspicion that abuse, neglect, mistreatment, including injuries of unknown source, exploitation, theft, or a crime has been committed against a resident of the facility. Policy Guidelines and Interpretation: 1. Internal Reporting: a. All covered individuals are required to immediately report any occurrences of potential mistreatment, abuse, neglect, mistreatment, including injuries of unknown source, adverse events, exploitation, theft, or crimes committed against a resident that they observe, hear about, or suspect to the administrator or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. b. All covered individuals are required to immediately report any adverse event that results in the death or serious injury of a resident to the facility administrator or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as an administrator in the administrator's absence.
The facility's Abuse, Neglect, Theft and Crimes Investigations policy, dated 2/23, documented this facility does not condone any form of resident abuse. This facility will take all reports of abuse, neglect, mistreatment, including injuries of unknown origin, against its residents seriously and will attempt to investigate allegations with the intent of detecting any wrongdoing, determining causative factors and when indicated, implementing corrective actions to prevent reoccurrence. Policy Guidelines and Interpretation: 1. The Administrator will immediately suspend any employee who has been accused of resident abuse pending the outcome of the investigation. 2. The facility will immediately implement investigative pathways associated with the event including the preservation of the scene, evidence, and the identification of witnesses. Resident Protection Investigation Paths, Injuries of Unknown Source, complete an incident report, if one has not been generated, include in investigative file. Do a full body exam, check range of motion, consult with physician, pull schedules, staffing pattern worksheets, and resident room rosters from at least 24 hours prior to the alleged event or injury and at the time the injury was noted to generate a list of individuals that will need to provide statement or be interviewed. Continue physical assessments and obtain vital signs at least every shift for the next 72 hours.
The CMS 671 Form dated 12/17/2024 documents there are 88 residents residing at the Facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on interview and record review, facility administration failed to direct and monitor the activities of the nursing department managers to identify nursing concerns/changes in condition. This fai...
Read full inspector narrative →
Based on interview and record review, facility administration failed to direct and monitor the activities of the nursing department managers to identify nursing concerns/changes in condition. This failure has the potential to affect all 88 residents residing in the facility.
Findings Include:
R2's Progress Note, dated 11/15/24 at 10:16 AM, documents the following: slight discoloration to the right posterior foot observed, appears to be an injury, green in color and edema noted to the right foot. Origin unknown, no incident reported, facial grimacing observed when palpated. Nurse Practitioner (NP) notified; hospice nurse notified.
R2's Progress Note, dated 11/20/24 at 8:48 AM, documents the following: writer was notified that R2's knee was very swollen. MD (Medical Doctor) is already aware of the situation, there was an x-ray performed.
R2's Progress Note, dated 11/22/24 at 3:12 AM, documents the following: R2's right knee is very swollen and complains of pain, medicated for pain.
R2's Progress Note, dated 12/1/24 at 11:13 AM, documents the following: Aide notified nurse of resident's right knee looking abnormal. Upon assessment the right knee was swollen with minimal pain to touch. MD notified and stated to refer resident to orthopedic surgeon as outpatient. DON notified.
R2's Progress Note, dated 12/6/24 at 1:45 PM, documents the following: R2's right knee continues to be monitored. The hospice nurse was consulted to look at patient's knee. Upon evaluation the knee was swollen, and red. Writer asked hospice nurse for an order for pain medication. Tramadol was ordered TID (Three times daily) and as needed.
R2's Progress Note, dated 12/7/24 at 12:7?24 at 1:40 PM, documents the following: Nurse was informed by nursing that resident was noted to have something sticking out of her knee. Upon assessment this nurse noted an area to her right knee that looked like bone sticking out of the knee with clear and red fluid flowing from the area. Vitals within normal limits. Emergency services contacted. MD/hospice made aware. POA phoned with no answer, Administrator notified. Ambulance in route.
R2's Progress Note, dated 12/9/24, documents the following: Resident admitted to the hospital with a right femur fracture. Administrator, DON, and MD notified.
On 12/11/24 at 9:37 AM, V1, Administrator, stated staff did not notify her of R2's injury that was documented on 11/15/24 and if she would have known about it, she would have investigated it.
On 12/17/24 at 12:40 PM, V2, Director of Nursing, DON, stated he discusses with V1, Administrator, in the morning department head meeting, any concerns in the nursing department, falls, incidents, the 72 hour reports, etc. V2 stated he was notified by nursing staff 11/15/24 that R2's knee was swollen, they got x-rays, they were negative for fracture, showed a possible effusion and this was discussed in the department head meeting, unsure of date. V2 stated he was not notified by the nursing staff on R2 again until 12/7/24, when the bone was sticking out of the knee. V2 stated he told the nurse, unsure of whom, to notify the MD. V2 stated R2 was on hospice so normally when a resident is on hospice, they would notify hospice first, then notify the physician to verify the orders. V2 stated he was not notified by nursing of any changes or worsening with R2's leg from 11/5/24 until 12/7/24 and he would expect to be notified of any changes, concerns or anytime hospice was notified and then he would have discussed it with V1, Administrator, at the meeting.
On 12/17/24 at 2:05 PM, V1, Administrator, stated she does not recall being notified by the nursing department or managers of any changes with R2, until 12/7/24 when R2 was sent to the hospital. V1 stated she would expect the nursing department managers to notify her of any changes.
The Administrator Essential Duties and Responsibilities document the following: Direct and monitor the activities of department heads and provide management guidance and information to assure efficient operation and to adhere to organization policies and procedures. Assure quality of care is provided to residents in accordance with the current federal, state, and local standards, guidelines and regulations governing all areas.
The Long-Term Care Facility Application for Medicare and Medicaid form, CMS 671, dated 12/17/24, documents there are 88 residents residing in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to have a Quality Assessment and Assurance (QAA) meeting to identify concerns within the facility quarterly and with the required members in at...
Read full inspector narrative →
Based on interview and record review the facility failed to have a Quality Assessment and Assurance (QAA) meeting to identify concerns within the facility quarterly and with the required members in attendance. This failure has the potential to affect all 88 residents residing in the facility.
Findings Include:
The QAPI (Quality Assurance Performance Improvement) Sign-In Sheet documents the last QAA meeting was held on 1/25/24 with the MDS (Minimum Data Set)/CPC (Care Plan Coordinator), treatment nurse, restorative nurse, infection control nurse, DON (Director of Nurses) and administrator in attendance. There is no documentation that the medical director attended the meeting.
On 12/17/24 at 11:25 AM, V1, Administrator, stated the last QAA meeting was held in January 2024, and they are supposed to be held quarterly.
The Quality Assurance Process Improvement and Compliance (QAPIC) policy, dated 4/22/10, documents the following: The purpose of this plan is to provide a framework using common principles found in risk management, quality improvement and compliance methodologies for the development of structures and processes that supports the mission and values of our organization; that encourages a systems approach to performance assessment and improvement; that promotes high quality resident care; that protects facility assets; and that fosters a culture of compliance with all regulatory and ethical standards. With the support of the Governing Members this organization will establish a QAPIC committee made up of key administrative staff, the medical director, compliance officer/liaison, and other members as deemed appropriate by the Committee and/or Governing Members.
The Long-Term Care Facility Application for Medicare and Medicaid form, CMS 671, dated 12/17/24, documents there are 88 residents residing in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to ensure nurse aides completed the required 12 hours of education per year. This has the potential to affect all 88 residents residing in the ...
Read full inspector narrative →
Based on interview and record review the facility failed to ensure nurse aides completed the required 12 hours of education per year. This has the potential to affect all 88 residents residing in the facility.
Findings include:
The Learner Status report given by V1, Administrator, on 12/17/24, documents the following:
V24, CNA (Certified Nursing Assistant), hire date of 5/30/23, documents V24 has completed 0% of education for the past year; V25, CNA, hire date of 4/5/23, documents V25 has completed 0% of education for the past year; V26, CNA, hire date of 2/8/17, documents V26 has completed 34.62% of education for the past year; and V27, CNA, hire date of 10/3/18, documents V27 has completed 0% of education for the past year.
On 12/17/24 at 11:25 AM, V1, Administrator, stated the CNAs are supposed to have 15 hours of education per year. V1 stated they used to hold a blitz for education twice per year so the CNAs could get their education, they stopped doing that and changed over to an electronic education system, the managers have been pushing for the past year for them to get their education completed, but it isn't working. V1 stated herself, the Human Resource Director, and CNA Supervisor and responsible for monitoring their education.
The Certified Nurse Aide policy, dated 3/15/23, documents they shall attend all mandatory in-services and maintain 12 hours of continuing education each year.
Long Term Care Facility Application for Medicare and Medicaid form, CMS 671, dated 12/17/24, documents there are 88 residents residing in the facility.
Nov 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation the facility failed to prevent resident to resident abuse for 3 of 5 residents...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation the facility failed to prevent resident to resident abuse for 3 of 5 residents (R2, R3, R5) reviewed abuse in the sample of 5.
Findings Include:
1. R2's MDS dated [DATE] documents R2 is cognitively intact.
R2's Electronic Health Record documents R2 has diagnoses of Cerebrovascular Disease, Acquired Absence of right and left leg below the knee, Atrial Fibrillation, Chronic Kidney Disease, and Non compliance with Medications.
R3's MDS dated [DATE] documents R3 is moderately cognitively impaired.
R3's Electronic Health Record documents R3 has in part the diagnoses of Post Traumatic Stress Disorder, Anxiety Diosrder, Violent Behavior, and Bipolar Disorder.
R3's Care Plan dated 3/22/24 documents (R3) has a history of severe abuse, neglect, and confinement. She has a heightened level of fear especially anxiety and mistrust of others Goal: safety will be maintained. [NAME] doe will be placed on her door instead of her name. Information concerning (R3) can only be given to (V3) (V1 or V2) to be notified if anyone calls for her. (R3's) care plan dated 5/9/24 also document increase in behaviors non-compliance verbal and physical aggression paranoia, hallucinations and delusions Goal: she will not have an increase in behaviors. Observe and report increase in behaviors.
R2's Nurse's Note dated 10/5/24 documents Activity worker notified (this) writer that this resident (R2) grabbed the back of a female resident's (R3) chair and pushed it extremely hard causing female resident (R3) to roll into the wall really hard. Residents (R2 and R3) were separated resident (R2) was asked why he pushed the other resident (R3) he (R2) stated to activity worker he was tired of her running into his damn chair. DON (Director of Nursing notified along with Administrator.
On 11/14/24 at 10:30 AM, R3 was inside the nurses station with staff, and she was cursing the staff.
On 11/15/24 at 9:35 AM, V9 Activity Aide stated, I was doing an activity game. They play multiple games according to their own level. It was at 10:00 AM. The smokers kept coming into the room asking about smoke break. (R3) asked about smoke break I told her (R3) I would be there in a minute. She (R3) accidently bumped into R2's chair. (R2) then pushed her chair hard into this white thing that is near the wall. (R3) began crying, but she was not hurt. I (V9) immediately called the nurse. V9 was asked who she should have reported it to she said the nurse and the nurse called the DON. She was unsure it the administrator was actually notifed.
On 11/15/24 9:40 AM, V8, LPN (Licensed Practical Nurse) stated, yes they came to the desk and told me that (R2) had pushed (R3's) chair into the wall. (R2) told me that he was tired of (R3) running into his chair.
On 11/15/24 at 10:02 AM, V1, Administrator stated they did not have an investigation for this resident to resident altercation.
2. R5's MDS dated [DATE] documents R5 is moderately cognitively impaired.
R5's Electronic Health Records Diagnoses Cerebral Infarction, Hemiparesis, Hemiplegia, HTN, Repeated Falls, Slurred Speech
R5's Nurses Note dated 10/23/24 documents staff made this writer aware that a female resident (R3) hit this resident (R5). Resident (R5) states she hit me right here in the face and pointed at his chin. Resident (R5) unclear as to why he was hit, or what caused her(R3) to hit him (R5). Resident (R5)states it does not hurt, and there is no bruising nor discoloration noted to the area. MD (Medical Doctor) made aware, NNO (No New Orders) at this time. Resident's (R5) sister/POA (Power of Attorney) contacted and made aware. She voices no concerns. Resident (R5) currently sitting in his wheelchair watching tv (television), no s/s (signs or symptoms) of distress noted. Plan of care ongoing.
R3's Nurses Note dated 10/23/24 documents writer was notified by staff that resident (R3) was physically abusive towards another resident (R5). Staff stated this resident (R3) punched another resident in the face multiple times. This resident (R3) was removed from area by other staff members and placed at nurses station. Writer notified the Administrator (V1) along with DON (V2) began an investigation
IDPH Notification form dated 10/23/24 documents (R3) was witnessed striking (R5), while at the table residents separated and no injuries. Families and physician notified staff and other residents were interviewed. No issues with the investigation was found
The facility policy Abuse Prevention Program dated 2/2023 documents this facility affirms the right of our residents to be free from abuse (verbal, mental, sexual, or physical.) Abuse means physical, mental, or sexual assault inflicted upon a resident other than accidental means in a facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation the facility failed to investigate resident to resident abuse for two of five...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation the facility failed to investigate resident to resident abuse for two of five residents (R2, R3) reviewed for abuse in the sample of 5.
Findings Include:
The facility policy Abuse Prevention Program dated 2/2023 documents this facility affirms the right of our residents to be free from abuse (verbal, mental, sexual, or physical.) Abuse means physical, mental, or sexual assault inflicted upon a resident other than accidental means in a facility.
R2's MDS dated [DATE] documents R2 is cognitively intact.
R3's MDS dated [DATE] documents R3 is moderately cognitively impaired.
R2's Nurse's Note dated 10/5/24 documents Activity worker notified (this) writer that this resident (R2) grabbed the back of a female resident's (R3) chair and pushed it extremely hard causing female resident (R3) to roll into the wall really hard. Residents (R2 and R3) were separated resident (R2) was asked why he pushed the other resident (R3) he (R2) stated to activity worker he was tired of her running into his damn chair. DON (Director of Nursing notified along with Administrator.
On 11/15/24 at 9:35 AM, V9, Activity Aide stated, I was doing an activity game. They play multiple games according to their own level. It was at 10:00 AM. The smokers kept coming into the room asking about smoke break. (R3) asked about smoke break I told her (R3) I would be there in a minute. She (R3) accidently bumped into R2's chair. (R2) then pushed her chair hard into this white thing that is near the wall. (R3) began crying, but she was not hurt. I (V9) immediately called the nurse. V9 was asked who she should have reported it to she said the nurse and the nurse called the DON. She was unsure it the administrator was actually notifed.
On 11/15/24 9:40 AM, V8, LPN (Licensed Practical Nurse) stated, yes they came to the desk and told me that (R2) had pushed (R3's) chair into the wall. (R2) told me that he was tired of (R3) running into his Chair.
On 11/15/24 at 10:02 AM, V1, Administrator stated they did not have an investigation for this resident to resident altercation.
Oct 2024
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent employee to resident physical abuse by a staff member for 1...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent employee to resident physical abuse by a staff member for 1 of 3 residents (R2) reviewed for abuse in the sample of 4. This failure resulted in R2 sustaining a bloody lip causing him to be upset and having pain.
Findings include:
On 10/22/24 at 3:15 PM R2 was sitting outside on patio. He stated a CNA (Certified Nursing Assistant) hit him about a week ago. He stated they were talking stuff to each other and she hit him one time in the mouth with her fist. He stated it hurt.
On 10/23/24 at 12:20 PM R2 stated when V4, CNA, hit him in his mouth with her fist he was very upset. He stated it hurt a lot. He stated V4 got a wet cloth and wiped the blood off his lips.
The facility's Illinois Department of Public Health (IDPH) Notification Form dated 10/13/24 at 10:00 PM documents, under description of Accident, Causes, Injuries and Action taken by Establishment as a result of Accident: Reported to Administrator at 10:00 resident told family member CNA hit him in the mouth. CNA sent home. Investigation ongoing. R2 was identified as the resident referred to in the report. The form documents the police were not informed at time of the report. It documents the type of incident is alleged physical abuse.
The facility's Final Report of the Abuse Investigation dated 10/18/24 at 8:38 AM documents, 10/16/24 I (V1, Administrator) called (V4, CNA) this AM and ask she come in as the investigation has been completed and we need to speak to her about the results. (V4) arrived at 11:08; she arrived to speak with myself and (V2, Director of Nursing (DON) in the multipurpose room. I presented the termination paperwork and reasoning being the investigation and camera review provided substantial evidence and it was believed this incident probably did happen. She refused to sign the termination paper. When she exited the building, she walked around to the back of the building then drove around; that's when the (local) police department blocked her in, she parked her car and (local) police department took her into custody.
The facility's document labeled, (V4) Resident Abuse Incident 10/13/24 Video Investigation documents a timeline of what V15, the facility's IT director observed on the camera footage minute by minute as he reviewed the footage. It documents, 7:25:50 Employee appears to be punching at resident.
On 10/22/24 at 1:30 PM the facility's video camera coverage dated 10/13/24 between 7:15 AM and 7:26 AM was observed with V1 Administrator. The camera footage showed the inside of R2's room with his feet and legs visible. On the footage V4 is observed entering R2's room and standing at the foot of his bed. V4 then grabs R2's sheets/blankets in her hands and pulls but it appears he is pulling against her and keeping sheet/blanket pulled up. V4 lets go of the sheet/blanket and raises her arms with hands fisted and thrusts both fists towards area where R2's torso and head would be located. Unable to see if she makes contact with R2 or not, but then V4 stops and closes the door to R2's room with her on the inside.
On 10/23/24 at 9:43 AM V8, Licensed Practical Nurse (LPN) stated she heard about R2's allegation that a CNA had hit him in the mouth when staff were talking about it around her. She stated she did not do anything at the time because they were not talking directly to her, they were just talking around her. She stated it was about 6:30 PM and it was halfway through her shift, and they said it happened on day shift, so she thought it had already been reported. She stated she thinks she notified (V2), DON and (V13), Assistant Director of Nursing (ADON) at that time just to make sure they were aware. She stated she had talked to R2 at the beginning of her shift, and he had not said anything to her about a CNA hitting him at that time. V8 stated around 9:30 PM R2's sister, (V11) came walking out of the dining room and was irate, wanting to know what was going to happen to the CNA who hit R2. V8 stated she went and looked at R2's lip and had to pull it up to see the mark on it. She stated it was small area, described it as you could cover it with the tip of your finger, and was white, like it was old, not red or bleeding. V8 stated she had tele-messaged the DON and ADON earlier and told the sister it would be addressed tomorrow. V8 stated she did not notify the administrator because she did not know she was supposed to. She stated she was not aware the administrator is over the DON, so she messaged the DON and ADON.
On 10/23/24 at 10:29 AM V2 stated the first he heard about the incident regarding R2 being hit in the mouth by V4, CNA was on 10/13/24 around 8:30 PM from V12, R2's niece. V2 stated he did not know if (V8) had sent him a message earlier that evening and stated he could not find the message on his phone. V2 stated he sometimes has problems with his phone, so he doesn't know if she tried to message him or not. V2 stated he did not call and talk to staff after R2's niece called him. He stated he came in the next day and talked to R2 and assessed him. V2 stated R2 didn't seem to remember the incident and did not have any marks or bleeding on his lip when he assessed him. He stated he would have expected V8 to assess the resident as soon as she heard about it to check for injuries and ask what happened, and to report it to the administrator.
On 10/23/24 at 12:15 PM V11, R2's sister/POA (Power of Attorney) stated R2 had called her around 11:30 AM on Sunday, October 13, 2024, and told her he wanted her to come up and see him. She stated he did not say anything about the CNA hitting him, he just said he wanted her to come, so she did not get in a hurry to get up to the facility. V11 stated when she got to the facility it was around 4:30 PM and R2 was not in his room so she went and found him in the dining room. She stated he was eating dinner, and she noticed his left side of his mouth was swollen and she asked him what happened, and he told her (V4) got mad at him that morning because he did not want to get out of bed, and they were talking shit and she hit him in the mouth. V11 stated she looked in his mouth and his gums were bloody, and he had a little piece of meat (skin) hanging from him left upper lip. She stated he was complaining of pain while he was eating. V11 stated she went and asked the nurse (V8) that had just come on duty on the afternoon shift what had happened, and she stated she did not know anything about it and V11 stated she told her what (R2) had told her about the CNA hitting him in the mouth that morning. V11 stated she could not remember the nurse's name but stated She is here today. V11 walked up to the nurse's station and identified V8 as the nurse she spoke to on Sunday, October 13, 2024, about R2 stating he had been hit in the mouth by V4. V11 stated on that Sunday when she reported the incident to V8, V8 told her she would need to do a report and report it to the DON. V11 stated this conversation and V8's observation of R2's mouth happened in the hall after he left the dining room and was on the way back to his room at about 4:45 PM. V11 stated she did talk to V8 again because V8 thought R2 was talking about a different CNA but R2 clarified to V8 that it was V4, CNA who had hit him. V11 stated she and V8 both asked him why he did not tell staff what happened, but he didn't really have a reason. V11 stated she is upset because it is a resident's right to stay in bed a little longer if they want and he should not have been abused just because he didn't want to get up when V4 wanted him up.
On 10/23/24 at 12:46 PM V14 Social Service Director (SSD) stated she did see R2 on Monday morning before lunch the day after V4 had allegedly hit him. She stated she did not see any active bleeding, but he did have a piece of meat hanging on his left upper lip. She stated he did complain of pain to his mouth.
On 10/23/24 at 2:16 PM V10, CNA Supervisor, stated she did not work on Sunday, October 13, 2024, but she did work on the next day, and she saw R2 in the dining room where she helps pass breakfast trays. She stated he was acting his usual self, and she did see he had marks on his upper and lower lips that looked like impressions from his teeth. She stated she looked closer at his lips because she had seen some dried blood on his lips around that area.
On 10/23/24 at 1:10 PM V1, Administrator, stated it would never be acceptable for a staff to hit a resident. V1 stated she had not reported V4 to the Department of Professional Regulations yet because she was waiting for the police report to send to them. She stated she did not immediately terminate V4 but did suspend her because she wanted to make sure the police got what they needed so she wouldn't get away with what she did. She stated the police viewed the camera footage on Monday afternoon and decided to press charges against V4 for assaulting R2.
R2's Face Sheet documents his diagnoses to include Chronic Obstructive Pulmonary Disease, Unspecified, Chronic Kidney Disease, Stage 3B, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Other Seizures, Chronic Systolic (Congestive) Heart Failure, Schizophrenia, Need for Assistance with Personal Care, Peripheral Vascular Disease, Hypertension, Cerebral Infarction, and Generalized Anxiety Disorder.
R2's Order Summary Report dated 10/22/24 documents his medications include Xarelto 15 milligrams (mg), a blood thinner which he takes daily.
R2's Minimum Data Set (MDS) dated [DATE] documents his Brief Interview for Mental Status Score (BIMS) is 12, which indicates he is moderately cognitively impaired, and he requires substantial to maximal assist to perform bed to chair and chair to bed transfers.
R2's Care Plan initiated on 2/22/22 and revised on 10/17/24 documents, (R2) is at risk for making repeated inappropriate sexual comments/gestures towards staff, verbal/physical/sexual abuse and threats/accusations against staff r/t (related to) impulsiveness, impaired cognition. The goal for this care plan documents, He will refrain from making inappropriate sexual comments and/or suggestions toward staff. He will not touch female staff in a sexually suggestive manner. This care plan was updated on 10/13/24 with the intervention: Monitor open area to lip for s/s (signs and symptoms) of infection. Notify Psyche NP (Nurse Practitioner) of incident. Offer comfort and reassurance as indicated. Per the care plan these interventions were initiated on 10/16/24.
R2's Care Plan initiated on 12/21/21 and revised on 10/16/24 documents, (R2) is at risk for skin breakdown and injury related to incontinence, decreased mobility, poor safety awareness and renal disease. 10/13/24 Open area to lip (nosocomial)). Intervention added on 10/16/24 documents, Monitor open area to lip for s/s of infection. Administer pain medications as indicated / requested.
The facility's document, Personnel Action Form, dated 10/15/24 documents V4 was terminated for inappropriate conduct. Description of Action or Event documented: 10/13/24 at 7:25 AM Resident complained a CNA hit him in the mouth with a closed fist. Investigation and camera review shows a reasonable probability that this did occur. Police plan to press charges. Action taken: Termination.
The facility's policy, Abuse Prevention Program, revised 2/2023, documents, This facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical), neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. this facility therefore prohibits acts of mistreatment, neglect, abuse and/or crimes from being committed against its residents. This facility desires to establish a resident sensitive and resident secure environment.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to immediately report an allegation of employee physical abuse to the administrator and notify the local law enforcement for 1 of 3 residents ...
Read full inspector narrative →
Based on interview and record review, the facility failed to immediately report an allegation of employee physical abuse to the administrator and notify the local law enforcement for 1 of 3 residents (R2) reviewed for reporting of abuse allegations in the sample of 4.
Findings include:
On 10/23/24 at 12:20 PM R2 stated when V4 hit him in his mouth with her fist he was very upset. He stated it hurt a lot. He stated V4 got a wet cloth and wiped the blood off his lips.
The facility's Illinois Department of Public Health (IDPH) Notification Form dated 10/13/24 at 10:00 PM documents, under description of Accident, Causes, Injuries and Action taken by Establishment as a result of Accident: Reported to Administrator at 10:00 resident told family member CNA hit him in the mouth. CNA sent home. Investigation ongoing. R2 was identified as the resident referred to in the report. The form documents the police were not informed at time of the report. It documents the type of incident is alleged physical abuse.
The facility's Final Report of the Abuse Investigation dated 10/18/24 at 8:38 AM documents, 10/16/24 I (V1, Administrator) called (V4, CNA) this AM and ask she come in as the investigation has been completed and we need to speak to her about the results. (V4) arrived at 11:08; she arrived to speak with myself and (V2, Director of Nursing (DON)) in the multipurpose room. I presented the termination paperwork and reasoning being the investigation and camera review provided substantial evidence and it was believed this incident probably did happen. She refused to sign the termination paper. When she exited the building, she walked around to the back of the building then drove around; that's when the (local) police department blocked her in, she parked her car and (local) police department took her into custody. The final report documented that the police were notified on 10/14/24 at 7:45 AM.
The facility's document labeled, (V4) Resident Abuse Incident 10/13/24 Video Investigation documents a timeline of what V15, the facility's IT director observed on the camera footage minute by minute as he reviewed the footage. It documents, 7:25:50 Employee appears to punching at resident.
On 10/23/24 at 9:43 AM V8, Licensed Practical Nurse (LPN) stated she heard about R2's allegation that a CNA had hit him in the mouth when staff were talking about it around her. She stated she did not do anything at the time because they were not talking directly to her, they were just talking around her. She stated it was about 6:30 PM and it was halfway through her shift, and they said it happened on day shift, so she thought it had already been reported. She stated she thinks she notified (V2), DON and (V13), Assistant Director of Nursing (ADON) at that time just to make sure they were aware. She stated she had talked to R2 at the beginning of her shift, and he had not said anything to her about a CNA hitting him at that time. V8 stated around 9:30 PM R2's sister, (V11) came walking out of the dining room and was irate, wanting to know what was going to happen to the CNA who hit R2. V8 stated she went and looked at R2's lip and had to pull it up to see the mark on it. She stated it was small area, described it as you could cover it with the tip of your finger, and was white, like it was old, not red or bleeding. V8 stated she had tele-messaged the DON and ADON earlier and told the sister it would be addressed tomorrow. V8 stated she did not notify the administrator because she did not know she was supposed to. She stated she was not aware the administrator is over the DON, so she messaged the DON and ADON.
On 10/23/24 at 10:29 AM V2, Director of Nursing, stated the first he heard about the incident regarding R2 being hit in the mouth by V4, CNA was on 10/13/24 around 8:30 PM from V12, R2's niece. V2 stated he did not know if (V8) had sent him a message earlier that evening and stated he could not find the message on his phone. V2 stated he sometimes has problems with his phone, so he doesn't know if she tried to message him or not. V2 stated he did not call and talk to staff after R2's niece called him. He stated he came in the next day and talked to R2 and assessed him. V2 stated R2 didn't seem to remember the incident and did not have any marks or bleeding on his lip when he assessed him. He stated he would have expected V8 to assess the resident as soon as she heard about it to check for injuries and ask what happened, and to report it to the administrator.
On 10/23/24 at 11:10 AM V2 provided a copy of the tele-message from R2's Electronic Medical Record (EMR) that was dated 10/13/24 at 8:32 PM sent by V8 marked Secure Conversations that documented, the resident's sister stated he was struck in the mouth by an aid this morning for refusing to get out of bed and also that his shoes are missing and the resident stated that his roommate brother took them. V2 stated he would not have seen this communication until he was back in the facility on his computer. He stated if there is something important to report to him, staff would need to call him on his cell phone directly.
The facility's document, Personnel Action Form, dated 10/14/24 documents V8 was given a disciplinary/corrective action for event that happened on 10/13/24 at 5:35 PM which was described as, Not following Abuse Policy and failing to notify administrator of alleged abuse, which is not following policy. Per this form, expectations for employee are: Report alleged abuse to administrator immediately. Under Employee's comments on this document, V8's handwritten response documented, The incident occurred on a prior shift. I was unaware that it wasn't reported due to the nurse on the prior shift contacting the family for the resident, but I did reach out and tele-messaged the DON/ADON during my shift to see if they were aware of the incident at 6:30 PM when the family member asked me what action was being taken about it and stated she wanted the CNA who was responsible fired. Unaware that I was supposed to contact the administrator.
On 10/23/24 at 12:15 PM V11, R2's sister/POA (Power of Attorney) stated she arrived at facility around 4:30 PM and R2 was not in his room so she went and found him in the dining room. She stated he was eating dinner, and she noticed his left side of his mouth was swollen and she asked him what happened, and he told her (V4) got mad at him that morning because he did not want to get out of bed, and they were talking shit and she hit him in the mouth. V11 stated she went and asked the nurse (V8) that had just come on duty on the afternoon shift what had happened, and she stated she did not know anything about it and V11 stated she told her what (R2) had told her about the CNA hitting him in the mouth that morning. V11 stated she could not remember the nurse's name but stated She is here today. V11 walked up to the nurse's station and identified V8 as the nurse she spoke to on Sunday, October 13, 2024, about R2 stating he had been hit in the mouth by V4. V11 stated on that Sunday when she reported the incident to V8, V8 told her she would need to do a report and report it to the DON. V11 stated this conversation and V8's observation of R2's mouth happened in the hall after he left the dining room and was on the way back to his room at about 4:45 PM. V11 stated she did talk to V8 again because V8 thought R2 was talking about a different CNA but R2 clarified to V8 that it was V4, CNA who had hit him. V11 stated she and V8 both asked him why he did not tell staff what happened, but he didn't really have a reason.
On 10/23/24 at 1:10 PM V1, Administrator, stated it would never be acceptable for a staff to hit a resident. V1 stated she had not reported V4 to the Department of Professional Regulations yet because she was waiting for the police report to send to them. She stated the police were notified on 10/14/24 and viewed the camera footage on Monday afternoon and decided to press charges against V4 for assaulting R2. V1 stated she should have been notified immediately with a phone call when staff were first aware of R2's allegation that V4 had hit him. V1 stated tele-messages are not appropriate to notify her of abuse because they are not monitored all the time when management is not in the facility.
The facility's document, Personnel Action Form, dated 10/15/24 documents V4 was terminated for inappropriate conduct. Description of Action or Event documented: 10/13/24 at 7:25 AM Resident complained a CNA hit him in the mouth with a closed fist. Investigation and camera review shows a reasonable probability that this did occur. Police plan to press charges. Action taken: Termination.
The facility's policy, Abuse Prevention Program, revised 2/2023, under the section Policy Guidelines and Interpretation documents, 1. All covered individuals are required to immediately report any occurrences of potential mistreatment, abuse, neglect, mistreatment, including injuries of unknown source, adverse events, exploitation, theft, or crimes committed against a resident that they observe, hear about, or suspect to the administrator or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. Under Federal law covered individuals are required to report suspicions that a crime has been committed against a resident to the Department and local law enforcement as described below. 2. For crimes that result in serious bodily injury as defined above a covered individual must report by phone or facsimile within two (2) hours of the formulation of a reasonable suspicion.
Oct 2024
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview, and Record Review, the facility failed to administer ordered medications resulting in 1of 1 res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview, and Record Review, the facility failed to administer ordered medications resulting in 1of 1 resident missing multiple doses of intravenous (IV) antibiotics in the sample of 9. This failure resulted in R2 missing multiple doses of IV antibiotics for acute infections prolonging IV antibtiotic course.
Findings include:
R2's Facesheet documents an admission date of 9/12/2024. Diagnosis include Acute and subacute infective endocarditis, Bacteremia, Enterococcus as the cause of diseases, Dementia, Chronic Obstructive Pulmonary Disease.
R2's Minimum Data Set, MDS, dated [DATE] documents R2 is severely cognitively impaired. R2 is dependent on staff for mobility and transfers.
R2's Care Plan dated 9/12/2024 documents R2's daughter chose for R2 to be a Full Code. Full Treatment: Primary goal is attempting to prevent cardiac arrest by using all indicated treatments.
R2's order sheet dated 9/13/2024 documents Ampicillin Sodium Injection Solution Reconstituted 2 Gm, use 2000 mg intravenously four times a day related to Infection and Inflammatory reaction due to other Cardiac and Vascular Devices, Implants and Grafts, Sequela.
R2's order sheet dated 9/13/2024 documents Ceftriaxone Sodium Injection Solution Reconstituted 2 Gm, use 2 gram intravenously two times a day related to Infection and Inflammatory reaction due to other Cardiac and Vascular Devices, Implants and Grafts, Sequela.
R2's progress notes dated 9/15/2024 at 2:33PM documents R2 has pulled out peripherally inserted central catheter, PICC, line. Physician notified and Power of Attorney, POA, is at bed side. R2 has new orders to go to hospital to have PICC line replaced. Hospital notified this nurse there is no one there to put it back in today. POA notified and staff will send R2 out in the morning to have replaced. Physician also notified.
R2's progress notes dated 9/15/2024 at 4:15PM document Health Sutures were removed that secure the wings of the now dislodged PICC Line to the skin. No bleeding to the I.V. site noted.
R2's progress notes dated 9/15/2024 10:12PM document Orders Ampicillin Sodium Injection Solution Reconstituted 2 GM. Use 2000 mg intravenously four times a day related to Infection and Inflammatory Reaction. PICC line dislodged. V2, Director of Nursing, DON, aware.
R2's progress notes dated 9/15/2024 at 10:13PM documents Ceftriaxone Sodium Injection Solution Reconstituted 2 GM. Use 2 gram intravenously two times a day related to Infection and Inflammatory Reaction. PICC line dislodged.
R2's progress notes dated 9/16/2024 at 10:32AM documents R2 is being transported to hospital per Physician orders for PICC line replacement. Transferred to recliner chair to stretcher via 3 assists, including EMS and nursing staff.
R2's medication administration sheets, MARS, dated 9/1/2024-9/30/2024 document Ceftriaxone Sodium Intravenous Solution Reconstituted 2 Grams. Use 2000 milligrams, mg, intravenously every 12 hours for antibiotic. Start date on 9/13/2024 at 8:00AM. MARS document Ceftriaxone Sodium not administered on 9/15/2024 evening dose due to #9, other /see progress notes. Ceftriaxone Sodium not administered on 9/16/2024 due to #6 hospitalized . R2's MARS dated 9/25/2024 6:00PM has no signature that Ceftriaxone Sodium was administered.
R2's medication administration sheets, MARS, dated 9/1/2024-9/30/2024 document Ampicillin Sodium Injection Solution Reconstituted 2 grams (Ampicillin Sodium). Use 2000mg intravenously four times a day related to Infection and Inflammatory Reaction. Start date on 9/13/2024 at 8:00AM. MARS document Ampicillin Sodium not administered on 9/15/2024 at 12:00PM and at HS, hours of sleep due to #9, other /see progress notes. R2's MARS dated 9/16/2024 at AM have no documentation of Ampicillin Sodium given. R2's MARS dated 9/25/2024 at 12:00PM and 6:00PM have no documentation that Ampicillin Sodium administered.
R2's progress notes dated 9/16/2024 at 9:57AM document R2's wife called inquiring if R2 was sent out to hospital. Writer informed spouse that R2 was still at facility and waiting for ambulance to arrive. Writer called Emergency Medical Services, EMS, again and operator stated EMS would arrive in 30 minutes.
On 10/1/2024 V8, R2's Power of Attorney, POA, stated My Dad had a blood infection and if he didn't get the antibiotics he would die. There were times I was in the room and no nurse came in and gave him his antibiotics. When his PICC line was out he missed several doses of his antibiotics. They did not care. They just said no one is able to reinsert the PICC line.
On 10/1/2024 at 4:00PM V1, Administrator, stated R2 pulled out his PICC line on 9/15/2024. He then missed some doses of the antibiotic. We called the hospital and there was no one to reinsert the PICC line until 9/16/2024. That is the procedure if a resident's PICC line becomes dislodged, they are sent to the hospital for it to be reinserted. Then the hospital kept him for several days and transferred him to another hospital. We would not have taken R2 as a resident if we had known he had to get antibiotics every 6 hours.
On 10/1/2024 at 8:30AM V2, Director of Nursing, DON, stated R2 pulled his PICC line out. He had to be sent out to the hospital to get it reinserted. We don't have many RN's, Registered Nurses, to give IV meds so it is usually me who gives them.
On 10/1/2024 at 3:35PM V7 Pharmacist stated Whether or not the medication error is significant depends on the status of the resident. Intravenous antibiotics are a big deal and missing them is a big deal.
On 10/3/2024 at 7:50AM V9, Licensed Practical Nurse, LPN, stated I took care of R2 a lot. I am the one who sent him out to the hospital when his PICC line was out. I remember the hospital had no one to put the PICC line back in, so he didn't go out over the weekend.
Facility policy updated 1/14/2020 states Medications will be administered in a safe, efficient, and accurate manner to residents for whom they are prescribed and in accordance with current acceptable nursing practice. Medication must be administered as ordered by the physician.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview, and Record Review, the facility failed to administer ordered medications to 1 of 1 resident (R2...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview, and Record Review, the facility failed to administer ordered medications to 1 of 1 resident (R2) in the sample of 9.
Findings include:
R2's Face sheet documents an admission date of 9/12/2024. Diagnosis include Acute and subacute infective endocarditis, Bacteremia, Enterococcus as the cause of diseases, Dementia, Chronic Obstructive Pulmonary Disease.
R2's Minimum Data Set, MDS, dated [DATE] documents R2 is severely cognitively impaired. R2 is dependent on staff for mobility and transfers.
R2's Care Plan dated 9/12/2024 documents R2's daughter chose for R2 to be a Full Code. Full Treatment: Primary goal is attempting to prevent cardiac arrest by using all indicated treatments.
R2's order sheets dated 9/12/2024 document Carbidopa-Levodopa Oral Tablet 10-100 MG (Carbidopa-Levodopa). Give 3 tablet by mouth three times a day. Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day. Folic Acid Oral Tablet 1 MG (Folic Acid) Give 1 mg by mouth one time a day. Duloxetine HCl Oral Capsule Delayed Release Sprinkle 20 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day.
R2's order sheets dated 9/13/2024 Ceftriaxone Sodium Injection Solution Reconstituted 2 GM (Ceftriaxone Sodium) Use 2 gram intravenously two times a day. Ampicillin Sodium Injection Solution Reconstituted 2 GM (Ampicillin Sodium). Use 2000 mg intravenously four times a day.
R2's order sheets dated 9/21/2024 Senna-Docusate Sodium Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 2 tablet by mouth every 12 hours. Spiriva Respimat Inhalation Aerosol Solution 2.5 MCG/ACT (Tiotropium Bromide Monohydrate) 2 puff inhale orally one time a day. Polyethylene Glycol Powder (Polyethylene Glycol 1450) Give 17 gram by mouth one time a day for Bowels. Therapeutic Multivit/Mineral Oral Tablet (Multiple Vitamins w/ Minerals).
R2's progress notes dated 9/15/2024 at 2:33PM documents R2 has pulled out peripherally inserted central catheter, PICC, line. Physician notified and Power of Attorney, POA, is at bed side. R2 has new orders to go to hospital to have PICC line replaced. Hospital notified this nurse, there is no one there to put it back in today. POA notified and staff will send R2 out in the morning to have replaced. Physician also notified.
R2's progress notes dated 9/15/2024 at 4:15PM document Health Sutures were removed that secure the wings of the now dislodged PICC Line to the skin. No bleeding to the I.V. site noted.
R2's medication administration sheets, MARS, dated 9/1/2024-9/30/2024 document Ceftriaxone Sodium Intravenous Solution Reconstituted 2 Grams. Use 2000 milligrams, mg, intravenously every 12 hours for antibiotic. Start date on 9/13/2024 at 8:00AM. MARS document Ceftriaxone Sodium not administered on 9/15/2024 evening dose due to #9, other /see progress notes. Ceftriaxone Sodium not administered on 9/16/2024 due to #6 hospitalized . R2's MARS dated 9/25/2024 6:00PM has no signature that Ceftriaxone Sodium was administered.
R2's medication administration sheets, MARS, dated 9/1/2024-9/30/2024 document Ampicillin Sodium Injection Solution Reconstituted 2 grams (Ampicillin Sodium). Use 2000mg intravenously four times a day related to Infection and Inflammatory Reaction. Start date on 9/13/2024 at 8:00AM. MARS document Ampicillin Sodium not administered on 9/15/2024 at 12:00PM and at HS, hours of sleep due to #9, other /see progress notes. R2's MARS dated 9/16/2024 at AM have no documentation of Ampicillin Sodium given. R2's MARS dated 9/25/2024 at 12:00PM and 6:00PM have no documentation that Ampicillin Sodium administered.
R2's MAR sheets dated 9/1/2024-9/30/2024 documents the following medications not being administered on 9/28/2024 at 6:00AM: Duloxetine Hcl oral capsule delayed release sprinkle 20mg. Folic Acid oral tablet one mg. Furosemide oral tablet 20mg. Polyethylene glycol powder 17gms. Senna docusate oral tablet. Carbidopa Levodopa oral tablet. Spiriva Respimat inhaler aerosol solution. Multi vitamin tablet. All medications have a 9/22/2024 start date.
R2's progress notes dated 9/15/2024 10:12PM document Orders Ampicillin Sodium Injection Solution Reconstituted 2 GM. Use 2000 mg intravenously four times a day related to Infection and Inflammatory Reaction. PICC line dislodged. V2, Director of Nursing, DON, aware.
R2's progress notes dated 9/15/2024 at 10:13PM documents Ceftriaxone Sodium Injection Solution Reconstituted 2 GM. Use 2 gram intravenously two times a day related to Infection and Inflammatory Reaction. PICC line dislodged.
R2's progress notes dated 9/16/2024 at 9:57AM document R2's wife called inquiring if R2 was sent out to hospital. Writer informed spouse that R2 was still at facility and waiting for ambulance to arrive. Writer called Emergency Medical Services, EMS, again and operator stated EMS would arrive in 30 minutes.
R2's progress notes dated 9/16/2024 at 10:32AM documents R2 is being transported to hospital per Physician orders for PICC line replacement. Transferred to recliner chair to stretcher via 3 assists, including EMS and nursing staff.
R2's Hospital History and Physical dated 9/17/2024 documents Chief Complaint: Confusion and lost IV access. R2 reportedly presented on 9/16/2024 to local hospital, and staff were unable to place a PICC line. R2 admitted locally and transferred to medical center for PICC line placement. Assessment/Plan Principal Problem: COPD with exacerbation, Parkinson' Disease, Status Post placement of cardiac pacemaker, age related physical debility, Bacteremia due to Enterococcus, Bacterial Endocarditis, Dementia, Sinus node dysfunction, Septic embolism. Continue ampicillin 2000mg every six hours, Ceftriaxone 2000mg daily until 10/17/2024. Will need PICC replaced once confusion improves. Goal for discharge: Management of resolution of confusion, PICC line placement.
R2's progress notes dated 9/21/2024 at 3:45PM admission Assessment R2 was readmitted to facility from hospital via stretcher on 09/21/2024 at 3:15 PM.
R2's progress notes dated 9/28/2024 at 6:18AM documents R2's medications were unavailable, pharmacy contacted at 11:51PM in an attempt to get them delivered STAT, tech states the meds will be out as soon as possible. Reached out to pharmacy again at 6:00AM spoke with pharmacist to get an update, he stated the delivery has been verified and they are waiting on the backup pharmacy to fulfill the order so they can deliver it. DON aware of situation, and family has also spoken with DON.
R2's progress notes dated 9/28/2024 at 7:42AM documents Pharmacy called at 7:42AM and made this nurse aware that they were able to refill all the medication except his multivitamin. The pharmacy rep let this nurse know that they would be sending the meds out as soon as possible.
R2's progress notes dated 9/30/2024 at 6:45AM documents EMS arrived for discharge to another facility.
On 10/1/2024 V8, R2's Power of Attorney, POA, stated My Dad had a blood infection and if he didn't get the antibiotics he would die. There were times I was in the room and no nurse came in and gave him his antibiotics. When his PICC line was out he missed several doses of his antibiotics. They did not care. They just said no one is able to reinsert the PICC line.
On 10/1/2024 at 4:00PM V1, Administrator, stated R2 pulled out his PICC line on 9/15/2024. He then missed some doses of the antibiotic. We called the hospital and there was no one to reinsert the PICC line until 9/16/2024. That is the procedure if a resident's PICC line becomes dislodged, they are sent to the hospital for it to be reinserted. Then the hospital kept him for several days and transferred him to another hospital. We would not have taken R2 as a resident if we had known he had to get antibiotics every 6 hours.
On 10/1/2024 at 8:30AM V2, Director of Nursing, DON, stated R2 pulled his PICC line out. He had to be sent out to the hospital to get it reinserted. We don't have many RNs, Registered Nurses, to give IV meds so it is usually me who gives them.
Facility policy updated 1/14/2020 states Medications will be administered in a safe, efficient, and accurate manner to residents for whom they are prescribed and in accordance with current acceptable nursing practice. Medication must be administered as ordered by the physician.
Aug 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent residents fro...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent residents from wandering into other resident's rooms for 1 of 3 resident's (R8) reviewed for wandering in a sample of 16.
Findings include:
R8's Face Sheet, with an admission date of 08/01/24, documented R8 has diagnoses of but not limited to vascular dementia, unspecified severity, with other behavioral disturbance and wandering in diseases.
R8's Minimum Data Set (MDS), dated [DATE], documented R8 is severely cognitively impaired and requires assistance with all his activities of daily living (ADL).
R8's Care Plan, with an admission date of 08/01/24, documented R8 is an elopement risk/wanderer related to (r/t) impaired cognition and poor safety awareness. Interventions were but not limited to If wander guard is noted to be removed/missing, put Resident on frequent face checks or 1:1, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes, and distract him from wandering by offering pleasant diversions, structured activities, food, conversation, television, ambulating.
R8's Wandering/Elopement Assessment, dated 08/01/24, documented R8 is a high risk with a score of 15.
R8's Progress Notes, dated 8/2/2024 at 1:29 PM, documented Behavior Note: Resident has been wandering within the facility this morning. Resident constantly redirected. Resident noted walking into other Resident's room in which he was seen by Staff pulling covers back trying to get in bed with another Resident. Resident redirected again. This writer notified Administrator and she is aware of the matter. Resident has refused all meds offered to him. Multiple attempts made.
R8's Progress Notes, dated 8/2/2024 at 4:14 PM, documented Social Services Note R8 was admitted into facility on 08/01/2024. He is here as a long-term resident with no discharge plans. R8 has a diagnosis (dx) of Vascular Dementia. Resident is alert and oriented (A&O) times (X) 1. He wanders throughout the facility aimlessly. He does not focus when being spoken to. His expression would be considered as flat affect. A wander guard has been placed on him.
R8's Progress Notes, dated 8/3/2024 at 3:36 PM, documented 15:46 Health Status Note: Unable to redirected verbally at this time. Resident up ambulating going from room to room. Attempting to get into to bed with peers. Running at times when trying to verbally redirect. Does not responding to touch will pull away. Staff continue to let resident monitor to prevent falling or altercation with fellow peer.
R8's Progress Notes, dated 8/7/2024 5:05 PM, documented Health Status Note: Attempted to exit facility thru fire door. Resident was assisted back per staff member. Ambulate with staff member with slow and steady gait. Staff member state resident lost footing in grass dropping to knees. Resident assisted self-up at that time. Unable to give passive range of motion (PROM) due to confusion. Unable to verbally redirect. Continue to ambulate ad-lib.
On 08/13/24 at 01:05 PM, R8 was observed walking out of his room and going down the 600-hallway. He was observed walking into one of the rooms on the 600 hallway and then back out. R8 then proceeded to walk down the 100 hallway and into one of the rooms on that hall and then back out. When R8 came out of the room located on the 100-hallway staff were observed to be present and redirected him.
On 08/14/24 at 10:30 AM, V8, Certified Nursing Assistant (CNA) stated that it depends who is working on how well the residents who wander are supervised.
On 08/14/24 at 01:55 PM, R6 was asked how he felt about resident's wandering into his room. He stated that he tells them to leave that they are in the wrong room and hopes the resident will listen to him because they are invading his space.
On 08/14/24 at 02:00 PM, R2 was asked how he felt about resident's wandering into his room. R2 state he just tells them to get out. He said he doesn't want them to steal his stuff and he feels disappointed the staff don't do their job and keep the residents who wander supervised.
On 08/14/24 at 03:15 PM, V1, Administrator and V2, Director of Nursing (DON) stated they would expect the staff to redirect the residents who wander into other resident's room to redirect them out of the other resident's room. V2 stated they should safely remove the wandering resident and try to prevent the occurrence of that situation.
The facility's policy, Behavioral Assessment, Intervention, and Monitoring, revision date of December 2016, documented Policy Interpretation and Implementation General Guidelines 1. Behavior is the response of an individual to a wide variety of factors. The factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. 2. Behavior is regulated by the brain and is influenced by past experiences, personality traits, environment, and interactions with other people. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. It further documents Monitoring 3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor blood sugars regularly and administer insulin...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor blood sugars regularly and administer insulin as ordered for 1 of 11 residents (R2) reviewed for medications in the sample of 16.
Findings include:
R2's admission Record, with admission date of 05/10/24, documented R2 has diagnoses of but not limited to cerebrovascular accident (CVA), acquired absence of left and right leg below the knee, Type II diabetes mellitus, peripheral vascular disease (PVD), atrial fibrillation, chronic kidney disease (CKD), hypertension (HTN), phantom limb syndrome.
R2's Minimum Data Set (MDS), dated [DATE], section C documented resident is cognitively intact with a Brief Interview Mental Status (BIMS) of 15. Section GG documents impairment on both lower extremities and requires a wheelchair. He requires setup assistance with eating, oral hygiene, partial assistance with upper body dressing, substantial assistance with showering, lower body dressing, and personal hygiene and dependent with toileting hygiene. Section H stated that he is always continent of both bowel and bladder.
R2's Care Plan, dated 5/28/24 documented interventions for emotional, intellectual, and social needs from staff, Activities of Daily Living (ADL) self-care deficit, limited physical mobility, cardiac risk, bilateral leg pain risk, oral/ dental pain risk, fall risk, fatigue risk, infection risk, Gastrointestinal (GI) bleed risk, mood fluctuation risk with repeated threats to sue the facility, and skin breakdown risk.
R2's Physician's Orders, with an order date of 05/10/24, documented R2 was to receive Humalog Insulin (Lispro) 5 units Subcutaneous (SQ) three time a day (TID). R2 was also to receive Humalog Insulin per sliding scale SQ three time a day as indicated along with the scheduled does of Humalog insulin.
R2's Physician's Order, with start date of 07/18/24, documented R2 was to receive 24 units of Glargine Insulin SQ at bedtime.
R2's Medication Administration Record (MAR), from August 1st through August 13th regarding his Humalog insulin (Lispro) 5 units TID order, documented R2 did not receive his scheduled 7:00 AM 5 units of Humalog insulin on 08/01/24, 08/02, 08/03, 08/04, 08/07, 08/08, 08/10, and 08/11/24. R2 did not receive his 11:00 AM scheduled 5 units on 08/01/24, 08/02, 08/03, 08/04, 08/05, 08/06, 08/07, 08/09, 08/10, 08/11, 08/12, 08/13, and 08/14/24. R2 did not receive his 4:00 PM scheduled 5 units on 08/01/24, 08/02, 08/03, 08/04, 08/05, 08/06, 08/07, 08/08, and 08/09/24.
R2's MAR for the month of August 2024 was reviewed and documented the following. From the dates of August 1, 2024, through August 13, 2024, he did not receive his scheduled 24 units of Glargine insulin 08/01/24 through 08/11/24.
On 08/13/24 at 9:20 AM, during R2's interview he stated he doesn't take scheduled medications by mouth because he doesn't think the staff know what the medications, they are giving him are for. R2 stated that he was supposed to have his blood sugar checked four times per day and that last weekend it was not checked all day Saturday, Sunday, or Monday morning.
On 08/13/24 at 1:00 PM, follow up interview with R2 was conducted and R2 was asked if he ever refused his medication and he stated, I refuse all of them except for insulin and Tylenol. When asked if he refuses his accucheck testing, R2 stated that he does not.
R2's Progress Notes were reviewed and no documentation of notification to the physician as to why R2's scheduled Humalog and Glargine insulin was held.
During this investigation during continuous direct observation from 10:00 AM to 12:00 PM on 08/14/24 was made with no nursing professionals observed entering R2's room or talking with him.
On 08/14/24 at 11:25 AM, Review of R2's electronic medical record (EMR) and MAR was conducted. R2's MAR documented he had refused his blood glucose check at 11:00 AM on 08/14/24.
On 08/14/24 at 11:50 AM, R2 was questioned by surveyor if his nurse had asked him if he wanted his accucheck preformed prior to lunch, R2 stated he was not asked, and he did not receive an accucheck.
On 08/14/24 at 1:10 PM, Interview with V9, Pharmacist at facility's pharmacy, clarified orders for R2s Humalog and Lantus. V9 stated that the Humalog is ordered for 5 units three times per day routinely plus an additional Humalog sliding scale insulin depending on R2's blood sugar. A scenario was provided to V9 asking if R2's accucheck was 178, he (R2) should receive Humalog 5 units routine plus 2 units sliding scale? To which V9 said if that had not been given, she would consider that a medication error. This surveyor also reviewed the order for R2's Lantus 24 units every night. V9 said this should be given routinely. If the nurse has a question regarding medication being given based on a blood sugar reading, she should notify the physician with her concerns for any other orders. V9 said if the Lantus was not given as ordered she would consider this a medication error.
On 08/14/24 at 2:02 PM, V1, Administrator stated she would expect the nurses to follow the physician's orders, if the resident refuses medication she would expect them to reattempt to give it and educate the resident on what could happen if they don't take the medication.
The facility's policy Medication Administration General Principles, with a revision date of 01/14/2020, documents Policy: Medications will be administered in a safe, efficient and accurate manner to residents for whom they are prescribed in accordance with current acceptable nursing practice. It further documents Policy Guidelines and interpretation: 5. Where applicable (e.g. physician's orders) vital signs should be obtained prior to the administration of medications whose indications require these measures.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure food was served at the proper temperature for 3 of 8 residents (R1, R2, and R6) reviewed for food in the sample of 9.
...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure food was served at the proper temperature for 3 of 8 residents (R1, R2, and R6) reviewed for food in the sample of 9.
Findings include:
On 07/23/24 at 12:35 PM, a test tray was obtained after all the residents had been served. It consisted of turkey and gravy on a slice of bread, mixed vegetables, and scalloped potatoes. Food temperatures were obtained with a digital thermometer after the thermometer had been calibrated. The temperatures were as follows: Turkey and gravy temperature was 127 degrees Fahrenheit (F). It was lukewarm, had a slimy texture, and a salty taste. The scalloped potatoes were 163 degrees F, they were hot and had a very bland taste. The mixed vegetables were 115 degrees F, were lukewarm, undercooked, and bland.
On 07/23/24 at 8:50 AM, R1 who is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 stated someday's the food is okay and someday's it isn't. He said the food does have some flavor but at times it's cold.
On 07/23/24 at 8:55 AM, R2 who is cognitively intact with a BIMS of 15 out of 15 stated the food at the facility is sometimes cold when he would get it.
On 07/23/24 at 10:55 AM, V4, Certified Nursing Assistant (CNA) said some of the residents have complained their food had been cold and she would offer to go and warm it up for them.
On 07/23/24 at 12:25 PM, V9, Dietary Manager stated he has had residents' complaint to him their food was cold. He said he offered to heat it up for them or he would even offer them a whole new tray.
On 07/23/24 at 1:30 PM, R6 who is cognitively intact with a BIMS of 15 out of 15 stated the food at times was cold when she would get her meal, but she thinks it's because they were short in the kitchen.
On 07/23/24 at 1:40 PM, V10, Licensed Practical Nurse (LPN) stated yes, some of the residents have complained to her about their food being cold at times.
On 07/24/34 at 9:43 AM, This surveyor asked V1, Administrator for the facility's policy and procedure regarding food preparation and temperatures.
On 07/24/34 at 10:43 AM, V1, Administrator stated they do not have a policy for food preparation and temperature, they follow the state guidelines.
On 07/24/24 at 3:15 PM, V1, Administrator stated she would expect the food to meet the state temperature guidelines when being served.
The facility's resident council meeting minutes, dated 04/29/24, documented resident states that sometimes the food does not taste good.
Apr 2024
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate tracheostomy care for 1 of 3 resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate tracheostomy care for 1 of 3 residents (R136) reviewed for respiratory care, in a sample of 30.
Findings include:
On 4/04/24 at 12:10 PM, R136 was observed with light yellow drainage on the drain sponge around his tracheostomy site, V14, Certified Nurse's Assistant (CNA), asked V2, Director of Nurses (DON), to change the tracheostomy dressing. V2 removed R136's soiled dressing, did not cleanse the tracheostomy site prior to applying the clean drain sponge.
R136's Medical Diagnosis Listing, undated, documented that R136 has a diagnosis of Acute and Chronic Respiratory Failure and Tracheostomy Status.
R136's Minimum Data Set (MDS), dated [DATE], documented that R136 receives oxygen, suctioning and tracheostomy care.
R136's Care Plan, dated 5/28/23, documents R136 is at risk for impaired oxygenation and difficulty breathing related to diagnosis of Respiratory Failure with placement of tracheostomy and to use universal precautions at all times.
R136's Physician Order Sheet (POS), documented an order, dated 1/19/24, for tracheotomy/respiratory monitoring every shift related to Acute/Chronic Respiratory Failure and tracheostomy status.
On 4/05/24 at 8:25 AM, V2, DON, stated that tracheostomy care utilizes sterile technique. V2 stated that staff are to perform hand hygiene, gel in, gel out. V2 stated that when doing a procedure, staff are to wash their hands, put gloves on, then when changing procedures, they are to wash their hands again and re-glove.
The Tracheostomy Care policy, dated 8/2013, documented, Aseptic technique must be used. Sterile gloves must be used during aseptic procedures. Site and stoma care: apply clean gloves. Clean the stoma with two peroxide soaked gauze pads. Rinse the stoma with saline soaked gauze pads. Wipe with dry gauze. Disinfect the stoma with the antiseptic soaked gauze pads. Allow to air dry or wipe with clean, dry gauze. Apply a fenestrated gauze pad around the insertion site. Remove gloves. Wash hands.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to follow infection control practices to prevent infectio...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to follow infection control practices to prevent infection in 1 of 6 residents (R136) reviewed for infection control in the sample of 30.
Findings include:
1. On 4/04/24 at 12:10 PM, R136 was observed with light yellow drainage on the drain sponge around his tracheostomy site, V14, Certified Nurse's Assistant (CNA), asked V2, Director of Nurses (DON), to change the tracheostomy dressing. V2 had gloves on prior to being asked to change the dressing due to having to turn off R136's tube feeding for staff to perform catheter care on R136. V2 did not change gloves nor perform hand hygiene prior to providing care to the tracheostomy site. V2 took the new drain sponge, opened the package and sat it on R136's bed, still in the opened package. V2 then removed R136's soiled dressing, did not change gloves, perform hand hygiene or cleanse the tracheostomy site prior to applying the clean drain sponge.
On 4/04/24 at 1:30 PM, V15, Licensed Practical Nurse (LPN), was observed suctioning R136's tracheostomy. V15 washed her hands, opened the suctioning kit, donned clean gloves, turned around, touched the suction machine, poured sterile water into an opened container that had been sitting out on R136's bedside stand (not a new sterile container). V15, then touched the suction catheter and began suctioning R136, after suctioning once, V15 then took the suction catheter, placed it in the container with the sterile water to clear any drainage from the catheter. V15 then proceeded to touch the outside of R136's tracheostomy tube while attempting to place it down the inner part of the tube. V15 did not maintain a sterile field while providing tracheostomy care, change gloves or perform hand hygiene when going from a clean to dirty field.
R136's Medical Diagnosis Listing, undated, documented that R136 had a diagnosis of Acute and Chronic Respiratory Failure and Tracheostomy Status.
R136's Minimum Data Set (MDS), dated [DATE], documented that R136 receives oxygen, suctioning and tracheostomy care.
R136's Care Plan, dated 5/28/23, documented that R136 was at risk for impaired oxygenation and difficulty breathing related to diagnosis of Respiratory Failure with placement of tracheostomy and to use universal precautions at all time.
R136's Physician Order Sheet (POS), documented an order, dated 1/19/24, for tracheotomy/respiratory monitoring every shift related to Acute/Chronic Respiratory Failure and tracheostomy status.
On 4/05/24 at 8:25 AM V2, DON, stated that tracheostomy care utilizes sterile technique. V2 stated that staff are to perform hand hygiene, gel in, gel out. V2 stated that when doing a procedure, staff are to wash their hands, put gloves on, then when changing procedures, they are to wash their hands again and re-glove.
The Suctioning the Lower Airway policy, dated 10/2010, documented, The purpose of the policy is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract. Use sterile equipment to avoid widespread pulmonary and systemic infection. Suctioning of the lower airway is a sterile procedure. All equipment that comes into contact with the lower airway must be sterile. Procedure: Perform hand antisepsis. Put on gloves. Connect one end of suction tubing to suction unit and place the other end near the resident. Turn on suction unit and adjust to appropriate negative pressure. Remove Gloves. Open suction catheter kit. Place sterile drape across the resident's chest. Remove sterile cup, touching only the outside. Fill cup with 100 cc (cubic centimeters) sterile saline or sterile water. Apply sterile gloves. Holding the catheter in dominant hand and the tubing in the non-dominant hand, connect the catheter to the tubing. Suction a small amount of water from the cup to verify negative pressure. Rest catheter tip on sterile surface. Insert the catheter into airway without applying suction. Advance the catheter until resistance is med. Pull back 1-2 cm (centimeters). Apply intermittent suction and slowly withdraw catheter. Rinse catheter and tubing with sterile saline or sterile water until clear.
The Tracheostomy Care policy, dated 8/2013, documented, Aseptic technique must be used. Sterile gloves must be used during aseptic procedures. Site and stoma care: apply clean gloves. Clean the stoma with two peroxide soaked gauze pads. Rinse the stoma with saline saline soaked gauze pads. Wipe with dry gauze. Disinfect the stoma with the antiseptic soaked gauze pads. Allow to air dry or wipe with clean, dry gauze. Apply a fenestrated gauze pad around the insertion site. Remove gloves. Wash hands.
The Hand Hygiene policy, dated 9/2017, documented, Proper hand hygiene practices reduce the transmission of pathogenic microorganisms to residents, visitors, and other staff members.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R36's Face Sheet, documented that R36 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemipare...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R36's Face Sheet, documented that R36 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, muscle weakness, need for assistance with personal care, and history of falling.
R36's MDS, dated [DATE] documented that R36 was cognitively intact, required extensive one person assistance with bed mobility and extensive two person assistance with transfer.
R36's Care Plan, initiated 7/19/23, documented that R36 was at risk for falls related to weakness, fatigue, poor trunk control, and poor safety awareness.
R36's Fall Risk Assessment, dated 7/18/23, documented that R36 was at high risk for falling.
R36's Progress Note, dated 7/18/23 at 9:09 AM, documented that R36 had a witnessed fall during transfer.
R36's Fall Investigation Worksheet, completed 7/19/23, documented that R36 was being transferred by staff member when her knees buckled, causing her to fall. The Recommendation/Intervention was two person assistance with transfers.
R36's Care Plan Intervention, initiated 7/19/23, documented that R36 required two assist with gait belt when transferring.
On 4/4/24 at 9:07 AM, V21, CNA, assisted R36 with transfer from bed to wheelchair. V21 held residents left arm and gait belt, counted to three, then helped lift R36 up as R36 pivoted into the locked wheelchair. V21 stated that R36 is always a one person assist with gait belt for transfers.
On 4/4/24 at 10:10 AM, V12, Restorative Licensed Practical Nurse (LPN), stated, (R36)'s fall happened when they were transferring her to the bathroom. There was only one aid there and it wasn't enough, so now it's supposed to be two. It's in the care plan and in the computer so the aides can see. (R36) can stand and help staff transfer sometimes, but not always.
3. R15's Face Sheet, undated, documented that R15 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, age-related osteoporosis, osteoarthritis, postural kyphosis, contracture of right hand, Alzheimer's dementia, and repeated falls.
R15's MDS, dated [DATE], documented that R15 was cognitively intact, used wheelchair, required substantial/maximal assistance with rolling from left to right, was dependent with transfer, and the activity of walking did not occur.
R15's Care Plan, initiated 11/15/22, documented that R15 was at risk for falls and injury related to behaviors, poor safety awareness, impatience, impulsivity and weakness.
R15's Fall Risk Assessment, dated 1/17/24, documented that R15 was at high risk for falling.
R15's Care Plan Interventions, revised on 6/14/23, documented that included a placement of a floor mat along R15's bed.
On 4/2/24 at 10:10 AM, R15 was sleeping in bed in her room. Floor mats were leaned up against the wall across from R15's bed and were not placed down next to R15's bed.
On 4/2/24 at 11:09 AM, V19, CNA, stated that R15 does not normally have floor mats beside her bed and was unsure why the mats were placed against the wall because R15 was not a fall risk.
On 4/2/24 at 1:40 PM, 4/3/24 at 12:18 PM, 4/3/24 at 4:02 PM, and 4/4/24 at 7:50 AM, R15 was lying in bed in her room with no floor mat beside her bed.
On 4/3/24 at 4:02 PM, V18, CNA, stated that she did not think that R15 was a fall risk and was unaware of her requiring floor mats beside her bed.
4. R8's Face Sheet, documented that R8 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, morbid obesity with alveolar hypoventilation, schizoaffective disorder, left knee pain, muscle weakness, and stage 3 pressure ulcer to right buttock.
R8's MDS, dated [DATE], documented that R8 was cognitively intact, dependent with rolling from left to right, and dependent with transfer.
R8's Fall Risk Assessment, dated 8/9/23, documented that R8 was at high risk for falling.
R8's Care Plan, initiated 6/8/22, documented that R8 was at risk for falls related to morbid obesity, weakness, and shortness of breath with exertion.
The Facility's Fall Log, undated, documented that R8 had a witnessed fall on 11/24/23 at 11:03 AM.
R8's Care Plan Intervention, dated 11/24/23 documented, Educate staff on the importance of not pulling resident back in her w/c (wheelchair) with pad to only adjust her in chair with (mechanical) lift.
R8's Progress Notes, for the month of November 2023, did not contain any documentation regarding R8's 11/24/23 fall.
On 4/3/24 at 2:00 PM, R8's 11/24/23 Fall Investigation was requested from V1, Administrator.
On 4/4/24 at 10:10 AM, V12, Restorative LPN, stated that R8 did have a fall on 11/24/23, but she did not have a Fall Investigation. She continued to state that staff were transferring R8, and when they pulled back the pad in the chair to readjust her, she slipped to the floor. V12 stated that because of this, R8 is now only transferred with a mechanical lift.
On 4/4/24 at 4:10 PM, V1, Administrator, stated that she expects fall investigations to be completed after each fall and that progressive interventions to be added and implemented at all times.
The Facility's Accidents and Incidents Policy, revised 2/20/23, documented, All incidents and accidents occurring at the facility will be reported, investigated, and tracked in accordance with the guidelines contained herein. It continues, An incident report must be initiated by the charge nurse or the nursing supervisor on the scene of the incident. It continues, Preliminary investigation is conducted by the first responders in conjunction with the charge nurse and/or department supervisor if department supervisor is on site. It continues, The Administrator or his/her designee will be responsible for assigning an investigator(s) to complete the investigation of an incident/accident. It continues, Unless otherwise specified, investigations should be initiated as soon as practicable however they should be completed with {sic} five (5) days of the event. It continues, The safety committee will review the incident report and preliminary investigation and implement new intervention(s) based on the environmental and/or resident conditions which may be the root cause of the accident, along with staff interview and MD (Medical Doctor) recommendation. It continues, If a fall or fall event continues despite new interventions, analysis will be performed to determine the appropriateness of the current interventions and implement new interventions or provide rationale as to why the current plan remains relevant. It continues, Ensure any new interventions have been entered on the resident's plan of care.
Based on interview, and record review facility failed to provide adequate supervision to prevent an elopement, investigate a fall and follow fall precautions in 4 of 8 residents, (R8, R15, R36, R78) reviewed for accidents/supervision, in a sample of 30.
Findings include:
1. R78's Progress Note, dated 3/24/2024 at 1:05 PM, documented, Resident eloped from building was spotted by the staff and brought back to facility. This nurse requested a shower and done a body assessment. Resident don't have any new open areas. And know has a wander guard on right wrist. Wife was notified and DON (Director of Nurses). Resident is safe.
The Final Investigative Report, dated 3/28/24, documented that at 11:09 AM on 3/24/2024, V1, Administrator was notified that V11, Certified Nurse's Assistant (CNA), who had left for her 15-minute break, found R78 off the facility premises at 11:06 AM. No initial injuries were noted, R78 was placed in V11's car and returned to the facility carrying a bible. V11 stated at first, R78 didn't want to get into the car because it smelled like cigarettes. After some talking she was finally able to talk him into getting into the car and she was able to return him to the facility. The building, R78's room and windows were checked for failures and were cleared. The windows were intact. All alarmed exit doors were checked and all alarms sounded when opened. The nurse completed a full body assessment with no injuries, open areas or bruising noted. Wife was made aware of elopement. Wander Guard placed on right wrist. R78 is a VA (Veteran) resident who is also diagnosed with dementia, he is able to carry a conversation but information given is not always appropriate. V1 spoke with R78 this morning and he believed he and his wife were at a fishing lodge staying in a cabin, he asked what cabin V1 was staying in. V1 explained I'm up front with administrator on the door. I ask him to stop and speak to me prior to leaving with his wife. He also explained to me how he was roller skating last night. He is very pleasant to speak with however very confused. Maintenance performs audits and audio checks of door alarms on a frequent basis to ensure alarms are performing as we would expect them to do when the door is opened. Camera review shows R78 walking up the 100 hall towards the lobby then entering the multipurpose room for a couple minutes then walking up to the front desk standing next to a visitor who was speaking to the receptionist. R78 then turned to his right and exited the building through the front door at 11:03 AM.
R78's Medical Diagnosis Listing, undated, documented that R78 has a diagnosis of Vascular Dementia, Cerebral Infarction and Wandering.
R78's Minimum Data Set (MDS), dated [DATE], documented that R78 has a BIMS (Brief Interview for Mental Status) score of 7, which is severe cognitive impairment.
R78's Elopement Assessment, dated 3/9/24, documented that R78 has potential or low risk for elopement.
R78's Elopement Assessment, dated 2/16/24, documented that R78 was at high risk for elopement.
R78's Care Plan, dated 3/26/24, documented that R78 was an elopement risk/wanderer related to impaired cognition and poor safety awareness. R78's care plan fails to document R78's elopement risk or interventions to prevent elopement prior to 3/26/24.
On 4/05/24 at 8:20 AM, V11, CNA, stated that she was not sure how R78 got out of the building. V11 stated that she lives right down the road from the facility and was heading home on her break around 11:00 AM to check things at her house. She continued to state that she saw R78 walking, picked him up and brought him back to the facility. V11 stated that R78 was not injured. V11 stated that R78 didn't say where he was going, he was just walking. V11 stated that R78 had not attempted to get out of the building before, he would wander throughout the building and go into other resident rooms.
On 4/05/24 at 8:35 AM, V1, Administrator, stated that R78 had not attempted to elope from the facility prior to his elopement. V1 stated that R78 stayed in his room or around the nurse's station. V1 stated that R78 was in the military and flew a plane prior to the age of 18. V1 stated that R78 was busy so they contacted his wife to find out what kind of things R78 would do to keep him busy and she (R78's wife) said that when R78 wouldn't really do anything, if he was bored, he would go rent a plane to fly. V1 stated that R78's wife brought him in some books yesterday and they give him things to work on, i.e. wheelchairs, etc. V1 stated that when R78 eloped, he did not have a wander guard at that time and that it was implemented after he eloped. V1 stated that the facility camera showed R78 standing at the front entrance/receptionist area, there was a visitor at the receptionist desk talking to the receptionist, R78 was standing between the visitor and the wall, turned and walked out of the front door. V1 stated that V11, CNA, saw R78 walking and picked him up. V1 stated that R78 did not get hurt. V1 stated that R78 has the wander guard now and that they keep him busy with different activities.
The Elopement Prevention Policy, dated 3/1/16, documented, The purpose of the policy is to establish guidelines ensuring that each resident is assessed to determine if they are at risk for elopement/flight and when determined to be at risk to ensure that they receive appropriate, individualized interventions to reduce that risk. Nothing in this policy is meant to provide assurances as to the ability of the facility to prevent an elopement from occurring. Elopement occurs when a resident leaves the facility without the expressed knowledge or approval of the facility or an authorized representative of the facility. Residents identified as being at risk will have an individualized plan of care developed and implemented that attempts to reduce their elopement or flight risk.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure foods were stored in a manner that prevents foodborne illness. This has the potential to affect all 81 residents livin...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure foods were stored in a manner that prevents foodborne illness. This has the potential to affect all 81 residents living in the Facility.
Findings include:
On 4/2/24 at 8:15 AM, in the standing refrigerator there were two pitchers containing a dark liquid that were not dated nor labeled. There were two individual cups with a brown creamy liquid inside that were dated 4-2 but did not document the contents inside. There were four sandwiches dated 3/31 that were not labeled. There were 24 individual cups with a clear liquid substance that were not labeled nor dated.
On 4/2/24 at 8:17 AM, bowls were stored in a plastic bin on a rack next to the toaster. The bowls were not covered nor stored upside down, potentially allowing debris from the toaster area to fall inside.
On 4/2/24 at 8:20 AM, the dry storage area had a pair of work boots in the corner of the room behind the can rack.
On 4/2/24 at 8:25 AM, the walk in refrigerator had a plastic container of a white creamy substance that was not labeled. There was a cylindrical loaf of processed meat in a pan and a loaf of fresh, unprocessed meat in a pan that were not labeled.
On 4/2/24 at 8:23 AM, the walk in freezer had a tray of nine individual bowls of rainbow sherbet that were not labeled nor dated. There was a plastic bag with meat patties and a plastic bag with ground meat that had been previously opened and resealed, but were not labeled nor dated. There was another tray with individual bowls of chocolate ice cream that were covered, but were not labeled nor dated.
On 4/2/24 at 8:48 AM, V4, Dietary Manager, stated that the patties in freezer were pepper patties and the ground meat was sausage for pizza. He stated he will get labels on them and will have staff get labels on the chocolate ice cream and sherbet.
On 4/2/24 at 4:10 PM, V1, Administrator, stated that she expects the facility to follow its food storage policies and label and date all foods.
The Facility's Food Receiving and Storage Policy, revised 7/2014, documented, Foods shall be received and stored in a manner that complies with safe food handling practices. It continues, All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).
The Facility's Refrigerators and Freezers Policy, revised 12/2014, documented, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. All food shall be appropriately dated to ensure proper rotation by expiration dates.
The Facility's Long-Term Care Facility Application for Medicare and Medicaid, dated 4/2/24, documented that there are 81 residents living in the facility.
Dec 2023
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to perform a safe and appropriate transfer for 1 of 3 residents (R14) ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to perform a safe and appropriate transfer for 1 of 3 residents (R14) reviewed for falls in the sample of 28. This failure resulted R14 obtaining a gash to head and sent out to hospital.
Findings include:
R14's Face Sheet documents R14 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, persistent vegetative state, chronic respiratory failure, tracheostomy status, multiple contractures, and bed confinement status.
R14's Minimum Data Set (MDS) dated [DATE] documented R14 required total dependence with 2+ person assistance for bed mobility and transfer.
R14's Care Plan initiated 8/17/21 documented R14 was dependent on staff for all ADL (Activities of Daily Living) needs related to suffering a closed head injury and remained in a non-verbal, vegetative state, responsive only to touch. The Care Plan documents R14 was at risk for fall and/or injury related to seizures.
R14's Fall Risk assessment dated [DATE] documented R14 was at High Risk for falls.
The Facility's Fall Log documents R14 fell during staff assist on 11/27/23.
R14's Fall Investigation by V13, (Licensed Practical Nurse/ LPN), on 11/27/23 at 2:06 PM documents V14's (CNA /Certified Nurse Aid) reported he fell out of bed during patient care and has a dash (gash) on his right forehead. The investigation documented R14 was unable to respond and had a laceration to the top of his scalp.
R14's Late Entry Progress Note dated 11/27/23 at 3:15 AM documents, The cna (CNA) informed this nurse during patient care that the resident fell out of bed. Resident has a dash to the r/t (right) side of his forehead, resident unable to speak to determine any pain, resident was transported to (Hospital) via EMT (Emergency Medical Technician) around 3:15 pm for further eval (evaluation), vitals were taken and his POA (Power of Attorney) were notified.
R14's Hospital Records from 11/27/23 admission document R14 had superficial lacerations to forehead and right parietal scalp.
R14's Care Plan revision on 11/27/23 documents, Educate staff that resident is 2 assist with patient care and transfers.
On 12/5/23 at 10:20 AM, V3 (Social Services Director) stated R14 was usually lying in bed in the same position, and she had never seen him move about in his bed.
On 12/5/23 at 10:39, V1 ( Administrator), stated V14 (CNA) turned R14 over during incontinent care, and he rolled out of bed.
On 12/5/23 at 10:42 AM, V13 (LPN) stated R14 should have had two people with him during care.
On 12/5/23 at 11:05 AM, V11 (LPN) stated R14 has a brain injury and requires total care with two person assistance for turning, repositioning, and transfer.
On 12/5/23 at 11:32 AM, V14 (CNA) stated she was changing R14 by herself, and when she turned him onto his left side he started coughing really hard and just rolled off onto the floor. She stated she always performed care on R14 by herself in the past, but now he is a two person assist.
On 12/5/23 at 11:45 AM, V2 (Director of Nursing /DON), stated V14 was cleaning R14, and R14 ended up on the floor. V2 stated he would have expected two CNA's to have been providing care to R14.
On 12/5/23 at 1:30 PM, V1 stated she would expect two people to have been assisting R14 with care at the time of his fall. V1 stated the Facility does not have a policy regarding falls.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to protect residents from abuse for 6 of 6 residents (R1, R2, R4, R1...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to protect residents from abuse for 6 of 6 residents (R1, R2, R4, R11,R12, R13) reviewed for abuse in the sample of 28.
Findings include:
1. R11's Final IDPH Abuse Investigation dated 11-6-2023 documents at approximately 3 pm V1 (Administrator) was notified by agency Licensed Practical Nurse (LPN) (V18) who witnessed R11 caressing the buttocks and thigh of R12 as she laid in bed sleeping.
R11's Physician Order Summary (POS) undated documents R11's pertinent medical Diagnosis as Paranoid Schizophrenia, Major Depressive Disorder, Recurrent, Unspecified and Mild Intellectual Disabilities.
R11's Minimum Data Set (MDS) dated [DATE] documents R11 is cognitively intact; does not exhibit any indicators of psychosis (e.g. hallucinations or delusions); no physical or verbal behavioral symptoms exhibited; no behavioral symptoms directed towards others exhibited and no wandering behaviors exhibited.
R11's Criminal history background Report dated 4/3/19 documents that R11 had charges of Aggravated Sexual Assault (1989-sentenced to (6) six years in prison); violation-Sex Offender Registration (1999-sentenced to (1) one year Conditional Discharge) and Failure to Report Change of Address (2005-Sentenced to 90 days in jail and 2 years probation.
R11's Criminal History background Report dated 4/3/19 documents that R11 is low risk depended upon his medical condition, satisfactory behaviors since admission and no recent criminal history, (R11) was assessed to not pose a threat to others in the nursing facility.
R12's Minimum Data Set (MDS) dated [DATE] documents R12 has moderate cognitive impairment; does not exhibit any indicators of psychosis (e.g. hallucinations or delusions); no physical or verbal behavioral symptoms exhibited; no behavioral symptoms directed towards others exhibited and no wandering behaviors exhibited.
R12's Physician Order Summary undated documents R12's pertinent medical diagnosis as Senile Degeneration of Brain, not Elsewhere Classified; Unspecified Dementia Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance,and Anxiety; Cognitive Communication Deficit; Bipolar II Disorder ; Generalized Anxiety Disorder.
On 11/7/23 when interviewed by V1, R11 denied rubbing R12's body at all. He stated he had gone in her room to give her a dollar.
On 11/30/23 at 1:20 PM, V28 (Certified Nursing Assistant/CNA) stated R11 is quiet and socializes with all the residents. Is unaware of any inappropriate behaviors.
On 12/5/23 at 8:00 AM, V14 (CNA) stated she heard that R11 was observed in R12's room, but had not witnessed R11 in any residents room unless he was pushing them to their rooms. Have not witnessed any negative behaviors.
On 12/5/23 at 9:58 AM, V3 (Social Worker) stated R11 admitted to being in R12 's room. When asked about the incident R11 stated No, that's what they said. So I guess so. Facility has not had a problem with R11 going into residents' rooms. R11 was in a group home prior to coming to this facility. He did not return to the group home after the surgery on his hips because they said they could not meet his medical needs. I am unaware if there were any incidents of inappropriate behaviors in the group home.
On 12/5/23 at 10:26 AM, V1 stated R11 has been in the facility since 11/2021 and has not caused any problems and has always acted the same. R11 walks constantly in the hallways and to the dining room. There are no reports that he has been going in other resident rooms. R11 helps the other residents like going to get things for them. There have been no behaviors reported at all until this incident. R11 is not on probation or parole and is not required to report to law enforcement.
On 12/5/23 at 3:00 PM, R11 denied touching R12 but admits to being in her room. States this was the first time he went into R12's room or any other residents room without their permission. R11 states he talks to all the residents. Denies that he is in a relationship with R12.
On 12/5/23 at 2:29 PM, V16 (CNA) stated she had not observed any inappropriate behaviors from R11.
On 12/7/23 at 1:18 PM, V24 (Activity Director) stated R11 is laid back and basically truthful. R11 is real helpful to other residents by pushing them in their wheelchair, go getting them coffee, etc. R11 has not been observed cross or upset with the other residents. When the other residents are acting out, R11 moves away from them. I have not heard or seen any inappropriate behaviors.
On 12/7/23 at 3:03 PM, V21 (CNA) stated she works evening and night shift and have not observed any inappropriate behaviors from R11.
On 12/8/23 at 8:05 AM, V19 (LPN) stated R11 has never bothered anyone. R11 often pushes residents in their wheelchair, gets them coffee and does other things for the residents. R11 was on what is considered the women's hall for a long time and did not have any incidents. R11 is mentally limited; uncertain as to why he was moved from the group home to the facility. Staff are aware of R11's sexual abuse history and do monitor him and have not observed any inappropriate behaviors in R11.
Attempts were made during this investigation to contact V18 and were unsuccessful.
2. R1's Final Abuse Investigation dated 11/15/23 documents at approximately 5:30pm V1 (Administrator) was notified by V2 (Director of Nursing/DON) that there had been a non-injury Resident to Resident between R1 and R4 in the dining room. The DON stated that R1 was hollering out when R4 walked by R1 and told R1 to shut up. R1 called him a derogatory name, R4 stopped and swatted at R1, staff intervened and residents were separated.
R1's Physician Order Summary undated documents R1's medical diagnosis as Alzheimer's Disease with Late Onset, Schizoaffective Disorder, Bipolar Type, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with Other Behavioral Disturbance.
R1's Minimum (MDS) dated [DATE] documents R1 has moderate cognitive impairment; no physical or behavioral symptoms of psychosis; no physical behaviors but verbal behavioral symptoms exhibited daily; wandering behavior exhibited 1-3 days.
R4's Physician Order Summary undated documents R4's pertinent medical diagnosis as Violent Behavior, Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Wandering in Diseases, classified Elsewhere.
R4's Minimum Data Set (MDS) dated [DATE] documents R4 is moderately impaired for Cognitive Skills for Daily Decision Making; R4 exhibits inattention and disorganized thinking behavior was continuously present and does not fluctuate; physical and verbal behavioral symptoms occurred 1-3 days; Other behavior symptoms not directed towards others such as hitting or scratching himself, pacing, rummaging, public sexual acts, disrobing in public, throwing or screaming, disruptive sounds was documented.
On 12/8/23 at 8:05 AM, V19 (Licensed Practical Nurse/LPN) stated R4 had never paid any attention to R1 until she yelled at him and called him a N------. R1 walks all the time and does have behaviors of yelling and screaming. Most of the residents ignore her but R4 responded to her this time by hitting her.
3. R2's Final Investigation dated 10/20/23 documents at approximately 12 pm V1 (Administrator) was notified by V29 (Ombudsman) that R4 had sent her a video which may be a public site with videos of the facility's residents. The Power of Attorney (POA) voiced concern that it would viewed by someone that might recognize R4 and call the facility. The video showed R4 wandering around the dining room holding a fork. R4's face was clearly visible and R4 was yelling and cursing calling R2 names. R4 appeared to respond at one point but his response was unable to be heard.
R2's Physician Order Summary undated documents R2's medical diagnosis as Bipolar disorder, Unspecified Major Depressive Disorder, Recurrent Severe Major Depressive Disorder, Recurrent Severe without Psychotic Features, Post- Traumatic Stress Disorder, Unspecified Hallucinations, Unspecified Antisocial Personality Disorder.
R2's Minimum (MDS) dated [DATE] documents moderate cognitive impairment; no physical or behavioral symptoms of psychosis; no physical behaviors but verbal behavioral symptoms exhibited daily; wandering behavior exhibited 1-3 days.
On 11/21/23 at 2:54 PM, R2 stated he video-taped R4 because he feared for his safety and if anything happened to him, his (R2's) family will know who caused him harm. R2 stated R4 was videotaped twice. Once when he tried to come into R2's room and in the dining room when R4 approached R2 with a fork.
4. A Final IDPH investigation dated 10/8/23 documents at approximately 1:20 PM on 10/8/23 an agency employee reported that there had been an altercation between 2 residents in the dining room where they had hit each other. (R13) was frustrated that R4's wander guard was alarming as he was going out to smoke and turned around and hit R4; then they exchanged swings until staff intervened.
R13's Physician Order Summary undated documents R13's pertinent medical diagnosis as Bipolar Disorder, unspecified and Cognitive Communicative Deficit.
On 12/5/23 at 3:32 pm R13 who was alert to person, place and time stated R4 had attacked him several times and they were unprovoked attacks. R13 had no idea why R4 attacked him. R13 stated R4 rubbed up against him and it pissed him (R13) off. R13 did not know if R4 was getting off on it or not but he (R13) don't like that F----t s--t! R13 stated R4 had not done anything like that before but everyone knew he was a F----t.
5. R4's Nurse's Progress Notes dated 7/6/23 documents R4 was re-admitted to the facility 7/6/23.
R4's Nurse's Progress noted dated 7/8/23 documents a Resident - staff altercation when R4 was physically aggressive towards staff. R4 punched the staff stated in the chest when attempting to get him toileted and dressed.
R4's Nurse's Progress notes dated 7/23/23 documents a Resident -Staff altercation. During morning med pass around 0815 R4 punched a staff member in the jaw during care. Staff were attempting to toilet and dress where R4 continued being physically aggressive.
R4's Nurse Progress Notes dated 7/28/23 documents a Resident-Staff altercation. R4 became very aggressive, kicking and swinging during incontinent care. After leaving R4's room R4 proceeded to follow the staff member out the room and down the hall, where staff made several attempts to go around resident. Staff member was walking down the hall when R4 struck the staff in the back of the head from behind.
R4's Nurse Progress Notes dated 8/15/23 documented R4 kicked a staff member in face. Resident is combative while changing clothing.
R4's Nurse Progress Notes dated 8/19/23 documents a Resident-Staff altercation. R4 began to swing and tried to hit staff member at this time because staff member was walking to slow.
R4's Nurse Progress Notes dated 10/8//23 documents a Resident-Resident altercation. R4 was fighting with another resident in the dinner room, staff separate residents but the other resident refuse to leave the dinner room because it was time to smoke.
R4's Nurse Progress Notes dated 10/12/23 documents a Resident-Resident altercation when R4 was taken out the dining room by two staff members related to splitting food on residents and staff members faces. Resident to Staff altercation occurred when staff were trying to redirect resident, R4 struck the nurse in face with a closed fist.
On 12/5/23 at 10:26 AM, V1 stated in the altercation with R1, (R4) was triggered by R1 loudly screaming and name calling. In the altercation between R4 and R13. R13 was the aggressor and R4 was defending himself. R4 does have history of violent behavior but staff are doing better with him. R4 was Care Planned for his aggressive behaviors.
R4's Care Plan dated 9/20/23 documents R4 is at risk to be physically aggressive/cause harm to others related to Dementia, History of harm to others, Poor impulse control 09/09/2023, Notify Administrator/DON/POA. Deescalate the situation with one on one, separate residents 15 min face checks. Another resident struck him; 10/08/2023, Notify Administrator/DON/POA. Remove him to a quieter environment another resident hit him and he returned hit. 10/20/2023 Staff to remove silverware from tables as soon as residents are done eating. If R4 is noted to be walking around with silverware in hand, get him to give it to you and then take to the kitchen. 11/16/2023, He hit another resident Send to Armed services hospital psych. ward Notify Administrator of occurrence.
There was no Behavioral Tracking of R4's behaviors in R4's Clinical Records.
The facility policy Abuse Prevention Program with a revision date 2/2023 documents in part, This facility affirms the right of our residents to be free from abuse (verbal, mental, sexual, or physical), neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical and chemical restraints that are not required to treat a resident's medical symptoms. This facility therefore prohibits acts of mistreatment, neglect, abuse and/or crimes from being committed against its residents. This facility desires to establish a resident sensitive and resident secure environment
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer medications as ordered by the physician resulting in resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer medications as ordered by the physician resulting in residents receiving scheduled medications outside of the prescribed period for 4 of 4 residents (R2, R3, R4, R5) reviewed for medications in a sample of 28.
Findings include:
1. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact; has verbal behaviors directed toward others (e.g. threatening others, screaming at others, cursing at others) that occurred daily. R2's behavior significantly affects his care and his behavior significantly affects his participation in social interactions and activities; significantly disrupt care or living environment; R2's behavior is described as worse. R2's Electronic Medication Administration Record (eMAR) for November 2023 documents pertinent diagnosis as Post Traumatic Stress Disorder (PTSD) and Impulse Disorder and Bipolar.
R2's Physician Order Sheet (POS) undated documents an order for Furosemide 20 mg 1 tab daily for bilateral lower extremities edema with a start date of 11/30/23; Ibuprofen 600 mg every 6 hours as needed,for pain with a start date of 11/7/23; Novolog Injection Solution, 100 Unit/ml 5 Units subcutaneously with meals for hyperglycemia; Novolin R Injection Solution 100 Unit/mL per Sliding Scale before meals for hyperglycemia with a Start Date 10/11/23; Insulin Glargine 100 Unit/mL 26 Units for hyperglycemia with a Start Date 10/11/23; Quetiapine Fumarate 400 mg (0.5 tablet at bedtime) for behaviors with a Start Date 10/2/23; Hydrocodone-Acetaminophen 5-325 mg every 8 hours for pain with a Start Date 8/29/23; Accu-checks every morning and at bedtime with a Start Date 9/26/23; Tylenol 325 mg 2 tabs every 6 hours as needed for a pain with a Start Date 8/27/23; Prednisone 20 mg 1 tab daily for inflammation with a Start Date 8/13/23; Ferrous Sulfate 325 (65 Fe) mg 1 tablet daily for supplement with a Start Date 8/13/23; Metformin 500 mg 1 tab daily for diabetes with a Start Date 8/13/23; Oxcarbazepine 600 mg twice a day for seizures with a Start Date of 8/12/23; Metoprolol 50 mg (0.5 tablet) twice a day for Hypertension with a Start Date 8/12/23; Accuchecks four times a day with a Start Date 8/12/23; Allopurinol 100 mg 2 tablets daily for gout with a Start Date 8/13/23 and Atorvastatin 80 mg (0.5 tablet in the evening) to lower Cholesterol with a Start Date 8/12/23.
On 11/21/23 at 2:54 PM, R2 stated, I don't have an issue with medications.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Novolog Injection Solution 100 Unit/ML (Insulin Regular) inject as per sliding scale at 11:00 AM. R2's eMAR dated 11/6/23 documents received 11 units of Novolog- Regular at 2:06 PM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Novolog Injection Solution 100 Unit/ML (Insulin Aspart) inject 5 unit subcutaneously with meals at 12:00 AM. R2's eMAR dated 11/6/23 documents received 5 units of Novolog- Aspart at 2:14 PM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Metoprolol 50 mg (Give 0.5 tablet) at 4:00 PM. R2's eMAR dated 11/6/23 documents received Metoprolol 50 mg (Give 0.5 tablet) at 9:10 PM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Atorvastatin 80 mg (Give 0.5 tablet) at 4:00 PM. R2's eMAR dated 11/6/23 documents received Atorvastatin 80 mg (Give 0.5 tablet) at 9:10 PM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Oxcarbazepine 600 mg at 4:00 PM. R2's eMAR dated 11/6/23 documents R2 received Oxcarbazepine 600 mg at 9:10 PM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Novolog Injection Solution 100 Unit/ML (Insulin Regular) inject as per sliding scale at 7:00 AM. R2's eMAR dated 11/6/23 documents received 4 units of Novolog- Regular at 10:09 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Allopurinol 100 mg (give 2 tablets) at 8:00 AM. R2's eMAR dated 11/7/23 documents R2 received Allopurinol 100 mg x's 2 at 10:13 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Metoprolol 50 mg (give 0.5 tablet) at 8:00 AM. R2's eMAR dated 11/7/23 documents R2 received Allopurinol 100 mg at 10:13 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Novolog Injection Solution 100 Unit/ML (Insulin Aspart) inject 5 unit subcutaneously with meals at 8:00 AM. R2's eMAR dated 11/7/23 documents received 5 units of Novolog- Aspart at 10:09 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Oxcarbazepine 600 mg at 8:00 AM. R2's eMAR dated 11/7/23 documents R2 received Oxcarbazepine 600 mg at 10:13 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Metformin 500 mg at 8:00 AM. R2's eMAR dated 11/7/23 documents R2 received Metformin 500 mg at 10:13 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Ferrous Sulfate 325 (65 Fe) mg at 8:00 AM. R2's eMAR dated 11/7/23 documents R2 received Ferrous Sulfate 325 (65 Fe) mg at 10:13 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Prednisone 20 mg at 8:00 AM. R2's eMAR dated 11/7/23 documents R2 received Prednisone 20 mg at 10:13 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Metoprolol 50 mg (give 0.5 tablet) at 8:00 AM. R2's eMAR dated 11/8/23 documents R2 received Metoprolol 50 mg (give 0.5 tablet) at 10:25 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Allopurinol 100 mg (give 2 tablets) at 8:00 AM. R2's eMAR dated 11/7/23 documents R2 received Allopurinol 100 mg x's 2 at 10:25 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Novolog Injection Solution 100 Unit/ML (Insulin Aspart) inject 5 unit subcutaneously with meals at 8:00 AM. R2's eMAR dated 11/8/23 documents received 5 units of Novolog- Aspart at 10:25 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Prednisone 20 mg at 8:00 AM. R2's eMAR dated 11/8/23 documents R2 received Prednisone 20 mg at 10:25 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Ferrous Sulfate 325 (65 Fe) mg at 8:00 AM. R2's eMAR dated 11/7/23 documents R2 received Ferrous Sulfate 325 (65 Fe) mg at 10:25 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Metformin 500 mg at 8:00 AM. R2's eMAR dated 11/8/23 documents R2 received Metformin 500 mg at 10:25 AM.
R2's Physician Order Summary Report undated documents R2 was scheduled to receive Oxcarbazepine 600 mg at 8:00 AM. R2's eMAR dated 11/8/23 documents R2 received Oxcarbazepine 600 mg at 10:25 AM.
R2's Behavioral Monitoring note dated 11/15/23 documents R2 exhibited behaviors of being aggressive and verbally abusive towards staff.
2. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively intact; has not exhibited any hallucinations or delusions, has not exhibited any physical or verbal behaviors and has not had any rejection of care. R3's (eMAR) dated November 2023 documents R3's pertinent medical diagnosis as Systemic Lupus Erythematous, Unspecified ; Sarcoidosis, Uspecified Schizoaffective Disorder, Bipolar Type, Anxiety Disorder, Unspecified; Polyneuropathy, Unspecified; Polyosteoarthritis, Unspecified.
R3's Physician Summary Order (POS) undated documents orders for the medications Lidoderm Patch 5% on for 12 hours and off for 12 hours for pain with a Start Date of 12/10/23; Artificial Tears Solution 1.4% , 2 drops twice daily for Dry eyes with a Start date 12/9/23; Paliperidone 6 mg 1 tab daily for restlessness with a Start Date 10/4/23; Busperidone 7.5 mg every morning and at bedtime for Anxiety with a Start Date of 11/2/23; Meclizine 25 mg 1 tablet every 8 hours as needed for dizziness with a Start Date 11/29/23; Norco (Hydrocodone-Acetaminophen) 7.5-325 mg every 4 hours for Chronic Pain with Start Date 11/1/23; Simethicone 180 mg 1 tablet with meals for gas pains with Start Date 11/1/23; Trazedone 100 mg 1 tablet at bedtime for insomnia with a Start Date 11/1/23; Lyrica 100 mg 1 capsule every 8 hours for polyneuropathy; Prednisone 10 mg 1 tablet a day for Lupus with a Start Date 11/3/23; Senna 8.6-50 mg 2 tablets twice a day as needed for constipation with a Start Date 10/24/23; Glycolax 17 gm once per day for constipation with a Start Date 10/25/23; Ibuprofen 600 mg 1 tablet every 8 hours for chronic pain with a Start Date 10/17/23; Hydroxyzine 25 mg 1 tablet 3 times per day for restlessness; Ativan 1 mg 1 tablet a bedtime for anxiety with a Start Date 10/3/23; Albuterol 2 puffs every 4 hours for shortness of breath with a Start Date 9/28/23; Hydroxychloroquine 200 mg 1 tablet a day for Lupus with a Start Date 9/29/23; Nifedipine ER 60 mg 1 tablet daily for hypertension with a Start Date 9/29/23; Ferrous 324 (38 Fe) mg for supplementation 1 tablet daily with a Start Date 9/29/23; Clopidogrel 75 mg 1 tablet a day for prophylaxis with Start Date 9/29/23; Chlorothalide 25 mg 1 tablet a day for hypertension with a Start Date 9/29/23; Losartan Potassium 100 mg 1 tablet a day for hypertension with a Start Date 9/29/23; Odansetron 4 mg 1 tablet every 6 hours as needed for nausea with a Start Date 10/10/23.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 12:00 PM. R3's eMAR dated 11/5/23 documents R3 received Norco 7.5-325 mg at 2:00 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 4:00 PM. R3's eMAR dated 11/5/23 documents R3 received Norco 7.5-325 mg at 7:27 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Hydroxyzine 25 mg at related to Schizoaffective Disorder, Bipolar Type, Anxiety Disorder Unspecified at 12:00 PM. R3's eMAR dated 11/5/23 documents R3 received Hydroxyzine 25 mg at 2:00 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Hydroxyzine 25 mg at related to Schizoaffective Disorder, Bipolar Type, Anxiety Disorder Unspecified at 4:00 PM. R3's eMAR dated 11/5/23 documents R3 received Hydroxyzine 25 mg at 7:28 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Hydroxyzine 25 mg at related to Schizoaffective Disorder, Bipolar Type, Anxiety Disorder Unspecified at 4:00 PM. R3's eMAR dated 11/6/23 documents R3 received Hydroxyzine 25 mg at 9:21 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 4:00 PM. R3's eMAR dated 11/6/23 documents R3 received Norco 7.5-325 mg at 9:19 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 8:00 PM. R3's eMAR dated 11/6/23 documents R3 received Norco 7.5-325 mg at 9:19 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 12:00 AM. R3's eMAR dated 11/7/23 documents R3 received Norco 7.5-32 at 2:44 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 4:00 AM. R3's eMAR dated 11/7/23 documents R3 received Norco 7.5-325 mg at 5:58 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Hydroxyzine 25 mg at related to Schizoaffective Disorder, Bipolar Type, Anxiety Disorder Unspecified at 4:00 PM. R3's eMAR dated 11/7/23 documents R3 received Hydroxyzine 25 mg at 6:03 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 4:00 PM. R3's eMAR dated 11/7/23 documents R3 received Norco 7.5-325 mg at 6:03 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Hydroxychloroquine Sulfate 200 mg one time a day for Lupus at 8:00 AM. R3's eMAR dated 11/8/23 documents R3 received Hydroxychloroquine Sulfate 200 mg at 10:12 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Paliperidone ER 6 mg at related to Schizoaffective Disorder, Bipolar Type, at 8:00 AM. R3's eMAR dated 11/8/23 documents R3 received Paliperidone ER 6 mg at 10:12 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Hydroxyzine 25 mg at related to Schizoaffective Disorder, Bipolar Type, Anxiety Disorder Unspecified at 8:00 AM. R3's eMAR dated 11/8/23 documents R3 received Hydroxyzine 25 mg at 10:11 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 12:00 PM. R3's eMAR dated 11/8/23 documents R3 received Norco 7.5-325 mg at 2:00 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Buspirone 7.5 mg at related to Anxiety Disorder Unspecified at 8:00 AM. R3's eMAR dated 11/8/23 documents R3 received Buspirone 7.5 mg at 10:11 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Lidoderm Patch 5% for pain 8:00 AM. R3's eMAR dated 11/8/23 documents R3 received Lidoderm Patch 5 % at 10:11 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Prednisone 10 mg for inflammation at 8:00 AM. R3's eMAR dated 11/8/23 documents R3 received Prednisone 10 mg at 10:11 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 12:00 AM. R3's eMAR dated 11/10/23 documents R3 received Norco 7.5-325 mg at 6:47 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 4:00 AM. R3's eMAR dated 11/10/23 documents R3 received Norco 7.5-325 mg at 6:46 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Lidoderm Patch 5% for pain 8:00 AM. R3's eMAR dated 11/13/23 documents R3 received Lidoderm Patch 5 % at 10:39 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 12:00 PM. R3's eMAR dated 11/13/23 documents R3 received Norco 7.5-325 mg at 3:07 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Hydroxyzine 25 mg at related to Schizoaffective Disorder, Bipolar Type, Anxiety Disorder Unspecified at 12:00 PM. R3's eMAR dated 11/13/23 documents R3 received Hydroxyzine 25 mg at 3:07 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Hydroxyzine 25 mg at related to Schizoaffective Disorder, Bipolar Type, Anxiety Disorder Unspecified at 4:00 PM. R3's eMAR dated 11/13/23 documents R3 received Hydroxyzine 25 mg at 7:41 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 4:00 PM. R3's eMAR dated 11/13/23 documents R3 received Norco 7.5-325 mg at 7:40 PM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 12:00 AM. R3's eMAR dated 11/14/23 documents R3 received Norco 7.5-325 mg at 3:17 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 4:00 AM. R3's eMAR dated 11/14/23 documents R3 received Norco 7.5-325 mg at 3:17 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 12:00 AM. R3's eMAR dated 11/15/23 documents R3 received Norco 7.5-325 mg at 3:28 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 4:00 AM. R3's eMAR dated 11/15/23 documents R3 received Norco 7.5-325 mg at 3:28 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 12:00 AM. R3's eMAR dated 11/16/23 documents R3 received Norco 7.5-325 mg at 6:08 AM.
R3's Physician Order Summary Report undated documents R3 was scheduled to receive Norco 7.5-325 mg every 4 hours for pain related to Chronic Pain at 4:00 AM. R3's eMAR dated 11/16/23 documents R3 received Norco 7.5-325 mg at 6:08 AM.
R3 received 4 doses of Norco (11/6, 11/10, 11/15, 11/16) less than 4 hours apart.
On 11/21/23 at 10:24 AM, V10 (Pharmacist) stated administration of the Norco 7.5/325 mg in less than the ordered time of every four hours is not necessarily ideal but will not cause a problem but can increase lethargy, drowsiness and confusion.
On 12/7/23 at 9:07 AM, V9 (Pain Management Nurse Practitioner) stated she was the Pain Management Nurse Practitioner for R3. Just took recent X-rays for R3 and indicated the need for current pain medication regiment. R3 would also have some pain associated with the Lupus. V9 stated she was unaware of the medication administration of the Norco not being administered as ordered, every 4 hours. V9 stated she indicates on her orders if a resident wants to be awaken for medication. If a resident misses a dose because they are sleeping, then they miss a dose and is not supposed to be getting a double dose of the medication.
3. R4's Minimum Data Set MDS dated [DATE] documents R4 is moderately impaired for Cognitive Skills for Daily Decision Making; R4 inattention and disorganized thinking behavior was continuously present and does not fluctuate; physical and verbal behavioral symptoms occurred 1-3 days; exhibited behavior symptoms not directed towards others such as hitting or scratchingmself, pacing, rummaging, public sexual acts, disrobing in public, throwing or screaming, disruptive sounds; R4 did exhibit rejection of care 1 to 3 days; wandering behavior of this type occurred 1 to 3 days.
R4's Physician Order Summary (POS) undated documents R4's pertinent active diagnosis as Violent Behavior, Bipolar Disorder, Unspecified Dementia, unspecified severity without behaviors, psychosis/mood/anxiety, wandering in diseases, classified elsewhere, violent behavior and Alcohol Dependence with withdrawal, Delirium.
R4's (POS) undated documents medication orders for Amlodipine 10 mg 1 tablet a day for hypertension with a Start date 10/26/23; Aspirin 81 mg 1 tablet a day related to Chronic Systolic (Congestive) Heart Failure with a Start Date 10/26/23; Atorvastatin 40 mg 1 tablet at bedtime for high cholesterol with a Start Date 10/26/23; Cholecalciferol 100 mcg 1 tablet every day shift for supplementation with a Start Date 10/26/23; Escitalopram 10 mg 1 tablet daily for Behaviors with a Start Date 10/26/23; Lisinopril 20 mg (give 0.5 tablet) 1 tablet a day for hypertension with a Start Date 10/26/23; Melatonin 5 mg 1 tablet a bedtime for insomnia with a Start Date 10/25/23;; Multivitamin 1 tablet daily for supplementation with a Start Date 10/26/23; Polyethylene Glycol 17 grams daily for constipation with a Start Date 10/26/23; Trazodone 50 mg 1 tablet twice a day for Behaviors with a Start Date 10/25/23; Gabapentin 400 mg three times per day for seizures with a Start Date 10/19/23; Olanzapine 10 mg (give 0.5 tablet) 3 times per day for Bipolar with a Start Date 10/19/23.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Cholecalciferol 100 mcg at 6:30 AM. Electronic Medication Administration Record (eMAR) dated 11/5/23 documents R4 received Cholecalciferol 100 mcg at 9:08 AM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Aspirin 81 mg at 8:00 AM. Electronic Medication Administration Record (eMAR) dated 11/5/23 documents R4 received Aspirin 81 mg at 2:50 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Trazodone 50 milligram (mg) at 8:00 AM. Electronic Medication Administration Record (eMAR) dated 11/5/23 documents R4 received Trazodone 50 mg at 2:50 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Multiple Vitamins-Minerals at 8:00 AM. Electronic Medication Administration Record (eMAR) dated 11/5/23 documents R4 received Multiple Vitamins-Minerals at 2:50 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive/ Polyethylene Glycol 3350 Powder 30 milliliters (ml) at 8:00 AM. Electronic Medication Administration Record (eMAR) dated 11/5/23 documents R4 received Polyethylene Glycol 3350 Powder 30 milliliters (ml) at 2:50 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Amlodipine 10 milligram (mg) at 8:00 AM. Electronic Medication Administration Record (eMAR) dated November 2023 documents R4 received Amlodipine 10 mg at 2:50 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Lisinopril 20 mg (give 0.5 tablet) at 8:00 AM. Electronic Medication Administration Record (eMAR) dated November 2023 documents R4 received Lisinopril 20 mg (give 0.5 tablet) at 2:50 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Olanzapine 10 mg (give 0.5 tablet) at 4:00 PM. Electronic Medication Administration Record (eMAR) dated 11/5/23 documents R4 received Olanzapine 10 mg (give 0.5 tablet) at 7:29 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Gabapentin 400 mg at 4:00 PM. Electronic Medication Administration Record (eMAR) dated November 2023 documents R4 received Gabapentin 400 mg at 7:29 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Trazodone 50 mg at 4:00 PM. Electronic Medication Administration Record (eMAR) dated November 2023 documents R4 received Trazodone 50 mg at 7:29 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Olanzapine 10 mg (give 0.5 tablet) at 4:00 PM. Electronic Medication Administration Record (eMAR) dated 11/6/23 documents R4 received Olanzapine 10 mg (give 0.5 tablet) at 9:21 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Gabapentin 400 mg at 4:00 PM. Electronic Medication Administration Record (eMAR) dated 11/6/23 documents R4 received Gabapentin 400 mg at 9:21 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Trazodone 50 mg at 4:00 PM. Electronic Medication Administration Record (eMAR) dated 11/6/23 documents R4 received Trazodone 50 mg at 9:21 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Cholecalciferol 100 mcg at 6:30 AM. Electronic Medication Administration Record (eMAR) dated 11/8/23 documents R4 received Cholecalciferol 100 mcg at 9:01 AM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Melatonin 5 mg at 8:00 PM. Electronic Medication Administration Record (eMAR) dated 11/12/23 documents R4 received Melatonin 5 mg at 9:51 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Olanzapine 10 mg (give 0.5 tablet) at 8:00 PM. Electronic Medication Administration Record (eMAR) dated 11/12/23 documents R4 received Olanzapine 10 mg (give 0.5 tablet) at 9:51 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Atorvastatin 40 mg at 8:00 PM. Electronic Medication Administration Record (eMAR) dated 11/12/23 documents R4 received Atorvastatin at 9:51 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Olanzapine 10 mg (give 0.5 tablet) at 4:00 PM. Electronic Medication Administration Record (eMAR) dated 11/13/23 documents R4 received Olanzapine 10 mg (give 0.5 tablet) at 7:42 PM.
R4's Physician Order Summary Report undated documents R4 is scheduled to receive Gabapentin 400 mg at 4:00 PM. Electronic Medication Administration Record (eMAR) dated 11/13/23 documents R4 received Gabapentin 400 mg at 7:42 PM.
4. R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact, has not exhibited any behaviors and is totally dependent.
R5's Physician Summary Order undated documents R5's pertinent diagnosis are Long-term (current) Use of Anticoagulants, Resistant to Multiple Antimicrobal Drugs, Other Muscle Drugs Spasm, Quadriplegia, Neuromuscular Dysfunction of Bladder, Pressure Ulcer on Right Buttock, Fusion of Spine, Spinal Stenosis and Slow Transit Constipation.
R5's Physician Summary Order undated documents medication orders Amlodipine 5mg 1 tablet daily for hypertension with a Start Date 8/30/23; Aspirin 81 mg 1 tablet daily for cardiovascular with a Start Date 8/30/23; Cholecalciferol 25 mcg supplementation 1 tablet daily with Start Date 8/30/23; Loratadine 10 mg 1 tablet a day for allergies with a Start Date 8/30/23; Melantonin 5 mg 1 tablet at bedtime for insomnia with a Start Date 8/30/23; Prevastatin 40 mg 1 tablet at bedtime for cholesterol with a Start Date 8/30/23; Prucalopride 2 mg 1 tablet daily for constipation with a Start Date 8/30/23; Warfarin 3 mg 1 tablet at bedtime for blood thinner with a Start date of 9/9/23; Wafarin 0.5 mg 1 tablet at bedtime for blood thinner with a Start Date 10/21/23; Ciprofloxacin 750 mg 1 tablet twice a day for UTI with a Start Date 11/15/23; Famotidine 20 mg 1 tablet 2 times a day for stomach acids with a Start Date 8/30/23; Hiprex 1 gram 2 times a day for UTI with a Start Date 8/30/23; Metronidazole 500 mg 2 times a day for UTI with a Start Date 11/15/23; Polyethylene Glycol 17 grams 2 times a day for constipation with a Start Date of 8/30/23; Saccharomyces 250 mg 2 times a day for probiotic with a Start Date 8/30/23; Senna 8.6-50 mg 2 tabs 2 times a day for constipation with a Start Date 8/30/23; Vitamin C 1000 mg 2 times per day for UTI with a Start Day 8/30/23; Baclofen 5 mg 1 tablet 3 times a day for neck pain with Start date 8/30/23; Hydralazine 25 mg 1 tablet 3 times a day for hypertension with a Start Date 8/30/23; Protein Oral 30 ml 3 times a day for wound healing with a Start Date 10/9/23; Reglan 5 mg 1 tablet 3 times a day for GERD with a Start Date 8/30/23; Acetaminophen 325 mg 2 tabs every 6 hours for headaches with a Start Date 8/29/23; Albuterol 2 puffs every 6 hours as needed for wheezing/ shortness of breath with a Start Date 8/29/23; Fleet enema 7-19 gm/118 ml, insert 118 ml rectally every 24 hours, as needed for constipation with a Start Date 9/15/23; Magnesium Citrate 296 ml as needed for constipation with a Start Date 8/29/23; Oxybutynin 5 mg 1 tab every 8 hours as needed for hyperactive bladder with a Start Date 8/29/23; Phenazopyridine 100 mg 1 tablet every 8 hours as needed for pain with a Start Date 8/29/23; Simethicone 125 mg 1 tablet every 6 hours as needed for flatulence with a Start Date 8/29/23; Terazosin 1 mg tablet every 8 hours as needed for hypertension with a Start Date 8/29/23.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Loratadine 10 mg at 8:00 AM. R5's eMAR dated 11/5/23 documents R5 received Loratadine 10 mg at 1:42 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Baclofen 5 mg at 8:00 AM. R5's eMAR dated 11/5/23 documents R5 received Baclofen 5 mg at 1:42 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Famotidine 20 mg at 8:00 AM. R5's eMAR dated 11/5/23 documents R5 received Famotidine 20 mg at 1:42 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Amlodipine 5mg at 8:00 AM. R11's eMAR dated 11/5/23 documents R5 received Amlodipine 5 mg at 1:42 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Hiprex 1 gram at 8:00 AM. R5's eMAR dated 11/5/23 documents R5 received Hiprex 1 gram at 1:42 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Saccharomyces capsule 500 mg at 8:00 AM. R5's eMAR dated 11/5/23 documents R5 received Saccharomyces capsule 500 mg at 1:43 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Protein Oral Liquid 30 ml at 8:00 AM. R5's eMAR dated 11/5/23 documents R5 received Protein Oral Liquid 30 ml at 1:43 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Cholecalciferol 25 mcg at 8:00 AM. R5's eMAR dated 11/5/23 documents R5 received Cholecalciferol 25 mcg at 1:43 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Prucalopride Succinate 2 mg at 8:00 AM. R5's eMAR dated 11/5/23 documents R5 received Prucalopride Succinate 2 mg at 1:43 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Senna-Docusate 8.6-50 mg (give 2 tablets) at 8:00 AM. R5's eMAR dated 11/5/23 documents R5 received Senna-Docusate 8.6-50 mg (give 2 tablets) at 1:43 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Polyethylene Glycol 3350 Packet 17 gram at 8:00 AM. R5's eMAR dated 11/5/23 documents R5 received Polyethylene Glycol 3350 Packet 17 gram at 1:43 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Reglan Oral tablet 5 mg at 8:00 AM. R5's eMAR dated 11/5/23 documents R5 received Reglan Oral tablet 5 mg at 1:43 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Aspirin 81 mg at 8:00 AM. R5's eMAR dated 11/5/23 documents R5 received Aspirin 81 mg at 1:43 PM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Hydralazine 25 mg at 8:00 AM. R5's eMAR dated 11/20/23 documents R5 received Hydralazine 25 mg at 11:24 AM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Loratadine 10 mg at 8:00 AM. R5's eMAR dated 11/20/23 documents R5 received Loratadine 10 mg at 11:24 AM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Baclofen 5 mg at 8:00 AM. R5's eMAR dated 11/20/23 documents R5 received Baclofen 5 mg at 11:23 AM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Prucalopride Succinate 2 mg at 8:00 AM. R5's eMAR dated 11/20/23 documents R5 received Prucalopride Succinate 2 mg at 11:24 AM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Saccharomyces capsule 500 mg at 8:00 AM. R5's eMAR dated 11/20/23 documents R5 received Saccharomyces capsule 500 mg at 11:24 AM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Hiprex 1 gram at 8:00 AM. R5's eMAR dated 11/20/23 documents R5 received Hiprex 1 gram at 11:24 AM.
R5's Physician Order Summary Report undated documents R5 was scheduled to receive Protein Oral Liquid 30 ml at 8:00 AM. R11's eMAR dated 11/20/23 documents R5 received Protein Oral Liquid 30 ml at 11:24 AM.
On 11/21/23 at 12:36 PM, V5 (Licensed Practical Nursing/ LPN) stated when you are trying to cover more than Hall and take care of the residents you can take longer to pass medications.
On 11/22/23 at 8:00 AM, V2 (Director of Nursing) stated medications are administered as ordered. Some residents will ask for pain medications earlier than it can be administered. Then we those that watch the clock who demanded that an scheduled dose be administered on the dot regardless if the nurse is taking care of other residents.
On 11/22/23 at 4:58 PM, V7 (LPN) stated, I am a new nurse and sometimes it takes me awhile to pass meds but I let the r[TRUNCATED]
Nov 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on interview, observation and record review the facility failed to provide the necessary foot treatments to avoid complications in residents that are prone to develop foot problems to 2 of 12 re...
Read full inspector narrative →
Based on interview, observation and record review the facility failed to provide the necessary foot treatments to avoid complications in residents that are prone to develop foot problems to 2 of 12 residents (R2, R6) out of a sample of 22.
Findings include.
1. R2's Face Sheet undated documents, an admission date of 11/30/22.
R2's Physician Summary Order Report dated, as of 11/1/2023 documents, pertinent diagnosis as Type 2 Diabetes Mellitus without Complications and Acute Embolism & thrombosis of unspecified deep veins of lower extremity, bilaterally.
R2's Minimum Data Set, (MDS), dated , 9/13/23 documents, that R2 has moderate cognitive impairment with disorganized thinking and inattention continuously present and does not fluctuate. R2 is totally dependent in bathing, personal hygiene and dressing and has impairment on both sides in upper and lower extremities. R2 is bedridden and does not use any mobility devices. R2 does not have any infection of the feet, Diabetic foot ulcers or open lesions on the feet.
On 10/20/23, at 8:30 AM V3 stated, she has cut the toenail of other residents but do not recall cutting the nails of R2.
On 10/20/23, at 11:34 AM V5 stated, the Nurses can cut toenails not the CNAs.
On 10/20/23, at 11:00 AM V7 Grandmother to R2 stated, that R2 was not receiving foot care and her toenails were falling off.
On 10/20/23, at 11:34 AM R2 stated, her daughter has been cutting her nails. No Doctor or staff has cut her nails.
On 10/20/23, at 11:34 AM R2's toenails were observed to be approximately 1/2 inch long, thick, discolored, irregular shaped and not trimmed.
R2's Showers Sheets were reviewed for 8/15, to 10/27/23 documents, nail care was not completed 3 (8/15, 10/13 10/24) out of 12 times; nail care was completed 7 out of 12 times and there were 2 times (9/22,10/27) where there was no documentation, indication whether nail care was completed or not.
2. R6's Face sheet undated documents, his admission date as 7/23/21.
R6's Physician Order Summary Report dated as of 11/1/23 documents, pertinent admitting diagnosis are Diffuse Traumatic Brain Injury with Loss of Consciousness Greater Than 24-Hours without Return to Pre-Existing Conscious Level with Patient Surviving, Subsequent Encounter, Persistent Vegetative State, Need for Assistance in Personal Care, Contracture of Muscle, Left Upper Arm, Contracture of Muscle, Right Upper Arm, Contracture of Muscle, Left Lower Leg Contracture of Muscle, Right Lower Leg, Contracture of, Right Elbow, Contracture of Left Elbow, Contracture of left Hand and Contracture bathing, personal hygiene and dressing's Right Hand.
R6's Minimum Data Set, dated , 9/13/23 documents, R6 is totally dependent in bathing, personal hygiene and dressing and has impairment on both sides in upper and lower extremities. R6 is bedridden and does not use any mobility devices. R6 does not have any infection of the feet, diabetic foot ulcers or open lesions on the feet.
R6's shower sheets were reviewed for 8/8, to 10/31/23 documents, nail care was not completed 2 (9/22, 10/27) out of 10 times; documentation, on 9/22 indicated that R6's nails needed to be cut; there was no documentation, 1 (10/6) out of 10 times and documentation, indicating nail care was completed 7 out of 10 times.
On 10/20/23, at 8:30 AM V3 stated, she has cut the toenail of other residents but do not recall cutting the nails of R6.
On 10/31/23, at 9:32 AM V10 Restorative CNA stated, R6's hand splints used to prevent R6's fingernails from digging into the palm of his hand.
On 10/31/23, at 2:30 PM V1 Administrator stated, while the facility do not have a policy on foot care she would expect staff to care for the whole person. I rely on the Medical Records Coordinator to ensure our residents are being seen by the Podiatrist. We can schedule outside appointments with the Podiatrist if needed. We just need to be aware of the problem.
On 10/31/23, at 2:00 PM V2 Director of Nursing, (DON), stated, staff are conducting weekly skin check checks on all residents and are to alert the Nurse if there is a problem with any issued discovered. Long fingernails and toenails are certainly something that need to be addressed.
On 10/31/23, at 1:10 PM V17 Medical Records, stated, the Podiatrist generates his own list of facility residents to be seen. The Podiatrist visits every 2 months and sees approximately 50-60 people during each visit. Residents can be and have been added to the list if the staff thinks it is needed. I did not realize that there were residents that were not being seen by the Podiatrist. I knew we had some residents that refused but not any residents that had not been seen. That would be the Nurse's fault not mine.
Podiatry generated lists of facility residents dated February 2,2023, April 14, 2023, June 22, 2023, and September 18, 2023, did not document, R2's or R6's name on the list and nor were their names added to the list by facility staff.
Apr 2023
8 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to follow physician orders to maintain acceptable paramet...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to follow physician orders to maintain acceptable parameters of nutrition in 5 of 6 residents (R16, R18, R19, R27, and R82) reviewed for nutrition in the sample of 31. This failure resulted in continued, significant weight loss for R18 and R82 and worsening of R27's pressure ulcer.
Findings include:
1-R18's Face Sheet documents R18 was admitted to the facility on [DATE] and has diagnoses including cerebral infarction; dysphagia, oropharyngeal phase; diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter; chronic obstructive pulmonary disease, unspecified; spastic quadriplegic cerebral palsy, abnormal weight loss, and contractures of left wrist, left hand, right hand, left ankle and foot, and right ankle and foot.
R18's Minimum Data Set (MDS) dated [DATE] documents R18 is severely cognitively impaired, requires total dependence with 2+ person physical assistance for bed mobility and transfer, and requires total dependence with one person assistance for eating.
R18's Care Plan, undated, documents, (R18) is at risk for difficulty chewing/swallowing and weight loss r/t (related to) poor PO (oral) intake, dx (diagnosis) oropharyngeal dysphagia and having obvious caries.
R18's Progress Note dated 4/14/23 documents, RD Note: weight status. Weight (4/11)-124.4 lbs (pounds), BMI (Body Mass Index)-16.4. Significant weight loss noted -6.8 lbs x 1 month (5.2%), -14.6 lbs x 6 months (10.5%). Regular, puree diet order with (fortified) cereal at breakfast, (high calorie) supplement 90 mL QID (four times daily), and HS (bedtime) snack. Assisted at meals. Per nursing conversation typically does not eat well at lunch but good at breakfast/dinner. Continue to encourage intakes and provide alternatives as indicated at meals.
R18's Order Summary Report for the month of April 2023 documents order for regular diet, pureed texture, regular consistency, (fortified) cereal at breakfast, HS snack, (nutritional) shake for breakfast and dinner for impaired swallowing. There is an order for 90 milliliters (mL) of (high calorie) supplement four times daily dated 12/1/23.
R18's Medication Administration Record (MAR) for the months of December 2022 through April 2023 does not document the high calorie supplement was given from 12/1/23 through 4/25/23.
R18's Weights and Vitals Summary printed 4/26/23 documents R18 weighed 136.2 pounds on 1/3/23 and weighed 124.4 pounds on 4/11/23. This reflects an 11.8-pound weight loss or 8.6% weight loss over three months.
2-R82's Face Sheet documents R82 was admitted to the facility on [DATE] and has diagnoses including catatonic disorder due to known physiological condition; schizophrenia, unspecified; osteomyelitis of vertebra, sacral and sacrococcygeal region; pressure ulcer of sacral region, stage 4; gastrostomy status; and need for assistance with personal care.
R82's MDS dated [DATE] documents R82 is moderately cognitively impaired, requires total dependence with 2+ person assistance for bed mobility, total dependence with one person assistance for eating, and activity of transfer did not occur.
R82's Care Plan, undated, documents, (R82) is at risk for nutritional deficits r/t (related to) poor intake. (R82) is at risk for abdominal pain/discomfort, constipation r/t reduced motility, pain medication and poor PO (oral) intake. (R82) is at risk for fluctuations in weight r/t impaired cognition, hallucinations/delusions, poor intake with need for G-Tube (gastrostomy) placement. RD recommended Increased protein needs related to coccyx wound on 1/19/23.
R82's CMP (Comprehensive Metabolic Panel) dated 3/17/23 documents albumin (blood serum protein) of 3.1g/dL (grams per deciliter) with reference range of 3.5-5.5 g/dL.
R82's Progress note dated 4/14/23 documents, RD Note: TF (tube feeding)/wound status. Weight (3/3)-211 lbs, BMI-34.1. Significant weight loss -22.8 lbs x 1 month (9.8%), -41.4 lbs x 4 months (16.3%). Receiving regular diet order with double protein and (high calorie) supplement 90mL TID (three times daily) started 3/30 for added kcal (kilocalories)/pro (protein) support. Tube feeding support also in place to help meet nutritional needs: (controlled carbohydrate) formula 1.5 (calorie per mL) 55 mL/hr continuous from 6p-6a. Provides: 990 kcal/54g (grams) pro, 501 mL water (1101 mL total water with flushes). Tube feeding recently increased 3/30 due to weight loss.
R82's Order Summary Report) printed 4/27/23 documents order for regular diet, regular texture, regular consistency, and double protein at breakfast for nutrition in addition to supplemental tube feeding 6P to 6A. There is an order for (carbohydrate controlled) enteral feeding at 60mL/hr (hour) continuous x 23 hours. There is an order for 90 mL (high calorie) supplement three times a day dated 3/30/23 and an order for 1 packet of (skin integrity) supplement twice per day dated 3/1/23. These orders do not specify whether the supplements are to be given by mouth or by feeding tube.
R82's MARs for the months of March and April 2023 do not document high calorie supplement or skin integrity supplement were given, as of 4/27/2023.
R82's Weights and Vitals Summary printed 4/27/23 document R82 weighed 252 pounds on 11/30/2022 and 202.4 pounds on 4/27/23 which reflects a 49.6-pound weight loss or 19.6% weight loss over 5 months.
3-R27's Face Sheet documents R27 was admitted to the facility on [DATE] and has diagnoses including dysphagia, oropharyngeal phase; mild protein-calorie malnutrition; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; muscle weakness, and pressure ulcer of sacral region, stage 3.
R27's MDS dated [DATE] documents R27 is severely cognitively impaired, requires total dependence with 2+ staff assistance for bed mobility and transfer, requires total dependence with one person assistance for eating, and has one stage 3 pressure ulcer that was not present upon admission with treatments including nutrition or hydration intervention to manage skin problems.
R27's Care Plan, undated, documents, (R27) is at risk for skin breakdown and infection r/t bowel and bladder incontinence. (R27) is at risk for weight loss r/t advancing disease and age. Interventions: Supplements and snacks as ordered.
R27's Progress Note dated 3/9/23 documents, RD Note: weight/wound status. Weight (3/6)-151.8 lbs, BMI-22.4. Significant weight loss triggering -23.2 lbs x 6 months. Weight showing slow trend down the past 3 months. Multiple nutrition interventions in place.
R27's Weights and Vitals Summary dated 4/28/23 documents R27 weighed 175 pounds on 9/6/22 and 153.4 pounds on 4/7/23. This reflects a 21.6-pound weight loss or 12.3% weight loss over 7 months.
R27's Wound Care Plus Evaluation dated 3/16/23 documents stage 3 on coccyx measuring 1.3 centimeters (cm) length x 2.0 cm width x 0.2 cm depth. The length and width of the wound/skin issue stayed the same compared to the previous visit's conclusion. R27's Wound Care Plus Evaluation dated 3/21/23 documents stage 3 on coccyx measuring 1.0 cm length x 1.7 cm length x 0.2 cm depth. The length and width of the wound/skin issue stayed the same compared to the previous visit's conclusion. R27's Wound Care Plus Evaluation dated 3/30/23 documents stage 3 on coccyx measuring 4.3 cm length x 5.7 cm width x 0.2 cm depth. The length and width of the wound/skin issue stayed the same compared to the previous visit's conclusion. R27's Wound Care Plus Evaluation dated 4/4/23 documents coccyx wound. No dimensions documented; however, it documents the length and width of the wound/skin issue deteriorated compared to the previous visit's conclusion. R27's Wound Care Plus Evaluation dated 4/14/23 documents stage 3 on coccyx measuring 6.0 cm length x 8.0 cm width x 0.4 cm length. The length and width of the wound/skin issue deteriorated compared to the previous visit's conclusion.
R27's Order Summary Report printed 4/27/23 documents order for regular diet, pureed texture, regular consistency, (fortified) cereal at breakfast, variety snack TID (three times daily) 11am, 2pm, homemade shake at L/D (lunch and dinner). There is an order for 120 mL (high calorie) supplement four times daily dated 2/12/21 and an order for 120 mL (skin integrity) supplement four times daily dated 11/9/22.
R27's MARs for the months of February 2022 through April 2022 do not document R27 received any (skin integrity) supplement.
On 4/26/23 at 3:42 PM, V2, Director of Nursing (DON), stated, The orders for supplements should show up on the MAR. If the nurses see the order, they should know residents should get it, but if it's not on the MAR there is no other documentation that they have been receiving it.
4/28/23 at 8:10 AM, V30, Licensed Practical Nurse (LPN), stated she would not know she was supposed to give the supplements if they were not listed on the MAR.
On 4/27/23 at 12:52 PM, V18, Registered Dietitian (RD), stated, The (high calorie supplement) is for extra calories and protein and is used for residents who are losing weight or are underweight. The (skin integrity supplement) is used to support wound healing. If they are not getting the supplements, they might continue to lose weight.
On 4/27/23 at 12:10 PM, V25, Wound Nurse Practitioner, stated nutritional supplements and protein supplements play a big role in wound healing. She stated she tries to educate staff on the importance of giving supplements as ordered because of the effect they have on a resident's pre-albumin level which directly affects wound healing. V25 stated if a resident has supplements ordered, they should be getting them as ordered.
On 4/28/23 at 9:44 AM, V1, Administrator, stated expects staff to follow physician orders for nutritional supplements
4. R16's Undated Face Sheet, documents she was admitted to the facility on [DATE] diagnoses included paranoid schizophrenia and anxiety.
R16's Care Plan, dated 11/22/2022 documents at risk for weight loss related to poor/decreased PO (by mouth) intake. Goal: maintain adequate nutritional status as evidenced by maintaining weight, no s/sx (signs and symptoms) of malnutrition through review date. Interventions: administer medications as ordered, offer honey buns and juice just before dinner, eating 1 limited assist with all meals as indicated provide verbal and tactile cues prior to completing task for her. Invite her to activities that promote additional intake, observe/for report PRN any s/s of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide, serve diet as ordered. Monitor intake and record q (every) meal. RD to evaluate and make diet change recommendations PRN. Weights as ordered/monthly. Weekly weights. Monitor/record/report to MD PRN s/s of malnutrition.
R16's MDS, dated [DATE] documents alert, 56 inches and 87 lbs. No weight loss or weight gain documented.
R16's Registered Dietitian Progress Note, dated 3/9/2023 at 3:27 PM, documents weight (3/9) 84 pounds BMI 18.8 significant weight loss triggering -4.6 lbs x 1 month -10.6 lbs x 11/7 (11.2%) weight with noted fluctuations 82-89 lbs since mid-December 2022. Receiving mechanical soft diet order with meals in bowls, health shake with meals, 2 cal/ml supplement 90 ml QID, snack TID, super cereal at breakfast, magic cup at lunch and dinner and weekly weights to monitor nutritional status. Continue current POC (plan of care) with multiple interventions in place. Monitor, continue to encourage intakes and provide alternatives at meals as indicated. RD f/u PRN. Recommend: 1. reweigh to confirm weight status. 2. Currently with mechanical soft diet in orders, noted 2/20 health status note for upgrade to regular. suggest clarifying current diet texture in orders.
R16's POS, dated 3/16/2023 documents regular diet regular texture and consistency. Serve all meals in bowls. Iced tea with all meals. Health shake with all meals. Super cereal at breakfast, snacks TID (three times a day) ice cream with meals for difficulty chewing/swallowing related to dysphagia.
R16's POS, dated 3/2023 no documentation of a health shake, ice cream or snacks TID were administered or if the resident refused them.
R16's MDS, dated [DATE] documents resident not able to complete the interview, 56 inches and 89 lbs. No weight loss or weight gain documented.
R16's RD Progress Note, dated 4/14/2023 at 11:38 AM documents, weight (4/12)-80.8 lbs, BMI-18.1. Significant weight loss triggering -7.8 lbs x 1 month (8.8%), -13.8 lbs x 11/7(14.6%). Receiving regular diet with meals in bowls, health shake with meals, super cereal at breakfast, magic cup lunch/dinner, ice cream at meals, snack TID. 2 cal/ml supplement 120 ml QID for added nutrition support. Per nursing conversation resident will refuse meals if she is sleeping encouragement needed to get up and eat at meals. She will typically only eat in the dining room and accepts med pass supplement only if she is in the dining room. currently noted to be on isolation related to ESLB in urine which is likely cause of weight trend down. Recommend: 1. Provide increased encouragement/assist at meals while on isolation 2. when resident is off isolation encourage going to dining room for meals and provide 2 cal/ml med pass supplement at mealtimes as this is what resident prefers. 3. D/C magic cup at lunch/dinner as resident is already receiving ice cream with meals. Refer to RD PRN
R16's Weight Change Progress Note, dated 4/14/2023 at 1:39 PM, documents resident has triggered for a 5% loss and dietitian consult has been sent and has new recommendation and guardian has been notified.
R16's Electronic Medical Record, dated 4/19/2023 R16 weighed 80.6 lbs.
R16's Weight Change Progress Note, dated 4/21/2023 at 11:44 AM documents resident has triggered for a 5% weight loss and there are no recommendations.
R16's Electronic Medical Record, dated 4/25/2023 R16 weighed 84.8 lbs.
R16's POS, dated 4/2023 no documentation of a health shake, ice cream or snacks TID were administered or if the resident refused them.
On 4/26/2023 at 12:15 PM R16 observed sitting on the side of her bed eating grilled cheese. There was no health shake or ice cream on her tray and no dietary card on her lunch tray.
5. R19's Undated Care Plan documents she at risk for fluctuations in weight r/t poor appetite/PO intake, impaired cognition. Interventions: maintain adequate nutritional status as evidenced by maintaining weight, no s/sx of malnutrition through review date. Administer medications as ordered. Explain and reinforce to her the importance of maintaining the diet ordered. Encourage her to comply. Explain consequences of refusal, obesity/malnutrition risk factors. Invite her to activities that promote additional intake. Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Observe for/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated.
Provide, serve diet as ordered. Notify nurse of any refusal to eat/drink. RD to evaluate and make diet change recommendations PRN.
R19's POS, dated 11/3/2022, documents regular texture, regular consistency, fortified foods lunch and dinner, ice cream and magic cup with lunch and supper, super cereal at breakfast snacks TID (3 times a day) ice cream for all meals.
R19's Electronic Medical Record, documents weight 1/6/2023 101.2 pounds and 1/9/2023 102.4 pounds.
R19's Weight Change Progress Note, dated 1/12/2023 2:05 PM documents consult sent to dietitian today r/t weight loss.
R19's Registered Dietitian RD) Progress Note, dated 1/16/2023 12:02 PM, documents weight(1/9)-102.4 lbs, BMI-16. Significant weight loss triggering from 1/6 weight -6.4 lbs x 1 month(5.9%). Slight 1.2 lb trend back up x 3 days. Receiving regular diet, fortified food at lunch/dinner, ice cream/magic cup with lunch/dinner, super cereal at breakfast. 2 cal/ml supplement 60 ml TID for added nutrition support. Setup help at meals. RD attempt to visit resident today- would not answer any of RD questions. Per previous notes resident has hx of only talking when she wants to. Mirtazapine 7.5 mg daily ordered which may help aid in appetite stimulation but noted per MAR is refusing medication often. At increased nutritional risk related to bipolar, MDD, schizophrenia dx. No further weight loss desired. Recommend: 1. Increase 2 cal/ml supplement to 90 ml TID for nutrition support 2. Offer snack TID between meals 3. Increased supervision at meals with encouragement for adequate PO intakes. RD to f/u PRN.
R19's RD Progress Note, dated 1/18/2023 11:52 AM documents Per dietitian 1. Increase 2 cal/ml supplement to 90 ml TID for nutrition support. 2. Offer snack TID between meals. 3. Increased supervision at meals with encouragement for adequate PO intakes. RD to f/u PRN. Orders have been entered per MD and Guardian has been notified.
R19's Medication Administration Record (MAR) dated 1/2023, no documentation of 2 cal supplement or snacks administered per physician's orders.
R19's Electronic Medical Record, dated 2/2/2023 documents weight 110.8 lbs.
R19's R19's Weight Change Progress Note, dated 2/3/2023 8:57 AM, documents Resident has triggered for a 5% weight gain and there are no recommendations and guardian has been notified.
R19's Electronic Medical Record, dated 2/7/2023 documents weight 111.4 lbs.
R19's Weight Change Progress Note, dated 2/9/2023 at 10:01 AM documents resident has triggered for a 5% weight loss and there are no recommendations.
R19's RD Progress Note, dated 2/9/2023 at 2:12 PM, documents weight (2/7)-111.4 lbs, BMI-17.4. Significant weight gain triggering +9 lbs x 1 month (8.8%). Weight gain desired with low BMI status. Receiving regular diet with multiple nutrition interventions: fortified food at lunch/dinner, ice cream/magic cup with lunch/dinner, super cereal at breakfast, snack TID. 2 cal/ml supplement 90 ml TID for added nutrition support. Setup help at meals. Continue current POC. RD to f/u PRN.
R19's Electronic Medical Record, dated 2/16/2023 documents weight 100 lbs.
R19's Electronic Medical Record, dated 2/20/2023 documents weight 100 lbs.
R19's RD Progress Note, dated 2/20/2023 at 11:57 AM documents weight (2/20)-100 lbs, BMI-15.7. Significant weight loss triggering from gain on 2/2(-10.8 lbs x 2/2 9.7%). Receiving regular diet with multiple nutrition interventions: fortified food at lunch/dinner, ice cream/magic cup with lunch/dinner, super cereal at breakfast, snack TID. 2 cal/ml supplement 90 ml TID for added nutrition support. Setup help at meals. Recommend: increase 2 cal/ml to 90 ml QID for added nutrition support and refer to MD (physician) for possible re-initiation of appetite stimulant. RD to f/u PRN.
R19's Weight Change Progress Note, dated 2/21/2023 at 2:06 PM, documents resident had triggered for a 5% weight loss, and she has new orders and guardian has been notified
R19's POS, dated 2/21/2023 documents an order 2Calories/ml four times a day (QID) for supplement.
R19's Medication Administration Record (MAR) dated 2/2023, no documentation of 2 cal supplement or snacks administered per physician's orders
R19's RD Progress Note, dated 3/2/2023 at 10:36 AM documents, weight (3/2)-99.6 lbs, BMI-15.6. Significant weight loss triggering -11.2 lbs x 1 month (10.1%). Weight overall stable since 2/16. Noted weight loss triggering from gain 2/2,2/7. Weight previously stable between 102-108 lbs since admit. Receiving regular diet with multiple nutrition interventions: fortified food at lunch/dinner, ice cream/magic cup with lunch/dinner, super cereal at breakfast, snack TID. 2 cal/ml supplement 90 ml increased to QID 2/21 for added nutrition support. Setup help at meals with assist as needed. Noted behaviors with schizophrenia/bipolar dx which may be affecting intakes. Multiple interventions in place to help meet EEN. Continue to encourage intakes at meals and supplementation. Goal is for weight maintenance. Refer to RD PRN.
R19's POS, dated 3/2/2023 a new physician's order for weekly weights.
R19's Electronic Medical Record, dated 3/2/2023 documents weight 99.6 lbs.
R19's Weight Change Progress Note, dated 3/3/2023 at 11:24 AM documents resident has triggered for a 5% weight loss and there are no recommendations.
R19's Electronic Medical Record, dated 3/6/2023 documents weight 98.8 lbs.
R19's Quarterly MDS, dated [DATE] documents resident is severely cognitively impaired, eating supervision with setup help only, 67 inches tall, weighed 99 pounds, weight loss of 5% in last month or loss of 10% or more in 6 months: no or unknown.
R19's Electronic Medical Record, dated 3/15/2023 documents weight 96.4 lbs.
R19's Weight Change Progress Note, dated 3/17/2023 at 8:53 AM, documents resident has triggered for a 5% weight loss and there are no recommendations.
R19's Electronic Medical Record, dated 3/20/2023 documents weight 96.0 lbs.
R19's Electronic Medical Record, dated 3/29/2023 documents weight 90.4 lbs.
R19's Restorative Program Note, dated 3/31/2023 at 12:09 PM, documents resident has triggered for a 5% weight loss there are no recommendations and consult has been sent to dietitian.
R19's Medication Administration Record (MAR) dated 3/2023, no documentation of 2 cal supplement or snacks administered per physician's orders
R19's RD Progress Note, dated 4/3/2023 at 10:01 AM documents, weight (3/29)-90.4 lbs, BMI-14.2. Significant weight loss triggering -9.2 lbs x 1 month (9.2%), -10.8 lbs x 1/6(9.2%). -18.4 lbs x 11/9(16.9%). Receiving regular diet with multiple nutrition interventions: fortified food at lunch/dinner, ice cream/magic cup with lunch/dinner, super cereal at breakfast, snack TID. 2 cal/ml supplement 120 ml increased to QID 3/30/2023 for added nutrition support. Setup help at meals with assist as needed. Weekly weights ordered to monitor nutrition status. Noted that mirtazapine previously ordered. Hx of refusing medications. Noted non-compliant with labs/outside appointments. RD has tried to visit resident to get food preferences/help assist with nutrition but wound not answer any questions. Noted behaviors with schizophrenia/bipolar dx which likely effecting intakes. Multiple interventions in place to help meet EEN (estimated energy needs.) Due to behaviors and noncompliance with meds/labs/outside appointments resident is not an appropriate candidate for tube feeding support-refer to MD about this if agreeable. Continue to encourage intakes at meals and supplementation. No further weight loss desired. Refer to RD PRN.
R19's POS dated 4/4/2023 documents Mirtazapine 7.5 mg no reason ordered.
R19's Electronic Medical Record, dated 4/6/2023 documents weight 98.0 lbs.
R19's Electronic Medical Record, dated 4/12/2023 documents weight 90.0 lbs.
4/14/2023 1:49 PM Weight Change Nursing Progress Note, documents resident has triggered for a 5% weight loss and guardian has been notified.
R19's Electronic Medical Record, dated 4/18/2023 documents weight 91.0 lbs.
R19's Restorative Program Note, dated 4/21/2023 at 11:33 AM documents resident has triggered for a 5% weight loss, and she remains on weekly weights.
R19's Electronic Medical Record, dated 4/25/2023 documents weight 91.0 lbs.
R19's Medication Administration Record (MAR) dated 1/2023, no documentation of 2 cal supplement or snacks administered per physician's orders.
On 4/25/2023 at 11:40 AM V13, CNA stated she recently told the facility RD that R19 was losing a lot of weight, but she wasn't sure anyone was doing anything about it. V13 stated she gives her a snack when she remembers but R19 doesn't always eat it and there was no place for her to documents a resident ate a snack in the CNA charting. V13 stated dietary staff put magic shakes on the resident's meal tray she's never seen R19 get a magic shake.
On 4/25/2023 at 12:10 PM V11, CNA stated she told V1, Administrator R19 was losing weight a few days ago but she wasn't instructed to offer her anything other than take her to the dining room for meals. V11 didn't know what a magic shake was and didn't know who administers it to the resident.
On 4/26/2023 at 8:15 AM R19's meal ticket documents ice cream lunch and dinner and super cereal for breakfast. R19 was observed eating breakfast in the dining room. R19 ate oatmeal, half a piece of toast and a bowl of cold cereal. There was no magic shake on her tray. R19 ate 50% of breakfast.
On 4/26/2023 at 12:30 PM V17, CNA stated she told the charge nurse (name unknown) that V19 is losing weight a few weeks ago but no one gave her permission to give R19 snacks or anything additional. V17 didn't know what a magic shake was and stated that would come from dietary on the tray.
On 4/27/2023 at 12:05 PM R19 sat up on the side of her bed eating a grilled cheese sandwich and strawberry ice cream. No magic shake was on her lunch tray. R19 ate 50% of lunch.
The Facility's Skin Ulcer-Wound Policy effective 8/15/2018 documents, Policy: All caregivers are responsible for preventing, caring for, and providing treatment for skin ulcerations. Purpose: 1) To identify at risk residents for potential breakdown or ulcerations. 2) To prevent breakdown of tissue or ulcerations. 3) To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations. Risk Factors included Under nutrition, malnutrition, and hydration deficits. Skin Ulcer Prevention included Following Registered Dietician recommendations to promote optimum nutrition when possible.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report 2 allegations of abuse for 1 (R50) of 2 residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report 2 allegations of abuse for 1 (R50) of 2 residents sampled for abuse in a sample of 31.
Findings include:
R50's Undated Face Sheet documents, she was admitted to the facility on [DATE] diagnoses included dementia and generalized anxiety disorder.
R50's Minimal Data Set, (MDS), dated [DATE] documents, moderately cognitively impaired two plus persons physical assist for bed mobility, transfer, dressing and toilet use. Extensive assistance one plus person physical assist for personal hygiene. Delirium: behavior not present. Behavior: delusions.
R50's Un-witnessed Report, dated 2/25/2023 at 5:45 AM, V16 documents, This nurse was called down to this pt's, (patient's), room to find her sitting with her back against her bed. She stated, to this nurse that she fell. She denies having any pain or injury, she was assessed by this nurse and was lifted back into her bed by this nurse and 3 other staff members. Her family is going to be notified, as well as the DON and the doctor's group. She was started on neuro checks, at 5:45 AM. She refused to allow this nurse to take her vitals, she insisted that she was pushed to the floor by someone. This pt. states she was pushed out of her bed by someone.
R50's Witnessed Fall Report, dated 3/2/2023 documents, at 10:48 AM V15, MDS/Care Plan Coordinator documents, The housekeeper called this nurse to (R50's) room, stating she was on the floor. Upon entering her room, (R50) was noted to be lying on her left side with her wheelchair partially on top of her. She had on non-skid socks, and was dressed appropriately for the day, her clothing was clean and dry. Her room was dimly lit, floor was clean and dry. (R50) Someone threw me on the floor. Go get my mom and dad, they know how to get me up.
On 4/27/2023 at 10:00 AM, V15 MDS/Care Plan nurse stated, she recalled (R50) was reported to be on the floor and she was yelling out for her mom and yelling that someone threw her out of bed. Upon admission (R50's) family told staff that she hallucinates and is delusional, so she chopped it up to (R50) saying someone threw her out of bed was (R50) being delusional, she didn't report it to anyone. V15 stated, this was not an allegation of abuse, because the resident was delusional.
On 4/27/2023 at 3:37 PM V2, DON, (Director of Nursing), stated, when a resident is found on the floor and reports to staff that they were pushed that is considered an allegation of abuse, staff should initiate an investigation immediately, and call V1 and himself, to let them know the investigation was started. The charge nurse should have all staff, write a statement as to what occurred. V2 stated, he works the floor sometimes and was assigned to (R50) on 3/2/2023 day shift from 6:30 AM to 2:30 PM. Staff reported to him that (R50) was on the floor and he went into the room to assess her. Staff reported to him that (R50) stated, someone threw her on the floor. V2 stated, an abuse investigation should have been initiated for both that day and 2/24/2023, when (R50) alleged staff pushed her down. V2 stated, these allegations of abuse should have been reported to IDPH, (Illinois Department of Public Health), as well. V2 stated, he expected staff to follow the facility's abuse policies and procedures.
The Facility's Reporting of Abuse Policy, revised 2/2023, documents external reporting: upon receipt of an allegation or upon the formulation of a reasonable suspicion that abuse against a resident the facility Administrator or his/her designee will initiate external reports to the following: the administrator or his/her designee will immediately contact the department. Illinois facilities may contact the Department's Regional Office during weekdays by phone or fax. During off-hours the Department's compliant hotline shall be contacted. Within twenty-four hours following the occurrence/allegation, a written report shall be sent to the Department. Within five business days from the event or report the facility will submit a report to the Department a description of the initial allegation, facts obtained and a summary of all interviews conducted, a brief conclusion and corrective action taken if necessary.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to investigate two allegations of abuse for 1 of 2 (R50) ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to investigate two allegations of abuse for 1 of 2 (R50) in a sample of 31.
Findings include:
1. R50's Undated Face Sheet documents she was admitted to the facility on [DATE] diagnoses included dementia and generalized anxiety disorder.
R50's Minimal Data Set, (MDS), dated [DATE] documents moderately cognitively impaired two plus persons physical assist for bed mobility, transfer, dressing and toilet use. Extensive assistance one Plus person physical assist for personal hygiene. Delirium: behavior not present. Behavior: delusions.
R50's Care Plan, dated 12/14/2022 documents (R50) at risk for increase in behaviors, non-compliance, verbal/physical aggression, paranoia, hallucinations, delusions r/t, (related to), GDR, (gradual dose reduction), attempt and/or discontinuation of psychotropic medication. She will not have an increase in behaviors due to GDR in medication through the next review. Aripiprazole 5mg (AP), Phenytoin 100mg AM/200 mg HS (AC), GDR from 300 mg HS 06/17/22, Mirtazapine7.5mg (AD), DC 4/14/2022, Lorazepam 0. 5mg (AA), DC 11/11 2019, Quetiapine 50mg (AP), DC 7/30/2019. Observe for/report increase in behaviors, paranoia, hallucinations, delusions, decrease in socialization and/or decreased participation in activities. 10/2/2022 (R50) is at risk for changes in mood r/t DX, (diagnoses), hallucinations, delusions, and dementia with behavioral disturbances. She has a history of traumatic event, (being raped), and will relive the past as though it just happened, (per son). She will say that someone is in her bed, someone has just hurt her even though the event happened 50 years ago. Interventions: She will be oriented to place and time as indicated. Assessed by Deer Oaks LCSW. Result: She is unable to meaningfully participate with services due to cognition. OBRA PAS/MH Screen, there is no reasonable basis to suspect MI/DD/ID. Administer medications as ordered. Observe for/report if present, any adverse side effects. Encourage her to express feelings. Notify her son is she is having any manic episodes, acute onset of confusion. Shows on [NAME]. Observe for, report to MD (physician) if present: acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills. Observe for/report to MD any risk for harming others: increased anger, labile mood or agitation, threats towards other.
R50's Un-Witnessed Report, dated 2/25/2023 at 5:45 AM, V16 documents, This nurse was called down to this pt.'s, (patient's), room to find her sitting with her back against her bed. She stated to this nurse that she fell. She denies having any pain or injury, she was assessed by this nurse and was lifted back into her bed by this nurse and 3 other staff members. her family is going to be notified as well as the DON and the doctor's group. she was started on neuro checks at 5:45 AM. she refused to allow this nurse to take her vitals, she insisted that she was pushed to the floor by someone. This pt. states she was pushed out of her bed by someone.
R50's Witnessed Fall Report, dated 3/2/2023 documents at 10:48 AM V15, MDS/Care Plan Coordinator documents, The housekeeper called this nurse to (R50's) room, stating she was on the floor. Upon entering her room, (R50) was noted to be lying on her left side with her wheelchair partially on top of her. She had on non-skid socks, and was dressed appropriately for the day, her clothing was clean and dry. Her room was dimly lit, floor was clean and dry. (R50) Someone threw me on the floor. Go get my mom and dad, they know how to get me up.
R50's Nursing Progress Note, dated 3/2/2023 at 10:51 AM V15, MDS/ Care Plan Coordinator documents, Witnessed fall while attempting to transfer self from her wheelchair to her bed. The housekeeper called this nurse to (R50's) room, stating she was on the floor. Upon entering her room, (R50) was noted to be lying on her left side with her wheelchair partially on top of her. She had on non-skid socks was dressed appropriately for the day, her clothing was clean and dry. Her room was dimly lit, floor was clean and dry. (R50) stated, Someone threw me on the floor, go get my mom and dad, they know how to get me up. She did not want to perform ROM, (range of motion), and this nurse didn't do PROM, (passive range of motion), to BLE, (bilateral lower extremities), at that time due to c/o, (complaint of), pain and being resistive/combative with attempts to assess her. I made her as comfortable as I could on the floor, placing a pillow under her head while attempting to diffuse her behaviors. When her roommate (R7) was asked if she witnessed (R50) fall (R7) stated, She went to stand up and I told her not to stand, that she was gonna fall. She wouldn't listen to me and stood up anyway. That's when she fell. Her nurse entered the roommate that time and took over care. MD, (physician), notified of fall with c/o LUE/LLL pain.
On 4/27/2023 at 1:30 PM V21, CNA stated, she works day shift from 6:30 AM to 2:30 PM and recalled (R50) was observed on the floor on 3/2/2023. V21 stated got the nurse, (name unknown), and her, the nurse and V2, DON assisted (R50) off the floor. V21 stated, she recalled (R50) told her, the nurse and the DON were in the room and heard (R50) say someone threw her on the floor so she didn't report it, because the DON was in the room.
R50's Social Services Notes, dated 2/1/2023 through 4/27/2023 no documentation of (R50) made allegations of abuse stating staff threw her out of bed or onto the floor.
On 4/26/2023 at 10:00 AM R50 was observed sitting up in her wheelchair in her room. R50 stated, A man through me from my bed and onto the floor. I don't know his name but he big and tall and mean.
On 4/27/2023 at 10:00 AM, V15 MDS/Care Plan nurse stated she recalled (R50) was reported to be on the floor and she was yelling out for her mom and yelling that someone threw her out of bed. Upon admission (R50's) family told staff that she hallucinates and is delusional, so she chopped it up to (R50) saying someone threw her out of bed was (R50) being delusional. She didn't report it to anyone. V15 stated this was not an allegation of abuse because the resident was delusional.
On 4/27/2023 at 2:15 PM V24, NA, (Nurse Assistant), works night shift 10:30 PM to 6:30 AM and recalled (R50) fell out of bed at the end of February 2023 and stated a man pushed her onto the floor. V24 stated she knew no one pushed (R50) down and knew there was no man in (R50's) room, because she was on the hall at that time. (R50) always says a man pushes her down and so it's nothing new.
2. R7's MDS dated [DATE] documents moderately cognitively impaired.
On 4/27/2023 at 1:00 PM R7 was up in a Broda chair in her room. R7 replied Yes to all IDPH state surveyor's questions regarding R50's fall. IDPH surveyor asked R7 if someone pushed her roommate (R50) to the floor, if someone pushed her roommate (R50) out of bed and if she saw (R50) fall by herself and who pushed her roommate (R50.)
On 4/27/2023 at 3:37 PM V2, DON stated when a resident is found on the floor and reports to staff that they were pushed that is considered an allegation of abuse staff should initiate an investigation immediately and call V1 and himself to let them know the investigation was started. The charge nurse should have all staff write a statement as to what occurred. V2 stated he works the floor sometimes and was assigned to assigned to (R50) on 3/2/2023 day shift from 6:30 AM to 2:30 PM. Staff reported to him that (R50) was on the floor and he went into the room to assess her. Staff reported to him that (R50) stated someone threw her on the floor. V2 stated an abuse investigation should have been initiated for both that day and 2/24/2023 when (R50) alleged staff pushed her down. V2 stated these allegations of abuse should have been reported to IDPH as well. V2 stated he expected staff to follow the facility's abuse policies and procedures.
On 4/27/2023 at 9:50 AM V1, Administrator state (R50's) family told staff she is delusional and hallucinates and it is care planned. There are no abuse investigations regarding (R50) for 2023 and she didn't view (R50's) statements as abuse because she has a history of being delusional and hallucinates, that's why this wasn't investigated.
The Facility's Abuse Policy, revised 2/2023 documents this facility does not condone any form of resident abuse. The facility will take all reports of abuse against its residents seriously and will attempt to investigation allegations with the intent of detecting any wrongdoing, determining causative factors and when indicated implanting corrective actions to prevent reoccurrence. Allegations of abuse will be reported to the compliance officer. The facility administrator will conduct or assign the investigation of the alleged incident to an appropriate individual. Abuse investigations will be initiated as soon as practicable but no later than 24 hours following a report. During any investigation the assigned investigator will follow all resident protection policies until a conclusion is researched and/or corrective actions are implemented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide and implement progressive interventions for r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide and implement progressive interventions for repeated falls, for 1 (R32) of 3 residents in the sample of 31.
Findings include:
R32's Face sheet documents an admission date of 7/23/2019 with diagnosis of COPD, Type 2 Diabetes Mellitus, History of Falling, Major Depressive Disorder, and Acute Congestive Heart Failure.
On 4/26/2023 at 9:00AM R32 observed in room sitting in wheelchair with door closed. No call light observed with in reach, no sign noted on wall for bowel and bladder training, and no urinal noted close to resident.
Facility fall log dated 4/25/2023 documents, R32 sustained falls on 7/29/22, 10/29/22, 4/17/22, 4/19/22, 5/18/22, 5/21/22, 6/27/22, 8/28/22, 2/7/23, 2/16/23, 3/9/23 and 4/13/23.
R32's Morse Fall Risk Assessments dated 3/31/22, 6/14/22, 1/30/23, 2/16/23, 3/9/23, 4/3/23, 4/13/23 all show R32 is at high risk for falls.
R32's Care Plan dated 7/9/2023 documents R32 is at risk for falls r/t weakness, shortness of breath, fatigue, poor safety awareness, extensive history of falls prior to admission. Interventions include: Ensure R32 always has on non-skid socks, explain to him why the purpose of the nonskid surface. Educate him/reinforce on the importance of requesting assist with transfers/toileting tasks due to weakness. Ensure call light is within reach and educate on use with all waking rounds. Remind him to request assist from staff when wanting to move furniture. Ant tippers and Antiroll backs on wheelchair. Nonslip cushion sleeve for wheelchair. Remove all linens, objects from bathroom floor/in pathway.
Educate on importance of ensuring wheelchair is locked when not in use/prior to transferring in/out of wheelchair. Educate/demonstrate locking/unlocking wheelchair.
Educate on the importance of requesting assist with transfers.
Ensure that he is wearing appropriate footwear when ambulating or mobilizing in w/c, (wheelchair).
Keep urinal at bedside, within reach when in bed and wheelchair.
Ask him (R32) if he needs to toilet with rounds and as needed.
Remind him to request assist with picking anything up off the floor, due to weakness and impaired mobility.
R32's Minimum Data Set, MDS, dated [DATE] documents, R32 is moderately cognitively impaired and requires extensive assist of 1 person for transfers.
R32's MDS, dated [DATE] documents, R32 is moderately cognitively impaired and requires extensive assist of 1 person for transfers.
R32's MDS dated [DATE] documents R32 is moderately cognitively impaired and requires extensive assist of 1 person for transfers.
R32's progress notes dated 2/16/2023 11:49AM documents, Nurse was informed by staff that she heard a noise from R32's room and R32 noted to be laying on floor. Went into assess and R32 was noted on floor in sitting position. R32 stated, I was trying to pick up my refrigerator and slid out of my chair. R32 alert and oriented no injuries noted no pain voiced. R32 denies hitting head. R32 assisted to wheelchair with two staff assist.
R32's progress notes dated 3/9/2023 at 5:11AM document, screams for help was heard from R32's room. Upon assessment R32 was found on the floor near the sink, wheelchair pushed away from near R32, and his head was by the vent. R32 complained of getting up to the TV and then to his sink when he lost his balance and fell. R32 reports pain to head and left shoulder. Report called to POA on file and ok to send to Emergency Department.
R32's progress notes dated 4/13/2023 at 2:15PM documents, R32 called out for nurse's help. Nurse went in and observed R32 lying on the floor. R32 stated, that he was trying to wash his hands after using the restroom and slipped and fell. No injuries were observed. Physician notified.
Fall investigations dated 4/17/22 documents, R32 fell transferring to wheelchair. Wheelchair was unlocked and slid out from under R32. No injury. Intervention for restorative to evaluate. Educate on locking wheelchair and calling for assist with transfers.
Fall investigations dated 5/18/22 R32 fell out of wheelchair after he sneezed. Landed on right knee. No injury documented. Intervention placement of dycem.
Fall investigations dated 5/21/22 R32 fell coming out of the shower and slipped on a towel and fell on back. No injury. Intervention to remove all objects and linens on floor.
Fall investigations dated 6/27/22 R32 fell attempting to stand from wheelchair. Fell to knees. Skin tear to left forearm. Wheelchair unlocked. Interventions to place sign on wall to remind to call for assist. Educated on locking wheelchair and asking for assist with transfers, and dycem in wheelchair.
Fall investigations dated 7/29/22 R32 fell standing up putting candy bars in his pocket. Flopped down in wheelchair, flipping wheelchair back, hitting head and back on the floor. No injuries. R32 sat on buttocks and assisted x 2 with gait belt into wheelchair. Interventions anti tippers to wheelchair and refer to restorative program.
Fall investigations dated 8/28/22 R32 slid to floor out of wheelchair. No injury. Interventions include nonskid cushion cover with strap for wheelchair cushion.
Fall investigations dated 10/29/22 R32 flopped in wheelchair and flipped wheelchair over. No injury. Interventions include raise seat back, apply anti tippers and anti-rollback.
Fall investigations dated 2/16/2023 R32 fell in room attempting to move his refrigerator. No injury. Interventions remind R32 to request assist from staff when wanting to move furniture.
Fall investigations dated 3/9/2023 R32 fell after standing and losing balance. Hit head. No interventions listed.
R32's order sheets dated document Skilled Occupational Therapy 4 times a week for 4 weeks with treatment to include: self-care management, and neuro [NAME].
No directions specified for order.
On 4/26/2023 at 9:00AM R32 stated I am supposed to ask for help, but I don't want help. I've fallen a few times. I have trouble with my balance. I recently fell at my sink. I was washing up and had water on the floor and I slipped. Therapy works with me for balance.
On 4/28/2023 at 10:30AM V2, Director of Nurses, DON, stated I would expect a resident that has had repeated falls to have progressive interventions and an up-to-date care plan.
Facility fall policy updated 2/20/2023 documents All incidents and accidents occurring at the facility will be reported, investigated, and tracked in accordance with the guidelines contained herein. Reports of findings will be forwarded to the Director of Nursing and or Administrator.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to discontinue an unnecessary indwelling urinary catheter for one of three residents (R36) reviewed for Urinary Tract Infections ...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to discontinue an unnecessary indwelling urinary catheter for one of three residents (R36) reviewed for Urinary Tract Infections (UTI) in the sample of 31.
Findings include:
On 4/25/23 at 11:04 AM R36 was observed to have an indwelling urinary catheter in a dignity bag. He had personal protective equipment (PPE) set up outside his door with signs on the door indicating he is on contact and droplet isolation.
ON 4/25/23 at 11:10 AM V3, Licensed Practical Nurse (LPN) stated R36 is on contact isolation due to ESBL (Extended spectrum beta-lactamase) in his urine and droplet isolation for pseudomonas in his trach.
On 4/27/23 at 1:00 PM V26, R36's daughter, stated she does need to ask the staff here (in facility) why R36 still has a catheter in. She stated he had it in the hospital, but they didn't say anything about him keeping it in after he came back. She stated the doctor did not say anything about him having to keep it after leaving the hospital. V26 stated R36 did have a UTI while he was in the hospital.
On 4/27/23 at 2:00 PM V2, Director of Nursing (DON) stated catheter care cannot be observed on R36 because he does not have a catheter. After discovering R36 does have a catheter, V2 stated R36 must have had it in the hospital and the nurses did not remove it when he came back.
On 4/27/23 at 2:08 PM V21, Certified Nursing Assistant (CNA) and V27, CNA, performed indwelling urinary catheter care for R36.
On 4/27/23 at 2:32 PM V20, Licensed Practical Nurse (LPN) stated she is not sure why R36 has an indwelling urinary catheter. She stated he didn't have it before he went to the hospital but maybe hospice ordered for it to be left in.
R36's Face Sheet documents his diagnoses to include Cerebral Atherosclerosis, Vascular Dementia, and Sepsis, Unspecified Organism (added 4/11/23). There are no diagnoses listed that would indicate a need for R36 to have an indwelling urinary catheter.
R36's Physician Order Summary dated 4/27/23 documents the following order dated 4/25/23: Contact Isolation for DX (diagnosis): ESBL in Urine.
R36's Hospital Discharge Progress Notes dated 4/22/23 document, Foley catheter, placement date 4/11/23; Foley insertion reason: I&O (Intake and Output)-Strict I&O or Critically Ill requiring I&O every 1-2 hours. There was no order at time of hospital discharge to continue R36's indwelling urinary catheter.
R36's Hospital document, After Visit Summary dated 4/22/23 documents his diagnoses to include Severe Sepsis and includes an order for Ertapenem 1 Gram in sodium chloride 0.9% 50 milliliters inject into vein daily for 2 days through 4/24/23. R36's hospital progress notes document he was receiving this medication for treatment of multi-drug resistant gram-negative organism: Extended spectrum beta-lactamase pathogen (ESBL).
R36's handwritten Hospice Orders dated 4/27/23 at 12:25 PM do not include an order for an indwelling urinary catheter.
On 4/28/23 at 8:45 AM R36 was noted to still have an indwelling urinary catheter in place. There was still no order for an indwelling urinary catheter in R36's physician orders.
On 4/28/23 at 8:56 AM V2 stated R36's indwelling urinary catheter was not removed because V31, Nurse Practitioner, said to leave it in for R36's comfort.
On 4/28/23 at 9:47 AM V1, Administrator, stated she would expect there to be an order in place for a resident to have an indwelling urinary catheter. She stated she does not think comfort is an acceptable diagnosis for an indwelling urinary catheter for R36 because he does not have any wounds that would cause him discomfort.
On 4/28/23 at 11:15 AM a new order was noted in R36's Physician Orders that documents, 4/22/23 return to facility with indwelling (urinary) cath from hospital. waiting on RR (record review) from hospital stay 4/11 to 4/22 for labs/diagnostics/hp (history and physical) before (urinary) cath is d/c (discontinued).
R36's Care Plan does not include a focus of an indwelling urinary catheter or catheter care.
The facility's policy, Indwelling Urinary Catheter and Catheter Care, revised 2/6/23, documents, This policy outlines the management and care of indwelling urinary catheters and catheter associated urinary tract infections (CAUTI). Aseptic insertion, maintenance and timely removal of Foley catheters reduces the incidence of catheter associated UTIs and thus their resultant complications. Resident with indwelling catheter will receive care compliant with recommended strategies under the professional medical judgement of the provider to prevent CAUTI. Purpose: 1. To provide quality of resident care. 2. To reduce the risk of harm to residents. 3. To ensure CDC (Centers for Disease Control) and best practice recommendations are followed for residents with indwelling urinary catheters. 4. To provide a single reference document reflecting best practices for preventing CAUTI. All residents admitted to the facility who have or may require indwelling urinary catheters will follow the facility's protocol: All residents who have or may require indwelling urinary catheters, will follow best practice recommendations for care/maintenance, daily assessment for necessity, and prompt removal. Several components will be utilized to prevent or reduce risk of CAUTI. These components are: Avoid unnecessary urinary catheters and maintain catheters based on provider orders and guidelines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected 1 resident
Based on interview, and record review the facility failed to ensure staff are vaccinated for COVID-19, (Human Coronavirus Infection). The facility failed to develop a policy that includes a process fo...
Read full inspector narrative →
Based on interview, and record review the facility failed to ensure staff are vaccinated for COVID-19, (Human Coronavirus Infection). The facility failed to develop a policy that includes a process for: ensuring staff are vaccinated for COVID-19 and have a contingency plan for staff who are not vaccinated and do not have an exemption or temporary delay. This failure has the potential to affect all 90 residents who reside in the facility.
Findings include:
The Center for Medicare and Medicaid Services, (CMS), Centers for Clinical Standards and Quality/Quality, Safety, & Oversight Group memorandum, (QSO-22-07 memo), dated 12/28/21 documents On November 05, 2021, CMS published an interim final rule with comment period (IFC). This rule establishes requirements regarding COVID-19 vaccine immunization of staff among Medicare- and Medicaid-certified providers and suppliers. This memo documents CMS expects all providers 'and suppliers' staff to have received the appropriate number of doses by the timeframes specified in the QSO-22-07 unless exempted as required by law or delayed as recommended by CDC (Centers for Disease Control and Prevention). This memo documents facilities must have policies and procedures to ensure that all staff are vaccinated for COVID-19, and 100% of the facility's staff are vaccinated for COVID-19 or have a qualifying exemption or temporary delay within 60 days of the memo date. This memo refers to Attachment A for Long Term Care Facilities. Attachment A documents the following: The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (i)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents; (ii) A process for ensuring that all staff specified in paragraph (i)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (i)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the facility has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains: (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications;
(ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19.
The facility's COVID-19 Staff Vaccination Status for Providers documents the facility has 128 employees, 119 employees are completely vaccinated, 3 employees have pending or granted non-medical exemptions. No employees have a temporary delay or are a new hire, and no employees are not vaccinated without an exemption or delay. This information indicates 95% of the facility's employees are vaccinated or have an exemption/delay. This form documents the following staff were partially vaccinated V32 Dietary Aid, V33 Activity Assistant, V34 CNA (Certified Nursing Assistant), V35 Activity Assistant, V36 CNA, V37 CNA.
Facility staffing schedule V32 Dietary Aid worked 4/12/2023, 4/13/2023, 4/16/2023, 4/17/2023, 4/19/2023 through 4/24/2023. V34 CNA worked 4/12/2023, 4/13/2023, 4/18/2023, 4/20/2023, 4/25/2023. V35 Activity Assistant worked 4/12/2023, 4/13/2023, 4/14/2023, 4/17/2023, 4/18/2023, 4/20/2023, 4/21/2023, 4/22/2023, 4/25/2023. V36 CNA worked 4/12/2023 through 4/16/2023, 4/18/2023, 4/20/2023 through 4/25/2023. V37 CNA worked 4/14/2023, 4/17/2022 through 4/19/2023, 4/21/2023 and 4/24/2023. V33 was terminated.
V1 stated I have to send this report in every week, so I thought we were current.
Facility policy updated 3/8/2022 states In accordance with Illinois Executive Order 2021/2022 (COVID 19 Executive Order N0.88 amended) amended February 4, 2022, beginning March 15, 2022, Health Care Workers Must be up to date on COVID-19 vaccinations in order to be considered fully vaccinated against COVID-19. An individual is considered up to date on COVID -19 vaccinations when they have received all CDC recommended COVID-19 vaccines including any booster doses when eligible.
Eligible team Members who have not received at least one dose of the COVID-19 vaccine by December 5, 2021, and those who are not fully vaccinated by January 4, 2022, will be placed on administrative leave without pay for up to 90 days to achieve compliance. Eligible Team Members who remain noncompliant after 90 days will be terminated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to answer call lights in a timely manner for 6 0f 6 residents (R53, R39...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to answer call lights in a timely manner for 6 0f 6 residents (R53, R39, R22, R67, R80, R188) in the sample of 31.
Findings include:
On 4/28/2023 at 8:15AM V1, Administrator, stated I would expect call lights to be answered immediately.
On 4/27/2023 at 3:00PM V2, Director of Nursing, stated I would expect call light to be answered with in 1 minute.
On 4/26/2023 at 2:00PM R80 stated, I don't even try to use the call light. That's a joke. They never answer call lights.
On 4/27/2023 at 11:30AM R188 stated, During the day Monday through Friday, the call lights may only take a few minutes. On the weekends call lights can take hours.
On 4/26/2023 at 2:00PM Facility asked to gather 5 residents with no cognitive deficits to attend group meeting. During group meeting R53, R39, R22, R67 all stated call lights take a long time to be answered.
R80's Minimum Data Set, MDS, dated [DATE] documents R80 has no cognitive impairments.
R188's MDS dated [DATE] documents R188 has no cognitive impairments.
Resident Council minutes dated 2/20/2023 documents in New Business Residents states that CNAs (Certified Nursing Assistants), are taking too long to answer call lights.
No facility policy available, on 4/28/2023 at 8:15AM V1, Administrator, stated We have no call light policy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the Facility failed to store, prepare and serve food in accordance with food safety guidelines. This has the potential to affect all 90 residents li...
Read full inspector narrative →
Based on observation, interview, and record review, the Facility failed to store, prepare and serve food in accordance with food safety guidelines. This has the potential to affect all 90 residents living in the facility.
On 4/25/23 at 12:10 PM there were several broken tiles, a saltshaker and a Styrofoam cup on the floor behind the ice machine. There was approximately ¼ inch of water standing in the bottom of the ice scoop container.
On 4/25/23 at 12:17 PM there was a significant amount of dirt and grease on the pipes running behind the stove and on the backside of the equipment.
On 4/25/23 at 12:22 PM in the dry storage room there were crumbs scattered across pots and pans on the bottom shelf of a storage rack.
On 4/25/23 at 12:24 PM in the standing freezer there was approximately 1 inch of ice crystals on all of the shelves.
On 4/25/23 at 12:25 PM there were 12 individual containers of pudding in the standing refrigerator that were not labeled.
On 4/25/23 at 12:33 PM, V8, Cook, obtained temperatures from the steam table after the last resident tray was served using a metal calibrated thermometer. The steak measured 88.2 degrees Fahrenheit (F), the pureed bread measured 101.2 F. The chicken fried steak measured 131.6 F. The pureed lettuce measured 67.7 F. The pureed steak measured 83.4 F. The tomatoes measured 67.1 F. The ranch dressing measured 68.0 F.
4/26/23 at 12:45 PM, V7, Dietary Manager (DM), stated the mechanical soft diets received the same steak as regular, because it was shredded.
On 4/25/23 at 12:42 PM, V7, DM, stated, That (meal) was supposed to be served cold. It should have been on ice. There was no ice underneath the cold items on the steam table during the meal service.
On 4/25/23 at 1:37 PM, V7, DM, stated she does not have a policy on food temperatures, and they follow the state regulations.
On 4/28/23 at 9:44 AM, V1, Administrator, stated she expects the food service department to follow guidelines for food safety.
The Facility's Resident Census and Conditions of Residents Form (CMS 672) dated 4/25/23 documents there are 90 residents living in the Facility.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from verbal abuse for 1 of 6 residents (...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from verbal abuse for 1 of 6 residents (R2) reviewed for abuse, in the sample of 7.
Findings include:
R2's Face Sheet dated 11/9/2023 documents R2 has a diagnosis of Paranoid Schizophrenia, Restlessness and Agitation, as well as Hostility.
R2's Care Plan dated 2/8/2021 documents, (R2) is at risk for physical aggression and potential abuse of other residents and staff related to anger, poor impulse control. (R2) makes repeated threats against staff due to impatience and paranoia. Interventions include: When he makes a complaint, take down complaint and investigate for root cause of complaint and validity. When the resident becomes agitated, intervene before agitation escalates. Guide away from source of distress; engage calmly in conversation; If response is aggressive, staff to walk calmly away and approach later.
On 2/8/2023 at 9:00 AM, V1, Administrator, stated, We had one abuse reportable. (R2) cussed at a CNA (Certified Nursing Assistant) and she cussed back at him. We terminated her.
On 2/8/2023 at 10:00 AM, R2 stated, I am being abused. The other night, I put on my call light and a CNA told me, Don't be on the mother f*cking light!. R2 was not sure who the CNA was. R2 said he told V3, CNA Supervisor, that a CNA cussed him out.
On 2/8/2023 at 11:28 AM, V2, Director of Nursing (DON), initally stated he was not aware of any abuse allegations. V2 then stated, Ohh, (V10, CNA)- that just reminded me. I wasn't there at the time it happened, but I can say, she shouldn't have said what she said. It was something about his (R2's) wife. There was never a formal complaint made to me and I don't know who it was reported to. It was word of mouth. I have been down there (R2's room) so many times about him saying stuff, I don't know what is true. He is the abuser and I have to protect my staff from him abusing them.
On 2/8/2023 at 11:45 AM, V4, Licensed Practical Nurse (LPN), stated, I heard about a CNA who got fired (for a verbal altercation with R2). I wasn't here so I don't really know what happened. He was cussing her and I guess she got tired of it.
On 2/8/2023 at 2:30 PM, V5, LPN, stated, I didn't hear it (what V10 said to R2) but it was reported to me and she was sent home. They did an investigation. I did hear them being loud down there (the hall). I think she was talking about his wife. I asked him (R2) about it and he said she said some thing to him and it was none of her business.
The Facility's Illinois Department of Public Health Notification Form dated 11/8/2023 documents, (R2) and (V10) had an altercation where (R2) began cussing and calling (V10) names and (V10) responded back by calling him names.
The Facility's untitled document dated 11/8/2023 documents The administrator was notified at approximately 8:00 PM by (V5, LPN) Licensed Practical Nurse, that there had been a confrontation between (R2) and (V10). She (V5) explained that they were both cussing and yelling at each other in the hall. It continues to document, 7:35 AM on 11/9/2023 I (V1, Administrator) went to speak to (R2). He stated he was standing at his door chit chatting with (V6, CNA) while she was charting when (V10) came down the hall with snacks and asked (R2) if he wanted an apple or banana. He (R2) then said, 'No, I don't want nothing from you' and she replied, 'F*ck you mother f*cker, you're the reason your wife is dead!'
If further documents, 11/9/2023 at 2:30 PM I (V1) spoke with (V5) who confirmed that (V10) had cursed back at (R2). (V6) said she was charting and (V10) was coming down the hall and asked (R2) if he wanted a banana or an apple. He (R2) stated, 'I don't want sh*t you got, you d*ck [NAME] b*tch' to which (V10) replied, 'F*ck you, F*ck you, you're the reason your wife is dead'. That is when (V6) and (V10) walked to the nurses' station to inform (V5) what had transpired.
It further documents, She (V10) was terminated due to her behavior.
The Facility's Abuse Prevention Program dated March 2018 documents, Purpose: This Facility affirms the right of our residents to be free from abuse (verbal, mental, sexual, or physical), neglect, misappropriation of resident's property, exploitation, corporal punishment, involuntary seclusion, and physical and chemical restraints that are not required to treat a resident's medical symptoms. This Facility therefore prohibits acts of mistreatment, neglect, abuse, and /or crimes from being committed against its residents. This Facility desires to establish a resident sensitive and resident secure environment. It further documents, Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within hearing distance, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again.
Mar 2022
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to adminiter medications as ordered. There were 44 opportunities with 3 errors resulting in an 6.82% medication error rate. The e...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to adminiter medications as ordered. There were 44 opportunities with 3 errors resulting in an 6.82% medication error rate. The errors involved 2 residents (R75, R45) in the sample of 29 out of 7 residents observed during the medication administration.
Findings include:
1. On 3/9/2022 at 11:50 AM, V16, Licensed Practical Nurse (LPN), administered medications for R75. V16 did not administer artificial tears solution 1% to R75. V16 stated the resident (R75) is a veteran and he gets his medication through the VA (Veteran's Administration) and his medications take a while to come in. V16 documented the artificial tears solution 1% was not available.
R75's 3/2022 Physician's Order Sheet (POS) documents the order to administer artificial tears solution 1% Instill 1 drop in both eyes four times a day for dryness.
2. On 3/9/2022 at 12:15 PM, V16, LPN, administered Gabapentin 300 mg and Feosol 325 mg via g tube to R45.
R45's 3/2022 POS documents the orders to administer Gabapentin 300 mg by mouth three times a day for neuropathy pain (nerve pain) and Feosol 325 mg by mouth three times a day for anemia.
On 3/9/2022 at 12:20 PM, V16, LPN, stated that R45's medications are ordered by mouth, but R45's preference is to take all medications via g tube. V16 stated she started working here over a year ago and R45 has been taking his medications via g tube before she started. V16 stated she hasn't contacted the R45's physician about it because it's always been this way.
On 3/9/2022 at 12:23 PM, R45 stated, I have a g tube so I'm going to use it. About a year ago, I took 7-10 medications by mouth at once and I choked on them and that left a sour taste in my mouth and so I want all medications to be taken by g tube. I haven't spoke to the doctor about it.
On 3/10/2022 at 1:00 PM, V2, Director of Nurses (DON), stated she expected staff to administer medications per physician's orders including the correct route. V2 stated she didn't understand why R45's medications were ordered by mouth if he prefers his medications to be administered via g tube that staff would just call the resident's physician and get the order changed. V2 stated R75's Artificial Tears was available at the facility, V16 was not correct in stating they have to wait for the VA to send the medication, the facility purchases it and the VA reimburses the facility.
The facility's Medication Administration General Principles policy and procedure, revised 1/14/2020, documents, Policy: Medications will be administered in a safe, efficient and accurate manner to residents for whom they are prescribed and in accordance with current acceptable nursing practice. It continues under Policy Guidelines and interpretation: 2. Medications mus be administered as ordered by the physician. It further documents, 6. Medications will be administered in accordance with the six (6)'Rights. f. Right Route: Verify this against the MAR and medication label. Routes medication can be given include but are not limited to; orally, opthalmologically, intravenously, intramuscularly, or enterally. 7. Individuals administering medications should check the medication label against the medication administration record multiple times to verify that the right drug in the right dose and right dosage form is being given at the right time and by the right route.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents are free of significant medication errors for 1 of...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents are free of significant medication errors for 1 of 5 residents (R22) reviewed for medications in the sample of 29.
Findings include:
R22's Face Sheet, documents he was admitted to the facility on [DATE] with diagnosis to include cerebral infarction (stroke.)
R22's Physician's Order Sheet (POS), dated 1/11/2022, documents Warfarin Sodium (anticoagulant/blood thinner medication) give 7.0 mg at bedtime for treating/preventing blood clots.
R22's Care Plan, dated 1/10/2022, documents the resident was at risk for bruising and bleeding related to daily use of aspirin and statin (high cholesterol medication.) The anticoagulant medication was not addressed on the resident's care plan.
R22's Care Plan dated 1/20/2022 was revised on 3/10/2022 documents the facility addressed he was on an anticoagulant. Focus: Resident is at risk for bruising and bleeding related to use of anticoagulant. Goal: he will not suffer adverse side effects of medication use. Interventions: administer medications as ordered by physician, labs as ordered, report abnormal labs results to the physician. Observe for/report PRN (when needed) adverse reactions of anticoagulant therapy, blood tinged or blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs, observe skin with daily care for changes in color and/or open areas and report if present.
R22's 1/2022 Medication Administration Record (MAR) documents Warfarin 7.0 mg tablet documents 29 doses of those 29 doses, four have no documentation that the dose was given.
R22's 2/2022 MARdocuments Warfarin 6.5 mg tablet (one 6.0 mg tablet and one 0.5 mg tablet) documents 54 doses of those 54 doses, 18 have no documentation that the dose was given.
R22's MAR, dated 3/1/2022 through 3/8/2022, documents Warfarin 6.5 mg tablet (one 6.0 mg tablet and one 0.5 mg tablet) documents 16 doses of those 16 doses, 3 have no documentation that the dose was given.
On 3/11/2022 at 8:15 AM, V16, Licensed Practical Nurse (LPN), opened the medication cart and showed R22's Warfarin tablets. The medication cart contained R22's Warfarin 6.0 mg tablet and 0.5 mg tablet medication pack dated 3/8/2022 still in the medication cart in a red high alert bag. There was Warfarin dated 3/11/2022 and 3/12/2022 on the cart as well. The Warfarin 6.5 mg dose is prescribed to be administered at 9:00 PM so V16 doesn't administer this medication.
On 3/11/2022 at 8:40 AM, V27, LPN, stated she is an agency nurse and works evening shift from 2:30 PM to 10:30 PM. V27 stated she worked 3/8/2022 and stated she was assigned to R22. V27 stated when she administers medications she signs it off as given on electronic medication administration record (EMAR.) She did not know why R22's Warfarin 6.0 mg tablet and 0.5 mg tablet would still be in the medication cart. V27 stated she did not recall any medication being in a red alert bag so she may have missed administering the Warfarin medication to R22 but she wasn't sure. V27 stated she always checks the medication and date on the medication pack to ensure it is the correct medication, correct date and correct dose before administering it.
On 3/10/2022 at 9:12 AM, V2, Director of Nurses (DON), stated she expected when a resident is on a blood thinner medication it should be care planned because of the side effects of the medication, Warfarin could cause excessive bleeding and bruising. V2 stated a blank box on the MAR typically means the medication was not given. V2 stated she expected staff to document a progress note explaining why the medication was not administered.
On 3/11/2022 at 8:30 AM, V2, DON, observed R22's Warfarin dated 3/8/2022 in the medication cart and stated it must not have been administered. V2 stated she expected all medications, including Warfarin to be administered per the date that is listed on the medication package.
On 3/10/2022 at 9:10 AM, V1, Administrator, stated the facility does not have a Warfarin/blood thinner policy.
https://www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/a-patients-guide-to-taking-warfarin documents, Warfarin must be taken exactly as prescribed.
Never increase or decrease your dose unless instructed to do so by your healthcare provider. If a dose is missed or forgotten, call your healthcare provider for advice.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on observation and interview, the Facility failed to maintain food temperatures to ensure food is served at palatable temperatures. This has the potential to affect all 86 residents residing in ...
Read full inspector narrative →
Based on observation and interview, the Facility failed to maintain food temperatures to ensure food is served at palatable temperatures. This has the potential to affect all 86 residents residing in the facility.
Finding includes:
On 3/8/2022 at 8:25 AM, the following food temperatures were obtained off the kitchen steamtable using calibrated metal thermometer: pureed eggs were 123 degrees Fahrenheit (F), and the boiled egg was 116 degrees F.
On 3/8/2022 at 12:23 PM, V6, Dietary Manager stated, I am not sure what the serving temperature for hot items should be. I will have to look at the paperwork. But yes, I would expect the policy to be followed.
On 3/9/2022 at 12:38 PM, the following food temperatures were obtained from the kitchen steamtable using metal calibrated thermometer: pureed green beans were 124.5 degrees F, mechanical soft pulled pork was 125.7 degrees F, mashed potato puree were 122.0 degrees F, and potato salad was 51.9 degrees F. V6 stated, Whenever we take the top off of the steam table, all the steam comes out. I think we need a new steam table.
On 3/9/2022 at 1:20 PM, V3, Administrator in Training, stated there is no policy regarding food holding and serving temperatures. V3 stated, I would expect our staff to follow the regulations.
The Resident Census and Condition of Residents Form, CMS 672, dated 03/08/2022, documents that the facility has 86 residents living in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 86 residents liv...
Read full inspector narrative →
Based on observation and interview, the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 86 residents living in the facility.
Finding includes:
On 3/8/2022 at 7:52 AM, in the kitchen, there were three containers of dry cereal with no label or date.
On 3/8/2022 at 7:56 AM, there were two bags of potato chips in the dry storage area that were not labeled or dated. One package was open, but not sealed. The other package was wrapped in plastic wrap. There was a package of instant mashed potatoes that was half empty with no label or date. There was a half empty large bag of farfalle pasta with no label or date. There was an opened bag of brownie mix sealed with saran wrap with no label or date. There was a chicken gravy mix wrapped up in plastic with no label or date. Two plastic bins with brown powdery substance and one small bag containing white powdery substance were not labeled or dated. There were two 28-ounce instant vanilla pudding/pie mix packages that were wrapped in plastic, but not labeled or dated. There was a 24-ounce package of strawberry gelatin, a package of cheesecake mix and a bag of powdered sugar, all opened with no label or date.
On 3/8/2022 at 8:07 AM, in the main kitchen area, V7, Dietary Aide, was holding a pitcher with a white powdery substance inside. No label or date on pitcher. V7 stated, This is thickener.
On 3/8/2022 at 8:09 AM, in the walk-in freezer there were ice crystals to left side of the cooling unit, about 1 inch in thickness. Half of a round cake was wrapped up in plastic wrap with no date or label. There was a large clear plastic bag with approximately 50 pieces of unknown meat. V5, Cook, stated, Those are chicken thighs. We usually label and date everything, but whoever put this in here didn't. There was a bag of opened pepperoni, approximately 10 pounds in size, without a label or date. There was a plastic bag of opened hash browns that was not sealed, labeled or dated. There was an opened plastic bag of biscuits that were not dated or labeled. There was an opened 25-pound box of premade chocolate chip cookies that was not resealed, labeled, or dated.
On 3/8/2022 at 8:14 AM in the main kitchen area, there were three 18-quart plastic containers labeled thickener, sugar, and flour that were not dated.
On 3/8/2022 at 8:15 AM in the walk-in refrigerator, there was a package of sliced ham that was open, but not resealed, labeled or dated. There was a whole smoked ham that was re-sealed, but not labeled or dated. There was a 16-ounce carton of beef base that was opened, but not dated. There were three stainless steel containers containing cooked chicken strips, chicken gravy, and ketchup. These were covered with plastic wrap, but not dated or labeled. There was a 5-pound brick of cheese that had been opened with no label or date.
On 3/8/2022 at 8:17 AM, in the refrigerator there were three trays full of glasses stacked up on the bottom shelf. V7, Dietary Aide, stated it was Kool Aid. Each of the 41 glasses was covered in plastic wrap, but none were labeled or dated. On the middle shelf, there were 5 glasses containing clear and orange liquid that had plastic wrap on top but were not labeled or dated. V7 reported these contained thickened water and thickened juice. On top shelf were five salads covered in plastic wrap with no dates or labels. On the top shelf was a 46-ounce container of opened nectar thickener that was not dated.
On 3/8/2022 at 8:21 AM, there were industrial size spice containers containing seasoned salt, garlic powder, dark chili powder, ground mustard, paprika, basil, oregano, nutmeg and allspice with no date. On the same shelf, there was a 32-ounce box of baking soda that was dated but left open and not resealed.
On 3/8/2022 at 12:23 PM, V6, Dietary Manager, stated, I would expect staff to label and date all items. I tell them that every day.
On 3/9/2022 at 1:20 PM, V3, Administrator in Training, stated there is no policy regarding food storage and labeling/dating. V3 stated, I would expect our staff to follow the regulations.
The Resident Census and Condition of Residents form, CMS 672, dated 03/08/2022, documents that the facility has 86 residents living in the facility.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 6 life-threatening violation(s), Special Focus Facility, 8 harm violation(s), $347,886 in fines, Payment denial on record. Review inspection reports carefully.
- • 55 deficiencies on record, including 6 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $347,886 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
✓ Report will be sent to your email
About This Facility
What is Autumn Meadows Of Cahokia's CMS Rating?
CMS assigns AUTUMN MEADOWS OF CAHOKIA an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Autumn Meadows Of Cahokia Staffed?
CMS rates AUTUMN MEADOWS OF CAHOKIA's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 49%, compared to the Illinois average of 46%.
What Have Inspectors Found at Autumn Meadows Of Cahokia?
State health inspectors documented 55 deficiencies at AUTUMN MEADOWS OF CAHOKIA during 2022 to 2025. These included: 6 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 8 that caused actual resident harm, and 41 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Autumn Meadows Of Cahokia?
AUTUMN MEADOWS OF CAHOKIA is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 150 certified beds and approximately 88 residents (about 59% occupancy), it is a mid-sized facility located in CAHOKIA, Illinois.
How Does Autumn Meadows Of Cahokia Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, AUTUMN MEADOWS OF CAHOKIA's overall rating (1 stars) is below the state average of 2.5, staff turnover (49%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Autumn Meadows Of Cahokia?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Autumn Meadows Of Cahokia Safe?
Based on CMS inspection data, AUTUMN MEADOWS OF CAHOKIA has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 6 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Autumn Meadows Of Cahokia Stick Around?
AUTUMN MEADOWS OF CAHOKIA has a staff turnover rate of 49%, which is about average for Illinois nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Autumn Meadows Of Cahokia Ever Fined?
AUTUMN MEADOWS OF CAHOKIA has been fined $347,886 across 3 penalty actions. This is 9.5x the Illinois average of $36,558. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Autumn Meadows Of Cahokia on Any Federal Watch List?
AUTUMN MEADOWS OF CAHOKIA is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.