TIMBER POINT HEALTHCARE CENTER
For profit - Corporation
110 Beds
ATIED ASSOCIATES
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
6/100
#411 of 665 in IL
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Timber Point Healthcare Center has received a Trust Grade of F, indicating significant concerns regarding its care and operations. Ranking #411 out of 665 facilities in Illinois places it in the bottom half, and #4 out of 6 in Adams County suggests only one local option is better. While the facility is improving-reducing its issues from 18 in 2024 to 15 in 2025-serious concerns remain. Staffing ratings are below average at 2 out of 5 stars, with a turnover rate of 48%, which is around the state average, but they do have better RN coverage than 75% of facilities, which can help catch important health issues. Unfortunately, recent inspections uncovered critical failures, including the failure to administer prescribed pain medications to residents suffering from severe conditions, resulting in uncontrolled pain and withdrawal symptoms. Additionally, some residents developed painful pressure ulcers due to a lack of proper care and assessments, highlighting both the weaknesses in their current operations and the potential risks for residents.
- Trust Score
- F
- In Illinois
- #411/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $51,555 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 50 minutes of Registered Nurse (RN) attention daily — more than average for Illinois. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 36 deficiencies on record. Higher than average. Multiple issues found across inspections.
6/100
Bottom 39%
Review needed
18 → 15 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 18 issues
2025: 15 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Illinois average (2.5)
Below average - review inspection findings carefully
Staff Turnover: 48%
Near Illinois avg (46%)
Higher turnover may affect care consistency
Federal Fines: $51,555
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: ATIED ASSOCIATES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 36 deficiencies on record
2 life-threatening 2 actual harm
Jun 2025
15 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
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 update the care plan with pressure relieving intervent...
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 update the care plan with pressure relieving interventions, implement pressure relieving interventions to prevent facility acquired pressure ulcers, conduct routine skin checks, and perform Braden Scale Assessments (Pressure Risk Assessments) quarterly as directed by the facility's policy for three of five residents (R4, R10, and R32) reviewed for pressure ulcers in the sample of 44. These failures resulted in R4 developing two facility acquired painful stage two pressure ulcers to R4's buttocks, R32 developing a facility acquired unstageable deep tissue pressure injury to R32's right heel that continues to worsen, and R10 developing a facility acquired painful unstageable pressure ulcer to R10's right heel that required surgical debridement (removing of damaged tissue).
Findings include:
The facility's Measurement of Alterations in Skin Integrity policy dated [DATE] documents Policy: 1. At first observation of any skin condition, the charge nurse or treatment nurse is responsible to measure and/or describe skin condition in the clinical record. 2. All measurements will be recorded in centimeters. All wounds/ulcers (i.e. (example) pressure, arterial, diabetic, venous) will be measured weekly and results recorded in a clinical record. Wound Assessment: 2. Pressure Injuries: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose fat is visible in the ulcer and granulation tissue epibole (rolled wound edges) are often present. Sloth and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If sloth or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. (example) dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precedes skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent or tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness, pressure injury (Unstageable Stage 3 or Stage 4). Do not use (DTPI) (Deep Tissue Pressure Injury) to describe vascular, traumatic, neuropathic, or dermatologic conditions.
The facility's Prevention of Pressure Wounds policy dated [DATE] documents Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. See policy and procedure for specific task, such as bathing, incontinent care, and repositioning. General Guidelines: 1. Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. 2. The most common site of a pressure injury is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulders blades, backbone, hips, knees, heels, ankles, and toes. 3. Pressure can also come from splints, casts, badges, and wrinkles in the bed linen. If pressure injuries are not treated when discovered, they quickly get larger, become very painful for the resident, and often time become infected. 4. Pressure injuries are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e. (example), perspiration, feces, urine, wound discharge, soap residue, etc. (et cetera) decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. 5. Once a pressure injury develops, it can be extremely difficult to heal. Pressure injuries are a serious skin condition for the resident. 6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Interventions and Preventive Measures: General Preventive Measures 1. Identify risk factors for pressure injury development. 2. For a person in bed: a. Change position at least every two hours or more frequently if needed; b. Determine if resident needs a special mattress; c. If a special mattress is needed, use one that contains foam, air, as indicated; 13. Protect bony prominence's as needed. Residents with Risk Factors - Bed-fast 1. Change position at least every two hours and more frequently as needed. 2. Use a special mattress that meets clinical condition. 5. Unless resident has both sacral and ischial pressure injuries, avoid placing directly on the greater trochanter for more than momentary placement. Resident with Risk Factors -Chair-fast 2. Residents who are able to cooperate and understand should be taught to shift weight every 15 minutes while sitting in a chair. Equipment and Supplies 1. Tools for assessing skin and pressure injury risk: a. Braden Risk Assessment Form.
The facility's Braden Pressure Ulcer Risk Assessment Tool dated [DATE] documents The Braden scale is recognized by the AHCPR (Agency for Healthcare Research and Quality) as being an appropriate clinical tool for determining Pressure ulcer risk because of the amount of clinical research supporting its reliability and validity. The Braden Scale has 6 (six) subscales: sensor, perception, moisture, activity, mobility, nutrition, and friction/shear. Form Completion Instructions: 1. This form should be completed for every new admission, weekly for the first month, at least quarterly, and with any significant change in condition. 7. Use the scale listed on the top of the page to determine the resident's Risk Level. A score of 19 or above indicates no risk. A score of 18 or less indicates risk of pressure ulcer development. 9. Review the subscales scores in each category to determine appropriate individualized interventions to be implemented where needed. These individualized interventions should be part of the plan of care.
1.) R10's current Physician's Order Report dated [DATE] through [DATE] documents R10 is an [AGE] year-old with the diagnoses of a history of a right femur fracture with closed reduction, Type II Diabetes Mellitus, Transient Cerebral Ischemic Attack, Hyperlipidemia, and Lack of Coordination.
R10's MDS (Minimum Data Set) assessment dated [DATE] documents required substantial/maximum assistance of staff for rolling left and right and transfers, was at risk for developing pressure ulcers, and currently had no pressure ulcers at that time.
R10's MDS assessment dated [DATE] documents R10 is severely cognitively impaired, requires substantial/maximum assistance of staff for rolling left and right and transfers. This same MDS documents R10 is at risk for developing pressure ulcers and currently has an unstageable pressure ulcer that was facility acquired.
R10's Electronic Health Record dated [DATE] through [DATE] does not document that R10 receives routine skin checks.
R10's Braden Scale assessment dated [DATE] documents R10 had a score of 15, indicating R10 was at a mild risk of developing a pressure ulcer. This same assessment documents R10's mobility was very limited.
R10's Braden Scale assessment dated [DATE] documents R10 had a score of 16, indicating R10 was at a mild risk of developing a pressure ulcer. This same assessment documents R10's mobility was slightly limited.
R10's Electronic Health Record does not include any further Braden Scale Assessment since [DATE].
R10's Pressure Ulcer assessment dated [DATE] documents, Date Pressure Ulcer Observed: [DATE]. Length 3.5 cm (centimeters) by width 2.0 cm by depth 0.5 cm. Moderate serosanguinous (pale red to pink, thin, and watery) exudate (drainage). Stage: Unstageable-slough (dead tissue) and or eschar (layer of dead tissue).
R10's Progress Notes dated [DATE] documents, Pressure ulcer noted to right heel.
R10's current Care Plan does not include any pressure relieving interventions until [DATE], once R10 already developed a pressure ulcer to the right heel.
R10's Wound Center Progress Notes dated 5-28-25 and signed by V20 (Advanced Practice Nurse) documents, History of Present Illness: [DATE]: Has heel boots, however at nursing home, not been consistently applied. [DATE]: Follow/up for right heel pressure injury. (R10) has not had foam heel lift boot on during the day, only at night. Bilateral heel lift boots. (R10) still complains of pain. Discussed the importance of off-loading. [DATE]: Follow/up for right heel pressure injury. Slough debrided today. Wound Assessment: Right heel is a chronic stage three pressure injury pressure ulcer acquired on [DATE] and has received a status of not healed. [DATE] subsequent wound encounter measurements are 2.5 cm (centimeters) length by 0.7 cm width, by 0.1 cm depth. There is a moderate amount of sero-sanguineous drainage noted. 1-25% (percent) slough, 51-75% eschar. The peri-wound skin exhibited edema. (R10) to wear heel lift boots at all times even when in the wheelchair during the day. Start betadine (anti-septic solution) paint to the area. Continue with heel lift boots.
On [DATE] from 9:30 AM to 10:15 AM R10 was sitting in her wheelchair with her heels in padded boots. These boots did not have a pressure off-loading cavity to the heels, therefore pressure was not being relieved to either of R10's heels.
On [DATE] at 10:00 AM V7 (Registered Nurse/RN) provided a treatment of betadine solution to R10's right heel pressure ulcer. R10's right pressure ulcer was dark purple in color and approximately 2.5 cm long by 0.6 cm wide with an unmeasurable depth.
On [DATE] at 10:15 AM V7 (RN) stated, (R10's) wound to the right heel was caused by pressure. (R10) did not wear any kind of pressure relieving boots and did not have her heel off-loaded while in bed prior to development of the pressure ulcer.
On [DATE] V2 (Director of Nursing/DON) stated, Braden Scale Assessments are supposed to be performed quarterly and with a significant change in status. (R10) has not had a Braden Scale Assessment completed since [DATE]. (R10) was due to have a Braden Scale Assessment done on [DATE]. Either I or (V11/MDS Coordinator) were responsible for completing (R10's) Braden Scale Assessment in April.
On [DATE] at 11:20 AM V20 (Wound Clinic Advanced Practice Registered Nurse) stated, (R10's) wound to the right heel was caused by pressure. (R10) should have had her heels off-loaded and pressure relieving interventions implemented prior to (R10) developing the pressure ulcer to the right heel. That would have help to prevent (R10) from developing a pressure ulcer to the right heel. (R10's) pressure relieving boots should have had a hole cutout in the heel to prevent pressure. Regular padded boots would not relieve pressure and (R10) would need her heels always off-loaded if the boots did not have a heel cutout. (R10) does have pain to the right heel pressure ulcer. I had to surgically debride (R10's) right heel wound on [DATE]. (R10) should always have someone doing weekly skin checks while at the facility.
On [DATE] at 11:30 AM V2 (DON) stated, I looked back in (R10's) medical record and (R10) has not been receiving skin checks since [DATE]. Somehow this was missed. If (R10) was receiving skin checks prior to [DATE] the pressure ulcer would have been found before it was found as bad as it was. When the pressure ulcer to (R10's) right heel was found it was unstageable and very big. (R10) did not have any care planned pressure relieving interventions prior to the development of (R10's) pressure ulcer to the right heel.
2.) On [DATE] at 8:49 AM, R4 was laying supine in R4's bed. R4 stated that R4 has a wound on her coccyx. R4 stated the staff don't put a bandage on the area, but they clean it when she is changed. R4 further stated R4's bottom hurts all the time. R4's mattress was a standard foam mattress.
On [DATE] at 9:40 AM, V17 (Certified Nursing Assistant), V18 (Certified Nursing Assistant), and V19 (Certified Nursing Assistant) provided perineal care to R4 in R4's bed. V17 cleaned barrier cream off R4's coccyx and there were two small open areas each comparable in size to a pea at the top of each side of R4's buttocks. V17 confirmed R4 was not on a pressure relieving air mattress. V17, V18, and V19 stated they were unsure of how long R4's coccyx had openings.
R4's current care plan documents R4 is at risk for developing pressure ulcers related to decreased mobility, incontinence, and morbid obesity. This same care plan documents R4 requires extensive assistance for mobility and transfers with a mechanical lift.
R4's Braden assessment dated [DATE], documents R4 has mild risk for skin impairment.
R4's current care plan documents R4 is to have a pressure relieving mattress on R4's bed.
R4's Physician order dated [DATE] documents R4's bed is to have a pressure relieving mattress.
On [DATE] at 10:00 AM, V23 (Registered Nurse) stated V23 was not aware R4 had open areas on R4's buttocks.
On [DATE] at 10:05 AM, R4's electronic medical chart does not contain documentation of any pressure areas on R4's buttock.
R4's Nurse progress note dated [DATE] by V2 (Director of Nursing) documents R4 has two stage two pressure ulcers on R4's coccyx and wound nurse will evaluate.
3.) R32's Nurse Progress Note dated [DATE] at 11:13 AM, documents R32 received a shower and R32's heels on R32's feet were soft and boggy and R32 seemed like R32 had pain when heels were touched. R32's right heel appears to have a deep tissue injury (DTI). R32 was placed in heel boots for protection and comfort. Staff educated on ensuring repositioning every two hours and offloading heels.
R32's MDS dated [DATE] documents R32 is severely cognitively impaired. R32's MDS documents R32 is dependent on staff for all ADLs.
R32's Braden assessment dated [DATE] documents R49 is at high risk for skin alterations.
R32's current care plan documents R32 is at risk for skin alterations related to dementia, poor safety awareness, and fragile skin. R32's current care plan does not contain pressure relieving interventions to prevent pressure ulcers.
R32's Wound Note dated [DATE] documents to apply zero pressure heel boots while in bed with a wedge cushion and skin prep (preparation) twice daily.
R32's Wound Note dated [DATE] documents R32 has an unstageable pressure ulcer to the right heel measuring 2.5 cm x 4 cm that continues to worsen. This note documents R32's pressure ulcer was found [DATE] and the area was pale and soft. R32's pressure ulcer on [DATE] was dark red in color and unblanchable. R32 has orders for skin prep to heels twice daily, heel protectors while in bed, and turn and reposition while in bed every two hours. R32 is unable to communicate her needs due to cognitive decline secondary to dementia. R32 is non ambulatory.
R32's Nurse Progress Note dated [DATE] documents R32's left heel has a 3.5 cm x 2.0 cm intact wound that was black in color and was irregular shaped. Skin prep as ordered, and heel protectors are in place.
On [DATE] at 9:30 AM, R3 was sitting in R32's high back wheelchair with socks on R32's feet. R32's heels were touching the floor of the dining room with no pressure relieving interventions in place, including heel protector boots as ordered.
On [DATE] at 11:41 PM, R32 's right heel was open to air and R32's heel had a large dark brown/black pressure ulcer covering the right heel. R32 was lying in bed with bilateral heels on a foam mattress. R32 did not have an air mattress and did not have heel protector boots on as ordered.
On [DATE] at 2:21 PM, V26 (Nurse Practitioner) stated R32's right heel continues to worsen and V26 states it's because pressure is not being relieved to the heel as V26 directed the staff to do. V26 further stated whether it's when R32 is sitting up in R32's chair or in bed and the boots are not being applied correctly, the continued pressure to R32's heel is still an issue that would cause R32's right heel pressure ulcer to worsen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 develop a plan of care to address advanced directives for one of two...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a plan of care to address advanced directives for one of two residents (R44) reviewed for advanced directives in the sample of 44.
Findings include:
The facility's Advanced Directive and Advanced Care Planning/POLST (Physician Orders for Life Sustaining Treatment) Guideline dated [DATE] documents Purpose: It is the practice of the facility to establish, implement and maintain written guidelines for advanced directives and advanced care planning/POLST. The resident has the right and the facility will assist the resident to formulate an advance directive at their option. Procedure: G. During the quarterly RAI (Resident Assessment Instrument) process and with any significant changes of condition, facility staff will a. Identify, clarify, and review the existing care instructions and whether the resident wishes to change or continue instructions from the advance directive. e. Changes to the resident choices for advanced directives will be documented, included in the resident plan of care, State specific documents will be updated as necessary, physician orders will be obtained to reflect new choices as applicable, and all items will be communicated to staff providing resident care. Advance Care Planning A. In order for a resident to exercise his or her right to make informed choices about care and treatment in preparation for a time when the resident may not be able to make decisions, designated personnel and/or physician will assist with defining and clarifying medical issues and presenting the information regarding relevant health care issues to the resident or his/her legal representative, in a language that the resident can understand, as appropriate. B. The interdisciplinary team will identify, clarify, and review, as part of the comprehensive care planning process, the existing care instructions along with resident's goals wishes as the resident's medical condition changes.
R44's IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form dated 4-9-24 and signed by V12 (R44's) Power of Attorney documents, No CPR: Do Not Attempt Resuscitation (DNR). Comfort-Focused Treatment.
R44's Current Care Plan does not include a plan of care to address R44's advanced directives.
On [DATE] at 1:48 PM V11 (Care Plan Coordinator) stated, (R44) does not have a current Advanced Directives Care Plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to protect the resident's right to be free from misappropriation of intravenous medication for one of one resident (R319) reviewe...
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Based on observation, interview, and record review the facility failed to protect the resident's right to be free from misappropriation of intravenous medication for one of one resident (R319) reviewed for misappropriation of medications out of a sample list of 44.
Findings include:
The Abuse Prevention Policy undated documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. Misappropriation of a resident's property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.
R64's Nurse Progress Notes dated 5/26/25 at 1:15 PM, document V23 (Registered Nurse) received an order to infuse a one-liter bag of normal saline intravenously at maximum flow. V23 further documents that V23 inserted a 22-gauge intravenous needle in R64's left forearm and infused one liter of normal saline by gravity tubing at maximum flow.
On 06/01/25 at 11:01 AM, in R64s room an intravenous pole with an empty one liter bag of Normal Saline that was hanging from the pole and dated 1/7/25 with (R319's) name on the printed pharmacy label.
On 6/1/25 at 11:05 AM, R64 stated R64 received intravenous fluids sometime last week and that bag hanging was the fluids V23 (Registered Nurse) infused.
On 06/01/25 at 11:25 AM, V2 (Director of Nursing) stated R64 was given the intravenous fluids last week. V23 called V2 and made V2 aware that V23 hung a bag of fluids that was in the medication storage room that had belonged to a former resident (R319). V2 stated V2 told V23 to remove (R319's) name off the bag. V2 stated V2 was not aware the date on the intravenous bag was 1/7/25 or that the bag was still in R64's room. V2 stated V23 should have used a bag of normal saline from the facility medication back up supply.
On 06/03/25 at 8:03 AM, V23 stated that V23 was struggling to remove the bag of fluids from the medication storage unit. V23 stated there were extra bags of fluids in the medication storage room so V23 grabbed one and infused an extra bag of normal saline instead. V23 stated V23 was aware the bag V23 infused in R64 belonged to a former resident R319.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
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 issue a bed hold notice for two of two residents (R25 and R28) revie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to issue a bed hold notice for two of two residents (R25 and R28) reviewed for hospitalization in the sample of 44.
Findings include:
The facility's Bed Hold and readmission policy dated November 2016 documents Standards: 1. Residents, or their designated representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours. The facility provides written notification at the time of transfer as included in the designated state form. The notice to the resident or the representative will specify the facility's policy, the duration of the state bed hold policy and the reserve bed payment policy. 2 In the event of an emergency hospitalization the resident or their representative shall be notified by telephone or in person of this policy, within 24 hours, and asked to provide the facility with their decision. The staff member making the call or explaining the policy may accept verbal determination as to whether the resident desires bed hold or having their name placed on their reservations/waiting list and shall document same in the medical record and end the progress notes. Follow up written confirmation may be required.
1. R25's Census Record and Progress Notes documents R25 was sent to the hospital and admitted for 24-hour observation from 12/20/24 through 12/21/24.
R25's Electronic Health Record does not include evidence of R25 receiving a bed hold notice upon transfer to the hospital on [DATE].
On 06/01/25 at 10:05 AM R25 stated, I went to the hospital in December 2024 for chest pain. I did not get a bed hold notice when I was sent for chest pain.
On 06/02/25 at 10:20 AM V1 (Administrator) stated R25's medical record does not include evidence of a bed hold being given to R25 when R25 was transferred to the hospital on [DATE].
2. R28's Face Sheet documents R28 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Diabetic Neuropathy, Dementia, Chronic Kidney Disease (Stage 3), and Malignant Neoplasm of Uterus.
R28's Nursing Note dated 4/17/25 at 3:05 PM documents R28 was sent to the ER/emergency room for treatment of constipation.
R28's Electronic Health Record does not include evidence of R28 receiving a bed hold notice upon transfer to the hospital on 4/17/25.
R28's emergency room Summary dated 4/17/25 documents that R28 was seen in the ER on [DATE] for constipation.
On 6/2/25 at 2:20 PM V1/Administrator stated that R28 was sent to the ER on [DATE] and there was not a bed hold done for R28.
On 6/3/25 at 8:25 AM, V25/Registered Nurse stated that a bed hold should be given to the resident when they are sent to ER.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 accurately code a MDS (Minimum Data Set) Assessment for one of 17 re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to accurately code a MDS (Minimum Data Set) Assessment for one of 17 residents (R44) reviewed for MDS accuracy in the sample of 44.
Findings include:
The facility's Comprehensive Assessment/MDS Policy undated documents Policy: It is the policy of this facility to perform a comprehensive, accurate, standardized, reproducible assessment of each residence status following admission, quarterly thereafter and annually in order to obtain information vital to the development of the resident's plan of care. In addition to facility approved departmental assessment forms, the assessment shall be summarized using a standardized federally and state approved uniform data set. Standards: 11. All assigned disciplines shall participate in the completion of the MDS assessment form and shall verify accuracy and completion of each respective section by indicating the letter of the section, adding their signature and dating. The scope of each discipline's assessment is defined by professional practice or industry guidelines.
R44's Physician's Orders dated 04/11/2025 document, Admit to hospice.
R44's MDS assessment dated [DATE] Section O Special Treatments, Procedures, and Programs documents R44 does not receive any special treatment, procedures, and programs, including hospice.
On 06/02/25 at 10:42 AM V11 (MDS Coordinator) stated R44's MDS assessment dated [DATE] is inaccurately coded and I should have marked that R44 receives hospice services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
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 refer a resident to the PASRR (Preadmission Screening and Resident R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to refer a resident to the PASRR (Preadmission Screening and Resident Review) State Agency to obtain a Level II PASRR after being diagnosed with a Mental Illness for one of one resident (R31) reviewed for Mental Illness in the sample of 44.
Findings Include:
The Pre-admission Screening and Resident review (PASRR) policy, undated documents It is the policy of this facility to 1. Comply with Federal, State and the appointed screening agency Maximus, in standards addressing the PASRR assessment/screening process. 2. Request full and complete PASRR materials (Level 1 and 2) from each referral source prior to or soon following admission. Procedure: 1. A facility representative shall request the complete screening from the referral source. 2. A copy of all the materials received will be placed in the residence business file and the EMR (electronic medical record) at the discretion of administration.
R31's admission Record documents that R31 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Depression Disorder. On 2/1/21 R31 was diagnosed with Bipolar II Disorder.
R31's current Physician Orders documents R31 has an order for Quetiapine (Antipsychotic medication) 300 mg (milligrams) two tablets by mouth at bedtime for Bipolar II Disorder.
R31's Medical Record reviewed 6/1/25 does not include evidence of the facility obtaining R31's PASRR Level II after being diagnosed with Bipolar II Disorder on 2/1/21.
On 6/2/25 at 2:07 PM, V27/Social Service Director stated that R31 did not have a PASRR II It was never requested. V27 verified that R31 got the diagnosis of being Bipolar on 2/1/21 and that is when the PASRR II should have been done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
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 ensure the fingernails were kept trimmed for two of 17...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the fingernails were kept trimmed for two of 17 residents (R29 and R37) reviewed for ADL (Activities of Daily Living) Assistance in the sample of 44.
Findings include:
The facility's Nail Care Guidelines dated 2/23 documents Guidelines: Nail care includes routine cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.
1. R29's MDS (Minimum Data Set) assessment dated [DATE] documents R29 requires substantial/maximal assistance of staff for personal hygiene.
R29's Shower Sheets dated 03/01/25 through 06/02/25 document R29's fingernails have not been trimmed during this timeframe.
On 06/01/25 at 9:54 AM R29 was lying in bed. All of R29's fingernails were long, jagged, and extended past her fingertips. R29 stated she cannot remember the last time her nails were clipped. R29 stated she would like them clipped.
2. R37's MDS assessment dated [DATE] documents R37 is severely cognitively impaired and requires touching assistance of staff for personal hygiene.
R37's Shower Sheets dated 04/16/25 through 06/02/25 document R37's fingernails have not been trimmed during this timeframe.
On 06/01/25 at 9:43 AM R37 was lying in bed. All of R37's fingernails were long, jagged, and extended past his fingertips. R37 stated he would like his fingernails cleaned and trimmed.
On 06/03/2025 at 9:10 AM V2 (Director of Nursing) stated, All residents' nails should be trimmed short and clean. All residents should get their nails cleaned and trimmed if needed with all showers. If the residents are diabetic, then the nurse would need to trim the nails.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
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 follow the Advanced Directive for one of two residents (R65) reviewe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow the Advanced Directive for one of two residents (R65) reviewed for Advanced Directive in the sample of 44.
Findings include:
The Advanced Directive and Advanced Care Planning/POLST (Physician Orders for Life Sustaining Treatment) Guideline dated [DATE] documents Purpose: It is the practice of the facility to establish, implement and maintain written guidelines for advanced directives and advanced care planning/POLST. The resident has the right and the facility will assist the resident to formulate an advance directive at their option. Procedure: G. During the quarterly RAI (Resident Assessment Instrument) process and with any significant changes of condition, facility staff will a. Identify, clarify, and review the existing care instructions and whether the resident wishes to change or continue instructions from the advance directive. e. Changes to the resident choices for advanced directives will be documented, included in the resident plan of care, State specific documents will be updated as necessary, physician orders will be obtained to reflect new choices as applicable, and all items will be communicated to staff providing resident care. Advance Care Planning A. In order for a resident to exercise his or her right to make informed choices about care and treatment in preparation for a time when the resident may not be able to make decisions, designated personnel and/or physician will assist with defining and clarifying medical issues and presenting the information regarding relevant health care issues to the resident or his/her legal representative, in a language that the resident can understand, as appropriate. B. The interdisciplinary team will identify, clarify, and review, as part of the comprehensive care planning process, the existing care instructions along with resident's goals wishes as the resident's medical condition changes.
R65's Medical Record documents that R65 was admitted to the facility on [DATE] with the following, but not limited to diagnoses: End Stage Renal Disease, Chronic Pulmonary Edema, Dependence on Renal Dialysis, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Heart Failure, Emphysema, and Malignant Neoplasm of Upper-inner Quadrant. The Medical record also documents that R65 passed away on [DATE].
The IDPH (Illinois Department of Public Health) UNIFORM PRACTITIONER ORDER FOR LIFE-SUSTAINING TREATMENT (POLST) FORM dated [DATE] documents that R65 requested NO CPR (Cardiopulmonary Resuscitation): Do Not Attempt Resuscitation (DNAR).
R65's Nursing Note written by V22/Registered Nurse dated [DATE] at 11:02 PM, documents At 10 PM this nurse (V22) entered the room to give (R65) her HS (bedtime) meds (medications) and put on (R65's) Bipap (Bilevel Positive Airway Pressure machine). (R65) was lying in bed on her right side, HOB (Head of Bed) was elevated and o2 (oxygen) was on. (R65) was unresponsive with no pulse and no respiration. Had CNA call 911 while this nurse ran to check DNR (Do Not Resuscitate) status and grab the crash cart. CPR (Cardiopulmonary Resuscitation) was initiated until code status was confirmed. 911 also arrived and confirmed code status. Ambulance left with copy of POLST and face sheet.
The CPR (Cardiopulmonary Resuscitation) Checklist dated [DATE] documents that R65 was given CPR by V21/Certified Nursing Assistant/CNA.
On [DATE] at 11:32 AM, V21/CNA stated that she was working the evening shift and heard V22/RN yell that R65 was not breathing. V21 went to R65's room and started doing compressions. V22 returned to the room and told V21 to stop the CPR that R65 was a DNR. V21 also stated I didn't know that I needed to know the code status before I started CPR. There needs to be a better way to know someone's status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 ensure an indwelling urinary catheter bag was secured ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an indwelling urinary catheter bag was secured and off the floor for one (R64) of two residents reviewed for catheters in the sample list of 44.
Findings include:
The Urinary Catheter Care policy dated September 2005 documents The purpose of this procedure is to prevent infection of the resident's urinary tract. General Guidelines: 11. Be sure the catheter tubing and drainage bag are kept off the floor.
R64's current Physician Orders document R64 was admitted to the facility on [DATE] with a 16 F (French) indwelling (urinary) catheter for urinary retention.
On 06/01/25 at 11:02 AM, R64 was laying supine in bed with R64's indwelling urinary catheter bag laying on the floor next to R64's bed.
On 06/03/25 at 10:00 AM, V5 (Licensed Practical Nurse) stated indwelling urinary catheter bags should be secured to the side of the bed and below the bladder. V5 further stated a urinary catheter bag should never be on the floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interview, and record review the facility failed to resolve several repeated grievances for eight of eight residents (R5, R14, R23, R30, R31, R47, R50, R58) reviewed for grievances in a sampl...
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Based on interview, and record review the facility failed to resolve several repeated grievances for eight of eight residents (R5, R14, R23, R30, R31, R47, R50, R58) reviewed for grievances in a sample of 44.
Finding Include:
The facility's grievance policy dated/revised 1/2025, documents, To provide a process to assist residents, their representatives such as other interested family members or other resident advocates in filing grievances or complaints when such requests are made. Consistent with 483.12(c)(1), by anyone furnishing services on behalf of the provider, all alleged violations involving neglect, abuse, including injuries of unknown source and/or misappropriation of resident property will be immediately reported to the administrator of the provider as required by state law. Written grievance decisions will include the date the grievance was received, a summary statement of the resident grievance, steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents concern(s), a statement as to whether the grievance as confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, the date the written decision was issued.
R5's grievance form dated 12/19/2024, documents R5 filed a grievance of missing clothing items.
R14's grievance form dated 1/13/2025, documents R14 filed a grievance of missing clothing items.
R23's grievance forms dated 8/20/2024 and 12/19/2024 document R23 filed grievances of missing clothing items.
R30's grievance form dated 5/27/2025, documents R30 filed a grievance of missing clothing items.
R31's grievance forms dated 8/20/2024, and 12/19/2024, documents R31 filed grievances of missing clothing items.
R47's grievance form dated 8/20/2025, documents R47 filed a grievance of missing clothing items.
R50's grievance form dated 1/24/2025, documents R50 filed a grievance of missing clothing items.
R58's grievance form dated 12/19/2024, documents R58 filed a grievance of missing clothing items.
The facility's Resident Council Grievance form dated 6/18/2024, documents continuing issue of missing clothing items.
On 6/2/2025 at 10:02 AM during resident council meeting R5, R14, R23, R30, R31, R47, R50, and R58 stated they have made numerous grievances of their clothes missing and their clothes have never been found or resolved.
On 6/3/2025 at 11:00 AM, V1 (Administrator) confirmed missing laundry is an ongoing issue.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure oxygen tubing was changed weekly as ordered and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure oxygen tubing was changed weekly as ordered and dated for five of five residents (R5, R12, R13, R38, and R39) reviewed for oxygen in the sample of 44.
Findings include:
The facility's Respiratory Therapy Prevention of Infection policy dated 8/2008 documents The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the Procedure - Infection Control Considerations Related to Oxygen Administration 7. Change the oxygen cannula and tubing every seven (7) days, or as needed. 8. Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. Documentation - The following information should be recorded in the resident's medical record: 1. The date and time the respirator therapy was performed.
1.) R38's current Physician Order Report documents, 04/22/25 Oxygen: Change tubing and mask weekly and PRN (as needed).
R38's Treatment Administration Records (TARs) dated 06/01/25 through 06/02/25 document, Oxygen: Change tubing and mask weekly and as needed on Sundays. These same TARs document R38's oxygen tubing was not changed on Sunday (06/01/25).
On 06/01/25 at 10:29 AM R38 was lying in bed with oxygen on at two liters via nasal cannula. R38's nasal cannula and oxygen tubing were not labeled with a date.
2.) R5's Medical Record documents that R5 was admitted to the facility on [DATE] with diagnoses which included Emphysema and Acute and Chronic Respiratory Failure with Hypoxia.
R5's Physicians Orders printed 6/3/25, documents Oxygen at four liters continuous. Order date 11/18/24. Change oxygen tubing weekly and as needed (label) once a day on Sunday night. Order date 5/16/24.
R5's Treatment Flowsheet dated 6/1/25 - 6/30/25 documents to change oxygen tubing weekly and as needed (label) once a day on Sunday night. It was not signed as being done on Sunday 6/1/25.
On 6/01/25 at 9:52 AM R5 was sitting in a chair in her room wearing oxygen by nasal cannula. The tubing was dated 5/11/25. R5 stated that the oxygen tubing has not been changed in a while. R5 removed the nasal cannula from her nose and stated, This nose piece is dirty and gummed up.
3.) R12's Medical Record documents that R12 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease.
R12's Physicians Orders printed 6/3/25, documents Oxygen at two liters as needed. Order date 12/18/23. Change oxygen tubing and clean filters weekly on Sundays. Order date 5/1/24.
On 6/1/25 at 10:00 AM, R12 was wearing oxygen lying in bed resting. R12's oxygen tubing was not labeled with the date or initials. R12 stated that she does not know when the tubing was last changed but it is not changed weekly.
4.) On 06/01/25 at 9:59 AM, R39's oxygen tubing was connected to the oxygen concentrator in R39's room. R39's oxygen tubing was not labeled with the date.
5.) On 6/1/25 at 10:02 AM, R13's oxygen tubing was connected to the oxygen concentrator in R13's room. R13's oxygen tubing was not labeled with the date.
On 6/2/25 at 10:00 AM, V23 (Registered Nurse) stated all oxygen tubing should be dated.
On 06/2/25 at 11:58 AM V2 (Director of Nursing) stated, All oxygen tubing should be labeled with the date changed and should be changed every week on Sundays.
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 monitor and record cool down temperatures for prepared meats, label opened food items in the refrigerators, label opened dry food...
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Based on observation, interview, and record review the facility failed monitor and record cool down temperatures for prepared meats, label opened food items in the refrigerators, label opened dry foods, and failed to use correct dish machine sanitizing test strips. These failures have the potential to affect all 69 residents residing in the facility.
Findings include:
The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6-1-25 and signed by V1 (Administrator) documents 69 residents currently reside within the facility.
The facility's two stage cool down process policy (not dated), documents, Potentially hazardous foods will be cooled properly to prevent food borne illness. Foods will be cooled to proper temperatures. The time and temperature of food cooling will be documented at two- and four-hour intervals.
The facility's labeling and dating food policy (not dated), documents, Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality of product for the residents and minimize waste. Bagged or boxed food once removed from original package will be placed in an ingredient bin that is labeled with the common name of the food, date the item is placed, use by date: mark with the date or day or number of days from opened date. Use by date will be based either from manufacturers use by date first or recommended maximum storage period.
The facility's dishwashing procedure policy (not dated), documents, To prevent food borne illness, all dish wares will be cleaned in the dish machine. For temperature sanitizing machines attach a 160 EF (EfferSan sanitizing test strip) to a clean, dry, cool plate; weave a 10-degree Fahrenheit test strip in the tines of a fork; or run through the wash/rinse cycle a maximum reading thermometer to determine if the sanitizing water reaches 180 degrees Fahrenheit.
On 6/2/2025 at 9:00 AM, on one of the facility's kitchen counters there was a bag of opened hot dog buns with no date opened with the top folded over. V15 (Dietary Manager) confirmed these should have been sealed and dated.
On 6/2/2025 at 9:00 AM, the facility's refrigerator located in the back of the kitchen contained several opened undated foods such as liquid eggs, onion, shredded cheese, and an open bottle of soda not belonging to a resident. V15 confirmed these items should have been dated and the soda should not have been in the refrigerator.
On 6/2/2025 at 9:10 AM, V15 removed quaternary test strips to use in the sanitizing machine, placed strip on a small white plate, placed the plate on a dish washing rack, then placed a clear plastic cup on top of test strip and ran this through a cycle in the sanitizing machine.
On 6/2/2025 at 9:15 AM, V15 confirmed she did not know what test strips to use on the sanitizing machine and she did not have the correct test strips. V15 confirmed this dishwasher needs 160 EF sanitizer test strips to accurately measure the dish machine for sanitizer levels and the facility does not have the correct test strips to test the dish machine.
On 6/2/2025 at 9:30 AM, V16 (Kitchen Cook) stated she was cooking a pork loin for 5/3/2025. V15 confirmed kitchen staff were not using a cool down log for meals cooked ahead of time.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to track infections of individuals who enter or live in the facility per CMS (Central Management Services) requirement. This failure had the po...
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Based on interview and record review the facility failed to track infections of individuals who enter or live in the facility per CMS (Central Management Services) requirement. This failure had the potential to affect all 69 residents residing in the facility.
Findings Include:
The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6-1-25 and signed by V1 (Administrator) documents 69 residents currently reside within the facility.
The facility's Infection Prevention and Control Manual Infection Prevention and Control Program (not dated) documents, A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards. A system of surveillance that is designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. When and to whom possible incidents of communicable disease or infections should be reported to.
On 6/3/2025 at 1:30 PM, V2 (Director of Nursing/DON) confirmed they had no tracking of infections currently or in the past for residents or employees.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to designate or hire a full-time infection preventionist per CMS (Central Management Services) requirement. This failure had the potential to a...
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Based on interview and record review the facility failed to designate or hire a full-time infection preventionist per CMS (Central Management Services) requirement. This failure had the potential to affect all 69 residents residing in the facility.
Findings Include:
The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6-1-25 and signed by V1 (Administrator) documents 69 residents currently reside within the facility.
The facility's Infection Prevention and Control Manual Infection Prevention and Control Program (not dated) documents, The facility will designate one or more individual(s) as the infection preventionist(s)(IP)(s) who is responsible for the facility's IPCP (infection prevention control program). The infection preventionist will have primary professional training in nursing, medical technology, microbiology, epidemiology, or another related field. Is qualified by education, training, experience, or certification, works at least part time at the facility, has completed specialized training in infection prevention and control. The facility IP will also be a member of the facility's quarterly assessment and assurance committee and report to the committee on the IPCP on a regular basis.
On 6-1-25 at 11:08 AM V1 (Administrator) stated, We (the facility) terminated (V6/Prior Infection Preventionist) on 2-13-25. (V4) is working on the Infection Preventionist Training but has not completed the training yet. The facility has not had a full-time Infection Preventionist since 2-13-25.
CONCERN
(F)
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 record review and interview the facility failed to ensure all Certified Nursing Assistants received 12 hours of annual in-service training. This failure has the potential to affect all 69 res...
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Based on record review and interview the facility failed to ensure all Certified Nursing Assistants received 12 hours of annual in-service training. This failure has the potential to affect all 69 residents residing within the facility.
Findings Include:
The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6-1-25 and signed by V1 (Administrator) documents 69 residents currently reside within the facility.
All CNA (Certified Nursing Assistant) trainings from 1/1/2024 through 6/2/2025 were reviewed and no CNAs received 12 hours of required annual in-service training.
On 6/3/2025 at 1:30 PM, V2 (DON/Director of Nursing) confirmed all CNAs currently employed at the facility have not received 12 hours of annual in-service training required.
Dec 2024
3 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to notify the physician of a resident not receiving a physician ordered enteral nutrition formula by gastrostomy tube for one of three resident...
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Based on record review and interview the facility failed to notify the physician of a resident not receiving a physician ordered enteral nutrition formula by gastrostomy tube for one of three residents (R1) reviewed for physician notification in the sample of three.
Findings include:
The facility's Gastric Tube Feeding via Continuous Pump policy dated 08/2008 documents, Purpose: The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. Verify compliance with physician's order, including the product volume and infusion rate. Report any complications promptly to the physician.
1. R1's Hospital Discharge Orders dated 11-21-24 document, Tube Feeding: Osmolite 1.5 at a goal rate of 45 ml (milliliter) per hour.
R1's Medications Flowsheet dated 11-21-24 (R1's Admission) through 11-30-24 documents R1 did not receive her physician ordered Osmolite 1.5 calorie/ml (milliliter) at 45 ml per hour via gastrostomy tube on 11-21-24 through 11-25-24.
R1's Medical Record does not include documentation of a physician being notified of R1 not receiving her physician ordered Osmolite nutritional tube feeding as ordered from 11-21-24 through 11-25-24.
On 12-13-24 at 2:30 PM V2 (Director of Nursing) stated, The nurses did not call the physician or gastroenterology specialist to let them know that they did not have Osmolite to administer to (R1) as ordered. The nurses should have called the physician to get an order for a substitute formula until we (the facility) were able to get the Osmolite.
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 F0620
(Tag F0620)
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 follow their Admission's Contract to perform an inventory of a resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow their Admission's Contract to perform an inventory of a resident's personal belongings for one of three residents (R3) reviewed for personal belongings in the sample of three.
Findings include:
R3's admission Contract dated 8-20-24 documents, An inventory sheet will be provided for you and/or your family to fill out to identify all belongings upon admission. Please complete the inventory sheet in its entirety and sign/date. If you need assistance with filling out the inventory sheet, please contact a facility staff member and someone will be assigned to assist you.
R3's MDS (Minimum Data Set) assessment dated [DATE] documents R3 is cognitively intact.
R3's Medical Record does not include an Inventory Sheet of R3's personal belongings.
On 12-13-24 at 12:40 PM R3 stated, When I came into the facility my caregiver brought in a tote of my belongings. The staff made me leave my things with them for three days. The staff said they clean everything before bringing the stuff into the facility to prevent bugs. No one filled out an inventory list of my belongings, and no one gave me an inventory list to fill out.
On 12-14-24 at 11:00 AM V1 (Administrator) stated, The staff never completed an inventory sheet for (R1). All residents should have an inventory sheet completed on admission that includes all of their belongings brought into the 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
Tube Feeding
(Tag F0693)
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 administer a physician ordered enteral nutrition formula by gastrost...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to administer a physician ordered enteral nutrition formula by gastrostomy tube for one of one resident (R1) reviewed for a gastrostomy feeding tube in the sample of three.
Findings include:
The facility's Gastric Tube Feeding via Continuous Pump policy dated 08/2008 documents, Purpose: The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. Verify compliance with physician's order, including the product volume and infusion rate. Documentation: 1. The date and time the procedure was performed. 2. The amount and type of enteral feeding.
1. R1's admission Record documents R1 was admitted to the facility from the hospital on [DATE] with the diagnoses of alcoholic cirrhosis of the liver, severe protein-calorie malnutrition, gastrostomy, ulcerative chronic pancolitis, gastrostomy, and hypocalcemia.
R1's Hospital Discharge Orders dated 11-21-24 document, Tube Feeding: Osmolite 1.5 at a goal rate of 45 ml (milliliter) per hour.
R1's Medications Flowsheet dated 11-21-24 (R1's Admission) through 11-30-24 documents R1 did not receive her physician ordered Osmolite 1.5 calorie/ml (milliliter) at 45 ml per hour via gastrostomy tube on 11-21-24 through 11-25-24.
On 12-13-24 at 2:30 PM V2 (Director of Nursing) stated, (R1) did not receive Osmolite 1.5 calorie at 45 ml per hour from 11-21-24 through 11-25-24. The pharmacy sent the wrong formula (Jevity) to the facility and the nurses did not let me know and did not give (R1) any feeding by g-tube (gastrostomy tube). I was not told until Monday (11-25-24) that (R1) did not receive the Osmolite on 11-21-24 through 11-25-24. The nurses should have called me so I could have made sure (R1) got the Osmolite as ordered.
On 12-13-24 at 6:45 PM V22 (LPN/Licensed Practical Nurse) stated, I worked 11-23-24 and 11-24-24 from 6:00 PM through 6:30 AM and did not give (R1) any g-tube feeding those nights. The facility did not have Osmolite in-house to give (R1).
On 12-13-24 at 7:15 PM V23 (RN/Registered Nurse) stated, I did not give (R1) a g-tube feeding on 11-22-24 from 6:00 PM through 6:00 AM. We (the facility) did not have the Osmolite in-house to give.
Jul 2024
9 deficiencies
CONCERN
(D)
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 observation, interview and record review, the facility failed to develop a personalized Care Plan for 1 resident (R67) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a personalized Care Plan for 1 resident (R67) of 24 residents reviewed for personalized Care Plans in the sample of 34.
Findings Include:
The Care Planning policy dated August 2006, documents Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.
R67's current computerized medical record, documents R67 was admitted to the facility on [DATE] with a diagnosis of Venous Insufficiency (Chronic) (Peripheral), Sciatica, Left Side (Primary), Major Depressive Disorder, Anxiety Disorder, Hypertensive Heart Disease Without Heart Failure, and Localized Edema.
R67's MDS (Minimum Data Set) dated 6/10/24 documents a BIMS (Brief Interview for Mental Status) Score of 13/15, indicating cognition intact.
On 07/08/24 at 10:47 AM, R67 was sitting in her room in her wheelchair. R67 stated her legs have been swelling a lot and R67 needs to wear compression stockings daily.
R67's Physician Orders dated 6/4/24 documents that R67 is to wear (vascular compression stockings) from 6:00 AM to 6:00 PM daily.
R67's Care Plan does not document that R67 should wear compression stockings.
On 7/9/24 at 2:07 PM, V2/Director of Nursing stated there is not a Care Plan for R67 wearing Compression Hose.
On 7/10/24 at 12:36 PM, V3/Assistant Director of Nursing/Wound Nurse stated (R67) has Venous Insufficiency and has an order to wear compression stockings. There was no Care Plan for R67's compression stockings so I added it today that (R67) needs to have them on daily from 6:00 AM to 6:00 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on Observation, Interview and Record Review, the facility failed to provide physician ordered Ketoconazole cream (anti-fungal topical cream) timely to a resident with known topical yeast growth ...
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Based on Observation, Interview and Record Review, the facility failed to provide physician ordered Ketoconazole cream (anti-fungal topical cream) timely to a resident with known topical yeast growth for one of one resident (R38) reviewed for skin conditions in the sample of 34.
Findings include:
The facility's Drug Order Policy (undated), documents It is the policy of this facility to obtain a physician's order for all medications and treatments and to process medication orders to ensure the resident's medical plan of care is implemented, on a timely basis. This same policy documents All orders from a licensed practitioner for resident drugs are processed by a licensed nurse and entered in the resident's medical record. The medication orders are processed timely, i.e. (that is) called/faxed to the selected pharmacy, is indicated on the resident identification. Drug order shall be transcribed onto the medication record by the licensed nurse who received them as soon as practical after the physician's order is received.
R38's current care plan, dated 6/26/24, documents (R38) is at risk for pressure ulcers and other alteration to skin integrity due to Diabetes Mellitus, Heart Failure, Weakness, Obesity and COPD (Chronic Obstructive Pulmonary Disease). (R38) was admitted to the facility with a pressure ulcer to the coccyx area and a growth by the right side of groin. Areas are healed. This care plan lists interventions Treatments will be done as ordered.
On 7/9/24 at 9:45 AM, R38 was in his room lying in bed. R38 stated They (the facility) are not processing or completing orders like they're supposed to. I had an order for a fungal cream starting on 6/11/24. I never got it, and no one could tell me why or where it was. They just didn't have it. I went back to the doctor a while later and told them and then the doctor's office ordered it again. R38 stated he has had his leg removed and he gets yeast growth in skin fold areas on his body which is why the doctor ordered an anti-fungal cream.
R38's nursing progress note, dated 6/11/24 at 2:43 PM, documents (R38) returned from an appointment with (V9, R38's Primary Physician) to start Ketoconazole. No percentage written or where to apply, or dosage. Will fax office to ask.
R38's electronic medical record does not document any further clarification on the Ketoconazole order until 6/28/24 (17 days after the medication was originally ordered to be initiated).
R38's nursing progress note, dated 6/28/24 at 10:43 AM, documents (V9) was following up with a cream that was ordered. They (V9's office) had sent the script (prescription) to our pharmacy. This nurse will place order for (Ketoconazole) cream as (V9) ordered.
On 7/10/24 at 12:00 PM, V8 (Licensed Practical Nurse/Infection Control Preventionist) stated (R38) does get Ketoconazole cream to his groin area because he has a history of a growth there and gets yeast areas in his groin folds. If there are paper orders or faxes from physician's office, they should get added to the computer by the nurse and then they are scanned into the resident's record.
On 7/10/24 at 3:15 PM, V2 (Director of Nursing) confirmed there was a delay in the Ketoconazole cream being started for R38 and stated she wasn't exactly sure why there was confusion or delay with starting it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide physician ordered yogurt with all meals, obtain physician ordered daily weights, provide lunch meals when out of the f...
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Based on observation, interview and record review, the facility failed to provide physician ordered yogurt with all meals, obtain physician ordered daily weights, provide lunch meals when out of the facility at scheduled hemodialysis, communicate with the dialysis center before and after treatments, monitor a central venous catheter dialysis port and ensure a resident's care plan documents detailed dialysis care and required services for a resident receiving renal hemodialysis for one of one resident (R38) reviewed for dialysis in the sample of 34.
Findings include:
The facility's Dialysis Transfer Agreement, dated 7/19/10, documents Facility shall ensure that all appropriate medical, social, administrative and other information accompany all designated residents at the time of transfer to (dialysis) Center. This information shall include, but is not limited to, where appropriate, the following: Appropriate medical records, including history of the designated resident's illness, including laboratory and x-ray findings; Treatment presently being provided to the designated resident, including medications and any changes in a patient's condition (physical or mental), change of medication, diet or fluid intake; Any other information that will facilitate the adequate coordination of care, as reasonably determined by the center. This policy also documents Center will develop a written protocol governing specific responsibilities, policies, and procedures to be used in rendering dialysis services to designated residents at Center, including but not limited to, the development and implementation of a designated resident's care plan relative to the provision of dialysis services. Facility will provide for the interchange of information useful or necessary for the care of the designated resident and will inform Center of a contact person at facility whose responsibilities oversight of provision of dialysis services by Center to the designated residents of the facility.
The facility's Post Dialysis Monitoring and Observation with Implanted A-V (arteriovenous) Shunt policy, dated 1/2018, documents To monitor site: Monitor site daily for redness or signs of inflammation. If any bleeding or oozing at the site is noted, apply pressure gauze dressing and notify physician. General Information: When a new A-V access site is created a central line (Central Venous Catheter) is generally used during the healing process (usually several weeks.) Complete the dialysis communication form with any information request by the certified dialysis facility.
The facility's Catheter Insertion and Care - Hemodialysis Catheters policy, dated 9/1/16, documents Hemodialysis catheters will only be accessed by medical staff who have received training and demonstrated clinical competency regarding the use of this catheter. Dressing Change: If the dressing becomes wet, dirty, or not intact, the dressing shall be changed by a nurse trained in this procedure. Follow central line dressing change procedure. Bleeding from insertion site: Mild (post- dialysis), this can be expected. Apply pressure to insertion site and contact dialysis center for instructions. Major (post-dialysis), apply pressure to insertion site, contact emergency services and dialysis center. Verify that clamps are closed on lumens. This is a medical emergency. Do not leave resident alone until emergency services arrives. Documentation: The nurse should document in the resident's medical record every shift as follows: Location of catheter; Condition of dressing (interventions if needed); If dialysis was done during shift; Any part of report from Dialysis Nurse post dialysis being given; Observations post-dialysis.
The facility's Nutrition and Hydration to Maintain Skin Integrity policy, dated 8/2008, documents The purpose of this procedure is to provide guidelines for the assessment of resident nutritional needs, to aid in the development of an individualized care plan for nutritional interventions, and to help support the integrity of the skin through nutrition and hydration. This policy also documents Hydration Evaluation: The specific amount of hydration needed is specific for each resident and fluctuates as the resident's condition fluctuates. Risk factors for dehydration include: Fluid restriction secondary to renal dialysis.
R38's current care plan, dated 6/26/24, documents (R38) requires dialysis three times per week at (dialysis center) on Monday, Wednesday and Friday. He has a diagnosis of End Stage Renal Disease. Interventions for the plan of care document Assess for fluid excess. Monitor dialysis access site for signs and symptoms of complications. Notify medical doctor of weight gain and/or fluid volume excess. This plan of care does not document emergency central venous catheter care, complications to watch for at the site, protocols and procedure for venous catheter dressing changes, weight and vital sign parameters or a (dialysis center) specific plan of care for R38's individualized renal dialysis treatment.
R38's current Physician Order Sheet, dated 7/10/24 documents R38 has diagnoses of End Stage Renal disease, Type two Diabetes Mellitus and Hypertensive Heart disease with Heart Failure. This order sheet documents R38 has an order for Daily weight- please obtain before breakfast each day. Start date 5/15/24. This Physician order sheet also documents and order for Offer yogurt with all meals, three times a day. Start date 6/28/24.
On 7/9/24 at 9:45 AM, R38 was in his room lying in bed. R38's chest and abdomen were uncovered and unclothed. R38's left upper chest mid clavicular line contained a square gauze and tape dressing and had an attached tape covered catheter line dangling. R38 stated he is taken to renal dialysis every Monday, Wednesday and Friday each week. R38 stated, I have a dietary order for yogurt to be with given with every meal. I get it once in a while. There was none this morning. At this time R38's breakfast meal slip was reviewed and did not include yogurt on the list of tray content items. R38's breakfast tray did not have any evidence of a yogurt container or that yogurt was given to R38 with breakfast. R38 stated that he goes to dialysis around 9:00 AM on the scheduled days and doesn't return until around 4:00 PM. R38 stated They never send a sack lunch with me for these appointments. I can only recall two times they did send a sack lunch it was processed lunch meat that I am not supposed to have due to the sodium and phosphorous content. At dialysis they check my weight, not here (at the facility) but I tell them when I get back what I weigh. They (Facility and Dialysis) don't send any paperwork back and forth with me. Just me. The nurses (at the facility) don't do anything with my port. I have had this port (central venous catheter) since January of this year when my old shunt went bad. If I shower, they will cover it or change the dressing when it gets wet but that's all.
On 7/9/24 at 12:55 AM, R38's lunch tray was delivered. At this time R38 was sitting in his room on the edge of his bed. R38's lunch tray did not contain any yogurt.
R38's electronic medical record does not document any pre or post dialysis monitoring, observations or dressing changes to R38's central venous catheter port. This record also does not contain any documentation of communication between the facility and R38's dialysis administration center.
R38's weight record from 5/15/24-7/9/24 does not document daily weights were completed for R38.
On 7/10/24 at 12:00 PM, V8 (Licensed Practical Nurse/ Infection Control Preventionist) confirmed that dialysis and the facility do not have any documented communication related to R38's dialysis treatments. V8 stated, Dialysis calls about one time a month and asks about (R38's) changes or issues. We look at his central venous catheter, but I don't know that it's charted anywhere. It isn't on the Medication or Treatment Administration record. I can't think of where we would be flagged to chart the assessment, swelling, bleeding or observation of the port anywhere specific. With showers we do cover that area with plastic and may change the dressing if it gets wet. There is no paper transferred back and forth with dialysis. They don't send any communications back with him, nor do we send them a paper on dialysis days. (R38) has had the line in his chest since January I believe.
On 7/10/24 at 12:08 PM, V6 (Dietary Manager) stated I don't have any communication with dialysis related to (R38) or their dietician. I am not sure how to talk to them. They (dietary staff) are supposed to be sending (R38) with peanut butter and jelly sandwich or lunch meat or something. The kitchen staff should send that each time he goes out to dialysis, but I don't know if the dialysis facility has a place to keep items cold or not. I don't have any documentation or record to show when sack lunches are sent with (R38) and what contents. They should be giving (R38) yogurt with every meal. I know we got some today so maybe he didn't have it this morning. I am not sure why he wouldn't have gotten yogurt yesterday though. I bet they just forgot to put it on his tray for breakfast and lunch.
On 7/10/24 at 12:15 PM, V7 (Cook) stated I work full time and get here about 5:30 AM in the morning. I know we did try to send a sack lunch with (R38) a couple times, but no one ever came and picked up the bag. That was probably a couple weeks ago. I am not aware that (R38) has taken a lunch with him since then. Maybe we should put it on his breakfast tray because he leaves before lunch for his dialysis.
On 7/10/24 at 12:43 PM, V3 (Assistant Director of Nursing) stated Dialysis does (R38's) weights before and after treatment at their facility, not here. We don't send any communication plan to dialysis, and they don't send any forms back. I don't have any dialysis plan or specifics for him in his record aside from what we have care planned. V3 confirmed that she doesn't have any documentation to show R38's dialysis catheter port is being assessed, monitored or has dressings changed.
On 7/10/24 at 3:15 PM, V2 (Director of Nursing) stated she isn't sure why there is not orders, assessment or nursing documentation to show R38's dialysis port is being assessed or cared for.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to identify and monitor targeted psychotic behaviors to warrant the use of Abilify (antipsychotic medication) and attempt a gradu...
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Based on observation, interview and record review, the facility failed to identify and monitor targeted psychotic behaviors to warrant the use of Abilify (antipsychotic medication) and attempt a gradual dose reduction of the medication in the past year for one of three residents (R25) reviewed for antipsychotic medications in the sample of 34.
Findings include:
The facility's Antipsychotic Medication Use policy dated/revised August 2008 documents, The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms, and risks. Nursing staff will document an individual's target symptom(s). The Attending Physician will identify, evaluate, and document with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. Based on assessing the resident's symptoms and overall situation, the Physician will determine whether to continue, adjust, or stop existing antipsychotic medication.
R25's Physician Order Sheet, order dated 8/18/23, and order start date of 8/19/23, documents R25 has orders for Abilify (aripiprazole) (antipsychotic medication) tablet; 15 mg (milligrams); oral give one tablet orally to be given once a day. This sheet also documents R25's diagnoses for medication is for bipolar disorder, current episode depressed, severe, with psychotic features.
R25's Care Plan dated 3/26/24, documents R25 receives antipsychotic medication but does not include R25's specific behaviors to monitor for the use of an antipsychotic medication. This same care plan documents, (R25) makes inappropriate comments to others, has manipulative behaviors, and manic behaviors such as trouble sleeping.
R25's Behavior/Intervention Monthly Flow Record dated June and July 2024 documents R25 is being monitored for verbalized sadness, verbalized anxiety, and irritability. This same flow sheet documents R25 has had no behaviors.
R25's Medications Flowsheet dated June and July 2024 documents to monitor for inappropriate comments, and verbalized anxiety. This same flow sheet documents R25 has had no behaviors.
R25's Electronic Medical Record does not include evidence of a GDR (gradual dose reduction) for Abilify (aripiprazole) tablet; 15 mg (milligrams) or a pharmacy recommendation to conduct a GDR within the last twelve months. V2/Director of Nursing verified a GDR has not been conducted or pharmacy recommendation has not been received for R25 in the last twelve months. V2 stated a GDR should be performed at least every 12 months.
On 7/8/24 at 1:36 PM, R25 was sitting in the activities room coloring on her color sheet. No behaviors observed.
On 7/9/24 at 1:55 PM, R25 was waiting for the Resident Council Meeting and was calmly coloring and talking to another resident. No behaviors observed.
On 7/10/24 at 1:25 PM, V2 stated R25's targeted behaviors were inappropriate comments and has not had a gradual dose reduction (GDR) in the past twelve months. V2 stated (R25) targeted behaviors for Abilify are inappropriate comments. V2 stated R25 tries to manipulate and lie but is cooperative most of the time. V2 states, I am trying to reduce the Abilify, but I was told since we are reducing her Buspirone (used as an antidepressant) we are not allowed to reduce both at the same time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions for a resident with a Central Venous Catheter dialysis port for one of one resident (R3...
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Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions for a resident with a Central Venous Catheter dialysis port for one of one resident (R38) reviewed for Dialysis in the sample of 34.
Findings include:
The facility's Enhanced Barrier Precautions policy, dated 2023, documents It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multi-drug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. High-Contact resident care activities include: Dressing, Bathing/Showering, Transferring, Provide Hygiene, Changing Linens, Changing Briefs or toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing. Procedure: Post clear signage on the door/wall outside resident room. Provide isolation cart with personal protective equipment immediately outside resident room.
R38's current care plan, dated 6/26/24, documents (R38) requires dialysis three times per week at (dialysis center) on Monday, Wednesday and Friday. He has a diagnosis of End Stage Renal Disease. He currently has a dialysis port to his upper left chest. He has a fistula to his left arm that is not functioning.
On 7/9/24 at 9:45 AM R38 was in his room lying in bed. R38's chest and abdomen were uncovered and unclothed. R38's left upper chest mid clavicular line contained a square gauze and tape dressing and had an attached tape covered catheter line dangling. R38 stated he is taken to renal dialysis every Monday, Wednesday and Friday each week. R38 stated, I have had this port (central venous catheter) since January of this year when my old shunt went bad. R38's room did not contain a sign or any personal protective equipment to indicate that R38 was in isolation for enhanced barrier precautions.
On 7/10/24 at 12:00 PM, V8 (Licensed Practical Nurse/ Infection Control Preventionist) confirmed that R38 receives dialysis three times a week though a central venous line in his upper left chest and is not on enhanced barrier precautions. V8 stated We look at his central venous catheter, but I don't know that it's charted anywhere. (R38) hasn't been on any recent isolation that I recall of any kind. He has had the line in his chest since January I believe.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected most or all residents
Based on observation, record review and interview the facility failed to provide readily available grievance forms and failed to post grievance/complaint procedures in a prominent location throughout ...
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Based on observation, record review and interview the facility failed to provide readily available grievance forms and failed to post grievance/complaint procedures in a prominent location throughout the facility. This has the potential to affect all 70 residents residing in the facility.
Findings include:
The facilities CMS (Centers for Medicare and Medicaid services) Long Term Care Facility Application four Medicare and Medicaid Form 671 dated 7/8/24 and signed by V1/Administrator documents 70 residents currently reside within the facility.
The facility's Grievance Policy dated 11-2016 documents, A copy of the facility's grievance/complaint procedures is posted in prominent locations throughout the facility. Grievance postings will include the contact information of the grievance official including name, business address, e-mail, and phone number.
On 7/9/2024 at 2:00 PM during resident council meeting R25, R30, R53, R36, and R40 all stated that they do not know where or how to file a grievance.
On 7/10/2024 at 10:30 AM, a wooden box was located to the left of the activity director's office with a typed document stating, You may place your grievance in box or staff may assist you if you would like. If you have questions, you may ask preferred staff members V4/Social Service Director, or V1/Administrator we will all be happy to help. Beside the box was little pieces of blank square paper, but no official grievance forms were observed outside of the box.
On 7/10/2024 at 2:15 PM, a tour was conducted with V1/Administrator asking V1 to show where the prominent location(s) are for the grievance procedure in the building. V1 verified there was not a posted grievance procedure in any prominent locations around the building.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to provide the resident/resident representatives with a written notice of transfer. This has the potential to affect all 70 resident's residing...
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Based on interview and record review the facility failed to provide the resident/resident representatives with a written notice of transfer. This has the potential to affect all 70 resident's residing in the facility.
Findings include:
R43's medical record documents that R43 was transferred to a local hospital on 3/15/24. No evidence of a facility notification to R43 of a transfer/discharge was present in R43's chart.
R56's medical record documents that R56 was transferred to a local hospital on 6/4/24. No evidence of a facility notification to R56 of a transfer/discharge was present in R56's chart.
On 7/8/24 at 1:15 PM V2/DON verified the facility did not provide R43, R56, or their representatives with a written notice of transfer. V2/DON stated, I am not aware of a written notice of transfer form we (the facility) are supposed to give to the residents when they discharge to the Hospital. We (the facility) only send the continuity of care form that has the resident's current vitals and medications. The nurses would be the ones to give the resident the written notice of transfer, but they are not aware of that form and have not been giving it to any resident as I am just now finding out about it.
On 7/10/24 at 8:42 AM V4/Social Service Director stated, I do not give a resident or their representative a copy of a written notice of transfer. I am not even aware of that form.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide food items on the Always Available Menu to residents that requested substitution items from their meals. This has the potential to ...
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Based on interview and record review, the facility failed to provide food items on the Always Available Menu to residents that requested substitution items from their meals. This has the potential to affect all 70 residents living in the facility.
Findings:
The document, Food Substitution, no date, states, Residents may be offered a substitute if desired.
The Dietary List, Facility Always Available (Foods), no date, states, Chef's Salad; Cottage Cheese; Chicken Nuggets; Deli Sandwich; Cheeseburger; Chicken Salad Sandwich; Egg Salad Sandwich; Ham Salad Sandwich; Tuna Salad Sandwich; Grilled Cheese Sandwich; Peanut Butter and Jelly Sandwich; Lettuce and Tomato Salad; Fruit Plate; French Fries; Mashed Potatoes.
On 7/09/24 at the 2:00 PM, Resident Council Meeting, the following residents, (R25, R30, R36, R40, R52), stated, We can get a peanut butter and jelly sandwich and maybe a fruit plate, but that is all that we can get. The Certified Nursing Assistants will ask the [NAME] to make us a grilled cheese, or a cheeseburger with lettuce and tomato or something like that and they tell us that the cook refuses to make them or anything else we ask for. The residents also stated that they are afraid to request anything different from the menu because they will not only not get what they request, but they are served their meals after everyone else gets their meal and it may be cold. The residents also stated that they were not aware of an Always Available Menu, and had not been given this document or offered anything off of it besides the peanut butter and jelly sandwich or fruit plate.
The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 7/08/24 and signed by V1, Administrator, documents 70 residents currently reside within 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, interview and record review, the facility failed to use Cool Down Temperature Logs for potentially hazardous food. This has the potential to affect all 70 residents living in the...
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Based on observation, interview and record review, the facility failed to use Cool Down Temperature Logs for potentially hazardous food. This has the potential to affect all 70 residents living in the facility.
Findings:
The document, Two Stage Cool Down Process, dated 2015, states, Potentially hazardous foods will be cooled properly to prevent food borne illness. Foods will be cooled to proper temperatures. A two stage cooling process will be followed: Stage I: Cool foods from 135 degrees Fahrenheit (F) to 70 degrees F within two (2) hours. Stage II: Cool foods from 70 degrees F to 41 degrees F within four (4) hours. (Total of Six (6) hours.) If prepared from ingredients at room temperature: Cool foods from 70 degrees F to 41 degrees F within four (4) hours.
The document, Hazard Analysis Critical Control Point (HACCP) Cooling Log, dated 2024, states, Record temperatures every hour during the cooling cycle. The supervisor of food operation will verify proper cooling procedures by routinely monitoring work activity and reviewing this log. Cooling temperatures will be documented.
On 7/08/24 at 10:10 AM, the HACCP Cooling Log was blank for the month of July. There were no other Cool Down Temperature Logs for previous months.
On 7/08/24 at 10:15 AM, V6, Dietary Manager, stated, Yes, we do sometimes prepare foods that would be considered hazardous the day before it is served. I just found out a couple of weeks ago that the cool down temperatures are supposed to be recorded. I put the form out and told the cooks to start using the HACCP form, but I guess they forgot. I will make sure the cooks start using the form. The meals for today were prepared today.
The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 7/08/24 and signed by V1, Administrator, documents 70 residents currently reside within the facility.
Mar 2024
4 deficiencies
2 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 F0697
(Tag F0697)
Someone could have died · 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 prescribed opioid medications to keep resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer prescribed opioid medications to keep residents' pain controlled, failed to perform a pain assessment while the residents were not receiving their prescribed opioid medications, and failed to develop a pain plan of care for two of three residents (R1 and R2) reviewed for pain in the sample of three. These findings resulted in R1, who suffers from bone cancer, experiencing uncontrolled lower back pain and resulted in R2, who suffers from Osteomyelitis from a flesh-eating wound caused by a spider bite, experiencing uncontrolled severe continuous and unbearable pain to his right lower leg wound.
These failures resulted in an Immediate Jeopardy.
While the immediacy was removed on 3-11-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring.
Findings include:
The facility's Pain Management policy dated 07/2019 documents, Policy: It is the policy of the facility to facilitate resident safety, independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish the goals through an effective pain management program. The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. Pain assessment protocol may be initiated under any of the following situations: Resident received routine pain medication and/or pain is not controlled and a change in pain identification related to behavior, cognition, or mood. An immediate care plan will be initiated at the time of admission for any resident with physician orders for pain management, when the resident expresses pain, or exhibits behaviors indicative of having pain. An interdisciplinary process and care plan will be developed and implemented based on the assessed findings, pain rating scale, and pain-relieving strategies (interventions). A provision of pain treatment that includes pharmacological and non-pharmacological interventions will be included in the care plan. Responsible use of opioid's medications will include the monitoring of the use of opioids.
The United States Food and Drug Administration Safety Communication Website article dated 4-9-19 documents, Opioid's are a class of powerful prescription medicines that are used to manage pain when other treatments and medicines cannot be taken or are not able to provide enough pain relief. Rapid discontinuation can result in uncontrolled pain.
R1's History and Physical dated 8-10-23 documents, Chief complaint is intractable back pain. Multiple Myeloma. (R1) has known Multiple Myeloma has been under therapy by Oncology. (R1's) pain has become severe. (R1) cannot ambulate. Pains all up and down (R1's) spine. (R1) apparently has lesions at various levels of the spine with her myeloma.
R1's Face Sheet documents R1 is an [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Multiple Myeloma not having achieved remission and low back pain.
R1's admission Orders dated 8-23-24 document R1 was admitted to the facility on Fentanyl (Opioid) 75 mcg (microgram)/hour transdermal extended release one all up patch every 72 hours. Morning time is a hard time of day regarding pain. (R1) is able to sleep at night. Location (of pain) is mid-back today. Planning to increase fentanyl patch (dose).
R1's Care Plan dated 8-23-23 (Admission) through 3-7-24 does not include a plan of care to address R1's chronic pain due to Multiple Myeloma.
R1's Progress Notes dated 10-4-24 and signed by V4 (R1's Palliative Physician) document, (R1) is being seen in the geriatric clinic today for palliative care follow-up regarding pain management associated with Multiple Myeloma.
R1's Progress Notes dated 10-5-24 and signed by V6 (RN/Registered Nurse) document, (R1) seen by (V4/R1's Palliative Care Physician) with Fentanyl patch increased to 100 mcg per hour for diagnosis of cancer pain. Follow-up with (V4) in four months. Will continue to monitor.
R1's Physician's Orders dated 10-5-24 through 3-8-24 document, Fentanyl 100 mcg per hour one patch transdermal once a day every three days at 9:00 PM for the diagnoses of Multiple Myeloma not having achieved remission.
R1's Medication Flow Sheets dated 1-1-24 through 2-31-24 document R1's Fentanyl Patch 100 mcg/hour transdermal placed at 9:00 PM was not administered as scheduled on 1-25-24, 1-28-24, 1-31-24, or 2-3-24. These same Medication Flow Sheets document R1 did not have a Fentanyl 100 mcg/hour patch applied until 2-6-24.
The facility's email dated 2-5-24 and sent to the facility's pharmacy from V2 (Director of Nursing) states, I am not sure how things need to be fixed, but (R1) has been without her Fentanyl patch going on two weeks which is completely unacceptable. This is becoming a huge problem of people going days without their narcotics and is causing residents to being in a great deal of pain or even worse going into withdrawals.
R1's Progress Notes dated 2-21-24 and signed by V4 (R1's Physician) document, A few weeks ago (R1) was having significant issues with delirium at night and there was a night where an ambulance had to be called. On further investigation from family, turns out (R1) had not been getting her fentanyl patches. I am unsure about what efforts (if any) the facility pursued to get (R1) her pain medications. Not only was my office unavailable during this time, the patient's primary care provider's office was available and our nurse practitioner who rounds at the facility would have also been available to help troubleshoot. This appears to be inadequate care and my duty as a mandatory reporter required me to report this. Assessment and recommendations: 1. Encounter for palliative care. 2. Multiple Myeloma not having achieved remission. 3. Bone Metastasis. 4. Cancer related pain.
R1's Medical Record does not include a completion of a pain assessment after R1 did not receive her scheduled Fentanyl patch from 1-25-24 through 2-6-24.
On 3-8-24 at 9:30 AM R1 was lying in bed in her room. R1 stated, I did not know I wasn't getting my pain medication. I know my lower back was on fire. Most all of my pain is in my lower back.
On 3-8-24 at 9:45 AM V2 (Director of Nursing/DON) stated R1 went without her scheduled Fentanyl Patch for from 1-25-24 through 2-6-24. V2 also stated R1's Fentanyl Patch was given for R1's pain related to bone cancer. V2 confirmed R1 did not have a pain assessment conducted after missing her Fentanyl Patch dose.
On 3-8-24 at 11:00 AM V4 (R1's Palliative Care Physician) stated, I am responsible for (R1's) palliative care. I saw (R1) in my office on 2-21-24. I was told on 2-21-24 that (R1) did not receive her Fentanyl patch for two weeks. I was not informed by the nursing home of (R1's) Fentanyl patch not being available or administered. (R1) should not have gone two weeks without Fentanyl. Fentanyl is the only medication that keeps (R1's) pain control. (R1) has excruciating pain from bone cancer and I have had to increase (R1's) Fentanyl dose to keep the pain under control. No other pain medication has been effective.
On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, I did not know (R1) had went without Fentanyl for two weeks. (R1) should not have never been without her Fentanyl, especially for two weeks. I was only notified one day (1-19-24) of the need for a signed prescription. (R1) has bone cancer to her spine and her pain is very detrimental to her.
On 3-8-24 at 12:25 PM V8 (R1's Power of Attorney) stated, On 2-1-24 I called the nurse (V9/RN), and she told me (R1) had been out of her Fentanyl patch for two weeks and that was causing her night terrors. (R1) was going crazy and was in such pain while being out of her Fentanyl. It was just awful. (R1) has terrible bone pain and cancer.
On 3-8-24 at 4:25 PM V10 (MDS/Minimum Data Set Coordinator) stated, (R1) did not have a pain plan of care developed prior to today. I am responsible for developing pain care plans. I do not have a reason as to why (R1) did not have a pain care plan.
2. R2's Face Sheet documents R2 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Type II Diabetes Mellitus and a non-pressure chronic ulcer of unspecified part of right lower leg.
R2's MDS assessment dated [DATE] documents R2 is cognitively intact and has frequent pain at a pain intensity of 7 on a 0-10 pain scale (zero being no pain and ten as the worst pain you can imagine).
R2's Pain Observation assessment dated [DATE] documents R2 had almost constant moderate pain at a 7 and received scheduled and as needed pain medications for pain control.
R2's Progress Notes dated 1-8-24 and signed by V7 (Nurse Practitioner) document, (R2) requested to see me due to pain not currently controlled with Oxycodone 10 mg every four hours PRN (as needed). New orders: Schedule Oxycodone 10 mg tablets three times daily and continue with current Oxycodone 10 mg one tablet every four hours as needed.
R2's Care Plan dated 8-16-23 (Admission) through 3-7-24 does not include a plan of care to address R2's chronic pain due to Osteomyelitis and wound to the right lower leg.
R2's Physician's Order Report date 3-1-24 through 3-8-24 documents, Order date 1-8-24 to current: Oxycodone 10 mg (milligram) tablet two tablets three times daily. Order date 11-30-23 to current: Oxycodone 10 mg one tablet every four hours as needed (PRN).`
R2's Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2's Oxycodone 10 mg two tablets was not administered as ordered on 1-26-24 at 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, and 1-28-24 at 8:00 AM. These same Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2 did not receive a PRN dose of Oxycodone 10 mg on 1-26-24 through 1-31-24.
R2's Progress Notes dated 1-28-24 at 3:11 PM and signed by V9 (RN) documents R2 was complaining of increased pain and withdrawals due to his scheduled pain medication not being available from pharmacy due to insurance. This same not documents R2 remained in bed and was not eating meals.
R2's Progress Notes dated 1-29-24 at 1:47 PM and signed by V11 (RN) documents, (R2) has remained in bed thus far today. (R2) went all weekend and today without pain medication.
R2's Medical Record does not include a completion of a pain assessment after R2 did not receive his scheduled Oxycodone on 1-26-24 through 1-28-24.
On 3-8-24 at 11:10 AM R2 was lying in bed. R2's right lower leg was wrapped in gauze. R2 stated, I was out of the Oxycodone for three days. I was bit by a recluse spider and that is why I am here for treatment. When I was out of the Oxycodone, I was having withdrawals of nausea, vomiting, and dry heaving and I was having pain at an 11 on a 1-10 pain scale. The pain was continuous and unbearable. It felt like my wound was split open and burning.
On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, I oversee (R2's) care at the facility. (R2) ran out of Oxycodone on 1-26-24. I was not notified of the need for a prior authorization until (R2) already ran out. (R2) did not get his medication for three days. (R2) got bitten by a [NAME] Recluse spider that caused a wound with bone exposure. (R2) has Osteomyelitis (bone infection) and has had several debridements done and has a lot of pain with this wound. I am sure his pain was excruciating when he had to go without his Oxycodone.
On 3-8-24 at 9:45 AM V2 (DON) confirmed that R2 did not have a pain assessment completed after missing his scheduled doses of Oxycodone on 1-26-24 through 1-29-24.
On 3-8-24 at 4:25 PM V10 (MDS Coordinator) stated, (R2) did not have a pain plan of care developed prior to today. I am responsible for developing pain care plans. I do not have a reason as to why (R2) did not have a pain plan of care.
The Immediate Jeopardy started on 1-25-24 at 9:00 PM when R1's scheduled Fentanyl patch 100 mcg/hour was not administered to treat R1's excruciating bone cancer pain.
V1 (Administrator) and V2 (DON) were notified of the Immediate Jeopardy on 3-11-24 at 9:36 AM.
On 3-13-24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:
1. On 3-13-24 R1's opioid pain medications were available and being administered. On 3-11-24 R1 was assessed and re-evaluated by V10 (MDS/Minimum Data Set Coordinator) for adequate pain control and pain levels that were tolerable, and V10 updated R1's care plan to include pain relieving interventions/medications.
2. On 3-13-24 R2's opioid pain medications were available and being administered. On 3-11-24 R2 was assessed and re-evaluated by V10 for adequate pain control and pain levels that were tolerable, and V10 updated R2's care plan to include pain relieving interventions/medications.
3. On 3-13-24 all residents who currently had orders for opioid pain medications had their pain medications available and were being administered.
4. On 3-11-24 V1, V2, and V10 assessed and re-evaluated all residents for adequate pain control and pain levels that were tolerable.
5. On 3-11-24 V1 and V2 ensured all residents had tolerable pain levels.
6. On 3-11-24 V1 and V2 in-serviced all facility nurses and department heads on the facility's Pain Clinical policy and procedure, performing pain assessments with changes in pain management or an increase in pain, and the facility's Pain Management policy.
7. On 3-11-24 V1 and V2 in-serviced all facility nurses and department heads on developing pain care plans and implementing pain relieving interventions.
9. On 3-11-24 V13 (Medical Director) made aware of the Immediate Jeopardy regarding pain control concerns.
10. On 3-11-24 the facility conducted an emergency QA (Quality Assurance) meeting regarding all Pain policies and procedures and concerns with pain control.
Date of Completion: 3/11/2024
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
Pharmacy Services
(Tag F0755)
Someone could have died · 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 obtain scheduled opioid medications from the pharmacy ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain scheduled opioid medications from the pharmacy for two of three residents (R1 and R2) reviewed for pharmacy services in the sample of three. This failure resulted in R1 abruptly stopping and missing her scheduled Fentanyl patch (Opioid Medication) for two weeks resulting in R1 experiencing withdrawal symptoms of a fall, night terrors, drooped eyes with continuous blinking, shallow and quick breaths, non-reactive pupils, garbled speech, and hypertensive. This failure also resulted in R2 abruptly stopping his scheduled Oxycodone (Opioid Medications) for three days resulting in R2 experiencing withdrawal symptoms of refusing to eat, chills, nausea, and vomiting.
These failures resulted in an Immediate Jeopardy.
While the immediacy was removed on 3-11-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring.
Findings include:
The facility Pharmacy's Preventing and Detecting Adverse Consequences and Medication Errors policy dated 10-25-14 documents, Facility staff monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness, when the following conditions occur: 1. A clinical significant change in condition/status. a. An unexplained decline in function or cognition. b. A worsening of an existing problem or condition. c. A new or worsening psychiatric manifestation or distressed behavior. d. Acute onset of signs or symptoms or worsening of a chronic problem. Medication error. G. The attending physician is notified promptly of any significant error or adverse consequence. J. The following information is documented in an incident report and in the resident's clinical record: Factual description of the error or adverse consequence. Name of physician and time notified. Physician's subsequent orders. Resident's condition for 24 to 72 hours or as directed.
The United States Food and Drug Administration Safety Communication Website article dated 4-9-19 documents, Opioid's are a class of powerful prescription medicines that are used to manage pain when other treatments and medicines cannot be taken or are not able to provide enough pain relief. Patients taking opioid pain medicines long-term should not suddenly stop taking your medicines without first discussing with hour health care professional a plan for how to slowly decrease the dose of the opioid and continue to manage your pain. Even when the opioid dose is decreased gradually, you may experience symptoms of withdrawal. Rapid discontinuation can result in uncontrolled pain or withdrawal symptoms. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.
R1's Face Sheet documents R1 is an [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Multiple Myeloma not having achieved remission and low back pain.
R1's admission Orders dated 8-23-24 document R1 was admitted to the facility on Fentanyl (Opioid) 75 mcg (microgram)/hour transdermal extended release one all up patch every 72 hours.
R1's Care Plan dated 9-29-23 documents, (R1) is at risk for falling related to her recent hospital stay for COPD (Chronic Obstructive Pulmonary Disease), cancer with chemotherapy treatments, and generalized weakness. Approach: 1-29-24 (R1) will be schedules to see her physician for night terrors.
R1's Physician's Orders dated 10-5-24 through 3-8-24 document, Fentanyl 100 mcg per hour one patch transdermal once a day every three days at 9:00 PM for the diagnoses of Multiple Myeloma not having achieved remission.
R1's Medication Flow Sheets dated 1-1-24 through 2-31-24 document R1's Fentanyl Patch 100 mcg/hour transdermal placed at 9:00 PM was not administered as scheduled on 1-25-24, 1-28-24, 1-31-24, or 2-3-24. These same Medication Flow Sheets document R1 did not have a Fentanyl 100 mcg/hour patch applied until 2-6-24.
R1's Clinical Record does not include documentation, as directed by the facility pharmacy's Preventing and Detecting Adverse Consequences and Medication Errors policy. of physician notification or a factual description of why R1 did not receive her scheduled Fentanyl Patch from 1-25-24 through 2-6-24, or R1's condition while missing the scheduled dose of her Fentanyl Patch from 1-25-24 through 2-6-24.
R1's Progress Notes dated 1-29-24 at 5:49 AM and signed by V5 (RN/Registered Nurse) document, At 5:45 am (R1) heard yelling (female's name) and had fallen in room. Fall was witnessed by roommate who states (R1) was having a nightmare and got out of bed unaware. (R1) was observed trying to stand herself up when this nurse entered the room. (R1) states she hit her knees a bit and her back. (R1) states this is a normal occurrence for her, and she needs to see someone about the night terrors. No other noticed injuries other than some bruising starting to bilateral knees.
R1's Medication Error Report signed by V1 (Administrator) and V2 (Director of Nursing) on 1-31-24 documents, Medication as ordered: Fentanyl 100 mcg (micrograms)/hour patch. Description of error: Medication unavailable/no refills. Date of error: 1-25-24, 1-28-24, and 1-31-24. Reason for error: Pharmacy error. Corrective action taken: Working with pharmacy and physician to get resolution. Measures taken to prevent recurrence (this section is incomplete).
R1's Progress Notes dated 2-3-25 at 12:57 AM and signed by V5 (RN) document, This nurse was called into resident's room by the CNA (Certified Nursing Assistant) asking me to lay eyes on (R1). (R1) at this time was having a night terror. Upon assessment, (R1) was noted to have drooped eyes with continuous blinking, shallow, quick breaths, non-reactive pupils, and hypertensive. (R1) was responding appropriately to some questions but speech was also garbled and hard to comprehend. This nurse asked another nurse to also lay eyes and 911 was called at 4:32 AM. Shortly after, (R1) became more responsive and appeared to just be having a night terror that she had not fully come out of. EMS arrived at 4:35 AM and evaluated and was determined to be stable.
The facility's email dated 2-5-24 and sent to the facility's pharmacy from V2 (Director of Nursing) states, I am not sure how things need to be fixed, but (R1) has been without her Fentanyl patch going on two weeks which is completely unacceptable. Last week I spoke with pharmacy, and they stated that they needed a renewal script signed and sent over by the doctor of which was done on 1-29-24. Today I find out that these patches still have not been sent and my nurse was told my pharmacy that there was no dosage attached to the ordered. I was not notified of this nor was the doctor notified of anything. (V7/Nurse Practitioner) pulled the order that she personally send last week and the correct dosage that you can see in the forwarded message. The dosage is clearly attached. This is becoming a huge problem of people going days without their narcotics and is causing residents to being in a great deal of pain or even worse going into withdrawals. There needs to be something figures out or communications sent from the pharmacy to me as well as the prescriber for narcotics needing new scripts signed/renewed so that I can follow-up before the resident runs out of the medication.
R1's Physician's Progress Notes dated 2-21-24 and signed by V4 (R1's Palliative Care Physician) document, A few weeks ago (R1) was having significant issues with delirium at night and there was a night where an ambulance had to be called. On further investigation from family, turns out (R1) had not been getting her fentanyl patches. There was a list of excuses that the nursing home provided, though (V2/Director of Nursing) never did get back to the family about why the patches had no bed obtained from pharmacy or why physician involvement was no pursed in order to get the right order. The nursing home did not send a med (medication) list with (R1) so we will work on getting one. About four to six weeks ago (R1) went through opioid withdrawal because the facility did not have (R1's) fentanyl patches. I am unsure about what efforts (if any) the facility pursued to get (R1) her pain medications. Not only was my office unavailable during this time, the patient's primary care provider's office was available and our nurse practitioner who rounds at the facility would have also been available to help troubleshoot. This appears to be inadequate care and my duty as a mandatory reporter required me to report this. Assessment and recommendations: 1. Encounter for palliative care. 2. Multiple Myeloma not having achieved remission. 3. Bone Metastasis. 4. Cancer related pain. 5. Drug-induced constipation. 5. Opioid withdraw delirium resolved.
On 3-8-24 at 9:30 AM R1 was lying in bed in her room. R1 stated, I did not know I wasn't getting my pain medication. I know my lower back was on fire. Most all of my pain is in my lower back. I fell and was not feeling very well a few weeks ago.
On 3-8-24 at 9:45 AM V2 (Director of Nursing/DON) stated, I was informed on 1-25-24 that (R1's) Fentanyl patch was not delivered by pharmacy, and we needed a renewal slip from the physician. On 1-30-24 I was told (R1) still did not have her Fentanyl delivered by pharmacy. I called pharmacy and they said the script (V7/Nurse Practitioner) sent on 1-29-24 did not include the amount. I looked at the script and it did include the amount. I called the pharmacy again on 1-31-24 and (R1) still had not received the Fentanyl patch and said they still did not have a physician script. On 2-5-24 I was told (R1's) Fentanyl was still not delivered by pharmacy. I sent an email on 2-5-24 and told them it us unacceptable for (R1) to have to go two weeks without her Fentanyl. Finally, the pharmacy delivered it that night. I did not know (V4/R1's Palliative Care Physician) was the physician prescribing (R1's) Fentanyl. The facility switched pharmacies on 1-1-24 and pharmacy has communication issues.
On 3-8-24 at 11:00 AM V4 (R1's Palliative Care Physician) stated, I am responsible for (R1's) Palliative care. I saw (R1) in my office on 2-21-24. I was told on 2-21-24 that (R1) did not receive her Fentanyl patch for two weeks and was experiencing withdrawals. I was not informed by the nursing home of (R1's) Fentanyl patch not being available or administered. It is very dangerous to abruptly stop Fentanyl. (R1's) experiencing night terrors, garbled speech, shallow respirations, and falls would have definitely been withdrawal symptoms from abruptly stopping her Fentanyl. When the pharmacy was not sending the Fentanyl I should have been contacted. The facility should have been doing everything in their power to get the Fentanyl and should have been following up with me and pharmacy daily. (R1) should not have gone two weeks without Fentanyl. Fentanyl is the only medication that keeps (R1's) pain control. (R1) has excruciating pain from bone cancer and I have had to increase (R1's) Fentanyl dose to keep the pain under control. No other pain medication has been effective.
On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, The pharmacy the facility started using a new pharmacy January 1, 2024, and this pharmacy has not been good. I did not know (R1) had went without Fentanyl for two weeks. (R1) should not have never been without her Fentanyl, especially for two weeks. I was only notified one day (1-19-24) of the need for a signed prescription. (R1) has bone cancer to her spine and her pain is very detrimental to her. The facility should have been notifying a physician and pharmacy daily to get (R1's) Fentanyl in before it ran out or used an alternate pharmacy to get the medication. The facility should not be letting their residents run out of medications.
On 3-8-24 at 12:25 PM V8 (R1's Power of Attorney) stated, (R1) told me that she fell out of bed because she had nightmares. (R1) said 911 was called and came to see her. On 2-1-24 I called the nurse (V9/RN), and she told me (R1) had been out of her Fentanyl patch for two weeks and that was causing her night terrors. (V9) told me 911 had a hard time waking her up and thought she was having seizure like activity. I called (V2) on a Monday (2-5-24) and told (V2) that (R1) was out of her pain patch and (V2) told me she was not out of the pain patch and was not aware of (R1) being out of the pain patch. I did not hear back from (V2), so I called back on a Wednesday (2-7-24) and spoke to (V2). (V2) did say (R1) fell out of bed once and had been out of her Fentanyl patch for two weeks. (V2) said (V7) tried to send the prescription in to pharmacy, but the facility still did not receive the prescription. I was never notified of (R1) falling out of bed or being out of Fentanyl or 911 being called. (V2) told me the pharmacy got the Fentanyl on 2-8-24.
On 3-8-24 at 1:00 PM V9 (RN/Registered Nurse) stated, (R1) did not have her Fentanyl patch for two weeks and was having withdrawals and night terrors.
2. R2's Face Sheet documents R2 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Type II Diabetes Mellitus and a non-pressure chronic ulcer of unspecified part of right lower leg.
R2's Physician's Order Report date 3-1-24 through 3-8-24 documents, Order date 1-8-24 to current: Oxycodone 10 mg (milligram) tablet two tablets three times daily. Order date 11-30-23 to current: Oxycodone 10 mg one tablet every four hours as needed (PRN). `
R2's Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2's Oxycodone 10 mg two tablets was not administered as ordered on 1-26-24 at 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, and 1-28-24 at 8:00 AM. These same Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2 did not receive a PRN dose of Oxycodone 10 mg on 1-26-24 through 1-31-24.
R2's Progress Notes dated 1-28-24 at 3:11 PM and signed by V9 (RN) documents R2 was complaining of increased pain and withdrawals due to his scheduled pain medication not being available from pharmacy due to insurance. This same not documents R2 remained in bed and was not eating meals.
R2's Progress Notes dated 1-29-24 at 1:47 PM and signed by V11 (RN) documents, (R2) has remained in bed thus far today. Withdrawal symptoms present due to new script needing written for Oxycodone. (R2) went all weekend and today without pain medication. Complained of chills, feeling hot, nausea, vomiting, and overall feeling sick. (R2) refused both breakfast and lunch.
On 3-8-24 at 11:10 AM R2 was lying in bed. R2's right lower leg was wrapped in gauze. R2 stated, I was out of the Oxycodone for three days. I was bit by a [NAME] Recluse spider and that is why I am here for treatment. When I was out of the Oxycodone, I was having withdrawals of nausea, vomiting, and dry heaving and I was having pain at an 11 on a 1-10 pain scale. The pain was continuous and unbearable. It felt like my wound was split open and burning.
On 3-8-24 at 9:45 AM V2 (Director of Nursing/DON) stated, (R2) had to go without his Oxycodone for three days because the pharmacy said they did not receive his prior authorization. (R2) experienced withdrawal symptoms.
On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, The facility should not be letting their residents run out of medications. I oversee (R2's) care at the facility. (R2) ran out of Oxycodone on 1-26-24. I was not notified of the need for a prior authorization until (R2) already ran out. (R2) did not get his medication for three days until I called (V2) and told her the facility needs to pay for the medication until (R2's) prior authorization gets sent. (R2) got bitten by a [NAME] Recluse spider that caused a wound with bone exposure. (R2) was having withdrawals and should not have gone without his Oxycodone.
The Immediate Jeopardy started on 1-25-24 at 9:00 PM when R1's scheduled Fentanyl patch 100 mcg/hour was not delivered by pharmacy to treat R1's bone cancer pain, causing R1 to experience opioid withdrawals symptoms.
V1 (Administrator) and V2 (DON) were notified of the Immediate Jeopardy on 3-11-24 at 9:36 AM.
On 3-13-24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:
1. On 3-13-24 R1's opioid pain medications were available and being administered.
2. On 3-13-24 R2's opioid pain medications were available and being administered.
3. On 3-13-24 all residents who currently had orders for opioid pain medications had their pain medications available and were being administered.
4. On 3-11-24 V1 and V2 reviewed the facility's Controlled Substance Prescriptions Policy to ensure the policy included ordering and receiving controlled medications to ensure that all controlled (opioids) are filled immediately.
5. On 3-11-24 V1 and V2 in-serviced all facility nurses and department heads on notifying V1 and V2 immediately when opioid medication is not delivered by the pharmacy and V2's responsibility of contacting the pharmacy and taking action to ensure the medication is available and /or administered as ordered by the physician.
6. Pharmacy has been sending a controlled substance requiring prescription report daily to V1's and V2's email since 3-11-24 and this report has been reviewed daily by V1 and V2.
7. On 3-11-24 V2 in-serviced all facility nurses and department heads on notifying the attending physician, and /or nurse practitioner, V2, and V1 when a medication is not administered as ordered by the physician, ensuring all residents medications are obtained prior to the medications running out, and ordering and faxing medication refills to the pharmacy.
8. On 3-11-24 V13 (Medical Director) pharmacy staff were in-serviced by V1 and V2 regarding the facility's Controlled Substance Prescription Policy to ensure Opioid medications are filled and delivered to the facility immediately.
9. On 3-11-24 V13 (Medical Director) made aware of the Immediate Jeopardy regarding pharmacy concerns and opioid medications not being available for administration.
10. On 3-11-24 the facility conducted an emergency QA (Quality Assurance) meeting regarding all of the new pharmacy policies and procedures.
13. On 3-13-24 the pharmacy conducted an in-service with all nurses regarding medication pass guidelines for controlled substances.
Date of Completion: 3/11/2024
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to notify the physician and a resident's representative immediately once prescribed opioid medications were not obtained or administered as ord...
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Based on record review and interview the facility failed to notify the physician and a resident's representative immediately once prescribed opioid medications were not obtained or administered as ordered for two of three residents (R1 and R2) reviewed for notification of changes in the sample of three.
Findings include:
1. R1's Physician's Orders dated 10-5-23 through 3-8-24 document, Fentanyl 100 mcg per hour one patch transdermal once a day every three days at 9:00 PM for the diagnoses of Multiple Myeloma not having achieved remission.
R1's Medication Flow Sheets dated 1-1-24 through 2-31-24 document R1's Fentanyl Patch 100 mcg/hour transdermal placed at 9:00 PM was not administered as scheduled on 1-25-24, 1-28-24, 1-31-24, or 2-3-24. These same Medication Flow Sheets document R1 did not have a Fentanyl 100 mcg/hour patch applied until 2-6-24.
R1's Progress Notes dated 1-29-24 at 5:49 AM and signed by V5 (RN/Registered Nurse) document, At 5:45 am (R1) heard yelling (female's name) and had fallen in room. Fall was witnessed by roommate who states (R1) was having a nightmare and got out of bed unaware. (R1) was observed trying to stand herself up when this nurse entered the room. (R1) states she hit her knees a bit and her back. (R1) states this is a normal occurrence for her, and she needs to see someone about the night terrors. No other noticed injuries other than some bruising starting to bilateral knees.
On 3-8-24 at 11:00 AM V4 (R1's Palliative Care Physician) stated, I am responsible for (R1's) palliative care and prescribing (R1's) Fentanyl patch. I saw (R1) in my office on 2-21-24. I was told on 2-21-24 that (R1) did not receive her Fentanyl patch for two weeks and was having night terrors and withdrawal symptoms. I was not informed by the nursing home of (R1's) fentanyl patch not being available or administered, or about (R1) having withdrawals. I should have been informed immediately of (R1) not receiving her Fentanyl patch and the need for a written prescription.
On 3-8-24 at 12:25 PM V8 (R1's Power of Attorney) stated, (R1) told me that she fell out of bed because she had nightmares. (R1) said 911 was called and came to see her. On 2-1-24 I called the nurse (V9/RN), and she told me (R1) had been out of her Fentanyl patch for two weeks and that was causing her night terrors. I was never notified of (R1) being out of Fentanyl, falling, or having night terrors until I called (V9) on 2-1-24. Somebody should have let me know.
2. R2's Physician's Order Report date 3-1-24 through 3-8-24 documents, Order date 1-8-24 to current: Oxycodone 10 mg (milligram) tablet two tablets three times daily. Order date 11-30-23 to current: Oxycodone 10 mg one tablet every four hours as needed (PRN). `
R2's Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2's Oxycodone 10 mg two tablets was not administered as ordered on 1-26-24 at 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, and 1-28-24 at 8:00 AM.
On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, The facility should not be letting their residents run out of medications. I oversee (R2's) care at the facility. (R2) ran out of Oxycodone on 1-26-24. I was not notified of the need for a prior authorization until a day after (R2) already ran out of his Oxycodone.
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure the residents' representatives were invited and attended care plan conferences for two of three residents (R1 and R3) reviewed for ca...
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Based on record review and interview the facility failed to ensure the residents' representatives were invited and attended care plan conferences for two of three residents (R1 and R3) reviewed for care planning in the sample of three.
Findings include:
The facility's Care Planning-Interdisciplinary Team policy dated 08/06 documents, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.
1. R1's Medical Record dated 8-24-23 through 3-8-24 does not include any documentation of V8 (R1's Power of Attorney/POA) being invited or attending R1's care plan meetings except on one occasion (2-14-24).
On 3-8-24 at 12:25 PM V8 (R1's Power of Attorney) stated, I have not been invited to a care plan meeting since (R1) was admitted until 2-14-24. I need to be involved with (R1's) care plan meetings to ensure the facility is taking appropriate care of (R1).
2. R3's Medical Record dated 3-1-23 through 3-8-24 does not include documentation of R3's Power of Attorney/POA (V12) being invited or attending R3's care plan meetings.
On 3-8-24 at 12:55 PM R3 stated, I do not think (V12) comes to my meetings. I would like for (V12) to be able to.
On 3-8-24 at 2:00 PM V10 (MDS/Minimum Data Set Coordinator) stated, The facility does not have a care plan coordinator right now. I cannot find any documentation of (V8) or (V12) being invited to (R1's) and (R3's) care plan meetings, except for the one meeting (V8) attended on 2-14-24.
Feb 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 F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident's pain was controlled, and assess pain on a daily basis for one of one reviewed for pain in the sample of t...
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Based on observation, interview, and record review, the facility failed to ensure a resident's pain was controlled, and assess pain on a daily basis for one of one reviewed for pain in the sample of three. These failures resulted in R2 having excruciating pain during wound care.
Findings include:
The facility's Pain-Clinical Protocol, dated 2008, documents, The staff will discuss significant changes in levels of comfort with the attending physician who will adjust interventions accordingly. This may include adjustments of regular and PRN (as needed) analgesic doses to find the best combination of effectiveness and tolerable side effects, or possible addition of non-pharmacological interventions.
R2's Care plan, dated 11/14/23, documents, R2 has increased potential for complications and discomfort related to the diagnosis of arthritis. The care plan also documents the following interventions: Monitor and record any complaints of pain: location, duration, quantity, quality, alleviating factors, aggravating factors; Monitor and record any non-verbal signs of pain: (e.g. guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc.); Use pain relief measures: (distraction, imagery, relaxation, etc.) Evaluate/record/report effectiveness.
R2's Physician's orders, dated 1/14-2/14/24, document that R2 has the following pain medication orders: oxycodone-acetaminophen 7.5-325 mg one tablet every six hours; ibuprofen 400 mg one tablet every eight hours; Tylenol 325 mg two tablets every four hours as needed for pain.
R2's Pain Observation, dated 2/7/24, documents that R2 states that she has almost constant pain.
R2's MAR (Medication Administration Record), dated 2/1-2/15/24, has no documentation of R2's pain being assessed on a daily basis with the administration of pain medication.
On 2/13/24 at 11:13 a.m., R2 was alert leaning forward in her wheelchair. R2 stated I have two pressure ulcers on my backside. I have a really big area on my right calf. It is from a stocking thing that was way to tight and I told that CNA (Certified Nurse Aide) to not put it on. They tell me I need to lay down more, but I hate to use the (full mechanical lift) more than I need to I don't like that thing. It hurts so bad when they get me up and down. I've got a bad hip that if they move that leg it's instant awful pain. The hip needs replaced, but they won't do surgery on me. I absolutely dread when they change my dressings. The one on my leg is awful. It burns so bad when they do it. I swear every single time I cry. The one on my backside hurts when they do it as well. I feel like I'm going to cry, but I'm able to hold that one in normally. I just pray they would heal up so I wouldn't have to go through that pain.
On 2/14/24 at 9:10 am,, R2 was alert lying in bed. R2 asked V3 (wound nurse) if V3 could do her buttocks wound dressing changes before doing her legs since it was so painful for the dressing changes on her legs. V2 (Director of Nursing) was also present during R2's wound care. R2 stated, I'm sorry I'm going to yell out and probably cry because these hurt so bad. V3 removed a silicone border foam dressing from R2's coccyx and R2's left ischium. V3 cleansed both wounds with normal saline. During the cleansing, R2 was grimacing. R2's coccyx wound was a open area with depth. The base of R2's coccyx pressure ulcer was 75% covered yellow gray tissue (slough). So it is undetermined as to how deep the actual wound is. V3 began to pack the coccyx wound, and R2 began to cry out, Ow (Ouch) it hurts. Please stop. Ow!. V3 replied with I'm sorry, and continued performing wound care. R2 continued to cry out until V3 covered the wound with a silicone border foam dressing. R2 also had an open area with depth to R2's left ischium. As V3 began packing that area, R2 started crying out in pain again until the wound was covered with the silicone border foam dressing. Then, V3 began to remove the gauze roll from R2's right leg, and R2 began to cry stating, I don't like this one it burns so bad! V3 proceeded to removed the dressing covering R2's right calf. R2 began to bite her blanket to muffle her crying out as tears were coming out of her eyes. She began to scream, Ow! What are you doing? Don't! Please stop it's burning so bad! R2's entire back of her right calf was a large open/raw area. V3 began to cleanse the wound with normal saline and R2 began yelling out again for V3 to stop because it was burning so bad. V3 covered the wound with (Sodium Chloride impregnated gauze dressing)and and ABD (abdominal) pad. Then, she covered it all with a gauze roll while R2 continued to cry out. After the treatment was completed R2 kept repeating, I'm so sorry I was crying and yelling those dressing changes just hurt so bad!
On 2/15/24 at 9:40 a.m., V3 stated that prior to wound care, R2 had pain medication at 6:00 a.m. when she received Ibuprofen 400 mg and oxycodone-acetaminophen 7.5 -325 mg (milligrams).
On 2/20/24 at 10:52 a.m., V4 (Registered Nurse) stated, (R2) has a lot of pain, especially in her hips and her legs. She cries out a lot still. She cries if we turn her, roll her, or even if someone bumps her wheelchair. When we do her dressing changes she complains a lot about the burning in her right calf. She will keep repeating, 'It burns. It burns.' She normally gets her scheduled oxycodone at 6:00 a.m., and then we do her dressing changes between 6:30-7:00 a.m. Even when we give it at that time she still complains about the wound care and positioning during it as well. She has a horribly bad hip. It hurts her more to lay down then be up in her wheelchair.
On 2/20/24 at 10:45 a.m., V6 CNA stated that (R3) cries out in pain when they transfer her in the (full mechanical lift). She complains about her legs hurting her. She complains that her right calf burns and is painful pretty frequently.
On 2/20/24 at 9:40 a.m., V5 (Nurse Practitioner) stated, I'm not aware that (R2) doesn't lay down because of it hurting during the transfer. She has a hip that she needs replaced, but the surgeons are not wanting to replace it, and it causes her pain with movement. I know that she struggles with pain during the dressing changes, especially her right calf dressing change. If her pain isn't under control with the oxycodone, I'm going to have to try something different.
On 2/20/24 at 11:10 a.m., V2 stated, (R2) did cry out quite a bit during the dressing change last Thursday (2/15/24). I've never heard her cry out like that before, but we continued to do the wound care. She had her scheduled pain medication that morning, but she doesn't have anything PRN. The scheduled pain medication should cover her. She complains of the right calf wound burning with the dressing change. If someone complains of pain during a dressing change I just try to get it done faster so the pain will stop sooner.
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 assess a newly identified pressure ulcer, and obtain ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess a newly identified pressure ulcer, and obtain a physician ordered treatment for two of three residents (R1, R3) reviewed for pressure ulcers in the sample of three.
Findings include:
The facility's Prevention of Pressure Wounds policy, dated 1/17, documents, Once a pressure injury develops, it can be extremely difficult to heal. Pressure injuries are a serious skin condition for the resident. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of developing pressure injury.
1. R1's Braden Scale Assessment, dated 10/25/23, documents a score of 13 putting R1 at a moderate risk for developing pressure ulcers.
R1's Nurses' note, dated 1/17/24 at 10:02 a.m., documents that R1 was sent to the emergency room at 9:57 a.m.
R1's Discharge Return Anticipated MDS (Minimum Data Set), dated 1/17/24, documents that R1 was discharged to the hospital on this date with a Stage 2 pressure ulcer.
R1's ED (Emergency Department) History and Physical, dated 1/17/24 at 2:28 p.m., documents, Assessment & Plan: Grade 2 sacral coccygeal pressure ulcer.
On 2/14/24 at 1:10 p.m., V3 (wound nurse) stated that she wasn't aware of (R1) having any type of pressure ulcer prior to her being discharged to the hospital.
On 2/14/24 at 1:14 V2 (Director of Nursing) stated, I was the one that sent her out to the hospital that day. I remember changing a (silicone border foam dressing) on her coccyx. I don't remember if there was anything there. It may have been reddened.
On 2/20/24 at 10:52 a.m., V4 (Registered Nurse) stated that R1 had an open area on her coccyx before she left to go to the hospital on 1/17/24.
R1's current medical record has no documentation of a Stage 2 pressure ulcer assessment prior to R1's discharge to the hospital nor of a physician ordered treatment.
On 2/14/24 at 10:24 a.m., R1 had a silicone border foam dressing in place and a packing in the wound. V3 (Wound Nurse) removed the packing. R1 had an open area with depth, and the base of the wound was 100% covered with yellow slough therefore it was unable to be determined the depth. V3 stated that R1's wound was currently unstageable with the base being covered with slough.
On 2/20/24 at 9:40 a.m., V5 (Nurse Practitioner) stated that when she saw (R1) on 1/11/24 she did not have a Stage 2 pressure ulcer on her coccyx, but she did have one present on admission to the hospital on 1/17/24. If there was a (silicone border foam dressing) on her coccyx then there should have been a treatment order and I should have been notified. I was not notified that she had a Stage 2 pressure ulcer on her coccyx until she was readmitted on [DATE].
2. R3's (Admission) Body Map, dated 2/8/24, documents that R3 has an unstageable pressure ulcer to her right lower buttock that measures 6 cm (centimeters) x 4 cm as well as an area to the coccyx/sacral area that measures 4 cm x 4 cm x 1.5 cm.
R3's Physician's orders, dated 1/14/24-2/14/24, document that R3 was admitted with a physician ordered treatment for R3's pressure ulcer on her coccyx. R3's physicians orders have no documentation of a physician ordered treatment for R3's pressure ulcer to her right lower buttock.
On 2/14/24 at 10:04 am, V3 (Wound Nurse) removed a heart shaped silicone border foam dressing from R3's coccyx area. R3 had an open area with depth to her coccyx, R3 also had an irregular shaped wound to her right lower buttock that was covered with slough (gray black tissue). The right lower buttock wound was partially covered by the silicone border foam dressing edges.
On 2/14/24 at 10:14 a.m., V3 confirmed there was no physician ordered treatment in place for R3's right lower buttock pressure ulcer.
Apr 2023
3 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 F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to prevent diversion of a controlled substance for three of three residents (R1, R2, R3) reviewed for misappropriation of property...
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Based on observation, interview and record review the facility failed to prevent diversion of a controlled substance for three of three residents (R1, R2, R3) reviewed for misappropriation of property in a sample of five.
Findings include:
A Facility Abuse Policy dated as reviewed 2/2020 states, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility, therefore, prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This policy defines misappropriation of property as, The deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent.
R1's Physician's orders (POS) dated 12/8/23 documents R1 was prescribed Morphine concentrate (Sulfate) 100mg (milligrams)/5ml (milliliters) oral medication with a dose of 0.5ml (10mg) every hour as needed for pain or air hunger.
R2's POS dated 6/19/22 documents R2 was prescribed Morphine concentrate (Sulfate) 100mg/5ml oral medication with a dose of 0.5ml (10mg) every hour as needed for pain or air hunger.
R3's POS dated 10/26/22 documents R3 was prescribed Morphine concentrate (Sulfate) 100mg/5ml oral medication with a dose of 0.25ml (5mg) as needed for pain.
A Facility Incident Report Form with a fax cover sheet dated 4/6/23 and with an occurrence date of 4/6/23 documents that an initial report was sent to the State Agency on that date because, RN (Registered Nurse) staff nurse reported that R1 and R2's Morphine noted to be missing. Investigation initiated and remained ongoing. (Local Law Enforcement) has been notified. This incident report form includes a Timeline of events which documents that on 4/3/23 V4 (RN) reported there were missing bottles of residents' Morphine during the morning shift-to-shift narcotic count. This timeline documents that after a search of the medication cart, medication room, and the nurses' station the Morphine bottles were not found. This timeline documents that at 4:00p.m. on 4/3/23 facility nurses were given an in-service on narcotic medication pass and counting of narcotics. This form documents that local law enforcement was not notified of the potential diversion of residents' Morphine bottles until 4/6/23. This form also documents the two suspected nurses were given a urine drug screen to determine presence of opioid narcotics on 4/3/23.
A Facility Incident Report Form dated 4/19/23 documents,(State Agency) surveyor and DON (Director of Nurses/V2) noted that (R3) morphine count sheet to read 27ml (milliliters) and the bottle reads 24ml. Investigation initiated and is ongoing. (Local Lae Enforcement) is here at present time and notified.
On 4/19/23 at 2:50p.m. V2 (Director of Nurses/DON) stated that once the allegation of missing Morphine was reported by V4 on 4/3/23, the remaining bottle of Morphine Sulfate oral solution belonging to R3 was pulled out of the medication cart. V2 stated that R1 should have had two bottles of Morphine, R2 should have had one bottle, and R3 should have had one bottle in the drawer but three of the four bottles were missing. V2 proceeded to remove a partially used bottle of Morphine Sulfate 20mg (milligrams)/ml (milliliter) from the locked drawer in her office. V2 placed the bottle on her desk and noted that the bottle only contained approximately 24ml out of the 30ml originally in the bottle. V2 proceeded to note that on the controlled substance record for this bottle, there should be 27ml remaining. V2 stated she already knew as of 4/3/23 that nursing staff could not account for the discrepancy between the volume that should have been in R3's Morphine bottle and what was actually in the bottle. V2 stated she did not report this discrepancy to V1 as part of the diversion of narcotics investigation which was started on 4/3/23.
R3's Controlled Substance Record which records doses remaining in R3's bottle of Morphine Sulfate liquid 20mg/ml dated as dispensed 3/20/23 documents that as of 4/4/23 V4 was the last to sign this document when V4 administered 0.25ml of Morphine (5mg) to R3 with a volume of 27ml recorded as still in the bottle.
On 4/24/23 at 1:56p.m. V4 stated that she was R1, R2, R3's nurse on Friday 3/31/23 for the day shift. V4 stated that there were four bottles of Morphine Sulfate oral medication stored in the locked narcotics box of the medication cart, two for R1, one each for R2 and R3 during her shift-to-shift narcotic count with V8 (RN). V4 stated that during the shift-to-shift narcotic count on 4/3/23 with V5 (Licensed Practical Nurse/LPN), which was the next time V4 worked, R1 and R2's three Morphine Sulfate bottles were missing along with their controlled substance record used to log the doses removed from the bottle. V4 stated she refused to sign the shift-to-shift narcotics count log because she knew those medications might have been diverted. V4 stated she reported her suspicion to V2. V4 stated that the remaining Morphine Sulfate bottle in the cart belonging to R3 was removed and given to V2 during the investigation. V4 stated that V5 stated she noticed there weren't as many Morphine bottles as the last time she worked, but that V5 thought the medications were discontinued. V4 stated that nurses are supposed to put the bottles of liquid morphine on a flat surface to measure the remaining volume in the bottles in order to properly reconcile the narcotics count. V4 stated that she and the other nurses had not been verifying the quantity of Morphine left in each bottle but, instead, they were just verifying the number of bottles present.
On 4/24/23 at 10:50a.m. V7 (LPN) stated that she worked the day shift as R1, R2, R3's nurse on 4/1/23 and 4/2/23. V7 stated that on 4/1/23 she and V8 counted the narcotic drawer during the morning shift-to-shift narcotic count. V7 stated there was only one bottle of Morphine locked in the narcotic drawer at that time. V7 stated she had worked on 3/27/23 on the same hallway but does not recall how many bottles of Morphine were in the narcotics box on that date.
On 4/24/23 at 5:35p.m. V8 stated he worked the night shift on 3/31/23. V8 stated when he counted the Morphine bottles with V7 at approximately 6:00a.m. 4/1/23, he thinks there were three bottles.
On 4/19/23 at 9:00a.m. and 10:32a.m. and on 4/24/23 at 12:40p.m. V1 (Administrator) stated that on 4/3/23 V4 came in to work the day shift at 6:00a.m. after having last worked on 3/31/23. V1 stated that V4 noted on Monday 4/3/23 during the shift-to-shift narcotic count there was only 1 bottle of Morphine Sulfate left in the medication cart which belonged to R3. V1 stated that V4 refused to take over the medication cart on 4/3/23 because she had counted four bottles of Morphine Sulfate belonging to R1, R2 and R3 when she worked 3/31/23 and V4 knew that none of those residents would have used that much morphine over the weekend. V1 stated that after V4 alerted the facility there were narcotics not accounted for, V2 (Director of Nurses) proceeded to search through the medication carts, residents' rooms, and the nurses' station to find the missing medications. V1 stated that whoever took the Morphine also took the Controlled Substance Records for each bottle making it hard to determine how much morphine was taken for sure. V1 stated there were five nurses who worked between 3/31/23 to 4/3/23 using that medication cart and all were interviewed. V1 stated that based on their interviews, two nurses who gave conflicting accounts of how many bottles of Morphine were in the narcotic drawer were suspected of having diverted the medication during their shifts 3/31/23 and 4/1/23. V1 stated that on the afternoon of 4/3/23 after an exhaustive search for the missing bottles of Morphine concentrate and after interviewing nursing staff, V1 formed a suspicion that the three missing bottles of Morphine were stolen or diverted. V1 stated that the original investigation was for R1 and R2's missing bottles of Morphine, but that she had been informed on 4/16/23 that R3's partially used bottle of Morphine was missing several doses. V1 stated that she compared R3's medication administration record (MAR) to R3's Morphine bottle controlled substance record/log and found that V8 had not signed out three doses of 0.25ml each. V1 stated that even after accounting for three doses, there was less Morphine in R3's bottle than what is accounted for in R3's medical record. V1 stated she initially watched the facility's security video footage of 3/31/23 when V8 worked the night shift, and on 4/1/23 when V7 worked the day shift. V1 stated she noted that on 4/1/23 V7 took the medication cart into R3's room and closed the door on two different occasions. V1 stated that in the afternoon of 4/1/23, V7 took her medication cart in to R3's room for approximately 40 minutes while R3's door was closed. V1 stated that nurses do not normally take medication carts into residents' rooms. V1 stated that she also did not understand why V7 would close R3's door if V7 was administering medications. V1 stated that she reviewed R3's controlled substance record and Medication Administration Records (MARS) for 4/1/23 and saw that V7 documented that she administered 0.25ml of Morphine Sulfate to R3 at 7:00a.m. and again at 11:40 in the morning. V1 stated that she compared the video times of V7 passing medications to R3's controlled substance record and found that V7 did not go into R3's room at or around 7:00a.m. or 11:40a.m. V1 stated that V7 did not go into R3's room until 8:47a.m. and exited at 9:03a.m. V1 stated the next time V7 entered R3's room was at 1:00p.m. where V7 remained for 40 minutes with the door closed. V1 stated that because V7's documented Morphine administration times did not match the video times, V1 decided to watch the video from the previous time V7 worked on R1, R2, R3's unit, which was 3/27/23. V1 stated the video camera only records video from the hallway in front of R3's room, therefore, V1 could not determine if V7 entered R1 or R2's room to administer any medications. V1 stated that R1 and R2 have Morphine ordered but do not generally experience pain and, therefore, do not usually use any Morphine. V1 stated that R1 and R2's Morphine bottles, and the controlled substance records that go with each bottle are missing, so if V4 had not noticed the three bottles of Morphine were missing 4/3/23, it may have been a longer period of time before the facility realized diversion of narcotics had occurred. V1 stated that on 3/27/23 V7 documented that she administered Morphine Sulfate to R3 at 7:10a.m. and 1:00 in the afternoon. V1 stated the video shows that V7 did not go into R3's room at 7:00a.m. to administer any medication but that V7 did enter R3's room at 8:47 that morning. V1 stated that on 3/27/23 at 1:00p.m., the video shows that V7 placed a pill in a medication cup but never took the bottle of Morphine out of the locked drawer to prepare a dose for R3. V1 stated the video shows V7 taking only the cup with a pill into R3's room but no liquid Morphine Sulfate as was documented.
On 4/24/23 at 11:26a.m. V11 (Sheriff's Deputy) stated he is investigating a diversion of Morphine Sulfate oral medications from the facility. V11 stated that he and the facility narrowed the suspects down to two nurses but cannot determine which one diverted the medication. V11 stated that V7's urine toxicology was negative for opioids but V8's urine toxicology report was positive. V11 stated that both V7 and V8 have prescriptions for opioid medications related to pain, and both V7 and V8 have a documented allergy to Morphine. V11 stated that both nurses denied having diverted any medications. V11 stated that, for now, he knows a diversion occurred but cannot prove who did it.
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 observation, interview and record review the facility failed to immediately report diversion of controlled substances to local law enforcement or the State Agency for three of three residents...
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Based on observation, interview and record review the facility failed to immediately report diversion of controlled substances to local law enforcement or the State Agency for three of three residents (R1, R2, R3) reviewed for reporting of alleged violations in a sample of five.
Findings include:
A Facility Abuse Policy dated as revised 2/2020 states, When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee, shall notify (The State Agency) immediately. This policy states, If there is a reasonable suspicion that a crime has been committed, and that, does not involve serious bodily injury, then report to local law enforcement as soon as possible but within 24 hours of when the suspicion was formed.
A Facility Incident Report Form with a fax cover sheet dated 4/6/23 and with an occurrence date of 4/6/23 documents that an initial report was sent to the State Agency on that date because, RN (Registered Nurse) staff nurse reported that R1 and R2's Morphine noted to be missing. Investigation initiated and remained ongoing. (Local Law Enforcement) has been notified. This incident report form includes a Timeline of events which documents that on 4/3/23 V4 (RN) reported there were missing bottles of residents' Morphine during the morning shift-to-shift narcotic count. This timeline documents that after a search of the medication cart, medication room, and the nurses' station the Morphine bottles were not found. This timeline documents that at 4:00p.m. on 4/3/23 facility nurses were given an in-service on narcotic medication pass and counting of narcotics. This form documents that local law enforcement was not notified of the potential diversion of residents' Morphine bottles until 4/6/23. This form also documents those two nurses were given a urine drug screen to determine presence of opioid narcotics on 4/3/23.
On 4/19/23 at 2:50p.m. V2 (Director of Nurses/DON) stated that once the allegation of missing Morphine was reported by V4 on 4/1/23, the remaining bottle of Morphine Sulfate oral solution belonging to R3 was pulled out of the medication cart. V2 stated that R1 and R2 had a total of three bottles that were missing and the only bottle that could be accounted for belonged to R3. V3 proceeded to remove a partially used bottle of Morphine Sulfate 20mg (milligrams)/ml (milliliter) from the locked drawer in her office. V2 placed the bottle on her desk and noted that the bottle only contained approximately 24ml out of the 30ml originally in the bottle. V2 proceeded to note that on the controlled substance record for this bottle, there should be 27ml remaining. V2 stated she already knew as of 4/3/23 that nursing staff could not account for the discrepancy between the volume that should have been in R3's Morphine bottle and what was actually in the bottle. V2 stated she did not report this discrepancy to V1 as part of the diversion of narcotics investigation.
On 4/19/23 at 9:00a.m. and 10:32a.m. V1 (Administrator) stated that on 4/3/23 V4 came in to work the day shift at 6:00a.m. after having last worked on 3/31/23. V1 stated that V4 noted on Monday 4/3/23 during the shift-to-shift narcotic count there was only 1 bottle of Morphine Sulfate left in the medication cart which belonged to R3. V1 stated that V4 refused to take over the medication cart on 4/3/23 because she had counted four bottles of Morphine Sulfate belonging to R1, R2 and R3 when she worked 3/31/23 and V4 knew that none of those residents would have used that much morphine over the weekend. V1 stated that after V4 alerted the facility there were narcotics not accounted for, V2 (Director of Nurses) proceeded to search through the medication carts, residents' rooms, and the nurses' station to find the missing medications. V1 stated there were five nurses who worked between 3/31/23 to 4/3/23 using that medication cart and all were interviewed. V1 stated that based on their interviews, two nurses who gave conflicting accounts of how many bottles of Morphine were in the narcotic drawer were suspected of having diverted the medication during their shifts 3/31/23 and 4/1/23. V1 stated that on the afternoon of 4/3/23 after an exhaustive search for the missing bottles of Morphine concentrate and after interviewing nursing staff, V1 formed a suspicion that the three missing bottles of Morphine were stolen or diverted. V1 verified that she did not immediately notify the State Agency or local law enforcement with her suspicions, but instead, notified both the State Agency and local law enforcement three days later on 4/6/23. On 4/24/23 at 12:40p.m. V1 stated that the original investigation of missing Morphine Sulfate bottles was for R1 and R2, but that she had been informed on 4/16/23 that R3's partially used bottle of Morphine was missing several doses. V1 stated that she compared R3's medication administration record (MAR) to R3's Morphine bottle controlled substance record/log and found that V8 had not signed out three doses of 0.25ml each. V1 stated that even after accounting for three doses, there was less Morphine in R3's bottle than what is accounted for in R3's medical record. V1 stated that she notified V11 (Sheriff's Deputy) and the State Agency on 4/16/23 after V2 informed her R3's Morphine bottle had doses missing that could not be accounted for.
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
Based on interview and record review the facility failed to ensure an accurate reconciliation of controlled substances was performed during the shift-to-shift narcotic count which affected one of thre...
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Based on interview and record review the facility failed to ensure an accurate reconciliation of controlled substances was performed during the shift-to-shift narcotic count which affected one of three residents (R3) reviewed for pharmacy procedures in a sample of five.
Findings include:
A Controlled Substance Storage policy dated 10/25/14 states, A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications. In addition, this policy states, At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted, and Any discrepancy in controlled substance counts is reported to the director of nursing and pharmacy PIC immediately. The director of nursing documents irreconcilable discrepancies in a report to the administrator.
A Facility Incident Report Form dated 4/19/23 documents,(State Agency) surveyor and DON (Director of Nurses/V2) noted that (R3) morphine count sheet to read 27ml (milliliters) and the bottle reads 24ml. Investigation initiated and is ongoing. (Local Law Enforcement) is here at present time and notified.
On 4/19/23 at 2:50p.m. V2 (Director of Nurses/DON) stated the facility has an ongoing investigation into diversion of liquid Morphine Sulfate concentrate. V2 stated two residents (R1, R2) had bottles of Morphine bottles taken from the nurses' medication cart, but R3's partially used bottle of Morphine was not taken by the perpetrator. V2 stated that as an effort to prevent further misappropriation, V2 locked R3's Morphine in her office during the investigation. V2 proceeded to remove a partially used bottle of Morphine Sulfate 20mg (milligrams)/ml (milliliter) from the locked drawer in her office. V2 placed the bottle on her desk and noted that the bottle only contained approximately 24ml out of the 30ml originally in the bottle. V2 proceeded to note that on the controlled substance record for this bottle, there should be 27ml remaining. V2 stated she already knew as of 4/3/23 that nursing staff could not account for the discrepancy between the volume that should have been in R3's Morphine bottle and what was actually in the bottle. V2 stated she asked V4 (Registered Nurse/RN), the last person who signed out a dose of R3's Morphine, if she verified the amount left in the bottle during shift-to-shift narcotic count and at the time she dispensed the medication. V2 stated V4 told her she did not know when the volume/ number of remaining doses left in the bottle was last verified with the controlled substance record.
R3's Controlled Substance Record which records doses remaining in R3's bottle of Morphine Sulfate liquid 20mg/ml dated as dispensed 3/20/23 documents that as of 4/4/23 V4 was the last to sign this document when V4 administered 0.25ml of Morphine (5mg) to R3 with a volume of 27ml recorded as still in the bottle.
On 4/24/23 at 1:56p.m. V4 stated that she was the nurse who initially noticed there were bottles of Morphine Sulfate concentrate belonging to R1 and R2 missing from the medication cart on 4/3/23. V4 stated R3's bottle of Morphine was the only bottle that wasn't taken. V4 stated that during the investigation, it was discovered that there were fewer doses remaining in R3's bottle than what was recorded on the controlled substance record. V4 stated that nurses are supposed to put the bottles of liquid morphine on a flat surface to measure the remaining volume/doses in the bottles to properly reconcile the narcotics count. V4 stated that she and the other nurses had not been verifying the quantity of Morphine left in each bottle but, instead, they were just verifying the number of bottles present.
On 4/24/23 at 12:40p.m. V1 stated that on 4/16/23 V2 notified V1 that R3's partially used bottle of Morphine was missing several doses. V1 stated that she compared R3's medication administration record (MAR) to R3's Morphine bottle controlled substance record/log and found that V8 had not signed out three doses of 0.25ml each. V1 stated that even after accounting for three doses, there was less Morphine in R3's bottle than what is accounted for in R3's medical record. V1 stated that after she talked with the nurses who reconcile the liquid Morphine bottles during the shift-to-shift narcotic count, she discovered that nurses were only counting the number of bottles and not the number of doses left in the bottles. V1 stated that the Morphine bottle has a clear narrow area on the side with measurements to determine how much liquid Morphine remains in the bottle. V1 stated the bottles must be placed on a flat surface to make an accurate determination of the number of doses left. V1 stated that on the controlled substance record nurses were just writing the doses they gave but still not ensuring the correct volume was in the bottle.
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?"
- "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: 2 life-threatening violation(s), 2 harm violation(s), $51,555 in fines, Payment denial on record. Review inspection reports carefully.
- • 36 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $51,555 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (6/100). Below average facility with significant concerns.
Bottom line: Trust Score of 6/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Timber Point Healthcare Center's CMS Rating?
CMS assigns TIMBER POINT HEALTHCARE CENTER an overall rating of 2 out of 5 stars, which is considered 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 Timber Point Healthcare Center Staffed?
CMS rates TIMBER POINT HEALTHCARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 48%, compared to the Illinois average of 46%.
What Have Inspectors Found at Timber Point Healthcare Center?
State health inspectors documented 36 deficiencies at TIMBER POINT HEALTHCARE CENTER during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 32 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 Timber Point Healthcare Center?
TIMBER POINT HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ATIED ASSOCIATES, a chain that manages multiple nursing homes. With 110 certified beds and approximately 67 residents (about 61% occupancy), it is a mid-sized facility located in CAMP POINT, Illinois.
How Does Timber Point Healthcare Center Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, TIMBER POINT HEALTHCARE CENTER's overall rating (2 stars) is below the state average of 2.5, staff turnover (48%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Timber Point Healthcare Center?
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?" "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?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Timber Point Healthcare Center Safe?
Based on CMS inspection data, TIMBER POINT HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-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 Timber Point Healthcare Center Stick Around?
TIMBER POINT HEALTHCARE CENTER has a staff turnover rate of 48%, 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 Timber Point Healthcare Center Ever Fined?
TIMBER POINT HEALTHCARE CENTER has been fined $51,555 across 2 penalty actions. This is above the Illinois average of $33,594. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Timber Point Healthcare Center on Any Federal Watch List?
TIMBER POINT HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.