What is CASEY REHAB AND NURSING's CMS rating?

CASEY REHAB AND NURSING has a two-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does CASEY REHAB AND NURSING have any serious inspection findings?

Yes, CASEY REHAB AND NURSING has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 49 total deficiencies from recent inspections.

What are the staffing levels at CASEY REHAB AND NURSING?

CASEY REHAB AND NURSING has a four-star staffing rating from CMS with 0.82 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is CASEY REHAB AND NURSING located?

CASEY REHAB AND NURSING is located in CASEY, IL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does CASEY REHAB AND NURSING have?

CASEY REHAB AND NURSING has 69 certified beds.

Who owns CASEY REHAB AND NURSING?

CASEY REHAB AND NURSING is a for profit - partnership facility and is part of the STERN CONSULTANTS chain.

Is CASEY REHAB AND NURSING safe?

CASEY REHAB AND NURSING has documented safety concerns including 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Do nurses at CASEY REHAB AND NURSING stick around?

CASEY REHAB AND NURSING has average staff turnover at 48%, which is typical for the nursing home industry.

Was CASEY REHAB AND NURSING ever fined?

Yes, CASEY REHAB AND NURSING has been fined $90,523 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is CASEY REHAB AND NURSING on any federal watch list?

No, CASEY REHAB AND NURSING is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at CASEY REHAB AND NURSING?

Medicare inspectors have found 49 deficiencies at CASEY REHAB AND NURSING: 1 critical, 2 serious, 46 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting CASEY REHAB AND NURSING?

Families visiting CASEY REHAB AND NURSING should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does CASEY REHAB AND NURSING compare to other nursing homes?

CASEY REHAB AND NURSING has a 2-star overall rating, which is below average compared to other nursing homes in IL. Families should carefully review inspection findings and consider alternatives.

CASEY REHAB AND NURSING | 18/100 (Grade F)

Aug 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide adequate pain control for one (R2) of three residents review...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide adequate pain control for one (R2) of three residents reviewed for pain on the sample list of seven.Findings Include: R2's Physician Order Sheet (POS) dated August 2025 documents R2 was admitted to the facility on [DATE]. R2 is diagnosed with Type II Diabetes Mellitus with Diabetic Polyneuropathy and Muscle Weakness among other medical diagnoses. R2's POS documents a physician order on 7/4/25 for Acetaminophen tablets 650 milligrams by mouth every six hours as needed for mild pain. If more than three doses given in 48 hours- staff are to notify the physician or advanced practice provider. R2's POS documents a physician order on 7/14/25 for Tramadol 50 milligrams by mouth as needed for pain. R2's Medication Administration Record (MAR) dated July 2025 documents R2 received more than three doses of Acetaminophen in 48 hours' time on 7/7/25, 7/8/25, 7/9/25, 7/10/25, 7/11/25, and 7/12/25. There is no documentation that a physician or advanced practice provider were notified of R2's frequent use of the as needed Acetaminophen. The MAR documents R2 rated her pain at an eight or higher for eleven of the fourteen Acetaminophen doses administered from 7/7/25 to 7/12/25. R2's Progress Note dated 7/11/25 at 8:40 PM documents R2 complained of right shoulder pain and V2 Director of Nurses requested a more effective pain medication and was waiting on response from the advance practice nurse. R2's Progress Note dated 7/12/25 at 2:57 AM documents V15 Medical Director was notified of R2's increased pain and request for better pain control. V15 ordered Tramadol 50 milligrams every eight hours as needed for pain. However, V15 could not send the new script to the pharmacy because V15 was not in his office. On 8/13/25 at 3:05 PM V2 Director of Nurses confirmed R2 often complained of pain during her stay in the facility. V2 confirmed R2 was given Acetaminophen more than three times in 48 hours on multiple occasions throughout her stay. V2 confirmed nursing should have notified a physician concerning the continued use of acetaminophen per the order. V2 confirmed on the evening of 7/11/25 R2's pain was unbearable for her, and she requested a stronger pain medication than Acetaminophen. R2 stated she reached out the to the Nurse Practitioner on-call however did not hear back so the nurse on duty overnight (V9 Registered Nurse) reached out to V15 Medical Director (MD) for a different pain medication order. V2 stated V15 ordered Tramadol however could not send the new script to the pharmacy so the nurses could not get the medication out of the medication dispensing machine. V2 confirmed R2 was not able to receive the new Tramadol medication until 7/12/25 at 3:16 PM. V2 stated R2 was tearful and uncomfortable throughout the night. V2 stated staff repositioned her and tried to keep her as comfortable as possible but there was a delay in getting her the pain medication that should not have happened. V2 stated R2's pain did improve some with the administration of the Acetaminophen however she did still require an increase in pain relief (Tramadol) and should not have had to wait 18 hours for the medication to be available. V2 acknowledged a change in procedure is required to make sure medications are available when needed for residents even after hours or on weekends.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate services for a resident with a di...

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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 provide appropriate services for a resident with a diagnosis of dementia for one resident (R7) of three residents reviewed for dementia services on a sample list of seven.Findings include: R7's Physician Orders Sheet (POS) dated August 2025, documents R7's diagnosis as: Dementia, mild, with agitation and anxiety disorder.R7's Wandering/Elopement Risk assessment dated [DATE], documents R7 is high risk for elopement.On 8/13/25 at approximately 10:30 AM, a personal alarm was sounding. V7 Certified Nursing Assistant (CNA) ran out the front door towards R7 who was seen walking towards the parking lot. V7 CNA assisted R7 back into the building to the Business Office with V12 Business Office Manager (BOM). On 8/13/25 at approximately 12:10 PM, a personal alarm was sounding. V2 Director of Nursing (DON) ran out the front door towards R7 who was seen walking towards the parking lot. V2 DON assisted R7 back into the building. On 8/13/25 at 12:14 PM, V2 DON stated R7 is very agitated today. V2 stated R7 worries about going to the bank, worried about R7's jeweler, and paying R7's bills. V2 stated R7 is progressively declining. V2 stated staff should be doing 15-minute checks on R7 and making sure R7's needs are being met. V2 stated V12 BOM has not had dementia training and may not know what to do with/for R7. V2 stated dementia training should be completed immediately after starting (working). On 8/13/25 at 12:57 PM, V1 Administrator stated R7 was put on 1:1 with staff after the last time R7 tried to escape. V1 stated just in the last two to three days R7 has been going to the door. V1 stated R7 does have an alarm bracelet on, R7 was given a calendar to show when rent is due, and staff has been letting R7 go out into the courtyard. V1 stated dementia training should be done with onboarding and before starting work at the facility. On 8/13/25 at 1:18 PM, V7 CNA stated V7 took R7 to the business office because R7 always wonders about paying R7's rent. V7 stated R7 does exit seek because R7 is always wants to go to the bank and wondering about rent. On 8/13/25 at 1:45 PM, V2 DON stated R7 was exit seeking a few weeks ago but it has been more frequent this week, so we are moving R7 to the south hall (locked unit). V2 also stated the nurses should be documenting the follow up from R7 getting out of the facility and what interventions were used.R7's Nursing Progress Notes written by V5 LPN, dated 8/8/25 at 1:26 PM, documents exit seeking x 2, continues to think he needs to go to the bank to make arrangements to pay the rent, re-education unsuccessful due to cognition. R7's Nursing Progress Notes written by V5 LPN, dated 8/11/25 at 1:46 PM, documents exit seeking x 3 out the front door, staff had to assist back inside.On 8/13/25 at 1:52 PM, V5 Licensed Practical Nurse (LPN) stated V5 continued to remind R7 his bank account is not here, and someone takes care of R7's business. V5 stated the only other options we have are to follow R7 around or walk with R7 and keep trying to explain this to him to help R7 remember, keep repeating things to him. V5 stated this man (R7) goes out the door about every day and it has been going on for the last week and a half on a daily basis. On 8/13/25 at 2:55 PM, V6 Registered Nurse (RN) stated she does not know where the elopement logbook is and can't say V6 was ever showed that.On 8/13/25 at 3:00 PM, V14 RN, stated V14 is still kind of new so V14 is not sure where the elopement logbook is.The facility's Wandering and Elopement Assessment and Prevention Policy dated Revised 6/4/24, documents all residents shall be assessed for risk of elopement/unsafe wandering, to ensure their safety and prevention from elopement. This same policy documents all departments shall be made aware of the elopement log and the location. This policy also documents the facility uses a multi-faceted approach to prevent elopement including staff education regarding understanding wandering, responsibility to identify, report, and intervene for wandering/elopement risk for residents.

May 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure fall interventions were implemented for one (R2...

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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 fall interventions were implemented for one (R2) of three residents reviewed for accidents on a sample list of three residents. Findings Include: R2's undated care plan documents R2's medical diagnoses include dementia with agitation, delusional disorders, essential hypertension, spinal stenosis, lumbar region without neurogenic claudication, vitamin B12 deficiency anemia, anxiety disorder, other malaise, urinary tract infection, depression, and psychotic disturbance. R2's undated Care Plan includes fall interventions actively in place as Call Don't Fall sign visible in room, toilet every hour, non-slip strips in front of toilet, scoop mattress, non-slip strips next to bed, non-slip material to recliner and wheelchair seat, 15-minute wellness checks, therapy to screen for services, non-slip strips in front of recliner, Certified Nursing Aide (CNA) to assist to bed at 9:00 pm, and move R2's room closer to nurse station. R2's Visual Bedside Kardex, undated, documents R2 is to have non-skid socks or appropriate footwear at all times, 15-minute safety checks, offer bathroom assistance every hour, maximum assistance with bed mobility and transfers, and all laboratory results to be monitored per physician order. R2's Minimum Data Set (MDS) dated [DATE] documents moderate cognitive impairment with hallucinations, delusions, impaired decision making, sundowning behaviors, non-compliance, and short-term memory loss. The MDS also documents R2 frequently refuses cares and has wandering behaviors. Section GG documents toileting activity requires substantial/maximum assist and R2 has frequent incontinence. R2's individual fall log, undated, documents R2 sustained falls on 3/2/25, 3/20/25, 3/22/25, 3/27/25, 4/6/25, 5/5/25, 5/15/25, 5/18/25, and 5/24/25. R2's Nurse Progress Notes document on 5/5/25 R2 was found on the floor in front of the recliner and R2 stated the recliner threw her out. On 5/6/25 R2's Care Plan, undated, documents the new intervention to add non-slip strips in front of the recliner. R2's May 2025 Progress Notes document on 5/14/25 staff reported R2 had two plus pitting edema to R2's bilateral lower extremities and 11 hours later at 12:30am on 5/15/25, R2 was found in front of the recliner on the floor in R2's room with R2 stating she was trying to go brush her teeth and use toilet. The Progress Notes document the nurse practitioner was notified and the new intervention to have Certified Nursing Assistant (CNA) assist R2 to bed at 9:00pm every night. R2's Nursing Progress Notes dated 5/18/25 document R2 was screaming for help and was found on the floor next to the bedside table in front of the recliner in R2's room with R2 stating she was trying to go use toilet. On 5/20/25 R2's Care Plan, undated, documents the new intervention to move R2 closer to nurse's station. R2's Nurse Practitioner Visit Note dated 5/19/25 documents R2 had a recent unwitnessed fall and documents a diagnosis of hyponatremia and new order for a blood test on 5/22/25. R2's Physician Order Sheet (POS) dated 5/28/25 documents an order for a blood Basic Metabolic Panel (BMP) on 5/22/25. R2's Medication Administration Record for May 2025 documents the order for the BMP was not completed. R2's medical record does not document the CMP was completed or that the physician was notified. R2's medical record does not document hourly toileting. R2's Point of Care (POC)15-minute check log dated 5/15/25 - 5/28/25 does not document ordered safety checks every 15 minutes. On 5/28/25 between 11:00am and 12:00pm continuous observation of R2's room entrance and hallway were completed. At no time was staff observed entering R2's room to complete 15-minute safety checks. On 5/28/25 at 12:35 pm R2 was in the wheelchair in front of the recliner in the room with the bedside table on the left of R2. There was no Call Don't Fall sign in the room. R2's Recliner and wheelchair seat did not have non-slip material in the seat. Non-slip strips were not present on the bathroom floor and the toilet paper holder was broken and hanging off the wall. On 5/28/25 at 12:35 pm R2 stated she currently has no pain but does have episodes of pain stating, of course I have pain from falling all over these floors!' R2 stated she recalls falling in the bathroom a few days ago and confirmed breaking the toilet paper holder. R2 stated she needs to have shoes on all the time, so she doesn't fall. During conversation R2 was rolling the wheelchair back and forth with the brakes in the locked position. R2 demonstrated locking and unlocking the brakes and in both settings. R2 was able to move freely in the wheelchair. On 5/28/25 at 1:40 PM V2 Director of Nurses verified that 15-minute checks were not being accurately documented. V2 stated tomorrow on 5/29/25, R2 will be moved to the dementia unit for better observation of the resident. V2 stated she is unclear why there are no non-slip strips on the bathroom floor as she was sure they were there last Friday 5/23/25. V2 stated she's unsure why R2 doesn't have non-slip material in the wheelchair and recliner. Regarding the BMP blood test for R2, V2 stated the nurse checked off the test on the MAR on 5/21/25 as not obtained and therefore the test was not completed. V2 verified no follow up or provider notification of the missed blood test was completed. V2 agreed that R2's change of condition on 5/14/25 could have contributed to R2's early morning fall on 5/15/25 and that the order given by the nurse practitioner for blood testing was to diagnosis any new medical issues related to the change of condition. The facility policy titled Fall Reduction Prevention dated 10/30/24 documents the purpose is to provide an environment that remains as free of accident hazards as possible and to identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. The policy states all witnessed, unwitnessed and any near falls should be investigated. Resident should be evaluated for change in condition and provider notification should be completed. Current fall prevention interventions should be evaluated, and new interventions should be initiated.

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to timely initiate antibiotic treatment for a urinary tract infection for one of three (R3) residents reviewed for falls in the sample list of ...

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Based on interview and record review the facility failed to timely initiate antibiotic treatment for a urinary tract infection for one of three (R3) residents reviewed for falls in the sample list of three. Findings include: R3's Nursing Note dated 3/31/2025 at 10:55 AM documents R3 continued post fall monitoring with increased weakness and lethargy noted. R3's urostomy was draining dark amber, slightly cloudy urine. V3 Nurse Practitioner was notified, and new orders received. R3's Physician Order dated 3/31/25 documents to obtain urinalysis and culture if indicated. R3's urinalysis and culture with print date 4/5/25 documents leukocyte esterase (white blood cell enzyme) 3+ (normal is negative), white blood cells 10-15 (normal is 0-5), and few bacteria, mucus and white blood cell clumps (all abnormal). These results document greater than 100,000 colony forming units per milliliter (cfu/ml) of mixed bacterial flora with multiple species present and recommends a repeat sample collection if indicated. R3's urinalysis and culture, with print date of 4/9/25, documents leukocytes esterase 4+, white blood cells 20-30, and moderate bacteria and white blood cell clumps. These results document greater than 100,000 cfu/ml of mixed bacterial flora with multiple species present. R3's Progress Note dated 4/10/25, recorded by V3, documents R3 was evaluated due to staff request for increased confusion and urine sent to lab. This note documents an order for Augmentin 500-125 milligrams (mg) by mouth twice daily for seven days for urinary tract infection. R3's Physician Orders dated 4/10/25 and 4/11/25 document to administer Augmentin 500-125 mg by mouth twice daily for seven days. R3's April 2025 Medication Administration Record documents Augmentin was not started until 4/12/25 at 8:00 AM. R3's Nursing Note dated 4/11/2025 at 8:55 PM documents R3's ordered antibiotic was not available in the facility's backup medication system, the pharmacy was notified and verified the medication would be sent to the facility. R3's nursing notes do not document V3 was notified of the delay in starting R3's antibiotic. The facility's Inventory on Hand (backup medication system) documents Augmentin is supplied in 875-125 mg tablets, and not in 500-125 mg tablets. On 5/28/25 at 11:16 AM V2 Director of Nursing stated R3's 4/9/25 urinalysis results were reported to V3 on 4/9/25 through (messaging software), and V3 saw R3 on 4/10/25 and ordered Augmentin. V2 stated the 500 mg dose was not supplied in the facility's backup medication system, so the medication was not started until 4/12/25 when the medication arrived from the pharmacy. V2 stated the facility has a backup pharmacy system, and staff should notify the facility's pharmacy who contacts a backup pharmacy to supply the medication. At 12:34 PM V2 stated physician notification is documented in the nursing notes, including when a medication is not given. On 5/28/25 at 12:09 PM V3 stated V3 rounded in the facility weekly on Thursdays and antibiotics should be implemented by the next morning, or that evening if the facility has the medication in the back up medication system. V3 stated the pharmacy should have delivered R3's Augmentin that night so that it could be started the next morning. V3 stated if the facility would have reported the medication dose was not available. V3 would have given additional orders and asked what dose the facility had on hand. The facility's undated pharmacy guide, titled What to Do If a Medication is Not Available during a Med Pass documents the following: Verify/review pharmacy deliveries. Check the backup medication system for the medication, remove dose, and administer to the resident. If the medication is not available, check to see if there is an alternative medication that can be given with a physician's order. If the medication is not located or unavailable in the backup supply, notify the pharmacy to request delivery from a backup pharmacy and verify the medication will be sent out on the next pharmacy delivery. Notify the provider that the medication was not available to administer as ordered/scheduled and request an order to hold the medication until delivery from pharmacy. These steps will avoid the need to document that medications are not available, will ensure residents receive medications timely, will avoid further potential delay in treatment.

Jan 2025 8 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

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 prevent cross contamination during wound care for one (...

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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 prevent cross contamination during wound care for one (R24) resident's left plantar heel open diabetic ulcer, failed to monitor R24's left heel diabetic ulcer and failed to follow physician orders for R24's left heel wound treatments for one of two residents (R24) reviewed for skin conditions in a sample list of 27 residents. R24 experienced the worsening of her left heel open wound due to dressing changes not being completed per physician order and not being provided timely incontinence care which led to R24's dressing to be fully saturated with wound drainage and urine which required antibiotics due to a Staphylococcus (Staph) infection. Findings include: R24's medical diagnosis list documents medical diagnoses of Acute Osteomyelitis of the Left Ankle, Diabetes Mellitus Type II with foot ulcer, Morbid Obesity and Polyneuropathy. R24's Minimum Data Set (MDS) dated [DATE] documents R24 as cognitively intact. This same MDS documents R24 requires maximum assistance for toileting and moderate assistance for personal hygiene. R24's Physician Order Sheet (POS) dated January 2025 documents a physician order starting 12/24/24 of left plantar heel: Cleanse with Normal Saline, apply nickel thick Santyl (chemical debriding agent) to wound bed. Cover with absorbent pad and secure with gauze roll daily and as needed if loose or soiled. R24's POS documents a physician order starting 1/3/25 and ending 1/13/25 for Amoxicillin 875 milligrams (mg) Give 875 mg by mouth two times a day related to non-pressure chronic ulcer of Left Heel and midfoot. R24's Skin Integrity care plan initiated 8/24/24 documents (apply) dressing to (R24's) Left Foot. Observe dressing every shift. Change dressing and record observations of site daily. R24's care plan intervention dated 4/3/24 instructs staff to provide incontinence care as needed. This same care plan documents an intervention dated 4/3/24 to monitor, document and report and signs and/or symptoms of infection. R24's Weekly Wound Log dated 12/24/24 documents R24's Left Plantar Heel Diabetic wound with Calcaneus bone exposed as initiating in facility on 7/24/24 as having slough and necrotic tissue with yellow, increased purulent drainage, foul odor and measuring 11.6 centimeters (cm) long by 5.0 cm wide by 0.8 cm deep. R24's Weekly Wound Log dated 12/31/24 documents R24's Left Plantar Heel Diabetic wound with Calcaneus bone exposed as initiating in facility on 7/24/24 as having slough and necrotic tissue with yellow, increased purulent drainage, foul odor and measuring 11.8 centimeters (cm) long by 6.0 cm wide by 0.8 cm deep. R24's Weekly Wound Log dated 1/7/25 documents R24's Left Plantar Heel Diabetic wound with Calcaneus bone exposed as initiating in facility on 7/24/24 as having slough and necrotic tissue with yellow, increased purulent drainage, foul odor and measuring 12.0 centimeters (cm) long by 6.9 cm wide by 1.0 cm deep. This same log documents an antibiotic was started for Methicillin Resistant Staphylococcus Aureus (MRSA) of R24's Left Plantar Heel wound. R24's Treatment Administration Record (TAR) does not document R24's Left Plantar Heel wound dressing change was completed on 1/3, 1/5, 1/6, 1/10, 1/12 and 1/17/25. R24's Nurse Progress Noted dated 1/9/25 at 9:39 AM documents Interdisciplinary Team (IDT) met to discuss R24's behaviors with no refusals of care noted. On 1/14/25 at 10:45 AM R24 was sitting in her wheelchair with her Left foot on a stationary foot pedal. R4's Left foot and ankle were wrapped in gauze that was completely saturated with yellow drainage. R4's gauze dressing was saturated from the upper ankle area to the toes. On 1/14/25 at 11:20 AM V4 Registered Nurse (RN) completed R24's dressing change to her Left Plantar Heel Diabetic Ulcer. V4 RN did not use hand hygiene, nor change gloves after removing R24's saturated, contaminated dressing prior to cleansing R24's entire Left Plantar Heel open wound. R24's prior dressing of a four inch long by four inch wide blue absorbent pad, a white six inch long by four inch wide absorbent pad and an entire roll of gauze were all saturated with yellow drainage. R24 did not have any intact skin on the entire bottom of her Left foot from the pads below the toes to the heel and expanding the entire width of R24's foot. R24's Heel bone was exposed. On 1/15/25 at 9:45 AM R24 was sitting in her wheelchair with her Left foot on a stationary foot pedal. R4's Left foot and ankle were wrapped in gauze that was completely saturated with yellow/pink drainage. R4's gauze dressing was saturated from the upper ankle area to the toes. On 1/14/25 at 10:50 AM R24 stated the staff don't always change her Left Plantar Heel dressing like it is supposed to be done by the Physician order. R24 stated the dressing changes are 'hit and miss'. R24 stated, Look at my (Left) foot. It is soaked. I just got done with an antibiotic for that wound. You would think they (staff) would at least keep it clean. I would do it myself, but I can't reach my foot. On 1/14/25 at 11:40 AM V4 Registered Nurse (RN) stated she should have changed her gloves in between removing R24's old dressing and cleansing R24's Left Plantar Heel open wound. V4 RN stated cross contaminating R24's wound could cause her wound to become re-infected. V4 RN stated R24's dressing was saturated with not only wound drainage but also with urine. V4 stated R24 was incontinent of urine which contaminated her Left Heel wound. V24 RN stated R24's prior dressing had a strong urine odor. V4 RN stated staff should have provided incontinence care for R24 so that the urine did not contaminate R24's dressing and/or open wound. On 1/16/25 at 11:00 AM V2 Director of Nurses (DON) stated licensed nurses are expected to follow the physician orders for R24's dressing changes to her Left Heel. V2 DON stated R24 admitted to the facility in March 2024 with this same wound, it resolved and after two months it reappeared in July 2024. V2 DON stated R24's Left Plantar Heel open wound is categorized as a Diabetic Ulcer and started in July as a small 4.0 cm area on her Left Heel and has worsened to cover her entire bottom of R24's foot. V2 DON stated R24 has been on antibiotics via a Peripherally Inserted Central Catheter (PICC) line for this same wound in the recent past and was just on Amoxicillin 875 mg from 1/3/25-1/13/25 for the same Heel wound. V2 DON stated the staff should be very careful with all resident wounds, but especially with R24's Left Heel open wound to no contaminate it due to this could cause another infection. On 1/17/25 at 2:00 PM V1 Administrator stated the staff failed to monitor R24's Left Heel wound by not providing incontinence care timely to not allow R24's urine to contaminate R24's Left Heel open wound. V1 Administrator stated R24 can be non-compliant, but it is the responsibility of the staff to make sure R24's dressing is kept clean and dry. V1 Administrator stated the facility does not have any documentation that shows the staff were monitoring R24's wound, documenting treatments were completed as per the Physician order or implementing care plan interventions to reduce the risk of R24's wound worsening. The facility policy titled Wound Care revised 11/9/2018 documents staff are to apply gloves, remove dressing to be changed and discard, then remove gloves and discard. Perform hand hygiene, apply new gloves and clean wound bed per order. The facility policy titled Skin Prevention, Assessment and Treatment revised 5/2/2022 documents staff are to provide incontinence care after each incontinent episode, keep skin clean and dry. The goal of wound care of to protect the ulcer from contamination.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to obtain a Level 2 screening for a resident newly diagnosed with severe mental illness to determine if there was a need for spe...

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Based on observation, interview, and record review, the facility failed to obtain a Level 2 screening for a resident newly diagnosed with severe mental illness to determine if there was a need for specialized mental health services. This failure effects one resident (R2) out of two residents reviewed for pre-admission screening on the sample list of 27. Findings include: On 1/14/25 at 11:04 AM, R2 was lying in bed in his own room. R2 was speaking in a hyper-manic pattern and was unable to maintain the topic of conversation. R2's Census Detail documents R2 was admitted to the facility 10/12/2006. R2's Interagency Certification of Screening Results dated 8/16/06 documents R2 did not qualify as being developmentally disabled, and there was no reasonable basis to suspect a mental illness. R2's Medical Diagnoses List documents R2 was diagnosed with Delusional Disorder (Severe Mental Illness) on 1/26/21, and Affective Mood Disorder (can be included as severe mental illness) also on 1/26/21. There was no documented screening for Level 2 services for R2 in the medical record after the date of these new diagnoses. On 1/15/25 at 11:35 AM, V1, Administrator, displayed her computer screen for the (pre-admission screening service provider) and stated the only pre-admission screening showing up was on 8/16/06 and there was no Level 2 screen in the system.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to complete a discharge summary for one (R48) resident out of one resident reviewed for discharge in a sample list of 27 residents. Findings i...

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Based on interview and record review the facility failed to complete a discharge summary for one (R48) resident out of one resident reviewed for discharge in a sample list of 27 residents. Findings include: The facility policy titled Discharge Summary revised 11/5/2019 documents a discharge summary shall be prepared for each resident discharged from the facility. When the facility anticipates a resident's discharge to a private residence or to another nursing care facility a discharge summary will be developed which will assist the resident to adjust to his or her new living environment. R48's Electronic Medical Record (EMR) documents R48 admitted to facility on 6/30/22 and discharged on 10/21/24. R48's Care Plan initiated 2/26/24 documents (R48) wishes to be discharged but has no supportive family/caregivers. (R48) is independent and mostly requires verbal cues for task completion as well as medication management due to intellectual disability related cognitive deficits. R48's Medical Record does not include a discharge summary/recapitulation of stay, Physician order for discharge nor nurse progress note documenting R48's discharge. On 1/15/25 at 1:30 PM V1 Administrator stated the facility does not have any documentation of a discharge summary and/or recapitulation of stay. Physician order for R48's discharge nor any nurse progress notes documenting R48's discharge. V1 Administrator stated R48 requested to move to another Skilled Nursing Facility (SNF), so a referral was sent and R48 moved to that SNF. V1 stated there is no documentation due to this facility was purchased by another corporation on 11/1/24 so all the resident information was given to the old facility corporation.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to maintain safe storage of oxygen cylinders by failing to secure an oxygen tank to prevent being tipped over. This failure effe...

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Based on observation, interview, and record review, the facility failed to maintain safe storage of oxygen cylinders by failing to secure an oxygen tank to prevent being tipped over. This failure effects one resident (R23) out of six reviewed for accidents on the sample list of 27. Findings include: On 1/15/25 at 11:30 AM, there was an E type (3 feet tall, 5 inches diameter, containing between 2,200 and 3,000 pounds per square inch of gas pressure) free standing and not secured in any manner inside the doorway of R23's room. R23 was reclining in bed approximately 10 feet from the oxygen cylinder. On 1/15/25 at 11:35 AM, V1, Administrator, and V2, Director of Nursing, both confirmed oxygen tanks should not be left free standing on the floor without some kind of securement. V1 made an exclamation of, Oh no, why? The facility policy Oxygen Administration and Storage dated 3/8/22 documents E tanks must be secured in a holder. The tank may never be left unsecured at any time. This policy further documents oxygen cylinders must be stored in accordance with the NFPA (National Fire Protection Association) regulations. The current (2024) NFPA regulations to ensure safe handling and operation of oxygen cylinders documents to use racks or chains to secure oxygen cylinders (tanks). On 1/15/25 at 11:45 AM, R23's Nurses Note dated 1/9/25 documents R23 had an episode of low blood oxygen levels on 1/9/25 but had no documented use of any oxygen since that date.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to properly label medications and failed to monitor expiration dates on medications administered for one (R4) resident out of nine...

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Based on observation, interview and record review the facility failed to properly label medications and failed to monitor expiration dates on medications administered for one (R4) resident out of nine residents reviewed for medication administration in a sample list of 27 residents. Findings include: The facility policy titled Administering Medications revised October 15, 2023 documents medications shall be administered according to Physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. The facility policy titled Storage, Labeling of Over the Counter Medication, Destruction and Disposal of Medication revised 11/9/2021 documents no discontinued, outdated or deteriorated medications shall be available for use in the facility. Expired medications are to be removed from areas medication carts prior to or at the time of expiration. Medications must be dated upon opening the container, however it may be stored in an individual resident section (of the medication cart) and used for all residents. 1. R4's Physician Order Sheet (POS) dated January 2025 documents a physician order for Zinc Gluconate 50 milligrams (mg), Multivitamin daily, Ibuprofen suspension 100 mg/1 milliliter (ml) give 10 ml, Pantoprazole suspension 4 mg/1 ml give 10 ml per Gastrostomy Tube (G-Tube). On 1/16/25 at 9:30 AM V12 Licensed Practical Nurse (LPN) administered 10 milliliter (ml) of R4's Pantoprazole suspension which had a sticker on the back side of the bottle that read Do Not Use after 1/4/25. V12 LPN administered 10 ml of R4's Ibuprofen suspension. This same bottle of Ibuprofen did not have a medication instruction label. V12 LPN administered Zinc Sulfate 220 mg to R4. V12 administered R4's multivitamin. from a bottle of stock multivitamins with no open date documented on the bottle. On 1/16/25 at 12:30 PM V12 Licensed Practical Nurse (LPN) stated she did not notice the difference between R4's Medication Administration Record (MAR) instructing to administer Zinc Gluconate 50 mg and R4's medication card of Zinc Sulfate 220 mg. V12 LPN stated she should have noticed the difference and questioned R4's Zinc order prior to administering. V12 stated she did not see the sticker on the back of R4's liquid Pantoprazole bottle that ready Do Not Use after 1/4/25. V12 stated R4's Pantoprazole originally comes in a powder form and the pharmacy reconstitutes it to a liquid form. V12 stated because of this the liquid reconstituted form expires much faster. V12 stated she should have seen this and will get the bottle replaced so that no one else makes that error. V12 LPN confirmed there was no label on R4's Ibuprofen suspension. V12 LPN stated she saw that the house stock bottle of Multivitamins did not have an open date. On 1/16/25 at 1:35 PM V2 Director of Nurses (DON) stated all resident medications should have a label. V2 DON stated licensed nurses should not administer expired medications or medications that the expiration date is unknown. V2 DON stated these errors would not be a medication error but definitely would be medication labeling errors. V2 DON stated anytime a house stock bottle of medication is opened, the nurse should write on the bottle what date it was opened so that other nurses will know when to dispose of that bottle. V2 DON stated V12 LPN should have notice the difference in R4's POS order for Zinc Gluconate and the medication card that read Zinc Sulfate. V2 stated this is again another labeling issue due to the facility recently changed pharmacies and the new pharmacy labeled the medication card for R4's Zinc Gluconate as Zinc Sulfate due to a pharmacy exchange. V2 DON stated V12 LPN did not administer the wrong medication but should have questioned the label being different from the POS. On 1/16/25 at 2:45 PM V15 Registered Pharmacist/Pharmacy Manager stated there is no significant clinical difference between Zinc Sulfate 220 mg and Zinc Gluconate 50 mg. V15 stated administering Zinc Sulfate 220 mg instead of Zinc Gluconate 50 mg would not be considered a medication error but should have been questioned by facility staff prior to giving. V15 stated this is a therapeutic pharmacy exchange. V15 stated administering expired Pantoprazole would also not be considered a medication error at that point but should have been noted by the facility staff and a new bottle obtained. V15 stated all medications should have a label including the name and administering instructions. V15 stated any medications that the facility provides should follow the facility medication labeling policy.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident record was complete for one (R48) resident out o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident record was complete for one (R48) resident out of one resident reviewed for closed records in a sample list of 27 residents. Findings include: R48's Electronic Medical Record (EMR) documents R48 was admitted to the facility on [DATE] and discharged on 10/21/24. R48's Electronic Medical Record (EMR) does not include Physician Orders, Nurse Progress Notes, Physician Progress Notes, Social Service Progress Notes, R48's weight and vital signs, Activities of Daily Living (ADL) charting and Assessments. On 1/14/25 at 2:00 PM V1 Administrator stated the facility is unable to provide documentation of R48's stay at facility due to a recent change in ownership. V1 stated R48 discharged on 10/21/24 to another skilled facility per R48's request. V1 Administrator stated whatever information is documented in the EMR is the only information the facility can provide. V1 stated R48's EMR is incomplete, and the facility has no paper documentation of R48's stay. V1 Administrator stated there is no policy for this, but it is known that the facility is expected to have complete medical records of all residents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to wear the proper Personal Protective Equipment (PPE) whe...

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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 wear the proper Personal Protective Equipment (PPE) when providing feeding assistance and when administering medications to residents who are COVID-19 positive on Droplet and Contact Isolation Precautions for two of five residents (R38 and R20) reviewed for Infection Control in a sample list of 27 residents. Findings include: The facility policy titled Administering Medication revised 10/15/23 documents adherence to established facility infection control procedures shall be followed during the administration of medications. 1.) R20's Minimum Data Set (MDS) dated [DATE] documents R20 as severely cognitively impaired. This same MDS documents R20 is dependent on staff for assistance with eating. R20's Laboratory Report dated 1/6/25 documents R20 tested positive for COVID-19. R20's Physician Order Sheet (POS) dated January 2025 documents a physician order starting 1/6/25 and ending 1/16/25 for (R20) of COVID Positive--COVID-19 Room. Isolate (R20). Standard, droplet and contact isolation every shift. All services provided in room. R20's Care plan does not include a focus area, goal nor interventions for R20's COVID-19 Contact and Droplet isolation precautions. On 1/14/25 at 12:48 PM V8 Certified Nurse Aide (CNA) did not wear gown nor gloves when assisting R20 to eat her lunch meal at a table by the nurses station. R20 was sitting at a table feeding herself her lunch. V8 CNA walked over to R20 without washing hands, or using hand hygiene, picked up R20's contaminated spoon and assisted R20 to finish eating her lunch. On 1/16/25 at 12:10 PM V8 CNA stated she did not know she was supposed to wear gloves when providing feeding assistance to a COVID-19 positive resident (R20). 2.) R38's Lab Report dated 1/6/25 documents R38 tested positive for COVID-19 on 1/6/25. R38's Physician Order Sheet (POS) dated January 2025 documents a physician order starting 1/6/25 and ending 1/16/25 of COVID Positive--COVID-19 Room. Isolate (R38). Standard, droplet and contact isolation. All services provided in room. On 1/15/25 at 11:51 AM V6 Licensed Practical Nurse (LPN) did not wear an N95 mask, gloves nor gown while she administered R38's scheduled noon medications. Signs for Droplet Precautions and Contact Precautions were posted outside R38's room door. A bin was sitting outside R38's room door with Personal Protective Equipment (PPE) supplies. On 1/15/25 at 11:55 AM V6 LPN stated V6 was aware that R38 is currently on Droplet and Contact Isolation Precautions due to being positive for COVID-19 and should have worn the appropriate PPE. V6 stated V6 could contaminate other residents by not wearing the proper PPE for COVID-19 precautions. On 1/17/25 at 2:00 PM V2 Director of Nurses (DON) stated staff should wear the proper Personal Protective Equipment (PPE) when providing feeding assistance and/or medications to any COVID-19 positive resident. V2 DON stated gloves should be worn to help prevent the spread of COVID-19 and any other organism.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to maintain their survey results book in a manner accessible to residents. This failure has the potential to affect all 51 reside...

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Based on observation, interview, and record review the facility failed to maintain their survey results book in a manner accessible to residents. This failure has the potential to affect all 51 residents residing in the facility. Findings include: On 1/15/25 at 9:44 AM, during the resident group meeting, none of the four residents in attendance (R14, R18, R24, and R45) were able to state where the survey results book was located. On 1/16/25 at 1:41 PM, the survey book was located five feet six inches above the floor in a wall caddy directly outside the facility business office. There was no sign in the facility to indicate where the survey results book was kept. On 1/16/25 at 2:52 PM, V1 Administrator, and V14, Regional Representative, confirmed a resident in a wheelchair could not reach the survey results book in it's current location. V14 stated if the caddy on the wall was his, he would rip it off and move it lower. V1 stated she would get the book relocated. The facility Long-Term Care Facility Application for Medicare and Medicaid (1/17/2025) documents 51 residents reside in the facility.

Aug 2024 3 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

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 provide supervision of a severely cognitively impaired...

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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 provide supervision of a severely cognitively impaired resident, with a history of elopement, to prevent the resident from leaving the facility unnoticed and unattended. Due to R1's frontal lobe dementia, V20 physician stated (R1) could have been hit by a car, fallen and obtained a fracture, or been injured in a multitude of ways. This failure affects one (R1) of three residents reviewed for supervision. The immediate jeopardy began on 7/28/24 when R1 was allowed to leave the alarmed Dementia unit unsupervised resulting in R1 eloping 0.9 miles away from the facility. V1 Administrator was notified of the Immediate Jeopardy on 8/8/24 at 9:26 AM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 8/8/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training through ongoing Quality Assurance Performance Improvement (QAPI) review. Findings include: R1 was admitted to facility on 3/14/24. R1's Electronic Medical Record (EMR) documents medical diagnoses as Dementia, Major Depressive Disorder, Altered Mental Status, Cognitive Decline, Colostomy Status and history of Cerebral Vascular Accident (CVA) and Chronic Ulcerative Enterocolitis. R1's admission Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as independent in transferring and ambulating. R1's Elopement Evaluation dated 3/21/24 documents R1 as high risk for elopement. R1's Social Service Progress Note dated 3/21/24 documents (R1) has a behavior of exit seeking but is able to be redirected. R1's Medical Record does not include any further social service progress notes. R1's Care Plan dated 3/25/24 documents R1 has wandering behavior and may demonstrate a risk for leaving unattended/elopement due to Altered Mental Status. R1's Care Plan documents an intervention dated 3/25/24 for R1 to have every 15 minute checks. R1's Care plan was first updated on 7/29/24 to include an intervention for staff to monitor R1 at all times when off the Dementia unit. R1's Physician Order Sheet (POS) dated August 2024 documents a physician order dated 7/29/24 of (R1) not to leave facility unless with staff or Power of Attorney (POA) for appointments per POA, (V17). This same POS documents a physician order to start Aspirin 81 milligrams (mg) daily. R1's Nurse Progress Notes document on: 3/23/24 at 9:45 PM (R1) exited the facility via the service door. (R1) was harder to redirect than the other four times. Semi combative. (R1) was assisted by staff to her room. 5/21/24 at 7:00 PM (R1) exit seeking. (R1) went out the front door and over by the trees on our property. Redirected back inside. 5/27/24 at 8:00 PM (R1) exited the building two times with more attempts. 6/1/24 at 6:50 PM (R1) exited out the Northwest service door. Easily re-directed back into the building. 6/16/24 at 'evenings' (R1) in and out of the South (Dementia) unit. (R1) did exit the building one time. 6/18/24 at 5:00 AM (R1) adamant to exit the south hall door. (R1) did get out the front door, exiting the building. (R1) is very swift. Escorted back inside with some difficulty. The facility Investigative Report of Missing Resident dated 7/29/24 documents R1 alert and oriented times one, ambulates independently and eloped from the facility on 7/28/24. This same report documents Family of (R1) called facility to notify (facility) of location (of R1). This same report documents R1 was found at V17 (R1's daughter) house. R1 left the facility unnoticed and unsupervised, at night, after dark in extreme heat and high humidity. R1 walked to a family member's house approximately 11 blocks (0.9) miles from the facility, crossing multiple streets, near a highway/culverts/guardrails/deep ditches. The public website titled www.timeanddate.com documents the high temperature for 7/28/24 was 85 degrees with 88% humidity. On 8/6/24 at 2:00 PM V15 Certified Nurse Aide (CNA) stated, I pushed the code into the door alarm on the Dementia Unit so that (R1) could go out into the main nursing home and sit on the couch. We (staff) do that all the time. I didn't know (R1) was supposed to be supervised when she was off the unit. (V16) CNA and I decided at around 7:30 PM that V16 CNA could go on lunch since it was so quiet on the hall. Right after (V16) left for break, residents started getting up and it became very busy. I didn't check on (R1) or let any other staff know she was sitting alone out there. I guess I should have. V15 stated when R1 returned to the Dementia unit, she continued to pace up and down the hallway. On 8/2/24 at 2:45 PM V10 Licensed Practical Nurse (LPN) stated R1 eloped from facility the evening of 7/28/24. V10 LPN stated R1 was sitting on a couch in the resident lounge area of the main nursing home about 7:30 PM prior to her eloping. V10 stated R1 resides on the alarmed Dementia unit and does occasionally wander through the main nursing home area unsupervised. V10 LPN stated V16 Certified Nurse Aide (CNA) had left the Dementia Unit at 7:30 PM and saw R1 sitting on the couch as she walked by to go to a break. V10 LPN stated it was reported to V10 that no other staff were present with R1 and that V16 did not stay with R1 nor report to anyone that R1 was not being monitored. V10 LPN stated R1 has a long history of 'escaping' the facility. V10 LPN stated R1 has been known to watch staff punch in the alarm codes, wait for the area to clear and then let herself out of the alarmed doors without the alarms sounding. V10 LPN stated the door alarms had not sounded that evening prior to R1 being reported as missing. V10 LPN stated, (R1) has eloped from the facility multiple times before 7/28/24 due to the lack of supervision and (R1) being very sneaky. V10 LPN stated, V16 CNA reported to V10 LPN at 8:30 PM that R1 could not be located. V10 LPN stated, I took off on foot looking around the outside of the building. It was so hot that night. It was dark out by the time we (facility) realized (R1) had eloped. There were dozens of people searching for (R1) including the police, emergency medical services (EMS), off duty facility staff, community neighbors and the facility staff. We (staff and volunteers) searched all over for her. I came across a couple walking their dog and they helped look for (R1) also. I walked about five blocks and then had to come back to the facility because it was miserably hot outside. My clothes were drenched. I don't know how (R1) ever made it as far as she did without passing out. (R1) had just gotten back from the hospital earlier that day for a Small Bowel Obstruction. (R1) was found by her family through (V17's) (R1's) family member's home camera system. (V17) notified the facility of (R1's) whereabouts and then we went to go pick her up. (V17) told us to hurry up and go get her because she was with (V18) (R1's) family member and (V18) did not know how to deal with (R1). (V17) stated 'you never know what (V18) will do'. I called (V2) Director of Nurses (DON) at 9:09 PM after (V17) reported (R1's) whereabouts and then (V2) and I went to get (R1). When (V2) Director of Nurses (DON) and I got to (V17's) house, (R1) looked hot and tired. (R1) looked exhausted. (R1's) face was red and somehow her colostomy bag had come off and she was just a mess with BM (bowel movement) all over her. On 8/6/24 at 9:30 AM V2 Director of Nurses (DON) stated R1 admitted to facility on 3/14/24. V2 DON stated R1 has exited the facility and left the property 'multiple times' prior to 7/28/24. V2 DON stated R1 was supposed to be on 15 minute checks since admission. V2 DON stated, I got the call from (V10) Licensed Practical Nurse (LPN) at 8:30 PM stating (R1) could not be located. We (facility) started a search throughout the building and could not find (R1). There were a lot of people out on the streets looking for (R1). (R1's) family (V17) was the one who called the facility and let us know where (R1) was. I believe (R1) was back inside the facility at 9:30 PM. Otherwise, we would still be looking for (R1). (R1) had left the building so many times before that night, I think she knew right where to go. V2 DON stated no resident should be allowed off the Dementia Unit without staff monitoring them. V2 DON stated, The reason why people have to stay back on the Dementia Unit is because they don't know any better. We (facility) are supposed to keep them safe. (R1) is a tough one because she is alert, ambulatory and determined to leave. (R1) gets physically aggressive when staff try to re-direct her but that is our (facility) problem to solve. We have to do better or (R1) is really going to get hurt. V2 DON stated R1's care plan had not been updated since her admission. V2 DON stated, We (facility) have talked about (R1's) exit seeking and previous elopements in morning meeting but that was never brought back to the staff. The staff rely on the care plan to be able to know what interventions to use. If the care plan is not updated, then the staff have to rely on word of mouth and that is not always accurate. On 8/6/24 at 10:20 AM V1 Administrator stated, (R1) has Frontal Lobe Dementia and really does not belong in our facility. (R1) is too much risk due to her being so mobile, having very poor safety awareness, Dementia and being sharp enough to be able to obtain the codes to the security doors on the Dementia unit. The night (7/28/24) (R1) eloped from the facility, R1 was sitting on the couch unattended by staff out in the main area of the nursing facility. We (facility) aren't even sure which door (R1) exited from. (R1) is quick. The staff had previously been in serviced on the need to always have two staff members on the Dementia unit at all times. That night there was one nurse (V10) Licensed Practical Nurse (LPN) and two (V15, V16) Certified Nurse Aides (CNA) on that unit. (V10) was on another hall and the two CNA's (V15, V16) were supposed to stay on the Dementia Unit. Apparently, V16 CNA left the hall to take a break which left V15 CNA on the hall by herself. That is when (R1) eloped. (R1) was supposed to be checked on every 15 minutes and wasn't. (R1) has been on 15 minute checks since she admitted . There is no reason my staff shouldn't have done those. (R1) gets confused every time she leaves the facility. (R1) had just came back from the hospital that day due to having a Small Bowel Obstruction. That paired with the fact that (V17) was on vacation, I think (R1) was even more adamant on leaving the facility. On 8/6/24 at 1:50 PM V20 Medical Director stated, There was failure from the facility to maintain the safety of (R1). The facility policies and Centers for Medicaid and Medicare Services (CMS) regulations were not followed. V20 stated, In a general statement, anything could have happened to (R1). (R1) could have been hit by a car, fallen and maybe obtained a fracture, or been injured in a multitude of ways. If there was adequate staff the night in question, the facility did not supervise (R1) as she needed to be and therefore (R1) eloped without the knowledge of the staff. On 8/7/24 at 1:40 PM V23 Nurse Practitioner stated, (R1) has a very specific type of Dementia with Frontal Lobe involvement. I have met with (R1) several times and can say that (R1) should not be allowed outside of the Dementia unit unsupervised. (R1's) Dementia would prevent her from being able to make safe decisions. (R1) should not be walking unsupervised off the facility property. (R1) has a higher risk than others due to her Dementia and impulsivity. V23 NP stated R1 is not able to make sound, safe decisions without the assistance of staff. V23 stated R1 could have been injured from falling, hit by a car, or tripped due to her shuffling fast pace. V23 NP stated R1 could have had heat related symptoms like a heat stroke due to her being unable to recognize those symptoms due to her Dementia. On 8/7/24 at 3:10 PM V24 Director of Psychiatry program for facility stated V24 is familiar with R1. V24 stated R1 should never be allowed to be unsupervised when out of the alarmed Dementia Unit. V24 stated, There are not only environmental factors that (R1) may be injured from while walking outside of the Dementia Unit but (R1) has what you call 'excitable agitation.' (R1) has increased agitation with verbal and physical aggressive behaviors when anyone attempts to redirect (R1). If (R1) were out in the community by herself and came across another person who attempted to redirect (R1) that would most likely agitate (R1) and the other person may respond negatively to that interaction possible creating harm for (R1) from a physical altercation. (R1) has impulsivity along with very poor judgement and decision making efforts. (R1) thinks like a small child with no impulse control. (R1) would have significant risk of harm due to her aggressive behaviors related to her Dementia. On 8/2/24 at 1:10 PM V9 (R1) Power of Attorney (POA) stated R1 left the faciity on 7/28/24 without any staff aware of her elopement. V9 POA stated, My other sister (V17) lives about a mile from the facility. (V17) normally visits regularly and takes (R1) back to her house. (V17) has cameras at her house and that is how we found (R1). (V17) saw (R1) on the front porch of (V17's) house. (V17) then called (V18) (R1's) family member to go over to (V17's) house and I called (V10) Licensed Practical Nurse (LPN) to let the facility know where (R1) was. I don't believe (R1) was badly hurt at all. (R1) has escaped that facility lots of times but this is the furthest she has gone. I don't know what we are going to do with (R1). The staff know (R1) leaves all the time and can't seem to stop her. Maybe they (staff) need more training or something. They (staff) are trying but I want (R1) to be safe too. On 8/2/24 at 10:25 AM V7 Maintenance Director stated the alarms are not checked on the weekends so there is no way to know if the alarms were working on the weekend R1 eloped from facility. On 8/2/24 at 2:06 PM V14 Certified Nurse Aide (CNA) stated, (R1) tried to leave the unit all the time. (R1) sits out in the main resident lounge area off the Dementia unit. The staff out there are supposed to keep an eye on her. I don't know how much good that does since (R1) knows the codes to the doors. On 8/2/24 at 10:17 AM R1 was walking up and down the hallway on the Dementia unit. R1's room is located at the end of the hall directly next to the exit door. R1 walked up to exit door on the Dementia unit and attempted to push the door open. On 8/6/24 at 11:30 AM R1 was pacing the hall of the Dementia Unit. R1 pushed another resident in a wheelchair out of her way to get to the exit door. R1 opened the exit door slightly as staff redirected R1 away from the door. On 8/7/24 at 2:25 PM R1 pushed a heavy wooden chair out of her way in the hallway to walk up to the exit door on the Dementia Unit. R1 attempted to open the door as staff redirected R1. The Immediate Jeopardy that began on 7/28/24 and was removed on 8/8/24 when the facility took the following actions to remove the immediacy. 1. R1's Care Plan was reviewed by the Interdisciplinary Team (IDT) on 8/8/24. On 8/9/24 V8 Resident Care Coordinator (RCC)/Licensed Practical Nurse (LPN) stated the IDT team reviewed and updated R1's care plan and added new interventions to aide in preventing R1 from eloping from the facility again. V8 stated she had a direct role in updating R1's Care Plan. 2. V1 Administrator stated all staff present in facility were in serviced on R1's updated elopement preventions on 8/8/24. 3. The Facility Elopement Policy, Missing Resident and Door Alarm Policy were reviewed by V26 Director of Clinical Operations. V26 stated on 8/12/24 that the facility policies were reviewed on 8/8/24 and were in compliance with state and federal regulations. 4. All staff will have access to and review a communication binder at the beginning of their shift for any safety intervention updates. V8 RCC/LPN stated on 8/9/24 the communication binder was implemented on 8/8/24 and is a new intervention to inform staff of any changes with residents at risk for elopement. V8 RCC/LPN stated V8 will take the communication binder to all Quality Assurance meetings Monday through Friday for the IDT team to review and update. V8 RCC/LPN stated the communication binder will be updated on the weekends through the on call nurse if necessary. 5. V1 Administrator initiated an in-service with all staff in the facility on 8/8/24. Elopement Policy, Missing Resident Policy, Door Alarm Policy, Communication Binder, Dementia Care Policy were included in this in-service. V1 stated the staff present were instructed that safety interventions to prevent elopement must be followed. V1 Administrator stated on 8/9/24 that any staff not present for the in servicing on 8/8/24 will be in-serviced prior to the beginning of their next scheduled shift. V2 DON stated the new hire staff will be trained during orientation through the new employee packet. Any other PRN (as needed) staff, agency staff or staff that have not worked yet will be in serviced. V2 DON will train nurses and V21 will train new hire CNA's. V2 DON stated the department manager will complete the training for any new hire staff for their own departments. 6. V8 RCC/LPN stated V8 initiated chart reviews and updating care plans on 8/8/24 and V8 completed all chart reviews and updated care plans for all residents at risk for elopement on 8/9/24. 7. All exit doors and devices were assessed on 8/8/24 by V7 Maintenance Director. V7 Maintenance Director stated on 8/8/24 that all exit doors and any existing alarms were checked, and all were functioning properly. V7 stated V7 will continue to check all the exit doors and alarms through the week and the on call nurse will check them on the weekends. 8. The elopement binder was reviewed and updated on 8/8/24. V12 Social Service Director (SSD) stated V12 will update the elopement binder with each new admission. V12 stated V12 takes the resident's picture and fill out the elopement resident details form. V12 stated she reviewed the elopement binder on 8/8/24 and found no issues. 9. The IDT team will ensure current safety interventions are being followed for their assigned residents. V1 Administrator stated these audits will occur three times per week for four weeks. V1 stated the IDT team was instructed to report any concerns to V1 Administrator and/or V2 Director of Nurses (DON) for corrective action if necessary. 10. V1 Administrator will perform a drill to determine the effectiveness of staff training on the Elopement Policy, Missing Person Policy and Door Alarm Policy, on random days and different shifts four times in one month. Any concerns identified following the drills will be immediately addressed through additional education by V1 Administrator. V1 stated the facility will have drills starting next week. 11. V7 Maintenance Director stated V7 will continue to check all the exit doors and alarms through the week. 12. The on call nurse will check the exit doors, alarms and devices on the weekends. V7 Maintenance Director stated any problems with the exit doors, alarms or devices will be reported to V1 Administrator. V4 Dietary Manager confirmed that all the exit doors and alarms were functioning properly on 8/10/24 and 8/11/24 during weekend rounds. V8 RCC/LPN confirmed that resident exit alert devices were functioning properly on 8/10/24 and 8/11/24 during resident device checks done by nursing staff and V8. 13. The communication binder will be reviewed twice weekly by V1 Administrator and/or V2 Director of Nurses. V1 Administrator stated this audit has been initiated and will be ongoing for the remainder of the month. V1 Administrator stated V1 reviewed the binder on 8/8/24 prior to putting the binders on the nurses stations. 14. Residents at risk for elopement will be reviewed weekly during Quality Assurance (QA) meetings. V1 Administrator stated the facility began on 8/8/24 to review all residents at risk for elopement and finished the initial review on 8/9/24. V1 stated the elopement binder was reviewed on 8/9/24 and will be updated with any change of status for existing residents and updated with any new information for new residents. 15. All action plans will be reviewed weekly for four weeks by the Quality Assurance Team. V1 stated if there are any concerns or noncompliance, the QA team led by V1 Administrator will resolve any issues immediately. The facility presented an abatement plan to remove the immediacy on 8/8/24. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility two separate times on 8/8/24 for revisions. The facility presented revised abatement plans on 8/8/24 and the survey team accepted the abatement plan on 8/8/24.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0944 (Tag F0944)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to provide in servicing to staff members on the facility Quality Assurance Performance Improvement (QAPI) program. This failure has the potenti...

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Based on interview and record review the facility failed to provide in servicing to staff members on the facility Quality Assurance Performance Improvement (QAPI) program. This failure has the potential to affect all 44 residents residing in facility. Findings include: The facility Daily Midnight Census dated 8/2/24 documents 44 residents residing in the facility. The undated facility Quality Assurance Performance Improvement (QAPI) Solution Revolution Policy documents QAPI includes all employees, all departments and all services provided. The facility educates staff on intervention and anticipation of resident's needs. A facility wide training will be conducted to inform everyone in the facility about the QAPI plan. These trainings will be conducted often and in multiple ways through regular all-staff meetings, department staff in-services, change of shifts report time. Dialogue, examples, exercise, etc. On 8/7/24 at 10:00 AM V22 Registered Nurse (RN) stated V22 has not received any training on the Quality Assurance Performance Improvement (QAPI) process. V22 RN stated, I think that is something the managers do but I really don't know. I haven't had any kind of training on that. On 8/7/24 at 1:40 PM V25 Certified Nurse Aide (CNA) stated V25 has not received any training on QAPI. V25 CNA stated, I have never heard of that. On 8/9/24 at 1:45 PM V19 Certified Nurse Aide (CNA) stated V19 has not received any QAPI program training. On 8/9/24 at 9:26 AM V1 Administrator stated the facility management team including the Medical Director has QAPI meetings at least quarterly. V1 stated the information brought back to the staff is by word of mouth. V1 stated, Apparently we (facility) are not educating the staff on new interventions for residents or any updates to policies or processes. If our staff do not know what those updates are, they will never be implemented.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to provide twelve hours of mandatory training for Certified Nurse Aides (CNA) yearly. This failure has the potential to affect all 44 residents...

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Based on interview and record review the facility failed to provide twelve hours of mandatory training for Certified Nurse Aides (CNA) yearly. This failure has the potential to affect all 44 residents residing in facility. Findings include: The facility Daily Midnight Census dated 8/2/24 documents 44 residents residing in facility. The facility Inservice Attendance sheets dated August 2023 through August 2024 do not document V27, V28, V29, V30 and V31 Certified Nurse Aide (CNA) have completed twelve hours of mandatory training. The facility provided documentation of employee hire dates and in-services documents the following: V27 Certified Nurse Aide (CNA) was hired on 5/25/2022 and has completed six hours of in-services in the past twelve months. V28 CNA was hired on 10/25/22 and has completed six hours of in-services in the past twelve months. V29 CNA was hired on 9/12/22 and has completed four hours of in-services in the past twelve months. V30 CNA was hired on 9/7/1994 and has completed eight hours of in-services in the past twelve months. V31 CNA was hired on 9/1/22 and has completed five hours of in-services in the past twelve months. On 8/13/24 at 3:00 PM V21 Lead Certified Nurse Aide (CNA) stated all CNA staff should have twelve hours of training every year. V21 stated the trainings are provided by the facility and anyone not present should be receiving the education. V21 stated V21 cannot provide documentation of in-services for V27, V28, V29, V30 and V31.

May 2024 3 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate fall interventions and keep equipment out of th...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate fall interventions and keep equipment out of the hallways for one of three residents (R1) reviewed for falls on the sample list of 12 residents. Failing to ensure R1 was wearing appropriate footwear resulted in R1 falling and sustaining a laceration that required sutures. Findings include: R1's undated Cumulative Diagnosis Log documents R1's diagnoses as: Agitation due to Dementia, Major Neuro Cognitive Disorder, and Alzheimer's Disease probable with Behavioral Disturbances. R1's Nursing admission Assessment documents R1 admitted to the facility on [DATE]. R1's Fall Risk assessment dated [DATE], documents R1 as a high fall risk. R1's Minimum Data Set, dated (MDS) dated [DATE], documents R1 has disorganized thinking and an altered level of consciousness. This same MDS documents R1 has had falls prior to admission to the facility. R1's Psychosocial assessment dated [DATE], documents R1 is easily distracted, is forgetful, has short and long term memory problems, wanders and paces, agitated, and has severe impairment with decision making and problem solving. R1's AIM (Assess, Intercommunicate, Manage) for Wellness report dated 4/28/24 at 10:30 AM, documents a crash was heard and down the hallway and R1 was lying next to a mechanical lift, R1 was on R1's right side, R1 sustained an abrasion to R1's right elbow. R1's Nursing Progress Note dated 4/28/24 at 12:30 PM, documents R1 has been up walking the halls. R1's AIM for Wellness report dated 4/28/24 at 4:00 PM, documents a witnessed fall. R1's Nursing Notes dates 4/28/24 at 6:20 PM, documents an order for blood draws and a urinalysis for repeated falls. R1's AIM for Wellness report dated 4/29/24 at 10:20 AM, documents R1 fell in the hall while ambulating independently, was not witnessed, assessed and found bleeding from a head injury and a small laceration on outer left eyebrow. This same report documents R1 was transported to the hospital. R1's Emergency Documentation notes dated 4/29/24, document a two centimeter linear laceration above the left eyebrow which was repaired with three sutures in the emergency room. R1's also had a diagnosis of a fall as a reason for this same visit. R1's Care Plan dated 5/1/24, documents the intervention for one fall on 4/28/24, to educate staff to keep hall clear and free of clutter; for the second fall on 4/28/24, to obtain a CMP (complete metabolic panel), CBC, (complete blood count) and a urinalysis (UA); for the fall on 4/29/24 to ensure appropriate footwear; and for a fall on 5/1/24, medication review requested. On 5/14/24 at 3:45 PM, V6 Licensed Practical Nurse (LPN) stated R1 wanders around the building. V6 stated R1 walks around a lot and wears gripper socks mostly during the evening and V6 does not know what other shoes R1 has. V6 stated that on 4/28/24, R1 was doing normal wondering and R1 was by the back door by the weight scale and one foot hanging off but R1 was trying to sit on the ground and lost her balance and fell on her bottom and was leaning over to R1's left elbow holding her up. On 5/14/24 at 1:22 PM, V3 Certified Nursing Assistant (CNA) stated R1 was walking like R1 normally does and she sometimes looks down when walking and we cue her to look up. V3 stated V3 passed R1 and was helping another resident and does not know if R1 had shoes on or what shoes they were. V3 stated R1 has slip on shoes and some slide sandals that are plastic and not safe to wear and there is no back on her shoes. On 5/14/24 1:40 PM, V1 Administrator stated R1 had a pair of sandals with a big wide band across the top and no straps in the back and a pair of slip on tennis shoes. On 5/14/24 at 3:15 PM, V5 Licensed Practical Nurse stated R1 has a pair of slip on tennis shoes with no laces and no back and a slipper sock thing with no back on it and it has a plastic sole. V5 stated R1 would be so tired from walking but would keep going that's when V5 thought R1's shoes might not be good. V5 stated she does not remember what if anything was on R1's feet when she fell that time. On 5/14/24 at 2:46 PM, V2 Director of Nursing (DON) stated R1 has a pair of tennis shoes which are slip-ons with no back and also wears a pair of yellow slippers with no back. V2 stated R1's husband was called after R1's fall from 4/29/24 so he could bring in another pair of shoes. V2 stated this was an intervention after that fall. V2 stated this should have been an earlier intervention because R1's shoes were not really safe. V2 stated R1 ran into a mechanical lift that was in the hallway on 4/28/24 which was not supposed to be there because it is a hazard. V2 stated the urine should have been obtained as soon as possible after the order was given since the order was given after the second fall on 4/28/24. V2 confirmed the order for a UA was given on 4/28/24 and was not obtained until 5/2/24. The facility's Fall Prevention Policy dated Revised 11/10/18, documents this policy is to provide for resident safety and to minimize injuries related to falls.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free of physical abuse by anothe...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free of physical abuse by another resident for three of three residents (R1, R7, R8) reviewed for physical abuse on the sample list of 12. Findings include: The facility's Incident Report Form - Illinois Department of Public Health (IDPH) Notification dated 2/23/24, documents R8 was in the dining room when R8 reached out and made contact with R7's forehead. R7 and R8 were separated and assessed. R8's undated Face Sheet documents R8's diagnoses as: Unspecified Dementia, Unspecified Severity, with Psychotic Disturbance, Depression Unspecified, and Unspecified symptoms and signs involving Cognitive Functions and Awareness. R8's Minimum Data Set (MDS) dated [DATE], documents R8 is not cognitively intact. R8's Care Plan dated 2/27/24, documents R8 is known/has a history of displaying inappropriate behavior and has a history of hitting staff. R8's untitled document dated 1/4/24, documents R8 having behaviors which include physical aggression-push, grab, physical abusive-hit, scratch, and does not respect personal space. The facility's IDPH Notification Form dated 5/6/24, documents R1 made contact with R7's face. R1 and R7 immediately separated and assessed. R1's undated Face Sheet documents R1's diagnoses as: Mild Neurocognitive Disorder due to known Physiological condition with behaviors and Unspecified Dementia, Unspecified severity with Agitation. R1's MDS dated [DATE], documents R1 is not cognitively intact. R1's Psychosocial assessment dated [DATE], documents R1 enters bedrooms uninvited, rummages in other's space, and is socially inappropriate. R1's Care Plan dated 4/25/24, documents R1 is/has the potential to be physically aggressive, pinches, bites, and kicks. On 5/23/24 at 1:05 PM, R8 stated she never hit anyone on the forehead or any where else. R8 stated R8 does not think she knows R7 and she doesn't remember hitting anyone. R8 stated R8 might have bumped into someone accidentally but has never hit anyone her whole life. On 5/23/24 at 1:15 PM, R1 was asked about the incident with R7. R1 is not able to stop walking, look at someone's face, understand or communicate. On 5/24/24 at 10:00 AM, R7 stated R1 kept coming in R7's room and R7 asked R1 to please leave and R1 just looked at R7. R7 stated R7 told R1 that R1 is not supposed to be in R7's room. R7 stated R1 kept banging on R7's closet door and R7 had a big shirt on and R1 hit the shirt and R7's face. On 5/24/24 at 10:10 AM, R7 stated R7 went to sit at her (R7) table in the dining room and R8 sat down and R8 asked if R7 wanted a cup of coffee and R7 stated it's right over there and R7 pointed to where the coffee was. R7 stated R8 got up and flicked the side of my (R7) head and moved to a different table. On 5/14/24 at 3:32 PM, V6 Licensed Practical Nurse (LPN) stated R1 can have aggressive behaviors at times. On 5/24/24 at 11:00 AM, V18 LPN stated R1 sometimes has physically aggressive behaviors. On 5/23/24 at 12:15 PM, V1 Administrator confirmed R1 made contact with R7's face and confirmed R8 made contact with R7's forehead. The facility's Abuse Prevention Program Policy dated Revised 11/28/2016, documents this facility is committed to protecting our residents from abuse by anyone including other residents. This policy also documents this facility desires to prevent abuse by establishing a resident sensitive and resident secure environment. This policy also documents as part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders to obtain a repeat Esophagogastroduodenosco...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders to obtain a repeat Esophagogastroduodenoscopy (EGD) for one resident (R2) and failed to collect a urinalysis for one resident (R1). R1 and R2 are two of three residents reviewed for following physician orders in the sample list of 12. Findings include: 1.) R1's undated Cumulative Diagnosis Log documents R1's diagnoses as: Agitation due to Dementia, Major Neuro Cognitive Disorder, and Alzheimer's Disease probable with Behavioral Disturbances. R1's Minimum Data Set (MDS) dated [DATE], documents R1 is always incontinent of urine and requires assist with toileting. On 5/14/24 at 3:45 PM, V6 Licensed Practical Nurse (LPN) confirmed, labs (laboratory blood work) and a urinalysis (UA) were ordered for R1 on 4/28/24 at 6:20 PM. V6 stated the telephone order and blood draw information are put on the laboratory sheet and then night or day shift staff obtain the specimens. V6 stated she passed the information on to V7 LPN (night shift) who drew the blood for the laboratory. V6 stated V6 did not obtain the UA for R1 because R1 did not want to sit down all evening. V6 stated the order to get a UA should not have gone through so many nurses before it was obtained. On 5/14/24 at 2:46 PM, V2 Director Of Nursing (DON) stated the urine should have been obtained as soon as possible after the order was given since the order was given after the second fall on 4/28/24. V2 confirmed the order for a urinalysis was given on 4/28/24 and obtained on 5/2/24. 2.) R2's undated Cumulative Diagnosis Log documents R2's diagnoses as: Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure, Cardio Vascular Accident, Coronary Artery Disease, Peripheral Artery Disease, History of Pulmonary Embolism, Chronic Kidney Disease Stage III. R2's Physician Order Sheet (POS) dated 5-1-24 - 5-31-24, documents R2's diet order as mechanical soft, thin liquids, swallow precautions, supervision at meals, anti-reflux precautions, small meals, small bites at meals and limit acidic food. This same POS documents Oxygen 2-4 liters to maintain oxygen saturation above 90%. R2's Situation, Background, Assessment, and Recommendation (SBAR) form dated 1/28/24, documents food/foreign substance stuck in R2's throat with increased aspiration risk, request to be sent to the emergency department (ED) for removal. R2's Final Report for 1/28/24, ED visit documents EGD completed with findings of food impaction from the oropharynx to the lower third of the esophagus removed using suction, rescue net and rat-tooth forceps - at the completion of the exam, the esophagus was free of any residual foreign body or debris - recommend minced or soft to chew diet for the next month as patient remains high risk for repeat obstruction - refer for repeat EGD in 4 weeks to perform esophageal dilation. On 5/21/24 at 1:30 PM, V2 stated R2 was on an antibiotic (ATB) when trying to schedule EGD appointment from 1/28/24 doctor's order but there is no documentation for this or for another appointment being scheduled within the 4 week time frame that was ordered. On 5/22/24 at 12:43 PM, V9 transport, stated she was in charge of making appointments for residents but it became too much due to so many transports. V9 stated V9 was not aware of R2 needing an appointment four weeks from R2's ED visit on 1/28/24. V9 stated sometimes V9 would get orders and sometimes V9 would not get orders especially if new nurses were working. The process for nurses includes stages such as checking medical orders, prescribing medications, and documenting executed orders. Ensuring the proper implementation of medical orders by nurses is essential for ensuring patient safety. Maintaining patient safety relies significantly on clear and carefully reviewed medical orders by nurses, serving as mechanisms to prevent practice errors. Incorrect implementation of medical orders poses a significant risk of severe harm to patients. BMC Nurs. 2024; 23: 113. Published online 2024 [DATE]. doi: 10.1186/s12912-024-01775-6

Dec 2023 1 deficiency

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to employ the services of a full time Director of Nursing. This failure has the potential to affect all 48 residents residing in ...

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Based on observation, interview, and record review the facility failed to employ the services of a full time Director of Nursing. This failure has the potential to affect all 48 residents residing in the facility. Findings include: On 12/19/23 at 9:45 upon entrance to the facility, V1, Administrator was not available to complete the entrance conference. When asked to complete the entrance conference with the Director of Nursing (DON), V3, Environment Director stated the facility does not have a DON, and has not had a DON for months. On 12/19/23 at 10:05 am V2, Regional Director of Operations confirmed the facility does not have a Director of Nursing. On 12/19/23 and 12/20/23 there was not a Director of Nursing working in the facility. The facility's CMS-802 form dated 12/19/23 documents 48 residents reside in the facility.

Dec 2023 13 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely complete the Preadmission Screening and Resident Review (PASA...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely complete the Preadmission Screening and Resident Review (PASARR) Level-1 screening and failed to complete the recommended Level-2 screening for one of one residents (R47) reviewed for required screenings on the sample list of 27. Findings Include: R47's Physician Order Sheet (POS), dated December 2023, documents R47 was admitted into the facility on 4/26/23 and has medical diagnoses of Sever Bipolar Disorder with Psychotic Features and Dementia with Behavioral Disturbances. The undated Maximus computer screen-shot documents R47's Level-1 PASARR screen was submitted on 8/9/23. R47's Notice of PASARR Level-1 Screen Outcome documents R47's Level-1 Screening results were received by the facility on 12/6/23 and recommended R47 be referred for a Level-2 screening due to Mental Health Disability. On 12/07/23 at 10:45 AM V1 Administrator stated R47 was first admitted on [DATE]. The Level 1 PASARR was not submitted to be completed until 8/9/23 and those results, showing a Level 2 screening should be completed, were not received by the facility until 12/6/23.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to implement physician ordered fall prevention interventions. This failure affects one resident (R8) out of six reviewed for fal...

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Based on observation, interview, and record review, the facility failed to implement physician ordered fall prevention interventions. This failure affects one resident (R8) out of six reviewed for falls on the sample list of 27. Findings Include: R8's current Physician Order Sheet, dated for December 2023 documents a physician order for R8 to have a bed and chair pressure alarm. On 12/5/23 at 10:31 AM, R8 was seated in a wheelchair in the facility Family Room. There was not any alarm on R8's wheelchair. V2 Assistant Director of Nursing stated, We are using a pommel cushion in (R8's) wheelchair so we don't have a double restraint. I think the chair alarm maybe refers to a recliner. On 12/5/23 at 10:58 AM, R8's room did not contain any kind of a chair, including a recliner. On 12/6/23 at 3:38 PM V2 stated, The pommel cushion does not prevent (R8) from standing up (not a restraint), she does it all the time. V2 further stated, The pressure alarm did not prevent (R8) from standing up (also not a restraint), she will stand up regardless. R8's Care Plan for Falls dated from 12/12/19 documents R8 experienced 16 falls in the four year period of residency at the facility. A fall intervention dated 7/30/23 documents, Fall from wheelchair without injury, staff to replace pressure alarm batteries. This intervention is documented as D/C (discontinue) to indicate the staff had changed the batteries. This same Care Plan for Falls has an intervention dated 12/14/22 Pommel cushion to wheelchair indicating R8 had the pommel cushion and the pressure alarm simultaneously in the recent past.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to properly clean and maintain a Continuous Positive Airway Pressure (CPAP) machine and mask for one of one residents (R43) revi...

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Based on observation, interview, and record review, the facility failed to properly clean and maintain a Continuous Positive Airway Pressure (CPAP) machine and mask for one of one residents (R43) reviewed for respiratory care on the sample list of 27. Findings Include: The facility's Bilevel Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) policy dated 3/8/13 documents CPAP machines provide continuous positive pressure to the airways of spontaneously breathing residents. Machine circuits are to be cleaned every week and as needed. External filters should be cleaned once a week and as needed. R43's Physician Order Sheet (POS) dated December 2023 documents R43 is diagnosed with Aspiration Pneumonia, Quadriplegia, Seizures, Altered Mental Status, and Mild Cognitive Impairment. R43 has an order to use a Continuous Positive Airway Pressure (CPAP) machine at bedtime. On 12/5/23 at 11:40 AM R43's Continuous Positive Airway Pressure (CPAP) mask was stored in a plastic bag however the mask was visibly soiled and had white debris all over the inside of the mask. The CPAP machine's water reservoir was dry and the entire bottom and sides of the reservoir had thick, dried, white, scaly residue. On 12/5/23 at 11:40 AM V2 Assistant Director of Nursing (ADON) confirmed R43's Continuous Positive Airway Pressure (CPAP) mask was dirty and appeared to have not been cleaned in a while. V2 also confirmed the CPAP water reservoir was dry and appeared to have mineral deposits (hard, scaly white residue) coating the bottom and sides of the reservoir. V2 ADON confirmed the mask should have been cleaned and should be cleaned after every use especially since R43 produces a lot of sputum and saliva. V2 also confirmed staff should be cleaning the reservoir weekly and or as needed and staff should be using distilled water to fill the water reservoir.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to obtain a physician's rationale for declining a Registered Pharmacist recommendation to reduce the dosage of an Anti-depressant/ sedative (T...

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Based on interview and record review, the facility failed to obtain a physician's rationale for declining a Registered Pharmacist recommendation to reduce the dosage of an Anti-depressant/ sedative (Trazodone). This failure affects one resident (R35) out of five reviewed for psychotropic and unnecessary medications on the sample list of 27. Findings Include: R35's Pharmacist Consultation Report dated 7/26/23 documents the facility's Registered Pharmacist gave the facility a reminder that V13, Nurse Practitioner, had declined to accept the Pharmacist recommendation to decrease Trazodone on 6/22/23, but had not provided a rationale as a basis for disagreeing with the recommendation. On 12/7/23 at 2:09 PM, V1 Administrator stated, Here is the return form from V13. This return form with a rationale was dated 8/11/23, 46 days after the initial recommendation from the Pharmacist.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to maintain resident bed side rails in a safe condition. This failure affects one resident (R2) of 12 reviewed for bed side rails...

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Based on observation, interview, and record review the facility failed to maintain resident bed side rails in a safe condition. This failure affects one resident (R2) of 12 reviewed for bed side rails in the sample list of 27. Findings include: On 12/5/2023 at 11:52 AM R2 was resting in bed with the left (room side) half-length side rail raised in the upward position. The rail vertical supports were spaced 7.5-8.5 apart. R2 reported using the rail for bed mobility and positioning. On 12/8/2023 at 10:02 AM R2 remained in bed with the side rail in the raised position. V11 (Licensed Practical Nurse) was present and observed the spacing on the vertical supports on the rail and confirmed the spacing of the supports was a hazard. R2's undated medical diagnosis list documents R2's medical diagnoses include Physical Debility and Sleep Apnea. R2's comprehensive assessment (9/19/2023) documents R2 has impaired range of motion in bilateral upper and lower extremities. R2's Physician Orders (December 2023) documents R2 uses oxygen via nasal cannula tubing. This creates an additional entanglement risk when used with side rails. R2's Bed Rail Evaluation (9/23/2023) documents R2 has Weakness and Musculoskeletal Disorder. The Food and Drug Administration Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment (3/10/2006) documents to reduce the risk of entrapment, injury, and death, the maximum safe spacing in a bed side rail system should not exceed 4 3/4.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0568 (Tag F0568)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to issue required quarterly account statements for a resident trust fund account. This failure affects one resident (R11) of one reviewed for ...

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Based on interview and record review, the facility failed to issue required quarterly account statements for a resident trust fund account. This failure affects one resident (R11) of one reviewed for trust funds on the sample list of 27. Findings Include: On 12/6/2023 at 11:56 AM, R11 reported having a resident trust fund account in the facility and not receiving any quarterly financial statements. On 12/6/2023 at 2:39 PM, V10 (Business Office Manager) reported starting employment in the facility during February 2023 and since that time not providing R11 with trust fund quarterly statements. V10 reported knowing V10 needs to learn how to produce the statements. V10 reported historically V10 just provided residents their account balances upon request. V10 reported R11 handles R11's own finances in the facility. R11's admission Checklist (9/14/2021) documents R11 authorized the facility to hold R11's personal funds in a resident trust fund account with the facility. The facility Personal Funds Authorization (undated) documents the facility will provide residents with trust fund accounts quarterly statements of transactions on their accounts.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Direct...

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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 employ a Registered Nurse to serve as full time Director of Nursing. This failure has the potential to affect all 51 residents in the facility. Findings Include: On 12/5/2023 at 10:19 AM V1 Administrator confirmed the facility does not currently employ a Registered Nurse to serve as full time Director of Nursing. Upon survey entrance and throughout the survey (12/5/23- 12/8/23) there was no Director of Nursing present and employed by the facility. The facility's Facility assessment dated [DATE] documents a full time Director of Nursing is required in order to meet the resident's needs and provide competent support and care for the facility's resident population. The facility Long-Term Care Facility Application for Medicare and Medicaid dated 12/5/2023 documents 51 residents currently reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nu...

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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 employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 51 residents in the facility. Findings Include: On 12/07/2023 at 11:45 AM V6 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V6 reported being the full-time manager of the facility food service (person in charge) and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V6 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V6 reported the facility dietician only works in the facility one day per month. V6 also denied being a certified Food Protection Manager, as required, for every person in charge of a food service. V6 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Food Service Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. The Food and Drug Administration Food Code (2022) documents a dietary service Person in Charge (PIC) shall be a Certified Food Protection Manager. On 12/7/2023 at 1:40 PM V1 (Administrator) reported V6 (Dietary Manager) did not meet the qualifications of a Certified Dietary Manager. Throughout the duration of the survey, the kitchen failed to prevent the potential for physical cross-contamination of food, failed to ensure all dietary staff donned hair restraints, and failed to exclude flying insects from the kitchen areas. The Facility assessment dated [DATE] documents a full-time dietician or other clinically qualified nutrition professional is needed to provide competent support and care for the facility's resident population every day and during emergencies. On 12/7/2023 at 2:30 PM V6 reported food from the kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (12/5/2023) documents 51 residents reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to prevent the potential for physical cross-contamination of food and failed to ensure dietary staff donned required hair restrai...

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Based on observation, interview, and record review the facility failed to prevent the potential for physical cross-contamination of food and failed to ensure dietary staff donned required hair restraints. These failures have the potential to affect all 51 residents in the facility. Findings Include: 1. On 12/5/2023 at 10:16 AM V7 (Dietary Aide) was working in the food preparation area of the facility kitchen without any required hair restraint. 2. On 12/7/2023 at 11:32 AM a can opener was mounted on a food prep table in the kitchen. The opener was soiled with accumulations of metal shavings where the cutting blade contacts canned food items being opened. The cutting surfaces of the opener blade felt dull when touched. On 12/7/2023 at 11:50 AM V6 (Dietary Manager) observed the above can opener and stated the opener definitely needs cleaned. On 12/7/2023 at 2:30 PM V6 reported food from the kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (12/5/2023) documents 51 residents reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to ensure required personnel attended the required quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the p...

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Based on interview and record review, the facility failed to ensure required personnel attended the required quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 51 residents in the facility. Findings include: The undated Quality Assurance Plan documents the facility Quality Assessment & Assurance (QAA) Committee should identify opportunities for improvement should be used to keep all QAA members, including the Administrator and Director of Nurses, up to date on what is going on within the facility. On 12/8/2022 V1 Administrator provided five QAA Meeting Sign-In Sheets (1/16/23, 4/10/23, 7/17/23, and 10/16/23) for the previous year's QAA meetings. The January, April, July, and October 2023 QAA Meeting Sign-In Sheets do not document the facility's Director of Nursing was present at any of the meetings. On 12/5/23 at 4:00 PM V1 Administrator confirmed the facility has not employed a Director of Nurses (DON) and therefor the facility has not had a DON at the last four Quality Assurance Committee Meetings held on 10/16/23, 7/17/23, 4/10/23, and 1/16/23. V1 Administrator confirmed all required members of the QAA committee, including the Director of Nurses, should be present at all quarterly QAA meetings. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 12/5/23 documents 51 residents reside in the facility.

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 map and identify high risk areas for Legionella growth, failed to formulate a prevention plan, failed to formulate a plan for any identified...

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Based on interview and record review the facility failed to map and identify high risk areas for Legionella growth, failed to formulate a prevention plan, failed to formulate a plan for any identified cases of Legionella, and failed to identify facility water outlets for testing samples. This failure has the potential to affect all 51 residents residing in the facility. Findings Include: On 12/7/23 at 1:53 PM V1 Administrator provided an undated Legionella Environmental Assessment Form. At 2:54 PM V12 Maintenance Director provided an undated floor plan map. The facility's floor plan map (undated) was a fire safety map showing the locations of fire walls, egress routes, smoke detectors, fire extinguishers, and sprinkler heads. V12 stated, I don't have a mapping to show the water distribution or high-risk areas for Legionella, I know where the city water comes into the building. The Legionella Environmental Assessment Form (undated) documented the facility characteristics, such as city water supply, number of buildings on the property, number of rooms, average length of stay, emergency water systems such as sprinklers and eye wash stations, and ice machines. This Form did not identify any areas or fixtures as high risk for the growth of Legionella. This Form did not contain any measures to prevent the growth of Legionella. This form did not identify a response plan in the event of a positive case of Legionella. This Form did not document when the facility should initiate testing for Legionella, nor a plan for remediation if Legionella was discovered in the facility water fixtures. On 12/8/23 at 10:04 AM V1 Administrator acknowledged the lack of required components in the Environmental Form and stated, I think it sounds like I need an action plan. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 12/5/23 documents 51 residents reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0924 (Tag F0924)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain corridor handrails in sound and stable condi...

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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 maintain corridor handrails in sound and stable condition. This failure has the potential to affect all 51 residents in the facility. Findings Include: On 12/7/23 at 2:54 PM there was a one-foot section of handrail at the intersection of the two 200 halls which was loose and easily moveable up and down as well as rotating. There was a section of handrail between resident rooms [ROOM NUMBERS] which moved up and both directions sideways one and one-half inches, being unscrewed from the mounting bracket, and having screws protruding from the brackets. There was a section of handrail between resident rooms [ROOM NUMBERS] which had a loose mounting bracket that could be pushed one half inch recessed into the wall, allowing the handrail to move a commensurate amount, as well as having loose screws the length of the rail allowing the rail to be rotated. Between resident room [ROOM NUMBER] and the end of the corridor, the was a section of handrail with loose screws, allowing the rail to move and rotate over one-half inch. Between the therapy room and the end of the 200 corridor there was a section of handrail with loose screws, allowing the rail to move and rotate three-quarters of an inch. There was a section of handrail between the therapy room and resident room [ROOM NUMBER] with loose screws, allowing the rail to rotate one-half inch. Next to a storage room on the 200 hall, after resident room [ROOM NUMBER], there was a section of handrail with loose screws, allowing the rail to rotate one-half inch. Between the janitor room and the Minimum Data Set office on the back 200 hall, there was a section of handrail with loose screws, allowing the rail to rotate one-half inch. Between resident room [ROOM NUMBER] and the exit door, there was a section of handrail with loose screws, allowing the rail to rotate one-half inch. There was a section of handrail between resident room [ROOM NUMBER] and a storage room with loose screws, allowing the rail to rotate one-half inch. Between resident rooms [ROOM NUMBERS] there was a section of handrail which was not properly mounted on the wall bracket, being mounted to the downward curved portion of the bracket, causing the rail to be tight directly up against the wall at the end next to resident room [ROOM NUMBER]. The remainder of the rail slowly tapered away from the wall, creating an entrapment hazard for any resident using the handrail to get their hand caught as the rail tapered down to no clearance. There was a section of handrail between resident room [ROOM NUMBER] and the nursing station with loose screws that rotated one-half inch. There was a section of handrail between resident room [ROOM NUMBER] and the dining room with loose screws, allowing the rail to rotate three-quarters of an inch. There was a section of handrail between resident rooms [ROOM NUMBERS] with loose screws, allowing the rail to rotate three-quarters of an inch. Between the corner of the 100 hall and the exit door there was a rail with loose and missing screws allowing the rail to move one and one-half inches. Between resident room [ROOM NUMBER] and the hallway entrance there was a section of handrail with loose and protruding mounting screws, allowing the brackets to move and recede into the wall one-half inch. There was a section of handrail between resident rooms [ROOM NUMBERS] with loose screws, allowing the rail to rotate one-half inch. There was a section of handrail between resident rooms [ROOM NUMBERS] with loose screws, allowing the rail to move and rotate three-quarters of an inch. Between the janitor room and the shower room on the 100 hall there was a section of handrail with loose mounting screws, allowing the mounting brackets to move and recede into the wall one-half inch. On the facility's 100 hall there was a section of handrail between the two shower rooms with loose screws, allowing the rail to move and rotate one-half inch. Between resident rooms [ROOM NUMBERS], the section of handrail had loose screws, allowing the rail to rotate three-quarters of an inch. Between resident room [ROOM NUMBER] and the hallway fire door, a section of handrail with loose screws could move and rotate three-quarters of an inch. There was a section of handrail between resident rooms [ROOM NUMBERS] with loose screws that could move and rotate one-half inch. Between a storage room and the end of the 200 hall, there was a section of handrail with loose screws which moved and rotated one-half inch. During this tour of the facility handrails V12 Maintenance Supervisor made statements such as, Oh, I didn't know that was like that. Oh man that's loose. Oh yeah that needs fixed and I usually keep an eye on these things. When referring to the handrail between resident rooms [ROOM NUMBERS] with the entrapment hazard, V12 stated, I think someone must have hit that with the (full body mechanical lift). The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 12/5/23 documents 51 residents reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to maintain an effective pest control program by failing to exclude and prevent flying insects throughout the facility kitchen ar...

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Based on observation, interview, and record review the facility failed to maintain an effective pest control program by failing to exclude and prevent flying insects throughout the facility kitchen areas. This failure had the potential to affect all 51 residents in the facility. Findings Include: On 12/5/2023 at 10:28 AM three or more flies resembling fruit flies were flying around and resting on the kitchen dishwasher drainboard areas. On 12/7/2023 at 11:45 AM five or more flies resembling fruit flies were flying around and resting on the kitchen dishwasher drainboard areas. An additional fly surfaced and flew out of a nearby floor drain. The floor drain contained standing water and the interior pipe surface above the water was soiled with dark colored accumulations of debris. V6 (Dietary Manager) was present and stated the kitchen floor drains are the problem (causing the flies in the kitchen areas) and they (the flies) are so bad. Facility pest control contractor treatment reports (September-November 2023) document flies were present in the facility kitchen during each month from September-November 2023. On 12/7/2023 at 2:30 PM V6 (Dietary Manager) reported food from the kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (12/5/2023) documents 51 residents reside in the facility.

Nov 2023 6 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 F0557 (Tag F0557)

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 dignity of one (R1) resident by leaving R1's...

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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 dignity of one (R1) resident by leaving R1's soiled bedpan in plain view when not in use. This failure affects one (R1) resident out of three residents reviewed for dignity in a sample list of three residents. Findings include: R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has clear comprehension and can make self understood. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, eating, toileting, personal hygiene and extensive assistance of two people for dressing. On 11/2/23 at 10:30 AM R1 was lying in bed looking towards end of bed. R1's bedpan with remnants of stool inside bedpan was sitting on top of R1's suitcase at end of bed. R1's bedpan was not covered in any way and in plain view for visitors passing by with R1's door wide open. On 11/2/23 at 10:35 AM V20 Licensed Practical Nurse (LPN) placed R1's soiled bedpan in a plastic bag and removed it from R1's room. V20 LPN stated, Well this is just gross. They (staff) should not have left this in (R1's) room. On 11/2/23 at 10:40 AM R1 stated, They (staff) leave my bedpan out for everyone to see. I can't get up and clean it up. Sometimes they (staff) put it in the bottom drawer but other times they just leave it set out. It smells and I don't like to look at it. It is embarrassing. On 11/2/23 at 11:30 AM V18 Certified Nurse Aide (CNA) Supervisor stated, I normally make rounds every morning but I got busy and forgot. I didn't have the chance to make rounds so I missed (R1's) soiled bedpan sitting out. The staff should always clean up that kind of mess and put the clean bedpan in a plastic bag. The undated facility policy titled 'Resident Rights Policy' documents it is the policy of this facility to protect and promote the rights, protections, benefits and privileges of each resident according to State and Federal laws. Basic to all ensuing rights are: a right to a dignified existence, self-determination, and communication with and access to persona and services outside 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

Deficiency F0558 (Tag F0558)

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 resident preferences were being honored for ...

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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 resident preferences were being honored for one (R1) resident by serving R1 red meats and not providing two baths per week. This failure affects one (R1) resident out of three residents reviewed for resident preferences in a sample list of three residents. Findings include: R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has clear comprehension and can make self understood. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, eating, toileting, personal hygiene and extensive assistance of two people for dressing. R1's Care Plan documents an intervention dated 8/11/23 for staff to offer appropriate subs for foods not eaten. An intervention dated 8/11/23 for R1 to receive a bath two times per week. This same care plan instructs staff to provide bathing, hygiene, dressing and grooming per resident's preference as able. R1's shower sheets documented as completed as a bed bath with staff signing off on September-2,6, 9 (refused), 28 and 30; October 4,6,11,14,18,21,25 (refused) and 28 (refused). R1's medical record does not document any reattempts to provide R1 a bed bath after R1's refusals. This same medical record documents R1 did not have a bath for seven continuous days in October 2023. On 10/31/23 at 12:15 PM R1 was lying in bed. R1's hair is shoulder length and appears greasy. On 10/31/23 at 1:30 PM R1 stated, I am not supposed to have any red meats. I don't want red meat because it isn't good for my cholesterol. The doctor told me not to eat any red meat. They (facility) keep bringing me meals with red meat in them. The last three days I have been served red meat. I tell the girls (staff) that I don't want any red meat and I am told to just not eat it then. I want them to stop serving it to me. I am also supposed to get two baths a week. I don't get both. If I don't feel like it right in the moment and decline a bath then the staff never come back. Just because I don't feel like it right then doesn't mean I won't feel up to it later. They (staff) should at least come and ask again. On 10/31/23 at 1:30 PM V13 Dietary Manager stated, I am just a Dietary Manager. I am not certified. I have looked into getting certified in North Dakota but I have not started any of the classes yet. I feel like a fish out of water sometimes because I am so young and so new at this but I like it and want to do a good job. I talked to (R1) for a few minutes when she first came in but I didn't have enough staff that day so I didn't get to spend too much time with her. I don't look through the hospital records or through the resident charts. I just get a note from the floor nurses as to what the resident's diet should be and take their word for it. I told you I really don't know anything yet. I am learning. I don't attend the resident care plans because I don't have the time. We (facility) are very short staffed in the kitchen so I never have time to go. If a resident wants something specific or does not want certain foods, I can try to accommodate that. If I could just have some time to sit with (R1) I would be able to serve her better for what she wants. On 11/2/23 at 11:20 AM V14 Nurse Practitioner stated, Residents come to these facilities and have to change their lives all around. They are allowed to have preferences met by the facility. (R1) should not be served red meat if she does not want it. (R1) should be allowed to have two baths per week on her own schedule. Those are not unreasonable requests and should be honored. That is the least they (facility) can do. On 11/2/23 at 2:00 PM V1 Administrator stated resident preferences are supposed to be honored if they are within reason. V1 stated, (R1's) requests are very reasonable. If (R1) told the staff what her requests were then the staff should have told us (administration) so that we can help manage that. It is our staff that did not communicate. We will review all (R1's) preferences with her and get this straightened out. The undated facility policy titled 'Resident Rights Policy' documents it is the policy of this facility to protect and promote the rights, protections, benefits and privileges of each resident according to State and Federal laws. Basic to all ensuing rights are: a right to a dignified existence, self-determination, and communication with and access to persona and services outside 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

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 follow a Physician order to timely obtain a Urinalysis ...

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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 follow a Physician order to timely obtain a Urinalysis (U/A) with Culture and Sensitivity (C&S) and failed to provide complete incontinence care for one (R1) resident out of three residents reviewed for Urinary Tract Infections (UTI) in a sample list of three residents. Findings include: R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has clear comprehension and can make self understood. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, eating, toileting, personal hygiene and extensive assistance of two people for dressing. R1's Physician Order Sheet (POS) dated September 2023 documents R1 was prescribed Levaquin (antibiotic) 750 milligrams (mg) daily for five days for UTI. The facility no rinse perineal cleanser label documents, Disperse foam onto areas needing cleansing, then wipe the area clean, repeating until skin is cleansed. No rinsing is required, just towel dry after use. R1's Nurse Progress Note dated: 9/3/23 at 9:15 PM documents, (R1) stated her urine has an odor and pain when voiding. Asking (V14) Nurse Practitioner for Urinalysis (U/A) with Culture and Sensitivity (C&S) orders. 9/11/23 at 4:30 AM documents, (R1's) urine collected via straight catheter for U/A with C&S. R1's Microbiology Culture Report dated 9/14/23 for R1's U/A obtained on 9/11/23 documents, Greater than 100, 000 Klebsiella Pneumoniae gram negative species. On 11/1/23 at 2:05 PM V16 and V17 Certified Nurse Aides (CNA) provided perineal care for R1. V16 CNA used dry washcloths with no rinse cleanser to cleanse R1's perineal area. R1's skin was left with several areas of no rinse wet foam. V16 CNA did not dry R1's skin nor remove excess foam. Observed a half dollar sized non-blanchable closed reddened area to R1's upper right buttock. V17 CNA confirmed this reddened area was new and non-blanchable. On 11/1/23 at 2:45 PM V16 CNA stated, I did not use any towels to dry (R1) off. Should I have? I didn't think we (staff) had to rinse off the no rinse cleansers but I don't know if we should have to dry them (residents) too. I don't usually do that. I used the hand sanitizer on another hall but then I gathered up all the supplies and touched all the linens and things on (R1's) bedside table. On 11/1/23 at 2:47 PM V17 Certified Nurse Aide (CNA) stated, (R1) is a heavy wetter. I think (R1) takes water pills. I don't know if we (staff) should have dried her or not. There was some extra foam left on her so I guess that is really a wet product so we should dry her off. V17 CNA stated leaving wet foam on residents skin could cause breakdown. On 11/2/23 at 2:30 PM V2 Resident Care Coordinator (RCC) stated, (R1) did complain of symptoms of a Urinary Tract Infection (UTI) on 9/3/23. We (facility) got the order for the U/A with C&S on 9/4/23. For some reason, we (facility) did not obtain the urine specimen until 9/11/23. I don't know why it took so long but it did. There is no documentation between 9/3 and 9/11 to even say if we (facility) tried unsuccessfully to obtain the urine specimen. I really do not know but it should not have taken so long. On 11/2/23 at 11:15 AM V14 Nurse Practitioner (NP) stated, I remember that being a problem. (R1) complained of urinary symptoms so I ordered a U/A with C&S to be obtained on 9/4/23. The facility waited until 9/11/23 to get the urine sample from (R1). That is way too long. They (facility) should have obtained the urine sample either that day (9/4/23) or maybe the next day (9/5/23) but not wait seven entire days before obtaining the sample. (R1) could have ended up with Sepsis or Metabolic Encephalopathy or worse. That really did harm (R1) by waiting so long to get the urine sample. It is a simple procedure. The undated facility policy titled 'Diagnostic Services' documents all diagnostic tests must be ordered but the attending physician or the Medical Director. All orders for diagnostic services must be entered in the residents medical record and signed by the physician. Physician orders will be carried out promptly as ordered. When ordered by the Physician, cultures shall be obtained and completed as soon as practical and results reported to the physician as soon as results are available. The undated facility policy titled 'Giving Female Perineal Care' documents for staff to wash hands, rinse perineum with a wash cloth, discard the wash cloth, pat the area dry with a towel, rinse rectal area with wash cloth, discard the wash cloth, and pat the area dry with towel.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] document...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has clear comprehension and can make self understood. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, eating, toileting, personal hygiene and extensive assistance of two people for dressing. R1's Physician Order Sheet (POS) dated November 2023 documents a Physician order for R1 to wear Bi-Pap every night. On 11/2/23 at 10:30 AM R1's Bi-Pap mask sitting face down directly on bedside dresser. On 11/2/23 at 10:45 AM V20 Licensed Practical Nurse (LPN) stated, (R1's) Bi-Pap mask should be in a bag. It can get dirty otherwise and could cause an infection. On 11/2/23 at 1:50 PM V2 Resident Care Coordinator (RCC)/Licensed Practical Nurse (LPN) stated, All oxygen tubing and Bi-pap tubing should be kept up off the ground and in bags when not in use. The tubing can get dirty. We (staff) try to keep those things bagged up but sometimes we forget. Based on observation, interview, and record review the facility failed to change the oxygen tubing and humidifier bottle for two of three residents (R2, R3) and failed to properly store a Bilevel Positive Airway Pressure (BiPap) mask for one of three residents (R1) reviewed for respiratory care on the sample list of three. Findings include: The Oxygen Therapy policy dated August 2003 documents oxygen tubing should be changed on a weekly basis and the tubing changes should be dated and documented on the residents Treatment Administration Record (TAR). When using prefilled humidification, staff should date bottles when changed and changes need to be documented on the TAR. 1. R2's Physician Order Sheet (POS) dated November 2023 documents R2 is diagnosed with Acute on Chronic Respiratory Failure, Bilateral Pneumonia, and Chronic Obstructive Pulmonary Disease Exacerbation. The same POS documents an order for Oxygen at three liters nasal cannula to maintain an oxygen saturation at 90 percent or above. On 11/1/23 at 11:45 AM R2's oxygen was being administered via nasal cannula at three liters per nasal cannula. The oxygen tubing was not dated and the humidifier bottle was dated 10/15/23. 2. R3's undated Face Sheet documents a medical diagnoses of Obstructive Sleep Apnea. R3's Physician Order Sheet (POS) dated November 2023 documents R3 is diagnosed with Quadriplegia and Aspiration Pneumonia. The same POS documents an order for Oxygen at two liters nasal cannula to maintain an oxygen saturation at 90 percent or above. On 11/1/23 at 3:30 PM R3's oxygen was being administered via nasal cannula at two liters per nasal cannula. The oxygen tubing was not dated, the humidifier bottle was dated 10/15/23, and the humidifier oxygen tubing was dated 8/4/23. On 11/2/23 at 12:00 PM V1 Administrator and V2 Resident Care Coordinator confirmed oxygen tubing should be changed weekly, dated when changed, and documented as changed on the resident's Treatment Administration Record. Both V1 and V2 confirmed prefilled oxygen humidifier bottles should be changed weekly or as needed, dated when changed, and documented as changed on the residents Treatment Administration Record. Both V1 and V2 confirmed the short oxygen tubing that connects the humidifier bottle to the oxygen concentrator should be changed at least weekly and dated. Both V1 and V2 confirmed R2 and R3's oxygen tubing should have been dated when changed and the humidification bottles should have been changed weekly and dated when changed.

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent cross contamination during wound care and perin...

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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 prevent cross contamination during wound care and perineal care for one (R1) resident out of three residents reviewed in a sample list of three residents. Findings include: The facility policy titled 'Aseptic Wound and Skin Treatment Procedure' reviewed 3/16/23 documents the purpose is to prevent contamination of the wound, protect wound from mechanical injury, to stimulate, restore and promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structures and to promote resident comfort. Procedure: pull privacy curtain and close door to resident room, wash your hands, establish your clean and dirty fields. Put on gloves and remove soiled dressings and place in plastic bag at the end of the bed, remove gloves and place in plastic bag, wash your hands, put on clean gloves, place soiled dressings in plastic bag, remove gloves and place in plastic bag, wash your hands, put on clean gloves, apply clean dressing as ordered, remove gloves, discard in plastic bag and wash your hands. The undated facility policy titled 'Giving Female Perineal Care' documents for staff to wash hands, rinse perineum with a wash cloth, discard the wash cloth, pat the area dry with a towel, rinse rectal area with wash cloth, discard the wash cloth, and pat the area dry with towel. R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has clear comprehension and can make self understood. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, eating, toileting, personal hygiene and extensive assistance of two people for dressing. On 10/31/23 at 3:00 PM V2 Resident Care Coordinator (RCC)/Licensed Practical Nurse (LPN) completed R1's dressing change to Right Great Toe. V2 RCC did not wash hands prior to dressing change. V2 did not provide clean field. R1's bedside table was completely covered with R1's personal items. V2 moved R1's personal items on the bedside table and set all supplies down on R1's bedside table without cleaning the surface of bedside table. On 10/31/23 at 3:15 PM V2 Resident Care Coordinator (RCC)/Licensed Practical Nurse (LPN) stated, I really messed that up didn't I. I should have set up a clean field. I should have washed my hands before starting. I should have pulled the curtain and used some kind of trash bag to put the dirty dressing into. Cross contamination can cause infections. I can't believe I just did that. On 11/1/23 at 2:05 PM V16 and V17 Certified Nurse Aides (CNA) provided perineal care for R1. V16 nor V17 washed hands prior to start of perineal care. On 11/1/23 at 2:45 PM V16 CNA stated, We definitely should have washed our hands. I used the hand sanitizer on another hall but then I gathered up all the supplies and touched all the linens and things on (R1's) bedside table. On 11/2/23 at 2:35 PM V2 Resident Care Coordinator (RCC)/Infection Preventionist stated, Staff should always wash their hands prior to providing cares. Hand sanitizer is acceptable in between glove changes but they (staff) should always wash their hands before providing perineal cares.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Direct...

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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 employ a Registered Nurse to serve as full time Director of Nurses. This failure has the potential to affect all 53 residents in the facility. Findings Include: Upon survey entrance and throughout the survey (10/31/23- 11/2/23) there was no Director of Nurses present and employed by the facility. On 11/2/23 at 12:00 PM V1 Administrator confirmed the facility does not currently employ a full time Director of Nurses. V1 confirmed the facility census is currently 53 residents. The facility's Facility assessment dated [DATE] documents a full time Director of Nurses is required in order to meet the resident's needs and provide competent support and care for the facility's resident population.

Oct 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident (R1) was not subjected to physical abuse from ano...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident (R1) was not subjected to physical abuse from another resident (R5). This failure affects two residents. R1 is one of three residents reviewed for physical abuse in the sample list of three. R1 sustained a 2-centimeter occipital laceration to the top of the head with 3 staples. Findings include: R1's undated Face Sheet documents R1's diagnoses as Anxiety, Bipolar Mood Disorder, Dementia, Alzheimer's, Depression. R1's Minimum Data Set (MDS) dated [DATE], documents R1 severely cognitively impaired. R1's Hospital notes dated 7/25/23, document R1 as having a fall at the nursing home, traumatic injury of the head, and 2-centimeter occipital laceration to the top of the head with 3 staples placed. On 10/6/23 at 1:45 PM, V7 RN stated, R1 approached R5 from behind. When R5 turned around, R1 tried to hug R5, like a 'side hug'. R5 pushed R1 and R1 fell and hit the back of her head. R1 had to get staples in her head. On 10/9/23 at 11:05 AM, V10 CNA stated R5 can be aggressive with behaviors without being provoked. V10 stated R5 has been physically and verbally aggressive with staff and residents. The facility's Final Report for the incident occurring on 7/25/23, documents it was determined a physical altercation. R5 pushed R1 and R1 fell backwards which resulted in R1 receiving 3 staples to the crown of R1's head for a laceration that was sustained during the fall on 7/25/23. The facility's Abuse Prevention Policy dated Revised 11/28/2016, documents the facility affirms the right of the residents to free from abuse and the facility prohibits abuse to its residents. The policy also documents this policy is to assure the facility is doing all that is within its control to prevent abuse of the residents.

Jun 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to provide and doucment oxygen treatments as ordered for three (R1, R2 and R3) of three residents reviewed for respiratory needs f...

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Based on observation, interview and record review the facility failed to provide and doucment oxygen treatments as ordered for three (R1, R2 and R3) of three residents reviewed for respiratory needs from a total sample list of three. Findings include: The facility Oxygen Therapy policy dated March 2019 documents that oxygen is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Oxygen therapy may be used provided there is a written order by the physician, including management orders and the procedure for changing oxygen tubing/mask/cannula/and/or/tracheostomy mask on a weekly basis. 1). R1's June 2023 physician orders document oxygen to be used to maintain saturation levels above 90%. Oxygen saturations to be checked on every shift change and the oxygen tubing and water bottle weekly. R1's treatment administration records document that oxygen saturations were not documented on May 3, 2023 on the 2pm-10pm or 10pm-6am shift, May 10, 2023 on the 2pm-10pm shift, May 17, 2023 on the 6am-2pm or 2pm-10pm shift and the next day being hospitalized for pneumonia. R1's treatment administration records document that oxygen saturations were not documented on June 4, 5, 9, and 22 on the 6am-2pm shift and June 3, 8 and 22 on the 2pm-10pm shift and June 9 and 10 on the 10pm-6am shift. R1's undated, facility provided care plan does not document a plan of care for oxygen administration. On 6/22/23 at 8:50AM, R1 was sitting in a wheel chair in the common area of the facility watching television. R1 was wearing a nasal cannula attached to a portable tank. On 6/22/23 at 8:55AM, R1 stated, I had to stay in my room for a half of a day because they ran out of oxygen (pointing to his portable tank). If I don't have (oxygen) in this bag, as far as I'm concerned I don't have oxygen. I couldn't go to the dining room or leave my room. I worry that it will happen again. On 6/22/23 at 9:15AM, V2 Resident Care Coordinator (RCC) said that there was a case of the facility being low on liquid oxygen because the delivery was made to an incorrect town and that residents had to wait for the liquid oxygen to be delivered to the facility. 2). On 6/22/23 at 8:38AM, R2 was sitting up in a chair wearing a nasal cannula attached to a portable concentrator that was turned off and the tubing and humidification bottle were undated. When asked if she was getting any oxygen, R2 stated, I don't think that I am, but I need it. I wear 2 liters all of the time and I don't feel it coming out. On 6/22/23 at 8:40AM, V3 Registered Nurse, license pending stated, No, her oxygen is not on. I will turn it on. It has probably been turned off since her nebulizer treatment about 10 minutes ago. R2's physician orders does not contain an order for oxygen administration. R2's initial care plan does not document a plan of care for oxygen administration. R2's facility provided, undated care plan does not document a plan of care for oxygen administration. On 6/22/23 at 10:30AM, V2 Resident Care Coordinator said that R2 is supposed to have oxygen but that an order for oxygen had not been obtained. 3). On 6/22/23 at 8:45AM, R3 was sitting up in a chair wearing a nasal cannula attached to a portable oxygen tank. A wall concentrator was next to R3's bed. R3 stated that he used the wall concentrator at night. Neither the tubing, nor the humidification bottle was dated. R3's June physician orders document oxygen to be administered at 3 liters per nasal cannula to maintain oxygen saturations above 90 percent with oxygen saturations to be checked every shift. R3's June 2023 treatment administration record does not document oxygen saturations on June 1,2, 4, 5, 6, 7, 9, 10, 14, 16, 20 and 21 on the 6am-2pm shift. Additionally, no documentation of oxygen saturations were made on June 8, 13, and 21 on the 2pm-10pm shift and on June 6,7 and 9 on the 10pm-6am shift. R3's undated, facility provided care plan does not document a plan of care for oxygen administration. On 6/22/23 at 8:43AM, V3 Registered nurse, license pending, stated, Tubing and water are supposed to be dated. On 6/22/23 at 1:30PM, V9 Licensed Practical Nurse said that there is a place in the (treatment administration record) to document both that residents have their oxygen on and another to document the resident's oxygen saturation level. V9 LPN stated, You have to make sure both areas are documented on.

Jun 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

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 implement behavioral interventions for one resident's (...

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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 implement behavioral interventions for one resident's (R4) behaviors of rifling through others residents' belongings and disturbing residents while sleeping. This failure affected five (R1, R2, R3, R4 and R5) of five residents on the total sample list of five. Findings include: R4's Minimum Data Set, dated [DATE] documents R4 as severely cognitively impaired. R4's progress note dated 3/30/23 documents admission to the facility. On that same date, R4 is documented to be wandering in and out of resident rooms. R4's progress notes dated 3/31/23, 4/1/23, 4/3/23, 4/12/23, 4/22/23, 4/23/23, 5/8/23, 5/10/23, 5/11/23, 5/11/23, 5/13/23, 5/14/23, 5/15/23, 6/6/23, 6/7/23, 6/17/23 and 6/19/23 document R4's consistent behaviors of wandering into other resident rooms, pilfering through their belongings and not wanting to vacate the rooms or leave behind items that are not hers. On 6/20/23 at 9:30AM, the facility provided grievances of lost and found items include: R1's grievance dated 6/13/23, R2's grievance dated 6/7/23, R3's grievance dated 4/24/23 and R5's grievance dated 5/12/23. The facility assessment dated [DATE] documents that the facility will admit residents with impaired cognition if the resident is well controlled. The Ombudsman Resident Rights pamphlet provided upon admission to all residents dated Novemebr 2018 documents that residents have the right to expect that the facility will provide privacy and the protection of personal items. On 6/20/23 at 3:15PM, V1 Administrator stated that the facility did not have any policies or procedures regarding dementia care of residents, nor supervision of residents. On 6/20/23 at 1:33PM, R4 attempted to leave the facility through the back door, setting off the alarm, three staff members attempted to redirect R4. On 6/20/23 at 9:50AM R1 stated that he was missing several items. R1 then stated, I think that woman takes a lot of it. (R4) is her name and last night I woke up and she was standing in my room mumbling. That isn't ok. This is my room and I'm afraid to lay anything down for fear that she will take it. On 6/20/23 at 9:35AM, R2 stated, I was missing a hoodie but they found it. I really think most of what I lose, (R4) takes. She is a lady who wanders into our rooms and takes things. She took my remote and other stuff, but most of the time the staff find everything she takes. She would take everything that isn't nailed down and then take the nails! On 6/20/23 at 9:40AM, R3 said that he had a television remote, a coat and a coffee cup taken. All were found, but that, R4 comes into my room and gets into my drawers and takes my things. It makes me mad! On 6/20/23 at 1:21PM, R5 stated, I found my missing wallet, no one took it, but we have a lady here who comes into our rooms, rifles through our stuff and we've been dealing with it for some time. I just can't believe how often she is in our rooms. On 6/20/23 at 2:55PM, V3 Social Services Director said that R3 and R5 have both told her that R4 takes their things. Others have said it too, but I didn't think that I could use names on grievances. On 6/20/23 at 9:59AM, V5 Licensed Practical Nurse stated, (R4) has severe dementia and is ambulatory. She wanders into rooms and picks things up, especially at night. On 6/20/23 at 1:22PM, V6 Certified Nursing Assistant (CNA) stated, I've been here when (R4) has rifled through other people's things and when she tries to exit seek. It is just hard to deal with her. On 6/20/23 at 11:30AM, V1 Administrator stated, We have new and inexperienced staff and they don't always know how to manage a resident like R4. On 6/20/23 at 3:27 PM, V10 CNA stated that she had not received any dementia training at the facility. On 6/2023 at 3:32PM, V9 CNA stated that she had not received any dementia training at the facility. On 6/20/23 at 3:15PM, V2 Resident Care Coordinator stated, I don't know how we would keep R4 out of other resident rooms. We don't have formal dementia training. I'm trying to get someone to come in and provide dementia training. On 6/20/23 at 10:30AM, V1 Administrator stated, I understand that all residents have a right to privacy and to keeping their personal items. It is just so hard with R4. We would have to keep eyes on her at all times and while we are staffed per the guidelines, but the numbers don't take into account residents like (R4).

Jun 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure a resident's safe facility transport which res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure a resident's safe facility transport which resulted in a fall from the facility van wheelchair ramp. This failure affects one of three residents (R1) reviewed for falls on the sample list of seven. Findings include: R1's Profile Face Sheet dated 3/2/23 documents the following diagnoses: Degeneration of Nervous System Due to Alcohol, Neuralgia and Neuritis Unspecified, and Flaccid Hemiplegia affecting Left Nondominant Side. R1's Minimum Data Set (MDS) dated [DATE] does not document R1's cognitive assessment. R1's same MDS documents R1 requires supervision and set-up for transfers, locomotion on and off unit, physical staff assistance with ambulation, has limited range of motion in one lower extremity, is unable to stabilize without staff assistance while walking, and uses a wheelchair. R1's Cognitive assessment dated [DATE] documents R1's Brief Interview of Mental Status score as 15 out of a possible 15, indicating no cognitive impairment. The facility Fall Analysis Log dated April 2023 documents R1 fell on 4/7/23 at 9:00 am from the facility van. The same Fall Analysis Log documents the root cause of R1's 4/7/23 fall as w/c (wheelchair) flipped out of van. The same log documents: Intervention in place at the time of the fall Van/ Transport Safety Policy. The same fall log documents New Intervention Re-Edu (re-educate) staff. R1's A.I.M. (Assess, Intercommunicate, Manage) for Wellness progress note dated 4/7/23 documents R1 fell While out on transport. R1's Baseline Care Plan revised 4/7/23 documents: Fall with van transfer, re-ed (repeat education) transportation r/t (related/to) w/c (wheelchair) safety w (with)/transport. V3, Van Driver Mandatory Van Safety Demonstration In-Service dated on the back of the form 1/24/23, signed by V3 documents the following: Each (Corporation) Health Care Employee designated to drive our van at any point, must do the following driving demonstration in-service to ensure that they are able to drive and transport safely. The same safety demonstration, guides transportation employees to securely fasten and assist residents in wheelchairs into and out of the van. On 6/1/23 at 1:30 pm R1 stated the following: The facility transferred me to an appointment in the van (facility). We got to the (specific type) Clinic. The van driver unlatched the security floor straps that kept my wheelchair in place. I was facing forward, as my wheelchair started to roll backwards, down the slope in the van floor, towards the wheelchair ramp. Usually the van driver (later identified as V3) guides my wheelchair backwards and down the ramp, as she backs me out of the van. She (V3, Van Driver) usually has her hands on my wheelchair. That time she did not. That time, she (V3, Van Driver) was standing on the ground, at the foot of the ramp (located approximately seven feet behind the van per observation documented below). My (R1) wheelchair started rolling down the slope in the van floor. My wheelchair hit the top of the ramp and started rolling real fast. My wheelchair went off the right side of the ramp and flipped on its side. I was thrown onto the asphalt. I hit my head, right shoulder and back. The van driver did not call for an ambulance. The van driver turned my wheelchair upright and tried to lift me into it. She couldn't. I was hurting, and I instantly had a headache. I was able to lock the wheelchair brakes and climb into it (wheelchair) after several minutes of trying. My legs are semi-paralyzed. I had a spinal cord injury and surgery years ago. It was difficult but I managed to get in. I told them (unidentified) in the (specific type) Clinic what had happened. I got my (medication) treatment, which helps with my chronic pain and returned to the nursing home (facility). I told the nurse (unidentified) what had happened when I got back to the facility a couple hours later. On 6/1/23 at 2:10 pm V7, Licensed Practical Nurse (LPN) stated V7, LPN was the nurse on duty when R1 had the fall from the facility van, wheelchair ramp on 4/7/23. V7, LPN stated V7, LPN did R1's assessment upon R1's return to the facility. On 6/1/23 at 4:25 pm V3, Van Driver was standing at the back of the facility van. V3 stated she had taken R1 to the (specialty) clinic many times before 4/7/23. V3, Van Driver gave a demonstration of what happened when R1 fell off the van ramp 4/7/23. V3 went up into the van at the side of the van ramp and into the back area of the small, family sized van. V3 confirmed there was a 10-inch drop/slope in the van floor, leading out to the van's wheelchair ramp. The slope of the floor spanned from directly behind the two wheelchair floor anchors, extended approximately 18 inches to meet the van wheelchair ramp. V3 pulled the floor anchor safety belts out and displayed how the safety belts attach to the back of the wheelchair, at the top of the drop off on the van floor. V3 completed demonstration inside the van. V3 got out of the van and stood to the left of the wheelchair ramp. The van wheelchair ramp extended down, and out to the ground approximately seven feet. V3 stated This is about where I was standing (on the ground, at the middle of the van ramps left side) when (R1's) wheelchair started rolling back. I reached with one hand to stop the wheelchair as it picked up pace. I could not stop (R1) from falling off the right side of the ramp. He was moving too fast. I don't remember being given more education after the fall. I was just trained on van transport safety when I started driving residents to appointments about five months ago. I was educated on backing residents out of the van, with both hands on their wheelchair. I know that is what I am supposed to do. I should have been behind him (R1) the whole time. I asked (R1) if he wanted to go to the emergency room. He (R1) hit his head on the ground very hard and I thought he should go. I am not a nurse, but the fall was bad. He hit his back and shoulder on his backpack too. He said no, he didn't need to go to ER (emergency room). He (R1) just wanted to get into the (specialty) Clinic for his appointment. Together he and I tried to get him up from the parking lot and into his wheelchair. We tried several minutes. Finally, he was able to pull himself into the wheelchair without much help from me. He is a lot bigger than I am, and his legs don't work. I couldn't do much. V3, Van Driver also stated I called (V1, Administrator) right away. I told (V1, Administrator) what happened and (R1) wanted to go on into his appointment instead of the hospital. (V1, Administrator) said just bring him back to the facility after the appointment since (R1) refused to go to ER. That is what I did. (V1, Administrator) had me write a statement about everything that happened. I apologized to (R1) he again said he was ok.

Nov 2022 7 deficiencies

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 interview and record review the facility failed to offer the opportunity to formulate advanced directives in a timely m...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer the opportunity to formulate advanced directives in a timely manner to meet the resident choice and failed to accurately record resident choice for life sustaining measures in the medical record for two (R243 and R25) of two residents reviewed for advanced directives in a total sample list of 22. Findings include: 1) R243's undated face sheet documents a current admission date of 3/23/22. R243's Minimum Data Set, dated [DATE] documents R243 as cognitively intact. R243's physician order sheet dated November 2022 documents R243 as a full code. R243's Practitioner Order for Life-Sustaining Treatment Form (POLST) dated 10/28/22 documents, Do Not Attempt Resuscitation, Comfort Focused Treatment. 2) R25's undated face sheet documents an admission date of 9/22/22. R25's Minimum Data Set, dated [DATE] documents R25 as cognitively intact. R25's physician order sheet dated November 2022 documents code status as full code. R25's Practitioner Order for Life-Sustaining Treatment (POLST)form dated 11/9/22 documents, Do Not Attempt Resuscitation. R25's Power Of Attorney for Healthcare dated 2/3/21 documents quality of life is more important than quantity. On 11/16/22 at 9:00 AM V4 Social Services Director stated, The chart states that he is a Do Not Resuscitate. On 11/16/22 9:30AM V4 SSD stated, (R25) was a DNR until the form comes back from the doctor. On 11/16/22 at 10:10AM R25 stated that he wanted to be a do not resuscitate. On 11/17/22 at 11:50AM V2 Director of Nursing stated, They should be offered advanced directives on admission and they need to match. The facility provided an Advance Directive Policy reviewed date 9/27/17 which documents, Policy: The Patient Self Determination Act states that individuals have the right to make their own decisions and to formulate advanced directives to serve as decisions when the individual is incapacitated. It is the policy of this facility to honor resident's wishes as expressed in advanced directives regarding medically indicated treatments whenever possible. This facility shall take all steps necessary to comply with state and federal legislation relating to advanced directives. Procedure: At the time of admission each resident, (Power of Attorney), guardian or responsible party shall be given written information regarding resident rights and advanced directive. At this time, each resident/responsible party will be requested to furnish this facility with copies of all existing advance directives.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to notify R22 of discontinuation of Medicare services. This failure affects one resident (R22) of three reviewed for beneficiary notifications...

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Based on interview and record review, the facility failed to notify R22 of discontinuation of Medicare services. This failure affects one resident (R22) of three reviewed for beneficiary notifications in the sample list of 22. Findings include: On 11/16/2022 at 1:12PM, V11 (Business Office Manager) reported the facility did not issue R22 the required notifications of discontinuation of Medicare benefits following R22's discharge from therapy services on 10/26/2022. V11 reported R22 continued to live in the facility after 10/26/2022. R22's medical record (undated) did not document R22 received the Notice of Medicare Non-Coverage and the Advanced Beneficiary Notice of Non -Coverage following R22's discharge from Medicare.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0642 (Tag F0642)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to obtain and document required signatures to certify the accuracy of resident Minimum Data Set (MDS) assessments. This failure affects four r...

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Based on interview and record review, the facility failed to obtain and document required signatures to certify the accuracy of resident Minimum Data Set (MDS) assessments. This failure affects four residents (R15, R19, R20, R21) of five reviewed for MDS assessments in the sample list of 22. Findings include: R15's Minimum Data Sets (5/10/2022, 9/16/2022) fail to document assessor signatures for all completed sections of the assessments. R19's Minimum Data Sets (7/27/2022, 9/15/2022) fail to document assessor signatures for all completed sections of the assessments. R20's Minimum Data Set (8/8/2022) fails to document assessor signatures for all completed sections of the assessment. R21's Minimum Data Set (8/4/2022) fails to document assessor signatures for all completed sections of the assessment. On 11/16/2022 at 3:30PM, V1 (Administrator) reported the facility currently does not have a resident assessment coordinator working permanently in the facility, but only a person who travels between facilities. V1 reported the facility MDS assessments very well may have been late.

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 interview and record review the facility failed to justify the use of psychotropic medications by failing to track behaviors and complete assessments for the use of psychotropic medications i...

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Based on interview and record review the facility failed to justify the use of psychotropic medications by failing to track behaviors and complete assessments for the use of psychotropic medications in three (R13, R16 and R26) of five residents reviewed for psychotropic medication administration from total sample list of 22. Findings include: 1) R13's physician's order sheet dated April 2022 documents Risperidone (antipsychotic) 0.5 milligrams and Risperidone 0.25 milligrams to be given before bed, by mouth, with an order date of 7/26/21. The medical record did not contain an initial assessment or quarterly assessments for Risperidone use from 7/26/21 until 11/8/22. 2) R16s physician order sheet dated July 2022 documents Ziprasidone Hydrochloride (antipsychotic), 20 milligrams to be taken every other day by mouth with an order date of February 20, 2021. The medical record did not contain an initial assessment for Ziprasidone Hydrochloride for R16. The medical record did not contain quarterly assessments from February 20, 2021 until June 5, 2022. On 11/17/22 at 12:00PM, V2 Director of Nursing said that she was unaware of the required documents for psychotropic medication monitoring. 3. R26's Psychotropic Medication Quarterly evaluation dated 10/4/22 documents R25 is receiving 50 milligrams of Trazodone every day for Insomnia. This evaluation does not document which targeted behavior R26 is having or how many episodes of insomnia R26 has had. R26's Behavior tracking sheet nor medical record includes tracking for episodes of Insomnia. On 11/17/22 at 10:30 AM, V3 Resident Care Coordinator stated there is not behavior tracking for R26's episodes of Insomnia. V3 stated she completes the psychotropic assessments and she did not fill in the targeted behavior section on the assessment because the facility is not tracking R26's episodes of insomnia. The facility's Psychotropic Medication Policy with a revision date of 11/28/17 documents, 8. The Behavioral Tracking sheet of the facility will be implemented to ensure behaviors are being monitored. This policy also documents, 18. Any resident receiving psychotropic medication will have the Psychotropic Medication Assessment done at a minimum of every quarter.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 41 reside...

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Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 41 residents residing in the facility. Findings include: On 11/14/2022 at 11:09AM, V5 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V5 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training. Throughout the duration of the survey, the facility failed to safely thaw food, failed to store food at safe temperatures, failed to effectively sanitize dishes, failed to properly date and label food to prevent the potential for foodborne illness, and failed to maintain sanitary kitchen equipment. The Facility Assessment (7/2022) documents a full-time clinically qualified nutrition professional is needed to provide competent support and care for the facility's resident population every day and during emergencies. The Resident Census and Conditions of Residents report (11/14/2022) documents 41 residents reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to safely thaw food, failed to store food at safe temperatures, failed to effectively sanitize dishes, failed to properly date a...

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Based on observation, interview, and record review, the facility failed to safely thaw food, failed to store food at safe temperatures, failed to effectively sanitize dishes, failed to properly date and label food to prevent the potential for foodborne illness, and failed to maintain sanitary kitchen equipment. These failures have the potential to affect all 41 residents in the facility. Findings include: 1. On 11/14/2022 at 11:09AM, the kitchen pantry room reach-in-cooler interior temperature measured 59 degrees Fahrenheit by the facility thermometer located inside of the cooler and 60 degrees Fahrenheit by Illinois Department of Public Health thermometer. Two five pound chubs of raw hamburger and one six pound chub of pork sausage were located on the bottom shelf of the cooler and all three packages of raw meat were cold to the touch and partially frozen. A temperature log sheet (November 2022) was located on the door of the cooler and documented daily cooler temperatures ranging from 38-56 degrees Fahrenheit. Notably, the log sheet documented a column labeled Corrective Action Needed/Taken but no entries beneath the column heading were present. On 11/15/2022 at 11:11AM the sausage from above was still present and measured 57 degrees Fahrenheit by Illinois Department of Public Health thermometer. The air temperature of the cooler measured 49 degrees Fahrenheit by the same thermometer at 11:12AM. V6 (Cook) was present and reported the pork sausage would be used in the morning of 11/16/2022. V5 (Dietary Manager) was also present and reported the cooler containing the sausage goes cool then gets a little warm and the pork sausage will be used for breakfast on 11/16/2022. V5 reported the temperature of the cooler on 11/14/2022 at 7:30PM was 48 degrees Fahrenheit. V5 was unaware of the current sausage temperature of 57 degrees Fahrenheit. V5 reported the kitchen has other coolers available to thaw and store meat. On 11/15/2022 at 3:15PM, V5 (Dietary Manager) was asked if the cooler temperatures recorded by staff on the log sheet concerned V5 and V5 stated Yeah, (staff) should have told me sooner. V5 reported not thinking the food temperatures were improper until above 70 degrees Fahrenheit. V5 reported meat could be safely stored in a cooler at 70 degrees Fahrenheit. 2. On 11/14/2022 at 11:30AM the chemical sanitizer container supplying the mechanical dishwasher was empty. On 11/15/2022 at 11:14AM V7 (Cook) was operating the facility dishwasher. V7 produced a chemical test strip to demonstrate the dishwasher sanitizer concentration. The test strip measure zero sanitizer present in the wash water during the sanitizing portion of the wash cycle. On 11/16/2022 at 1:36PM, the mechanical dishwasher in the kitchen dish room was operating and the sanitizer portion of the wash cycle was tested with an Illinois Department of Public Health chemical test strip and measured 10 parts per million chlorine concentration. The dishwasher manufacturer nameplate documented 50 parts per million as the minimum chlorine concentration required to effectively sanitize dishes. V8 (Cook) was present and observed the test strip and associated color chart to determine the current chemical concentration of the operating dishwasher. V8 stated yes (the current concentration of chlorine sanitizer was 10 parts per million). V8 reported the kitchen was out of sanitizer solution, so staff added regular bleach to the empty jug of sanitizer supplying the dishwasher. On 11/17/2022 at 1:56PM, V5 (Dietary Manager) stated I think the regular bleach used above in place of the normal sanitizer solution was, in fact, food grade and approved for food service use. 3. On 11/14/2022 at 11:15AM the main kitchen reach-in-cooler contained an opened and half-full one-pound package of turkey bologna. The package was not labeled with the date of opening or the use-by date. On 11/15/2022 at 11:18AM turkey deli meat from above was still present in the cooler and remained undated. On 11/15/2022 at 11:38AM, V6 (Cook) reported only one resident eats the the turkey deli meat about twice a week, with the package exceeding the maximum time limit of seven days once opened and held cold to prevent the potential growth of pathogenic microorganisms. 4. The kitchen table-mounted can opener was soiled with accumulations of metal shavings throughout the duration of the survey. The Resident Census and Conditions of Residents report (11/14/2022) documents 41 residents reside in the facility.

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 ensure the facility's Infection Preventionist was certified. This failure has the potential to affect all 41 residents residing in the facil...

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Based on interview and record review the facility failed to ensure the facility's Infection Preventionist was certified. This failure has the potential to affect all 41 residents residing in the facility. Findings include: On 11/15/22 at 1:44 PM, V3 Infection Preventionist/Resident Care Coordinator stated she just started as the Infection Preventionist a couple months ago. Stated she is currently doing the Infection Preventionist training but has not completed it. The facility's Census and Condition report dated 11/14/22 signed by V1 Administrator documents there are 41 residents residing in the facility.

CASEY REHAB AND NURSING

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