HEARTLAND NURSING & REHAB
For profit - Corporation
81 Beds
WLC MANAGEMENT FIRM
Data: November 2025
Trust Grade
30/100
#540 of 665 in IL
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Heartland Nursing & Rehab has received a Trust Grade of F, which indicates significant concerns and places it in the bottom tier of facilities. It ranks #540 out of 665 in Illinois, meaning it is in the bottom half statewide, and #3 out of 3 in Clark County, suggesting that local options are limited. While the facility is showing a trend of improvement, reducing issues from 17 in 2024 to 2 in 2025, it still has a concerning 100% staff turnover, significantly higher than the state average of 46%. On the positive side, there have been no fines reported, indicating compliance with some regulations, and the RN coverage is average, although there are potential risks as the nursing staff has not maintained adequate infection logs or quality assurance measures. Specific incidents include a lack of a qualified food services director, improper kitchen utensil storage risking food contamination, and insufficient tracking of resident infections, highlighting both operational weaknesses and the need for better oversight.
- Trust Score
- F
- In Illinois
- #540/665
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 100% turnover. Very high, 52 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Illinois facilities.
- Skilled Nurses ✓ Good
- Each resident gets 54 minutes of Registered Nurse (RN) attention daily — more than average for Illinois. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
30/100
Bottom 19%
No red flags
17 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 2 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 100%
53pts above Illinois avg (47%)
Frequent staff changes - ask about care continuity
Chain: WLC MANAGEMENT FIRM
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is very high (100%)
52 points above Illinois average of 48%
The Ugly 40 deficiencies on record
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
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 a resident's right to be free from 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 a resident's right to be free from physical abuse by another resident. This failure affects one resident (R3) out of three reviewed for abuse on a sample list of eight. Findings include: R2's Medical Diagnoses list dated 8/20/25 documents R2 was diagnosed with Autism. Dementia. Anxiety, Insomnia, and Recurrent Depression. R2's Census Details of the same date document R2 had resided at the facility since 10/5/21. R3's Medical Diagnoses List dated 8/20/25 documents R3 was diagnosed with Dementia and Depression. R2's Census detail of the same date documents R3 had resided at the facility since 1/13/22. R2's Minimum Data Set, dated [DATE] documents R2 exhibits verbal behaviors such as screaming, threatening, and cursing, and physical behaviors such as hitting, kicking, pushing, grabbing, and scratching, directed at others which disrupt the living environment. This same Minimum Data Set documents R2 is independent in dressing and walking up to 150 feet. This Minimum Data Set documents R2's behaviors had worsened since the prior assessment dated [DATE]. R2's Minimum Data Set, dated [DATE] documents R2 exhibits physical behaviors directed at others, and other behavior such as hitting or scratching self, pacing, and rummaging, not directed at others. R2's Minimum Data Set, dated [DATE] documents R2 exhibited verbal behavior directed at others. R3's Minimum Data Set, dated [DATE] documents R3 had no exhibited behaviors and required staff supervision or assistance for all aspects of daily care. R2's Nursing Progress Note dated 6/24/25 documents R2 was up all night yelling, screaming, banging on room doors and exit doors, throwing a trash can, wandering in and out of other resident's rooms, and could not be redirected by staff. R2's Nursing Progress Note dated 7/7/25 documents R2 was in the hallway banging on the exit door, screaming dark outside repeatedly, and could not be redirected by staff. R2's Nursing Progress Note dated 8/7/25 documents after an allegation of abuse, (V2 Director of Nursing) watched a video recording of the incident to see R2 kicking another resident (R3) in the right lower leg repeatedly, an incident which prompted staff to send R2 to the emergency room for an evaluation. R3's Nursing Progress Note dated 8/7/25 documents R3 was in the dining room and without provocation, was kicked by R2 causing a small skin tear on R3's right shin. This note documents another resident (R4) had attempted to intervene in the incident which alerted staff to the incident who then intervened. The facility's List of Incidents dated for 6/26/25 through 8/20/25 documents an incident on 8/7/25 with R2 as the initiator of a resident-to-resident physical aggression and R3 being the recipient. The facility's Initial Report to IDPH dated 8/7/25 documents R2 and R3 involved in a resident-to-resident altercation. The facility's final report dated 8/13/25 documents R4 as the sole witness of the incident in the dining room, and video evidence of R2 kicking R3 in the lower leg. On 8/20/25 at 1:50 PM, R4 stated he had witnessed R3 seated in a wheelchair at a table in the dining room minding her own business, then R2 came up and kicked R3 in the leg, then R2 kicked R3 again and was laughing about it. R4 further stated R3 already had sores on her legs and R3's leg started bleeding again when R2 kicked R3. R4 then stated R2 kicked R3 again and he got up and said stop kicking her and that was when staff came and took R2 out of the dining room. R4 continued to state that there was not a lot of staff supervision in the dining room at the time because staff were bringing residents from their rooms to the dining room and then returned back to pick up other residents to bring to the dining room. R4 then stated R2 was back in the dining room the following day (8/8/25) and the staff supervision had not changed. R4 concluded by stating he had witnessed R2 walk up behind a resident (R6) about two and a half or three months ago and smack R6 in the back of the head when R6 wasn't doing anything, but there was no staff around at that time. R4's Minimum Data Set, dated [DATE] documents R4 received a score of 15 out of a possible 15 during a Brief Interview for Mental Status, indicating R4 is cognitively intact. On 8/20/25 at 2 PM, V2, Director of Nursing, stated she had not seen the actual event but did watch the video from the dining room and did see R2 standing by the window, then walk over to R3 who was several tables away and kick R3. V2 stated she had known R2 and her family for about 40 years and thought R3 had some resemblance to R2's mother who R2 used to act violently towards. V2 further stated R2 was on the Autism scale and often acted like whatever she wants, she wants right now, like a small child. V2 stated she had not heard any kind of report about R2 smacking R6 in the head. On 8/20/25 at 2:15 PM, V3, Minimum Data Set Coordinator, stated she had watched the kicking incident between R2 and R3 on the camera. V3 stated she had known R2 and her family for a long time. V3 stated R2 used to be violent with her mother and had talked with R2's sister (V10) who had questioned if R2 was having some regression to an earlier age. V3 stated R2's behavior had been getting worse not just with the Autism but also with her Dementia. V2 stated she had not heard anything about any event between R2 and R6. On 8/20/25 at 2:20 PM, V1, Administrator, stated he had reported the incident initially on 8/7/25 and finally on 8/13/25. V1 stated he had watched the kicking incident between R2 and R3 on video and saw R2 walk up to R3 and kick R3. V1 made a kicking motion with his leg as he made this statement. V1 confirmed R4 was alert and oriented and accurate in his statements. V1 stated he had not heard any reports about R2 smacking R6 on the back of the head. On 8/20/25 at 2:20 PM, there was a purple quart-sized drinking mug on the windowsill of the business office with a broken raised edge in the drinking rim. There was a note affixed to the drinking mug which documented R2 had thrown the cup at a staff member (V4, Certified Nursing Assistant) and broke the mug.
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 implement fall and accident prevention interventions ...
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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 fall and accident prevention interventions according to a resident's care plan and physician orders. This failure affects one resident (R3) out of three reviewed for falls on the sample list of eight. Findings include: R3's Face Sheet dated 8/20/25 documents R3 had a legally established power of attorney. R3's Medical Diagnoses list of the same date includes Dementia, Major Depression, Hypertension, and Osteoarthritis of the Right Knee. R3's Census Detail of the same date documents R3 was admitted to the facility 1/13/22. R3's Physician order Sheet dated 8/22/25 documents R3 has physician orders to include non-skid strips on the floor in front of her recliner initiated 7/1/24, and to wear (cloth protective leggings) initiated 5/31/25. R3's Minimum Data Set, dated [DATE] documents R3 requires staff supervision and assistance for all aspects of daily living including hygiene, dressing, bathing, transfers, and transitioning between sitting and lying positions, and transitioning from sitting to standing. R3's Care Plan for fall prevention dated from 7/14/24 documents R3 is a fall risk. R3's fall prevention interventions include the area around R3's recliner needs to be kept free of hazards, and (non-slip material) is to be kept in R3's wheelchair seat, both dated as initiated 7/14/24. This care plan includes additional fall prevention interventions including for staff to keep R3's nurse call device in reach, initiated 10/11/24. This same care plan documents R3 is unaware of her safety needs, has Dementia, and often bumps into furniture which results in impaired skin integrity. The staff intervention for this accident problem area was for staff to place (protective leggings) on both of R3's legs for added protection, dated as initiated 5/31/25. There was a second intervention for R3 to have these protective cloth leggings and sleeves on both legs and both arms, dated as initiated 6/2/25. R3's Nursing Progress Note dated 8/20/25 at 8:15 PM documents R3 experienced an unwitnessed fall from bed with multiple bruises, abrasions, and was complaining of right knee pain. A second note on this same date at 8:55 PM documents R3 had swelling of the right knee and above the right eyebrow and was sent to the emergency department for an evaluation. R3's Nursing Progress Notes dated 8/21/25 at 1:09 AM documents facility nursing staff received an update from the emergency department personnel of R3's evaluation results indicating R3 had no fractures, no internal head bleeding, and had surgical glue applied to her right forehead and right knee. A second note on this date at 4:04 AM documented R3's return to the facility and R3 was able to tell nursing staff she had been to the hospital and saw her son but he had to leave because it was getting late, was responding appropriately to questions, told the nurse she had fallen and what injuries she experienced, the nurse noted additional bruising on R3's right elbow in addition to documenting the surgical glue on R3's right eyebrow and right knee. This note further documents R3 stated she was ready to go to bed and might sleep in. On 8/22/25 at 10:20 AM, R3 was seated in her recliner in her own room approximately four feet away from her bed. R3's nurse call light device was hanging from the light fixture on the wall above the left side of R3's bed approximately seven feet away from R3 and on the opposite side of the bed from where R3 was seated. There were no non-skid strips on the floor in front of R3's recliner. R3 was not wearing the protective leggings, nor the cloth protective arm sleeves. On 8/22/25 at 10:35 AM, V3, Minimum Data Set Coordinator, stated she was the nurse on duty and was taking care of R3. V3 stated R3 should have the non-skid material in her wheelchair seat and she personally tries to go around and make sure every resident has the material in their wheelchair seat because the residents will slip out of the wheelchair. V3 observed R3's wheelchair and confirmed the non-slip material was not in the seat. Likewise, V3 affirmed R3's nurse call device was hanging on the light fixture on the opposite side of the bed and was out of R3's reach. V3 stated R3 could hold the call light in her hand but would not realize what the device was to be used for, and R3 might accidentally push the button. V3 noted and confirmed there was not any non-skid strip on the floor in front of R3's recliner and stated that R3 had not attempted to stand up in months. On 8/22/25 at 11::25 AM, V2, Director of Nursing, stated the skin tear observed on R3's right lower leg was not from a resident-to-resident incident from 8/7/25 but rather was from when R3 fell out of bed on 8/20/25. V2 stated R3 often has wounds on both legs due to bumping into things when mobile in her wheelchair because she isn't aware of her own safety needs. V2 confirmed R3's fall on 8/20/25 was unwitnessed. V2 further stated she had personally gone around the facility to check for the non-skid strips for each resident who used them because there had been several residents who changed rooms and R3 was one of those residents. V2 nodded in confirmation that R3 was supposed to be wearing the protective leggings and protective sleeves.
Dec 2024
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to protect resident's dignity by failing to place a urinary catheter collection bag inside a covering or pouch. This failure aff...
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Based on observation, interview, and record review, the facility failed to protect resident's dignity by failing to place a urinary catheter collection bag inside a covering or pouch. This failure affects two residents (R22 and R33) out of two reviewed for urinary catheters on the sample list of 26.
Findings include:
On 12/10/24 at 10:50 AM, R33's urinary catheter collection bag was positioned under his wheelchair without any covering, exposing approximately 400 cubic centimeters (cc's) of yellow colored urine inside the collection bag.
On 12/10/24 at 10:55 AM, V2, Director of Nursing, shook her head no to indicate she did not like residents' catheter collection bags to be exposed and without a dignity pouch or bag.
On 12/10/24 at 1:29 PM, V7, Private Caregiver for R22, stated it is about 50/50 whether the staff keep R22's urinary catheter collection bag covered. V7 stated there have been times when R22's family takes R22 out of the facility and she has had to run around the facility to look for a covering bag.
On 12/10/24 at 1:50 PM, V1, Administrator, stated it is his expectation that residents would have their urinary catheter collection bags covered for dignity.
The facility policy Quality of Life - Dignity dated 2001 documents each resident shall be cared for in a manner that promotes dignity, standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents by keeping urinary catheter bags covered.
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 observation, interview and record review the facility failed to request a Preadmission Screening and Resident Review PA...
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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 request a Preadmission Screening and Resident Review PASARR II Screening for (R26) who has a diagnosis of Schizoaffective Disorder and is receiving Antipsychotic medication. R26 is one of one resident reviewed for PASARR screening on a sample list of 26.
Findings Include:
R26's Medical Diagnosis sheet dated 12/13/24 lists (R26's) Primary Medical Diagnosis for admission on [DATE] as Interstitial Pulmonary Disease. Included with the list of diagnoses is Schizoaffective Disorder with date of 9/2/2022. The Medical Diagnosis Sheet states under the column Classification for the Schizoaffective Disorder as During Stay.
R26's PASARR (Preadmission Screening and Resident Review) Screen ,which is required for admission to the nursing facility, was completed on 8/8/2021 and documents (R26) did not need to be screened for a Level II screening. This PASARR screening was done when (R26) was a resident of a different nursing facility.
On 12/12/24 at 12:50 PM (R26) was sitting at the dining room table talking and showing items to an imaginary person. (R26) stated Is this not beautiful, I just love it. ( R26) then responded Thank you I am glad you like it. (R26) continued to talk to the open area.
R26's Physician's Order Sheet dated December 2024 documents (R26) takes the following medication for the diagnosis of Schizoaffective Disorder: Quetiapine Sulfate (Seroquel) (antipsychotic) tablets 25 mg (milligram) 1 tablet orally every day. The start date for this medication was 7/1/24.
On 12/13/24 at 11:00 AM V3, [NAME] President Clinical Operations stated No I can not find a PASARR II for (R26). I guess the facility did not request one.
R26's Care Plan dated 12/1/24 documents (R26) takes Psychotropic medications: Seroquel, Prozac and Trazodone to help (R26) with her depression and symptoms of Schizoaffective disease.
On 12/13/24 at 11:00 AM V3, [NAME] President Clinical Operations confirmed the facility did not have a policy for admissions regarding PASARR screenings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
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 document a discharge summary that includes a recapitulation of stay,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document a discharge summary that includes a recapitulation of stay, a final summary of the resident's status, and a post discharge plan of care. This failure has the potential to affect one of one resident (R49) reviewed for discharge on the sample list of 26.
Findings Include:
The facility's Discharge Summary and Plan Policy Statement dated 2/17/24 documents when a resident's discharge is anticipated, a discharge summary and medication plan will be developed to assist the resident to adjust to his/her new living environment. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's course of illness, treatment, or therapy since entering the facility, current laboratory, radiology, consultation, and diagnostic test results, physical and mental functional status, and the resident's ability to perform activities of daily living, among other things.
R49's Medical Diagnoses dated September 2024 documents R49 is diagnosed with Acute Kidney Failure, Unsteadiness on feet, Reduced Mobility, Cognitive Communication Deficit, Depression, and Heart Failure.
R49's undated Census Report documents R49 was admitted to the facility on [DATE] and discharged on 9/12/24.
R49's electronic medical record does not include documentation of a recapitulation of stay, a final summary of R49's status, and a post discharge plan of care.
On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed there was no discharge summary that includes a recapitulation of stay, a final summary of the resident's status, and a post discharge plan of care, including discharge instructions for R49.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide complete antibiotic doses for a urinary tract infection for one resident (R42) of one resident reviewed for infections on the sampl...
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Based on interview and record review, the facility failed to provide complete antibiotic doses for a urinary tract infection for one resident (R42) of one resident reviewed for infections on the sample list of 26.
Findings Include:
R42's Nursing Notes dated 11/9/24 at 2:13 PM, document per urology orders replaced indwelling catheter, also dip-tested urine to reveal abnormal urine sample, sending to lab for urine analysis (UA) and culture and sensitivity.
R42's Nursing Notes dated 11/12/24 at 2:10 PM, document V22 Medical Director aware of UA results, new order received for Bactrim DS everyday for five days.
R42's Medication Administration Record (MAR) dated November 2024, documents Bactrim DS tablet 800-160 milligrams (Sulfamethoxazole-Trimethoprim) one tablet by mouth twice a day for urinary tract infection for five days, with a start date of 11/12/24 at 8:00 AM. This same MAR has no indication that this antibiotic was given on 11/16/24 as the 8:00 AM dose and the 5:00 PM dose are not documented as given.
R42's Nursing Notes dated 12/8/24 at 3:12 PM, document R42's family member reports that R42 is complaining of abdominal pain and pressure in bladder and would like to have a UA done, and that V22 was faxed. R42's Nursing Note dated 12/9/24 at 10:09 PM, documents new order received to obtain a UA and culture and sensitivity if indicated.
R42's Urinalysis results dated collected 12/11/24 documents positive results for (infection) urine.
R42's Nursing Notes dated 12/12/24 at 7:43 AM, document a new order for Augmentin oral tablet 500-125 milligrams give one tablet by mouth two times a day for infection related to extended spectrum beta lactamase (ESBL) resistance.
On 12/12/24 at 10:10 AM, V2 Director of Nursing stated the orders were not written or transcribed correctly and the antibiotic was not completed on 11/16/24 and should have been. V2 also stated without finishing an antibiotic it could cause the infection not to be treated properly. V2 stated V2 is aware R42 has another urinary tract infection now and is being treated for it.
The facility's Administering Medications Policy dated Reviewed 2/17/24, documents medications are administered in accordance with the prescribers orders. This policy also documents the individual administering the medication initials the resident's MAR after giving each medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to accurately assess for smoking safety and failed to prov...
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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 accurately assess for smoking safety and failed to provide supervision for a potential smoking accident for one of one resident (R6) assessed for smoking safety on the sample list of 26.
Findings Include:
R6's Care Plan dated 1/31/2023 documents the following diagnoses: Presence of Right Artificial Shoulder Joint, Dependence on Renal Dialysis and Tobacco use. The same care plan for R6 documents a goal of (R6) will maintain safety while following smoking protocol. This was dated 7/9/24. An intervention for the goal was R6 is supervised while smoking. Date initiated 07/09/24. Another intervention for the goal was smoking materials are kept secured by staff. Date initiated 07/09/24.
R6's Minimum Data Set (MDS) assessment dated [DATE] which was a re-admission assessment documents 15 for (R6's) BIMS ( Brief Mental Status) score. R6 is cognitively intact.
The facility's assessment titled Smoking Assessment for (R6) on the following dates 8/2/24, 10/17/24 and 11/6/24 all document the following: Smoking Care Plan, The resident is a smoker, Goal: Resident will maintain safety while following smoking protocol. Intervention: Resident is supervised while smoking and Smoking materials are kept secured by staff.
On 12/12/24 at 11:10 AM (R6) was in her room and stated I keep my smoking materials in here, the nurses don't have them which is my cigarettes and lighter. (R6) then took out her cigarettes and lighter.
On 12/12/24 at 12:30 PM (R6) was sitting in the smoking area by herself smoking a cigarette. (R6) stated I thought I would grab a cigarette before I went to my doctor's appointment. I smoke outside here by myself. The staff does not come with me. If I am real nervous I will come outside at night and smoke a cigarette. I will let the nurse know I am going outside to smoke. I have never had staff sit with me while I smoke.
On 12/12/24 at 3:00 PM V4 Minimum Data Set/Care Plan Coordinator stated Yes, (R6) is capable of smoking by herself we do not go with her to smoke and she keeps her smoking items with her.
On 12/13/24 at 2:45 PM V2 Director of Nurses confirmed R6's smoking assessment and care plan need to be accurate and correlate with what R6 is actually doing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to notify the resident's physician of significant weight loss and failed to develop a plan of care to adequately address a resident's significa...
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Based on interview and record review the facility failed to notify the resident's physician of significant weight loss and failed to develop a plan of care to adequately address a resident's significant risk for weight loss. These failures affected one of one resident (R350) reviewed for nutrition on the sample list of 26.
Findings Include:
The facility's Weight Assessment and Intervention policy dated September 2008 documents the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents. Any change of 5% or more nursing will notify the Dietician and Primary Care Physician. Greater than 5% loss within one month will be considered severe weight loss.
R350's Medical Diagnoses list dated December 2024 documents R350 is diagnosed with Dysphagia and Gastrostomy Status.
R350's Physician Order Sheet (POS) dated December 2024 documents orders for R350 to be NPO (Nothing by Mouth) and for Enteral Feed, four times a day related to Severe Protein-Calorie Malnutrition. R350 is to be weighed weekly for four weeks.
R350's Weight record documented an admission weight on 11/27/24 as 174 pounds. On 12/1/24 R350's weight was 170 pounds. On 12/10/24 R350's weight was 161.4 pounds. This is a documented severe weight loss of 7.24%.
On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed R350 has had significant weight loss in the two weeks since her admission. V2 confirmed the facility had not yet notified V22 Physician of R350's weight loss and had not implemented any new interventions. V2 confirmed R350 was administering her own enteral feeding. V2 confirmed R350 admitted to the facility at severe risk for weight loss due to her NPO status, Gastrostomy status, recent history of cancer, recent chemotherapy, recent radiation, severe protein malnutrition, recent hospitalization, recent infection, throat pain, dysphagia, and recent 30 pound weight loss prior to admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to monitor and obtain a physician order regarding Gastrostomy site monitoring, dressing changes and self administration of medication via Gastr...
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Based on interview and record review the facility failed to monitor and obtain a physician order regarding Gastrostomy site monitoring, dressing changes and self administration of medication via Gastrostomy tube. These failures have the potential to affect one of one resident (R350) reviewed for Gastrostomy Tube on the sample list of 26.
Findings Include:
R350's Medical Diagnoses list dated December 2024 documents R350 is diagnosed with Dysphagia and Gastrostomy Status.
R350's Physician Order Sheet (POS) dated December 2024 documents orders for R350 to be NPO (Nothing by Mouth) and for Enteral Feed, four times a day related to Severe Protein-Calorie Malnutrition.
On 12/10/24 at 11:32 AM R350 stated she administers her own feedings and medications through her gastrostomy tube.
On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed R350 administers her own feedings and medications via her gastrostomy tube. V2 confirmed there were no orders for self administration of medication, gastrostomy site maintenance/dressings or monitoring by staff, and no documentation that nursing staff had been monitoring R350's gastrostomy site for abnormal signs or symptoms.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to act on grievances from residents/family promptly, explain to residents how to file a grievance, inform residents where the sur...
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Based on observation, interview and record review, the facility failed to act on grievances from residents/family promptly, explain to residents how to file a grievance, inform residents where the survey book is located, and address lack of meal substitutes offered at mealtimes and not offering snacks at bedtime. This failure affects four of four residents (R3, R13, R21 and R25) reviewed for grievances in the sample list of 26.
Findings include:
On 12/11/24 at 10:00 AM, R3, R13, R21, and R25, all stated they can complain but that's as far as it goes. The residents stated staff say they will look into their concerns but the residents can not tell anything has been done. The residents stated they do not know about filling out a grievance form and they do not fill out grievances. The residents stated V9 Activity Director takes the complaints but then after that they do not hear anything more about it. The residents stated staff do not pass out snacks at bedtime and when asked about it they are only offered peanut butter and jelly (PBJ). The residents stated there is no anytime menu that they can see. The residents stated staff offer PBJ, grilled cheese, and cereal in the morning. The residents stated they have told V9 how bad the food is but nothing has changed. The residents stated meals are usually late and cold and breakfast is supposed to come at 7:00 AM and does not, that 12:00 PM lunch is late, and 5:00 PM supper is late. The residents stated they can not get hamburgers or hot dogs, and the potatoes are not done, and the fries are always cold and not done. The residents stated they have no idea where the survey book is located.
On 12/12/24 at 11:13 AM V9 stated V9 does not write down the concerns of residents on the sheet for the council meetings. V9 stated V9 had V1 Administrator and V2 Director of Nursing come to resident council meetings, but does not document resident concerns or document speaking with the manager for the concern area or document the outcome.
On 12/12/24 at 11:16 AM, V5 Dietary Manager, stated they have an always available menu that was posted but not now. V5 stated resident dislikes are put in a dining log and appear on meal tickets. V5 stated if residents don't like something we offer a second choice or always available menu. V5 stated at lunch today they have an alternative that they can choose from that is left over from the day before. V5 stated if residents don't like that they can choose off the always available menu. V5 stated this has been a consistent issue and V5 has only been here a few weeks so a couple of cooks have been choosing to offer a grilled cheese and PBJ only instead of using the always available menu. V5 stated these are issues they are fixing as well: cold food, food not tasting good, and late meals. V5 stated since V5 has been here they have been keeping temperature logs and they are better and V5 is re-tempting food herself. V5 stated serving times have been better but breakfast was late because there was no staff to take trays to the residents. V5 stated snacks at night were not happening so she stays to make sure snacks are available. V5 stated the snack issue was just brought to her attention maybe three days ago by V6 Regional Dietary.
On 12/12/24 at 1:13 PM, with difficulty, the survey book was found by the front door in the corner with the name of the binder covered up by decor, not readily visible. This survey book has the surveys in it with survey dates of only 2022, no other years present
On 12/12/24 at 1:20 PM V1 was shown where the survey book was located, Christmas decor blocked the view of the survey book entirely. V1 verified that the survey book surveys were not up to date with only 2022 surveys being present in the survey book.
The facility's undated Grievance Policy documents the residents have the right to file grievances and concerns either written or verbally. A staff member may file a grievance on behalf of a resident. Grievances should be directed to the Administrator (Grievance Official) of the facility. The Administrator will immediately begin to address the grievance upon receipt, immediately discuss the issue with the individual and advise of an appropriate time frame to address the issue.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R14's undated Diagnoses list documents R14's diagnoses as Obstructive Sleep Apnea, Nasal Congestion, and Insomnia.
R14's POS...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R14's undated Diagnoses list documents R14's diagnoses as Obstructive Sleep Apnea, Nasal Congestion, and Insomnia.
R14's POS dated 12/13/24, documents oxygen at 3 liters per nasal cannula as needed for shortness of breath.
On 12/10/24 at 10:20 AM, R14's oxygen tubing and water bottle were both dated 11/25/24. R14 stated he uses oxygen every night.
3. On 12/10/24 at 10:10 AM, R4 was seated in an electric wheelchair in the North Hall wearing and utilizing oxygen from a portable tank mounted on the wheelchair through a nasal cannula tubing. R4's nasal cannula tubing did not have a date on it to indicate when it was last changed.
On 12/10/24 at 10:12 AM in R4's room there was a room air concentrator with a humidifier bottle with a date written on the bottle of 12/1/24 to indicate the extension tubing was last changed on this date. There was a green plastic extension tubing connected to the humidifier bottle and the extension tubing had a piece of white tape with a date written on the tape of 11/17/24. There was a nasal cannula tubing connected to the green extension tubing with a piece of white tape on the cannula tubing of 11/17/24. There was a nasal cannula tubing on the seat of R4's recliner which was likewise dated 11/17/24.
On 12/10/24 at 10:12 AM, R4 stated he had requested the nasal cannula and extension tubing be changed once per month instead of the once per week routine the nurses had been conducting.
R4's Physician Order Sheet dated 12/11/24 documents a physician order for R4's oxygen tubing, humidifier bottle, and plastic holding bag to be changed weekly on Sunday nights.
R4's historical Physician Order Sheets dating back through August 2024 document R4 began continuous oxygen therapy on 8/5/24. R4's Nursing Data Collection assessment dated [DATE] documents R4 had no oxygen use.
R4 Nursing Progress Notes dated back through 8/1/24 do not document that any of the nursing staff providing care for R4 had spoken to R4 to inform him of any risks of changing the oxygen tubing monthly instead of weekly, or alternative sanitation procedures to changing the oxygen tubing every week.
On 12/12/24 at 10:31 AM V2, Director of Nursing, and V3, [NAME] President of Clinical Operations, both stated they had not heard about R4 requesting to have his oxygen tubing changed monthly instead of weekly, and to their knowledge no one had spoken to R4 to inform R4 about infection control risks, or to explore other possible methods to sanitize R4's oxygen tubing such as soaking the tubing in soap and water, nor had anyone documented any of this.
Based on observation, interview, and record review the facility failed to change, date and store oxygen tubing, humidifier bottles, nebulizer masks, and suctioning equipment in a sanitary manner for four of five residents (R4, R14, R34, R350) reviewed for oxygen in the sample list of 26.
Findings Include:
The facility policy Departmental Respiratory Therapy Prevention of Infection dated reviewed 4/27/24 documents the oxygen administration supplies consist of oxygen tubing and humidifier bottle. This policy documents to change the oxygen tubing cannula every seven days, and to discard the entire administration set up every seven days.
1. R34's Medical Diagnoses list dated December 2024 documents R34 is diagnosed with Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure.
R34's Physician Order Sheet (POS) dated December 2024 documents an order for oxygen per nasal cannula at three liters continuously. R34 also has an order for nebulizer treatments every four hours as needed. The oxygen tubing and humidifier bottle should be changed every Sunday night and stored in a plastic bag.
On 12/10/24 11:54 AM R34's portable oxygen tubing was undated and hanging over the oxygen cylinder. R34's nebulizer tubing and mask were sitting on his bedside dresser.
On 12/10/24 at 11:55 AM V8 (R34's Daughter) confirmed R34's oxygen tubing is never stored in a bag and neither is nebulizer tubing/mask.
On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed R34's oxygen tubing and nebulizer mask and tubing should be changed, dated, and stored in a bag when not in use.
2. R350's Medical Diagnoses list dated December 2024 documents R350 is diagnosed with Pneumonia and Sepsis.
R350's Physician Order Sheet (POS) dated December 2024 documents an order that R350 may suction herself using an oral plastic suction catheter. Nursing to empty out machine after each use and clean catheter by putting catheter in a cup of water and suck it up until it is clear.
On 12/10/24 at 11:34 AM R350 stated she has been doing her own suctioning. Oral suction catheter appears dirty and is not covered.
On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed R350's suction catheter should be cleaned after each use and stored in a bag.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on Interview and record review, the facility failed to follow through with contacting Physicians for unaddressed Pharmacist recommendations, and failed to maintain documented evidence of Physici...
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Based on Interview and record review, the facility failed to follow through with contacting Physicians for unaddressed Pharmacist recommendations, and failed to maintain documented evidence of Physician responses to Pharmacist recommendations. This failure affects four residents (R12, R16, R22, R26) out of six reviewed for unnecessary medications on the sample list of 26.
Findings Include:
1. R16's Registered Pharmacist Consultant recommendation recorded in R16's Nursing Progress Notes dated 11/25/24 documents a Pharmacist recommendation to conduct an abnormal involuntary movement scale (AIMS) assessment to monitor for side effects of long-term Antipsychotic use. There was no documented evidence of a physician response, and no documented evidence of follow-up by the facility to obtain a physician response, in R16's electronic medical record (EMR). As of 12/11/24 at 11:20 AM, there was likewise no record of an AIMS assessment conducted for R16 historically.
2. R22's Registered Pharmacist Consultant Report dated 1/25/24 documents, This resident currently has an order for the Antipsychotic Seroquel 25 mg every night at bedtime. This resident does not have an approved diagnosis to support Antipsychotic use in the elderly with Dementia due to a black box warning of increased risk of mortality. CMS (Centers for Medicare and Medicaid Services) approves Antipsychotic use with the following diagnoses: Schizophrenia, Bipolar Disorder, Huntington's Disease, and Tourette's Syndrome. Please provide an approved diagnosis or justification for use below. The physician response section was blank.
R22's EMR did not include any documented evidence of a physician progress note nor any physician response to this Pharmacist recommendation. R22's Medical Diagnoses List dated 12/13/24 nor Physician Order Sheet dated 12/12/24 documented an approved diagnosis for R22's Seroquel, listed as prescribed for Anxiety, Irritability and Anger.
On 12/12/24 at 10:35 AM, V2, Director of Nursing, stated the consultant pharmacy review process is supposed to be that the Pharmacist does his reviews and makes a report, then he sends the report to the facility and to the doctor, then the doctor will address the recommendations when she is here. V2 and V3, [NAME] President of Clinical Operations, both stated R22's doctor is here every week.
4. R12's Medical Diagnoses List dated December 2012 documents R12 is diagnosed with Dementia with Behavioral Disturbance, Major Depression, and Anxiety.
R12's Physician Order Sheet dated December 2024 documents R12 is prescribed Risperidone (Antipsychotic) 0.25 milligram transdermal patch once daily related to psychosis with hallucinations, dementia with other behavioral disturbances, and anxiety disorder. R12 is also prescribed Sertraline (antidepressant) 50 milligrams daily related to major depressive disorder.
R12's Registered Pharmacist Consultant recommendation recorded in R12's Nursing Progress Notes dated 7/27/24, 8/26/24, 10/27/24, and 11/23/24 documents a Pharmacist recommendation to conduct an Abnormal Involuntary Movement Scale (AIMS) assessment to monitor for side effects of long-term Antipsychotic use. There was no documented evidence of a physician response, and no documented evidence of follow-up by the facility to obtain a physician response, in R12's electronic medical record (EMR). As of 12/11/24 at 12:00 PM there was likewise no record of an AIMS assessment conducted for R12 historically.
On 12/12/24 at 12:20 PM V3 [NAME] President of Clinical Operations confirmed R12 has not had any AIMS assessments completed prior to 12/11/24 and no psychotropic medication assessments completed at all. V2 also confirmed there was no documentation of any attempted Gradual Dose Reductions in the last year.
The facility's Abnormal Involuntary Movement Scale policy dated 9/1/24 documents the AIMS assessment should be performed before starting Neuroleptic drug therapy and then repeated every six months. All information should be documented in the resident's medical record.
The facility did not provide a policy regarding following pharmacy recommendations.
3. The Physician's Order Sheet dated December 2024 documents (R26) takes the following medication for the diagnosis of Schizoaffective Disorder: Quetiapine Sulfate (Seroquel) tablets 25 mg (milligram) 1 tablet orally every day. The start date for this medication was 7/1/24.
On 10/27/24 V21, (Consultant Pharmacist) did a Medication Regimen Review (MRR) for (R26). V21 recommended a dose reduction of the psychotropic medications Trazodone 100 mg (milligram) two tablets at night, Fluoxetine 20 mg 4 tablets 80 mg daily , Seroquel 25 mg QD (every day) and Bupropion ER 100 mg BID (twice a day) due to self reported fall. This information was sent to V22, (Medical Director and R26's physician). V22 did not respond to the request until 11/19/24 on R26's Nursing home visit. V22 documented she did not want to do a drug reduction on any of the medications however no reason was documented.
On 12/13/24 at 10:45 AM V2 Director of Nursing stated she does not receive the pharmacist recommendations from V21 because V21 emails them directly to V22. (R26) only had one MRR in her chart. V2 had to obtain the October visit from V22's office.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct psychotropic medication assessments, failed to maintain acc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct psychotropic medication assessments, failed to maintain accurate documentation in psychotropic medication assessments, failed to conduct abnormal involuntary movement assessments for Antipsychotic medications, failed to obtain a time period duration for PRN (as needed) psychotropic medications, and failed to attempt gradual dose reductions for residents receiving anti-psychotic medications. These failures affect five residents (R12, R16, R22, R26, and R29) out of six reviewed for unnecessary medications on the sample list of 26.
Findings Include:
1. R16's Medical Diagnoses list dated 12/13/24 documents R16 experiences medical conditions including Alzheimer's Disease and Dementia. R16's current Physician Order Sheet dated 12/13/24 documents R16 has physician orders for psychotropic medications including Sertraline (antidepressant) 25 milligrams (mg) daily, and Olanzapine (Antipsychotic) 2.5 mg daily. This same Physician Order Sheet documents R16 experiences additional medical conditions including Hallucinations and Paranoia, and Depression. R16's historical physician order sheets dating back to May of 2023 indicate R16 had been receiving these antidepressant and Antipsychotic medications routinely since that time.
On 12/10/24 at 11:05 AM, V17, Certified Nursing Assistant, stated R16 is a risk for elopement and experiences hallucinations and paranoia.
R16's Social Service quarterly assessment dated [DATE] documents R16 as taking one psychoactive medication listed as Memantine (N-Methyl-D-aspartate (NMDA) receptor agonist, not psychoactive) for Dementia. The Olanzapine and Sertraline are not listed.
R16's four most recent Minimum Data Sets (MDS's) dated 11/22/24, 8/23/24, 5/24/24, and 2/29/24 each document R16 had not had any attempted gradual dose reductions for the Antipsychotic medication Olanzapine, nor were there any documented physician notes to indicate R16 would be clinically contraindicated to attempt a decreased dosage.
R16's Assessments area of the electronic medical record (EMR) did not include any required quarterly psychotropic medication assessments. As of 12/11/24 at 11:20 AM, R16's EMR did not include any required abnormal involuntary movement scale (AIMS) assessments.
On 12/12/24 at 10:35 AM, V2, Director of Nursing, stated she would look into the facility's former EMR system to check if any of R16's quarterly psychotropic medication assessments or AIMS assessments were located there. At this same time, V3, [NAME] President of Clinical Operations, stated she would likewise look into the facility's former EMR system for any of R16's assessments. As of 12/13/24 at 2:55 PM, neither V2 nor V3 had provided any historical documentation that these assessments had been completed for R16.
2. R29's current Medical Diagnoses Lists dated 12/11/24 document R29 experiences medical conditions including Major Depression. R29's current Physician Order Sheet dated 12/11/24 documents R29 has physician orders for Bupropion (antidepressant) 300 mg extended release daily.
R29's EMR, including the Assessments area, did not include any required quarterly psychotropic medication assessments.
On 12/11/24 at 1:40 PM, V2, Director of Nursing, stated the facility practice is to place the psychotropic medication assessments and AIMS in the assessments portion of the EMR. V2 further stated the Psychotropic medications assessments are supposed to be completed quarterly, and the AIMS every 6 months.
3. R22's current Medical Diagnoses list dated 12/13/24 documents R22 experiences medical conditions including Dementia, and Irritability and Anger. R22's current Physician Order Sheet dated 12/12/24 documents R22 receives psychotropic medications including Quetiapine (Seroquel, Antipsychotic) 25 mg every 24 hours PRN (as needed) for Anxiety, and Lorazepam (Antianxiety) 0.5 mg every 8 hours PRN for Pain related to Irritability and Anger, give prior to showers and (urinary) catheter changes. R22's historical Physician Order Sheet documents R22 had been prescribed the Antipsychotic medication Quetiapine on a daily basis through December 4, 2024 when the Olanzapine was changed to PRN. The Quetiapine ordered on a PRN basis did not include any stop date nor duration of time for the order.
The Physician's Desk Reference 2024 documents Quetiapine is indicated for treatment of Major Depression (in conjunction with other antidepressant medications) and Bipolar Mania-Depressant Disorder. This same Physician's Desk Reference documents Lorazepam is indicated for the treatment of Generalized Anxiety Disorder.
On 12/13/24 at 2:55 PM, V2, Director of Nursing, stated the facility nursing staff has had some discussions about making sure there are stop dates and durations for the PRN (as needed) psychotropic medications. V2 stated there are only two full time nurses at the facility so V2 spends a lot of her time working in the direct care aspect in the facility and that makes it difficult to keep up with paperwork. V2 acknowledged the requirement for PRN psychotropic medications to be limited to 14 days or there needs to be a physician evaluation and justification documented to continue use.
5. R12's Medical Diagnoses List dated December 2012 documents R12 is diagnosed with Dementia with Behavioral Disturbance, Major Depression, and Anxiety.
R12's Physician Order Sheet dated December 2024 documents R12 is prescribed Risperidone (Antipsychotic) 0.25 milligram transdermal patch once daily related to psychosis with hallucinations, dementia with other behavioral disturbances, and anxiety disorder. R12 is also prescribed Sertraline (antidepressant) 50 milligrams daily related to major depressive disorder.
On 12/12/24 at 12:20 PM V3 [NAME] President of Clinical Operations confirmed R12 has not had any AIMS assessments completed prior to 12/11/24 and no psychotropic medication assessments completed at all. V2 also confirmed there was no documentation of any attempted Gradual Dose Reductions in the last year.
The facility's Psychotropic Medication Use policy dated December 2016 documents Psychotropic Medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and review. The need to continue PRN (as needed) orders for psychotropic medications beyond 14 days requires the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.
The facility's Abnormal Involuntary Movement Scale policy dated 9/1/24 documents the AIMS assessment should be performed before starting Neuroleptic drug therapy and then repeated every six months. All information should be documented in the resident's medical record.
4. The Physician's Order Sheet dated December 2024 documents (R26) takes the following medication for the diagnosis of Schizoaffective Disorder. Quetiapine Sulfate (Seroquel) tablets 25 mg (milligram) 1 tablet orally every day. Start date for this medication was 7/1/24.
12/11/24 (R26) chart did not have any AIMS (Abnormal Involuntary Movement Scale) assessment to review. When V2 was asked about (R26's) AIM's assessment at 11:20 AM, V2 stated I have to look and see if I can find it in the chart. V2 brought (R26's) AIM's assessment at 1:00 PM after it was completed. The assessment was dated 12/11/24 at 12:53 PM. V2 stated This is the only one I have.
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 provide the services of a qualified director of food and nutrition services. This failure affects all 42 residents residing i...
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Based on observation, interview, and record review, the facility failed to provide the services of a qualified director of food and nutrition services. This failure affects all 42 residents residing in the facility.
Findings Include:
On 12/10/24 at 9:55 AM, V5, Dietary Manager, was actively supervising and directing the food preparation and wares sanitation processes in the facility kitchen. At 11:50 AM and 12:08 PM, V5 was actively supervising and directing the meal service for lunch.
On 12/10/24 at 9:55 AM, V5 stated she was the Dietary Manager. V5 further stated she had a (national company) cooking sanitation certificate. V5 continued to state she did not have a Certified Dietary Manager certificate (CDM, 6 to 9 month clinical nutrition curriculum), nor a Certified Food Protection Professional certificate (CFPP, CDM equivalent). V5 stated the facility utilized the services of a Registered Dietician one day per month on a consultant basis. V5 concluded by stating she did not meet the state requirements for a Director of Food Services nor meet the definition of a Dietetic Service Supervisor by stating she was not a graduate of a national dietetic school program, had no experience in education or employment prior to 1990, and had no qualifying military experience.
On 12/10/24 at 10:10 AM, V6, Regional Dietary Representative, stated she, like V5, did not have a Certified Dietary Manager nor a Certified Food Protection Professional certificate. V6 stated she was currently enrolled in the Certified Dietary Manager course and that the ownership company would enroll V5 in the same course after approximately 30 days of V5's employment. V5 confirmed she would be enrolled in the course.
On 12/10/24 at 10:10 AM, V5's certificate was on the wall in V5's office and documented V5 held a valid Certified Food Protection Manager certificate (one day training certificate for cooking sanitation).
There was palatability, sanitation, lack of alternative menu items, lack of bedtime snacks, and potential contamination issues identified in the facility kitchen and meal services (reference F565 and F812).
On 12/10/24 at 10:40 AM, V1, Administrator, stated, the facility used to employ a Certified Dietary Manager, but she was off work on a family medical leave of absence and is not going to return to work, so the facility hired V5 and would work on getting V5 trained and qualified.
The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24 documents 42 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 maintain kitchen utensils to prevent potential contamination of food, and failed to prevent food contamination by storing ute...
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Based on observation, interview, and record review, the facility failed to maintain kitchen utensils to prevent potential contamination of food, and failed to prevent food contamination by storing utensils in bulk food containers. These failures have the potential to affect all 42 residents residing in the facility.
Findings Include:
On 12/10/24 at 10:15 AM, there was a metal, long handle measuring scoop located inside the bulk sugar bin. The handle of the scoop was in direct contact with, and partially buried by, the sugar.
On 12/10/24 at 10:15 AM, V5, Dietary Manager, and V6, Regional Dietary Representative, both stated the scoop should not be left in the sugar.
On 12/10/24 at 10:20 AM, there was a silicone blade spatula in a kitchen utensil drawer with a broken corner approximately three-quarters of an inch diagonal, exposing the granulated and rough internal material of the spatula. This granulated surface potentially would crumble off and contaminate food during preparation, and was not easily cleanable.
On 12/10/24 at 10:20 AM, V5 removed the spatula from the drawer to indicate she would throw it away.
The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24 documents 42 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 trend the facility's monthly infections. This failure has the potential to affect all 42 residents residing in the facility.
Findings Inclu...
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Based on interview and record review the facility failed to trend the facility's monthly infections. This failure has the potential to affect all 42 residents residing in the facility.
Findings Include:
The facility did not provide an Infection Control Surveillance and Monitoring Policy and no documents were provided for how the facility trends monthly infections to prevent further infection throughout the facility.
The facility has no documentation for the identified infections pattern/trend and interventions.
On 12/10/24 at 02:10 PM, V2 Director of Nursing (DON) Infection Preventionist (IP) stated V2 has not kept up with a log for infections for residents, and only has October and November 2024, for infection logs and only for residents and not for employees. V2 stated V2 and does not complete any Quality Assurance (QA) on infections that reoccur. V2 also stated there has been no completed trending for the facility's infections.
The facility's The Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24, documents there are 42 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to develop an infection prevention and control program that includes an antibiotic stewardship program and failed to review this policy annual...
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Based on interview and record review, the facility failed to develop an infection prevention and control program that includes an antibiotic stewardship program and failed to review this policy annually. This failure has the potential to affect all 42 residents residing in the facility.
Findings Include:
On 12/11/24 at 10:40 AM, V2 Director of Nursing (DON) stated V2 has not completed an Antibiotic Stewardship Program for the facility. V2 stated there are no antibiotic protocols or a system to monitor antibiotics in place.
The facility's Antibiotic Stewardship Program stated the purpose of the policy is to monitor antibiotic use of the residents. This policy has a date of 2/7/23, which has not been updated annually.
The facility's The Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24, documents there are 42 residents residing in the facility.
Aug 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to obtain a physician's order for oxygen and maintenance of supplemental oxygen for three residents (R1, R5, R6) of six residents ...
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Based on observation, interview and record review the facility failed to obtain a physician's order for oxygen and maintenance of supplemental oxygen for three residents (R1, R5, R6) of six residents reviewed for oxygen in a sample list of ten residents.
Findings Include:
1. R5's Care Plan updated 7/24/24 includes the diagnosis: Chronic Respiratory Failure.
On 8/5/24 at 10:00AM R5 was observed sitting in his room with oxygen in place at three liters per minute flow per nasal cannula.
On 8/5/24 at 10:30AM R5's physician's orders did not document a physician's order for supplemental oxygen.
R5's Treatment Administration Record (TAR) for August 1, 2024, to August 31, 2024, does not document a physician's order specifying when oxygen tubing/humidification bottle should be changed.
2. R6's Care Plan updated 7/30/24 documents (R6) has an Activities of Daily Living Self Care Performance Deficit: Activity Intolerance, Confusion, Dementia, Shortness of Breath. This Care Plan also documents a diagnosis of Chronic Obstructive Pulmonary Disease.
On 8/5/24 at 10:06AM R6 was observed sitting in his room with oxygen in place at three liters per minute flow per nasal cannula.
On 8/5/24 at 10:30AM R6's physician's orders did not document a physician's order for supplemental oxygen.
R6's Treatment Administration Record (TAR) for August 1, 2024, to August 31, 2024, does not document a physician's order specifying when oxygen tubing/humidification bottle should be changed.
3. R1's Care Plan updated 8/1/24 documents Risk for COPD Complication Chronic Obstructive Pulmonary Disease (COPD) Date Initiated: 08/01/2024.
R1's Physician's Orders document an order dated 6/27/24 for Oxygen 2-5 Liters per Minute Per Nasal Cannula for comfort/Shortness of breath.
R1's Treatment Administration Record (TAR) for August 1, 2024, to August 31, 2024, does not document a physician's order specifying when oxygen tubing/humidification bottle should be changed.
On 8/5/24 at 10:35AM V2, Director of Nursing verified R5 and R6 did not have a physician's order for supplemental oxygen and R1, R5, and R6 did not have a physician's order specifying when oxygen tubing/humidification bottle should be changed. V2 stated We just had a change in computer programs. I'm not sure how we missed those orders.
The facility policy Departmental (Respiratory Therapy) - Prevention of Infection revised November 2011 states: Check water level of any pre-filled reservoir every forty-eight (48) hours. Change pre-filled humidifier when the water level becomes low. Change the oxygen cannula and tubing every seven (7) days, or as needed. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to administer medication in a timely manner for one resident (R10) of four residents reviewed for timely medication in a sample l...
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Based on observation, interview, and record review the facility failed to administer medication in a timely manner for one resident (R10) of four residents reviewed for timely medication in a sample list of ten residents.
Findings Include:
R10's Medication Administration Record (MAR) documents R10 is scheduled to receive the following medications at 8:00AM: Ascorbic Acid 500Mg (Milligrams), Cholecalciferol 50Mcg (Micrograms), Famotidine 40Mg, Fluoxetine 20 Mg, Furosemide 40Mg, Gabapentin 100Mg, Phentermine 15Mg, Potassium Chloride 20Meq (Milliequivalents), Spiriva one puff, Symbicort 160/4.5Mcg one puff, Bupropion 100Mg, Cranberry Tab 900Mg, and MiraLAX 17Gm (Grams).
On 8/6/24 at 10:17AM V5, Licensed Practical Nurse (LPN) was observed preparing the above medications for R10 in the hall at the medication cart outside R10's room. V5 verified the medications were R10's 8:00AM doses. V5 stated the medications are late because I had another resident going in for cataract surgery and I got behind. It does happen sometimes especially when there is only one nurse working.
R10's MAR documents all the above medications were given at 8:00AM. V5 verified the records are filled in prior to administration so that MAR will not reflect actual time medications was given.
On 8/6/24 at 2:00PM V8, Licensed Practical Nurse (LPN) stated We give medications late on a regular basis. It's a big building and it's hard to get all the medication out within an hour especially if you have an emergency with a resident or you're the only nurse on duty. V8 and V9, Licensed Practical Nurse (LPN) verified the MAR does not reflect the actual time the medication was given.
On 8/6/24 at 2:05PM V2, Director of Nursing (DON) stated We only have 45 residents. The medications should be able to be out on time. V2 verified the time documented on the MAR does not record the actual time the medication was administered.
The facility's policy Administering Medications revised December 2012 states Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
Nov 2023
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to honor the choice to refuse the influenza vaccine for one (R22) of five residents reviewed for immunizations on the sample list of 31.
Findin...
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Based on interview and record review the facility failed to honor the choice to refuse the influenza vaccine for one (R22) of five residents reviewed for immunizations on the sample list of 31.
Findings include:
The facility's Influenza Vaccine policy with a revised date of August 2016 documents, Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. This policy also documents, A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record.
R22's Influenza and Pneumococcal Vaccine Consent/Declination form signed on 9/25/23 by V20 (R22's Power of Attorney) documents V20 declined to have R22 receive the Influenza Vaccine and the Pneumococcal (PCV20) Vaccine. This form is also signed by V9 Licensed Practical Nurse/Infection Preventionist.
R22's electronic immunization record documents R22 was given the Influenza Vaccine on 9/22/23 in the facility.
On 11/8/23 at 1:16 PM, V18 Regional Nurse confirmed that R22's record documents R22 was given the Influenza vaccine and confirmed that V20 signed a declination form not wanting R22 to receive the Influenza vaccine.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to evaluate and obtain orders for self administration of medications for two (R6, R26) of two residents reviewed for self adminis...
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Based on observation, interview, and record review the facility failed to evaluate and obtain orders for self administration of medications for two (R6, R26) of two residents reviewed for self administration of medications from a total sample list of 31 residents.
Findings include:
The facility provided Administering Medications Policy dated December 2012 documents that residents may only self-administer medication if the attending physician in conjunction with the interdisciplinary care planning team has determined that they have the decision making capacity to do so safely.
The facility provided Self-Administration of Medications Policy dated December 2016 documents that the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medication is clinically appropriate for the resident including a full and complete assessment of the resident's ability to self-administer medications. The staff and practitioner will document their findings of the assessment.
R6's November 2023 Medication Administration Record documents orders for Spiriva 2.5 microgram inhaler, take two puffs daily and Symbicort 160-4.5 microgram inhaler, take two puffs daily. There is no order for a Combivent inhaler.
On 11/7/23 at 8:35 AM, R6 stated that he used his Symbicort inhaler without supervision and that his Spiriva inhaler was not used because it was empty and that he could not recall how long it had been empty. R6 then pulled a Combivent inhaler out of his pocket and stated that he used it for emergencies.
On 11/7/23 at 8:40 AM, V10 Licensed Practical Nurse stated that R6 doesn't have an order to self-administer his medications. We don't have a doctor's order and they are supposed to have one to keep medication in their rooms and to self-administer medication.
R26's November 2023 Medication Administration Record documents orders for Trelegy-Ellipta 100-62.5-25 microgram inhaler, take two puffs daily.
On 11/7/23 at 9:15 AM, R26 stated that he was keeping his Trelegy-Ellipta 100-62.5-25 inhaler at his bedside and that it has been lost since 11/5/23. I don't know where it went, and I haven't used it since Saturday.
R26's November 2023 Medication Administration Record documents that Trelegy-Ellipta 100-62.5-25 microgram inhaler was not given on 11/5/23 and 11/7/23 and was administered on 11/6/23.
On 11/7/23 at 10:23 AM, V10 Licensed Practical Nurse said that the documentation on 11/6/23 for the Trelegy-Ellipta 100-62.5-25 microgram inhaler was likely a documentation error.
On 11/7/23 at 9:20 AM, V19 Licensed Practical Nurse stated that R26 doesn't have an order to self-administer medications and that an order is required to keep medication and self-administer at the bedside.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R27's Minimum Data Set, dated [DATE] documents that R27 is on an antipsychotic medication.
R27's August Medication Administra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R27's Minimum Data Set, dated [DATE] documents that R27 is on an antipsychotic medication.
R27's August Medication Administration Record documents no anti-psychotic medications were ordered for R27.
On 11/7/23 at 11:26 AM, V8 Minimum Data Set Coordinator stated, I must have mis-coded R27's Minimum Data Set. She has never been on an antipsychotic.
Based on interview and record review the facility failed to accurately code Minimum Data Set assessments for two (R50, R27) of 17 residents reviewed for assessments on the sample list of 31.
Findings include:
1. R50's Nursing Notes dated 9/06/2023 at 10:49 AM, documents R50 was discharged and medications including narcotics were sent with R50.
R50's Discharge Minimum Data Set assessment dated [DATE] documents R50 was discharged to the hospital.
On 11/8/23 at 3:00 PM, V18 Regional Nurse Consultant stated R50 was discharged to home not the hospital and that the Discharge Minimum Data Set assessment dated [DATE] was coded incorrectly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a pressure relieving intervention (cushion) fo...
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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 a pressure relieving intervention (cushion) for one of three residents (R22) reviewed for pressure ulcers in the sample list of 31.
Findings Include:
The facility's Prevention of Pressure Ulcers/Injuries policy with a revised date of July 2017 documents, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. This policy also documents, Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions.
R22's Face Sheet documents diagnoses including Pseudobulbar Affect, Vascular Dementia and Hypothyroidism.
R22's Minimum Data Set (MDS) dated [DATE] documents R22 is at risk for developing pressure ulcers, has a pressure reducing device for the chair and documents R22's mobility devices as a walker and a wheelchair.
R22's Skin Risk assessment dated [DATE] documents R22 is at risk for the development of pressure ulcers.
R22's Care Plan dated 2/14/23 documents R22 has a pressure reducing cushion to the wheelchair.
On 11/6/23 at 12:48 PM, R22 was in the dining room in R22's wheelchair and R22 did not have a cushion on the seat of R22's wheelchair. There was only the pressure alarm underneath of R22. On 11/7/23 at 2:02 PM, R22 was in R22's wheelchair wheeling R22's self in the hallway and R22 did not have a cushion in R22's wheelchair only the pressure alarm underneath R22.
On 11/8/23 at 11:00 AM, V8 Minimum Data Set Nurse and V18 Regional Nurse confirmed that R22 is supposed to have a pressure relieving cushion in R22's wheelchair.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide safe transport for one of three residents (R42...
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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 safe transport for one of three residents (R42) reviewed for accidents on the sample list of 31.
Findings include:
The facility's Operation Instructions for the shower chair with the model # SC9200 MS documents, Precautions: Exaggerated user movement in any direction or sitting on the edge of the seat may cause the chair to tip. This policy also documents, Safety/Maintenance Information: Make certain chair is assembled according to the enclosed instructions.
R42's Face Sheet documents a diagnosis of Altered Mental Status, Morbid (Severe) Obesity and Weakness. R42's electronic medical record documents R42's weight on 11/5/23 was 246.6 pounds.
R42's Minimum Data Set, dated [DATE] documents R42 has moderately impaired cognition, R42 does not walk and R42 is totally dependent on two staff for bathing.
On 11/6/23 at 10:44 AM, R42 was being pushed down the hallway from R42's room to the shower room, approximately 35 feet, in a shower chair. The shower chair is being held together at the bottom rails by two rubber straps.
On 11/8/23 at 9:49 AM, V18 Regional Nurse stated they should not transport residents in a shower chair.
On 11/8/23 at 10:52 AM, an unknown resident was in the shower room in the same shower chair with the rubber strap across the bottom rails of the chair.
On 11/8/23 at 11:03 AM, V19, CNA, stated that the reason the strap is on the bottom of the shower chair is because it's probably broken.
On 11/8/23 at 12:01 PM, the shower chair was in the shower room and the manufacturers label on the bottom rail of the chair documented the model # SC9200 with a date of 11/11/2009.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide oxygen per physician's orders for one of one r...
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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 oxygen per physician's orders for one of one resident (R42) reviewed for oxygen administration in the sample list of 31.
Findings include:
The facility's Oxygen Administration policy with a revised date of October 2010 documents Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. This policy also documents, Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.
R42's Physician Order dated November 2023 documents a diagnosis of Chronic Diastolic Congestive Heart Failure and documents an order for Oxygen at 2 liters per nasal cannula continually.
R42's Minimum Data Set, dated [DATE] documents R42 uses oxygen.
R42's Electronic Medication Administration Record dated November 2023 documents an order for Oxygen at 2 liters per nasal cannula with a start date of 8/31/23.
On 11/6/23 at 10:20 AM, R42 was in the bed with oxygen on via a nasal cannula and the oxygen concentrator was set at 4 liters.
On 11/7/23 at 9:15 AM, R42 was in R42's room in R42's wheelchair with the oxygen on via a nasal cannula. The oxygen concentrator was set on 4 liters. R42 stated that R42 thought it was supposed to be on 3 liters. At this same time V7 Registered Nurse confirmed the oxygen concentrator was set on 4 liters and stated V7 thought it was supposed to be set at 3 liters and proceeded to turn it down to 3 liters.
On 11/7/23 at 2:09 PM, R42 was in R42's bed with the oxygen on via the nasal cannula and the oxygen concentrator was set on 4 liters again.
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
Based on observation, interview, and record review the facility failed to relieve pain by failing to provide pain medication as ordered for three (R9, R32, R47) of three residents reviewed for pain on...
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Based on observation, interview, and record review the facility failed to relieve pain by failing to provide pain medication as ordered for three (R9, R32, R47) of three residents reviewed for pain on the sample list of 31 residents.
Findings include:
The facility Administering Medications Policy dated December 2012 documents that medication must be given as ordered including any required time frame.
1.) R9's undated diagnosis sheet documents Chronic Kidney Disease, Leg pain and Lymphedema.
On 11/6/23 at 10:43 AM, R9 was sitting up in wheelchair and rubbing shoulder and hands stating that she was in pain.
On 11/6/23 at 10:44 AM, R9 was sitting in a wheelchair in the dining room and stated, My pain patch ran out on Thursday, and they still haven't gotten it for me. I have been having a lot of pain. I have to get out of bed at night and sit up in my wheelchair to help with the pain, but I need my patch.
R9's October and November Medication Administration Record documents an order for a Butrans 10 micrograms per hour pain patch to be administered weekly (Thursdays).
On 11/7/23 at 1:14 PM, V7 Registered Nurse stated, (R9) should have had her patch weekly. She missed 12 days, from October 26 until November 6, 2023.
On 11/6/23 at 3:00 PM, V7 Registered Nurse stated, The physician knows that we need R9's patches and we don't have them yet. We don't assess her for pain, according to our records.
On 11/7/23 at 10:15 AM, V7 Registered Nurse stated that R9 received her patch last night it came in and was applied.
On 11/7/23 at 10:30AM, R9 stated, I finally got my patch last night at 10:30 PM. I guess it helps, because getting up out of my chair to go to the bathroom was really hard without the medicine.
On 11/7/23 at 2:00 PM, the box of R9's Butrans patches were dated as dispensed on 11/3/23 (Friday).
2.) R32's undated diagnosis sheet documents a primary diagnosis of Malignant Neoplasm of the Esophagus.
R32's October and November Medication Administration record documents an order for Oxycodone -Acetaminophen 10-325 milligrams to be take every four hours for pain.
On 11/7/23 at 1:25 PM, V7 Registered Nurse stated, R32 was out of his pain medication from Friday October 27, 2023, until Saturday, November 4, 2023.
On 11/7/23 at 2:10 PM, R32 stated, I didn't have my pain medicine for a while.
3.) R47's undated diagnosis sheet documents a primary diagnosis of an unspecified fracture of the first cervical vertebrae.
R47's November Medication Administration Record documents an order for Hydrocodone 10 milligrams/Acetaminophen 325 milligrams (Norco), one tablet as needed for pain every eight hours.
On 11/7/23 at 2:00 PM, R47 was wearing a cervical brace/collar and stated that his pain was currently a 6.5 of 10.
On 11/7/23 at 1:20 PM, V7 Registered Nurse stated, R47 was out of Norco (pain medication) for 2 days. He was out of the medication on the evening of October 30th, then he was out of the medication all day on October 31st and then when I came back to work on the first of November, I pulled the dose from the emergency box. Staff don't like the pharmacy process for getting medications out of the box, so they don't do it isn't right. He was definitely in pain.
On 11/7/23 at 2:00 PM, R47 stated, Yes, I was in pain. It isn't right. My friend with cancer didn't have his pain medicine either.
On 11/6/23 at 3:00 PM, V7 Registered Nurse confirmed that R9, R32 and R47 all had delays in pain medication being administered as ordered, with conditions that cause them consistent pain.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide pain medication as ordered by the physician for two (R9 and R32) of two residents reviewed for pain on the sample list of 31 residen...
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Based on interview and record review the facility failed to provide pain medication as ordered by the physician for two (R9 and R32) of two residents reviewed for pain on the sample list of 31 residents.
Findings include:
The facility Administering Medications Policy dated 12/2012 documents that medication must be given as ordered, including any required time frame.
1.) R9's October and November Medication Administration Record documents an order for a Butrans 10 micrograms per hour transdermal pain patch to be administered weekly (Thursdays).
On 11/6/23 at 10:44 AM, R9 was sitting in a wheelchair in the dining room and stated, My pain patch ran out on Thursday, and they still haven't gotten it for me. I have been having a lot of pain. I have to get out of bed at night and sit up in my wheelchair to help with the pain, but I need my patch.
On 11/7/23 at 1:14 PM, V7 Registered Nurse stated, (R9) should have had her patch weekly. (R9) missed 12 days, from October 26 until November 6, 2023.
On 11/6/23 at 3:20 PM, V22 Medical Director stated, I can tell you exactly when I got the fax from the facility and when we sent the order to the pharmacy. (The facility) requested (R9's) patch on 11/3/23 and it was ok'd by my partner. (R9) should have it by now.
On 11/7/23 at 10:15 AM, V7 Registered Nurse stated, (R9) received her patch last night it came in and was applied.
On 11/7/23 at 10:30AM, R9 stated, I finally got my patch last night at 10:30 PM. I guess it helps, because getting up out of my chair to go to the bathroom was really hard without the medicine.
2.) R32's October and November Medication Administration record documents an order for Oxycodone -Acetaminophen 10-325 milligrams to be take every four hours for pain.
R32's October and November Medication Administration record documents that R32 did not receive Oxycodone-Acetaminophen 10-325 milligrams from October 27, 2023, through Saturday November 4, 2023.
On 11/7/23 at 1:25 PM, V7 Registered Nurse stated, R32 was out of his pain medication from Friday October 27, 2023, through Saturday, November 4, 2023. He was in pain.
On 11/7/23 at 2:10 PM, R32 stated, I didn't have my pain medicine for a while.
On 11/6/23 at 3:20 PM, V22 Medical Director stated, The pain medication for R32 was requested on 11/1/23 and sent by my office to the pharmacy on the same day. My office and I are not the delay. The facility pharmacy is who they use, and they aren't open on weekends. I don't think that a nursing home pharmacy should be closed on the weekends. They need a backup or other plan.
On 11/6/23 at 3:00 PM, V7 Registered Nurse confirmed that R9 and R32 had delays in pain medication being received in the facility causing them consistent pain.
On 11/6/23 at 9:00 AM, V10 Licensed Practical Nurse stated, I think we only use (a local) pharmacy. I don't think that we have any other. We used to and it was so much better for the residents. I could just run out the door and get whatever the resident needed.
On 11/7/23 at 1:14 PM, V7 Registered Nurse stated, I'm not aware of any back-up pharmacy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R6's Psychoactive Medication Quarterly Evaluation dated 10/13/23 documents R6 is receiving Sertraline (antidepressant) 150 m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R6's Psychoactive Medication Quarterly Evaluation dated 10/13/23 documents R6 is receiving Sertraline (antidepressant) 150 mg once a day for the diagnosis of Depression.
R6's November 2023 Medication Administration Record documents an order dated 10/25/23 for Sertraline 200 mg capsule, one capsule by mouth once a day.
R6's medical record does not include an assessment for the increase in dose of the Sertraline.
On 11/8/23 at 2:00 PM, V18 stated the only assessment for R6's Sertraline was the assessment dated [DATE].
3.) R29's physician order dated 9/28/23 documents an order for Lorazepam (anti-anxiety) 1 milligram every eight hours as needed.
R29's progress note dated 10/31/23 at 5:04 PM, documents R29 was given one milligram of Lorazepam due to trying to bite, hit, and kick staff.
R29's medical record does not include an assessment for the use of Lorazepam.
On 11/8/23 at 2:30 PM, V18 Regional Nurse Consultant stated there was not an assessment for R29's use of Lorazepam.
Based on interview and record review the facility failed to assess the need for psychotropic medications and reassess the need for as needed antianxiety medication for three of five residents (R6, R22, R29) reviewed for unnecessary medications on the sample list of 31.
Findings include:
The facility's Antipsychotic Medication Use policy with a revised date of December 2016 documents, Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. Residents will not receive PRN (as needed) doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.
1.) R22's Face Sheet documents diagnoses including Pseudobulbar Affect, Anxiety Disorder, Major Depressive Disorder and Vascular Dementia.
R22's Electronic Medication Administration Record (EMAR) dated November 2023 documents orders for Venlafaxine HCL (Hydrochloride) ER (Extended Release) (antidepressant)150 mg (milligrams) one tablet everyday, Remeron (antidepressant) 15 mg at bedtime for an appetite stimulant with a start date of 9/7/23, Trazodone (antidepressant) 50 mg at bedtime with a start date of 10/20/23, Lorazepam (antianxiety) 0.5 mg every 8 hours as needed for anxiety with a start date of 4/25/23 and Haldol (antipsychotic) 0.5 mg twice a day with a start date of 10/17/23. This EMAR documents R22 has received all of the scheduled medications daily and received the as needed Lorazepam on 11/1/23, 11/2/23, two times on 11/4/23, on 11/5/23 and on 11/8/23.
R22's Psychoactive Medication Quarterly Evaluation dated 11/3/23 documents this evaluation was for Ativan (Lorazepam) 0.5 mg three times a day scheduled, not as needed (prn). This assessment is not accurate and R22's medical record does not document an assessment for the as needed Ativan which R22 has had ordered since 4/25/23. R22's medical record does not contain any psychotropic medication assessment for the use of Venlafaxine or for Haldol. R22's medical record does not contain any justification for the use of the PRN antianxiety medication Lorazepam since being ordered on 4/25/23.
On 11/8/23 at 12:14 PM, V18 Regional Nurse stated that V18 would expect psychotropic medication assessments to be completed and confirmed R22 was receiving an as needed antianxiety medication since 4/25/23. V18 stated V18 doesn't know why R22 is still on this medication.
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 assess a bed rail for areas of entrapment for one of one (R29) resident reviewed for bed rails on the sample list of 31.
Find...
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Based on observation, interview, and record review the facility failed to assess a bed rail for areas of entrapment for one of one (R29) resident reviewed for bed rails on the sample list of 31.
Findings include:
On 11/06/23 at 10:33 AM, R29 was lying in bed. There was a half side rail at the end of the bed. The gaps between the rails on the bed rail were greater than 4.5 inches. The gaps between the rail measured approximately 10 inches. V21 Caregiver stated the rail was added to the bed two weeks ago.
R29's medical record did not contain a bed rail assessment to identify areas of entrapment.
On 11/08/23 at 1:27 PM, V18 Regional Nurse Consultant stated that they did not have a bed rail assessment to identify areas of entrapment when the bed rail was placed on the bed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0848
(Tag F0848)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure arbitration agreements provide for the selection of an arbitration venue convenient to both parties. This failure has the potential ...
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Based on interview and record review, the facility failed to ensure arbitration agreements provide for the selection of an arbitration venue convenient to both parties. This failure has the potential to affect five residents (R48, R102, R202, R204, R208) of five reviewed for arbitration agreements on the sample list of 31.
Findings include:
The facility arbitration agreements signed by R48, R102, R202, R204, and R208 do not include any language providing for the selection of an arbitration venue convenient to both parties. The contract documents the arbitration will occur in the county where the facility is located.
On 11/8/2023 at 10:39 AM, V4 (Business Office Manager) reported the facility arbitration agreement does not have the required language related to arbitration venue selection.
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 to prevent the potential for physical cross-contamination of food. This failure has the potential to affect all 49 residents in the fac...
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Based on observation, interview, and record review, the facility to prevent the potential for physical cross-contamination of food. This failure has the potential to affect all 49 residents in the facility.
Findings include:
1. On 11/6/2023 at 10:02 AM, two ice scoops were stored in a container located adjacent to the facility ice maker. One scoop was made of white plastic and the other scoop was clear plastic. Both scoops were heavily chipped on the leading edges and missing pieces of plastic up to a quarter of an inch in size.
On 11/6/2023 at 12:16 PM, V3 (Dietary Manager) was using the white colored ice scoop from above to obtain ice from the ice maker for residents.
On 11/07/2023 at 12:12 PM, the white ice scoop from above remained in the storage container. V3 was present and stated no (she doesn't know where the missing chips of plastic from the scoops are located).
2. On 11/6/2023 at 12:16 PM, 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 makes contact with canned food items being opened.
On 11/07/2023 at 12:20 PM, the can opener remained soiled with metal shavings. V3 was present and observed the can opener and stated it (the can opener) needs a new blade, and it needs washed.
On 11/6/2023 at 12:02 PM, V3 reported the food prepared by the kitchen is available for all residents in the facility to consume.
The facility's Long-Term Care Facility Application for Medicare and Medicaid (11/6/2023) documents 49 residents reside in the facility.
Sept 2023
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive person centered care plan for one resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive person centered care plan for one resident (R1) of three residents reviewed for care plans in the sample list of three.
Findings include:
R1's undated Face Sheet documents R1's diagnoses as unspecified Psychosis not due to a substance or known physical condition, Non-traumatic Chronic Subdural Hemorrhage, unspecified Intracranial injury with loss of consciousness of unspecified duration, sequela, unspecified Mental Disorder due to known Physiological Condition, unspecified Mood.
R1's Minimum Data Set (MDS) dated [DATE], documents R1 as moderate cognitive impairment and inattention and disorganized thinking.
R1's Departmental Notes dated 7/27/23 at 9:48 PM, documents R1 was reported by north wing nurse that she was able to punch front door code and go outside. R1's Departmental Notes dated 8/15/23 at 10:00 AM, documents resident exited the front door of the facility to go to (a fast food restaurant), staff followed her (R1) out the door and assisted resident (R1) back into the building. R1's Departmental Notes dated 8/16/23 at 9:46 PM, documents resident (R1) exited out [NAME] door at 8:20 PM, found just off the patio. R1's Departmental Notes dated 9/13/23 at 8:43 AM, documents resident (R1) went outside door of facility.
On 9/27/23 at 10:24 AM, V2 Director of Nursing (DON) stated R1 is absolutely a risk for elopement. V2 stated R1's care plan does not have elopement risk put in until 9/12/23. V2 stated an elopement screen risk was done on 7/15/23 but should have been re-done again.
The facility's Care Plan Policy dated Revised April 2009, documents Care plans shall incorporate goals and objectives that lead to the resident ' s highest obtainable level of independence; goals and objectives are reviewed and/or revised: when there has been a significant change in the resident ' s condition; when the resident has been readmitted to the facility from a hospital/ rehabilitation stay; and at least quarterly.
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 interview and record review, the facility failed to provide adequate supervision for a resident (R1) at risk for elopin...
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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 supervision for a resident (R1) at risk for eloping from the facility. This failure affects one of three (R1) residents reviewed for elopement in the sample list of three.
Findings include:
R1's undated Face Sheet documents R1's diagnoses as unspecified Psychosis not due to a substance or known physical condition, Non-traumatic Chronic Subdural Hemorrhage, unspecified Intracranial injury with loss of consciousness of unspecified duration, sequela, unspecified Mental Disorder due to known Physiological Condition, unspecified Mood.
R1's Minimum Data Set (MDS) dated [DATE], documents R1 as moderate cognitive impairment, inattention and disorganized thinking.
R1's Departmental Notes dated 7/27/23 at 9:48 PM, documents R1 was reported by north wing nurse that she was able to punch front door code and go outside. R1's Departmental Notes dated 8/15/23 at 10:00 AM, documents resident exited the front door of the facility to go to (a fast food restaurant), staff followed her (R1) out the door and assisted resident (R1) back into the building. R1's Departmental Notes dated 8/16/23 at 9:46 PM, documents resident (R1) exited out [NAME] door at 8:20 PM, found just off the patio. R1's Departmental Notes dated 9/13/23 at 8:43 AM, documents resident (R1) went outside door of facility.
On 9/26/23 at R1's 2:38 PM V6 Licensed Practical Nurse (LPN) stated R1 got out the east door and the alarm went off then another time she (R1) went out the [NAME] door. V6 stated they did not know which direction R1 went and V8 found R1 on the next street over.
On 9/26/23 at 2:50 PM, V8 Certified Nursing Assistant (CNA) stated R1 did escape from the facility. V8 stated V8 and V7 CNA both went out the east door searching for R1. V8 stated R1 went through the yards and was by the next street over.
On 9/27/23 at 10:24 AM, V2 Director of Nursing (DON) stated R1 is absolutely a risk for elopement. V2 stated V9 was here when R1 got out the [NAME] door and R1 got close to the road. V2 stated we could see her but not get to R1 fast enough. V2 stated that on all the dates in R1's nursing notes R1 did try to get out. V2 stated on 7/27/23 R1 sat at the front door and watched people push the code. V2 stated on 8/15/23 when R1 got out she wanted to go to a fast food place.
On 9/27/23 at 2:45 PM, V7 CNA stated R1 has gotten out of the east door because she doesn't want to be here. V7 stated V8 and V10 CNA's found R1. V7 stated they had to walk off the property to find R1.
On 9/27/23 at 2:59 PM, V11 RN stated when R1 was brought back from the psych facility she had been here maybe 20 minutes and she went out the door and the alarm was sounding.
The facility's Elopement Policy dated Revised December 2007, documents Staff shall investigate and report all cases of missing residents.
Mar 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency 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 treat a resident with dignity by failing to allow a r...
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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 treat a resident with dignity by failing to allow a resident to maintain a personal possession as desired by the resident. This failure affects one resident (R3) in a sample of 4 residents reviewed for abuse prevention.
Findings include:
On 3/2/23 at 9:15 am, V1, Administrator, stated, We just had one allegation of abuse reported to me this morning involving a report that a Unit Aid (V5) had forced a resident (R3) into a wheelchair and threw (R3's) purse across the room. Receipt of this reported allegation was confirmed by V2, Director of Nursing.
The facility's Initial Report dated 3/2/23 at 9:41 am documented, Received allegation that staff (V5) forced resident (R3) to sit down and threw (R3's) purse. Staff (V5) was immediately suspended. The resident was assessed with no injuries noted. The following have been notified: POA, Doctor, [NAME] Police Department, and Ombudsman. An investigation has been initiated with final report to follow.
On 3/2/23 at 10:01 am, V4, Certified Nursing Assistant, stated, I witnessed something this past weekend. (V5) had grabbed a little pink gift bag from (R3) and threw it across the room. (R3) said, 'That's my bag', or 'I want my bag' but (V5) told (R3) it was trash. There wasn't any involvement with a purse that I saw.
On 3/2/23 at 10:01 am, accompanied by V4, there was no pink gift bag located in R3's room.
On 3/2/23 at 10:40 am, accompanied by V1, there was no pink gift bag located in R3's room.
On 3/2/23 at 3:25 pm, V3, Certified Nursing Assistant and Family of R3, stated, (R3) had a pink gift bag and would have a habit of putting her jewelry in bags like that. I received a report second hand from a former employee (V11) that (V5) had taken the pink bag from (R3) and threw it across the room and told (R3) that it was trash. V3 continued, I might think it was trash too but to (R3) that was her possession.
On 3/2/23 at 3:37 pm, V5, Unit Aid, stated, (R3) has periods when she thinks she is 'moving out' and puts all of her belongings in a bag and puts it out in the hallway, and that is what she was doing when I went into her room. V5 continued, I did take the bag from (R3) and tossed it aside, I didn't throw it across the room. When I left the room, I took the bag with me and threw it away in the trash. V5 further stated, It was a 99-cent paper bag, and I didn't see a problem with that.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interview and record review, facility employees failed to implement the facility's Abuse Prevention policy by failing to report an instance of suspected resident abuse immediately to the admi...
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Based on interview and record review, facility employees failed to implement the facility's Abuse Prevention policy by failing to report an instance of suspected resident abuse immediately to the administrator. This failure had the potential to affect 10 residents (R3, R5 through R10, and R12 through R14) residing on the facility's North Hall out of a facility census of 45.
Findings include:
The facility's Abuse Prevention Policies and Procedures dated 8-16-2019 documents facility staff are oriented at hire, and periodically trained, about their obligations to report any instances of suspected or possible abuse they observe, hear about, or suspect to the administrator immediately.
The facility's memorandum, Attendance, Cell Phones, and Abuse Policy dated 7/1/17, signed by V4, Certified Nursing Assistant, on 4/14/22, documents V4 confirms knowledge of the requirements to report any type of abuse immediately to a Supervisor, Administrator, or CEO. The facility's Inservice Sign-in Sheets dated 2/3/23 and 11/25/22 document V4 had received periodic training reviews for the facility's abuse prevention policies. These same Inservice Sign-in Sheets document V3, Certified Nursing Assistant, had also received these periodic training reviews for the facility's abuse prevention policies.
On 3/2/23 at 9:15 am, V1, Administrator, stated, I received a report this morning regarding (V5) Unit Aide allegedly forcing a resident (R3) into a wheelchair. On 3/3/23 at 1:15 pm, V1 stated, The allegation was reported to me by (V3) but (V4) never did until I talked to her. They both know to report.
On 3/2/23 at 10:01 am, V4, Certified Nursing Assistant, stated, I have worked here about a year. I have had training about abuse prevention. I received some in the employee handbook, in some papers they gave me, and we have had some In-services. I am supposed to report any abuse to the administrator. V4 continued, I witnessed (V5, Unit Aide) put his hands on (R3's) shoulders and pushed (R3) back into a wheelchair. I thought (V5) did it too rough and kind of slammed (R3) into the chair. I thought (V5) could have just asked (R3) to sit back in the wheelchair and (R3) would have done it. V4 further stated, This all happened last Saturday (2/25/23). I don't really have a reason why I didn't report it, I know I'm supposed to.
On 3/2/23 at 3:25 pm, V3, Certified Nursing Assistant, stated, I received an allegation from a second-hand source that (V5) had put his hands on (R3's) shoulders and was very rough when getting (R3) back in the wheelchair. This report came from a former employee (V11) who sent me a text message a little after midnight (on 3/2/23). V3 continued, I reported it to (V1, Administrator) this morning when he came into work, about 8:00 am or so. V3 further stated, I have worked here off and on since 1993 and I have received abuse prevention training lots of times. I am supposed to report it as soon as I see it or hear it. I waited until this morning because it was after midnight when I heard it and I figured (V1) would be in to work this morning.
The facility's Resident Roster dated 3/2/23 documents R3, R5, R6, R7, R8, R9, R10, R12, R13, and R14 reside on the facility's North Hall.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
Based on interview and record review, facility employees failed to report an instance of suspected resident abuse immediately to the administrator. This failure had the potential to affect 10 resident...
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Based on interview and record review, facility employees failed to report an instance of suspected resident abuse immediately to the administrator. This failure had the potential to affect 10 residents (R3, R5 through R10, and R12 through R14) residing on the facility's North Hall out of a facility census of 45.
Findings include:
The facility's memorandum, Attendance, Cell Phones, and Abuse Policy dated 7/1/17, signed by V4, Certified Nursing Assistant, on 4/14/22, documents V4 confirms knowledge of the requirements to report any type of abuse immediately to a Supervisor, Administrator, or CEO. The facility's Inservice Sign-in Sheets dated 2/3/23 and 11/25/22 document V4 had received periodic training reviews for the facility's abuse prevention policies. These same Inservice Sign-in Sheets document V3, Certified Nursing Assistant, had also received these periodic training reviews for the facility's abuse prevention policies.
On 3/2/23 at 9:15 am, V1, Administrator, stated, I received an allegation of abuse this morning regarding (V5) Unit Aide forcing a resident (R3) into a wheelchair.
On Thursday 3/2/23 at 10:01 am, V4, Certified Nursing Assistant, stated, I witnessed (V5, Unit Aide) put his hands on (R3's) shoulders and push (R3) back into a wheelchair. I thought (V5) did it too rough and kind of slammed (R3) into the chair. V4 further stated, This all happened last Saturday (2/25/23) on the day shift. We both worked until 6:00 pm that day but this happened during the day shift before 2:00 pm. I don't really have a reason why I didn't report it, I know I'm supposed to.
On Thursday 3/2/23 at 3:25 pm, V3, Certified Nursing Assistant, stated, I received a report from a second-hand source (V11, former employee) that (V5) had put his hands on (R3's) shoulders and was very rough when getting (R3) back in the wheelchair. V3 continued, I reported it to (V1, Administrator) this morning when he came into work, about 8:00 am or so. V3 further stated, I have worked here off and on since 1993 and I have received abuse prevention training lots of times. I am supposed to report it as soon as I see it or hear it. I waited until this morning because it was after midnight when I heard it and I figured (V1) would be in this morning.
The facility's Employee Time Sheet dated 2/22/23 through 3/7/23 documents V5 worked until 6:02 pm on Saturday 2/25/23, and from 5:51 am through 6:11 pm on Sunday 2/26/23. This same Time Sheet documents V5 came into work at 5:55 am on Thursday 3/2/23 and worked until 8:14 am, having access to the residents residing on the facility's North Hall.
The facility's Resident Roster dated 3/2/23 documents R3, R5, R6, R7, R8, R9, R10, R12, R13, and R14 reside on the facility's North Hall.
Nov 2022
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility to immediately begin an investigation of missing narcotics, failed to report an allegation of missing narcotics medications to the Stat...
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Based on observation, interview, and record review, the facility to immediately begin an investigation of missing narcotics, failed to report an allegation of missing narcotics medications to the State Agency and Police Department within the allotted time frame, and failed to timely remove the alleged perpetrator from the facility pending investigation. This failure affects two of three residents (R1, R2) reviewed for medication in the sample of three.
Findings include:
R1's Medication Administration Sheet (MAR) dated October 2022, documents an order for Hydrocodone Bitartrate/Acetaminophen (Norco) 10-325 milligrams (mg) tablet one tablet routine three times a day at 4 AM, 12 PM, and 8 PM. R2's MAR dated October 2022, documents an order for Oxycodone-Acetaminophen 10-325 mg take one tablet by mouth every four hours as needed for moderate to severe pain.
On 11/17/22 at 3:40 PM, V9 (Director of Clinical Services) stated V9 began an investigation of missing narcotics on 10/7/22 after it was reported on 10/6/22 to V1 (Administrator) and V10 (Director of Operations.)
On 11/17/22 at 3:56 PM, V10 stated V10 called the State Police to report the allegation but did not provide documentation of the State Police being notified. V10 stated the State Police did not come to the facility. At this time, V1, stated V1 did not call the local Police Department to report this incident but informed V10 on 10/6/22 after V4 Licensed Practical Nurse (LPN) reported to V1.
On 11/18/22 at 11:27 AM, V4 LPN stated V4 reported the missing narcotics to V1 Administrator on Sunday October 6, 2022.
On 11/18/22 12:15 PM, V11 (Owner of Facility), stated the investigation should have started immediately after it was reported, this is a crime. V11 also stated V11 told V2 (DON) and V10 to call the local Police Department and have them come to the facility now.
On 11/18/22 at 12:17 PM, V10 stated V10 told V1 and V2 that an investigation would need to be started and that V9 (Director of Clinical Operations) started the investigation on 10/7/22. V10 stated the investigation should have been started on 10/6/22 after being reported. V10 stated another investigation was started after the State surveyor reported it on 11/17/22. V10 stated V10, V2, V11 told the local Police V2, V10, V11, suspected V6 (LPN) after reviewing the narcotics count sheet (for R1 and R2). V10 stated the Police took V6 to the police station for an interview.
On 11/18/22 at approximately 1:00 PM, V10 stated the police let V6 leave the Police Station and V6 came back to the facility to ask what V6 needed to do, and that V1 Administrator told V6 to leave. At this same time, V11 stated V6 will not be returning to the facility.
On 11/18/22, approximately 10 AM, the local Police were at the facility.
The facility's Illinois Department of Public Health (IDPH) Report dated 11/17/22, documents this is the date the facility reported missing medications to IDPH.
The facility's punch in and punch out records document V6 LPN worked on the following days: 10/7/22, 10/10/22, 10/11/22, 10/12/22, 10/14/22, 10/15/22, 10/16/22, 10/18/22, 10/19/22, 10/20/22, 10/25/22, 10/26/22, 10/27/22, 10/28/22, 10/29/22, 10/30/22, 11/1/22, 11/2/22, 11/3/22, 11/4/22, 11/5/22, 11/7/22, 11/8/22, 11/9/22, 11/12/22, 11/13/22, 11/15/22, 11/16/22, 11/17/22. 11/18/22, having access to narcotics.
The facility's Abuse Prevention Policy and Procedure date 8/16/21, documents the facility affirms the right of the residents to be free from misappropriation of resident property. This same policy also documents the facility will ensure it is doing all that is within its control by filing accurate and timely reports, upon learning of the report, an incident investigation shall be initiated immediately. This policy also states the Administrator is required to report to Illinois Department of Public Health immediately or within one hour and report the alleged crime/abuse to local law enforcement and Adult Protective Services.
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 F0602
(Tag F0602)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to prevent the misappropriation of resident's narcotic pain medications. This failure affects two of three residents (R1, R2) reviewed for med...
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Based on interview and record review, the facility failed to prevent the misappropriation of resident's narcotic pain medications. This failure affects two of three residents (R1, R2) reviewed for medication in the sample of three.
Findings include:
On 11/17/22 at 1:00 PM, V1 Administrator stated the missing records and narcotics were reported to V1 on 10/6/22 in the evening by V4 Licensed Practical Nurse (LPN).
On 11/17/22 at 1:05 PM, V2 Director of Nursing stated V2 was called on 10/6/22 at 3:37 PM by V4 LPN and V5 Registered Nurse (RN) stating V4 and V5 discovered narcotics missing for R1 and R2. V2 stated V2 was on leave. V2 stated corporate people took over. V2 stated V4 and V5 found R2's Individual Resident Controlled Substance record in the shred bin already shredded and V4 and V5 took it out and taped it back together. V2 also stated V4 and V5 found R1's narcotic count sheet not shredded but in the locked shred bin. V2 stated these records for R1 and R2 should have come to V2 as V2 keeps them.
R1's Medication Administration Sheet (MAR) dated October 2022, documents an order for Hydrocodone Bitartrate/Acetaminophen (Norco) 10-325 milligrams (mg) tablet one tablet routine three times a day at 4 AM, 12 PM, and 8 PM. R1's Individual Resident's Controlled Substance Record dated 10/19/22 through 11/1/22, documents 10/19/22, amount received 42 tablets, 11/1/22, amount remaining 3 tablets. On 11/17/22 at 3:40 PM, V9 Director of Clinical Operations stated We didn't find the card with the three tablets left for R1's Norco.
On 11/18/22 at 11:27 AM, V4 LPN stated we have been having problems with narcotics disappearing, it has been reported before I think back in the spring. V4 stated V4 and V5 Registered Nurse (RN) decided to go through the shred bin because the sheets were not in the discontinued box. V4 stated V4 and V5 found the shredded narcotic count sheet for R2 and taped it back together and the sheet said there were 13 pills remaining but there were no pills anywhere to be found and we didn't know where the actual medication card was.
R2's MAR dated October 2022, documents an order for Oxycodone-Acetaminophen 10-325 mg take one tablet by mouth every four hours as needed for moderate to severe pain. R2's Individual Resident's Controlled Substance Record dated 10/19/22 through 11/4/22, documents 10/19/22, amount received 50 tablets, 11/4/22, amount remaining 13 tablets. On 11/17/22 at 3:40 PM, V9 Director of Clinical Operations stated We didn't find the card with 13 tablets on it, we didn't find it shredded, we didn't find it at all for R2.
The facility's Controlled Substances Policy dated Revised December 2012, documents the facility shall comply with all laws, regulations, and other requirements related to documentation of Schedule II and other Controlled Substances.
Oct 2022
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to obtain a physician order for oxygen administration, f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to obtain a physician order for oxygen administration, failed to keep a resident's oxygen tubing off the floor, failed to change oxygen tubing, and failed to label portable oxygen cannula/tubing according to the plan of care. These failures affect one of three residents (R30) reviewed for respiratory care on the sample list of 19.
Findings include:
R30's Physician Order Sheet (POS) dated October 2022 had an oxygen administration order added 10/27/22 as follows: Oxygen per nasal cannula at 3 (three) liters per nasal cannula (sic) continuous. Change oxygen equipment every Sunday.
R30's Minimum Data Set (MDS) dated [DATE] documents R30's Brief Interview of Mental Status score of seven out of a possible 15, indicating severe cognitive impairment. The same MDS documents R30 was on oxygen while not a resident at the facility and while residing in the facility.
R30's Care Plan dated 9/3/22 documents the following: Category Respiratory. I (R30) am receiving oxygen therapy due to diagnoses of History Respiratory Failure and anoxic brain injury. Care Plan Goal, Exhibits no shortness of breath per my (R30) report. Intervention (1.) Provide Humidification, label with date, change weekly. Intervention (6.) Change oxygen tubing weekly and as needed. Label with date. Keep tubing off floor. Store tubing in bag attached to concentrator or wheelchair. (7.) Administer oxygen therapy at three liters per nasal cannula or mask.
On 10/25/22 at 11:03 AM, R30 had an oxygen bed-side concentrator with humidifier bottle dated as changed 10/21/22. R30 has nasal cannula and tubing dated as changed 10/08/22. R30's oxygen flow rate was set at a delivery rate of two liters (physician ordered at three liters and identified on the care plan) per nasal cannula. R30 also has oxygen tubing with additional eight foot extension oxygen tubing. The oxygen tubing laid on the floor partially coiled that extended from R30's nasal cannula down onto the floor and over five feet to the oxygen concentrator. R30 also had an E-cylinder portable oxygen tank with undated tubing/nasal cannula laid on a bedside table. The E-tank portable oxygen was in R30's wheelchair. R30 stated I am not sure if they change anything. I really don't know for sure.
On 10/25/22 at 11:35 pm V4, Registered Nurse (RN) confirmed R30's oxygen tubing placement and tubing date. V4, RN stated (R30's) tubing should never be on the floor. Tubing should be changed and dated when changed every week.
On 10/26/22 at 9:05 am V2, Director of Nursing (DON) confirmed R30 does not have a physician order for oxygen. V2 also stated V2, DON heard about the problem with R30's oxygen tubing on the floor and dated 10/08/22. V2, DON also stated Tubing and humidifier bottles should be changed weekly and prn (as needed). Of course, the oxygen tubing should never be on the floor. I educated staff and we have provided the bags to put the tubing in, for everyone on oxygen.
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 properly label and store hot dogs, failed to maintain a sanitary can opener, and failed to use approved sanitizer for wiping bu...
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Based on observation, interview and record review the facility failed to properly label and store hot dogs, failed to maintain a sanitary can opener, and failed to use approved sanitizer for wiping bucket use. These failures have the potential to affect all 43 residents in the facility.
Findings include:
On 10/25/1022 at 11:55AM, a half-full bulk pack of uncooked hot dogs was stored in the kitchen walk-in-cooler. The hot dog package was not labeled with the date opened or a use-by date, as required.
At 12:00PM, a one-gallon bleach jug was located on a cart in the kitchen nearby sanitizer wiping buckets. V3 (Dietary Manager) was present and reported the jug of bleach was used for preparing sanitizer solution. The jug was not labeled for food service use and did not have the required pesticide registration identification. V3 reported being unsure if the bleach product was food grade.
On 10/25/2022 at 12:00PM, the kitchen can opener mounted on a preparation table was soiled with accumulations of food debris and the receiver was leaking a brown liquid onto the floor surface below the can opener. V3 was present and stated Aww, yeah, yes it (the can opener) does (need cleaned).
On 10/26/2022 at 12:26PM, the hot dog package from above was located on a food preparation table and remained unlabeled. V3 reported the kitchen normally takes a week and a half through two weeks to use an entire package of hot dogs. V3 reported the food in the kitchen is available for all residents to use.
The facility Resident Census and Conditions of Residents report (10/25/2022) documents 43 residents reside in the facility.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Illinois facilities.
Concerns
- • 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (30/100). Below average facility with significant concerns.
- • 100% turnover. Very high, 52 points above average. Constant new faces learning your loved one's needs.
Bottom line: Trust Score of 30/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Heartland Nursing & Rehab's CMS Rating?
CMS assigns HEARTLAND NURSING & REHAB an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Heartland Nursing & Rehab Staffed?
CMS rates HEARTLAND NURSING & REHAB's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 100%, which is 53 percentage points above the Illinois average of 47%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 100%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Heartland Nursing & Rehab?
State health inspectors documented 40 deficiencies at HEARTLAND NURSING & REHAB during 2022 to 2025. These included: 40 with potential for harm.
Who Owns and Operates Heartland Nursing & Rehab?
HEARTLAND NURSING & REHAB is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by WLC MANAGEMENT FIRM, a chain that manages multiple nursing homes. With 81 certified beds and approximately 47 residents (about 58% occupancy), it is a smaller facility located in CASEY, Illinois.
How Does Heartland Nursing & Rehab Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, HEARTLAND NURSING & REHAB's overall rating (1 stars) is below the state average of 2.5, staff turnover (100%) is significantly higher than the state average of 47%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Heartland Nursing & Rehab?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Heartland Nursing & Rehab Safe?
Based on CMS inspection data, HEARTLAND NURSING & REHAB has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Heartland Nursing & Rehab Stick Around?
Staff turnover at HEARTLAND NURSING & REHAB is high. At 100%, the facility is 53 percentage points above the Illinois average of 47%. Registered Nurse turnover is particularly concerning at 100%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Heartland Nursing & Rehab Ever Fined?
HEARTLAND NURSING & REHAB has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Heartland Nursing & Rehab on Any Federal Watch List?
HEARTLAND NURSING & REHAB is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.