THE HAVEN OF MEADOWBROOK
For profit - Limited Liability company
60 Beds
HAVEN HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#649 of 665 in IL
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Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Haven of Meadowbrook has received a Trust Grade of F, which indicates significant concerns about the care provided-essentially the lowest rating. It ranks #649 out of 665 nursing homes in Illinois, placing it in the bottom half of facilities statewide, and is the lowest-ranked option in Champaign County. While the number of reported issues has improved from 31 in 2024 to 19 in 2025, the facility still faces serious challenges, including 98 total deficiencies, with 9 classified as serious incidents that caused harm. Staffing is a critical concern, evidenced by a 1/5 star rating and only minimal RN coverage-less than 91% of facilities in Illinois-which compromises the quality of care. Specific incidents include a resident suffering a second-degree burn due to inadequate safety measures and failures to address residents' rights and dignity, which resulted in emotional distress for several individuals. Overall, while there are some signs of improvement, the weaknesses in care and safety pose significant risks for prospective residents.
- Trust Score
- F
- In Illinois
- #649/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $162,596 in fines. Higher than 75% of Illinois facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 19 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 98 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 3%
Review needed
31 → 19 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 31 issues
2025: 19 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 55%
Near Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $162,596
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: HAVEN HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (55%)
7 points above Illinois average of 48%
The Ugly 98 deficiencies on record
1 life-threatening 9 actual harm
Mar 2025
19 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Resident Rights
(Tag F0550)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review the facility failed to respect residents' right to be treated with dignity and respect for seven (R10, R31, R19, R29, R37, R45, R57) of seven residen...
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Based on observation, interview, and record review the facility failed to respect residents' right to be treated with dignity and respect for seven (R10, R31, R19, R29, R37, R45, R57) of seven residents reviewed for resident rights in the sample list of 39. This failure resulted in psychosocial harm of R10 and R57 causing R10 and R57 to be visibly upset and tearful.
Findings include:
The undated Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.
1.) The facility's Resident Council Minutes dated 9/19/24 document call lights need answered timely and Certified Nursing Assistants (CNA) say not my resident when asked to provide care or answer call lights for unassigned residents. The facility's Resident Council Minutes dated 10/17/24 document concerns with CNAs and Nurses needing attitude adjustments and using phrases not my job, not my resident. The facility's Resident Council Minutes dated 11/21/24 document concerns that kitchen staff refuse things when asked. The facility's Resident Council Minutes dated 12/20/24 document the CNAs need attitude adjustments and concerns with CNAs being on their cellular phones and not answering call lights timely. The Resident Council Minutes dated 2/20/25 document concerns with CNA, nurses and dietary staff needing attitude adjustments, and residents have to call the nurse's station due to call lights not being answered.
On 3/09/25 at 2:07 PM a resident council meeting was conducted. R29, R57, R37, R19 and R45 all confirmed call light wait times have been an ongoing problem with call lights being on for 45 minutes to an hour. R29 stated R29's main concern is that CNAs say I'll be right back or I'm not your CNA. R57 stated the CNA attitudes are atrocious and all residents agreed staff attitudes have been an ongoing problem. R29 and R57 stated when the residents complain about staff, the staff then intentionally don't answer their call lights, but were unable to identify which staff. R37 stated about a month ago R37 fell on the floor in his bathroom and waited for an hour and half with the call light on. R37 stated no staff came to answer R37's call light so R37 had to self transfer off of the floor and R37 reported this to unidentified staff. R29 stated V9 [NAME] had R57 in tears yesterday because R57 asked what the alternative was for dinner. R57 stated V9 said it's soup and sandwich and then V9 turned to an unidentified coworker and said V9 was tired of this and V9 was ready to clock out and go home. R57 stated staff, including V16 CNA, witnessed this incident. R57 stated R57 didn't feel V9's actions were considered abuse but more of a dignity and respect issue. R57 stated R57 felt scolded like a child. R29, R57, R37, R19 and R45 all stated V9 has a terrible attitude and tells the residents take it or leave it when it comes to the food. These residents also stated V13 CNA is always on V13's phone, V13 is rude, V13 has an attitude and tells residents that V13 will be right back but then doesn't return to answer the call light.
On 3/10/25 at 2:28 PM V16 CNA stated V16 witnessed the incident between R57 and V9 that occurred in the evening of 3/8/25. V16 stated R57 wanted to know what food was being served and V9 fired off at (R57) and was rude to R57. V16 stated V9 said R57 was getting on V9's nerves and V9 was ready to clock out and go home. V16 stated at that time R57 was upset/tearful and R57 didn't want anything to eat. V16 stated V16 reported this immediately to V1 Administrator.
On 3/10/25 at 10:41 AM V12 CNA stated V9 is short with the residents, V9's tone is loud, and V9 does not always get the residents the foods that they request from the kitchen.
On 3/10/25 at 2:09 PM V1 Administrator stated V1 had not been made aware of any concerns with V9's and V13's attitudes or dignity/respect. V1 stated V1 will need to follow up and do customer service education. On 3/11/25 at 10:37 AM V1 stated the dignity is part of the Resident Rights packet, which is what the facility uses as a policy.
2.) On 3/09/25 at 9:51 AM R31 stated CNAs (later identified as V16 and V15) got mad at R31's room mate, R10, causing R10 to cry. R31 stated R31 reported this to V8 Social Service Director who said V8 would follow up with V1 Administrator. R10 stated sometime last week the CNA (V16) came in to assist R10, this CNA was upset because night shift had not changed R10 or applied R10's lymphedema compression machine to R10's legs. R10 stated the CNA said night shift should have already applied R10's compression machine and changed R10. R10 told V16 that R10 was disgusted and V16 told R10 well it's my job. R10 stated the CNA caused R10 to cry, like I'm (R10) going to now. R10 was visibly upset and tearful. R10 stated R10 didn't feel abused by V16, but that it was more of a dignity/respect issue. R10 stated it was V16's tone of voice and R10 felt scolded by V16.
R31's Grievance/Complaint Form dated 3/6/25 documents R31 reported the CNAs came in very early to wake up R10, the CNAs were loud and upsetting R10 while they assisted R10 out of bed. R31 had asked the CNAs why R10 had to get up so early and they replied that they had to, which caused R10 to be very upset.
On 3/09/25 at 11:59 AM V8 stated on 3/6/25 R31 reported concerns that the CNAs had upset R10. The CNAs were complaining because R10 and R31 were complaining about getting up so early. V8 stated the CNAs told R31/R10 that was what they had to do. V8 stated this was reported to V1 on 3/7/25.
On 3/10/25 at 10:41 AM V16 CNA recalled the incident with R10. V16 stated night shift had not completed their assigned tasks for R10 one day last week which caused more work for the dayshift. V16 stated V16 was frustrated and should not have vented to R10 because R10 took it personally. V16 stated R10 was upset/crying and V16 reassured R10 and apologized at that time.
On 3/10/25 at 2:09 PM V1 stated V1 had not been made aware of any concerns with V15's and V16's attitudes or dignity/respect.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0659
(Tag F0659)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to have a physician order for medication found at the bedside for one (R39) of one resident reviewed for self administration of m...
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Based on observation, interview, and record review the facility failed to have a physician order for medication found at the bedside for one (R39) of one resident reviewed for self administration of medications in the sample list of 39.
Findings include:
The facility's Medication Administration policy dated 11/18/17 documents medications will not be kept at the bedside unless there is a physician order to do so.
On 3/09/25 at 8:50 AM there was a Combivent inhaler on R39's overbed table. R39 stated R39 self administers the inhaler, two puffs, two to four times per day and the inhaler is always kept in R39's room.
R39's March 2025 Physician Order Summary does not document an active order for the Combivent inhaler or for R39 to keep this medication at the bedside prior to 3/9/25.
On 3/9/25 between 12:48 PM and 12:52 PM V7 Registered Nurse stated R39 has an inhaler that R39 keeps in her room and self administers. V7 reviewed R39's active physicians orders and Medication Administration Record and confirmed there is no order for the Combivent inhaler. V3 Assistant Director of Nursing stated residents need an assessment and physician's order to keep medications at the bedside and self administer. V3 instructed V7 to follow up and get a physician's order for the inhaler.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement physician's ordered treatments, monitor dail...
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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 physician's ordered treatments, monitor daily weights, report weight gain, and develop a care plan for lymphedema and congestive heart failure (CHF) for one (R10) of two residents reviewed for edema in the sample list of 39.
Findings include:
On 03/09/25 at 9:51 AM R10 stated R10's legs are suppose to be wrapped every morning and removed every night, but that doesn't always get done. R10 stated R10's leg wraps have been on for several days. R10 stated R10 was hospitalized in November 2024 for cough and lymphedema. R10's legs had lymphedema and the leg wraps were sliding down onto R10's feet.
R10's Minimum Data Set (MDS) dated [DATE] documents R10 is cognitively intact. R10's active care plan lists diagnoses of Lymphedema and CHF, but does not document a problem, goal, and interventions to address R10's CHF and Lymphedema.
R10's January 2025 Physician's Order Summary documents an order to monitor weight daily, notify physician of 3 pound (lb) weight gain in one day or 5 lb gain in three days. R10's Physician Order dated 2/15/25 documents to apply leg wrap in the morning and remove at bedtime. This order has not been transcribed onto R10's March 2025 Treatment Administration Record (TAR).
R10's After Visit Summary dated 12/9/24, recorded by V23 Cardiologist Advanced Practice Registered Nurse, documents R10 has CHF, monitor weights daily, report gain of 2-3 pounds (lbs) in 24 hours or 5 lb in one week. There is no documentation in R10's medical record that daily weight monitoring was initiated prior to 1/3/25.
R10's Progress Note dated 1/8/25, recorded by V32 Physician, documents R10 was hospitalized in November 2024 and diuresed more than 60 lbs, R10's legs are swollen again and R10 has gained 36.8 lbs over the past month. R10's Progress Note dated 2/7/25, recorded by V32 documents R10 has a long history of lymphedema, R10's legs are dependent, R10's legs are heavy and thick, and R10 now has lymphedema wraps. This note documents R10 had lost 61 lbs of water weight and has now gained over 38 lbs back again.
R10's Monthly Weight and Vitals form ranging September-December 2024 documents R10's December weight as 292.8 lbs. R10's December 2024 and January - February 2025 Daily Weight Logs documents only one recorded weight of 248 lbs on 12/3/24. There are only 15 recorded weights between 1/1/25 and 2/28/25. R10 weighed 245.8 lbs on 1/3/25 and 258.8 lbs on 1/7/25, a 13 lb gain in one week. R10 weighed 248.6 on 1/9/25 and 263.6 on 1/14/2, a 15 lb gain in five days. R10's March 2025 Daily Weight Log documents R10 weighed 243.2 on 3/2/25, 245.4 lbs on 3/6/25, 249.2 lbs on 3/7/25 (3.8 lb gain in one day), and 250.1 lbs on 3/8/25 (6.9 lb gain in one week). There is no documentation in R10's medical record that V23 was notified of R10's listed weight gain.
On 3/09/25 at 10:09 AM V7 Registered Nurse stated R10 has a lymphedema compression machine that stopped working two days ago and the company has been notified. V7 stated sometimes night shift wraps R10's legs in the morning otherwise the day shift nurse wraps R10's legs. V7 stated the compression wraps are suppose to be removed at night and reapplied in the morning, and this should be documented on R10's TAR. V7 reviewed R10's March 2025 TAR. V7 stated there is nothing documented about applying R10's leg wraps only applying the lymphedema compression machine.
On 3/10/25 at 12:52 PM V3 Assistant Director of Nursing stated the nurses should document R10's leg wraps and lymphedema compression machine on R10's TAR. V3 stated R10's weights should be monitored daily. At 1:10 PM the weight log book was reviewed with V3. V3 confirmed the Daily Weight Logs were missing entries between December 2024 and February 2025. V3 stated R10's daily weights were initiated in January 2025. At 2:18 PM V3 stated R10 should have been weighed daily in December 2024 but the staff did not record R10's daily weights. V3 confirmed all of R10's weight documentation was provided. On 3/11/25 at 8:45 AM V3 stated the nurses should document physician notification in the nursing notes. V3 stated according to R10's January 2025 physician order, the nurses should notify V23 of a 3 lb weight gain in one day and 5 lb gain in three days. V3 reviewed R10's nursing notes and confirmed there is no documentation that R10's weight gain between January 2025-March 2025 was reported V23 after 1/9/25.
On 3/11/25 at 10:25 AM V22 Registered Nurse at V23's office stated R10 has been V23's patient since March 2024 and at that time R10 had lymphedema but did not have CHF. V22 stated there were no orders for monitoring R10's lymphedema or weights prior to R10 being hospitalized in November 2024 when CHF was added as a new diagnosis. V22 stated R10 was evaluated in the office by V23 on 12/9/24 and 1/9/25, and R10's next appointment is scheduled for 4/23/25. V22 stated per V23's notes, R10 should be weighed daily and the facility should notify V23's office of a 2 lb gain in one day and 4-5 lb gain in one week. V22 stated V22 did not see documentation that the facility had notified the office of R10's weight gains after 1/9/25.
On 3/11/25 at 12:48 PM V30 MDS/Care Plan Coordinator confirmed R10's care plan does not have a problem, goals, and interventions to address R10's lymphedema and CHF.
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
Based on observation, interview, and record review, the facility failed to obtain a treatment order for a newly discovered pressure area, monitor the area and follow manufactures recommendations for a...
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Based on observation, interview, and record review, the facility failed to obtain a treatment order for a newly discovered pressure area, monitor the area and follow manufactures recommendations for a treatment application for one resident (R43) of two residents reviewed for pressure ulcers in the sample list of 39.
Findings include:
R43's undated diagnoses list documents R43's diagnoses as: Acute and Chronic Respiratory Failure without Hypoxia, Type II Diabetes Mellitus without complications, Chronic Obstructive Pulmonary Disease, and Cognitive Communication Deficit. Pressure Wound is not listed as a diagnosis in R43's medical record.
R43's Hospice notes dated 12/19/24, document redness to buttocks. R43's medical Record has no other documentation regarding this area until another Hospice note dated 1/2/25. This Hospice note documents a stage II wound measuring 2 centimeters (cm) by 2 cm and recommended a treatment. A telephone order written on 1/8/25, was given with treatment orders for R43's pressure wound.
R43's Treatment Administration Records (TAR) for December 2024 has no documentation for the red area on R43's buttocks to be monitored, and the January 2025 TAR documents the treatment ordered on 1/8/25 did not start until 1/9/25.
There are no skin assessments for pressure wounds documented in R43's medical record.
R43's Minimum Data Set (MDS) has no documentation for a significant change for R43.
R43's Care Plan dated 6/6/24, has no documentation for a pressure wound and no interventions for wounds.
On 3/10/25 at 10:30 AM, V6, Licensed Practical Nurse (LPN), while providing a pressure wound treatment, did not cut the prescribed Calcium Alginate treatment to fit the wound bed. V6 cut the Calcium Alginate bigger than the wound bed including placing the Calcium Alginate over unaffected skin.
On 3/10/25 at 3:19 PM, V3 Assistant Director of Nursing (ADON) stated the Calcium Alginate should have been cut to the wound bed size and not covering good (unaffected) skin.
On 3/10/25 at 3:30 PM, V6 LPN stated the wound bed includes the entire area of the wound including peri-wound and wound bed. V6 stated if V6 tried to cut the Calcium Alginate to the wound bed size she would have contaminated the area.
The facility's undated package insert for Calcium Alginate wound dressing documents dressing may be cut to size prior to application and apply dressing to moist wound bed.
The facility's Prevention of Pressure Wounds dated January 2017, documents to review the resident's Care Plan to assess for any special needs of the resident. This same policy documents a pressure injury is usually formed when a resident remains in the same position for an extended period of time causing increased pressure or decrease of circulation to the area and subsequent destruction of tissue. This same policy documents the facility should have a system/procedure to assure assessments are timely and appropriate, and changes in condition are recognized, evaluated, reported and addressed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Medical Diagnosis sheet from the EMR (Electronic Medical Record) for R36 dated 3/11/25 documents the following diagnosis:...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Medical Diagnosis sheet from the EMR (Electronic Medical Record) for R36 dated 3/11/25 documents the following diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia, Urinary Retention and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. R36's current Medical Record documents R36 has a supra pubic catheter.
March 10, 2025 at 10:53 AM V5, CNA (certified nurse assistant) performed catheter care for R36. V5 use the no rinse disposable peri wipe cloths to clean R36. V5 washed her hands and put on a pair of gloves. V5 took a peri wipe cloth and started wiping R36's penis going in down strokes from the top to tip of the penis. V5 held the penis in one hand and started wiping R36's penis without changing the area of the cloth. V5 went over the same area two to three times not changing out the area on the peri wipe. V5 threw away the wipe and obtained another one and cleanse the other side of the penis doing the same procedure as before not changing the area. V5 then took a wipe and went around the head of the penis. V5 took another wipe and cleaned the catheter tubing starting at the top and went down the tubing 2 to 3 times using the same cloth and the same area. V5 then cleansed the insertion area of the catheter with a new peri wipe. V5 stated she was done with catheter care and went into the bathroom to wash her hands. V5 stated at 11:05 AM on 3/10/25 I should of used a new wipe each time I cleaned him.
Based on observation, interview, and record review the facility failed to provide complete and hygienic catheter care, failed to maintain the urinary catheter tubing and drainage bag off the floor, failed to have a physician order for a urinary catheter and failed to record catheter care and urinary output for two (R31, R36) of two residents reviewed for urinary catheters in the sample list of 39.
Findings include:
The facility's Catheter Care policy dated February 2018 documents for female catheter care, separate the labia and wash the perineal area prior to cleansing the urinary catheter.
1.) On 3/09/25 at 9:51 AM R31 stated staff doesn't always empty R31's urinary catheter drainage bag when requested. R31 stated R31 has had the urinary catheter for about a month and that no staff provide routine cleaning of the catheter. R31 stated the hospital staff cleaned R31's urinary catheter when R31 was at the hospital. R31 stated R31 has a history of bladder infections and urinary retention, which is why the catheter was inserted. On 3/10/25 at 8:48 AM R31 stated the Certified Nursing Assistant (CNA) last evening did not empty R31's catheter bag and urine leaked all over R31's bed.
On 3/10/25 at 9:15 AM R31 self propelled R31's wheelchair down the hall. R31's urinary catheter tubing was dragging the ground and the wheels of R31's wheelchair rolled over the tubing.
On 3/10/25 at 11:30 AM V12 and V5 CNAs entered R31's room. V12 provided R31's urinary catheter care and did not spread and clean R31's labia/perineal area. V12 only cleansed R31's catheter. R31's urinary catheter was wound around the securement device that was attached to R31's thigh in a knot formation, confirmed with V12 and V5. During R31's cares, R31's urinary drainage bag was on the side of the bed and touching the floor. V5 confirmed R31's drainage bag should not be touching the floor. At 11:56 AM R31's catheter drainage bag was still touching the floor. V12 stated a privacy bag is used for the wheelchair, but not when R31 is in bed. V12 confirmed V12 did not cleanse R31's labia/perineal area as part of R31's urinary catheter care. V12 stated V12 usually does that as part of catheter care and confirmed it should have been done.
R31's Minimum Data Set, dated [DATE] documents R31 as cognitively intact.
R31's March 2025 Physician Order Summary does not document an active order for a urinary catheter and size. R31's March Treatment Administration Record (TAR) does not document any routine catheter care/cleaning. This TAR documents to empty urinary catheter every shift, but does not consistently document the amount of urine output.
R31's Care Plan dated 11/21/24 documents urinary catheter use and an intervention to check tubing for kinks every shift.
On 3/10/25 at 12:21 PM V3 Assistant Director of Nursing stated R31 returned from the hospital on 2/21/25 with a urinary catheter due to retention. R31 has a urology appointment tomorrow and it may be removed, which is why there were no orders for urinary catheter size or changes. V3 stated the labia should be cleaned as part of female urinary catheter care. On 3/11/25 at 8:45 AM V3 stated the CNAs should empty the catheter every shift and the nurses record the amount of urine output every shift on the TAR. V3 stated catheter cleaning is done by the CNAs and should be documented on the TAR. V3 stated V3 will need to update R31's TAR to include catheter care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to implement gradual dose reductions (GDR), identify and track targeted behaviors, implement nonpharmacological interventions, and assess for t...
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Based on interview and record review the facility failed to implement gradual dose reductions (GDR), identify and track targeted behaviors, implement nonpharmacological interventions, and assess for the use of psychotropic medications for one of five residents (R14) reviewed for unnecessary medications in the sample list of 39.
Findings include:
The facility's Psychotropic Medication Policy dated 11/28/17 documents the following: An unnecessary drug is any drug used in an excessive dose, for excessive duration, without adequate monitoring, without indications for use, and drugs should be reduced or discontinued if adverse consequences are present. Rule out causative agents of behaviors, implement nonpharmacological interventions to decrease behaviors and prior to prescribing psychotropic medications, complete a Pre-Psychotropic Medication Assessment prior to a new psychotropic medication order and complete quarterly Psychotropic Medication Assessments. Residents with psychotropic medications will have documented behaviors and behavior tracking sheets implemented for monitoring. Residents will receive behavioral interventions and GDRs with reduction attempts at least twice per year unless clinically contraindicated and documented by a physician. The interdisciplinary team will review psychotropic medications quarterly and the care plan will identify targeted behaviors and approaches to address these behaviors.
R14's March 2025 Physician Order Summary (POS) documents orders for Clonazepam (Antianxiety) 0.5 milligrams (mg) by mouth twice daily, Amitriptyline (antidepressant) 50 mg daily, and Quetiapine (antipsychotic) 400 mg daily for Bipolar Disorder. R14's June 2024 POS documents orders for Clonazepam 0.5 mg twice daily (5/13/24), Amitriptyline 50 mg daily (1/24/23), and Quetiapine 400 mg daily (5/12/23).
R14's active care plan documents the use of psychotropic medications for anxiety, depression, and Bipolar, but does not identify R14's behaviors that warranted the use of these medications or nonpharmacological interventions to address R14's behaviors. There are no documented psychotropic medication assessments, targeted behavior monitoring and nonpharmacological interventions in R14's medical record within the last six months. There is no documentation that a GDR in Clonazepam was attempted or declined by a provider since prescribed in May 2024.
On 3/11/25 at 11:50 AM V3 Assistant Director of Nursing stated V3 was unable to locate behavior tracking for R14. V3 stated R14 doesn't really have any behaviors and is stable with R14's medications. At 12:19 PM V3 stated behaviors and nonpharmacological interventions should be on the resident's care plan. V3 was unsure what nonpharmacological interventions are used for R14 since R14 does not have any behaviors. At 1:17 PM V3 stated the former Director of Nursing was monitoring the psychotropic medication use and as of February V3 has been rounding with the psychiatric provider. V3 stated V3 was not trained to document any psychotropic medication assessments. V3 stated if the resident has a behavior we notify the doctor to obtain orders. V3 confirmed there were no documented psychotropic medication assessments for R14. At 2:45 PM V3 stated R14 has been on Clonazepam since May 2024 and there was no documentation that a GDR was attempted for this medication or documented declination for GDR by a provider.
On 3/11/25 at 12:48 PM V30 Minimum Data Set/Care Plan Coordinator stated V30 has been in this role for one month and had worked as a floor nurse for a couple months prior. V30 confirmed R14's care plan documents diagnoses but no targeted behaviors and nonpharmacological interventions to warrant the use of psychotropic medications. V30 stated R14 does not really have behaviors other than crying at times, getting frustrated, and gossiping with other residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation,interview and record review the facility failed to administer medications according to physician orders and manufacturer recommendations for two of five residents (R30 and R31) re...
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Based on observation,interview and record review the facility failed to administer medications according to physician orders and manufacturer recommendations for two of five residents (R30 and R31) reviewed for medication administration on the sample of 39. The facility had two errors out of 28 opportunities resulting in a medication error rate of 7.14 percent.
Findings include:
The facility's policy titled Medication Administration revision date 11/18/17 states Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given.
1.) R30's March 2025 Physician Order Sheet (POS) documents an order for Lisinopril 2.5 mg (milligram) once a day. The order continues to read to hold if systolic BP (blood pressure) is less than 100. On 3/10/25 at 8:45 am V6, LPN administered R30's Lisinopril V6 did not check R30's blood pressure before giving the medication. V6 stated the BP was 132/70 when asked where the BP could be found she stated I took it off the vitals form when it was taken earlier on night shift. V6 stated they did not have a form to document blood pressures.
On 3/10/25 at 10:30 AM , V3 Assistant Director of Nurses stated the BP is to be taken and written down before administering the medication Lisinopril.
2. R31's March POS documents an order for Zofran disintegrating tablet 8 mg every 6 hours as needed for nausea and vomiting. On 3/10/25 at 9:00 am V6 took R31's Zofran and put it in the medication cup along with the other medications (R31) was taking. The March 2025 Medication Administration Record documents Zofran is to be put under the tongue to dissolve and not swallowed. When V6 was asked about the Zofran not being separated from the other medications when returning to the medication cart on 3/10/25 at 9:10 AM V6 stated the resident usually picks the medication out of the med cup and leaves for last but R31 swallowed the medication whole this time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to follow a diet order for thickened liquids for one (R210) of 24 residents reviewed for meals in the sample list of 39.
Finding...
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Based on observation, interview, and record review the facility failed to follow a diet order for thickened liquids for one (R210) of 24 residents reviewed for meals in the sample list of 39.
Findings include:
The facility's Diet Orders policy dated June 2006 documents the physician should be contacted to receive diet orders, nursing notifies the dietary department in writing of the correct diet order using the Diet Order Form, and the food service manager is responsive for reviewing the resident's medical record to ensure a written order exists and matches the diet order. This policy documents Diet Order Forms are kept on file in the dietary department for staff to reference.
On 3/09/25 at 9:26 AM R210's breakfast tray contained regular consistency water and juice. V5 Certified Nursing Assistant (CNA) stated R210 refused breakfast, but R210 drinks a lot of water that is supposed to be thickened. V5 confirmed R210's breakfast tray contained regular consistency liquids.
On 3/09/25 at 1:27 PM R210 was in bed and R210's noon meal tray was at the bedside. R210's meal consisted of regular consistency water and lemonade. R210's meal tray card did not document thickened liquids. This was confirmed with V14 CNA. V14 stated R210 has been in the facility for approximately two weeks, R210 receives hospice care and has vomiting and congestion at times. V14 stated the CNAs know that R210 is suppose to have thickened liquids.
R210's March 2025 Physician Order Summary (POS) documents R210's diet as regular and does not list thickened liquids. R210's Nursing Note dated 2/20/25 at 9:00 PM documents gurgling oral care was provided, Atropine was given, and R210 remains on hospice care.
On 3/09/25 at 1:32 PM V19 Dietary Aide stated the nurses give diet orders to the dietary department and there should be a pink sticker documenting thickened liquids on the resident's tray card. V19 stated V19 was unable to locate any diet orders for R210 and will follow up. At 1:39 PM V20 [NAME] provided R210's Diet Order Form dated 2/22/25 for nectar thickened liquids. This form is signed by V7 Registered Nurse. V20 confirmed dietary staff should be serving R210 nectar thickened liquids.
On 3/9/25 at 1:37 PM V3 Assistant Director of Nursing stated R210's family had requested thickened liquids due to R210 coughing, but R210 is on a regular diet with regular liquids. On 3/9/25 at 3:16 PM V7 Registered Nurse stated V7 received R210's diet order for thickened liquids from the hospice nurse. V3 stated R210's POS will need to be updated with the diet order and told V7 that V7 should have obtained a physician order for the diet change from hospice.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
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 ensure residents have access to their personal funds for four (R57, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents have access to their personal funds for four (R57, R14, R19, R37) of seven residents reviewed for personal funds in the sample list of 39.
Findings include:
The facility's Resident Personal Trust Funds policy dated 4/15/24 documents the resident personal funds will be maintained in the business office and social services staff can assist residents in obtaining funds from the business office. This policy documents residents may make deposits or receive funds at the business office during regular business hours Monday through Friday or at the specified times posted in the facility. Withdrawals for less than $60 will be made immediately and over $60 will require a 24 hour notice.
1.) On 03/09/25 at 9:19 AM R14 stated R14 has a $60 monthly income that the facility keeps in trust fund account. R14 stated R14 does not have access to R14's personal funds on the weekends when V17 Business Office Manager isn't in the facility, which isn't right.
R14's Minimum Data Set, dated [DATE] documents R14 as cognitively intact.
The facility's Trial Balance for resident trust fund accounts dated 3/10/25 documents R14 has a personal fund accounts at the facility.
2.) On 3/9/25 at 2:07 PM, during the resident council meeting, R57, R19, and R37 stated they aren't able to obtain money from their personal funds account on the weekends and when V17 isn't at the facility. They stated they have to wait for V17 to return in order to get their money from their accounts.
The facility's Trial Balance for resident trust fund accounts dated 3/10/25 documents R19, R37, and R57 have personal fund accounts at the facility.
The facility's Resident Council Minutes dated 2/20/25 documents concerns that residents need to know how to get money from the business office when the manager has a day off.
On 3/10/25 at 10:48 AM V17 stated V17 manages the resident trust fund accounts and V1 Administrator is the only other person who has access to these accounts. V17 stated V17 only works one Saturday per month.
On 3/10/25 at 10:54 AM V1 Administrator stated V1 has access to the resident trust funds, but no one is here on the weekends to access these accounts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
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 provide quarterly statements for personal fund accounts for four (R1...
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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 quarterly statements for personal fund accounts for four (R1, R7, R14, R18) of seven residents reviewed for personal funds in the sample list of 39.
Findings include:
The facility's Resident Personal Trust Funds policy dated 4/15/24 documents the resident personal funds will be maintained in the business office and quarterly statements for all transactions will be provided to the resident or legal representative.
1.) On 03/09/25 at 9:19 AM R14 stated R14 has a $60 monthly income that the facility keeps in trust fund account.
R14's Minimum Data Set, dated [DATE] documents R14 as cognitively intact.
The facility's Resident Council Minutes dated 2/20/25 document concerns that residents need account statements for what they are paying for.
R14's Resident Statement dated 3/10/25 documents transactions between 1/1/25 and 3/5/25, with a remaining balance of $2,496.20.
2.) R7's Resident Statement dated 3/10/25 documents transactions between 1/2/25 and 3/3/25, with a remaining balance of $5, 199.75.
3.) R1's Resident Statement dated 3/1/25 documents transactions between 12/18/25 and 3/3/25, with a remaining balance of $381.00.
4.) R18's Resident Statement dated 3/10/25 documents transactions between 12/18/25 and 3/5/25, with a remaining balance of $2,078.69.
On 3/10/25 at 10:48 AM V17 Business Office Manager stated V17 manages the resident trust fund account and V17 has not provided quarterly statements to the residents after the facility's change of ownership on 11/1/24. At 1:20 PM V17 confirmed R1, R7, R14, and R18 all have personal funds accounts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R43's undated Face Sheet, documents R43's diagnoses as Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructiv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R43's undated Face Sheet, documents R43's diagnoses as Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, unspecified, Cognitive Communication Deficit, Muscle Weakness, generalized, unspecified Dementia,unspecified severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety.
R43's Physician Order Sheet (POS) dated 12/1/24-12/31/24, documents R43 is on Hospice. This same POS documents R43 was sent to the Emergency Department on 12/1/24 and returned to the facility on [DATE].
R43's shower sheets for December 2024, documents only three showers given on 12/10/24, 12/13/24, 12/31/24 and R43 should have had six showers; January 2025, documents only four showers given on 1/9/25, 1/18/25, 1/26/25, 1/31/25, and R43 should have had six showers; and February 2025, documents only two showers given on 2/2/25 and 2/18/25, and R43 should have had eight showers.
On 3/11/25 at 9:15am V3 Assistant Director of Nursing (ADON) stated all residents are scheduled for two showers a week, and if a resident refuses a shower after three attempts a bed bath is offered. V3 stated if the resident still refuses, a nurse is notified and documents it in the resident's chart. V3 stated after giving the resident a shower, the Certified Nursing Assistant (CNA) documents it on a shower sheet. V3 stated all showers must be documented on a shower sheet whether the resident receives a shower, bed baths or refusals.
Based on interview and record review, the facility failed to provide numerous showers as scheduled for dependent residents. These failures affect two residents (R9, R43) of three reviewed for activities of daily living in the sample list of 39.
1. On 3/9/25 at 9:00am R10 stated that R9 is R10's Husband and R9 does not get two showers a week. R10 stated that R9 needs help from staff to get a shower, due to R9's not knowing how to take one without someone helping R9.
On 3/11/25 at 9:15am V3 Assistant Director of Nursing (ADON) stated all residents are scheduled for two showers a week, and if a resident refuses a shower after three attempts a bed bath is offered. V3 stated if the resident still refuses, a nurse is notified and documents it in the resident's chart. V3 stated after giving the resident a shower, the Certified Nursing Assistant (CNA) documents it on a shower sheet. V3 stated all showers must be documented on a shower sheet whether the resident receives a shower, bed baths or refusals.
On 3/11/25 at 12:15am V29 Certified Nursing Assistant (CNA) confirmed that R9 has not had any documented showers in February or March 2025. V29 stated that V29 could not locate any shower sheets that document that R9 received a shower or bed bath and only one refusal was found. V29 stated R9 should be getting two showers a week, and if R9 gets a bed bath or refuses staff should be completing a shower sheet.
R9's Facility Census documents R9 was admitted to the facility on [DATE] and has the following medical diagnoses; Cognitive Communication Deficit, Need for Assistance with Personal Care, Unsteadiness on Feet, Dementia, Depression.
R9's Minimum Data Set, dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score six, severe cognitive impairment, and needs substantial assistance with showers.
R9's Care Plan dated 3/15/24 documents R1 requires extensive assist of 1 and gait belt transfers. R9 requires assistance from staff to complete Activities of Daily Living.
The facility's shower schedules document R9's showers are scheduled twice per week on Wednesdays and Fridays.
R9's February and March 2025 shower sheets provided by V3 Assistant Director of Nursing (ADON) and V29 Certified Nursing Assistant documents R9 has not received any showers in February and March and refused one shower on 2/17/25. There are no other documented showers, bed baths or refusals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to offer immunization education, immunization consent forms, and vaccinations for five residents (R9, R28, R41, R52, R160) of five residents r...
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Based on interview and record review, the facility failed to offer immunization education, immunization consent forms, and vaccinations for five residents (R9, R28, R41, R52, R160) of five residents reviewed for immunizations in the sample list of 39.
Findings include:
R9, R28, R41, R52, and R160 have no documentation of education for vaccinations, no consents for vaccinations, and no documentation of vaccines being offered or administered in their medical records.
On 3/11/25 at 2:30 PM, V2 Corporate Nurse stated there is no documentation for immunizations for the five residents (R9, R28, R41, R52, R160) requested.
The facility's Immunization of Residents Policy dated Revised 1/23/20, documents this facility will offer immunizations and vaccinations that aid in the prevention of infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to follow up on grievances and document actions taken for six (R19, R29, R36, R37, R45, R57) of six residents reviewed for grieva...
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Based on observation, interview, and record review the facility failed to follow up on grievances and document actions taken for six (R19, R29, R36, R37, R45, R57) of six residents reviewed for grievances in the sample list of 39. This failure has the potential to affect all 51 residents in the facility.
Findings include:
The facility's undated Resident Council Policy documents the purpose of the council meeting is to protect and preserve resident rights and for residents to discuss grievances/problems and to participate in the resolution of these concerns. This policy documents suggestions and complaints will be presented in writing to the facility's Administrator, Social Services Director, and other facility staff to review and implement follow up actions. The Concern/Suggestion form will be used to document concerns and the Administrator will respond to all council recommendations and complaints in writing, and per the facility's grievance policy.
The facility's Grievance policy dated November 2016 documents the facility will post information on how to file a grievance and the contact information for the grievance official. This policy documents grievances will be submitted in writing to the Administrator within five working days, the Administrator may delegate grievance investigations to relevant staff, and the Administrator will review the findings to determine corrective actions. This policy documents the resident or person who filed the grievance will be informed of the investigative findings and actions taken to correct the concern.
The facility's Resident Council Minutes dated 9/19/24 document concerns with locating work order forms for repairs, wanting day and night snacks, repetitive meals, missing laundry items, overlapping times for medication passes, Certified Nursing Assistants (CNAs) not answering call lights timely, timely toileting/incontinence cares, trash cans not being emptied and liners not replaced. The Resident Council Minutes dated 10/17/24 document concerns with housekeeping not changing mop heads between rooms, missing laundry items, CNA and nurse attitudes, staff sleeping on the job, and prompt medication times. The Resident Council Minutes dated 11/21/24 document concerns with kitchen staff refusing to provide requested items, posting menus, laundry sent to the wrong closet, replacing trash can liners, and late medications. The Resident Council Minutes dated 12/20/24 document concerns with wanting larger portions for meals, meals being cold and not served on time, changing mop heads between rooms, laundry items need marked, replacing trash can liners, CNA attitudes, call lights, and staff sleeping on the job. The Resident Council Meeting dated 1/16/25 documents concerns with meals being late and cold, laundry being returned to the wrong closet, trash can liners not being replaced, and CNAs saying they will be back but not returning. The Resident Council Minutes dated 2/20/25 document concerns with dietary/CNA/nurse attitudes, food being cold, missing meals, larger portions of food, trash cans not being emptied, call lights, and medications being on time.
The facility's Grievance Log ranging from 11/29/24-3/6/25 only documents grievances for resident council on 1/16/25 for laundry not being marked or returned, and on 2/20/25 for items not being returned timely or to the wrong closet. The Grievance/Complaint Report dated 1/16/25 documents concerns with housekeeping staff mopping restrooms and using the same mop head to mop the rest of the room. This form documents V1 Administrator spoke with the housekeeping supervisor, staff were re-educated on appropriate cleaning method, and this will be monitored by the housekeeping supervisor. The Grievance/Complaint Report dated 1/16/25 documents meals are served late and cold, V1 spoke with the kitchen staff about serving meals timely, and this will be monitored through ongoing observation and education. There are no other documented follow up actions for the concerns mentioned in the Resident Council Minutes.
On 3/09/25 at 2:07 PM, during the resident council meeting, R29, R19, R37, R45, and R57 reported ongoing concerns with not being able to access their money on the weekends, call light wait times, medications being late, staff attitudes, replacement of trash can liners, evening snacks/coffee, V9 [NAME] attitude, V13 CNA attitude, and meals being served late/cold. R37 stated R37 has a pair of pants that have been missing for over two months, this was reported to V21 Housekeeping Supervisor and V21 searched and was unable to find R37's pants. R57 stated R57 has been missing a pillowcase from R57's bedding set for about a month, V21 was aware, but the pillowcase was never found. These residents were unsure who to report grievances/concerns to other than bringing it up during the council meetings and were unsure of what actions the facility was taking to follow up on their reported concerns.
On 03/10/25 at 10:36 AM V33 Licensed Practical Nurse stated V33 is usually done with the morning medication pass by 10:00 AM. V33 stated the morning medications are scheduled to be given at 8:00 AM. At this time V33 was observed passing medications to R36. V33 confirmed V33's medications were R36's scheduled 8:00 AM medications. V33 stated R36 was the last resident for V33's morning medication pass. R36's March 2025 Medication Administration Record documents Amlodipine 10 milligrams (mg), Aspirin 81 mg, Multivitamin, Duloxetine 60 mg, Famotidine 20 mg, Ferosul 325 mg, Pregabalin 75 mg, Timolol 0.5% eye drops, Vitamin C 500 mg, Brimonidine 0.2% eye drops, Dorzolamide/Timolol eye drops, Sodium Bicarbonate 650 mg, Lisinopril 10 mg, and Torsemide 40 mg are scheduled to give at 8:00 AM.
On 3/11/25 at 10:49 AM V7 Registered Nurse confirmed medications are suppose to be given within an hour window before/after the scheduled time. V7 stated once or twice a week there are times when V7 hasn't been able to give medications within that time frame.
On 3/09/25 at 3:18 PM V18 Activity Director confirmed the repeated issues brought up in the resident council meetings. V18 stated V1 Administrator is notified of these concerns and V18 thought V1 documents the follow up actions. V18 reviews the concerns from the prior month at each meeting, but was unaware that V18 needed to have documentation on follow up actions taken for the concerns. On 3/10/25 at 9:43 AM V18 confirmed there were no documented follow up actions taken for the September 2024-February 2025 council meeting concerns, besides the 1/16/25 and 2/20/24 grievance forms.
On 3/09/25 at 3:33 PM V8 Social Services Director stated she receives the final grievance forms for concerns brought up during the council meetings. V8 stated V8 conducted the January 2025 council meeting. On 3/11/25 at 9:50 AM V8 stated V8 was unable to locate documentation of any grievances for September 2024-November 2024 that were not listed on the provided grievance log. V8 stated V8 is the person that grievances, including missing items, should be reported to and is responsible for ensuring grievances are be followed up on. V8 reviewed council minute concerns from the January and February 2024 meetings and confirmed the only grievances documented were on 1/16/25 and 2/20/25 regarding housekeeping, meals being late, and missing items. V8 stated V8 may have to start reviewing the resident council meeting minutes after each meeting to ensure the concerns are being followed up on and documented as grievances. V8 stated V21 Housekeeping Supervisor has a list of missing laundry items and V8 should get that list to ensure follow up actions are taken and documented.
The facility's Long Term Care Facility Application for Medicare and Medicaid dated 3/9/25 documents the facility has a census of 51 residents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to employ a Director of Nursing and failed to provide the services of a registered nurse for eight consecutive hours seven days a ...
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Based on observation, interview and record review the facility failed to employ a Director of Nursing and failed to provide the services of a registered nurse for eight consecutive hours seven days a week. This failure has the potential to affect all 51 residents residing in the facility.
Findings Include:
On 3/9/25, 3/10/25 and 3/11/25 there was not a full time Director of Nursing working in the facility.
The resident roster dated 3/9/25 documents 51 residents reside at the facility.
The facility's nursing working schedule from 2/24/25 to 3/10/25 documents the facility did not have the services of a Registered Nurse (RN) for eight consecutive hours on 2/24/25, 2/27/25, 2/28/25, 3/1/25 and 3/2/25.
On 3/10/25 at 9:00am V3 Assistant Director of Nursing stated the facility has not had a Director of Nursing (DON) since 1/31/25 when the pervious Director of Nursing took another job. V3 stated the facility does not always have Register Nurse coverage for eight consecutive hours seven days a week. V3 confirmed the documentation on the working schedule provided was an accurate record of RN coverage and that there has not been a full time Director of Nursing working in the facility since 2/1/25.
On 3/11/25 at 10:00am V1 Administrator confirmed that the facility has not had a full time Director of Nursing working in the facility since 2/1/25, and that they don't always have a Registered Nurse working every day.
The Facility's Assessment (no date) documents the Facility will Provide a full time Director of Nursing and proper nursing coverage.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 51 reside...
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Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 51 residents in the facility.
Findings include:
On 3/10/25 at 11:15AM and 3/11/25 11:30am V3 Dietary Manager was actively supervising dietary operations in the facility kitchen.
On 3/11/25 at 11:04am V3 Dietary Manager stated that V3 was hired a couple of weeks ago as Dietary Manager. V3 stated that V3's Food Safety/Dietary Manager Certificate expired over a year ago, and V3 is scheduled to take the test next month. V3 stated at this time V3 fails to meet the State of Illinois standards to be a food service manager or dietary manager.
On 3/11/25 at 2:02pm V1 Administrator confirmed that V3 Dietary Manager does not currently have a valid Food Safety/Dietary Manager Certificate as required.
The Facility Assessment (not dated) documents a full-time dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services is needed to provide competent support and care for the facility's resident population every day and during emergencies.
The facility Long-Term Care Facility Application for Medicare and Medicaid (3/9/25) documents 51 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to employ dietary support staff with the appropriate com...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to employ dietary support staff with the appropriate competencies to carry out the functions of the food and nutrition service. This failure has the potential to affect all 51 residents residing in the facility.
Findings include:
On 3/10/25 at 11:00am V26 Dietary Aide was preparing residents food, assisting with plating and distributing resident's meals.
On 3/11/25 at 3:30pm V19 Dietary Aide was preparing residents food, assisting with cooking residents food and preparing residents drinks.
On 3/10/25 at 11:00am V26 stated that V26 does not have any training in food service or nutrition and does not have a food handlers certificate.
On 3/11/25 at 11:04 am, V4, Dietary Manager, stated, We have six employees on the kitchen staff, four of those employees do not have a Food Handler's certificate. Those employees are (V19, V26, V27 and V28).
On 3/11/25 at 11:26 am, V1, Administrator acknowledge that V9, V26, V7 and V28 do not have a current Food Handlers Certificate.
The Illinois Public Act [PHONE NUMBER] documents, Anyone working with unpackaged food, food equipment, utensils, or food contact surfaces is defined as a food handler. Food handlers working in non-restaurants (nursing homes and long-term care facilities) must have the training completed, with enforcement to begin January 1, 2017.
The facility's Resident Census and Conditions of Residents dated 3/9/25 documents 51 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to annually implement and evaluate the effectiveness of a performance improvement plan. This failure has the potential to affect all 51 residen...
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Based on interview and record review the facility failed to annually implement and evaluate the effectiveness of a performance improvement plan. This failure has the potential to affect all 51 residents in the facility.
Findings include:
The facility's undated Quality Assurance Performance Improvement (QAPI) Plan documents the QAPI committee will conduct a self assessment of the facility on an annual basis and prioritize activities, policies and procedures and continually monitors for improvement through the use of self assessment. The facility will consider input from staff, residents, and family members, adverse events, performance indicators, survey findings, and complaints/grievances. Root Cause Analysis will be used for identifying contributing causal factors designed to get to the underlying cause of a problem, which leads to identification and effective interventions to make improvements. Measurements are used by gathering data and analyzing trends and implementation of interventions will be evaluated to ensure continuation and progress is continued or sustained.
On 3/11/25 at 12:08 PM V1 Administrator stated V1 became the facility's administrator in December 2024. V1 stated the facility did a PIP (Performance Improvement Plan) in April on preventative skin care and showers. At this time V1 provided the QAPI Plan 1 PIP - Preventative Skin Care and QAPI 2 PIP- Showers/Baths. The Preventative Skin Care PIP documents the goal is to provide preventative skin care through repositioning and hygienic skin care, and the facility will provide adequate interventions to prevent skin breakdown for residents identified to be at high or moderate risk. This PIP lists interventions, including staff training on skin care, preventative pressure ulcer care, and wound care; skin assessments will be completed for all residents upon admission, then weekly for four weeks, and then annually, quarterly, and with significant changes; the facility will ensure a proper treatment program has been implemented and closely monitored to promote healing or pressure ulcers; nursing staff will complete a QA form for newly identified skin conditions, this form will be given to the Director of Nursing and the wound will be documented on the Treatment Administration Record; and to re-evaluate treatment response at least every two to four weeks, review nutritional status monthly, and implement additional interventions and update the care plan to prevent worsening or re-occurring pressure ulcers. The Shower/Baths PIP documents the goal to ensure hygiene needs are met and showers/baths are scheduled at least weekly for all residents. This PIP lists interventions to formulate a current shower schedule for all resident rooms, formulate a tracking form to review and monitor showers weekly, in-service licensed staff on completing and documenting showers, and the QAPI team will continue to assess and monitor the shower process. There is no documentation of any follow up for these PIPs that includes monitoring, tracking, and evaluating the implementation for the listed interventions.
On 3/11/25 at 12:15 PM V1 stated the PIP provided is the only one V1 could locate for the last year. V1 Stated this documentation was found with the 4/26/24 QA meeting. At this time V1 was requested to provide documentation of implementation and evaluation of the April PIPs. At 12:35 PM V1 stated V1 was unable to locate any documentation of implementation and evaluation of the April PIPs. V1 stated the former Administrator was known to throw things away.
The facility's Long Term Care Facility Application for Medicare and Medicaid dated 3/9/25 documents the facility has a census of 51 residents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to have quarterly Quality Assurance meetings. This failure has the potential to affect all 51 residents in the facility.
Findings include:
The...
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Based on interview and record review the facility failed to have quarterly Quality Assurance meetings. This failure has the potential to affect all 51 residents in the facility.
Findings include:
The facility's undated Quality Assurance Performance Improvement (QAPI) Plan documents the facility will take a proactive approach to improve the care provided and will create systems to achieve compliance through tracking, investigating, and trying to prevent recurrence of adverse effects, investigating complaints, seeking feedback from residents and staff, setting targets for quality, and striving for deficiency free surveys. This plan documents the interdisciplinary team will ensure resident's needs are met through QA meetings.
QA meeting documented 1/9/25. All required members present.
On 3/11/25 at 12:08 PM V1 Administrator provided the facility's QAPI meeting dated 1/9/25. V1 stated V1 has been the Administrator since December 2024 and has only had one QA meeting in January 2025. At 12:15 PM V1 provided additional QAPI meeting sign in sheets dated 4/26/24 and 9/5/24. V1 stated the facility should have had QA meetings in July and October 2024. At 12:35 PM V1 stated V1 was unable to locate any additional QA sign in sheets for the last year.
The facility's Long Term Care Facility Application for Medicare and Medicaid dated 3/9/25 documents the facility has a census of 51 residents.
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
5. The Medical Diagnosis sheet from the EMR (Electronic Medical Record) for R36 dated 3/11/25 documents the following diagnosis: Urinary Retention and Benign Prostatic Hyperplasia with Lower Urinary T...
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5. The Medical Diagnosis sheet from the EMR (Electronic Medical Record) for R36 dated 3/11/25 documents the following diagnosis: Urinary Retention and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. R 36 has a supra pubic catheter with signage on his door stating Enhance Barrier Precautions (EBP) and placed in front of his door is a 3 drawer chest with gowns, masks and gloves in the drawers for staff and visitors to use before entering the room.
On 3/10/25 at 10:53 AM V5, CNA (certified nurse assistant) prepared to complete suprapubic catheter care for R36. R36 has signage on his door stating Enhance Barrier Precautions (EBP) and placed in front of his door is a three drawer chest with gowns, masks and gloves in the drawers for staff and visitors to use before entering the room. Before entering R36's room V5 did not put on a gown or mask. V5 placed gloves on her hands after entering the room and washing her hands at the resident's bathroom.
V5 stood next to R36's bed and stated I am going to perform catheter care on you to clean you up. V5 did not wear a gown or mask during the entire procedure.
Based on observation, interview, and record review, the facility failed to implement their water management plan, prevent potential cross contamination of a pressure sore and the treatment cart, and implement Enhanced Barrier Precautions. These failures have the potential to affect all 51 residents residing in the facility.
Findings include:
The facility's Water Management Plan-Legionella Bacteria Risk Management Policy dated 11/17/24, documents the facility will develop the following documents and process as components of the Water Management Plan which includes: identify the end user of water to determine at risk consumers, identify all areas where water is processed after entering facility, develop process flow diagrams to describe how water is processed at the facility, verify that the process flow diagrams are accurate by on-site verification, perform a Hazard Analysis based on process flow diagrams, and identify critical points. This policy states hot water tanks will have temperature checked everyday, deliverable hot/cold water temperatures checked weekly, hot water distribution checked weekly, eye wash station, tanks for house, kitchen, and laundry check flush for two minutes weekly.
The facility's Pressure Wound Treatment Policy dated January 2017, documents pressure injury treatment requires a comprehensive approach that includes: managing infections and maximizing the potential for healing.
1. On 3/11/25 at 10:20 AM, V24 Maintenance Director stated V24 does not have a test kit for testing the water and has no idea where to get them. V24 stated V24 started here 12/31/24 and the only book he has is the life safety book that has some Legionella stuff in it. V24 stated V24 is not doing the hot water distribution, eye wash station, not flushing hot water tanks, domestic hot water tanks for house, kitchen and laundry. V24 stated he needs some items that they do not have and, there is no floor plan for Legionella places.
The facility's Long Term Care Facility Application for Medicare and Medicaid dated 3/9/25 documents the facility has a census of 51 residents.
2. On 3/10/25 at 10:30 AM, V6 Licensed Practical Nurse (LPN), rolled the entire treatment cart into R43's room to complete a treatment on R43's pressure wound.
3. On 3/10/25 at 10:30 AM, V6 LPN placed wound cleanser on a 4 by 4 gauze pad and proceeded to wipe R43's pressure wound over and over using the same side of the 4 by 4 pad and never changing sides.
On 3/10/25 at 3:19 PM, V3 Assistant Director of Nursing (ADON) stated V6 should have changed sides of the 4 by 4 gauze while cleaning the wound and stated the treatment cart should not be brought into a resident's room.
4.) On 3/09/25 at 9:51 AM there was no EBP signage posted on R31's room door and no cart containing personal protective equipment (PPE) near R31's room doorway. R31 stated R31 has had a urinary catheter for about a month and R31 has a history of urinary tract infections related to urinary retention prior to the catheter being inserted.
On 3/10/25 at 11:30 AM as V12 Certified Nursing Assistant (CNA) entered R31's room to provider urinary catheter care, V5 CNA told V12 don't forget to wear a gown, don't make the same mistake I (V5) did. I (V5) just found out I'm suppose to wear a gown (for catheter care). There was no EBP signage on R31's room door and there was no cart containing PPE. V12 obtained a gown from a cart located a few doors down the hall. V5 and V12 confirmed they look for EBP signage and PPE carts to identify when PPE is needed. V5 and V12 confirmed there was no EBP signage posted or PPE cart for R31's room. At 11:56 AM V12 stated V12 had not received any training on EBP and was unsure of what cares required gowns to be worn for EBP.
On 3/10/25 at 12:21 PM V3 Assistant Director of Nursing stated R31 returned from the hospital on 2/21/25 with a urinary catheter. V3 confirmed R31 should be on EBP due to the catheter, EBP signage should be posted, and a cart for PPE should be outside of R31's room.
The facility's Enhanced Barrier Precautions (EBP) policy dated 7/13/23 documents EBP will be used to reduce the transmission of multidrug-resistant organisms and includes the use of gown and gloves when providing high-contact resident care activities for residents with open wounds and indwelling medical devices. This policy documents to post EBP signage and ensure disposable or washable gowns and gloves are available where high-contact resident care activities may be required.
Aug 2024
8 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
Safe Environment
(Tag F0584)
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 sufficiently staff housekeepers in order to provide a ...
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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 sufficiently staff housekeepers in order to provide a clean and homelike environment. This failure affects three (R2, R5, R6) of seven residents reviewed for housekeeping in the sample list of 13.
Findings include:
1.) On 8/13/24 at 3:45 PM, R6 stated the facility doesn't have enough housekeeping staff and R6's room isn't always cleaned daily. R6 stated no one has been in to clean R6's room yet today. R6's floor was sticky. There were paper towels on the bathroom floor, the garbage can was overflowing with garbage, and the toilet bowl contained dried feces.
R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact.
2.) On 8/13/24 at 4:06 PM, R2 stated housekeeping hasn't been in to clean R2's room yet today. There was dust and food wrappers observed on R2's floor. R2 stated housekeeping staff was out sick with COVID-19 (Human Coronavirus Infection) and the rooms weren't getting cleaned every day.
R2's MDS dated [DATE] documents R2 as cognitively intact.
3.) On 8/13/24 at 2:28 PM, R5 stated the facility does not have enough housekeepers and sometimes R5's room floor could be cleaner.
R5's MDS dated [DATE] documents R5 has a Brief Interview for Mental Status score of 12, the higher end of moderate cognitive impairment.
The facility's August 2024 Housekeeping/Laundry Schedule documents there were no housekeeping staff working 8/2/24-8/5/24, only laundry staff were scheduled.
On 8/13/24 at 10:20 AM, V9 Housekeeping Supervisor stated We haven't had housekeeping fully staffed for awhile, until this week. We schedule two each day, but have been working with one on the weekends. On 8/13/24 at 4:20 PM, V9 stated resident rooms are to be cleaned daily and was not sure the rooms were getting cleaned daily when the facility only had one housekeeper on duty. On 8/14/24 at 10:47 AM, V9 stated there should be two laundry staff and two housekeepers scheduled daily and the laundry staff have been having to cover housekeeping while staff were out sick with COVID-19. V9 stated one employee would work in laundry while the other worked as housekeeping.
The facility's undated Resident Rooms Routine Cleaning-Daily policy documents the daily cleaning includes sweeping the floor, emptying waste cans, mopping, and cleaning the bathroom.
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
ADL Care
(Tag F0677)
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 scheduled showers for one (R4) of seven residents reviewed f...
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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 scheduled showers for one (R4) of seven residents reviewed for Activities of Daily Living in the sample list of 13.
Findings include:
On 8/13/24 at 1:56 PM, R4 stated R4 prefers to have showers weekly, but R4 has not received a shower for two weeks since the facility has a COVID-19 (Human Coronavirus Infection) outbreak.
R4's Minimum Data Set, dated [DATE] documents R4 is cognitively intact and is dependent on staff for bathing.
The facility's Shower List dated 4/15/24 documents R4's showers are scheduled on Thursdays. R4's August 2024 shower sheets were requested from the facility on 8/15/24.
On 8/14/24 at 9:21 AM, V6 Registered Nurse stated there was a staffing shortage due to the COVID-19 outbreak on the second week of August, around the 9th, which affected showers being given.
On 8/15/24 at 11:11 AM, V8 Certified Nursing Assistant provided R4's shower sheet dated 8/1/24. V8 confirmed V8 is the facility's assigned shower aide. V8 stated that was the last day that R4 was given a shower, and R4 did not receive a shower last Thursday due to the COVID-19 outbreak.
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 F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to follow a physician ordered diet for one (R1) of five residents reviewed for diet in the sample list of 13.
Findings include:
...
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Based on observation, interview, and record review the facility failed to follow a physician ordered diet for one (R1) of five residents reviewed for diet in the sample list of 13.
Findings include:
On 8/13/24 at 11:10 AM, R1 stated R1 is a diabetic, but is not on a special diet. R1 states R1 just monitors what R1 eats.
On 8/13/24 at 11:55 AM and 12:35 PM, V10 Dietary Manager served all of the residents' meal trays. R1's meal tray consisted of Salisbury steak, gravy, mashed potatoes, one slice of bread, sunshine carrots, and ice cream. R1's meal tray card documented regular diet. V10 stated low concentrated sweets and controlled carbohydrate diets are similar, and the bread is not served for those diets for this meal.
R1's Brief Interview for Mental Status dated 7/30/24 documents R1 is cognitively intact. R1's August 2024 Physician's Order Summary (POS) documents R1's diagnoses include Type 2 Diabetes Mellitus and R1's diet is Controlled Carbohydrate.
On 8/14/24 at 3:50 PM, V10 confirmed R1's meal tray card documents regular diet and the prescribed diet on the POS should be what is documented on the resident's tray card. V10 stated V10 will have R1's tray card updated to reflect controlled carbohydrate diet. V10 confirmed R1 was served a regular diet which included mashed potatoes, bread, and ice cream for the noon meal on 8/13/24. At 3:53 PM, V10 provided R1's Diet Order Form dated 7/29/24 which documented under special notes Carb (carbohydrate) Control, and regular diet was checked. The line next to consistent carbohydrate diet did not have a check mark. V10 stated this form was provided by nursing and the Controlled Carbohydrate diet was not caught because the box next to the Controlled Carb diet was was not marked.
The facility's Week 1 Regular Menu dated April 2024 documents the noon meal as Salisbury steak, mashed potatoes, brown gravy, sunshine carrots, bread/margarine, and ice cream. This menu documents for 1800 Controlled Carbohydrate Diet (CCD) give fruit for dessert, skim milk, and no extra margarine; the 1500 CCD give fruit for dessert, 4 ounces skim milk, no extra margarine, 4 ounces juice at breakfast, and no extra breads/rolls with lunch and supper.
The facility's Therapeutic & Mechanically Altered Diets dated April 2006 documents diets are ordered by the physician and should be prepared and served as planned.
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 F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain functioning call lights for four (R3, R5, R8,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain functioning call lights for four (R3, R5, R8, R9) of four residents reviewed for call lights in the sample of 13.
Findings include:
1.) On 8/13/24 at 2:28 PM, R5 was lying in bed and there was a handheld bell on R5's bed beside R5. R5's room did not contain a call light cord attached to the call light box in R5's room. There was contact and droplet isolation signage posted on R5's room door. On 8/15/24 at 11:03 AM, R5 was in R5's room with a handheld call bell beside her. There was no call light cord plugged into the call light box in R5's room. R5 stated the other night R5 kept ringing the handheld bell and it took a long time for staff to answer, and usually R5 has to wait 30 minutes or more for staff to respond. R5 stated the staff told R5 that they didn't know where the bell sound was coming from.
On 8/13/24 at 3:22 PM, V17 Certified Nursing Assistant (CNA) stated R5's call light hasn't been working for a few weeks.
R5's Minimum Data Set (MDS) dated [DATE] documents R5 has moderate cognitive impairment, is frequently incontinent of bowel and bladder, and requires substantial/maximal assistance of staff for toileting.
2.) On 8/13/24 at 2:53 PM, R3 was lying in bed with a handheld bell next to R3. R3 stated R3's call light hasn't worked for a long time and that is why R3 has a handheld bell. R3 stated R3 started with a cough on 8/8/24, was told she had COVID-19, and was placed on isolation. R3 stated the staff can't hear the bell when R3's door is shut, and recently R3 had to wait an hour for R3's bell to be answered while R3 was lying in urine and feces. R3's call light was tested and it was not functioning.
On 8/13/24 at 3:06 PM, V16 CNA, stated R3's call light hasn't been working for a couple of weeks.
R3's MDS dated [DATE] documents R3 is cognitively intact, is frequently incontinent of bowel and bladder, and is dependent on staff for toileting assistance.
3.) On 8/14/24 at 9:33 AM, R8 was lying in bed and R8's call light was on. There was a handheld bell on R8's night stand beside R8's bed. R8 stated, R8's call light doesn't work causing the call light to stay on all of the time.
R8's MDS dated [DATE] documents R8 has severe cognitive impairment, is always incontinent of bowel and bladder, and requires substantial/maximal staff assistance for toileting.
4.) On 8/14/24 at 10:10 AM, R9 was lying in bed and there was a handheld bell on R9's night stand.
R9's MDS dated [DATE] documents R7 has severe cognitive impairment and is dependent on staff for Activities of Daily Living.
On 8/13/24 at 3:26 PM, V5 Licensed Practical Nurse stated R5 and R8 do not have functioning call lights which is why they are using handheld bells. V5 stated, V5 worked on 8/11/24 and R5's and R8's call lights were not working at that time.
On 8/14/24 at 9:43 AM, V18 CNA stated R5 and R8 do not have functioning call lights and are using handheld bells. V18 stated R5's room doesn't even have a call light plugged into the wall, because it doesn't work. V18 stated it recently affected the North Hall, R3's and R9's call lights, but it has been affecting the South Hall (R5's and R9's rooms) for awhile.
On 8/14/24 at 10:30 AM, V1 Administrator stated there are four call lights that aren't functioning and are stuck on; and they haven't been working correctly since V1's employment began in February 2024. V1 stated corporate and sister facility maintenance staff have been in the facility to evaluate the call lights. V1 stated an electrician is needed and either the call light system needs revamped or a whole new system, and the facility's budget hasn't allowed for that.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to staff a Registered Nurse (RN) for eight consecutive hours per day. This failure has the potential to affect all 46 residents residing in the...
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Based on interview and record review the facility failed to staff a Registered Nurse (RN) for eight consecutive hours per day. This failure has the potential to affect all 46 residents residing in the facility.
Findings include:
The facility's August 2024 Nurse Schedule and Nursing Daily Sheets dated 8/4/24 and 8/7/24 do not document an RN was scheduled to work.
On 8/14/24 at 1:51 PM-2:47 PM the facility's staffing and daily sheets were reviewed with V2 Director of Nursing. V2 reviewed employee time cards and schedules, and confirmed the facility did not have an RN on duty on 8/4/24 and 8/7/24. V2 stated V6 RN is the full time RN, V15 RN works as needed, V3 Minimum Data Set Coordinator is also an RN, and V2 fills in on the weekends when RN coverage is needed. V2 stated V2 and V3 were out sick with COVID-19, which is why there was no RN coverage on 8/4/24 and 8/7/24.
The facility's Room Roster dated 8/13/24 document 46 residents reside in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have adequate dietary staff to ensure meals are served timely. This ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have adequate dietary staff to ensure meals are served timely. This failure affects four (R1, R4, R5, R6) of five residents reviewed for meals in the sample list of 13. This failure has the potential to affect all 46 residents residing in the facility.
Findings include:
On 8/13/24 at 11:10 AM, R1 stated kitchen staff was out sick with COVID-19 (Human Coronavirus Infection), so the meals weren't served on time for two days before the facility had additional staff come in to help. R1 stated breakfast was served at 11:00 AM instead of 8:00 AM, lunch was around 3:00 PM, and supper was at 7:00 PM.
On 8/13/24 at 1:56 PM, R4 stated: Meals aren't served timely. This weekend it was 10:00 AM for breakfast and 1:00-1:30 PM for lunch. Meals aren't served timely.
On 8/13/24 at 2:28 PM, R5 stated recently the facility has lost many kitchen staff and meals are served two to three hours later than scheduled.
On 8/13/24 at 3:45 PM, R6 stated breakfast is served around 9:30 AM and supper around 6:15-6:30 PM.
R1's Brief Interview for Mental Status Score dated 7/30/24 documents R1 as cognitively intact. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact. R5's MDS dated [DATE] documents R5 has moderate cognitive impairment. R6's MDS dated [DATE] documents R6 is cognitively intact.
On 8/13/24 at 11:32 AM, V4 Licensed Practical Nurse stated the weekend of August 3rd and 4th meals were served late, breakfast was served at 9:00 AM, and an unidentified Certified Nursing Assistant had to help in the kitchen that day. V4 stated snacks were given to the residents during that time and additional staff was brought in for the lunch and supper meals.
On 8/13/24 at 11:55 AM, V10 Dietary Manager stated V10 has been employed at the facility for three weeks and things are slowly improving. V10 stated the facility had staffing issues previously and during the COVID-19 outbreak, but V10 has more staff this week. At 12:35 PM, V10 stated V10 considers meals timely if served within 25 minutes of the scheduled time.
On 8/13/24 at 1:20 PM, V13 Social Services Director stated during the last part of July and beginning of August 2024 V13 had to help in the kitchen prep the meal trays and wash dishes for a week or longer until the facility got additional kitchen staff. V13 stated the dietary manager had been replaced and we needed time to get staff trained. V13 stated there was one day that breakfast was served around 10:30-11:00 AM. V13 stated V13 made the third person working in the kitchen with a cook and dietary aide, and usually the facility has three dietary staff working at a time.
On 8/14/24 at 9:21 AM, V6 Registered Nurse stated there was one day that breakfast was served around 10:00 AM and lunch was served late around 4:00 PM. V6 stated V6 held insulin until the meals were served and blood sugars were not affected. V6 states it seems like the meals are generally served about an hour late. V6 stated some days they are short of staff in the kitchen and V13, along with other staff, have to help in the kitchen.
The facility's list of meal times provided by V1 Administrator, documents meals are scheduled at 8:00 AM, 12:00 PM, and 5:00 PM.
The facility's August 2024 Dietary Schedule documents between 8/4/24 and 8/11/24 there were six days with one kitchen staff and two days when V10 Dietary Manager was the second kitchen staff working for the 6:00 AM/7:00 AM-2:00 PM shift.
The facility's Facility assessment dated [DATE] documents the facility's staffing plan includes one food and nutrition supervisor, one cook, and one dietary aide for weekdays on day and evening shifts; and one cook and one dietary aide on the weekends.
The facility's Room Roster dated 8/13/24 documents 46 residents reside in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 a clean and sanitary kitchen. This failure has the potential to affect all 46 residents residing in the facility.
Fin...
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Based on observation, interview, and record review the facility failed to maintain a clean and sanitary kitchen. This failure has the potential to affect all 46 residents residing in the facility.
Findings include:
On 8/13/24 at 9:50-9:57 AM, the kitchen was toured with V10 Dietary Manager. There was dust and debris on the floor and dirt built up on the floor around the range and prep table. There were dark, dried splatters on the side of the range and on the wall near the three sink washing station.
On 8/13/24 at 11:55 AM-12:35 PM, V10 served the noon meal trays for all of the residents. V14 Dietary Aide swept the floor and there was a large pile of dirt and debris. There was dark dirt build up on the floor around the range and prep table, and there were dark, dried splatters on the side of the range and wall near the three sink station. This was confirmed with V10 and V11 Dietary Aide. V11 stated the floors are suppose to be swept and mopped at the end of each shift and should have been done last evening. V10 stated the kitchen is cleaned daily and a deep clean is done weekly, but V10 does not have a cleaning log or schedule.
The facility's Cleaning Schedule dated October 2014 documents: The Food Service Manager shall develop a cleaning rotation form that lists all cleaning tasks required for proper sanitation of the food preparation and serving areas. Tasks are divided into categories that must be completed daily, weekly, and monthly. Each position in the Dietary Department is assigned certain cleaning tasks to be completed at a particular frequency.
The facility's Room Roster dated 8/13/24 documents 46 residents reside in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to implement infection control measures to prevent the spread of COVID-19 (Human Coronavirus Infection) by failing to maintain a ...
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Based on observation, interview, and record review the facility failed to implement infection control measures to prevent the spread of COVID-19 (Human Coronavirus Infection) by failing to maintain a supply of N95 respirators, ensure staff wear appropriate Personal Protective Equipment (PPE), ensure staff wear PPE correctly, and routinely disinfect high touch surfaces during a COVID-19 Outbreak. This failure affects seven (R3, R5, R2, R10, R11, R12, R13) of seven residents reviewed for Infection Control in the sample list of 13. These failures have the potential to affect all 46 residents residing in the facility.
Findings include:
1.) The facility's August 2024 Staff Infection Control Log documents 16 employees tested positive for COVID-19 between 8/2/24 and 8/6/24. The Facility's August 2024 Resident Infection Control Log documents 24 residents tested positive for COVID-19 between 8/1/24 (when the outbreak began) and 8/8/24. Positive residents included R2, R3, R11, R12.
On 8/13/24 at 9:58 AM, V19 Resident Care Coordinator stated 24 residents have contracted COVID-19 during this outbreak that began on 8/1/24. V19 confirmed the outbreak affected all halls and there are COVID-19 positive and negative rooms on each hall. There was a sign posted on the entrance to the North Hall that stated this was a red zone and PPE is to be worn.
The North Hall was toured on 8/13/24 at 10:02-10:12 AM. There was a PPE cart located in the hallway that only contained isolation gowns. COVID-19 positive rooms and negative rooms were on this hall. Positive room doors contained droplet and contact isolation signage that instructed to don/doff (apply/remove) gown and gloves when entering/leaving the room, and remove face protection before room exit. V4 Licensed Practical Nurse (LPN) was administering medications and wearing a KN95 mask. V21 Housekeeper was cleaning COVID-19 positive and negative rooms working her way down the hall while wearing a KN90 mask with the bottom strap worn loosely below V21's chin. V21 entered R3's room wearing a KN90 mask, face shield, gown and gloves. V21 removed the gown and gloves, exited R3's room, and entered R10's room (a COVID-19 negative room) without changing her mask and disinfecting/changing eye protection.
The East Hall was toured on 8/13/24 at 10:12-10:27 AM. There were COVID-19 positive and negative rooms and the PPE cart in the hallway only contained isolation gowns. V20 Certified Nursing Assistant (CNA) was working on this hall wearing a KN90 mask. V9 Housekeeping Supervisor was working on this hall wearing a KN95 mask.
The South Hall was toured on 8/13/24 at 10:27 AM. There were COVID-19 positive and negative rooms, and the PPE cart in the hallway only contained isolation gowns.
On 8/13/24 at 10:36 AM, V8 CNA was on the East Hall wearing a KN90 mask. V8 stated V8 recently returned to work after having COVID-19. On 8/13/24 at 11:22 AM, V8 entered COVID-19 positive rooms while wearing a KN90 mask. On 8/13/24 at 11:29 AM, V8 CNA stated there is a supply of masks and face shields kept at the nurse's station (which was outside of the North/East/South Hall Red Zones). V8 stated face shields are changed daily and masks are changed every four hours. V8 confirmed V8 provides care for both COVID-19 positive and negative residents, and masks and eye protection are not changed or disinfected between positive and negative rooms. V8 confirmed a KN90 mask was worn in positive rooms.
On 8/13/24 at 11:03 AM, V21 Housekeeper mopped R11's/R12's (COVID-19 positive) room and then entered R13's room (negative room) without changing V21's mask or disinfecting/changing face shield. The lower strap of V21's mask was hanging loose underneath of V21's chin, and not secured behind V21's head. On 8/13/24 at 11:45 AM, V21 confirmed V21 was not changing V21's mask and eye protection between positive and negative rooms. On 8/13/24 at 1:54 PM, V21 stated V21 does not wear the lower strap of V21's mask because it causes the mask to be too tight. V21 stated, V21 has not received any training on how to properly wear a mask and V21 recently returned to work after having COVID-19 last week.
On 8/13/24 at 11:20 AM, V22 CNA was wearing a KN90 mask while working in the facility. On 8/13/24 at 2:20 PM, V22 was wearing a KN90 mask. V22 stated V22 wears this mask (referring to the mask worn) in the COVID-19 positive rooms and referred to the mask as being an N95 mask. V22 stated a supply of these masks are kept at the facility's entrance and face shields are kept in boxes at the nurses station. A bag of KN90 masks was located at the time clock entrance and V22 confirmed this type of mask is what the facility provides.
On 8/13/24 at 11:32 AM, V4 LPN confirmed V4 provides care for both COVID-19 positive and negative residents, and V4 has not been changing V4's mask and eye protection between positive and negative rooms. V4 stated staff have been wearing these masks (pointed to V4's KN95 mask) and eye protection for all residents since the outbreak began. V4 stated V4 has worked in other facilities where masks were changed more frequently.
On 8/13/24 at 12:43 PM, V18 CNA was walking the halls of the facility wearing a KN90 mask and the lower strap was worn loosely below V18's chin, and not secured behind V18's head.
On 8/13/24 at 2:24 PM, V5 LPN was wearing an N95 mask. V5 stated V5 bought her own supply of N95 masks and is only changing the mask daily and when soiled. V5 confirmed V5 is not changing her mask when going from positive and negative rooms, and V5 stated V5 was not instructed to do so.
On 8/13/24 at 2:42 PM, V23 CNA wore a KN90 mask into R2's room (positive room).
On 8/13/24 at 3:11 PM, V16 and V17 CNAs entered R3's room (positive room) and provided incontinence cares. V16's mask was a KN90 mask. At 3:22 PM, V16 and V17 left R3's room without changing their masks. V16 did not disinfect or change V16's face shield upon or after providing R3's cares.
On 8/14/24 at 9:21 AM, V6 RN was leaving the South Hall wearing a surgical mask and face shield. The entrance door to the hallway indicated red zone. V6 stated, only today V6 has been wearing surgical masks in addition to gown, gloves, and eye protection into the COVID-19 positive rooms.
On 8/14/24 at 9:36 AM, V18 CNA entered R2's room (positive room) wearing a KN90 mask and eye protection. The bottom strap of the mask hung loosely underneath of V18's chin. V18 did not apply gown or gloves prior to entering the room. On 8/14/24 at 9:43 AM, R2 stated V18 had COVID-19 on 8/3/24. V18 confirmed V18 was not wearing the lower strap of V18's mask. V18 stated there wasn't a reason for not wearing the strap other than V18 gets in a hurry when applying masks. V18 confirmed V18 has been wearing the KN90 masks into positive rooms. V18 stated V18 did not provide any cares while V18 was in R2's room. V18 confirmed V18 was not wearing a gown in the room. V18 stated V18 wasn't aware R2 was COVID-19 positive, but I guess there is an isolation sign on R2's door.
On 8/14/24 at 9:54 AM, V7 LPN was working on the North Hall and wearing a KN90 mask. V7 confirmed the KN90 mask is worn in COVID-19 positive rooms and referred to the mask as being an N95 mask.
On 8/14/24 at 10:16 AM, V2 Director of Nursing the facility had a limited supply of N95 masks when the COVID-19 outbreak began. V2 stated V2 had not been routinely ordering N95 masks since the facility had not routinely had any COVID-19 outbreaks. V2 stated the staff quickly went through the N95 masks, and V2 confirmed the facility has been without N95 masks during the outbreak once the supply ran out. V2 was asked what steps were taken to attempt to obtain a supply of N95 masks. V2 stated V2 contacted the local health department on 8/2/24 to request N95 masks since the facility had ran out. V2 stated the local health department provided the facility with a supply of KN95 and KN90 masks. V2 stated V2 had tried to order a supply from the facility's supplier, but the N95 masks were unavailable and V2 does not have documentation of this. V2 stated the facility only has a contract with one supplier so V2 did not attempt to obtain N95 masks from another supplier company. V2 stated V2 has not attempted to order N95 masks again after the initial attempt at the beginning of the outbreak. V2 stated N95 masks are the preferred mask to be worn in the COVID-19 positive rooms, and staff have been trained on the expectation that masks will be changed and eye protection disinfected between when leaving positive rooms prior to entering negative rooms. V2 confirmed gown and gloves should also be worn in COVID-19 positive rooms and the bottom strap of masks should be worn to ensure snug fit.
2.) On 8/13/24 at 11:03 AM, V21 Housekeeper mopped R11's/R12's (COVID-19 positive) room and then entered R13's room (negative room). On 8/13/24 at 11:45 AM, V21 stated there is no certain routine for cleaning COVID-19 rooms, V21 just works her way up and down the hall going from room to room.
On 8/14/24 at 9:05 AM, V24 Laundry Aide stated V24 has been having to assist with housekeeping since V9 Housekeeping Supervisor and V21 Housekeeper were out sick. V24 stated, resident rooms are disinfected/cleaned daily and the hallway railings and high touch surfaces are disinfected every other day.
On 8/14/24 at 9:16 AM, V21 stated high touch surfaces such as light switches and door knobs are disinfected every other day.
On 8/13/24 at 10:20 AM, V9 Housekeeping Supervisor stated: We haven't had housekeeping fully staffed for awhile, until this week. We schedule two each day, but have been working with one on the weekends. On 8/13/24 at 4:20 PM, V9 stated resident rooms are to be cleaned daily and was not sure the rooms were getting cleaned daily when the facility only had one housekeeper on duty. On 8/14/24 at 10:47 AM, V9 stated isolation rooms should be cleaned/disinfected last and high touch surfaces should be disinfected three times per day. V9 stated V9 is responsible for disinfecting high touch surfaces. V9 stated there should be two laundry staff and two housekeepers scheduled daily and the laundry staff have been having to cover housekeeping while staff were out sick with COVID-19. V9 stated one employee would work in laundry while the other worked as housekeeping.
The facility's August 2024 Housekeeping/Laundry Schedule documents there were no housekeeping staff working 8/2/24-8/5/24, and there were two laundry staff working during this time.
The facility's Room Roster dated 8/13/24 documents 46 residents reside in the facility.
The facility's COVID-19 Control Measures policy dated 5/19/23 documents during an outbreak staff must wear an N95 and eye protection during resident care and when in an area where residents may be encountered until 14 days have passed with no additional positive cases. This policy documents to wear an N95 mask, eye protection, gown and gloves when caring for COVID-19 positive residents. This policy documents to increase the frequency of cleaning and disinfecting high touch areas and to clean all resident rooms daily.
The Centers for Disease Control and Prevention Facemask Do's and Don'ts for Healthcare Personnel dated 6/2/20 documents not to allow a mask strap to hang down below your chin, and to secure the straps at the middle and base of your head.
Jul 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to administer a dietary supplement according to physician's orders for one resident (R3) of one resident reviewed for following physician's ord...
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Based on interview and record review the facility failed to administer a dietary supplement according to physician's orders for one resident (R3) of one resident reviewed for following physician's orders in the sample list of three.
Findings include:
R3's undated Cumulative Diagnosis Log, documents R3's diagnosis as: Transischemic Attack (TIA) and Cerebral Infarction.
R3's Physician Order Sheet (POS) dated 7/1/24 to 7/31/24, documents Med Pass 2.0 Supplement 60 milliliters (ML) by mouth twice a day.
R3's Medication Administration Record (MAR) dated 7/1/24 through 7/31/24, documents Med Pass 2.0 Supplement as not given to R3 on the following dates: 7/7/24, AM and PM; 7/11/24 AM and PM; 7/16/24 PM; and 7/19/24 AM.
On 7/18/24 at 3:06 PM, V2 Director of Nursing (DON), verified on previous dates, R3 did not receive Med Pass Supplement.
R3's Care Plan dated 3/22/24, documents to provide and serve supplements as ordered.
The facility's Conformance with Physician Medication Orders dated Reviewed 9/27/17, documents all medication, headache remedies, vitamins, etcetera shall be given upon written order of a physician.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to employ a clinically qualified Director of Food and Nut...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to employ a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 47 residents residing in the facility.
Findings include:
On 7/18/24 at 10:40 AM, V1 Administrator stated they do not have a Dietary Manager at this time, V1 stated the facility had a Dietary Manager for five days but that person abandoned the job so we let him go. V1 stated V1 has been working in the kitchen a lot and comes in every weekend and at other times to cook. V1 stated V2 Director of Nursing (DON) has also been helping to cook.
On 7/18/24 at 12:30 PM, V2 DON stated V2 has been cooking for the past one and a half to two weeks.
Throughout this survey, from 7/18/24 through 7/19/24, a Dietary Manager was not present in the facility.
The facility's Food Service Manager job summary dated 10/16, documents qualifications for this position include: must have taken or be willing to take the Dietary Managers Course and have passed the sanitation test or be willing to take the course approved by the state the facility is in.
The facility's room roster dated 7/18/24, documents 47 residents reside in the facility.
The Facility assessment dated [DATE], documents a Dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services 8 hours per day.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have qualified dietary aides and a cook. This failure ...
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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 have qualified dietary aides and a cook. This failure has the potential to affect all 47 residents who reside in the facility.
Findings include:
The Facility assessment dated [DATE], documents food and nutrition services staff be in the facility 14 hours per day.
The facility's Diet Aide job summary dated 10/16, documents a dietary aide must have passed the sanitation test or be willing to take the course approved by the state the facility is in and must receive food handler's training within 30 days of employment.
On 7/18/24 at 12:30 PM, V2 Director of Nursing (DON) stated V2 has been cooking at the facility for one and a half to two weeks.
On 7/18/24 at 3:30 PM, V1 Administrator stated V4, the cook, does not have a cooking/sanitation certificate, also V5 and V6 diet aides do not have a food handlers certificate at this time. At this same time, V1 stated V1 was not aware that V4 needed a cooking/sanitation certificate.
On 7/18/24 at 3:45 PM, V2 DON stated V2 does not have a certificate to be cooking.
On 7/19/24 at 8:30 AM, V4, cook, stated V4 does not have a cooking/sanitation certificate and just found out today (7/19/24) that V4 needed it.
The facility's Room Roster dated 7/18/24, documents 47 residents reside in the facility.
May 2024
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide a resident with an Advance Beneficiary Notice (ABN) at the termination of a Medicare Part A covered stay, thereby nullifying the re...
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Based on interview and record review, the facility failed to provide a resident with an Advance Beneficiary Notice (ABN) at the termination of a Medicare Part A covered stay, thereby nullifying the resident's right to continue therapy services at their own expense, or decline therapy services. This failure affects one resident (R5) out of a sample of three reviewed for Beneficiary Notices on the sample of 32.
Findings include:
R5's Beneficiary Protection Notification Review (undated) documents R5 began a Medicare Part A covered stay at the facility 3/26/24, with a last covered date of 4/4/24. There was no evidence that R5 received an Advance Beneficiary Notice of her options to decline to receive further therapy, or to continue therapy services at her own expense.
On 5/8/24 at 11:06 AM, V4, Business Office Manager, stated, I use the ABN notice for Medicare Part B. V4 then located ABN notices for two other residents discharged from Medicare Part A and stated, I don't know why I didn't make out an ABN for (R5).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to report and notify the Administrator and a supervisor of injuries of unknown origin and failed to notify the administrator of a resident to ...
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Based on interview and record review, the facility failed to report and notify the Administrator and a supervisor of injuries of unknown origin and failed to notify the administrator of a resident to resident incident for three of three (R11, R31 and R17) residents reviewed for Abuse Allegations in the sample list of three.
Findings include:
R11's undated Face Sheet documents R11's diagnoses as Acute Metabolic Encephalopathy, History of falling, repeated falls, need for assistance with personal care. R11's Physician Order Sheet (POS) dated 5/1/24-5/31/24, documents R11's diagnoses as Anxiety, Bipolar, Depression, Vertigo, Vitamin D Deficiency, Fibromyalgia, Chronic Back Pain.
R11's Nursing Notes dated 5/2/24 at 10:00 AM, document some bruises noted to A (anterior) R (right) and L (left) hands and upper stomach - resident (R11) denies hitting somewhere. There is no further documentation in R11's medical regarding this finding.
On 5/8/24 at 11:30 AM, facility Abuse allegations were reviewed. There is no documentation of R11's bruising being investigated.
R17's undated Face Sheet documents R17's diagnoses as Rheumatoid Arthritis,unspecified, need for assistance with personal care, Muscle Weakness, unsteadiness on feet, Anemia. R17's Care Plan dated 3/25/24, documents R17 has a diagnoses of Depression.
R31's undated Face Sheet documents R31's diagnoses as Multiple Sclerosis, Muscle Weakness, Heart Failure, Adult Failure to Thrive, Dyspnea, Ataxia. R31's Care Plan dated 3/22/24, documents R31 uses an antidepressant medication.
R31's Nurses Notes dated 4/12/24 at 4:30 PM, documents patient (R31) upset and arguing about her (R31's) television, she (R31) hid the remote after changing the sound to Spanish to upset her (R31's) roommate (R17). There is no documentation of R31 and R17's incident being investigated.
On 5/8/24 at 3:25 PM, V1 Administrator stated V1 did not know about either incident with R11, R17, or R31. V1 stated staff did not report anything to V1 and staff should have reported these incidents to V1 to be investigated.
The facility's Abuse Prevention Program Policy dated 2/2019, documents the facility will orient and train employees on how to recognize and report occurrences of abuse immediately to supervisory personnel; this facility is committed to protecting the residents from abuse by anyone. This same policy documents employees are required to immediately report any occurrences of potential/alleged abuse of residents to a supervisor and the administrator.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
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 comprehensive Minimum Data Set assessments (Resident Asses...
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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 comprehensive Minimum Data Set assessments (Resident Assessment Instrument) in the required time frames. This failure affects two residents (R14 and R39) out of two reviewed for assessment timing on the sample list of 32.
Findings include:
1. R14's comprehensive admission Minimum Data Set (MDS) dated [DATE], section A1600 documents R14 was admitted to the facility 12/21/23. This same MDS section A2300 documents an Assessment Reference Date of 12/28/23. This MDS documents the Care Area Assessments section V0200B2, and Care Plan Completion date section V0200C2, were signed as completed 3/27/24. This MDS section Z0500B documents the signed completion date as 3/27/24.
2. R39's comprehensive admission MDS dated [DATE], section A1600 documents R39 was admitted to the facility 12/20/23. This same MDS section A2300 documents an Assessment Reference Date of 12/27/23. This MDS documents the Care Area Assessments section V0200B2, and Care Plan Completion date section V0200C2, were signed as completed 3/27/24. This MDS section Z0500B documents the signed completion date as 3/27/24.
The Centers for Medicare and Medicaid Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual dated effective 10/1/23 documents the timetable for a comprehensive admission MDS completion date (Z0500B), and Care Area Assessment completion date (V0200B2) must be no later than the fourteenth day from the admission date. This same manual documents the Care Plan Completion date must be no later than 7 days after the MDS completion date and Care Area Assessment completion dates.
On 5/10/24 at 9:23 AM, V21, Minimum Data Set reimbursement Specialist, stated, When a resident is admitted to a facility, we set the ARD (Assessment Reference Date) for 14 days after the admission date, then we do the MDS the next day, so day 15 would be the completion date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
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 encode and transmit residents' Minimum Data Set Assessments (Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to encode and transmit residents' Minimum Data Set Assessments (Resident Assessment Instrument) within the required time frame. This failure affects two residents (R14 and R39) out of two reviewed for assessment transmissions on the sample list of 32.
Findings include:
1. R14's admission Minimum Data Set (MDS) dated [DATE] section A2300 documents an Assessment Reference Date of 12/28/23. This same MDS section Z0500B documents the signed completion date as 3/27/24 (reference F636).
2. R39's admission MDS dated [DATE], section A2300 documents an Assessment Reference Date of 12/27/23. This same MDS section Z0500B documents the signed completion date as 3/27/24 (reference F636).
The Centers for Medicare and Medicaid Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual dated effective 10/1/23 documents the timetable for transmitting a completed MDS is no later than twenty-one days after the completion date.
On 5/10/24 at 9:23 AM, V21, Minimum Data Set reimbursement Specialist, stated, When a resident is admitted to a facility, we set the ARD (Assessment Reference Date) for 14 days after the admission date, then we do the MDS the next day, then to transmit the MDS we get another 14 days after that.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to encode residents' Minimum Data Sets (Resident Assessment Instrument...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to encode residents' Minimum Data Sets (Resident Assessment Instrument) to accurately reflect residents' health status. This failure affects two residents (R13, R34) out of ten reviewed for Minimum Data Set accuracy on the sample list of 32.
Findings include:
1. R13's Minimum Data Set (MDS) dated [DATE] section M0100 documents R13 had a pressure ulcer. This same MDS section M0300 documents R13's pressure ulcer as a stage 3, full thickness of skin loss with underlying fatty tissue exposed, that was not present on admission to the facility. This same MDS section M1040 documents R13 had 2 venous or arterial ulcers present. This MDS section A1600 documents R13 was admitted to the facility 9/16/23.
On 5/8/24 at 09:38 AM, V14, Licensed Practical Nurse, stated, (R13) never had a pressure ulcer since he was admitted , he is mobile, gets himself up and down, and changes position on his own. (R13) did have some venous ulcers on both lower legs but that has all resolved. V5, Resident Care Coordinator, confirmed V14's statements by stating, (R13) never had any pressure ulcers.
R13's Treatment Administration Record dated for February 2024 documents the treatments for R13's venous ulcers were resolved as of 2/12/24. There was no documented evidence in R13's Treatment Record for January, February, March, nor April 2024 that R13 had ever received any treatment for a pressure ulcer. R13's comprehensive Medical Record including Nurses Notes, Pressure Ulcer Risk Assessments, Physician and Nurse Practitioner Notes, Registered Dietician Evaluations, and Care Plans, were likewise absent of any documentation about a pressure ulcer.
On 5/9/24 at 12:52 PM, V5, Resident Care Coordinator, again stated, After some further review of (R13's) record, (R13) never had a pressure ulcer since he has been here. V5 stated, (R13's) venous ulcers were resolved months ago in February (2024).
2. R34's Minimum Data Set, dated [DATE] section K0520B documents R34 had a feeding tube (either naso-gastric or abdominal) while a resident of the facility. This same MDS section A1600 documents R34 was admitted to the facility 10/19/22.
On 5/8/24 at 8:32 AM, V15, Certified Nursing Assistant, stated, I remember (R34) had a (urinary) catheter when he first got here, but I don't think he ever got any tube feedings. V5, Resident Care Coordinator, stated, I don't think (R34) ever had a g-tube (gastrostomy tube).
On 5/9/24 at 12:50 PM, V5 provided R13's History and Physicals dated 10/20/22, 10/25/22, and 11/7/22, directly after R34's admission, conducted by R34's Nurse Practitioner (V18). All three of these comprehensive physical assessments and clinical histories did not document R34 had any kind of feeding tube. The history and physical dated 10/20/22 documents R34 and a family member (V19) were considering hospice care due to Metabolic Encephalopathy, but R34 was still sitting up and eating and drinking well. This History and Physical documented that R34 and V19 would not want any heroic measures taken to prolong life and wanted to focus on comfort care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain a Level 2 Pre-admission Screening and Resident Review (PASARR) for a resident diagnosed with severe mental illness while residing in...
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Based on interview and record review, the facility failed to obtain a Level 2 Pre-admission Screening and Resident Review (PASARR) for a resident diagnosed with severe mental illness while residing in the facility. This failure affects one resident (R40) out of three reviewed for Pre-admission Screening on the sample list of 32.
Findings include:
R40's Level 1 PASARR dated 10/6/22 documents a Level 2 screen was not required because R40 was not diagnosed with any SMI (Severe Mental Illness), ID (Intellectual Disability), nor RC (Related Condition).
R40's Cumulative Diagnosis Log (undated) documents R40 has a medical diagnosis of Schizophrenia, a severe mental illness (SMI).
R40's current Physician Order Sheet (POS) dated for May 2024 documents R40 has a medical diagnosis of Psychosis, a severe mental illness (SMI). This same POS documents R40 was admitted to the facility 10/7/22.
On 5/8/24 at 4:07 PM, V4, Business Office Manager, stated, Usually the way it works is the information for the residents' screens are put in while the resident is in the hospital before they come here, so it is the hospital that puts the residents' information into the system. Maybe the hospital didn't have the mental illness diagnosis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow its shower and bathing policy and procedures to ensure all...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow its shower and bathing policy and procedures to ensure all residents received a bath/shower at least once a week. This failure affects two residents (R21 and R23) out of 3 residents reviewed for activities of daily living assistance from a total sample list of 32.
Findings include:
1. On 5/8/24 at 9:30am, R23 stated R23 needs total assistance from staff, which includes showers. R23 stated R23 is suppose to get 2 showers a week, but only gets them every once in a while. R23 stated R23 does not get 2 showers a week, and maybe gets 2 showers in a whole month.
On 5/9/24 at 1:30pm, V17 Certified Nursing Assistant stated when a resident receives a shower whether they are total dependent on staff or set up/supervision, a Shower/Abnormal Skin Report should be completed. V17 stated when the resident is completed with the shower, the Shower/Abnormal Skin Report is completed by the CNA assisting the resident and is placed in a box at the nurses station. V17 stated all residents are scheduled for 2 showers a week. V17 stated if a resident refuses a shower, the assigned CNA should still be completing a Shower/Abnormal Skin Report.
On 5/9/24 at 1:56pm, V15 Certified Nursing Assistant stated when V15 gives a resident a shower, after the shower is completed, V15 completes a Shower/Abnormal Skin report and places it in a box behind the nurses station. V15 stated that the nurse reviews and signs the Shower Sheet. V15 stated all residents are scheduled to receive 2 showers a week.
On 5/8/24 at 1:48pm, V5 Resident Care Coordinator stated that all residents are scheduled to receive 2 showers a week. V5 stated that after the residents receive their shower, the Certified Nursing Assistant completes a Shower/Abnormal Skin Report and they place it in the box behind the nurses station. V5 stated the nurse reviews the report and signs it. V5 stated that even if a resident refuses their shower, they must complete the Report.
R23's Facility Census documents R23 was admitted to the facility on [DATE] and has the following medical diagnoses; Atrial Fibrillation, Malignant Neoplasm of Prostate, Anemia, Type 2 Diabetes, Depression, Essential Primary Hypertension, Cardiac Arrhythmia, Insomnia, History of Extended Spectrum Beta Lactamase, Difficulty in Walking, Chronic Respiratory Failure with Hypoxia, Gastro-Esophageal Reflux Disease, Chest Pain, Atrial Flutter, Obstructive Sleep Apnea, History Pulmonary Embolism and Pulmonale.
R23's Minimum Data Set (MDS) dated [DATE] documents R23's Brief Interview for Mental Status (BIMS) score 14, cognitively intact.
R23's Care Plan dated 3/11/24 documents R23 requires extensive assist from staff to complete Activities of Daily Living (ADL) and transfers.
R23's Shower/Abnormal Skin Report documents from 4/1/24 till present, R23 received a shower on 4/17, 4/24 and 5/9/24.
2. On 5/9/24 at 9:01am, R21 stated that R21 is scheduled to receive 2 shower a week and is lucky to get 1. R21 stated R21 needs assistance from staff with R23's lower extremities and getting dressed. R21 stated that R21 has not been getting showered regularly.
R21's Facility Census documents R21 was admitted to the facility on [DATE] and has the following medical diagnoses; Post Traumatic Stress Disorder, Chronic Kidney Disease, Acute Kidney Injury, Obesity, Diabetes, Congestive Heart Failure, Sinusitis, History of Tracheostomy, Glaucoma, Coronary Artery Disease, Hypertension, Status Post Coronary Artery Bypass Graft, Atrial Fibrillation, Chest Pain, Ischemic Cardiopathy, Automatic Implanted Cardio Defibrillator, Obstructive Sleep Apnea, Hypertriglyceridemia, Unstable Angina, Myocardial Infarction, Hyperlipidemia, Peptic Ulcer, Elevated Troponin, Gerd, Chronic Obstructive Pulmonary Disease, Hypothyroidism, Vitamin D Deficiency, Anxiety, and Cholelithiasis.
R21's Minimum Data Set (MDS) dated [DATE] documents R21's Brief Interview for Mental Status (BIMS) score 14, cognitively intact.
R21's Care Plan dated 3/12/24 documents R21 requires stand by to limited assistance from staff at times to complete Activities of Daily Living (ADL). R21 requires 1 person assist to stand.
R21's Shower/Abnormal Skin Report documents from 4/1/24 till present, R21 received a shower on 4/17, 4/24 and 5/1/24.
Facilities Bath/Shower Policy dated 3/20/23 documents: Policy To ensure adequate hygiene needs are met. A bath/shower is scheduled for all residents in the facility at least weekly.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow physician orders in obtaining oxygen saturation levels and do...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow physician orders in obtaining oxygen saturation levels and documenting them on the residents Treatment Administration Record (TAR). This failure affects one resident (R23) reviewed for following physician orders from a total sample list of 32.
Findings include:
R23's Facility Census documents R23 was admitted to the facility on [DATE] and has the following medical diagnoses; Atrial Fibrillation, Malignant Neoplasm of Prostate, Anemia, Type 2 Diabetes, Depression, Essential Primary Hypertension, Cardiac Arrhythmia, Insomnia, History of Extended Spectrum Beta Lactamase, Difficulty in Walking, Chronic Respiratory Failure with Hypoxia, Gastro-Esophageal Reflux Disease, Chest Pain, Atrial Flutter, Obstructive Sleep Apnea, History Pulmonary Embolism and Pulmonale.
R23's Minimum Data Set (MDS) dated [DATE] documents R23's Brief Interview for Mental Status (BIMS) score 14, cognitively intact.
R23's Physician Order Sheet (POS) dated 4/1/24 to present documents Oxygen Saturation to be taken and charted every shift.
R23's Treatment Administration Record (TAR) documents R23's Oxygen saturation was not documented on 4/16/24 (6:00am-6:00pm), 4/17/24 (6:00am-6:00pm), 4/18/24 (6:00am-6:00pm and 6:00pm to 6:00am), 4/19, 4/20, 4/21, 4/22, 4/23, 4/24, 4/25, 4/26 and 4/27/24 (6:00pm-6:00am), 4/28, 4/29, 4/30/24 (6:00am-6:00pm and 6:00pm-6:00am), 5/1 and 5/24/24 (6:00pm-6:00am), 5/3, 5/4, 5/5, 5/6/24 (6:00am-6:00pm and 6:00pm- 6:00am).
R23's Care Plan dated 3/11/24 documents R23 has shortness of breath related to Chronic Obstructive Coronary Disease (COPD). R23 uses oxygen via nasal cannula continuous and that R23 also is administered inhalers.
On 5/8/24 at 9:30am, R23 stated that staff doesn't always check R23's oxygen level. R23 stated they do it occasionally, but not every day.
On 5/8/24 at 1:48pm, V5 Resident Care Coordinator confirmed that R23 has an order for R23's oxygen saturation level to be checked every shift. V5 said, after the nurse takes R23's oxygen saturation it should be documented in R23's Treatment Administration Record (TAR), per R23's Physician Orders. V5 confirmed that R23 was missing the following documentation in R23's TAR: 4/16/24 (6:00am-6:00pm), 4/17/24 (6:00am-6:00pm), 4/18/24 (6:00am-6:00pm and 6:00pm to 6:00am), 4/19, 4/20, 4/21, 4/22, 4/23, 4/24, 4/25, 4/26 and 4/27/24 (6:00pm-6:00am), 4/28, 4/29, 4/30/24 (6:00am-6:00pm and 6:00pm-6:00am), 5/1 and 5/24/24 (6:00pm-6:00am), 5/3, 5/4, 5/5, 5/6/24 (6:00am-6:00pm and 6:00pm- 6:00am).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to correctly perform supra pubic catheter care for one of one residents (R101) reviewed for catheter care in the sample list of 32...
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Based on observation, interview and record review the facility failed to correctly perform supra pubic catheter care for one of one residents (R101) reviewed for catheter care in the sample list of 32.
Findings include:
The Physician's Order Sheet (POS) dated 5/1/24 for R101 documents the following diagnosis: Chronic Obstructive Pulmonary Disease, Urinary Tract Infection, Chronic Heart Failure, and Neuropathy. The same POS documents catheter care to be provided by staff every shift for R101. R101 requires total assistance for all activities of daily living and requires a mechanical lift transfer with two assist.
On 5/8/24 at 10:10 AM, Certified Nurses Assistants (CNA) V7 and V10 provided catheter care to R101. V7 explained to R101 they were going to clean his supra pubic catheter and V10 was doing the actual care for the procedure. V10 while cleaning the supra pubic catheter continued to go over the same area three times without changing the position of the wash cloth. V10 stated on 5/8/24 at 10:30 AM, I did not realize I did that, you are to change the cloth each time you wash the catheter.
The facility's policy titled Catheter Care dated 3/15/23 documents to #7 to wash the catheter tubing from the opening of the urethra (supra pubic) outward 4 inches or farther if needed. Do not pull on the catheter.
V12, Regional Support stated on 5/8/24 at 11am, We do not have a separate policy for supra pubic catheter, the procedure will be the same.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
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 serve a physician ordered diet texture to a resident ...
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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 serve a physician ordered diet texture to a resident who required mechanically altered food. This failure affects one resident (R18) out of ten reviewed for diet textures on the sample list of 32.
Findings include:
On 5/7/24 at 12:35 PM, R18 was seated at a dining room table being assisted to eat by V7, Certified Nursing Assistant (CNA). R18 had a sandwich on his plate consisting of 2 slices of bread with thick slices and chunks of roast turkey. R18 had not eaten any of the sandwich since it was served at 12:22 PM.
On 5/7/24 at 12:35 PM, R18's tray card had a blue sticker with the word mechanical on the sticker.
When asked, V7, CNA, used a fork to lift the top piece of bread from the sandwich, then stated and confirmed, No that sure is not mechanical. V7 then went to the kitchen service window and obtained a new plate of lunch for R18 including mechanical texture of the roast turkey. R18 consumed approximately 90% of the mechanical texture turkey.
R18's current physician order sheet dated for May 2024 documents R18 has a physician order to receive mechanical soft diet texture.
R18's Nutritional assessment dated [DATE] documents R18 needs a mechanical texture diet due to having few teeth in poor condition which cause chewing or swallowing difficulties.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to answer call lights in a timely manner for seven residents (R21, R29, R31, R37, R39, R40, R46) and failed to provide privacy wh...
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Based on observation, interview and record review, the facility failed to answer call lights in a timely manner for seven residents (R21, R29, R31, R37, R39, R40, R46) and failed to provide privacy while giving an insulin injection in the dining room for one resident (R40) of eight residents reviewed for dignity in the sample list of 32.
Findings include:
Resident Council Meeting Minutes document the following: 6/23/2023, call lights need to be answered more timely; 7/21/2023, call lights are not being answered timely due to staff availability; 10/20/2023, call lights not being answered timely; 11/17/2023, second shift late answering call lights; 2/15/2024, answering call lights late; 3/21/2024, need to be more prompt answering call lights; 4/18/2024, call lights need to be answered sooner.
On 5/7/24 at 3:01 PM, during the resident council interview, R21, R29, R31, R37, R39, R40, R46, all stated call lights are not answered timely (on each shift).
R40's Physician Order Sheet (POS) dated 5-1-24 - 5-31-24, documents Insulin Lispro 100unit/milliliter - inject 5 units subcutaneous before meals.
On 5/8/24 at 12:17 PM, V14 Licensed Practical Nurse (LPN), administered insulin to R40 in which V14 injected insulin into R40's abdomen while in the dining room while other residents were present. At this same time V14 LPN stated we always do it this way in the dining room, no one has told me (V14) any different.
The facility's Residents' Rights pamphlet dated Revised 11/2018, documents you should receive the services included in the plan of care, your facility must provide services to keep your physical and mental health at their highest practical level, and you have a right to privacy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to label insulin pens after opening for five residents (R5, R15, R16, R27, R40) of five residents reviewed for insulin storage i...
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Based on observation, interview, and record review, the facility failed to label insulin pens after opening for five residents (R5, R15, R16, R27, R40) of five residents reviewed for insulin storage in the sample list of 32.
R5's Physician Order Sheet (POS) dated 5-1-2024 - 5-31-24, documents Insulin Glargine-YFGN Units 100 inject 15 units subcutaneous (SQ) two times a day; Fiasp 100 units/milliliter (ml) 3 ml pen inject 5 units SQ three times daily before meals and Insulin Fiasp 100ml 3 ml per sliding scale four times a day.
R15's POS dated 5-1-2024 - 5-31-24, documents Insulin Glargine -YFGN U100 inject 15 units SQ at bedtime, Insulin Lispro 100units/ml inject four times a day per sliding scale.
R16's POS dated 5-1-2024 - 5-31-24, documents Insulin Lispro 100u/ml SQ before meals four times a day.
R27's POS dated 5-1-2024 - 5-31-24, documents Novolog 100 units/ml per sliding scale four times a day, Insulin Aspart 100units/ml 3 ml four times a day.
R40's POS dated 5-1-2024 - 5-31-24, documents Insulin Lispro 100units/ml inject 5 units SQ before meals per sliding scale, Levemir 100units/ml inject 10 units SQ at bedtime.
On 5/8/24 at 12:17 PM, V17 Licensed Practical Nurse (LPN) was preparing to give insulin and the surveyor observed no open dates documented on the insulin pens for five residents (R5, R15, R16, R27, R40). V17 was asked about if and when the insulin pens should be dated when opened and V17 stated and pointed to the delivery received dates as the date of opened.
On 5/8/24 at 12:35 PM, V5 LPN/RCC (Resident Care Coordinator) stated the insulin pens should be dated when they are opened.
The facility's Procurement and Storage of Medications Policy dated 11/6/18, documents all medication containers shall be labeled with the date opened by the person breaking the seal.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure that food served was palatable and attractive. This failure affects seven (R21, R29, R31, R37, R39, R40, R46) resident...
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Based on observation, interview, and record review, the facility failed to ensure that food served was palatable and attractive. This failure affects seven (R21, R29, R31, R37, R39, R40, R46) residents reviewed for dining services.
Findings include:
On 5/7/24 at 3:01 PM, resident council interview was held. At this time, R21, R29, R31, R37, R39, R40, and R46 all stated the food is terrible, doesn't look appetizing, is either hot or cold when not supposed to be, and they have the same things.
Resident Council Minutes document: 6/23/24, food needs to be cooked more thoroughly; 9/15/23, cold food, want more fried chicken and magic cups; 12/21/23 cold food in dining room; 1/18/24, cold food all three shifts; 3/21/24, change meals, more coffee, too much butter; 4/18/24, hall trays for three meals are cold when they reach the residents, no coffee available to drink, more salt, pepper, sugar to be available, want alterations with how the food is being cooked.
On 5/8/24 at 12:30 PM, surveyor asked V1 Administrator to come to dining room. At this time, surveyor and V1 observed at least 7 lunch plates with yellow and orange carrots not eaten. When speaking to R21, R29, R31, R37, R39, R40, R46, all stated the carrots are hard and cold and afraid they will break their teeth if they eat them.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on four of eighteen days reviewed for RN staffing. This failure has the potential to affec...
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Based on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on four of eighteen days reviewed for RN staffing. This failure has the potential to affect all 49 residents in the facility.
Findings include:
The facility Nursing Schedules from April 23, 2024 through May 10, 2024 were reviewed for RN staffing. The Facility Nursing Schedule (April 23, 2024 through April 30, 2024) documents on 4/23/24, 4/25/24, and 4/27/24, the facility scheduled four (4) hours of RN coverage for a 24 hour period. This same record documents on 4/29/24, the facility scheduled zero (0) hours of RN coverage for a 24 hour period.
On 5/9/24 at 1:32pm, V5 Resident Care Coordinator confirmed the hours listed on the facility nursing schedule were correct and the facility failed to have sufficient RN coverage on 4/23/24, 4/25/24, 4/27/24, and 4/29/24.
The Long-Term Care Facility Application for Medicare and Medicaid report dated 5/8/24 documents 49 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 the range hood in a sanitary condition to protect food being prepared on the range, and failed to maintain the comme...
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Based on observation, interview, and record review, the facility failed to maintain the range hood in a sanitary condition to protect food being prepared on the range, and failed to maintain the commercial dishwasher sanitizer levels to sanitize meal service wares and utensils. These failures have the potential to affect all 49 residents residing in the facility.
Findings include:
1. On 5/7/24 at 9:28 AM, the range hood in the facility kitchen had a dull appearance and there was a general coating of a dull light brown colored greasy substance with darker brown grease trails running down the interior surface of the range hood. There was a pot of Brussels sprouts cooking on the range, as well as a cooked blueberry cobbler cooling on the side of the range, both items being directly underneath the hood.
On 5/7/24 at 9:28 AM, there was an applied sticker on the outside of the range hood which documented a last cleaning date of 6/27/23. V6, Dietary Manager, stated, That sounds about right. I have been trying to keep it clean myself, but we need to get the cleaning service to come back in here again.
2. On 5/7/24 at 9:36 AM, the facility commercial dishwasher was in active operation with V16, Dietary Aide, washing resident dish wares and utensils. V6, Dietary Manager, confirmed the dishwasher used chlorine to sanitize the dishes. V6 then tested the sanitation cycle with a chlorine test strip which resulted in the test strip showing a slight tinge of gray color, indicating a chlorine level of 10 parts per million (ppm) or less. V6 repeated the dishwasher cycle and tested a second time with the same results. V6 stated, The same thing happened back in February when the County Public Health was here, but we moved the tubing around and it was fine after that. After moving the tubing around and running 2 additional cycles, testing each cycle, the test result remained at 10 ppm or less. V6 stated, I will call the service company and get them to come out. V16, Dietary Aide, receiving no further instruction from V6, continued to run dishes through the dishwasher to complete the remainder of the breakfast dishes.
The facility's policy Ware-washing - Dishmachine dated 10/2009 documents, Before washing anything, use a test strip to check the sanitizer level, for chlorine sanitizers the level should be 50 - 100 ppm.
On 5/7/24 at 10:20 AM, V6, Dietary Manager, stated, I called the service company and they can't come today but said they would make it a priority to come tomorrow. We will start sanitizing the lunch dishes in the 3 compartment sink.
The facility's Resident Roster dated 5/7/24 and Form 671, Long Term Care Facility Application for Medicare and Medicaid dated 5/8/24, both document 49 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to conduct quarterly Quality Assurance (QA) meetings. This failure has the potential to affect all 49 residents residing in the facility.
Find...
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Based on interview and record review the facility failed to conduct quarterly Quality Assurance (QA) meetings. This failure has the potential to affect all 49 residents residing in the facility.
Findings include:
The facility's Quality Assurance meeting sign in sheets for the last year were requested and were provided by V1 (Administrator). The facility had a documented meeting on 4/26/2024. The QA Meeting sign in sheet dated 4/26/2024 documents the facility reviewed information from the months of January, February and March 2024. There are no documented QA meeting sign in sheets for any other quarterly committee meeting.
On 5/9/24 at 9:15 am, V1 Administrator and V12 Regional Support confirmed there were no more sign in sheets for the Quarterly Committee Meetings. V1 on 5/10/24 at 9:45 am, confirmed the meeting sheet dated 4/26/24 covered the months of January, February and March 2024.
The facility's undated policy titled Quality Assurance Plan documents the facility will have quarterly meetings.
The facility's Resident Roster dated 5/7/24 and Form 671, Long Term Care Facility Application for Medicare and Medicaid dated 5/8/24, both document 49 residents reside in the facility.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure therapy services were provided for three (R1, 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 ensure therapy services were provided for three (R1, R2, R3) of three residents reviewed for therapy services on the sample list of six.
Findings include:
On 3/14/24 from 9:00 AM to 2:00 PM there were no therapists working in the facility, and the therapy room was locked.
1. On 3/14/24 at 12:50 PM, R1 was sitting in R1's wheelchair in the dining room. R1 stated, I have not received any Physical or Speech therapy since I've been in the facility. I had orders to receive therapy, but there is no therapist in the building, and I was hoping to go home after therapy.
R1's Face Sheet documents R1 was admitted to the facility on [DATE].
R1's Physician Order Sheet (POS) dated 1/18/24 documents Occupational Therapy (OT) five times a week for four weeks. For therapy activities, Neuromuscular re-education, group therapy and self-care management.
R1's Physician Order Sheet (POS) dated 1/23/24 documents Speech Therapy (ST) two times a week for four weeks, to target cognitive skills, develop compensatory strategy.
R1's Physician Order Sheet (POS) dated 2/18/24 documents all therapy services (PT/OT/ST) on hold pending new contract.
2. R2's Face Sheet documents R2 was admitted to the facility on [DATE].
R2's Physician Order Sheet (POS) dated 2/13/24 documents Physical Therapy (PT) two times a week for four weeks. For therapy exercises, therapy activities, gait training and neurological reeducation.
R2's Physician Order Sheet (POS) dated 2/18/24 documents all therapy services (PT/OT/ST) on hold pending new contract.
3. On 3/14/24 at 9:40 AM, R3 was sitting in R3's wheelchair watching television. R3 stated, I am not getting ordered therapy due to the facility not having a contract with Physical/Occupational Therapy. I have not had any therapy in over a month. The reason why I am here is to receive therapy to get stronger and possibly go home.
R3's Face Sheet documents R3 was admitted to the facility on [DATE].
R3's Physician Order Sheet (POS) dated 1/18/24 documents R3 will receive Occupational therapy five times a week for four weeks and Physical Therapy two times a week for four weeks.
R3's Physician Order Sheet (POS) dated 2/18/24 documents all therapy services (PT/OT/ST) on hold pending new contract.
On 3/14/24 at 1:39 PM, V2 Director of Nursing (DON) said, the facility is currently not providing any therapy services to residents. V2 said, there are only three residents in the facility that were prescribed therapy services, R1, R2 and R3. V2 said, on 2/13/24 the facility was sent a letter documenting the termination of the therapy service agreement, with the final day of service as 2/18/24. V2 said, the facility has not provided any therapy services since 2/18/24.
The Facility assessment dated [DATE] documents resources provided by the facility include Occupational and Physical Therapy.
The Letter from Rehabilitation Therapy services dated 2/13/24 documents: Dear Administrator, Rehabilitation is providing a 5-day written notice of termination of Therapy Services with the facility due to failure to maintain payment terms, pursuant to Section 5.2.2 of the Therapy Services Agreement. Rehabilitation's final date of service will be Sunday, February 18, 2024.
Feb 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 care plan in the required twenty-one days ...
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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 care plan in the required twenty-one days after admission to the facility. This failure affects one resident (R1) on the sample of three reviewed for falls.
Findings include:
R1's admission Nursing assessment dated [DATE] documents R1 was admitted to the facility 1/19/24.
On 2/15/24 at 1:15 PM, there was not a comprehensive care plan located in R1's medical record.
On 2/15/24 at 1:25 PM, V3, Licensed Practical Nurse/ Resident Care Coordinator, stated, We have the baseline care plan in the chart.
On 2/15/24 at 1:25 PM, V16, Regional Clinical Nurse, stated, We have the baseline care plan in the chart, the comprehensive is on it's way. I think the comprehensive care plan is due 21 days after admission, 14 days to complete the initial minimum data set, then another seven days to complete the care plan, but I will need to check that to make sure.
On 2/15/24 at 1:48 PM, V16 stated, We do not have a comprehensive care plan for R1. V16 then confirmed, The requirement is 21 days after admission.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to revise a care plan for one (R2) of three residents reviewed for fall care plans.
Findings include:
The facility fall prevention policy dated...
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Based on interview and record review the facility failed to revise a care plan for one (R2) of three residents reviewed for fall care plans.
Findings include:
The facility fall prevention policy dated 11/10/2018 documents that all falls will be discussed in the morning quality assurance meeting and any new interventions will be written on the care plan.
R2's fall review documents that on 1/19/24 at approximately 11:00 PM, R2 fell in his room while using his walker and stumbled, sustaining a skin tear on his left elbow.
R2's fall care plan dated 3/1/16, documents R2's most recent fall was on 11/13/23. Neither the fall, nor any interventions from the 1/19/24 fall, were documented on the care plan.
On 2/15/24 at 9:10AM, V7 Social Services Director stated that R2's care plan did not have any interventions documented for the 1/19/24 fall.
On 2/15/24 9:15AM, V3 Resident Care Coordinator stated that R2's care plan should be updated and that neither the fall of 1/19/24, nor the interventions for that fall were documented on the care plan.
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 conduct a fall assessment, failed to implement interventions to prev...
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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 a fall assessment, failed to implement interventions to prevent falls, and failed to properly assess the resident after a fall for one (R3) of three residents reviewed for falls.
Findings include:
The facility fall prevention policy dated 11/10/2018 documents that fall assessments will be conducted with a change of condition. After a fall, a fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will document the circumstances of the fall in the nurse's notes, or an Assessment, Implement, Management (AIM) for Wellness form along with any new intervention deemed to be appropriate at the time. All falls will be discussed in the morning quality assurance meeting and any new interventions will be written on the care plan.
R3's fall assessment dated [DATE] documents R3 as a high risk for falls.
On 2/15/24 at 10:45AM, V15 Licensed Practical Nurse stated, I was working the night (R3) fell (2/2/24), it was actually in the morning a little before 5:00AM. An aid came down and told me that (R3) was on the floor. I went to his room and found him laying beside his bed with his head kind of under the bed. I asked him what happened and he told me that he just rolled out of bed. He said that he hit his head. I did an assessment and started vital signs and neurological checks. I called the Nurse Practitioner and his family. I'm not aware of any interventions or a huddle. He already had non-slip footwear and a low bed.
On 2/15/24 at 12:00PM, V3 Resident Care Coordinator confirmed that R3's medical record does not contain: a fall assessment on 2/2/24, documentation of a fall huddle regarding the fall, an interdisciplinary team meeting note regarding the fall, a nurse's note about the fall, nor an AIM for wellness form regarding the fall.
R3's care plan dated 2/2/24 documents an intervention to check R3 frequently while in bed.
On 2/15/24 at 11:25AM, R3 said that staff aren't in his room any more than usual.
On 2/15/24 at 2:20PM, V12 and V19 Certified Nursing Assistants stated that they were unaware that R3 had fallen.
On 2/15/24 at 2:35PM, V3 Resident Care Coordinator (RCC) stated, We don't have anyone on frequent checks in the building right now.
On 2/15/24 at 12:50PM, V3 RCC confirmed that R3's neurological checks were not completed correctly. They just stopped filling them out after ten hours. They should have done them for another three days. I will be doing an inservice on this.
On 2/15/24 at 3:10PM, V16 Regional Clinical Nurse stated, I would expect the staff to fill out a quality form including the assessment and interventions to put into place, to report the fall to the (Medical Doctor and the Power of Attorney) and to develop fall interventions, fill out neuro checks and document them on the care plan after a fall.
Sept 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 F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to offer and or provide influenza, pneumonia and Covid-19 vaccinations to three (R1, R3 and R4) of five residents reviewed for immunizations fr...
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Based on interview and record review the facility failed to offer and or provide influenza, pneumonia and Covid-19 vaccinations to three (R1, R3 and R4) of five residents reviewed for immunizations from a total sample list of five residents.
Findings include:
The facility provided Immunization of Residents Policy dated 1/23/20 documents that the facility will offer immunizations and vaccination that aid in the prevention of infectious disease unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director. Document the immunization on the resident's medication administration record and on the resident's immunization record.
V1 Administrator provided a list of residents who received the influenza and Covid-19 vaccinations or refused them. R1, R3 nor R4 were included on the list.
R1's undated face sheet documents admission to the facility on 2/26/23. R1's resident pneumonia vaccine consent dated 9/14/23 documents that R1 wanted the pneumonia vaccine but did not receive it.
On 9/20/23 at 1:30 PM, V1 Administrator said that she was not aware that the pneumonia vaccine had to be offered at all times of the year and thought that it could be offered with the flu, in October.
R3's undated face sheet documents admission to the facility on 5/10/23. R3's medical record does not document pneumonia vaccine being offered.
R4's undated face sheet documents admission to the facility on 7/3/23. R4's medical record does not document Covid-19 vaccine being offered.
On 9/20/23 at 2:00PM, V2 Director of Nursing stated that she could not find documentation of offers for vaccinations or refusals for R3 or R4.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to have an infection control program based on current standards including; maintaining infection control records, following guidelines for empl...
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Based on interview and record review the facility failed to have an infection control program based on current standards including; maintaining infection control records, following guidelines for employees returning to work, testing for Covid-19 as recommended and reporting outbreaks as directed. This failure has the potential to affect all 52 residents residing in the facility.
Findings include:
The facility provided Covid-19 Control Measures Policy dated 5/19/23 documents that health care providers with confirmed Covid-19 infection should remain off work for 10 days or 7 days with 2 negative tests on day 5 and day 7 and should be asymptomatic or mildly symptomatic with improving symptoms and fever free for 24 hours without the use of fever reducing medications. Additionally, the facility will maintain infection control logs, reviewing tracking daily for any patterns or trends and maintain employee infection control logs. The facility will review daily to identify any patterns or trends of employees exhibiting sign/symptoms of Covid-19. Employees who are ill will be asked if testing was done and the results will be requested. Written notification will be provided immediately to the local health department upon the confirmation of Covid-19 infection of a resident or staff member.
The facility Room Roster dated 9/20/23 documents 52 residents residing at the facility.
On 9/20/23 at 3:00 PM, V1 Administrator asked V3 Licensed Practical Nurse (LPN) for documentation of her Covid-19 test. V3 LPN then provided a document indicating a positive test result from the Covid-19 test on 9/5/23. V3 LPN's facility provided time card documents that V3 LPN returned to work on 9/8/23.
On 9/20/23 at 1:45 PM, V1 stated, I didn't keep track of all of the Covid-19 test results and that is how (V3 Licensed Practical Nurse) came back to work three days after a positive Covid-19 test. I didn't talk to everyone about their illness and that's one of the reasons that I need an infection preventionist, to keep track of things like that.
On 9/20/23 at 10:00 AM, V1 Administrator provided documentation of resident and employee testing on 9/1/23 and 9/6/23, but stated that the other testing dates had not been recorded, nor had any contact tracing been documented.
On 9/20/23 at 10:14 AM, V1 Administrator stated, I tested the residents and staff on day one and day five, but not on day three. I found out later that I should have. I didn't keep formal records for any of the testing. V1 also stated at this time, I had it all in my head. I know now that I should document everything.
On 9/20/23 at 9:11 AM, V9 Public Health District Communicable Disease Coordinator stated, To my knowledge, (this facility) doesn't have an infection preventionist. When I contact them, it is always (V1 Administrator) that I speak with. I have concerns that they don't have enough personal protective equipment and don't know when to contact (the local health department). It tends to be me contacting them after an outbreak has occurred and that isn't how it is supposed to work.
On 9/20/23 at 3:00 PM, V1 Administrator said that she should have consulted the local health department when the outbreak occurred.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have an infection preventionist on staff, responsible for the infect...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have an infection preventionist on staff, responsible for the infection control program. This failure has the potential to affect all 52 residents residing in the facility.
Findings include:
The facility Room Roster dated 9/20/23 documents 52 residents residing at the facility.
The facility provided Infection Control Surveillance and Monitoring Policy dated 4/11/22 documents that the facility shall employee, at a minimum, a part time Infection Control Preventionist.
The facility assessment dated [DATE] documents that the Infection Control Nurse is V12 Licensed Practical Nurse.
On 9/20/23 at 10:00 AM, V1 Administrator stated, I put V12 Licensed Practical Nurse on the facility assessment as the Infection Preventionist because I was going to have her take the class, but we didn't get to it. I don't have anyone functioning in the Infection Preventionist role other than me and I'm not a clinical person.
On 9/20/23 at 8:20 AM, V4 Licensed Practical Nurse stated, We were in outbreak due to Covid, but I don't know if we have an Infection Control Nurse, I can't answer that.
On 9/20/23 at 9:50 AM, V2 Director of Nursing said that she was unaware of who the Infection Preventionist was for the facility.
On 9/20/23 at 2:30 PM, V8 Minimum Data Set Coordinator said that she had the infection preventionist certification, but that she had never worked on the infection prevention program for this facility or on any component of the infection control program while employed at this facility.
On 9/20/23 at 9:11 AM, V9 Public Health District Communicable Disease Coordinator stated, To my knowledge, (this facility) doesn't have an infection preventionist. When I contact them, it is always (V1 Administrator) that I speak with. I have concerns that they don't have enough personal protective equipment and don't know when to contact (the local health department). It tends to be me contacting them after an outbreak has occurred and that isn't how it is supposed to work.
Aug 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
Deficiency F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to obtain a written Physician recommendation/order for admission to the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to obtain a written Physician recommendation/order for admission to the facility for one of three residents (R2) reviewed for Physician services in the sample list of three.
Findings include:
The facility's Physician Services policy with a revised date of 1/8/18 documents, Physician Services are those services provided by a physician responsible for the care of individual residents. Such services include, but are not limited to: A. A written report of a physical examination conducted five (5) days prior to, or within seventy-two (72) hours after admission; B. A medical evaluation of the resident and written order for care and treatment.
R2's Face Sheet documents R2 was admitted to the facility on [DATE]. R2's Physician's Order Sheet dated 7/3/23 through 7/31/23 documents diagnoses including Acute Systolic Heart Failure, Congestive Heart Failure, Coronary Artery Disease, Diabetes, Unstable Angina and Chronic Obstructive Pulmonary Disease.
R2's Nurse's Progress Note dated 7/3/23 at 2:30 PM documents R2 admitted to the facility from home and R2's spouse brought R2 to the facility in their personal vehicle. This Note documents that R2 is on 2 liters of continuous oxygen and documents that V7 Nurse Practitioner was notified of R2's admission.
R2's medical record does not document a Physician's Order or a Physician's recommendation for admission to the facility.
On 8/5/23 at 12:52 PM, V2 Director of Nursing confirmed there is not Physician's Order or Physician's recommendation for admission to the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident was seen and assessed by a Physician within 3...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident was seen and assessed by a Physician within 30 days after admission to the facility and failed to have documentation of Physician and/or Nurse Practitioner visits for two of three residents (R2, R3) reviewed for Physician Services in the sample list of three.
Findings include:
The facility's undated Admissions policy documents, Each resident shall be under the care of an attending physician of their choice. The attending physician must visit the resident at least once every thirty (30) days for the first 90 days after admission, and at least every 60 days thereafter. Each resident shall have a complete physical examination within five (5) days prior to, or within seventy-two (72) hours after admission.
1.) R2's Face Sheet documents R2 was admitted to the facility on [DATE]. R2's Physician's Order Sheet dated 7/3/23 through 7/31/23 documents diagnoses including Acute Systolic Heart Failure, Congestive Heart Failure, Coronary Artery Disease, Diabetes, Unstable Angina and Chronic Obstructive Pulmonary Disease.
R2's Nurse's Notes dated 7/3/23 documents R2 was admitted to the facility from home. R2's medical record does not contain documentation of a Physician's visit within 30 days of admission.
On 8/5/23 at 12:15 PM, V2 Director of Nursing confirmed there were no Physician Progress notes in R2's medical record. V2 confirmed that R2 had not been seen by a Physician since admission on [DATE].
On 8/5/23 at 12:55 PM, V1 Administrator stated that the last time V8 Physician was in the facility was on 6/29/23.
2.) R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including Other Sequelae of Cerebral Infarction, Muscle Weakness and History of Falling.
R3's medical record does not contain any documentation of Physician or Nurse Practitioner visits.
On 8/5/23 at 12:52 PM, V2 confirmed there is no documentation of Physician or Nurse Practitioner visits in R3's chart. V2 stated V2 does not know the last time R3 was seen by the Physician or Nurse Practitioner.
Jun 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain and document complete and accurate medical records. This failure affects four residents (R4, R8, R15, R22) of 13 rev...
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Based on observation, interview, and record review, the facility failed to maintain and document complete and accurate medical records. This failure affects four residents (R4, R8, R15, R22) of 13 reviewed for quality of care in urinary catheter care, medications, and skin treatments, on the sample of 24.
Findings include:
1. R22's current Physician Order Sheet (POS) for June 2023 documents a physician order for facility staff to Irrigate indwelling catheter with 60 ml (milliliters) of NSS (normal saline solution) on 10 (pm) - 6 (am) shift. This same POS documents a physician order for facility staff to provide catheter care every shift.
R22's Treatment Administration Record (TAR) for April 2023 documents the facility shifts as 10 (pm) to 6 (am), 6 (am) to 2 (pm), and 2 (pm) to 10 (pm). This same TAR had undocumented catheter care for 27 shifts out of a possible 90.
R22's TAR for May 2023 documents (incorrectly) the facility shifts as 6 (pm) to 6 (am) and from 6 (am) to 6 (pm). This same TAR had undocumented catheter care for 30 shifts out of a possible 62. This same TAR documents a change in the treatment order for the nightly irrigation for R22's catheter from nightly to PRN (as needed). There was not a corresponding physician order in R22's record to support the change in the irrigation order. This change of the catheter irrigation on the TAR resulted in undocumented irrigations for all 31 night shifts in May 2023.
R22's TAR for June 2023 documents (incorrectly) 2 shifts per day and had undocumented catheter care for 23 shifts out of a possible 60, and undocumented catheter irrigations for all 30 night shifts in June 2023.
On 6/27/23 at 3:56 pm, V3, Registered Nurse, stated, The nurses work a 12 hour shift but the CNAs (Certified Nursing Assistants) work 8 hours.
On 6/27/23 at 4:18 pm, V4, Licensed Practical Nurse, stated, We nurses work 12 hour shifts, the CNAs work 8 hours.
On 6/28/23 at 10:15 am, V6, Certified Nursing Supervisor, stated, The CNAs do the catheter care usually every shift. The CNAs work 8 hour shifts, first, second, and third.
On 6/29/23 at 3:18 pm, V1, Administrator, stated, I can't say for sure who changed that (catheter irrigation) order, but we have an LPN (Licensed Practical Nurse) who was a doctor in her country of origin and tends to overstep her bounds as a nurse.
On 6/29/23 at 3:27 pm, V2, Director of Nursing, stated, I have a good idea who changed that (irrigation) order. I tell my staff that even if they just change the timing of a medication to get a doctor's order.
2. R4's current POS for June 2023 documents a physician order for facility staff to provide (Indwelling) catheter care every shift.
R4's TAR for April 2023 documents 3 shifts per day and had undocumented catheter care for 15 shifts out of a possible 90. R4's TAR for May 2023 had undocumented catheter care for 56 shifts out of a possible 93. R4's TAR for June 2023 documents (incorrectly) as 2 shifts per day and had undocumented catheter care for 37 shifts out of a possible 60.
On 6/29/23 at 3:27 pm, V2, Director of Nursing, stated, I saw the blanks on the TARs and I have talked with my ADON (Assistant Director of Nursing) and said 'we are going to have to spend 5 minutes and flip through the TARs and MARs (Medication Administration Records) to make sure they are getting filled out.'
3. R15's current POS for June 2023 documents a physician order for facility staff to apply Bacitracin ointment topically to buttock BID (twice daily). This same POS documents a physician order for facility staff to apply house (facility stock) barrier cream to buttocks after each perineal care and episode of incontinence.
R15's TAR for May 2023 documents the bacitracin ointment order was initiated on 5/10/23. This same TAR had undocumented treatments for the bacitracin ointment for 20 out of a possible 43 applications. R15's TAR for June 2023 had undocumented treatments for the bacitracin ointment for 36 out of a possible 60 applications. R15's TAR for June 2023 did not include the order for the barrier cream to be applied after each perineal care and episode of incontinence. There was not a supporting document in R15's chart to discontinue this physician's order for the barrier cream.
On 6/28/23 and 6/29/23, V19, Licensed Practical Nurse, was observed passing medications and providing care on the hallway where R15 resided.
On 6/29/23 at 11:56 am, V2 Director of Nursing, V3 Registered Nurse, V4 Licensed Practical Nurse, and V19 Licensed Practical Nurse, all searched through both of the facility's treatment supply carts to look for the bacitracin ointment prescribed for R15. V19 specifically stated she did not know where the bacitracin was located. V3 located the bacitracin ointment in the treatment cart for the facility hall opposite from where R15 resided.
4. R8's closed (discharged resident) record documented R8 resided at the facility 11/15/22 through 12/2/22. R8's closed record included nursing notes, hospital histories, and nurse practitioner (V20) progress notes which documented R8 utilized an indwelling urinary catheter. R8's POS and TAR for November 2022 did not include any catheter care instructions nor documentation of any catheter care provided. R8's TAR for December 2022 was absent from the closed record.
R8's TAR for November included instructions for facility staff to conduct weekly skin checks for R8. There was only one skin check documented on 11/16/22, the skin checks for 11/23/22 and 11/30/22 are undocumented. The TAR for December 2022 was absent from R8's record.
R8's closed record included a Controlled Substance Proof of Use sheet which simply documented, (resident name) take 2 to 3 tabs po (by mouth) q (every) 3 hours prn (as needed) for pain. This Controlled substance Proof of Use Sheet did not document the name of the drug being accounted for, nor did this sheet document any dose strength of the tablets.
On 6/27/23, 6/28/23, and 6/29/23, at various times each day, V1 Administrator and V2 Director of Nursing, stated they had only recently began working at this facility. V1 and V2 stated they did not have knowledge of R8. On 6/29/23 at 3:15 pm, V1 stated, I wouldn't know what I could do to fix this (closed record), (R8) is gone.
May 2023
8 deficiencies
3 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to transcribe and implement physician orders for wound tre...
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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 transcribe and implement physician orders for wound treatments for one of four residents (R7) reviewed for wound care in a sample list of 11 residents. These failures resulted in R7's wounds deteriorating and R7 experiencing increased swelling and severe pain when staff failed to follow physician orders to wrap R7's legs/wounds.
Findings include:
R7's Medical Record documents medical diagnoses of Morbid Obesity, Diabetes Mellitus Type II, Chronic Kidney Disease, Macular Degeneration, Neuropathy, Lymphademic wounds of Right Lower Leg and Left Lower Leg.
R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 as requiring limited assistance of one person for bed mobility, transfers, and extensive assistance of one person for dressing, toileting and personal hygiene.
R7's Care Plan documents an intervention dated 9/18/22 that instructs staff to treat Lymphademic wounds as ordered.
R7's Wound Evaluation and Management Summary dated 5/3/23 documents R7's Lymphademic wound of Right Leg with partial thickness measuring 40 centimeters (cm) long by 16.5 cm wide by not measurable depth and Lymphademic wound of Left leg partial thickness measuring 40 cm long by 17 cm wide by not measurable depth. This same Summary documents physician orders to wrap both Right and Left leg Lymphademic wounds from ankles to knees with gauze wrap and elastic wrap twice per week for 30 days.
R7's Weekly Wound Tracking Sheet dated 5/3/23 documents R7's Lymphadema wound on Right Leg measuring 40 cm long by 16.5 cm wide by non-measurable length with no drainage, no odor as new wound and Lymphadema wound on Left Leg measuring 40 cm long by 17 cm wide by not measurable with no drainage, no odor as new wound.
R7's Physician Order Sheet (POS) dated May 1-31, 2023 does not document V22 Wound Physician orders to apply gauze wraps from ankles to knees and cover with elastic gauze wraps twice per week.
R7's Treatment Administration Record (TAR) dated May 1-31, 2023 does not document V22 Wound Physician orders to apply gauze wraps from ankles to knees and cover with elastic gauze wraps twice per week.
R7's Nurse Progress Notes do not document R7's Lymphadema wound dressings to Right and Left Lower Legs. These same progress notes do not document notification to Physician of treatments not being completed as ordered.
On 5/6/23 at 1:00 PM R7's bilateral lower legs and feet had no dressings in place. R7's Right and Left Lower legs had open areas with a moderate amount of yellow drainage. R7's wound drainage was observed on R7's legs and on R7's bed sheets.
On 5/7/23 at 9:30 AM R7's bilateral lower legs and feet had no dressings in place. R7's Right and Left Lower legs had open areas with a moderate amount of yellow/brown drainage.
On 5/9/23 at 1:15 PM R7's bilateral lower legs and feet had no dressings in place. R7's Right and Left Lower legs had open areas with a moderate amount of yellow/brown drainage. R7's wound drainage was observed on R7's legs and on R7's bed sheets.
On 5/6/23 at 1:05 PM R7 stated A week ago Friday (4/28/23) was the last day I was asked to get a shower. Someone cut off my dressings that day but then I didn't get my shower because I started not feeling well. No one has even offered to put them on since then (4/28/23) except (V22) Wound Physician. I know (V22) Wound Physician gave orders for them (staff) to wrap my legs because of my Lymphadema in both lower legs. My legs have been so swollen and painful since they (facility) are not doing their job. I ask the nurses to wrap them and they (staff) say they will but it never gets done. The pain isn't quite so bad when they are wrapped due to the compression. I just can't stand the pain.
On 5/10/23 at 10:00 AM V22 Wound Physician stated This facility definitely caused harm to (R7) by not dressing her Lymphademic wounds as ordered. There is no continuity in staffing so the orders never get processed. There have been several Administrators here and a few Director of Nurses (DON). One time I am here (facility) and talk to one person about the wound program and the next time it is someone else. No one knows what is going on here (facility) because no one wants to take responsibility for the care of the residents. I even asked the floor nurse one day if she wanted access to the online wound program physician notes so the orders could be printed off and she told me she 'didn't want to do all that'. It is that attitude that I see here (facility). (R7's) wounds could have been doing better but there is no continuity in care. V22 Wound Physician stated R7 has voiced to V22 that V22 is the only person who changes the resident dressings. V22 stated (R7) has these wounds that come and go. When I was here on 5/3/23, I resolved (R7's) other wounds and found two more. Now this week those two have gotten worse. I have seen (R7) before without the dressings in place. If the facility would stay on top of the treatment orders and complete the dressings (R7's) Lymphademic wounds on her lower legs might heal up and stay healed. (R7) has a lot going against her but it certainly doesn't help when the facility isn't completing the treatments I order.
The facility policy titled 'Conformance with Physician Orders' reviewed 9/27/17 documents the facility must maintain a complete and accurate listing of current orders on the resident's Physician Order Sheet (POS).
The facility policy titled 'Dressing Change' reviewed 3/16/23 documents Licensed Personnel should document dressing changes in nurse progress notes.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to transcribe and implement physician orders for pressure ...
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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 transcribe and implement physician orders for pressure sore treatments and failed to update a pressure sore care plan for one of four residents (R6) reviewed for pressure sores in the sample list of 11 residents. These failures resulted in R6's pressure sores deteriorating.
Findings include:
R6's Medical Record documents medical diagnoses of Decubitus Ulcers, Multiple Sclerosis, Chronic Kidney Disease, Venous Insufficiency, Muscle Weakness, Obstructive Sleep Apnea and Needs Assistance with Personal Care.
R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. This same MDS documents R6 requires limited assistance of one person for bed mobility, extensive assistance of one person for dressing, toileting and personal hygiene and total dependence of two people for transfers.
R6's Pressure Ulcer Risk assessment dated [DATE] documents R6 as high risk for pressure ulcers.
R6's Care Plan did not include updated pressure ulcer interventions for R6's Pressure Ulcers.
R6's Wound Evaluation and Management Summary (WEMS) dated 5/3/23 documents physician orders of Calcium Alginate covered with absorbent pad twice daily for R6's Right Upper Medial Ischium Stage 4 Pressure Ulcer, Left Buttock Stage 4 Pressure Ulcer, Right Upper Thigh Stage 3 Pressure Ulcer, Right Buttock Stage 3 Pressure Ulcer, and Calcium Alginate with absorbent pad twice weekly for R6's Right Calf Stage 3 Pressure Ulcer, Left Upper Calf Stage 3 Pressure Ulcer and Left Lower Calf Stage 3 Pressure Ulcer.
R6's Physician Order Sheet (POS) dated May 1-31, 2023 does not document V22 Wound Physician ordered treatments for R6's Pressure Ulcers to Right Ischium, Left Buttock, Right Upper Thigh, Right Buttock, Right Calf, Left Upper Calf and Left Lower Calf.
R6's Treatment Administration Record (TAR) dated May 1-31, 2023 does not document V22 Wound Physician ordered treatments for R6's Pressure Ulcers to Right Ischium, Left Buttock, Right Upper Thigh, Right Buttock, Right Calf, Left Upper Calf and Left Lower Calf.
On 5/9/23 at 11:35 PM V21 Licensed Practical Nurse (LPN) provided wound care for R6's Pressure Ulcers. R6's Right Upper Medial Ischium Stage 4 Pressure Ulcer was open with approximately 50% covered with black soft tissue. R6's dressing was saturated with a moderate amount of yellow and brown foul-smelling drainage. The peri-wound area was dark red and non-blanchable. R6's Left Buttock Stage 4 Pressure Ulcer had soft black center with yellow soft edges surrounded by open dark red tissue with moderate yellow and brown drainage. R6's Left Upper Lateral Calf Stage 3 Pressure Ulcer was dark brown with red soft tissue with copious amount of very foul, dark brown drainage. R6's prior dressing of Calcium Alginate and bordered foam was black, slimy and slid off of R6's leg as V21 LPN removed the outer drainage soaked gauze wrap. R6's room had foul odor from infected wounds throughout dressing changes. R6's Sacrum had a softball sized, open, dark brown and red wound with moderate amount of brown and yellow drainage. This same wound was dressed with Calcium Alginate covered by silk tape that was adhered to R6's Sacrum, covered by an absorbent pad. R6's Coccyx had been packed with gauze. R6's coccyx was open with approximately an inch of depth revealing muscle tissue and a dime sized white firm area in the center.
On 5/9/23 at 12:00 PM V21 Licensed Practical Nurse (LPN) stated (R6) has two new wounds on his Sacrum and Coccyx that are not documented in (V22's) Wound Physician notes from 5/3/23. Those wounds must be new. (R6's) wounds smelled horrible. I about had to leave the room. They have really gotten bad. I didn't know they were that bad. I checked the orders before changing the dressings but (R6's) wound orders were not on the POS or TAR so I just followed the orders on (V22's) Wound Physician progress notes. Those orders should be written on the POS and the TAR so the nurses know to change the dressings. It is no wonder they smelled so bad.
On 5/9/23 at 2:00 PM V1 Administrator stated (R6's) physician orders from (V22) Wound Physician should have been transcribed to (R6's) POS and TAR. I am saddened to see that my staff has failed so terribly. (R6) deserves to have the best care possible and he did not receive that here (facility). It breaks my heart to know that (R6) now has more significant Pressure Ulcers beyond those that were already there. We (facility) did not do the treatments, we failed to transcribe the orders, didn't update the careplan and most of all we failed (R6). My facility has to do better than that or we (facility) will never survive.
On 5/10/23 at 10:00 AM V22 Wound Physician stated This facility definitely caused harm to (R6) by not dressing all of his wounds as ordered. There is no continuity in staffing so the orders never get processed. There have been several Administrators here and a few Director of Nurses (DON). One time I am here (facility) and talk to one person about the wound program and the next time it is someone else. No one knows what is going on here (facility) because no one want to take responsibility for the care of the residents. I even asked the floor nurse one day if she wanted access to the online wound program physician notes so the orders could be printed off and she told me she 'didn't want to do all that'. It is that attitude that I see here (facility). (R6's) wounds could have been doing better but there is no continuity in care. V22 Wound Physician stated residents have voiced to V22 that V22 is the only person who changes the resident dressings. V22 stated (R6) has had pressure ulcers that have healed. (R6) definitely has the ability to heal. If the facility would start doing the treatments as ordered then maybe new wounds wouldn't keep showing up.
The facility policy titled 'Conformance with Physician Orders' reviewed 9/27/17 documents the facility must maintain a complete and accurate listing of current orders on the resident's Physician Order Sheet (POS).
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to administer multiple doses of antibiotic and antianxiety...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to administer multiple doses of antibiotic and antianxiety medication as ordered by the physician for two of three residents (R6 and R4) reviewed for medication administration in a sample list of 11 residents. Failing to administer R6's antibiotic therapy resulted in R6's stage four Ischium pressure sore deteriorating.
1.) R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact.
R6's Wound Evaluation and Management Summary (WEMS) dated 5/3/23 documents a physician order for Levofloxacin (Levaquin) 750 milligrams (mg) daily for fourteen days starting 5/3/23 and Clindamycin 300 mg three times per day for fourteen days starting 5/3/23 for a Right Upper Medial Ischium Stage 4 Pressure Ulcer infection.
R6's Physician Order Sheet (POS) and Medication Administration Record (MAR) dated May 2023 does not document R6's physician orders for Levaquin or Clindamycin.
R6's Medical Record documents a total of eight missed doses of Levaquin and 20 missed doses of Clindamycin.
On 5/9/23 at 11:35 AM V21 Licensed Practical Nurse (LPN) provided wound care to R6's Pressure Ulcers. R6's Right Ischium Pressure Ulcer was open with approximately 50% covered with black soft tissue. R6's dressing was saturated with moderate amount of yellow and brown foul-smelling drainage. The peri-wound of this area was dark red and non-blanchable. R6's Left Buttock Stage 4 Pressure Ulcer had soft black center with yellow soft edges surrounded by open dark red tissue with moderate yellow and brown drainage. R6's Left Upper Lateral Calf Stage 3 Pressure Ulcer was dark brown and red soft tissue with copious amount of very foul, dark brown drainage. R6's prior dressing of Calcium Alginate and bordered foam was black, slimy and slid off of R6's leg as V21 LPN removed outer gauze wrap. R6's room had foul odor from infected wounds throughout dressing changes.
On 5/9/23 at 2:30 PM R6's medication supply was observed and did not include Levaquin nor Clindamycin.
On 5/9/23 at 2:35 PM the facility Emergency Kit (E-Kit) was observed to contain Levaquin and Clindamycin.
On 5/9/23 at 12:00 PM V21 Licensed Practical Nurse (LPN) stated (R6's) wounds smelled horrible. I about had to leave the room. They have really gotten bad. I didn't know they were that bad. You can tell they are really infected.
On 5/9/23 at 3:00 PM V25 Pharmacist stated the pharmacy has not received any physician orders for R6's Levaquin and Clindamycin antibiotics.
On 5/10/23 at 10:00 AM V22 Wound Physician stated the facility caused harm to R6 by not providing antibiotic therapy due to R6's Right Ischium Pressure Ulcer had deteriorated. V22 stated No one knows what is going on here (facility) because no one wants to take responsibility for the care of the residents. Unfortunately it is the residents that suffer for the lack of care.
2.) R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired.
R4's Physician Order Sheet (POS) dated May 1-31, 2023 documents a physician order of Xanax 1.0 milligram (MG) twice daily for Anxiety.
R4's Medication Administration Record (MAR) dated May 1-31, 2023 documents R4's Xanax was not administered from 5/2/23-5/10/23 for a total of 14 missed doses.
R4's Medical Record does not document notification to (V26) Physician from 5/2/23-5/10/23 for R4's missed doses of Xanax.
On 5/6/23 at 9:20 AM the medication cart locked medication storage area did not have R4's Xanax nor Narcotic Administration count sheet to match.
On 5/5/23 at 3:15 PM R4 stated with tears rolling down her cheeks Please help them (facility) get me my Xanax. I have terrible Anxiety. I just cry all the time if I don't have it. They (facility) were giving it to me and now they aren't. I really need it.
On 5/6/23 at 9:30 AM V17 Licensed Practical Nurse (LPN) stated I don't have any Xanax for (R4). I don't know where it is but it is not in the cart. I will have to call pharmacy to find out what happened to it. (R4) has been asking me repeatedly for it. I know (R4's) anxiety is worse because she isn't getting it.
On 5/9/23 at 3:00 PM V25 stated the pharmacy dispensed a 30 day supply of (R4's) Xanax on 3/31/23. We (pharmacy) can not provide (R4's) Xanax again without a current prescription.
On 5/9/23 at 3:30 PM V1 Administrator stated We (facility) have been working today on getting (R4's) Xanax. (R4) has been very upset and crying more since she hasn't had it. We (facility) reached out to (V26) Physician today to ask for a renewed prescription. We (facility) haven't heard back yet. I don't know what took so long for us to attempt to contact (V26) Physician but (R4) should not have had any missed doses because of our (facility) error.
The facility policy titled 'Medication Administration' revised 11/18/17 documents the facility is to document any medications not administered for any reason by circling initials and documenting on the back of the MAR the date, time, the medication and dosage, reason for omission and initials. If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. Notify the physician as soon as practical when a scheduled dose of a medication has not been administered for any reason.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the dignity of residents when staff yelled at each other with...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the dignity of residents when staff yelled at each other with residents present. This failure affects two of three residents (R3, R9) reviewed for dignity in a sample list of 11 residents.
Findings include:
R3's Minimum Data Set (MDS) dated [DATE] documents R3 as moderately cognitively impaired.
R3's Initial Incident Report to Illinois Department of Public Health (IDPH) dated 5/9/23 documents alleged Verbal Abuse to R3 by V1 Administrator and V5 Certified Nurse Aide (CNA). This same report documents date of incident as 5/4/23.
On 5/6/23 at 1:30 PM R3 stated Those girls were yelling while I was sitting at the table. I didn't like it. It made me feel sad.
R9's Minimum Data Set (MDS) dated [DATE] documents R9 as moderately cognitively impaired.
R9's Initial Incident Report to Illinois Department of Public Health (IDPH) dated 5/9/23 documents alleged Verbal Abuse to R9 by V1 Administrator and V5 Certified Nurse Aide (CNA). This same report documents date of incident as 5/4/23.
On 5/5/23 at 2:30 PM V1 Administrator stated The morning of 5/4/23 I had a heated discussion with (V5) Certified Nurse Aide (CNA). (V5) was sitting at one of the dining room tables with (R3) and (R9) was sitting directly behind that table. I did raise my voice when speaking with (V5). (V5) was also yelling at me about the placement sheets. There was no foul language used, but I should not have used that tone in front of (R3, R9). I was just very frustrated with (V5) CNA. (R3, R9) should never have to have been witness to that conversation. V1 Administrator stated I didn't think of that as abusing (R3, R9) but now I see how that could be considered verbal abuse.
On 5/6/23 at 9:30 AM V5 CNA stated (V1) Administrator was screaming at me because of the staffing sheets. I just wanted to know where to go for the day so I could get started. (V1) was yelling and yes, I yelled back. I was just so mad. I feel bad now that I think about (R3, R9) sitting there having to listen to all that. It was not very nice.
The facility Long Term Care Ombudsman Program pamphlet titled 'Residents' Rights for People in Long Term Care Facilities' documents the facility must treat residents with dignity and respect and must care for residents in a manner that promotes quality of life.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 complete a fall investigation, develop and implement fa...
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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 complete a fall investigation, develop and implement fall interventions, and ensure a resident was transferred to the hospital in a timely manner after an unwitnessed fall with a head injury for one of three residents (R2) reviewed for falls in a sample list of 11 residents.
Findings include:
R2's Medical Record documents medical diagnoses of Multiple Falls, Generalized weakness, Memory Difficulties, Osteoarthritis of Multiple Joints, Parkinson's Disease, Chronic Pain, Dementia and Cardiovascular Accident (CVA).
R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring extensive assistance of one person for bed mobility, dressing, personal hygiene, total assistance of two people for transfers, total assistance of one person for toileting and supervision with eating.
R2's Care Plan documents all fall interventions starting on 11/9/21. R2's Care Plan does not document updated fall interventions with each recent fall on 3/15/23 and 5/1/23.
R2's Fall Risk assessment dated [DATE] documents R2 as a high fall risk.
R2's Physician Order Sheet (POS) dated May 1-31, 2023 documents a physician order for Clopidogrel (antiplatelet) 75 milligrams (mg) daily.
R2's Nurse Progress Notes dated 5/1/23 at 11:40 PM document (V19) Physician called at 8:25 PM regarding (R2's) fall on morning shift. (V19) Physician gave orders to send to emergency room for evaluation/treatment. Ambulance arrived at 8:40 PM. No bleeding noted from head wound.
R2's Hospital Records dated 5/1/23 document R2's Encounter Diagnosis as Primary Diagnosis-Unwitnessed Fall.
R2's undated Post Fall Root Cause Worksheet documents R2 had an unwitnessed fall in R2's room. This same Worksheet includes areas of 'Root Cause', 'What interventions to prevent another fall need to be implemented today', 'Why this intervention?', 'Safety Measures and Interventions' and 'Were all care plan interventions carried out' that were all blank.
On 5/6/23 at 8:30 AM Observed R2's posterior skull to have a nickel sized fading bruise.
On 5/7/23 at 10:15 AM V8 Certified Nurse Aide (CNA) stated I was (R2's) CNA on 5/1/23. I was on break from 10:00 AM-10:30 AM that morning. When I left for break, (R2) was sitting in his wheelchair in his room. V8 stated When I came back from my lunch break, the other staff told me (R2) had fallen. (R2) was already back in bed so I didn't see how he was laying when he fell. (R2) had a cut on the Right side of the back of his head that was bleeding and he was complaining of pain. I told (V20) Licensed Practical Nurse (LPN) (R2) needed to be sent out to the emergency room but (V20) said (R2) was ok. That was a very busy day. (V20) LPN was the only nurse that day and was already behind on her meds for all the residents. I watched (R2) closely the rest of the day. I did (R2's) vital signs every 15 minutes. Normally (R2) eats 100% for all meals and he refused his lunch that day so I told (V20) again there was something wrong with (R2). (R2) was complaining of his head hurting the whole day but (V20) wouldn't send him to the emergency room. (R2) should have gone to the ER as soon as he fell but (V20) wouldn't send him. I am only a CNA but can tell you when something is wrong with my residents and something was not right with (R2). (R2) was so tired that day too. I tried to keep (R2) awake because I heard that if someone hits their head they shouldn't go to sleep for awhile. That was another reason I knew something was wrong. (R2) doesn't usually get that tired. (R2) slides down in his wheelchair all the time. I don't know why they (facility) don't put some of that non skid material in (R2's) chair.
On 5/7/23 at 10:25 AM V23 Certified Nurse Aide (CNA) stated One of the housekeepers yelled at me that (R2) was on the floor on 5/1/23. When I got to (R2's) room, he was on the floor in front of his wheelchair. (V20) LPN assessed (R2) before we (staff) got him back up and put him to bed. (R2) had a nickel sized scrape on the Right side of the back of his head that was bleeding. I told (V20) LPN (R2) needed to be sent to the emergency room but she said no. I went up front and told (V1) Administrator about the fall. They (facility) waited until later that evening to send (R2) into the emergency room. I don't know why they (facility) waited because they should have sent (R2) in right after he fell because he hit his head and it was bleeding and he wasn't acting right.
On 5/7/23 at 8:00 AM V1 stated I am not able to provide a fall investigation for (R2's) fall on 5/1/23. The only documentation I have is the 'Post Fall Root Cause Worksheet' and the 'Resident Transfer Form.' There doesn't appear to have been an investigation done. I know they (staff) notified me around 10:00 AM 5/1/23 of (R2's) fall but I was not able to determine why (R2) fell or why (R2) was not sent to the emergency room timely. I am very frustrated with my staff right now for not doing their job. The fall careplan should have been updated, the full investigation should have been done and (R2) should have been sent out to the emergency room directly after his fall. There are no excuses. This should have all been taken care of on 5/1/23. We (facility) have to do better.
The facility policy titled 'Fall Prevention' revised 11/10/18 documents the nurse will place documentation of the circumstances of a fall in the nurses notes or on an Aim for Wellness form along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the Certified Nurse Aide (CNA) assignment worksheet. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.
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 F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to ensure four residents (R4, R5, R6, R7) health information was protected out of four residents reviewed for confidentiality of records in a s...
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Based on interview and record review the facility failed to ensure four residents (R4, R5, R6, R7) health information was protected out of four residents reviewed for confidentiality of records in a sample list of 11 residents.
Findings include:
R4's Weekly Wound Tracking Sheets dated 5/2/23 document R4's name. These same sheets document Left Plantar First Toe Diabetic Wound measuring 0.8 centimeters (cm) by 1.0 cm with 0.1 cm depth with moderate drainage and Left Plantar Foot Diabetic Wound measuring 2.2 centimeters (cm) by 1.7 cm with 0.1 cm depth with moderate drainage.
R5's Weekly Wound Tracking Sheet dated 5/2/23 documents R5's name. These same sheets document R5's Right Upper Back Stage 3 Pressure Ulcer measuring 3.5 cm long by 4.5 cm wide by 0.1 cm deep with moderate amount of drainage.
R6's Weekly Wound Tracking Sheet dated 5/2/23 documents R6's name. These same sheets document R6's Right Upper Medial Ischium Stage 4 Pressure Ulcer measuring 6.5 cm long by 6.0 cm wide by 0.3 cm deep with moderate amount of drainage, Left Buttock Stage 4 Pressure Ulcer measuring 0.8 cm long by 2.5 cm wide by 0.1 cm deep with light serous drainage, Right Posterior Upper Thigh Stage 3 Pressure Ulcer measuring 6.0 cm long by 6.5 cm wide by 0.1 cm deep with moderate amount of drainage, Right Lateral Calf Stage 3 Pressure Ulcer measuring 13.0 cm by 0.5 cm by not measurable depth with no drainage, Left Upper Lateral Calf Stage 3 Pressure Ulcer measuring 2.8 cm long by 2.0 cm wide by 0.1 cm deep with moderate drainage, Left Lower Lateral Calf Stage 3 Pressure Ulcer measuring 1.0 cm long by 0.5 cm wide by 0.1 cm deep with moderate drainage and Right Lower Buttock Stage 3 Pressure Ulcer measuring 2.0 cm long by 2.3 cm wide by 0.1 cm deep with moderate drainage.
On 5/9/23 at 12:00 PM R6 stated If the staff want to share information about my wounds that is okay with me but I don't think anyone else needs to know.
R7's Weekly Wound Tracking Sheet dated 5/3/23 documents R7's name. These same sheets document R7's Lymphadema wound on Left Inferior Lateral leg as resolved, Lymphadema wound on Left Anterior Leg as resolved, Lymphadema wound on Right Anterior Leg as resolved, Lymphadema wound on Right Leg measuring 40 cm long by 16.5 cm wide by non-measurable length with no drainage, no odor as new wound and Lymphadema wound on Left Leg measuring 40 cm long by 17 cm wide by not measurable with no drainage, no odor as new wound.
On 5/9/23 at 12:45 PM R7 stated I don't know why anyone would send pictures of my wound information to each other. That doesn't seem right to me. Only the staff are supposed to have that information. I didn't think that should ever leave this facility unless another doctor requests it or something. What is wrong with people nowadays? That isn't supposed to happen.
On 5/6/23 at 10:45 AM printed copies of pictures taken of R4, R5, R6 and R7's Weekly Wound Tracking sheets, that included resident identifying information, were reviewed. These same pictures showed both of V14's (Regional Clinical Nurse) hands holding the Weekly Wound Tracking sheets individually while V18, V14's non-employee family member took the pictures.
On 5/6/23 at 10:40 AM V1 Administrator stated (V14) Regional Clinical Nurse took all of the wound logs home with her to ensure they were complete. (V14) became ill this morning and is now hospitalized . But (V14) Regional Clinical Nurse sent me pictures from her cellular phone of the information requested and I was able to print those pictures out.
On 5/6/23 at 10:50 AM (V14) Regional Clinical Nurse stated I was holding the wound logs. Those are my hands you see in the pictures. (V18) (V14's) family member took the pictures. (V18) is not an employee of the facility and does not work at facility through agency pool. (V18) is a family member who does not provide care for those residents (R4, R5, R6, R7) in any way. I should not have allowed (V18) to see those documents. That is a breech of confidentiality. I was just trying to get the documents to the facility. I realize now that was not a good idea and could put our residents at risk. I know (V18) would never say anything but resident information shouldn't be shared. That is breaking Health Insurance Portability and Accountability Act of 1996 (HIPAA) laws.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a Registered Nurse (RN) at least eight hours pe...
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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 Registered Nurse (RN) at least eight hours per day and failed to employ a Full Time Director of Nurses (DON). These failures have the potential to affect all 54 residents residing in facility.
Findings include:
The Facility Daily Census Roster dated 5/5/23 documents 54 residents residing in facility.
The Facility assessment dated [DATE] documents the facility should have 44 hours of licensed nurses for each 24 hour period which should include an RN at least eight of the 24 hours. This same assessment documents the facility is to employ a Full Time Director of Nurses.
Facility Daily Placement sheets do not document a registered nurse scheduled on 4/27/23, 4/29/23, 5/1/23, 5/3/23, 5/4/23, 5/6/23 and 5/7/23.
On 5/5/23 during the survey no Director of Nurses was observed on duty at the facility.
On 5/6/23 no Registered Nurses were observed working day shift at facility.
On 5/7/23 no Registered Nurses were observed working day shift at facility.
On 5/5/23 at 2:00 PM V14 Regional Clinical Nurse stated I am not the DON for this facility. I have been coming in one day a week when I can to help keep things organized but I am not even the interim DON. We (facility) have hired a DON but that person doesn't start until 6/17/23. We (facility) are going to ask V2 RN if she would be willing to be a temporary interim DON so wish us luck!
On 5/7/23 at 1:00 PM V1 Administrator stated the facility did not have a DON until 5/6/23. V1 stated V2 RN accepted the role of interim DON on 5/6/23. V1 Administrator stated V2 RN is the only RN that works at facility. V1 stated the facility is actively trying to hire new staff and that there has been 'major staffing changes lately' that are being addressed.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, interview and record review the facility failed to post daily Nursing staffing. This failure has the potential to affect all 54 residents residing in facility.
Findings include:...
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Based on observation, interview and record review the facility failed to post daily Nursing staffing. This failure has the potential to affect all 54 residents residing in facility.
Findings include:
The Facility Daily Census Roster dated 5/5/23 documents 54 residents residing in facility.
On 5/5/23, 5/6/23 and 5/7/23 no observations were made of posted daily nursing staffing.
On 5/7/23 at 2:30 PM V1 Administrator stated There have not been any daily nurse staffing posted since I started three months ago. I did not know that it was supposed to be posted. I will get it posted today.
Apr 2023
22 deficiencies
4 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow a Physician's Order and weigh a resident daily t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow a Physician's Order and weigh a resident daily to monitor for fluid overload for one of one resident (R103) reviewed for Edema in the sample list of 39. This failure resulted in R103 being hospitalized for five days for Congestive Heart Failure exacerbation.
Findings include:
The facility's Laboratory Tests policy with a review date of 9/27/17 documents, Appropriate laboratory monitoring of disease processes and medications requires consideration of many factors including concomitant disease(s) and medication(s), wishes of the resident and family and current standards of practice.
R103's Physician's Order Sheet (POS) dated 4/1/23 through 4/30/23 documents diagnoses of Congestive Heart Failure and Left Lower Extremity Cellulitis. This POS documents an order to weigh once daily and notify Physician if a three pound weight gain in one day or five pounds in one week. R103's Minimum Data Set, dated [DATE] documents diagnoses including Atrial Fibrillation, Heart Failure and Hypertension.
R103's Treatment Administration Sheet (TAR) dated 3/1/23 through 3/31/23 documents an order dated 2/3/23 to weigh once daily and notify Physician if a 3 pound gain in one day or a 5 pound gain in one week. There are no weights recorded on this TAR from 3/1/23 to 3/31/23. R103's TAR dated 4/1/23 through 4/30/23 documents the same order with a start date of 2/3/23 to weigh once daily and notify the Physician if there is a 3 pound weight gain in one day or a 5 pound gain in one week. This TAR has no weights documented from 4/1/23 to 4/23/23.
The facility's Monthly Weight Grid for May 2022 through April 2023 documents R103's weight in March 2023 was 119 pounds and then R103's weight in April 2023 was 146.6 pounds.
R103's Nurse's Notes dated 4/6/23 at 6:00 PM documents R103 had a doctor's appointment and documents R103 was admitted to the hospital following the appointment and the note is signed by V6 Licensed Practical Nurse.
R103's Cardiology Office Visit note dated 4/6/23 documents R103 stated that R103's legs felt much more swollen than when R103 discharged from the hospital. V30 Cardiology Advanced Practice Registered Nurse documents that R103 has orders for the facility to notify the Physician if R103's weight increases 2-3 pounds in 25 hours or 5 pounds in one week. V30 documents there has been no encounters where the extended care facility has notified them of any weight gain. V30 documents R103's weight was 135 pounds on 2/2/23 and on this day (4/6/23) it was 142 pounds. V30 documents the physical exam for R103 demonstrates +(plus) 2-3 edema to lower legs and a skin tear with oozing of serous fluid to the right anterior lower leg. V30 documents R103 appears fluid overloaded. Oxygen was 73% (percent) on arrival. R103 has worsening peripheral edema and dyspnea (shortness of breath) on exertion. Send R103 to the emergency department for diuresis and further evaluation.
R103's hospital discharge orders dated 4/11/23 documents R103 was admitted since 4/6/23 and documents orders to weigh daily and monitor blood pressure, look for signs and symptoms of heart failure such as shortness of breath, swelling of feet and legs and swollen or tender abdomen. Call provider if symptoms develop or if you gain more than 3 pounds in a day or 5 pounds in a week.
R103's Nurse's Notes dated 4/11/23 documents R103 arrived at the facility at 5:02 PM and R103's admitting diagnosis was Acute Exacerbation of Congestive Heart Failure.
On 4/25/23 at 11:44 AM, V22 Restorative Certified Nursing Assistant stated that V22 completes the weekly and monthly weights but the daily weights are supposed to be completed by the floor Certified Nursing Assistants (CNA).
On 4/26/23 at 2:21 PM, V1 Administrator in Training stated that V22 Restorative CNA is supposed to complete the daily weights and V2 Interim Director of Nursing stated that if there is an order for daily weights they should be getting completed.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** a.)2.) R26's Minimum Data Set (MDS) dated [DATE] documents R26 as cognitively intact. This same MDS documents R26 as requiring l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** a.)2.) R26's Minimum Data Set (MDS) dated [DATE] documents R26 as cognitively intact. This same MDS documents R26 as requiring limited assistance of one person for bed mobility and transfers. This same MDS documents medical diagnoses of Cerebral Vascular Accident (CVA) Left side affected, Congested Heart Failure and Left side Hemiplegia.
R26's Care Plan does not include updated fall interventions after R26's 4/21/23 fall.
R26's Nurse Progress Notes does not document a fall in April. R26's last nurse progress note was dated 3/23/23.
R26's medical record does not document R26's 4/21/23 fall nor fall investigation.
R26's Fall Risk assessment dated [DATE] documents R26 as a high fall risk.
Facility Fall Analysis Log dated January-April 2023 does not document any falls for R26.
On 04/23/23 at 8:30 AM R26 stated I fell the other day. I was sitting up on the side of the bed. I tried to raise up a bit to reach my phone. The bed shifted over so when I sat back down, I fell on the floor. The staff came and lifted me back up to sitting on the side of the bed again. They (staff) told me the bed was not locked. I did not get hurt thank goodness but that could have been bad. I can't use my Left arm or Left leg that well so I could have been really hurt.
On 04/24/23 at 12:18 PM V2 Interim Director of Nurses (DON) stated she is unaware of R26 falling in recent history. (R26) is alert and oriented. If (R26) said he fell, then he did. We (facility) were just not aware of it. No one reported it. All falls should be investigated. The resident care plan should be updated with each fall with the new interventions added. I will have to educate (V3) Care Plan Coordinator to include the dates on all new items added to the careplan. I know the careplans do not include dates with the fall interventions but we (facility) are working on that.
On 04/24/23 at 12:24 PM V1 Administrator stated (R26) is alert and oriented. This fall on 4/21/23 was never reported to me, it was never investigated and not included on the fall tracking because we (facility) did not know about it.
On 4/25/23 at 1:30 PM V1 Administrator stated I spoke with (R26) about his fall on 4/21/23. (R26) told me the staff put his cellular phone on the bedside table but it was on the far side away from him so he could not reach it. (R26) said he was trying to reach for his phone when the bed rolled because it was unlocked so he fell. If the staff would have put (R26's) belongings within his reach, he never would have fallen. Another part of that problem was that the staff never reported this fall to me or (V2) Interim DON. The facility was not able to follow up, investigate the fall or update the care plan. We (facility) have to do better.
The facility policy titled 'Fall Prevention' revised 11/10/2018 documents conduct fall assessments on the day of admission, quarterly and with a change in condition. If residents with a high risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. Immediately after any resident falls the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM for Wellness form along with the new intervention on the CNA assignment worksheet. Reports all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.
Failures at this level required two different Deficient Practice Statements.
A. Based on observation, interview, and record review the facility failed to investigate falls to identify root cause and develop/implement post fall interventions for two (R21, R26) of three residents reviewed for falls in the sample list of 39. This failure resulted in R21 falling and sustaining a forehead laceration that required sutures.
B. Based on observation, interview and record review the facility failed to maintain a safe water temperature in resident's rooms for three residents (R102, R12, R101) and failed to secure an oxygen tank in a resident's room for one resident (R18). This failure affects four of seven residents reviewed for accidents in the sample list of 39.
Findings include:
a.)1.) On 04/23/23 at 8:26 AM R21 was asleep in bed. R21 had bruising to R21's right eye and R21's right forehead was covered with a gauze dressing. On 4/23/23 at 12:48 PM R21's right elbow was covered with a gauze dressing. R21 stated R21 had two recent falls. R21 stated R21 fell out of bed and hit R21's head while reaching for something on the floor. R21 was sent to the hospital following the fall. R21 fell a few days prior to the other fall while attempting to walk to the bathroom. R21 was unsure what steps the facility has taken to prevent falls. R21 stated R21 only uses R21's wheeled walker when ambulating outside of R21's room, and R21 did not have R21's wheeled walker when R21 fell.
The facility's April 2023 Fall Analysis Log does not document that R21 fell on 4/19/23 and 4/21/23.
R21's Minimum Data Set, dated [DATE] documents R21 has moderate cognitive impairment and requires limited assistance of one staff person for transfers, bed mobility, and toileting. R21's April 2023 Physician's Orders documents to administer Eliquis (anticoagulant) 5 milligrams by mouth twice daily. R21's Care Plan revised on 2/27/23 documents R21 has cognitive impairment and does not understand R21's mobility limits. Interventions include to observe and assess for use of mechanical devices and an interdisciplinary team review of assessments to determine safety interventions. This care plan does not identify R21 fell on 4/19/23 and 4/21/23 and does not document any post fall interventions after 2/27/23.
R21's Nursing Note dated 4/19/23 at 1:00 AM documents the following: At 10:15 PM, R21 was found on the floor of R21's room. R21 reported that R21 was walking without R21's walker towards the bathroom, opened the bathroom door, and fell. R21 did not have any injuries. R21's 4/19/23 fall investigation is incomplete, and does not document the root cause or that post fall interventions were developed/implemented.
R21's Nursing Notes document the following: On 4/21/23 at 9:00 PM documents R21 was found on the floor between the beds of R21's room. R21 was lying on R21's right side, head down, and partially on R21's abdomen. There was blood on the floor around R21. R21 had attempted to reach for an item on the floor, lost balance, and fell hitting R21's right elbow and right eyebrow causing laceration and hematoma (bruising/swelling.) R21 was transferred to the local hospital for treatment. R21 returned to the facility at 11:50 PM and the hospital closed R21's forehead laceration with glue.
R21's 4/21/23 fall investigation documents the following: Prior fall interventions include use of call light to request assistance and R21's call light was within reach. R21's walker was not in use at the time of R21's fall. The root cause is identified as R21 reached for an item on the floor, and R21 occasionally does not recognize R21's limitations. The new post fall interventions documented include R21 was educated on safety and to use the call light to request assistance.
R21's emergency room Note dated 4/21/23 documents fall, frontal head injury/laceration, contusion of right shoulder, and contusion with skin tear to right elbow as R21's reason for hospital visit. R21 was alert and oriented to person, place, time, and situation. R21 reported that R21 was sitting on the edge of R21's bed, reached for something on the floor, and fell forward striking R21's head. R21 had a 1-1.5 inch bleeding cut to the right upper eyebrow and two abrasions to the right elbow. The forehead laceration was closed with dissolving sutures.
On 4/25/23 at 9:55 AM V2 Interim Director of Nursing stated R21 fell out of bed and hit R21's head on 4/21/23, and the fall was unwitnessed. R21's head laceration was glued/closed at the hospital. V2 stated fall investigations are reviewed in the interdisciplinary team meetings. Root cause and post fall interventions are documented in the fall investigation and on the care plan. At 11:20 PM V2 stated the root cause of R21's 4/21/23 fall was that R21 attempted to reach for R21's snacks. The intervention implemented was to keep R21's personal items within reach. V2 was not aware that R21 had a prior fall on 4/19/23. V2 confirmed R21's 4/19/23 fall investigation was incomplete and did not include an identified root cause or that post fall interventions were developed/implemented.
On 4/25/23 at 12:18 PM V17 Nurse Practitioner stated the facility should evaluate falls and implement interventions to prevent additional falls. V17 stated it is hard to say if R21's 4/21/23 fall would have been prevented if post fall interventions were developed and implemented, since R21 is alert and oriented. V17 confirmed educational reminders for use of call light and wheeled walker would be appropriate fall interventions for R21.
b.)1.) R102's Care Plan with an admission date of 3/12/23 documents R102 has a self care deficit and needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADLs (Activities of Daily Living). R102's Minimum Data Set (MDS) dated [DATE] documents R102 requires limited assistance with mobility.
On 4/24/23 at 10:05 AM, R102 was in R102's room in a high back chair with R102's feet up in R102's wheelchair.
On 4/25/23 at 8:35 AM, the hot water temperature in R102's sink in the bathroom read 133.8 degrees Fahrenheit.
2.) R12's MDS dated [DATE] documents R12 requires supervision for mobility and that R12 has disorganized thinking.
On 4/25/23 at 8:30 AM, R12 was wheeling R12's self around R12's room and hallway in R12's wheelchair. The hot water temperature in R12's sink in the bathroom read 137.6 degrees Fahrenheit.
On 4/25/23 at 10:33 AM the hot water temperature in R12's room was 136.7 degrees Fahrenheit.
3.) R101's Care Plan dated 4/5/23 documents R101 has a self care deficit and requires supervision and/or assist to complete ADLs.
On 4/23/23 at 9:53 AM, R101 was in R101's room sitting on the side of the bed.
On 4/2523 at 8:35 AM, R101's water temperature in the sink in R101's bathroom was 133.8 degrees Fahrenheit.
On 4/25/23 at 11:48 AM, V15 Maintenance Supervisor and V16 Sister facility Maintenance Supervisor checked the water temperature in R12's bathroom sink and the temperature was 136.5 degrees Fahrenheit. V16 stated the water temperatures should be checked weekly. V15 stated that V15 has only been at the facility two weeks and yesterday (4/24/23) was the first time V15 had checked the water temperatures in the facility. V15 and V16 confirmed the water temperature was too high and could cause burns to the residents. V16 stated that some residents do not know to add cold water to the hot so they could get burnt. V16 stated the water temperature should be 110-112 degrees Fahrenheit.
4.) R18's Physician Order Sheet (POS) dated 4/1/23 through 4/30/23 documents diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Obesity and Obstructive Sleep Apnea. This POS documents and admission date of 12/31/22.
On 4/23/23 at 9:15 AM, there was an oxygen tank leaning up against a dresser in R18's room. The tank was not flat on the floor and the tank was not secured in any cart or other device.
On 4/24/23 at 11:09 AM, R18 was not in R18's room but the oxygen tank was still leaning up against the dresser unsecured.
On 4/26/23 at 12:33 PM, V2 Interim Director of Nursing confirmed the oxygen tank was leaning against the dresser and should not be. V2 stated that the oxygen tank should be secured in it's cart.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Incontinence Care
(Tag F0690)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) 04/26/23 08:59 AM R10's Physician Order Sheet (POS) dated April 1-30, 2023 documents medical diagnoses of Dysuria, Amnesia, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) 04/26/23 08:59 AM R10's Physician Order Sheet (POS) dated April 1-30, 2023 documents medical diagnoses of Dysuria, Amnesia, Hypertension, Atrial Fibrillation, Chronic Kidney Disease Stage 3, Neuropathy and Macular Degeneration. R10's Cognitive assessment dated [DATE] documents R10 as cognitively intact. R10's Care Plan does not document updated interventions for R10's 4/19/23 medical diagnosis of Dysuria.
R10's V23 Urology Progress Note dated 4/19/23 documents Chief complaint: Dysuria. Dysuria started a couple of days ago. Facility states there was blood in (R10's) incontinence brief. (R10) has burning and frequency of urination for two days with no abdominal pain no back pain, nausea, vomiting, fever or chills. Orders placed this encounter: Nitrofurantoin Monohydrate/Macrocrystals (Macrobid) 100 milligrams (mg) capsules and Phenazopyridine (Pyridium) 100 mg tablet.
R10's Nurse Progress Note dated 4/19/23 at 3:06 PM documents (R10) out of facility earlier this shift with son, who transported (R10) to Urology appointments. (R10) had complained of frequency and discomfort. New order received from urologist. Macrobid and Pyridium therapy. Orders transcribed in Medication Administration Record (MAR) and communicated to oncoming nurse.
R10's Medication Administration Record (MAR) dated April 1-30, 2023 documents a physician order dated 4/19/23 Macrobid 100 mg twice daily for seven days which was signed out as administered 4/20/23-4/26/23. This same MAR documents a physician order dated 4/19/23 100 mg three times per day for two days which was signed out as administered on 4/20/23-4/21/23.
Facility Emergency Kit (Ekit) Contents Report documents Macrobid 50 mg capsules as being contained in EKit.
On 04/23/23 at 1:36 PM R10 stated I was prescribed an antibiotic at (V23's) Urology office for my Urinary Tract Infection (UTI). R10 stated They (facility) let me wait an entire day before they (facility) gave me my antibiotic. (V23) Urologist told me I had a bad infection and needed treated immediately. I never had a problem with UTI's before I came in here (facility). But they (staff) make me wait to get changed so I just sit in pee. It is no wonder I got an infection.
On 4/26/23 at 9:15 AM V12 Licensed Practical Nurse (LPN) stated (V20) (R10's) family member took (R10) to a Urology appointment on 4/19/23. (R10) came back with orders for Macrobid 100 milligrams (mg) twice daily for seven days and Pyridium 100 mg twice daily for two days. I worked day shift that day and I remember there was some kind of delay for (R10's) Macrobid and Pyridium because (R10) is private pay so her family gets all of her medications. I never received (R10's) medications from the family before I left that day. The night shift nurse may have, but I did not. The facility has a box which emergency kit that has the Macrobid in it but since (R10) is private pay, we (staff) are not supposed to use medications from the emergency box for private pay residents.
On 4/26/23 at 9:35 AM V20 (R10's) family member stated (R10) made her own Urology appointment and then called me and asked me to take her. (R10) uses a wheechair so I came in to the facility and talked with them (staff). They (facility) took (R10) to the Urology appointment and I followed behind in my car. (V23) Urologist ordered two pills for (R10's) Urinary Tract Infection (UTI). One pill was an antibiotic and the other was for pain for (R10's) UTI. (V24) facility van driver drove (R10) back to the facility after her appointment. (V24) van driver had one of the bottles of pills with her to take back to the facility. After (V24) van driver got back to the facility, they (facility) called me and said that (V23's) office only filled one of the prescriptions and that they (facility) couldn't give one of the pills without the other. So I drove back to the clinic and had the other prescription filled. (V24) facility van driver met me back at the clinic so I didn't have to drive all the way across town again. I gave the pills to (V24) facility van driver. I did all that so that (R10) could get both of her medications started that same night of the appointment with (V23) Urologist.
On 4/26/23 at 9:40 AM V21 Registered Nurse stated V21 worked night shift the evening of 4/19/23. V21 RN stated I have no knowledge of any pills being brought to the facility for (R10). Normally after hours the North hall nurse would answer the door and if there were any medications left for any of my residents, the north hall nurse would let me know and I would have to check them in. I don't remember if there were any medications brought to me but I don't think that they were.
On 4/26/23 at 9:45 AM V10 Registered Nurse (RN) stated I remember that next morning when I came in I heard about (R10) being started on the Macrobid and Pyridium. There was some talk about the family having brought it in since (R10) is private pay so I checked the medication cart for her hall and the Macrobid and Pyridium were both in bottles sitting in the top drawer. The facility does keep the Macrobid in the emergency box but since (R10) is private pay we (staff) would have the family bring the medication in since they (family) would have to pay for it. We (staff) are not supposed to use the emergency box medications for private pay residents. I would if I had to but the family did bring in both medications the evening of 4/19/23. I am not sure why (V21) RN did not start those medications. V10 RN stated There is not a Urinalysis or Culture for (R10) but I can look in the hospital systems records to try to find out about those.
On 4/26/23 at 10:45 AM V1 Administrator stated (V24) facility van driver should not be transporting medications for residents. (R10's) Macrobid and Pyridium should have both been delivered to facility by a pharmacy.
On 4/26/23 at 2:00 PM V2 Interim Director of Nurses (DON) stated the facility did not follow up on R10's Dysuria that was treated with Macrobid (antibiotic). V2 stated there is no way to know if the antibiotic is working or not without having a Urinalysis or Culture and Sensitivity completed. V2 stated the facility should have followed up with (V23's) Urology office but did not.
Based on observation, interview, and record review the facility failed to monitor and record urinary catheter output for three (R39, R5, R8) residents. The facility also failed to document catheter care, ensure proper positioning of a urinary drainage bag, and timely treat a urinary tract infection for three (R39, R8, R10) residents. This failure affects four (R5, R8, R10, R39) of five residents reviewed for urinary tract infections and catheters in the sample list of 39. This failure resulted in R5 being hospitalized and diagnosed with a catheter malfunction and urinary tract infection.
Findings include:
A.1.) R5's Minimum Data Set (MDS) dated [DATE] documents R5 has severe cognitive impairment and requires extensive assistance of one person for toileting. R5's Care Plan dated 1/3/23 documents R5 has altered bladder elimination, neurogenic bladder, and a urinary catheter. Interventions include assess and report symptoms of urinary tract infections (fever, pressure, odorous urine, dark urine, pain, confusion, and abdominal distension), keep tubing free of kinks, intake and output every shift, and monitor/record changes in urine including urinary output.
R5's Nursing Notes document the following: On 1/16/23 at 6:48 PM R5 complained of burning and penile pain. Orders were received to change and flush R5's urinary catheter and obtain a urine sample for culture and sensitivity. R5's catheter was changed and R5 did not have any urinary output. R5 complained of some discomfort during catheterization. There are no documented nursing notes again until 1/17/23 at 2:00 PM when R5 was transferred to the emergency room for vomiting and complaints of lower abdominal pain.
R5's medical record does not document R5's urine output was recorded daily or each shift in January 2023. There is no documentation that the facility collected a urine sample before R5 was transferred to the emergency room on 1/17/23.
R5's Hospital Summary of Care dated 1/17/23 documents R5 presented to the emergency room for vomiting. R5's urinary catheter balloon was found to be inflated within the urethra, and could be the cause of R5's abdominal pain. R5's urinary catheter was repositioned/replaced and a urine specimen was collected. R5 was given intravenous fluids and intravenous antibiotics, and was discharged back to the facility. R5's Encounter Diagnoses are listed as Recurrent Urinary Tract Infection, Malfunction of urinary catheter, and Systemic Inflammatory Response Syndrome.
R5's computed Tomography of the abdomen dated 1/17/23 at 5:18 PM documents R5's (Urinary) catheter is malpositioned with the balloon inflated within the urethra. Small amount of air within the urinary bladder which is likely related to the (urinary) catheter. R5's Urine Culture dated 1/18/23 documents the urine contained greater than 100,000 colony forming units/milliliter of Staphylococcus aureus (bacteria).
On 4/24/23 at 8:59 AM V6 Licensed Practical Nurse (LPN) stated on 1/16/23 R5 had signs of urinary tract infection and V6 notified R5's physician. V6 changed R5's catheter and there was a minimal amount of urine returned. V6 stated there was not enough urine to collect a urine specimen. V6 stated R5 had some discomfort during catheterization, but R5 had been pulling on R5's catheter prior to catheterization. The next day R5 still had urinary tract infection symptoms, complained of abdominal pain, and V6 transferred R5 to the hospital. V6 was not aware that R5's urinary catheter balloon was found to be within R5's urethra.
On 4/25/23 at 12:25 PM V2 Interim Director of Nursing (DON) stated urinary catheter output should be monitored and documented every shift on the output monitoring log. V2 stated if there is no urine output then the physician should be notified.
On 4/25/23 at 12:40 PM V17 Nurse Practitioner stated the nurses should be monitoring residents with urinary catheters for signs of drainage, blood, and odorous urine. Urine output should be monitored and recorded at least once per shift. If there is no urine output for 6-8 hours, then they should notify the physician. If notified of decreased urine output soul recommend a bladder scan, palpation of the bladder, adjusting the catheter placement, and assessing for pain prior to transferring the resident to the hospital. These are interventions/treatments that could be performed and possibly prevent hospitalization. Decreased urine output could be a sign of a blockage or catheter malfunction. Urine stasis could contribute to the development of urinary tract infections.
2.) On 4/23/23 at 8:26 AM R8 stated staff provide R8's urinary catheter care, but was unsure how often the catheter tubing is cleaned.
04/26/23 10:21 AM V8 Certified Nursing Assistant (CNA) and V27 CNA transferred R8 from the recliner into bed with a full mechanical lift. During the transfer, R8's urinary drainage bag was hooked onto the mechanical lift sling and was positioned above R8's bladder. Urine backflowed from the urinary drainage bag tubing towards the catheter tubing. R8's urine contained white sediment. V8 cleansed R8's catheter tubing in a downward motion and raised R8's urinary drainage bag in the air, above R8's bladder. R8's urine in the drainage bag tubing backflowed into R8's urinary catheter tubing/bladder.
R8's MDS dated [DATE] documents R8 is cognitively intact and requires extensive assistance of one staff person for toileting. R8's Care Plan revised 6/13/22 documents R8 has a suprapubic catheter (inserted through the abdomen) with interventions that include the use of tubing with anti-reflux valves, position the drainage bag below bladder level to prevent reflux, empty collection bag at least each shift and record urine output.
R8's April 2023 Physician's Orders document an order for urinary catheter care to be completed every shift. R8's April 2023 Treatment Administration Record (TAR) does not document catheter care was administered on 16 shifts between 4/1/23 and 4/23/23. There is no documentation that urine output is documented each shift.
On 4/26/23 at 10:35 AM V8 CNA stated the urinary drainage bag is suppose to be kept below the level of the resident's kidneys. V8 stated the CNAs are to do catheter care at least every shift and the urine output is reported to the nurse to document. V8 stated the CNAs do not document catheter care.
On 4/26/23 at 10:45 AM V12 LPN provided the urinary catheter drainage bags that are used for R8. The drainage bag does not contain an antireflux valve. At 10:50 AM V2 DON confirmed R8's urinary drainage bags do not contain an antireflux valve (to prevent urine backflow into the catheter) at the connection port that connects to the urinary catheter.
3.) On 4/23/23 at 8:50 AM R39's urinary catheter tubing contained yellow urine with white sediment. R39 stated the CNAs perform R39's catheter care.
R39's April 2023 Physician's Orders includes orders to perform catheter care every shift. R39's April 2023 TAR does not document catheter care was administered 16 shifts between 4/1/23 and 4/23/23. There is no documentation that R39's urine output is documented each shift.
On 4/25/23 at 12:20 PM V4 LPN stated catheter care is documented on the Medication/Treatment Administration Record. V4 confirmed there is no documented urine output recorded for R8 and R39 for April 2023.
On 4/26/23 at 9:45 AM V2 Interim DON stated the nurses should initial the Treatment Administration Record and document refusals by circling the initials and recording the refusal in nursing note.
The facility's Intake and Output policy revised December 2021 documents the CNAs obtain urine output every 8 hours and report the output to the nurse to document on the intake and output record.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide adequate nutrition, identify significant weight...
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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 adequate nutrition, identify significant weight loss, complete dietary assessments, intervene and follow up with the physician and dietician for residents. These failures affect four (R5, R28, R45, R1) of four residents reviewed for weight loss and nutrition from a total sample list of 39. These failures resulted in significant weight losses for R5, R28 and R45.
Findings include:
1.) R28's diagnosis include: falls, dementia, hypertension, gastroesophageal reflux, Osteoporosis, hiatal hernia, Barretts esophagus.
On 4/22/23 at 12:45PM, after R28 had left the dining room, her plate was observed to have more than 90 percent of her food left on the plate.
On 4/23/23 at 12:47PM, R28 was sitting at lunch with plate in front of her with no one attempting to assist her to eat. V28 Certified Nursing Assistant (CNA) gave R28 one bite of dessert and then said, She doesn't eat well for us. Usually her husband comes to feed her, and then V28 CNA left the table.
On 4/23/23 at 1:30PM, after residents had left the dining room, V5 Dietary Manager confirmed that R28 had only bite eaten from her plate.
On 4/24/23 at 8:33AM, R28 was sitting at a dining room table with 3 other residents with a full plate of food. Staff are walking beside resident without assisting R28. R1, R28's table mate, began to feed R28. R28 continued to eat what R1 fed her.
On 4/25/23 at 11:45AM, V13 Dietician said that she did not know anything about R28's weight loss until 4/24/23 when the facility dietary manager called her to inform her of R28's weight loss. V13 Dietician said that she had not completed an assessment on R28, had never been a part of a weight meeting, and had not sent any recommendations for R28. V13 Dietician said that prior to the current dietary manager, the facility would not communicate with her about resident dietary needs. Now, V5 dietary manager is communicating with me well, but she just started.
The facility provided monthly weight grid document's R28's weights as the following in pounds: October 2022: 176.5, November: 178.6, December 2022: 178.2, January 2023: 170.0, February 2023: 167.10, March 2023: 160.10, and April 2023: 152.5.
The above weight losses are calculated at a 10.29 percent weight loss from January 2023 to April 2023 and a 13.6 percent weight loss from October 2022 to April 2023.
R28's undated care plan documents that R28 demonstrates dependency on a caregiver to assist with eating.
The facility, Resident Weight Monitoring Policy dated 3/19 documents that if there is an actual significant weight change, the resident, the power of attorney for health care, the physician and the dietician will be notified. The food service manager and interdisciplinary team will review the resident's weights and nutritional status and make recommendations for intervention. The dietician shall review and document all significant weight changes along with any recommended nutritional intervention in the dietary progress notes, in the medical record monthly. Significant weight changes are reviewed in the weekly weight committee meeting. The weight committee will also identify any trend of gradual weight loss or gain. Significant changes in weights are documented in the care plan with goals and approaches/interventions listed.
On 4/25/23 at 12:00PM, V13 Dietician stated, With (R28's) significant weight loss, we might have been able to prevent it. If she needs assistance with feeding, that needs to occur and I also need to be made aware of these residents so that I can intervene before the weight loss. With the system that they have had in place, I didn't know who needed to be seen and who didn't.
3.) The facility's Weight Report dated May 2022 - April 2023 documents R5's weights as follows: August 192 lbs. (pounds), September 195.2, October 184.2 (5.6% loss in 1 month), November 186, December is not recorded, January 171.4, February 161.6 (13.12% loss in 3 months/15.83% loss in 6 months), March 164.4, and April 164.
R5's Minimum Data Set (MDS) dated [DATE] documents R5 has severe cognitive impairment, R5's current weight is 160 pounds, and R5 has not had a significant weight loss within the last month or last 6 months.
R5's undated Care Plan problem area for Nutrition, documents the following: R5 is at risk for altered nutritional status and/or weight loss. R5 has had a decline with significant weight loss within the last 6 months and is on a No Added Salt Diet. The following undated interventions are listed as provide diet as ordered, refer to the Physician's Order Sheet (POS) for diet order, honor food preferences and dislikes, offer snack at bedtime and record amount consumed, monitor weights monthly or per the Registered Dietitian's (RD) recommendation, report significant weight changes to the physician and RD, follow the RD's recommendations, and assess current diet tolerance related to recent nausea/vomiting/diarrhea.
R5's medical record does not document that R5's additional significant weight loss after October 2022 was reported to the physician and RD. There are no completed nutritional/dietary assessments after 6/23/22. R5's medical record does not document R5's weights between 10/12/22 and 12/31/22.
R5's Physician Notification of Weight Change dated 10/12/22 documents R5 diet was regular and No Added Salt. The physician was notified of the one month weight loss of 5.64% loss and the interdisciplinary team recommended to continue to monitor R5's weights weekly for 4 weeks.
R5's April 2023 Physician's Orders documents R5's diet as No Added Salt, thin liquids, and may have meal of the month on special occasions. There is no documentation that R5 has nutritional supplements/fortified foods as part of R5's diet.
On 4/24/23 at 8:39 AM R5 was eating in the main dining room. R5's meal tray did not include any supplements/fortified foods. R5's dietary card does not document R5's diet includes supplements or fortified foods.
On 4/24/23 at 3:48 PM V2 Interim Director of Nursing (DON) stated when there is significant weight loss we notify the RD and physician and document the notification in the nursing notes. Nutritional interventions and the RD's recommendations are implemented. On 4/24/23 at 4:00 PM V2 stated the RD's recommendations are submitted to V2 by electronic mail and nursing follows up on getting approval from the physician to implement the recommendations. An order is then written and transcribed onto the POS and nutritional interventions are documented on the care plan. V2 reviewed R5's POS and Care Plan and confirmed there are no documented nutritional supplements or nutritional interventions to address R5's significant weight loss. On 4/25/23 at 12:25 PM V2 stated V2 was unable to locate any documentation of follow up, notification, and interventions to address R5's significant weight loss after October 2022. On 4/25/23 at 2:05 PM V2 stated V2 provided all of the weights that V2 could locate for R5 within the last year and confirmed there were no weights documented in R5's medical record between October 2022 and December 2022.
On 4/24/23 at 3:52 PM V5 Dietary Manager stated the RD comes to the facility twice per month. V5 stated nutritional assessments are completed quarterly and annually. R5 had a Urinary Tract Infection and was hospitalized around the time of R5's significant weight loss noted in October. The RD emails us the nutritional recommendations. The recommendations are placed in the resident's medical record. V5 gives the RD recommendations to the DON to review with the physician and implement the RD's recommended nutritional supplements. We did a weight review on R5 in January, and I thought we added a frozen nutritional supplement and nutritional juices.
On 4/24/23 at 4:15 PM V3 Care Plan Coordinator stated significant weight loss is documented on the MDS and confirmed R5's January 2023 MDS does not identify R5's significant weight loss.
On 4/25/23 at 11:53 AM V13 RD stated the facility has been inconsistent with reporting resident weight loss. The Dietary Manager is suppose to send V13 a list of residents to see at each visit and V13 expects to be notified of significant weight loss noted for 30, 90, and 180 days. V13 was not given a notification to evaluate R5 after November 2022. V13 stated V13 last evaluated R5 on 11/24/23 and completed a nutritional assessment at that time. V13 recommended a high calorie nutritional shake to be given three times daily with meals. V13's assessments are documented in the dietary section of the resident's medical record, and there have been issues with documentation being removed or missing from the records. Nutritional assessments are completed annually, quarterly, and with any significant weight changes. V13 is not always notified when the resident's annual assessment is due. V13 stated V13 would expect the health shakes to have been continued until R5 either refused them or R5's weight increased. V13 would recommend weekly weight monitoring if the resident is trending weight loss. V13 confirmed if R5's nutritional recommendations were implemented it could have prevented additional weight loss.
The facility's Resident Weight Monitoring policy dated as revised March 2019 documents weights are obtained monthly and reviewed by the Dietary Manager and DON by the 8th of the month. Monthly weights are recorded on the monthly weight report in the progress notes section of the resident's medical record. Significant weight loss of 5% or more in one month, 7.5% or more in 3 months, and 10% or more in 6 months are reported to the physician and dietitian. The resident's weights and nutritional status is reviewed by the dietary manager, interdisciplinary team, and dietitian, and interventions are recommended/implemented. The dietitian documents review, weight changes, and recommended nutritional interventions monthly in the dietary progress notes. Nursing is responsible to report the nutritional recommendations to the physician to obtain orders.
2.) R45's Physician Order Sheet (POS)dated 4/1/23 through 4/30/23 documents diagnoses including Physical Deconditioning, Diabetes Type 2, End Stage Renal Disease, Hiatal Hernia and Gastroesophageal Reflux. This POS documents Diet Orders of No Added Salt, Carbohydrate Controlled Diet, Regular Consistency, Fortified Milk Shake Twice Daily and 1500 ml (milliliters)/day Fluid Restriction.
The facility's Monthly Weight Grid May 2022 through April 2023 documents R45's weight for February 2023 as 154.2 pounds, March 2023 as 139.4 pounds and April as 127.6 pounds. This indicates a 9.6% weight loss in 30 days and a 17.25% weight loss in 60 days.
R45's medical record documents a Dietary Services Communication form completed by V13 Dietician documents R45 has experienced a significant weight loss times three months and documents R45 was refusing meals and supplements. This form documents Dietary Recommendations that V13 discussed with R45 and R45 agreed to take a (liquid protein supplement) 90 ml (milliliter) twice a day and add a grape nutritious juice. This form is dated 3/19/23 and signed by V13. This form has a place for the Physician to approve and sign and that is blank.
R45's Medication Administration Record dated 4/1/23 through 4/30/23 and R45's Treatment Administration Record dated 4/1/23 through 4/30/23 do not document an order for a liquid protein supplement or a grape nutritious juice.
On 4/24/23 at 4:05 PM, V8 Dietary Manager stated that V8 has never seen the Dietary Services Communication dated 3/19/23 for R45 signed by V13.
On 4/25/23 at 12:03 PM, V13 confirmed that V13 made these recommendation and that they should have been sent to the Physician to get an order and then should have been implemented. V13 stated that V13 filled out the communication form and put in the Director of Nurse's box as requested by the Director of Nursing.
R45's Dietary meal tray card documents R45 should have a Fortified Milk Shake at lunch and dinner.
On 4/23/23 at 1:04 PM, R45 had R45's meal tray in R45's room. R45 had a pork chop, stuffing, sweet potatoes, roll, two bowls of chicken noodle soup, lemon pie, applesauce, saltine crackers, lemonade and water. There was no Fortified Milk Shake on R45's tray.
On 4/24/23 R45 went to dialysis after breakfast. R45 did not receive a Fortified Milk Shake with the breakfast tray this day. R45 will not be in the facility for lunch so R45 will not receive a Fortified Milk Shake at lunch on this day.
On 4/26/23 at 2:21 PM, V2 Interim Director of Nursing stated that staff should be following Dietician recommendations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the dignity of a resident. This failure affects one (R49) res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the dignity of a resident. This failure affects one (R49) resident reviewed for dignity from the sample list of 39 residents.
Findings include:
R49's Minimum Data Set (MDS) dated [DATE] documents R49 as cognitively intact. This same MDS documents R49 as requiring supervision for bed mobility, personal hygiene and dressing.
R49's Care Plan does not include focus area, goal nor interventions for abuse prevention.
R49's Interdisciplinary Team (IDT) Meeting dated 2/24/23 documents Quality Assurance (QA) team met regarding allegation of abuse. Claiming verbal abuse from (V19) Licensed Practical Nurse (LPN). Intervention: Continued inservicing regarding resident abuse.
R49's Initial Incident Report to Illinois Department of Public Health (IDPH) dated 2/24/23. Final Incident Report to IDPH dated 2/25/23 documents Male resident with Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) reports asking for as needed (PRN) medication last evening. (R49) reported to staff at 8:00 AM on 2/24/23. When responding to (R49), (V19) LPN stated You are creepy. (R49) reports feeling as if he did something wrong. (V19) suspended pending investigation. Staff report conversation amongst staff member in hallway, stating that the building is creepy at night. Root cause: Resident misinterpreted conversation. Intervention: Abuse training provided to all staff. Continued staff training for abuse.
On 04/25/23 at 11:00 AM R49 stated There was a nurse (V19) Licensed Practical Nurse (LPN) sitting at the nurses station by my room. I had asked (V19) for a muscle relaxer so I could sleep better. (V19) was just sitting there doing her charting. I didn't want to bother her again so I just sat in my wheelchair in the doorway of my room. (V19) must have forgot I was there because after 15-20 minutes (V19) looked up and looked me straight in the eyes and said 'aren't you super creepy'. I felt so bad I just went back in my room. There was not any other staff around. It was just (V19) and me. I don't think (V19) abused me but I can say I don't like the way (V19) made me feel. Like I am some kind of pervert or something. I was just waiting for my muscle relaxer. I think they (facility) fired (V19) for that because she never came back.
On 04/25/23 at 04:18 PM V1 Administrator stated all residents should be treated with respect and dignity. V1 stated None of our staff should talk to residents in a condescending way or any way that makes them feel like less of a person. (R49) also told me that there were no other staff around but (V19). I am not sure why the investigation would say that but I was not here at that time. I spoke with (R49) just to follow up and he told me the same thing.
The facility undated Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities documents your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to provide a written Notice of Medicare Non-Coverage, (NOMNC) for three (R5, R46, R304) of three residents reviewed for beneficiary notificati...
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Based on record review and interview, the facility failed to provide a written Notice of Medicare Non-Coverage, (NOMNC) for three (R5, R46, R304) of three residents reviewed for beneficiary notifications, from a total sample list of 39.
Findings include:
Three Medicare discharged residents R5, R46, and R304, were selected for review from the list provided by V11, Business Office Manager.
On 4/23/23 at 10:30AM, V11 Business Office Manager provided unsigned beneficiary notices for R5 and R46 and no beneficiary notice for R304. V11 Business Office Manager then said that she could not locate signed beneficiary notices for any of the three residents.
On 4/25/23 at 9:17AM, V2 Interim Director of Nursing said that the facility did not have a policy on Advanced Beneficiary Notices or NOMNCs, but that they follow Medicare guidelines and all residents with Medicare days left should be given one of those forms. We don't have them for those residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of sexual abuse to the state survey agency. Thi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of sexual abuse to the state survey agency. This failure affects two (R15, R10) of three residents reviewed for abuse in the sample list of 39.
Findings include:
R15's Minimum Data Set, dated [DATE] documents R15 has severe cognitive impairment and receives antipsychotic medications. R15's undated Care Plan documents R15 displays inappropriate behaviors including sexual aggressive behaviors and making sexual comments to staff and other residents.
R15's Social Services Notes document the following: On 10/4/22 R15 has been making inappropriate comments to other residents. V7 Social Services Director was notified that R15 made inappropriate sexual comments to staff. On 10/10/22 R15 was inappropriate to staff and made sexual advances towards residents. This was reported to the Administrator In Training, and a report was filed. On 11/15/22 R15's room was changed. There is no documentation in R15's medical record that R15 was evaluated by a psychiatrist or provided psychiatric/behavioral services, and the facility was unable to provide documentation that R15 has been evaluated/treated by psychiatric/behavioral services.
R15's emergency room Discharge summary dated [DATE] documents R15 was transferred to the hospital for abnormal behavior and the facility requested a psychiatric evaluation. The facility reported that R15 walked into an unidentified resident's room and removed their blanket, and asked another unidentified resident when was the last time they had sex. The facility requested a psychiatric evaluation to see if R15 is safe to be around other residents.
The facility had no documentation that an abuse allegation involving R15 was reported to the state survey.
On 4/24/23 at 10:34 AM V7 Social Services Director stated R15 has vulgar sexual language towards staff and residents. When R15 first admitted R15 would rub and touch staff's legs. V7 reviewed R15's October social service notes and stated R15 made sexual advances and comments to R10. V7 was unable to recall specific details of the incident, but thought that R15 touched R10's lower back or hand while making a sexual comment or asking R10 if R10 would like to have sex. V7 reported the incident to the former administrator.
On 04/24/23 at 2:36 PM V1 Interim Administrator stated the facility does not have an investigative file for any abuse allegations involving R15 or R10. V1 stated V1 would consider R15's sexual comments and touching R10 as a sexual abuse allegation, and it should have been investigated and reported.
The facility's Abuse Prevention Program dated as revised 11/28/16 documents abuse allegations should be reported to the Department of Public Health.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to investigate an allegation of sexual abuse. This failure affects two ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to investigate an allegation of sexual abuse. This failure affects two (R15, R10) of three residents reviewed for abuse in the sample list of 39.
Findings include:
R15's Minimum Data Set, dated [DATE] documents R15 has severe cognitive impairment and receives antipsychotic medications. R15's undated Care Plan documents R15 displays inappropriate behaviors including sexual aggressive behaviors and making sexual comments to staff and other residents.
R15's Social Services Notes document the following: On 10/4/22 R15 has been making inappropriate comments to other residents. V7 Social Services Director was notified that R15 made inappropriate sexual comments to staff. On 10/10/22 R15 was inappropriate to staff and made sexual advances towards residents. This was reported to the Administrator In Training, and a report was filed. On 11/15/22 R15's room was changed. There is no documentation in R15's medical record that R15 was evaluated by a psychiatrist or provided psychiatric/behavioral services, and the facility was unable to provide documentation that R15 has been evaluated/treated by psychiatric/behavioral services.
R15's emergency room Discharge summary dated [DATE] documents R15 was transferred to the hospital for abnormal behavior and the facility requested a psychiatric evaluation. The facility reported that R15 walked into an unidentified resident's room and removed their blanket, and asked another unidentified resident when was the last time they had sex. The facility requested a psychiatric evaluation to see if R15 is safe to be around other residents.
The facility had no documentation that an abuse allegation involving R15 was investigated.
On 4/24/23 at 10:34 AM V7 Social Services Director stated R15 has vulgar sexual language towards staff and residents. When R15 first admitted R15 would rub and touch staff's legs. V7 reviewed R15's October social service notes and stated R15 made sexual advances and comments to R10. V7 was unable to recall specific details of the incident, but thought that R15 touched R10's lower back or hand while making a sexual comment or asking R10 if R10 would like to have sex. V7 reported the incident to the former administrator.
On 04/24/23 at 2:36 PM V1 Interim Administrator stated the facility does not have an investigative file for any abuse allegations involving R15 or R10. V1 stated V1 would consider R15's sexual comments and touching R10 as a sexual abuse allegation, and it should have been investigated and reported.
The facility's Abuse Prevention Program revised 11/28/16 documents investigative procedures for abuse include to review of written reports, interview the reporter, staff, witnesses, and residents, and review all circumstances of the incident. The facility will report results of abuse allegations to the state survey agency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to develop a comprehensive care plan for three of 17 residents (R45, R103, R18) reviewed for comprehensive care plans in the sampl...
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Based on observation, interview and record review the facility failed to develop a comprehensive care plan for three of 17 residents (R45, R103, R18) reviewed for comprehensive care plans in the sample list of 39.
Findings include:
The facility's Comprehensive Care Planning policy with a revised date of 7/20/22 documents, It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. The CCP (Comprehensive Care Plan) shall be reviewed after each Annual, Significant Change and Quarterly MDS (Minimum Data Set) and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs as identified by the IDPH (Interdisciplinary Team).
1.) R18's Physician Order Sheet (POS) dated 4/1/23 through 4/30/23 documents diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Obesity and Obstructive Sleep Apnea. This POS documents and admission date of 12/31/22. R18's Care Plan only documents the admission date of 12/31/22. There is no other dates documented on this care plan. This Care Plan does not document the use of oxygen.
On 4/23/23 at 9:15 AM, R18 was in R18's bed with oxygen on via a nasal cannula. The oxygen concentrator was set at 2.5 liters of oxygen and there was a portable oxygen tank in the room.
On 4/26/23 at 2:02 PM, V3 Care Plan Coordinator confirmed that R18's oxygen was not on the Care Plan and confirmed that it should be on R18's Care Plan.
2.) R45's Physician Order Sheet (POS) dated 4/1/23 through 4/30/23 documents diagnoses including Physical Deconditioning, End Stage Renal Disease and Congestive Heart Failure. This POS documents 9/24/22.
The facility's Monthly Weight Grid dated May 2022 through April 2023 documents R45's weight in February was 154.2 pounds, March 139.4 pounds and April 127.6 pounds. This equals a 9.6% weight loss in 30 days and a 17.25 % weight loss in 60 days.
R45's Care Plan only documents the admission date of 4/5/23 and 3/25/23. There are no other dates documented on this care plan. This Care Plan does not document that R45 receives dialysis or the significant weight loss.
3.) R103's POS dated 4/11/23 through 4/30/23 documents diagnosis of Acute Exacerbation of Congestive Heart Failure. This POS documents an order for Oxygen at 2 liters via a nasal cannula continuously.
R103's Care Plan documents an admission date of 2/3/23 and no other dates are documented on this Care Plan. R103's Care Plan does not document Congestive Heart Failure or the use of oxygen.
On 4/23/23 at 9:11 AM, R103 was in R103's room sitting on the bed. R103 had oxygen on 2.5 liters, the water bottle was dated 3/20/23.
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
Based on interview and record review the facility failed to implement pressure ulcer treatments and complete weekly skin and wound assessments for one (R8) of two residents reviewed for pressure ulcer...
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Based on interview and record review the facility failed to implement pressure ulcer treatments and complete weekly skin and wound assessments for one (R8) of two residents reviewed for pressure ulcers in the sample list of 39.
Findings include:
On 4/23/23 at 8:50 AM R8 stated R8 has wounds on R8's bottom, legs, and feet, and the dressings are changed daily.
R8's Wound Evaluation & Management Summaries recorded by V31 Wound Physician document the following: On 3/19/23 R8's right ischium stage 4 pressure ulcer measured 3 centimeter (cm) long by 3.5 cm wide by 0.2 cm deep. R8's left buttock stage 4 pressure ulcer was 1.8 by 1 by 0.1 cm. R8's right posterior, upper thigh stage 3 pressure ulcer measured 5.4 cm by 6 cm by 0.1 cm. There are no wound assessments again until 4/2/23. On 4/2/23 the right ischium wound was larger, 5.5 cm by 6 cm by 0.2 cm. The right upper thigh wound was larger, 6.5 cm by 8.5 cm by 0.1 cm. The left buttock wound was larger, 2.5 cm by 3.5 cm by 0.1 cm. The wound treatments are ordered as 1/4 strength Dakin's (bleach solution) soaked gauze, covered with abdominal pad, and secured with tape twice daily. There are no wound assessments again until 4/17/23. On 4/17/23 the right ischium was 5 cm by 6 cm by 0.2 cm. R8's left buttock wound was 1.5 cm by 0.5 cm by 0.1 cm. The right upper thigh wound was 6.5 cm by 7.5 cm by 0.1 cm. The left upper thigh was 1.5 by 2 by 0.1 cm. R3 had a newly identified right lateral calf Stage 3 pressure ulcer that was 12 cm by 1 cm by 0.1 cm and left lateral calf stage 3 pressure ulcer that was 1.5 cm by 1.3 cm by 0.1 cm. The treatment order for the new wounds documents to administer a petroleum gauze dressing, covered with an abdominal pad, and wrapped with gauze three times weekly. On 4/23/23 the right ischium was 5 x 6.5 x 0.3 cm. The right thigh wound was 6 x 7.5 x 0.1 cm. The left thigh wound was 1.5 x 2. x 0.1 cm. The treatment order for the ischium and thigh wounds document to administer calcium alginate, cover with abdominal pad, and secure with tape twice daily. The right lateral calf wound was 10 x 1 x 0.1 cm. The left upper lateral calf was 2.5 x 1.2 cm by no measurable depth. The calf wound treatments document to administer a skin protectant and apply a bordered foam dressing once weekly and as needed.
R8's April 2023 TAR documents to apply 1/4 Dakin's solution soaked gauze, cover with abdominal pad and secure with tape twice daily initiated on 4/5/23. This TAR does not document the location of the wounds where the treatment is to be administered, and does not document the treatment was administered on 9 shifts between 4/5/23 and 4/23/23. There is no documentation that the petroleum gauze treatment ordered on 4/17/23 was implemented. As of 4/26/23 R8's wound treatments for Calcium Alginate were not transcribed onto R8's TAR.
R8's March TAR documents to assess R8's skin daily, and this is not transcribed onto R8's April 2023 TAR. There are no documented routine skin assessments in R8's medical record for April 2023.
On 4/26/23 at 9:45 AM V2 Interim Director of Nursing stated skin assessments should be done at least weekly and documented on the TAR. V2 confirmed there are no documented skin assessments for R8 in April 2023. V2 stated R8's right calf Stage 3 Pressure Ulcer is an old wound that healed and then reopened. V2 confirmed V31's wound orders on 4/23/23 were not transcribed onto R8's TAR as of 4/26/23, and R8's April TAR does not document a petroleum gauze treatment. V2 confirmed R8's April 2023 Daikin's treatment does not identify the location of R8's wounds. V2 stated the facility just received V31's notes on 4/25/23. V2 stated V31 does not notify the facility of V31's scheduled visits and V31 does not round with any nurses. V31 does not communicate verbally V31's new orders, and the facility is not aware of V31's orders until V31 sends the facility V31's progress notes. V2 stated the nurses should initial the TAR and document refusals by circling the initials and recording the refusal in a nursing note. AT 11:02 AM V2 stated V2 provided all of R8's wound assessments after 3/19/23. V2 confirmed V31 visited only on 3/19/23, 4/2/23, and 4/17/23. V2 stated the nurses are responsible for obtaining wound measurements and assessments weekly in V31's absence, and the assessments should be documented in a progress note.
The facility's Skin Condition and Monitoring policy dated as revised 3/16/23 documents the nurses will assess and document the results of a skin evaluation and notify the physician to obtain treatment orders. Treatment orders will continue until the area is resolved. Skin abnormality documentation must be done when a wound is identified and at least weekly until healed. Documentation should include wound characteristics and measurements.
The facility's Pressure Sore Prevention Guidelines dated as reviewed on 3/16/23 documents that residents who are at moderate or high risk for developing skin breakdown will have routine skin assessments scheduled and recorded on the TAR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to evaluate residents pain and follow up with the physici...
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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 evaluate residents pain and follow up with the physician for two residents (R21, R39) reviewed for pain management in the sample list of 39.
Findings include:
1.) On 4/23/23 at 12:57 PM R21 stated R21 has back pain and the staff do not always give R21's pain medications timely when requested. Sometimes R21 has to wait an hour. R21's pain medications used to be every 4 hours, but now it is only every 12 hours. R21 stated the medication doesn't work like it did when it was every 4 hours, and R21 did not have to wait as long. R21's pain relief does not last 12 hours. R21 stated R21 has three fractured vertebrae.
R21's Minimum Data Set (MDS) dated [DATE] documents during the 5 day review period, R5 had occasional pain rated as a 5 on a scale of 1-10. R21's Care Plan dated 3/22/22 documents R21 has low back pain and includes interventions to monitor and interview for symptoms of pain and relief, assess pain intensity/location/duration, and administered medications as ordered and evaluate effectiveness.
R21's February 2023 Physician's Order Summary (POS) documents R21's orders included Norco 5-325 mg every 4 hours as needed for pain (PRN). The physician order dated 2/15/23 documents to schedule Norco 5-325 mg daily at 8:00 PM. There is no documented order to discontinue the PRN Norco order. R21's April 2023 POS documents R21's orders include: Duloxetine (Cymbalta) 60 milligrams (mg) by mouth daily as of 10/12/22. Acetaminophen 500 mg by mouth three times daily as of 12/1/22. Tramadol 50 mg by mouth three times daily as of 9/26/22. Gabapentin 400 mg by mouth four times daily 12/19/22. Norco 5-325 mg by mouth daily at 8:00 PM. Tizanidine Hydrochloride 4 mg by mouth three times daily as needed.
R21's April 2023 Medication Administration Record (MAR) does not document that Tizanidine was administered. R21's April 2023 MAR and Treatment Administration Record (TAR) do not document R21's pain is evaluated routinely.
R21's Physician Progress Note dated 12/1/22 documents R21's biggest complaint is pain. R21 reported that R21 hurt all over and described the pain as traveling pain. R21 spends most of R21's time in bed and only gets up for meals. R21's pain medications include Acetaminophen twice daily and Norco 5-325 mg every 4 hours as needed. Acetaminophen was increased to three times daily and will evaluate the usage of Norco over the next several weeks. If R21's pain continues, then additional adjustments may be needed including consideration of increasing Cymbalta.
R21's Brain and Spine Institute Physician Progress Note dated 3/1/23 documents the following: (R21's) x-ray shows disc degeneration, arthritis, slight curvature, some bone forming of the ligaments in the spine, and old deformity from (R21's) fractures. I think the next step is an MRI (Lumbar Spine Magnetic Resonance Imaging). (R21) has had fractures since last MRI. I think there could very well be something else going on that does not show on the x-ray. If the MRI shows the problem, fine. If not, the patient will need to talk to (R21's) doctor about visiting with a neurologist. Impression: Complicated situation with arthritis, disc degeneration, ligaments in the spine starting to turn to bone, and difficulty walking. Recommendation: MRI seems warranted. If that shows us the problem, we will deal with it. If it does not show the problem and the patient wants to take it further, (R21) will need to talk to (R21's) doctor about visiting with a neurologist for consultation.
R21's MRI dated 3/29/23 documents R21 has degenerative lumbar spine changes, wedge compression fractures of T12, L1 and L2 vertebral bodies, and there has been progressive height loss associated with L1 vertebral fraction in comparison to prior MRI. There is no documented follow up with R21's physician regarding R21's pain after R21's MRI.
On 4/25/23 at 12:25 PM V2 Interim Director of Nursing (DON) stated V2 was unable to locate any physician follow up for R21's pain. V2 was unable to locate the order to discontinue R21's PRN Norco. V2 stated pain assessments should be done every shift and documented on the MAR/TAR.
2.) On 4/23/23 at 1:02 PM R39 was sitting in R39's recliner moaning. R39 stated R39 waits 3-4 hours for pain medication to be given and R39 does not take any routine pain medication. R39 rated R39's pain as an 8 on a 1-10 scale.
R39's MDS dated [DATE] and 2/7/23 documents R39 is cognitively intact. During the 5 day review period R5 had frequent pain, rated at a 10 on a 1-10 scale, that interferes with sleeping. R39's Care Plan with goal date of 2/6/23 documents R39 has altered comfort/pain related to urinary catheter and risk for general pain. This care plan does not document R39 ha neuropathic leg pain and there are no new pain interventions documented after 8/23/21.
R39's April 2023 POS documents to administer Acetaminophen 650 mg by mouth twice daily as of 9/1/22, and Oxycodone Immediate Release (IR) 5 mg by mouth every 6 hours as needed for pain as of 9/14/22. R39's diagnoses include Diabetes Mellitus Type II.
R39's February 2023 MAR does not document PRN Oxycodone was administered during the month. R39's April MAR documents Oxycodone was administered 5 times between 4/1/23-4/18/23 for left leg pain. Three of the entries do not document that R39's pain was re-evaluated for the effectiveness of the medication. R39's April 2023 MAR/TAR, and March TAR do not document that R39's pain is evaluated routinely.
R39's medical record does not contain R39's March MAR. R39's Oxycodone Controlled Substance Proof of Use form documents 30 tablets were dispensed on 9/14/22. Thirty tablets were administered between 9/27/22 and 3/19/23, and five of those administrations were in March 2023.
R39's Physician Progress Note dated 12/1/22 documents R39 saw a neurologist in October and is not a candidate for surgery for R39's cervical spinal stenosis with myelopathy at C3-C4. R39 has progressively lost gait over the past year and a half and was evaluated by neurology on 3/29/22. R39 was diagnosed with cervical myelopathy with significant cord compression.
There is no documentation in R39's medical record that R39's pain was addressed and reported to R39's physician after 12/1/22. The facility failed to provide documentation of follow up between 12/2/22 and 4/24/23 to address R39's pain. R39's Physician Order dated 4/25/23 documents to administer Gabapentin 400 mg by mouth twice daily for neuropathy.
On 4/25/23 at 10:45 AM V4 Licensed Practical Nurse stated R39 has been having increased complaints of pain recently to R39's foot. R39 has scheduled Acetaminophen and PRN Oxycodone for pain. V4 stated the Oxycodone is effective, but as soon as it wears off R21 requests the medication again.
On 4/24/23 at 3:48 PM V2 Interim DON stated physician notification is documented in the progress notes. On 4/25/23 at 12:25 PM V2 stated pain assessments should be done every shift and documented on the MAR/TAR. On 4/25/23 at 2:05 PM V2 stated the nurses should re-evaluate pain after giving PRN pain medication and document the effectiveness on the MAR.
On 4/25/23 at 12:18 PM V17 Nurse Practitioner stated if residents are having increased signs of pain the PRN medication should be given and then evaluate the effectiveness. If the pain is unresolved, then the physician should be notified. If the resident has increased use of PRN medications for 3 or more days, then the provider should be notified. V17 stated V17 will follow up with R21's and R39's pain. At 3:06 PM V17 stated both R39 and R21 have neuropathy. V17 is referring R21 to the pain clinic to evaluate R21's neuropathy related to compression fractures. V17 will educate the nurses to utilize R21's PRN Tizanidine. V17 ordered scheduled pain medication to treat R39's neuropathy.
The facility's Pain Prevention & Treatment policy revised 12/7/17 documents: It is the facility policy to assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems, maximize ADL (Activities of Daily Living) functioning and enhance quality of life. The MDS Coordinator will complete the Pain Assessment Form at least quarterly and with any significant change in the resident condition. 2. Assessment of pain will be completed with changes in the resident's condition, self reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nursing notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment, intervention and resident response. 3. The Pain Management Flow Sheet will be initiated for those residents with but not limited to: routine pain medication, daily pain, diagnosis that may anticipate pain (i.e. (for example) arthritis, wounds, fractures, etc. (etcetera). 4. Information collected on the Pain Assessment Form will be used to formulate and implement a resident specific Pain Treatment Plan documented in the resident's care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure medications were stored/transported safely for a resident by allowing a non-authorized employee to transport medications. This failur...
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Based on record review and interview the facility failed to ensure medications were stored/transported safely for a resident by allowing a non-authorized employee to transport medications. This failure affects one (R10) of one resident reviewed for medication storage in a sample list of 39 residents.
Findings include:
Secretary of State Administrative Code section 1030.92 effective December 23, 2020 documents A type J restriction with appropriate numerical indicators includes other restrictions not listed in this section. Type J restrictions and numerical indicators are as follows: JO5 Driver authorized to operate a senior citizen transportation vehicle within classification. The driver operates a vehicle that is utilized solely for the purpose of providing transportation for senior citizens, as provided in IVC Section 6-106.3.
On 4/26/23 at 9:35 AM V20 (R10's) family member stated They (facility) took (R10) to the Urology appointment and I followed behind in my car. (V23) Urologist ordered two pills for (R10's) Urinary Tract Infection (UTI). One pill an antibiotic and the other was for pain for (R10's) UTI. (V24) facility van driver drove (R10) back to the facility after her appointment. (V24) van driver had one of the bottles of pills with her to take back to the facility. After (V24) van driver got back to the facility, they (facility) called me and said that (V23's) office only filled one of the prescriptions and that they (facility) couldn't give one of the pills without the other. So I drove back to the clinic and had the other prescription filled. (V24) facility van driver met me back at the clinic so I didn't have to drive all the way across town again. I gave the pills to (V24) facility van driver. I did all that so that (R10) could get both of her medications started that same night of the appointment with (V23) Urologist.
On 4/26/23 at 11:30 AM V24 facilitly van driver stated The day (4/19/23) (R10) went to the Urology appointment I dropped her off and picked her up. (V20) is (R10's) son. (V20) met (R10) and I there at the appointment. After the appointment was done, I took (R10) and one of (R10's) filled prescriptions back to the facility. When we (V24, R10) returned to facility, I was told that (R10) needed a second prescription and to meet (V20) back at the clinic. I drove back to the clinic pharmacy and met (V20) there. (V20) paid for the prescription and I took it back to the faciity. I handed both of the prescriptions to (V12) Licensed Practical Nurse (LPN). I have a special license (J05) that lets me transport the medications for our residents. I have been doing that for ten years. Am I not supposed to pick up the resident medications? It's a little late now since I have been doing it for so long.
On 4/26/23 at 11:45 AM V1 Admininstrator stated V24 faciity van driver has a 'J05' license that allows her to transport resident medications. I did not know that the 'J05' license only allows for the transportation of the elderly residents and not their medications. I will make sure (V24) does not do that again. I think it was an honest mistake but it still can't happen again.
The facility policy titled 'Procurement and Storage of Medications' revised 3/16/23 documents all medications shall be delivered directly from the pharmacy to the nurses station. Delivery must be made by a pharmacist or his agent, a delivery service, United States Postal Service or a Physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to prepare the safe texture of pureed food for three (R27, R48 and R102) of three residents reviewed for residents with pureed die...
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Based on observation, interview and record review the facility failed to prepare the safe texture of pureed food for three (R27, R48 and R102) of three residents reviewed for residents with pureed diet orders.
Findings include:
R27's April 2023 physician order sheet documents an order for pureed food. R48's April 2023 physician order sheet documents an order for pureed food. R102's April 22, 2023 physician telephone order sheet documents an order for pureed food.
On 4/24/23 at 10:50AM, V29 [NAME] stated that the pureed food currently on the steam table was ready to be served to residents.
On 4/24/23 at 10:45AM a pureed test tray was provided by the facility. The ham appeared lumpy and tasted chewy.
On 4/24/23 at 10:51AM, V5 Dietary Manager stated, ham is really hard to do. The Dietary Manager then tested the pureed ham and said that the pureed consistency wasn't right. I will fix this before it goes out to the residents.
On 4/25/23 at 11:45AM, V13 Dietician stated, Pureed food is to be smooth. It is to decrease the chances of choking.
The facility Therapeutic and Mechanically Altered Diets policy documents that it is the policy of the facility that therapeutic and mechanically altered diets are ordered by the physician and planned by the dietician. A therapeutic diet is a diet ordered to manage problematic health conditions. A mechanically altered diet is a diet specifically prepared to alert the consistency of food in order to facilitate oral intake. Examples include soft solids, pureed foods, and ground meal. Diets for residents who can only take liquids that have been thickened are also included in this definition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow their Antibiotic Stewardship policy by not obtaining Urinalys...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow their Antibiotic Stewardship policy by not obtaining Urinalysis with Culture and Sensitivity for two (R10, R39) residents prescribed antibiotic medications and failed to obtain a wound culture for one (R8) resident. This failure affects three (R10, R39, R8) of three residents reviewed for Antibiotic Stewardship in a sample list of 39 residents.
Findings include:
1.) R10's Physician Order Sheet (POS) dated April 1-30, 2023 documents medical diagnoses of Dysuria, Amnesia, Hypertension, Atrial Fibrillation, Chronic Kidney Disease Stage 3, Neuropathy and Macular Degeneration.
R10's Cognitive assessment dated [DATE] documents R10 as cognitively intact.
R10's V23 Urology Progress Note dated 4/19/23 documents Chief complaint: Dysuria. Dysuria started a couple of days ago. Facility states there was blood in (R10's) incontinence brief. (R10) has burning and frequency of urination for two days. Orders placed this encounter: Nitrofurantoin Monohydrate/Macrocrystals (Macrobid) 100 milligrams (mg) capsules and Phenazopyridine (Pyridium) 100 mg tablet.
R10's Medication Administration Record (MAR) dated April 1-30, 2023 documents a physician order dated 4/19/23 Macrobid 100 mg twice daily for seven days. This same MAR documents a physician order dated 4/19/23 100 mg three times per day for two days.
R10's medical record does not document a Urinalysis nor Urine Culture and Sensitivity.
On 04/23/23 at 1:36 PM R10 stated I was prescribed an antibiotic at (V23's) Urology office for my Urinary Tract Infection (UTI). R10 stated (V23's) office tried to check my pee but they couldn't get it so they just told me I had a UTI and gave me prescriptions for some pills.
On 4/26/23 at 9:15 AM V22 Licensed Practical Nurse (LPN) stated (V20) (R10's) family member took (R10) to a Urology appointment on 4/19/23. (R10) came back with orders for Macrobid 100 milligrams (mg) twice daily for seven days and Pyridium 100 mg twice daily for two days. I never called (V23) to see if there was a Urinalysis with Culture and Sensitivity (U/A with C&S) completed in (V23's) office.
On 4/26/23 at 9:40 AM V21 Registered Nurse stated V21 worked night shift the evening of 4/19/23. V21 RN stated I did not follow up with (V23) Urologist to see if a U/A was done or not.
On 4/26/23 at 9:45 AM V10 Registered Nurse (RN) stated There is not a Urinalysis or Culture for (R10) in (R10's) chart but I can look in the hospital systems records to try to find out about those.
On 4/26/23 at 2:00 PM V2 Interim Director of Nurses (DON) stated the facility did not follow up on R10's Dysuria that was treated with Macrobid (antibiotic). V2 stated there is no way to know if the antibiotic is working or not without having a Urinalysis or Culture and Sensitivity completed. V2 stated the facility should have followed up with (V23's) Urology office but did not.
The facility policy titled Antibiotic Stewardship Program reviewed 3/2023 documents the purpose is to improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished utilizing the Core elements. 2.) On 4/23/23 at 8:50 AM R8 stated R8 had a wound infection a couple weeks ago and received an antibiotic.
R8's Wound Evaluation & Summaries recorded by V31 Wound Physician document the following: On 3/9/23 V31 prescribed Levaquin (antibiotic) 750 milligrams (mg) by mouth daily for 10 days for R8's Right Upper Thigh Stage 3 Pressure Ulcer. On 4/2/23 R8's Right Ischium Stage 4 Pressure Ulcer had green discharge and V31 was concerned of infection. V31 prescribed Levaquin 750 mg by mouth daily for 10 days.
R8's April 2023 Medication Administration Record (MAR) documents Levaquin was administered 4/2/23 and 4/11/23. There is no documentation in R8's medical record that a wound culture was obtained in March and April 2023.
On 4/25/23 at 12:25 PM V2 Interim Director of Nursing stated cultures are only done when ordered by the physician. V2 confirmed cultures are used to determine that the antibiotic is appropriate based on the bacteria sensitivity report. On 4/25/23 at 2:05 PM V2 stated a wound culture was not done for R8's wound infection in April since one was not ordered.
3.) R39's April 2023 Physician's Order Summary documents R39 has a urinary catheter. R39's Urology Progress Note dated 4/5/23 documents R39 has a urinary tract infection and an order for Keflex (antibiotic) 500 mg by mouth twice daily for 7 days. R39's April 2023 MAR documents Keflex was administered. There is no documentation that a urine culture was obtained.
On 4/25/23 at 3:50 PM V2 stated a urine culture was not done for R39's 4/5/23 urinary tract infection.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assist five (R8, R5, R16, R28, R253) of five dependent ...
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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 assist five (R8, R5, R16, R28, R253) of five dependent residents reviewed for activities of daily living including: feeding, showering and shaving, from a total sample list of 39.
Findings include:
1) R28's Minimum Data Set, dated [DATE] documents R28 as cognitively impaired. R28's undated care plan documents that R28 demonstrates dependency on a caregiver to assist with eating.
On 4/23/23 at 12:47 PM, R28 was sitting at lunch with plate in front of her with no one attempting to assist R28 to eat. V28 gave R28 one bite of dessert and then left the table.
On 4/24/23 at 8:33AM, R28 was sitting at a dining room table with 3 other residents with a full plate of food. Staff are walking beside resident without assisting. At 8:35AM, R1, R28's tablemate, fed R28 a donut. R1 then continued to feed R28 eggs with a fork.
On 4/24/23 at 8:45AM, V12 Licensed Practical Nurse (LPN) stated while observing R1 continue to feed R28, A C.N.A. should be feeding R28, not another resident.2.) On 4/24/23 at 8:38 AM R5 was sitting in the dining room and had facial hair stubble to cheeks, chin, and upper lip.
R5's Minimum Data Set (MDS) dated [DATE] documents R5 has severe cognitive impairment and requires assistance of one staff person for hygiene and bathing. R5's March and April 2023 Shower Sheets were requested, and provided by V2 Interim Director of Nursing. R5 was offered/received showers on 2/27, 3/6, 3/9, 3/27, and 4/4/23. There are no other documented showers.
3.) On 4/23/23 at 8:47 AM R8 had long facial hair stubble to cheeks, chin, and upper lip. R8 stated sometimes R8 ends up with a long beard, because the staff don't shave R8. R8 stated the staff only shave us on shower days, and R8 only gets a shower every 1-2 weeks. R8 was unsure when R8's showers are scheduled, and stated R8 would like to be shaved at least every other day.
R8's MDS dated [DATE] documents R8 is cognitively intact and requires assistance of one person for bathing and hygiene. R16's MDS dated [DATE] documents R4 requires assistance of one staff person for bathing.
4.) On 04/24/23 at 11:03 AM a resident council meeting was held. R16 stated R16 has not had a shower in a week and a half, and is suppose to have showers twice weekly. R253 stated the facility is disorganized with showers and R253 has gone a week or more without a shower. R253 stated, You feel like you win the lottery when you get your shower. R8 stated R8 has gone 3 weeks without a shower.
R253's MDS dated [DATE] documents R253 is cognitively intact and requires assistance of one person for bathing. R16's MDS dated [DATE] documentst R16 requires assistance of one person for bathing.
The facility's undated shower schedule documents R5, R8, R16, and R253 are scheduled for showers twice per week. R8's, R16's, and R253's March and April 2023 Shower Sheets were requested, and provided by V2 Interim Director of Nursing. The shower sheets document the following: R8's showers were offered/given on 3/6/23 and 3/30/23. R16's showers were offered/given on 2/28, 3/3, 3/7, 3/9, 3/21 and 3/28/23. R253's showers were given on 3/1, 3/4, 3/8, 3/22, 3/23, 4/3, and 4/14/23. There were no other documented showers.
On 4/25/23 at 9:15 AM V2 stated showers are to be given twice weekly or per resident preference, and residents are to be shaved per preference on shower days. Staff should document refusals on the shower sheets. V2 stated V2 provided all of the requested shower documentation V2 could located for R5, R8, R16, and R253.
The facility's Bath/Shower policy reviewed 3/20/23 documents baths/showers will be scheduled at least weekly.
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.) On 4/23/23 at 11:50AM, R22 was laying in bed wearing oxygen at three liters per nasal cannula. The oxygen tubing, water bott...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) On 4/23/23 at 11:50AM, R22 was laying in bed wearing oxygen at three liters per nasal cannula. The oxygen tubing, water bottle, nor treatment sheets were labeled.
On 4/24/23 at 10:00AM, R22 said that she wears oxygen at all times.
R22's physician order sheet dated April 2023 documents an order for oxygen at three liters per nasal cannula continuously.
The facility provided policy dated 3/19 documents that oxygen therapy may be used provided there is a written order by the physician. The order must state liter flow per minute, mask or cannula, time frame. Change oxygen tubing/mask/cannula/and /or tracheostomy mask on a weekly basis. If using an oxygen tracheostomy mask, wash with warm soap and water daily and as needed. Date the tubing and humidification changes and document on the treatment sheet.
Based on observation, interview and record review the facility failed to obtain an order for oxygen administration and failed to label oxygen tubing and humidification bottles with change dates for residents. This failure affects four of five residents (R18, R101, R103, R22) reviewed for oxygen/respiratory equipment use in the sample list of 39.
Findings include:
1.) R18's Physician's Order Sheet (POS) dated 4/1/23 through 4/30/23 documents diagnoses including Chronic Obstructive Pulmonary Disease, Hypertension, Congestive Heart Failure, Obesity and Obstructive Sleep Apnea. This POS does not document an order for oxygen.
R18's Treatment Administration Record dated 4/1/23 through 4/30/23 does not document an order for oxygen administration or an order to change oxygen tubing or humidification bottles.
On 4/23/23 at 9:15 AM, R18 was in R18's bed and had oxygen on via nasal cannula and the oxygen concentrator was set on 2.5 liters. The humidification bottle is dated 3/11/23 and there is also a portable oxygen tank in R18's room.
2.) R101's Minimum Data Set (MDS) dated [DATE] documents R101 has diagnoses including Atrial Fibrillation, Coronary Artery Disease, Heart Failure and Chronic Obstructive Pulmonary Disease. This MDS documents R101 is receiving oxygen at the facility.
On 4/23/23 at 9:06 AM there is an oxygen tank in room and a concentrator that is set on 2 liters. The oxygen tubing is connected to the oxygen concentrator and is not dated with the date it was changed. The humidification bottle was dated 2/20/23 and is empty.
On 4/23/23 at 9:53 AM, R101 was in R101's room sitting on the side of R101's bed with the oxygen on via a nasal cannula. The tubing is not dated with a date it was changed and the humidification bottle is dated 2/20/23.
3.) R103's POS dated 4/11/23 through 4/30/23 documents a diagnosis of Acute Exacerbation of Congestive Heart Failure and documents an order for oxygen at 2 liters via a nasal cannula continuously.
On 4/23/23 at 9:11 AM, R103 was in R103's room sitting on the bed with oxygen on via a nasal cannula and the oxygen concentrator was set on 2.5 liters. The oxygen tubing was not dated with a change date and the humidification bottle was dated 3/20/23 with very little water left in it.
On 4/26/23 at 2:21 PM, V2 Interim Director of Nursing stated that if the resident is receiving oxygen there should be an order for oxygen and the oxygen tubing should be dated with the date it was changed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
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 had several failures related to behavioral services including: failed to ident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility had several failures related to behavioral services including: failed to identify a diagnosis of mental illness, ensure appropriate screening for mental illness, administer psychotropic medications, evaluate behaviors and psychotropic medications, and implement behavioral services/interventions for one resident (R15) reviewed for behaviors in the sample list of 39. This failure has the potential to affect two additional residents (R46, R10).
Findings include:
R15's Face Sheet documents R15 admitted on [DATE] and does not document R15 has a diagnosis of mental illness. R15's Minimum Data Set, dated [DATE] documents R15 has severe cognitive impairment and receives antipsychotic medications.
R15's April 2023 Physician's Order Summary (POS) documents the following: R15 has a diagnosis of Schizophrenia and Mood Disorder. Administer Fluphenazine Hydrochloride (antipsychotic) 15 mg/ml (milligrams/milliliter) inject 1/2 ml (12.5 mg) intramuscularly every 2 weeks as of 9/29/22. Administer Divalproex Sodium Delayed Release 250 mg by mouth twice daily for mood disorder as of 9/29/22. Administer Quetiapine (antipsychotic) 50 mg daily as of 9/29/22. Administer Administer Trazodone 50 mg by mouth daily as of 1/5/23. There are no documented psychotropic medication assessments for the use of these medications in R15's medical record prior to January 2023.
R15's Physician Progress Note dated 7/20/22 documents R15 was a new admission to the facility. R15's medications included Quetiapine 25 mg daily and Fluphenazine. R15's family reported R15 was diagnosed with Schizophrenia 10 years ago. R15's Screening Verification Form dated 7/12/22 documents a Level 1 Pre-admission Screening and Resident Review (PASARR) was completed and a Level 2 PASARR was not required due to no Mental Illness diagnosis known/suspected. There is no documentation in R15's medical record that a Level 2 PASARR was completed after R15 was diagnosed with Schizophrenia.
R15's undated Care Plan documents R15 displays inappropriate behaviors including sexual aggressive behaviors and making sexual comments to staff and other residents. This care plan does not document R15's Schizophrenia diagnosis or use/monitoring of antipsychotic medications. This care plan does not identify when R15's problem area and interventions for behaviors were developed/implemented.
R15's September 2022 Medication Administration Record (MAR) does not document Fluphenazine was administered during the month, as ordered. Quetiapine 50 mg was added once daily at bedtime in addition to the previously prescribed 25 mg as of 8/9/22.
R15's January 2023 Behavior Tracking documents R15 has irregular sleep patterns, makes inappropriate sexual comments to staff, and includes targeted interventions. There are no behavior tracking with targeted behavioral interventions in R15's medical record prior to January 2023. R15's January 2023-April 2023 Behavior Tracking does not include R15's sexual behaviors directed towards residents.
R15's Social Services Notes document the following: On 10/4/22 R15 has been making inappropriate comments to other residents. V7 Social Services Director was notified that R15 made inappropriate sexual comments to staff. On 10/10/22 R15 was inappropriate to staff and made sexual advances towards residents. This was reported to the Administrator In Training, and a report was filed. On 11/15/22 R15's room was changed. There is no documentation in R15's medical record that R15 was evaluated by a psychiatrist or provided psychiatric/behavioral services, and the facility was unable to provide documentation that R15 has been evaluated/treated by psychiatric/behavioral services.
R15's emergency room Discharge summary dated [DATE] documents R15 was transferred to the hospital for abnormal behavior and the facility requested a psychiatric evaluation. The facility reported that R15 walked into an unidentified resident's room and removed their blanket, and asked another unidentified resident when was the last time they had sex. The facility requested a psychiatric evaluation to see if R15 is safe to be around other residents. R15 was diagnosed with a urinary tract infection, and there is no documentation that R15 was evaluated by a psychiatrist on 10/5/22, prior to returning to the facility.
On 4/24/23 at 8:56 AM V11 Business Office Manager stated R15 did not admit to the facility with a diagnosis of Schizophrenia. V11 reviewed R15's PASARR on admission, R15 did not have a diagnosis of mental illness, so a Level 2 PASARR was not done. V11 stated V11 oversees the PASARRs and the hospital has the screening done prior to admission to the facility. V11 does not schedule PASARRs after admission and V11 has not received any training on PASARRs. V11 was not aware that a Level 2 PASARR is to be completed if a resident is diagnosed with a mental illness after admission.
On 4/24/23 at 10:19 AM V3 Care Plan Coordinator confirmed R15's care plan does not document dates for problem areas and interventions.
On 4/24/23 at 10:21 AM V3 Licensed Practical Nurse stated R15 has made sexual comments and asks staff if they enjoying having sex. R15 will pat staff on their bottoms and get close to them. A couple weeks ago R15 asked R46 if R46 enjoyed having sex. On 4/24/23 at 10:22 AM V10 Registered Nurse stated R15 voices requests for sexual favors to staff. On 4/24/23 at 10:50 AM V10 stated R15 really needs to be in a facility that specializes in psychiatric services. V10 did not think R15 has received outside psychiatric/behavioral services. Since R15 receives an antipsychotic injection, I would think R15 should see a psychiatrist.
On 4/24/23 at 10:34 AM V7 Social Services Director stated R15 has vulgar sexual language towards staff and residents. When R15 first admitted R15 would rub and touch staff's legs. V7 reviewed R15's October social service notes and stated R15 made sexual advances and comments to R10. V7 was unable to recall specific details of the incident, but thought that R15 touched R10's lower back or hand, and a made a sexual comment/asked R10 if R10 would like to have sex. V7 reported the incident to the former administrator and R10's room was changed. V7 stated the former administrator was friends with R15's family, and R15 had a history of sexual behaviors prior to admission. We moved R10's room closer to the nurses station to keep a closer eye on R10 and try to seat R10 with other male residents.
On 4/24/23 at 10:32 AM V2 Interim Director of Nursing confirmed R15 had no documented psychotropic medication assessments prior to January 2023. V2 stated psychotropic medication assessments are to be completed quarterly. On 4/24/23 at 12:28 PM V2 stated R15 had no behavior tracking prior to January 2022. V2 confirmed the nurses should sign the MAR when medications administered and confirmed R15's September MAR does not document Fluphenazine was administered as ordered. On 4/25/23 at 12:25 PM V2 stated V2 was unable to provide any documentation that R15 has had any behavioral or psychiatric services.
The facility's Psychotropic Medication Policy dated as revised 6/17/22 documents non-pharmacological interventions will be attempted prior to prescribing psychotropic medications. Psychotropic Medication Evaluations will be completed prior to prescribing a new psychotropic medication, within 14 days of admission, and quarterly. Behavior tracking will be used to monitor behaviors. Residents who receive antipsychotic medications will be reviewed at least quarterly by the interdisciplinary team. The resident's care plan will address the use of psychotropic medications and potential side effects, behaviors and interventions. A progress note will be documented quarterly for residents on psychotropic medications that includes the response to the medication, psychotropic medication evaluation, and behaviors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to offer, administer and/or obtain declination for Influenza Immunizati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to offer, administer and/or obtain declination for Influenza Immunization, Pneumococcal Polysaccharide Vaccine (PPSV) 23 or the Pneumococcal Conjugate Vaccine (PCV) 13, 15 and/or 20 Vaccines for four (R24, R26, R44, R49) residents out of four residents reviewed for Immunizations/Vaccinations in a sample list of 39 residents.
Findings include:
1.) R24's undated Face sheet documents an admission date of 4/22/2019. This same Face Sheet documents medical diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Essential Hypertension and Glaucoma.
R24's medical record does not document Influenza immunization, PPSV 23 vaccine nor PCV 13, 15 and/or 20 vaccines being offered, administered or declined.
2.) R26's undated Face sheet documents an admission date of 11/7/2017. This same Face Sheet documents medical diagnoses of Cerebral Vascular Accident (CVA), Hemiplegia affecting Left side and Congestive Heart Failure.
R26's medical record does not document Influenza immunization, PPSV 23 vaccine nor PCV 13, 15 and/or 20 vaccines being offered, administered or declined.
3.) R44's undated Face sheet documents an admission date of 8/19/2022. This same Face Sheet documents medical diagnoses of Myopathy, Chronic Kidney Disease and Cognitive Communication Deficit.
R44's medical record does not document Influenza immunization, PPSV 23 vaccine nor PCV 13, 15 and/or 20 vaccines being offered, administered or declined.
4.) R49's undated Face sheet documents an admission date of 2/7/23. This same Face Sheet documents medical diagnoses of Congestive Heart Failure, Diabetes Mellitus Type II and history of Pneumonia.
R49's Minimum Data Sheet (MDS) dated [DATE] documents R49 as cognitively intact.
R49's medical record does not document Influenza immunization, PPSV 23 vaccine nor PCV 13, 15 and/or 20 vaccines being offered, administered or declined.
On 4/25/23 at 9:30 AM R49 stated I have only been here a couple of months but I don't remember anyone asking me about the Influenza immunization or Pneumonia vaccination. I have had Pneumonia before so I probably would have taken that one.
04/23/23 11:31 AM V2 Regional Director of Clinical Operations/Interim Director of Nurses (DON)/Interim Infection Preventionist (IP) stated facility should offer every resident the Pneumococcal Vaccinations and Influenza Immunization for each new admission. V2 stated the facility should attempt to determine which immunizations the resident has had by calling the physician or obtaining hospital records to find out what vaccinations they had previous. V2 stated education is provided to the resident on each separate vaccination or immunization. V2 stated Due to turnover in the IP position, the facility is not able to provide any documentation for these four residents having had been offered the Influenza immunization or Pneumococcal vaccinations. We (facility) are trying to get all this mess straightened out. But at this time I don't have any documentation for those four residents.
The facility policy titled 'Immunization of Residents' revised 1/23/2020 documents the facility will offer immunizations and vaccinations that aid in the prevention of infectious diseases unless medically contraindicated or otherwise ordered by the residents attending physician or, the facilities medical director. Obtain a written order for the vaccination unless otherwise ordered by the attending physician. Obtain permission/consent from the resident or the resident's Power of Attorney (POA) to administer the ordered vaccine, unless contraindicated. Verify the date of last vaccination. Obtain proof of previous Pneumococcal or Influenza Vaccination for residents when able. Offer the PCV 13 or PPSV 23 as indicated utilizing the Pneumococcal Vaccination Algorithm. Offer the Pneumococcal vaccination within 30 days of admission. Offer the Influenza Immunization annually from October 1 through March 31 or as directed by the medical director. Document immunizations on the resident Medication Administration Record (MAR) and on the resident immunization record.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to have a Registered Nurse (RN) on duty for eight hours per day. This failure has the potential to affect all 52 residents residi...
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Based on observation, interview, and record review the facility failed to have a Registered Nurse (RN) on duty for eight hours per day. This failure has the potential to affect all 52 residents residing in the facility.
Findings include:
On 4/23/23 at 8:28 AM there were no RNs observed working in the facility. V4 Licensed Practical Nurse confirmed there was no RN on duty. V4 stated the facility has two RNs, V10 and V21.
The facility's April 2023 Nurse Schedule does not document the facility had a Registered Nurse on duty for 8 consecutive hours on 4/17, 4/18, and 4/20/23.
On 4/24/23 at 9:50 AM V10 RN stated V10 worked in the facility on 4/6, 4/7, 4/10, 4/12, 4/15, and 4/21/23.
On 4/24/23 at 3:23 PM V2 confirmed the facility did not have an RN for 8 consecutive hours on 4/17, 4/18, and 4/20/23.
The facility's Resident Census and Conditions of Residents dated 4/23/23 documents 52 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to employ a clinically qualified director of food and nutrition services. This failure has the opportunity to affect all 52 reside...
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Based on observation, interview and record review the facility failed to employ a clinically qualified director of food and nutrition services. This failure has the opportunity to affect all 52 residents residing in the facility.
Findings include:
On 4/24/23 at 11:00AM, V5 Dietary Manager was actively supervising kitchen operations for the facility and residents food preparation.
On 4/23/23 at 3:00PM, V5 Dietary Manager confirmed that she had not completed the course work needed to be a certified dietary manager.
On 4/25/23 at 11:45AM, V13 Dietician said that V5 Dietary Manager is not a certified dietary manager and that the facility has not had a certified manager for some time.
The facility resident census and condition report dated 4/23/23 documents 52 residents 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 properly label and store refrigerated food products to prevent food borne illness in residents. This failure has the potential ...
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Based on observation, interview and record review the facility failed to properly label and store refrigerated food products to prevent food borne illness in residents. This failure has the potential to affect all 52 residents in the facility.
Findings include:
On 4/23/23 at 8:05AM, a sign was noted on the front of the refrigerator that said, All food is to be labeled with an open date.
On 4/23/23 at 8:00AM, the following opened and partially used food items in the kitchen refrigerator were not labeled with an open date: salad dressing, salsa, cheddar cheese, sliced cheese and turkey.
On 4/23/23 at 8:10AM, V25 [NAME] stated, Not everything is labeled but it should be.
The facility provided Storage policy dated 10/20 documents, When using only part of a product, the remaining product should be in the original package or air tight container and labeled and dated.
The facility resident census and condition report dated 4/23/23 documents 52 residents 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 observation, interview and record review the facility failed to ensure resident personal clothing and bed linens were washed with sanitizing chemical and failed to ensure water temperature of...
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Based on observation, interview and record review the facility failed to ensure resident personal clothing and bed linens were washed with sanitizing chemical and failed to ensure water temperature of facility clothes washing machine was adequate. This failure has the potential to affect all 52 residents residing in facility.
Findings include:
The Facility Midnight Census Detail Report dated 4/23/23 documents 52 residents residing in facility.
The Commercial Washer Model T-900/950 Vended C-Series Control Operator's Manual Installation and Operation Instructions documents It is the responsibility of the owner to check this equipment on a frequent basis to ensure its safe operation. Separate hot and cold water lines must be provided. A 60 degree Celsius (140 degree Farenheight) hot water supply is recommended for best washing results. Do not exceed 88 degrees Celsius (190 degrees Fahrenheit) degree water temperature.
On 4/25/23 at 10:45 AM observed bottle of 'low temperature laundry solid chlorine sanitizer' with the word 'empty' written on top that was connected to water system of running washing machine with resident linens.
On 4/25/23 at 11:10 AM Observed V16 Maintenance Supervisor from another facility owned by same corporation obtain water temperature of 131.6 degrees Farenheit (F) of hand washing sink which has shared water line with washing machine.
On 4/25/23 at 10:52 AM V14 Housekeeping and Laundry Supervisor stated The sanitizer for the washing machines ran out yesterday morning. We (facility) do not have any more. I talked to (V1) yesterday when it ran out that we needed more and was told that it would be ordered. The truck should be here today or tomorrow. We (facility) have still been washing resident personals and all the linens without the sanitizer though because they (residents) need their laundry done.
On 4/25/23 at 11:15 AM V16 Maintenance Supervisor stated The facility washing machine and the handwashing sink are connected to the same hot and cold water lines. There is no mixing valve. There has to be a mixing valve to be able to control the temperatures of the washing machine and the hand washing sink seperately. Since there was no way to check the water of the washing machine, I tested the water at the sink because they are served from the same water. If the temperature of the sink water is too high and we turn the temperature down, then the washing machine water temperature would go down even more and it already is not high enough. The water running through the machine isn't hot enough to get the clothes clean and the water running to the hand washing sink will scald whoever uses it. So the washing machine not only doesn't have the sanitizer but it also doesn't have hot enough water. I don't think there is any type of policy for this you should just know it. I will help V15 facility Maintenance Supervisor get this straightened out but we are going to have to order parts.
Feb 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
Safe Transfer
(Tag F0626)
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 allow a resident (R3) to return to the facility after ...
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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 allow a resident (R3) to return to the facility after hospitalization. R3 is one of three residents reviewed for residents rights in the sample of three.
Findings include:
R3's [DATE] Physicians Order Sheet (POS) documents R3's diagnoses as: Acute Encephalopathy, Urinary Tract Infection (UTI), Gross Hematuria, Bladder Mass, Atrial Fibrillation, Chronic Anticoagulation, Acute Blood Loss Anemia, Chronic Diastolic Congestive Heart Failure. R3's Physician Orders by V17 Physician dated [DATE], documents R3 also has a diagnosis of End Stage Renal Disease on Dialysis.
R3's telephone order dated [DATE], documents to send R3 to the emergency room per V17 Physician.
On [DATE] 11:50 AM R3, while at the hospital, stated she was planning on coming back to the facility R3 left from but the facility said no.
On [DATE] 2:10 PM, V7 hospital liaison stated R3 and family were planning to return to the facility but the facility said they are unable to meet R3's needs and there is a 10 day bed hold that expired.
On [DATE] at 2:20 PM, V6, R3's daughter stated they have always wanted to come back to the facility but the facility said they would not take R3 back.
On [DATE] at 2:45 PM, V5 Director of Nursing (DON) stated the denial for R3 to return went through the regional team, the 10 day bed hold elapsed. At this same time, V8 Social Services stated the decision had been made to not let R3 return due to not having a bed available and 10-day bed hold passed, think it was for February 8.
On [DATE] at 3:15 PM, V8 Social Services presented the census from [DATE] which shows room S11A was vacant and available for R3 on [DATE].
The facility's Bed Hold Guarantee Policy dated Revised [DATE], documents: a Medicaid resident, whose hospitalization exceeds the 10-day bed hold period, may return to their previous room if available or immediately upon the first availability of a bed in a semi-private room.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to implement interventions to prevent accidents for five (R4, R12, R13, R16, R17) residents reviewed for accidents.
Findings incl...
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Based on observation, interview and record review the facility failed to implement interventions to prevent accidents for five (R4, R12, R13, R16, R17) residents reviewed for accidents.
Findings include:
R4's facility report to the Illinois Department of Public Health dated 2/11/23 documents that on 2/11/23, V10 Nursing Assistant tripped and spilled hot liquid on R4's arm causing redness.
R4's care plan dated 2/11/23 documents that the coffee splashed onto R4 when V10 Nursing Assistant lost her balance with the tray. The documented intervention is to place lids on hot beverages, along with monitoring R4's forearm for redness every 72 hours.
The facility incident log dated 2/11/23 documents R4's burn with the intervention of ordering lids for the cups.
On 2/15/23 at 8:31AM R4 stated, They poured hot water on my arm accidentally. V8 Social Services Director pulled R4's right sleeve up and on the right forearm was a light red burn with a pour pattern sized 4.5 centimeters by 4.8 centimeters by 8 centimeters.
On 2/15/23 at 10:55AM, V10 Nursing Assistant said that she tripped over her feet while carrying hot water and it spilled onto R4. V10 then stated, We are getting lids for the cups.
On 2/15/23 at 8:32AM V8 Social Services Director served R12 hot coffee without a lid and R13 hot water without a lid.
On 2/15/23 at 12:15PM, R16 was served hot chocolate and hot coffee without lids and R17 was served coffee by V19 Certified Nursing Assistant without a lid.
On 2/15/23 at 1:45PM, V5 Director Of Nursing stated, We didn't consider any other options for covering the hot liquids while waiting for the lids to arrive. I didn't think about saran wrap or anything else. That was certainly an option and I think that we will do that tonight for the evening meal.
On 2/16/23 at 2:45PM, V11 Dietary Manager said that she ordered the lids on Tuesday the 14th, as soon as she was told about the burn and intervention of the lids. I understand we didn't do anything right away and that an accident can happen at anytime. That's why I went to a sister facility today and got a couple of sleeves of lids to use tonight. (5 days post injury)
Jan 2023
5 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level require more than one deficient practice statement.
These failures resulted in an Immediate Jeopardy.
A. ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level require more than one deficient practice statement.
These failures resulted in an Immediate Jeopardy.
A. Based on observation, interview and record review the facility failed to provide targeted interventions to prevent repetitive burn injuries for R1, a resident with a history of tremors and burns from hot liquids. This failure resulted in a second degree burn on R1's left forearm. This failure affects one (R1) of three residents reviewed for accidents and supervision in a sample list of 9 residents.
The Immediate Jeopardy began on 1/6/23 when the facility failed to implement interventions to prevent R1 from burning himself. V1 Regional Director of Clinical Operations was notified of the Immediate Jeopardy on 1/25/23 at 12:55PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 1/25/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
Findings include:
a) R1's diagnoses include: Parkinson's disease, Dementia, Schizophrenia, Congestive Heart Failure, Benign Prostatic Hypertension, Severe Bipolar Affective Disorder with Psychosis, and Dysphasia.
R1's physician order for medications for tremors include: Carbi-Levodopa 25/100 four times daily and Rasaginine Mesylate 1 milligram daily (both taken since 8/29/22)
On 1/24/23 at 12:05 PM, V7 Certified Nursing Assistant stated, Oh yes, (R1) has tremors when he eats and drinks.
R1's Minimum Data Set, dated [DATE] documents R1 as moderately cognitively intact, requiring set up and supervision for meals.
On 1/5/23 at 2:45 PM, R1's change of condition report documents R1 spilled hot chocolate on his clothing resulting in reddened skin on his right arm and pain. On 1/6/23, the facility quality committee minutes document that R1 is having tremors and recommended interventions including using reusable cups, ice to cool drink and a sipping cup lid.
R1's care plan dated 1/6/23 documents interventions of a sipping cup lid for drinks, a regular coffee cup and ice to cool down the drinks.
On 1/24/23 at 9:30 AM, V2 Wound Nurse stated, On 1/10/23 early in the morning, R1 showed me the burn on his arm. He told me that he got burned from the hot chocolate at dinner but that he couldn't remember if anyone was around when it happened. He could not tell me if he told anyone. He just kept saying the Parkinson's, the Parkinson's. No one would [NAME] up to knowing when it happened. It had to have happened at supper (on 1/9/23). I didn't talk to the nurse on duty that night and I didn't document my interviews. I got an order from the doctor for treatment and had the medicine in hand 4 hours after I was made aware of the burn. I was horrified by the size and tissue damage. I know that they temperature checked the hot liquids that morning after they heard about the burn.
On 1/10/23 at 6:55 AM, R1's change of condition report documents that R1 presented to V2 wound nurse with a burn on his left forearm measuring 8.2 centimeters by 2.8 centimeters with an unknown depth. The physician was notified and orders were received to cleanse the wound with normal saline, apply Silvadene ointment and cover daily.
On 1/10/23 V6 Nurse Practitioner made an urgent visit to evaluate R1's burn. V6 Nurse Practitioner's Note documents that R1 has a partial thickness burn covered in eschar with a few blisters. The Note documents (R1) does have some tremors, this could have been how he spilled the hot chocolate. Spoke with nursing staff about more safety measure regarding hot liquids due to his tremor and high risk of injury.
On 1/24/23 at 9:25 AM, R1 received wound care to his left forearm burn. The area was observed to have a burn pattern splatter mark approximately 8 centimeters in length by 3 centimeters in width with a deep purple and red coloring surrounding the open scab area that was the size of half a dime. The wound was cleansed by V2 wound nurse and then Silvadene ointment was applied and covered. R1 stated, It hurt but it doesn't now. It was hot!
On 1/24/23 at 12:00 PM, V2 wound nurse stated, We ordered a sipping lid, but there weren't any available in the facility. So no, on 1/9/23 and 1/10/23, R1 didn't have the lid yet. I can't say if they put ice in his drink that night, but it still burned him.
On 1/24/23 at 9:50 AM. V5 Dietary Manager stated, I tempted the water for the hot chocolate that morning of the (second) burn (1/10/23) and it was 176 degrees (Fahrenheit).
On 1/30/23 at 1:00 PM, V11 Regional Administrator stated that hot drinks should be served at no more than 140 degrees Fahrenheit for safety.
On 1/24/22 at 9:55 AM, the hot chocolate water was temperature checked by facility staff measuring 172.6 degrees Fahrenheit.
On 1/24/23 at 12:00 PM, R1 was sitting in the dining room at a table by himself, across the room from the nurse's station.
On 1/24/23 at 12:06 PM, V2 wound nurse/director of nursing stated, (R1's) interventions weren't put into place like they should have been and I really don't like (R1) sitting so far from the nurse's station when he eats.
On 1/24/23 at 2:42PM, V4 Physician stated, I was not aware of the first burn. They should have told me about it. I was aware of the second burn and the way it was described to me, it was a second degree burn. They should have implemented interventions to prevent another burn. It was potentially preventable.
The immediate jeopardy that began on 1/6/23 was removed on 1/25/23 when the facility took the following actions to remove the immediacy.
1. On 1/10/2023 all staff were in-serviced on emergency care for burns, food temperatures, and newly acquired skin conditions by V1 Regional Director of Clinical Operations.
2. Residents no longer allowed drinking coffee/hot chocolate in their rooms when in bed. They must be upright at an over bed table or dining room table. Confirmed by V1, V12 Regional Administrator and direct care staff.
3. All residents will be supervised while consuming a meal on a hall tray, room tray or dining room tray. Confirmed by V1, V12 and direct care staff.
4. On 1/25/2023 all staff were in-serviced on emergency care of burns, food temperatures, staff expectations on room/hall trays, and notification of change in conditions, newly acquired skin conditions, comprehensive care planning, and the care needs notice by V1 Regional Director of Clinical Operations.
5. On 1/25/23, V2 Director of Nursing and V12 Regional Administrator were in-serviced on Incident Investigations by V1 Regional Director of Clinical Operations.
6. R1's orders and care plan were updated to include lidded cups for all drinks for safety. Completed on 1/10/23.
7. The facility initiated the use of the Care Need notice for care plan revisions to better communicate changes to the care plan to direct care staff. Completed on 1/10/23 and ongoing.
8. The quality assurance team will conduct random rounds to ensure residents and staff are following the room tray/hall tray and dining room observations. Confirmed by V1 and V12. Daily meetings will be held.
9. V12 Regional Administrator or designee will educate new staff members and new residents on the room tray/hall and dining room tray expectations. As needed.
10. V12 Regional Administrator or designee will in-service staff on emergency care of burns, food temperatures, staff expectations on room/hall/dining room trays, newly acquired skin conditions and notification of change in conditions weekly x 4 weeks and then monthly times 3 months starting 1/31/2023
11. As part of ongoing quality improvement V12 Administrator and/or V2 Director of Nursing will conduct random temperature audits of hot drinks being served from the dietary department to determine if hot beverages are being served in the normal range. To begin on January 31, 2023.
12. Dietary staff will be randomly testing hot liquid temperatures and using ice to decrease the temperature in liquids found hotter than 140 degrees. Started on 1/30/23.
B. Based on observation, interview and record review the facility failed to prevent a burn for R2, a resident with known hand weakness, resulting in a burn on R2's hand. These failures affect one (R2) of three residents reviewed for accidents and supervision from a total sample list of 9 residents.
Findings include:
b) R2's undated face sheet documents diagnoses including: Chronic Obstructive Pulmonary Disease, Weakness, Chronic Embolism and Thrombosis of deep veins, End Stage Renal Disease requiring Hemodialysis, Non-Hodgkin's Lymphoma, Anemia, Vitamin D deficiency, Peripheral Vascular Disease, Coronary Artery Disease, and Hypertension.
R2's Minimum Data Set, dated [DATE] documents R2 as cognitively intact requiring supervision for eating and drinking.
R2's admission prescreen for violence dated 11/22/22 documents, Resident is weak in the hands and arms. He does have weakness in his legs and can't stand for long period of time. He has to use the left hand to control his right hand to eat. He can't write.
R2's Dietary Notes dated 12/14/22 document, Family talked with administrator. At home, (R2) worked with cups with handles. They also asked for grips to be added to his silverware like he had in the hospital. Occupational Therapy agrees and also recommended an edged plate to help keep food from hitting the floor.
No interventions to prevent burns were put into place from admission until 1/6/23.
R2's quality meeting note dated 1/6/23 documents that on 1/5/23 R2 was drinking hot coffee from a foam cup and put a finger through the cup.
R2's physician order dated 1/5/23 documents an order for triple antibiotic ointment and bordered gauze for the wound.
R2's wound tracking documents on 1/5/23 a 1.4 centimeter by 1.1 centimeter by .1 centimeter right index finger burn.
On 1/25/23 at 2:40 PM, R2 stated that he put his finger through the foam cup and the coffee burned his right index finger leaving it with a blister. R2 said that he has neuropathy and that the coffee also spilled on his lap but it didn't burn him through his clothes. R2 stated that this happened in the dining room and that he usually reminded staff that he used a regular cup, but that they gave him the foam and he didn't want to complain.
On 1/25/23 at 2:45 PM, R2 demonstrated where the burn occurred on the right index finger. A scab the size of a dime was seen with redness around the area of the scab.
R2's care plan, dated 1/9/23 documents interventions to prevent future burns including using a mug with a handle.
Occupational therapy documented an order for R2's coffee cups to have a lid with a straw for all drinks on 1/20/23.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to provide the services of registered nurses 7 days in the month of January 2023. This failure has the potential to affect all 53 residents in ...
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Based on interview and record review the facility failed to provide the services of registered nurses 7 days in the month of January 2023. This failure has the potential to affect all 53 residents in the facility.
Findings include:
On 1/24/23 at 11:00 AM, the facility daily nursing sheets were reviewed for registered nursing coverage from January 1, 2023 to January 23, 2023.
The facility provided January nursing schedule, documents no registered nursing coverage on January 1, 7, 8, 14, 15, 21, 22.
On 1/25/23 at 12:55 PM, V9 New Director of Nursing stated, I don't see any registered nurses on the staffing sheets We don't have the coverage.
The facility provided census dated 1/24/23 documents 53 residents residing in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0839
(Tag F0839)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have qualified staff providing nursing care in the facility. The fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have qualified staff providing nursing care in the facility. The failure has the potential to affect all 53 residents residing in the facility.
Findings include:
V11's (Licensed Practical Nurse) personnel file documents that on [DATE], V13 Administrator in Training hired V11 to work as a licensed practical nurse at the facility.
V11 LPN's personnel file contains a copy of the Illinois Department of Financial and Professional Regulation license look up dated [DATE], 3:00 PM. This lookup identifies V11's license as expired on [DATE].
V11 LPN's personnel file contains an additional copy of the Illinois Department of Financial and Professional Regulation license look up dated [DATE], 8:26 AM. This lookup identifies V11's license as expired on [DATE].
On [DATE] at 12:58 PM, the facility ran V11 LPN's license lookup through the Illinois Department of Financial and Professional Regulation. This lookup identifies V11's license as expired on [DATE].
V11's facility provided time cards document from [DATE] to [DATE] V11 LPN worked 73 shifts as a licensed practical nurse in the facility.
On [DATE] at 3:15 PM, V2 Wound Nurse/Director of Nursing stated, V11 LPN would have definitely been taking care of all residents in the building because she was a night nurse and many nights we only staff with one nurse for the entire building.
The undated, facility provided, Licensed Practical Nurse job description documents that the Licensed Practical Nurse is a member of the health care team who contributes to the implementation of the nursing process by providing care to residents in non-complex situations and assisting in the care of residents who are extremely ill. Qualifications include: A current license in good standing in the state in which the facility is located. Responsibilities include but are not limited to providing basic physical care to assigned residents, administering medications with knowledge and understanding, utilizing techniques of infection control, reviewing physician orders, and providing nursing interventions such as dressings, treatments, feedings, suctioning, etcetera.
On [DATE] at 10:30 AM, V12 Regional Administrator stated, We have taken V11 LPN off of the schedule.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to implement a quality assurance program within the facility. This failure has the potential to affect all 53 residents residing in the facilit...
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Based on interview and record review the facility failed to implement a quality assurance program within the facility. This failure has the potential to affect all 53 residents residing in the facility.
Findings include:
On 1/26/23 at 4:00 PM, V2 Wound Nurse/Director of Nursing stated, I've been here since August and I can't say that there has been a quality meeting with everyone like the Medical Director, Administrator, and all of the people who should be there. We started in January and V1 Regional Clinical Nurse taught us what the quality meetings should be like. We haven't had any (performance improvement projects) PIPs where we've been able to really analyze data. We just aren't there.
On 1/30/22 at 2:30 PM, V12 Regional Administrator stated, I didn't find any performance improvement projects or sign in sheets for quarterly meetings since January of 2022. Our first one moving forward will be related to these tags and then after that it will be all department heads bringing their ideas to the meetings to get the program up and moving.
The undated facility provided Quality Improvement (QI) policy documents, Quality Indicator reports can be used for several things. We have been using them to help identify residents that may be reviewed during the survey. The QI reports should also be used to assist the facility in making quality improvement decisions. These reports can help direct the Quality Improvement team toward areas of resident care that may require attention and change. These reports can help to analyze and determine where changes need to occur in the processes of resident care.
The facility provided midnight census dated 1/24/23 documents 53 residents residing in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to have quarterly quality assurance meetings. This failure has the potential to affect all 53 residents residing in the facility.
Findings incl...
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Based on interview and record review the facility failed to have quarterly quality assurance meetings. This failure has the potential to affect all 53 residents residing in the facility.
Findings include:
The facility's undated Quality Assurance Plan documents that the quality assurance committee will conduct quarterly meetings at a minimum and other quality assurance meetings as identified.
On 1/26/23 at 4:00 PM, V2 Wound Nurse/Director of Nursing stated, I've been here since August and I can't say that there has been a quality meeting with everyone like the Medical Director, Administrator, and all of the people who should be there. We started in January and V1 Regional Clinical Nurse taught us what the quality meetings should be like.
On 1/27/23 at 3:00 PM, V12 Regional Administrator stated, I can't find any quarterly quality assurance sign in sheets since January 2022.
The facility provided midnight census dated 1/24/23 documents 53 residents residing in the facility.
Dec 2022
4 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to complete pressure ulcer treatments as ordered, complete...
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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 complete pressure ulcer treatments as ordered, complete weekly pressure ulcer monitoring, thoroughly assess pressure ulcers upon admission, obtain treatment orders for a newly identified wound and have documentation of identification of a new wound for two of four residents (R5, R4) reviewed for pressure ulcers in the sample list of nine. This failure resulted in R5's unstageable pressure ulcer deteriorating and increasing in size.
Findings include:
The facility's Pressure Sore Prevention Guidelines policy with a revised date of January/2018 documents, Any resident scoring a High or Moderate risk for skin breakdown will have scheduled skin checks on the Treatment Record. Skin checks will be completed and documented by the nurse.
The facility's Aseptic Wound and Skin Treatment Procedure with a revised date of January/2018 documents, Purpose: To prevent contamination of the wound, protect wound from mechanical injury, to stimulate, restore, and promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structures, and to promote resident comfort. Document procedure on treatment sheet.
1.) R5's Physician's Order Sheet dated 11/1/22 through 11/30/22 documents diagnoses including Skin Picking, Advanced Dementia, Neuropathy, Obesity and Diabetes. R5's Physician's Order dated 11/30/22 documents a treatment order for the left heel to cleanse with normal saline, pat dry, apply calcium alginate, cover with a foam dressing, secure with rolled gauze and change daily. R5's Physician's Order dated 11/30/22 documents a treatment order for the right buttock to cleanse with normal saline, pat dry, apply calcium alginate, cover with a bordered foam dressing and change daily. R5's Physician's Order dated 11/30/22 documents a treatment order for the right heel to cleanse with normal saline, pat dry, cover with a foam dressing and change three times a week.
R5's Treatment Administration Record dated 12/1/22 through 12/31/22 documents an order to apply skin protective wipe every shift and documents three shifts, 10:00 PM to 6:00 AM, 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM. There are not signatures indicating this treatment was completed at all in December. This Treatment Administration Record documents an order for the right heel to cleanse with normal saline, pat dry, apply three times a week and documents to be completed on the 10:00 PM to 6:00 AM shift and is to be completed on 12/2/22, 12/5/22, 12/7/22 and 12/9/22. This treatment is not signed out as completed on 12/5/22.
On 12/6/22 at 1:55 PM, V12 Licensed Practical Nurse removed R5's left heel protector boot and the dressing that was on the left foot was dated 12/3/22. The dressing had drainage soaking through. V12 confirmed the date was 12/3/22 and was supposed to have been changed on 12/5/22 but was not and confirmed there was drainage soaking through the dressing.
R5's medical record contains Wound Evaluations from V18 Wound Physician. R4's Wound Evaluation dated 10/26/22 documents the Unstageable Left Heel wound measured 4.5 cm (centimeters) x (by) 8 cm. There is no other wound measurements or assessments until 11/16/22, 21 days later. R5's Wound Evaluation dated 11/16/22 documents the Unstageable Left Heel wound measured 6.5 cm x 10 cm x 0.1 cm and wound progress is documented as Deteriorated.
On 12/6/22 at 2:35 PM, V3 Regional Administration confirmed that R5's chart did not contain a thorough assessment of R5's wounds on admission. V3 stated V3 could only find the depth of R5's Left Ischium wound and no other measurements or characteristics.
2.) R4's Physician's Order Sheet (POS) dated 12/1/22 through 12/31/22 documents diagnoses including Left Ischium Stage Four Pressure Ulcer, Cellulitis of Left Lower Extremity, Diabetes Type 2, Infected Wound and Chronic Kidney Disease. R4's POS documents treatment orders dated 11/30/22 for the Left Ischium to cleanse with normal saline, pat dry, pack with rolled gauze soaked in 1/4 strength bleach solution, cover with abdominal pad and change twice a day; the Sacrum to cleanse with normal saline, pat dry, apply calcium alginate, cover with foam dressing and change daily; the right ankle to cleanse with normal saline, pat dry, apply calcium alginate, cover with foam dressing and change three times a week; the left heel to cleanse with normal saline, pat dry, apply foam dressing and change three times a week; the left anterior leg to cleanse with normal saline, pat dry, apply calcium alginate, cover with an abdominal pad and change three times a week; the right anterior leg to cleanse with normal saline, pat dry, apply calcium alginate, cover with a silicone foam bordered dressing and change three times a week.
R4's Nursing admission assessment dated [DATE] at 8:15 PM does not document a thorough assessment of all of R4's wounds. The area on the left Ischium has no measurements for width or length. The depth is measured at 7 centimeters but no other characteristics are identified.
R4's Treatment Administration Record (TAR) dated 11/18/22 through 11/30/22 documents R4 daily skin check was not signed off as completed on 11/22/22 and 11/30/22. This TAR documents R4's Right Ischium treatment was not signed off as completed on the evening shift of 11/22/22 and 11/23/22 and both shifts on 11/30/22. R4's TAR documents R4's Left Lower Extremity treatment was not signed off as completed on 11/30/22. R4's TAR documents R4's Left Heel treatment was not signed off as completed on 11/30/22. R4's TAR documents R4's Right Leg and Right Foot treatment was not signed off as completed on 11/22/22 and 11/30/22. R4's TAR documents R4's Right Heel treatment was not signed off as completed on 11/22/22 and 11/30/22. R4's TAR documents R4's Left Ischium treatments was not signed off as completed on 11/22/22 both shifts, 11/23/22 both shifts, 11/24/22, 11/25/22, 11/26/22, 11/27/22 on the evening shift and 11/30/22 on both shifts. R4's TAR documents R4's Left Buttock treatment was not signed off as completed on 11/22/22, 11/23/22 and 11/30/22.
R4's TAR dated 12/1/22 through 12/31/22 documents R4's Left Ischium treatment was not signed off as completed on 12/5/22 on the evening shift.
On 12/5/22 at 4:00 PM, R4 stated that the nurses do not change R4's dressing as they are ordered to be changed. R4 stated the dressings were not changed last night (12/4/22) and had not yet been changed this day (12/5/22). R4 stated R4 really wants the wounds to heal so that they do not have to be treated when R4 goes home.
R4's Physician visit with V17 R4's Physician on 11/22/22 documents R4 was concerned that R4's dressings have not been changed consistently since R4 was admitted to the facility.
On 12/6/22 at 8:15 AM, V8 Licensed Practical Nurse (LPN) completed dressing changes for R4. When V8 removed R4's incontinent brief and there was a new open area on the right buttocks approximately 0.5 cm (centimeters) circular shape. V8 stated that V8 noticed that area yesterday and left a message for V18 Wound Physician regarding this new area but V8 stated V8 has not received a reply back. V8 confirmed there is no treatment order for this area and V8 did not complete a treatment for this area. V8 left this new area open and put a clean incontinence brief on R4.
R4's Minimum Data Set (MDS) dated [DATE] does not document any of the wounds that R4 had on admission.
On 12/7/22 at 10:45 AM, R4 stated that the nurses miss doing some of R4's treatments.
On 12/7/22 at 1:00 PM, V8 LPN confirmed there is still no treatment orders for R4's new wound on R4's buttocks. V8 stated that V18 Wound Physician will be back to the facility on [DATE].
The facility's Resident Council Meeting Minutes dated 9/23/22 documents concerns regarding wound not being done.
On 12/7/22 at 1:45 PM, V3 confirmed the nurse are to sign their initials on the Treatment Administration Record when they complete a treatment. V3 confirmed the Treatment Records are not complete.
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
Based on observation, interview and record review the facility failed to investigate a fall and failed to determine the root cause for falls for two of three residents (R6, R1) reviewed for falls in t...
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Based on observation, interview and record review the facility failed to investigate a fall and failed to determine the root cause for falls for two of three residents (R6, R1) reviewed for falls in the sample list of nine.
Findings include:
The facility's Fall Prevention policy with a revised date of 11/10/18 documents, Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM (Assess, Intervene, Manage) for Wellness along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA (Certified Nursing Assistant) assignment worksheet. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.
The facility's undated Fulfilling Fall Prevention Responsibilities policy documents, Charge Nurse: Conduct a 'Fall Huddle' with staff after the fall to obtain important information about the fall to help identify the cause of the fall. DON (Director of Nursing) Quality Assurance Analysis and Insure documentation of the root cause and new intervention is recorded in the medical record during the Morning QA (Quality Assurance) Meeting.
1.) R6's Nurse's Notes dated 10/23/22 at 5:20 PM documents, (R6) found sitting on floor mat next to bed, leaning against w/c (wheelchair). (R6) has not c/o (complaints of) pain, no swelling or bumps, no evidence of hitting (R6's) head. Dr. Notified. signed by V19 Licensed Practical Nurse.
The facility's Fall Analysis Log does not document this fall. On 12/7/22 at 11:14 AM, V3 Regional Administration confirmed there is no investigation of R6's fall on 10/23/22.
The facility's Fall Analysis Log documents R6 had a fall on 11/5/22 and the facility did not determine a root cause. This log documents a fall for R6 on 11/17/22 and the facility did not determine a root cause for this fall. The facility documented the root cause as R6 had poor safety awareness.
2.) R1's Physician's Order Sheet dated 11/1/22 through 11/30/22 documents diagnoses including Acute Diastolic Heart Failure, Hemodialysis, Acute Metabolic Encephalopathy, End Stage Renal Disease and Diabetes.
R1's Care Plan dated 9/20/22 and provided on 12/5/22 documents R1 has risk factors that require monitoring and intervention to reduce potential for self injury with interventions for non-skid footwear, lock wheelchair brakes, observe for unsafe transfers, monitor for signs of fatigue, monitor for changes in condition, assess cognitive deficits, keep environment well lit and clutter free, keep call light within reach at all times, remind of safety precautions and limitations and keep bed in low position with brakes on.
The facility's Fall Analysis Log documents R1 had a fall on 9/29/22 and the facility did not determine a root cause but documents a new intervention of putting a sign in R1's room. This log documents R1 had a fall on 9/30/22 and the facility did not determine a root cause but documents a new intervention of moving R1 closer to the nurse's station. This log documents R1 had a fall on 11/4/22 and the facility did not determine a root cause and documents new interventions of a scoop mattress and a fall mat placed. This log documents R1 had a fall on 11/7/22 and the facility did not determine a root cause but document a new intervention of a toilet seat riser. These interventions were not documented on the Care Plan provided on 12/5/22 by V1 Administrator in Training.
On 12/6/22 at 1:37 PM, V7 and V10 Certified Nursing Assistants (CNAs) stated that they do not remember R1 having any fall interventions in place. V7 stated they would tell R1 to turn R1's call light on when R1 needed help.
On 12/7/22 at 10:31 AM, V13 Certified Nursing Assistant stated there were no fall interventions in place for R1. There was no fall mat, no toilet seat riser, no sign in the room, no scoop mattress or floor mat.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to prevent cross contamination during wound care for one of four residents (R5) reviewed for wounds in the sample list of nine.
F...
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Based on observation, interview and record review the facility failed to prevent cross contamination during wound care for one of four residents (R5) reviewed for wounds in the sample list of nine.
Findings include:
The facility's Aseptic Wound and Skin Treatment Procedure with a revised date of January 2018 documents, Purpose: To prevent contamination of the wound, protect wound from mechanical injury, to stimulate, restore, and promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structures, and to promote resident comfort. 14. Clean the wound as ordered. Clean from center outward, never going back over area, which has been cleaned.
R5's Physician's Order Sheet (POS) dated 11/1/22 through 11/30/22 documents diagnoses including Skin Picking, Advanced Dementia, Failure to Thrive, Neuropathy and Diabetes. This POS documents a treatment order for the right buttock to apply calcium alginate, a foam bordered dressing and change daily.
On 12/6/22 at 1:55 PM, V12 Licensed Practical Nurse (LPN) completed a dressing change for R5 on R5's Right Buttock. V12 washed V12's hands and donned gloves. V12 dumped normal saline on a few 4 inch x (by) 4 inch gauze pads and wiped over the open wound several times over the same area of the wound with the same area of the dampened gauze. V12 changed V12's gloves and applied the calcium alginate and foam dressing.
On 12/7/22 at 1:45 PM, V3 Regional Administration confirmed the nurses should follow the policy for preventing cross contamination.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to complete wound treatments as ordered on multiple days for one of four residents (R2) reviewed for wounds in the sample list of nine.
Findin...
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Based on record review and interview the facility failed to complete wound treatments as ordered on multiple days for one of four residents (R2) reviewed for wounds in the sample list of nine.
Findings include:
The facility's Aseptic Wound and Skin Treatment Procedure with a revised date of January/2018 documents, Purpose: To prevent contamination of the wound, protect wound from mechanical injury, to stimulate, restore, and promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structures, and to promote resident comfort. Document procedure on treatment sheet.
R2's Physician Order Sheet (POS) dated 8/1/22 through 8/31/22 documents diagnoses including Anxiety, Falls, Dementia, Senile Degeneration of Brain, Weakness and Chronic Pain. This POS documents a treatment order for the affected cheek to apply antibiotic cream to the area twice daily.
R2's Treatment Administration Record (TAR) dated 8/1/22 through 8/31/22 documents the order for the affected cheek to apply povidone iodine twice a day. This TAR also documents an order to apply zinc oxide to R2's buttocks twice daily and as needed. This TAR documents both of these treatments were not signed out as completed on 8/10/22, 8/11/22, 8/12/22, 8/14/22, 8/15/22, 8/16/22, 8/17/22, 8/19/22, 8/20/22, 8/21/22 and 8/22/22.
On 12/7/22 at 1:45 PM, V3 confirmed the nurse are to sign their initials on the Treatment Administration Record when they complete a treatment. V3 confirmed R2's Treatment Records are not complete.
Nov 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
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 showers for three of three dependant residents (R1, R2, R3) ...
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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 showers for three of three dependant residents (R1, R2, R3) reviewed for showers in the sample of three.
Findings include:
1. R1's Physician Order Sheet (POS) dated November 2022 documents R1 is diagnosed with Chronic Obstructive Pulmonary Disease and Fibromyalgia.
R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact and requires physical help by one staff person for bathing.
The undated Shower Schedule documents according to R1's room number, she is to get showers on Mondays and Fridays on day shift.
R1's Shower/Abnormal Skin Reports reviewed for the last month were dated 11/7/22. There was no other documentation of any other showers provided for R1.
On 11/7/22 at 2:20 PM R1 stated staff don't offer showers and the last time she got a shower was over two week ago. R1 stated she would prefer a shower twice per week.
2. R2's Physician Order Sheet (POS) dated November 2022 documents R2 is diagnosed with Schizophrenia and Muscle Spasms.
R2's Minimum Data Set, dated [DATE] documents R2 is severely cognitively impaired and is totally dependant of one staff person for bathing.
The undated Shower Schedule documents according to R2's room number, he is to get showers on Tuesdays and Thursdays on day shift.
R2's Shower/Abnormal Skin Reports reviewed for the last month were dated 10/27/22, 11/1/22, and 11/3/22. There was no other documentation of any other showers provided for R2.
3. R3's Physician Order Sheet (POS) dated November 2022 documents R3 is diagnosed with Myopathy and Falls.
R3's Minimum Data Set, dated [DATE] documents R3 is cognitively intact and requires physical help by one staff person for bathing.
The undated Shower Schedule documents according to R3's room number, he is to get showers on Wednesday and Fridays on evening shift.
R3 had no Shower/Abnormal Skin Reports for the last month. There was no documentation of any showers provided for R3 within the last month.
On 11/7/22 at 1:28 PM R3 stated staff don't offer him showers and he can't remember the last time he got one. R3 stated he would prefer a shower twice per week.
On 11/8/22 at 1:00 PM V2 Director of Nurses confirmed staff need to provide assistance to all residents with showers at least once per week and need to document the showers on shower sheets which are then signed by the nurse on duty and reviewed by herself and management staff in morning meeting.
The facilities Bathing/Shower policy dated January 2018 documents it is the facility's policy to ensure adequate hygiene needs are met and a shower is given to all resident at least weekly. Showers are to be documented on the Shower/Abnormal Skin Report.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "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
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 9 harm violation(s), $162,596 in fines, Payment denial on record. Review inspection reports carefully.
- • 98 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $162,596 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Haven Of Meadowbrook's CMS Rating?
CMS assigns THE HAVEN OF MEADOWBROOK 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 The Haven Of Meadowbrook Staffed?
CMS rates THE HAVEN OF MEADOWBROOK's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 55%, which is 9 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 80%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at The Haven Of Meadowbrook?
State health inspectors documented 98 deficiencies at THE HAVEN OF MEADOWBROOK during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 9 that caused actual resident harm, 87 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates The Haven Of Meadowbrook?
THE HAVEN OF MEADOWBROOK 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 HAVEN HEALTHCARE, a chain that manages multiple nursing homes. With 60 certified beds and approximately 49 residents (about 82% occupancy), it is a smaller facility located in CHAMPAIGN, Illinois.
How Does The Haven Of Meadowbrook Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, THE HAVEN OF MEADOWBROOK's overall rating (1 stars) is below the state average of 2.5, staff turnover (55%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting The Haven Of Meadowbrook?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is The Haven Of Meadowbrook Safe?
Based on CMS inspection data, THE HAVEN OF MEADOWBROOK has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Haven Of Meadowbrook Stick Around?
Staff turnover at THE HAVEN OF MEADOWBROOK is high. At 55%, the facility is 9 percentage points above the Illinois average of 46%. Registered Nurse turnover is particularly concerning at 80%. 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 The Haven Of Meadowbrook Ever Fined?
THE HAVEN OF MEADOWBROOK has been fined $162,596 across 2 penalty actions. This is 4.7x the Illinois average of $34,705. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is The Haven Of Meadowbrook on Any Federal Watch List?
THE HAVEN OF MEADOWBROOK 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.