HILLTOP SKILLED NSG & REHAB
For profit - Limited Liability company
108 Beds
CREST HEALTHCARE CONSULTING
Data: November 2025
Trust Grade
5/100
#549 of 665 in IL
Photo by Hilltop Skilled Nursing and Rehabilitation
Photo by Hilltop Skilled Nursing and Rehabilitation
Photo by Hilltop Skilled Nursing and Rehabilitation
1 / 5 photos
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Hilltop Skilled Nursing & Rehab has received a Trust Grade of F, indicating significant concerns about the quality of care. This places the facility at #549 out of 665 nursing homes in Illinois, placing it in the bottom half of state facilities, but #2 out of 5 in Coles County, meaning just one local option is considered better. The trend is improving, with issues decreasing from 33 in 2023 to 15 in 2024, but the staffing situation is a concern, with a low rating of 1 out of 5 stars and a turnover rate of 56%, which is higher than the state average. The facility has faced $216,048 in fines, indicating compliance problems, and while RN coverage is average, it is critical to note serious incidents such as a resident who fell and sustained injuries due to inadequate supervision and another resident whose pressure sore worsened because care plans were not followed properly. Overall, while there are some signs of improvement, families should weigh these concerning issues in their decision-making process.
- Trust Score
- F
- In Illinois
- #549/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $216,048 in fines. Higher than 59% of Illinois facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 54 deficiencies on record. Higher than average. Multiple issues found across inspections.
5/100
Bottom 18%
Review needed
33 → 15 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 33 issues
2024: 15 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: 56%
10pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $216,048
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: CREST HEALTHCARE CONSULTING
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (56%)
8 points above Illinois average of 48%
The Ugly 54 deficiencies on record
3 actual harm
Oct 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain cleanliness of resident's mattresses. This failure affects one resident (R3) out of 24 reviewed for environmental cl...
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Based on observation, interview, and record review, the facility failed to maintain cleanliness of resident's mattresses. This failure affects one resident (R3) out of 24 reviewed for environmental cleanliness on the sample list of 43.
Findings include:
R3's Medical Diagnoses List dated 10/18/24 documents R3 experiences medical conditions including Dementia, Acquired Absence of Right Leg Above the Knee, and Acquired Absence of Left Leg Below the Knee.
On 10/15/24 at 1:21 PM, there were smeared and mounded clumps of an unidentified white food substance resembling cake at the foot end of R3's mattress. The two clumps were one and one-half inches long by three-quarters of an inch wide.
On 10/16/24 at 3:13 PM, the residue of the clumps of white food substance remained on the foot end of the mattress. The mounded clumps were not present, the surface residue was still on the mattress.
On 10/16/24 at 3:18 PM, V10, Certified Nursing Assistant (CNA), stated, As far as I know the housekeeping only cleans the mattresses when they need to be sanitized, I don't know if they have a schedule to clean them on resident's shower days. V10 further stated, The CNAs and the nurses have access to the sanitizing bleach wipes to use, what this looks like is the crumbs were probably on the sheets so when they move the sheets it gets down to the bottom of the bed.
On 10/16/24 at 3:23 PM, V11, Housekeeping Supervisor, stated, Housekeepers do clean mattresses for their deep cleaning sessions which they do one resident room daily for deep cleaning. V11 then stated, I know the CNAs brushed off the mattress yesterday because that was this resident's shower day and I was in the room cleaning the floor. The CNAs had asked me if they could swipe the crumbs on the floor so I could sweep them, but they obviously didn't wipe the mattress, just swiped the crumbs on the floor.
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 observation, interview, and record review, the facility failed to accurately encode residents' minimum data set assessm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately encode residents' minimum data set assessments concerning dental conditions. This failure affects two residents (R16 and R41) out of three reviewed for dental conditions on the sample list of 43.
Findings include:
1. On 10/15/24 at 10:51 AM, R16's upper denture was falling down to her lower lip while speaking. R16 was pushing the denture upwards with her tongue and lower lip repeatedly during a brief conversation, impairing R16's speech pattern. R16 stated, I know they have adhesive but I don't like to use it.
R16's Census Detail dated 10/18/24 documents R16 was admitted to the facility 9/10/24. R16's Comprehensive Minimum Data Set (MDS) dated [DATE] Section L documents R16 has no broken or loosely fitting dentures. This same MDS section documents unable to examine.
2. On 10/16/24 at 09:57 AM, R41's upper denture was falling down to her lower lip while speaking. R41 was repeatedly pushing the upper denture back into place with her tongue and lower lip during a brief conversation. R41 stated, I don't know if they have any adhesive, I never asked but I know my dentures move around a bit. If I decide to try some adhesive it would be nice to know they have it.
R41's Census Detail dated 10/18/24 documents R41 was admitted to the facility 5/6/24. R41's Comprehensive MDS dated [DATE] documents R41 has no broken or loosely fitting dentures. This same MDS documents unable to examine.
On 10/17/24 at 11:26 AM, V12, Minimum Data Set Coordinator (MDSC), stated, Those MDS were completed by (V13, former MDSC), who worked like a consultant and was not here at the facility but was completing the MDS offsite, so the 'unable to examine' was because (V13) was not onsite to do an examination of the residents.
The Minimum Data Set Manual dated October 2024 for Section L documents the person conducting the dental and oral assessment should use a gloved finger and a light source to examine the resident's mouth, lips, gums, palate, and cheek lining. This same manual documents for the person conducting the assessment to inspect a resident's dentures for cracks, chips, and cleanliness, and removal of the dentures is necessary for adequate assessment. This manual documents the code for 'unable to examine' is to be used for uncooperative residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan to include 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 develop a comprehensive care plan to include residents with denture problems. This failure affects two residents (R16 and R41) out of three reviewed for dental problems on the sample list of 43.
Findings include:
1. On 10/15/24 at 10:51 AM, R16's upper denture was falling down to her lower lip while speaking. R16 was pushing the denture upwards with her tongue and lower lip repeatedly during a brief conversation, impairing R16's speech pattern.
R16's Census Detail dated 10/18/24 documents R16 was admitted to the facility 9/10/24. R16's Comprehensive Minimum Data Set (MDS) dated [DATE] Section L documents R16 has no broken or loosely fitting dentures.
R16's Care Plan dated beginning 9/11/24 does not include any focus or problem area about R16's dentures including proper fit or cleaning care.
2. On 10/16/24 at 09:57 AM, R41's upper denture was falling down to her lower lip while speaking. R41 was repeatedly pushing the upper denture back into place with her tongue and lower lip during a brief conversation. R41 stated, I don't know if they have any adhesive, I never asked but I know my dentures move around a bit. If I decide to try some adhesive it would be nice to know they have it.
R41's Census Detail dated 10/18/24 documents R41 was admitted to the facility 5/6/24. R41's Comprehensive MDS dated [DATE] documents R41 has no broken or loosely fitting dentures.
R41's Care Plan dated beginning 5/6/24 does not include any focus or problem area about R41's dentures including proper fit or cleaning care
On 10/17/24 at 11:26 AM, V12, Minimum Data Set Coordinator (MDSC), stated, Those MDS were completed by (V13, former MDSC), who worked like a consultant and was not here at the facility but was completing the MDS offsite, so the 'unable to examine' was because (V13) was not onsite to do an examination of the residents. V12 further stated, I don't know if coding the loosely fitting dentures would trigger a CAA (Care Area Assessment) for a care plan, but I can confirm that the dental CAA is not triggered in Section V.
The Minimum Data Set Manual dated October 2024 for Section L documents, For individualized care planning purposes, consideration should be taken for residents to make sure that they are in possession of their dentures or partials and that they are being utilized properly for meals, snacks, medication pass, and social activities. Additionally, the dentures or partials should be properly cared for with regular cleaning and by assuring that they continue to fit properly throughout the resident's stay.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a recapitulation of stay for one (R58) resident out of one ...
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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 recapitulation of stay for one (R58) resident out of one resident reviewed for discharge in a sample list of 43 residents.
Findings include:
R58's undated Face Sheet documents R58 admitted to facility on 8/20/24 and discharged on 8/30/24.
R58's Minimum Data Set (MDS) dated [DATE] documents R58 as cognitively intact. This same MDS documents R58 as requiring maximum assistance with toileting, bathing, dressing, personal hygiene and transfers.
R58's Physician Order Sheet (POS) dated August 2024 documents medical diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Repeated Falls, Amnesia, Intervertebral Disc Degeneration, Benign Prostatic Hyperplasia, Obstructive Sleep Apnea, Acute Respiratory Failure with Hypoxia and Diabetes Mellitus Type II.
R58's Electronic Medical Record (EMR) does not document a completed recapitulation of stay.
R58's Discharge Plan and Instruction Report dated 8/30/24 documents a section titled 'Recapitulation of Stay' which was blank.
On 10/17/24 at 1:35 PM V1 Administrator stated the facility is unable to provide documentation of R58's recapitulation of stay. V1 stated R58 had a brief stay in the facility for therapy. V1 Administrator stated the facility does not have a policy on completing a resident's recapitulation of stay.
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 interview and record review the facility failed to provide safe and adequate assistance with showers to a dependant res...
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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 safe and adequate assistance with showers to a dependant resident. This failure affected one of one resident (R39) reviewed for Activities of Daily Living on the sample list of 43.
Findings Include:
R39's Medical Diagnoses List dated October 2024 documents R39 is diagnosed with Lumbar Spondylopathies, Spinal Cord Injury of Lumbar Region, Neuromuscular Dysfunction of Bladder, Depression, Left and Right foot Drop, and Neurogenic Bowel.
R39's Minimum Data Set, dated [DATE] documents R39 is cognitively intact. No documentation was entered for R39's showering needs.
R39's Minimum Data Set, dated [DATE] documents R39 requires partial to moderate assistance with showering and lower body dressing. R39 requires substantial or maximum assistance for putting on or taking off footwear. R39 requires supervision or touching assistance for tub or shower transfers.
R39's Care Plan dated 2/29/24 documents R39 has a self-care deficit and requires one person staff assistance for bathing. R39 is also at risk for falls and needs to be observed by staff for unsteady gait and balance.
The undated Shower Schedule documents R39's scheduled shower days are Mondays and Thursdays.
R39's Shower Sheets from 8/12/24 through 10/17/24 document R39 did not receive eight of the twenty scheduled showers she should have received. The dates of the missing showers are 8/15/24, 8/29/24, 9/5/24, 9/9/24, 9/12/24, 9/26/24, 10/14/24, and 10/17/24.
On 10/17/24 at 3:30 PM R39 stated she is supposed to get assistance with showers two times per week on Mondays and Thursdays. R39 stated most of the staff help her without any issues as she cannot reach her legs, feet, back, private areas, and occasionally needs help with washing her hair. R39 stated she is also a fall risk and does not feel safe being in the shower room, in the shower chair alone. R39 stated one particular staff member (V8 Certified Nurses Assistant CNA) does not want to provide the necessary assistance R39 requires for safe showering. V8 will either refuse to assist her with getting washed up or she will leave R39 in the shower room by herself and instruct her to pull the call cord when she is done. R39 stated this makes her feel uncomfortable and unsafe and she is not sure why V8 CNA doesn't want to help her (R39). R39 stated she will refuse showers if V8 is the one that is supposed to give it to her or sometimes V8 CNA won't even offer to give her showers. R39 stated on average she actually gets about one shower per week although she would like to receive the scheduled two showers per week at least.
On 10/18/24 at 11:02 AM V2 Director of Nurses confirmed staff are never to leave residents in the shower room in the shower chair alone. V2 confirmed R39 does require some assistance from staff to shower and is a fall risk, especially on wet tile or when attempting to maneuver the shower chair. V2 confirmed residents are scheduled for two showers per week. V2 confirmed V8 CNA should be assisting R39 with showers with a kind and respectful attitude. V2 confirmed R39's medical record should document all of her scheduled showers were either given or refused.
The undated Bath or Shower Procedure documents the purpose of the procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Staff is to stay with the resident throughout the bath and never leave the resident unattended in the shower. If feasible, the resident may bathe him or herself and staff will assist as needed. Staff are to assist with drying the resident and clothing the resident. Staff are to document procedure in the resident's electronic health record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure resident medical equipment was properly utilized...
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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 resident medical equipment was properly utilized for three (R8, R18, R42) residents out of three residents reviewed for safety in a sample list of 43 residents.
Findings include:
1.) R8's undated Face Sheet documents medical diagnoses as Comminuted Fibula Fracture, Morbid Obesity, Diabetes Mellitus Type II, Chronic Respiratory Failure, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominate side, Obstructive Sleep Apnea, Pulmonary Hypertension, Legal Blindness and Dependence on Supplemental Oxygen.
R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact.
R8's Hospital Discharge Record dated 10/11/24 documents R8 is to utilize 5 Liters of Oxygen per Nasal Cannula continuously.
On 10/15/24 at 11:55 AM R8 was wearing her nasal cannula with her oxygen concentrator set at 5 Liters. R8's Oxygen concentrator was plugged into a pink extension cord laying on top of her bedside dresser.
On 10/16/24 at 1:15 PM R8 was wearing her nasal cannula with her oxygen concentrator set at 5 Liters. R8's Oxygen concentrator was plugged into a pink extension cord laying on top of her bedside dresser.
On 10/15/24 at 11:57 AM R8 stated I have to wear Oxygen all the time. I can't go without it at all. The girls (staff) will plug me in wherever. I had someone bring in my pink extension cord so that I could plug in my phone and my small refrigerator. There are not enough plug ins in this room.
On 10/17/24 at 12:35 PM V14 Maintenance Director stated R8's Oxygen Concentrator should not be plugged into her extension cord. V14 Maintenance Director removed R8's Oxygen Concentrator plug from the extension cord and plugged it directly into a wall outlet.
2.) R18's undated Face Sheet documents medical diagnoses as Chronic Congestive Heart Failure, Interstitial Pulmonary Disease, Protein-Calorie Malnutrition, Lymphedema, Iron Deficiency Anemia, Peripheral Vascular Disease, Epilepsy, Edema, Borderline Intellectual Functioning, Cellulitis of Right and Left Lower Limbs, Kyphosis, Ileostomy status and Chondromalacia Patella.
R18's Minimum Data Set (MDS) dated [DATE] documents R18 as cognitively intact.
On 10/15/24 at 10:18 AM R18's bed was plugged into a power strip nailed to the wall next to R18's bed.
On 10/16/24 at 12:15 PM R18's bed was plugged into a power strip nailed to the wall next to R18's bed.
On 10/16/24 at 12:18 PM R18 stated I don't have enough wall plug ins for everything so I have to plug things into the extension cord (pointing to the extension cord nailed to the wall).
3) On 10/15/24 at 2:01 PM, R42's electric bed was plugged into an extension cord power strip, along with a personal unit refrigerator.
On 10/17/24 at 12:30 PM V14 Maintenance Director stated all of the resident beds and all medical equipment should be plugged directly into the wall outlets. V14 stated There is too much electrical draw on the extension cords for the beds and medical equipment to be plugged into those. It could be a fire hazard. I do building rounds monthly and have had to move electrical cords before. I tell the staff not to do that but they (staff) do it anyway.
On 10/17/24 at 2:15 PM V1 Administrator stated the facility does not have a policy that states medical equipment should not be plugged into extension cords. V1 stated the expectation for staff is to plug all resident beds and medical equipment into the wall outlet for safety.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain physician responses from pharmacist recommendations in a timely manner, and failed to develop their pharmacist policy to include tim...
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Based on interview and record review, the facility failed to obtain physician responses from pharmacist recommendations in a timely manner, and failed to develop their pharmacist policy to include timeframes for the steps in the monthly medication regimen reviews. This failure affects two residents (R16 and R44) out of five reviewed for unnecessary medications on the sample list of 43.
Findings include:
1. R16's Census Detail dated 10/18/24 documents R16 was admitted to the facility 9/10/24.
R16's Hospital Discharge Orders dated 9/10/24 document R16 had a physician ordered prescription for Semaglutide (Rybelsus) (Antidiabetic) 7 milligrams daily.
R16's current Physician Order Sheet dated 10/17/24 documents R16's medication Rybelsus did not start until 9/24/24.
R16's Consultant Pharmacist (V20) Recommendation dated 9/14/24 documents a notation R16 had a physician order for the medication Rybelsus on R16's hospital discharge record which was not present in the R16's electronic medical record. V20 documented to clarify this with the physician and update the electronic medical record for R16. This same recommendation was not signed by the primary physician until 9/23/24.
On 10/17/24 at 12:00 PM, V2, Director of Nursing, stated, The admitting nurse put a checkmark beside that medication on the hospital discharge orders, she must have not known what it is because it doesn't populate in the electronic medical record. She must have put the question mark there and was going to come back to it and just forgot. In anyway, the medication got missed. V2 further stated, We do have a process that a second nurse is supposed to review the admission orders for each resident so things don't get missed.
2. R44's Consultant Pharmacist Recommendations to Nursing dated 4/10/24, V21, Consultant Pharmacist documents R44 has an order for Lorazepam PRN (as needed) without a stop date, according to regulations PRN medications can only be used for 14 days without a physician documenting a rationale for continued use. This recommendation form has checkboxes for a physician response to: 1) discontinue the medication; 2) continue use of the medication for (specify) number of days as the benefits outweigh the risks; and a space for the physician to document a rationale for continued use past the 14 days. This same form documents hospice patients are not excluded from this requirement.
R44's electronic medical record contained identical Pharmacist Consultant Recommendations dated 6/12/24, and 8/12/24. None of the three recommendations had a signature, a selected option, nor rationale from a physician.
On 10/18/24 at 10:20 AM, V2, Director of Nursing, stated , (R44) is receiving hospice services so it is just a main standard for hospice, but I don't find any response from the doctor about it. V2 then stated, Usually the way these are supposed to work is the pharmacist sends us the recommendations, then I send them to the physicians.
The facility policy Consultant Pharmacist Service Provider Requirements dated 1/18/24 does not include any timeframe for the pharmacy medication regimen review process for the facility to obtain a response from the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
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 honor one (R260) residents food preferences out of nine...
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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 honor one (R260) residents food preferences out of nine residents reviewed for meal service in a sample list of 43 residents.
Findings include:
R260's undated Face Sheet documents medical diagnoses as Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Orthostatic Hypotension, Dementia, Vitamin D Deficiency, Anemia and Chronic Kidney Disease Stage 3. This same Face Sheet documents R260 admitted to the facility on [DATE].
R260's Minimum Data Set (MDS) dated [DATE] documents R260 as moderately cognitively impaired.
R260's Electronic Medical Record (EMR) does not include a food preferences interview.
R260's Nutritional careplan was initiated 10/15/2024. R260's Careplan did not include a nutritional focus area, goal nor interventions prior to 10/15/24. R260's careplan intervention dated 10/8/24 documents R260 is of Hindu faith.
On 10/15/24 at 12:45 PM R260 was served a Polish sausage, macaroni salad, spinach, chocolate chip cake with a glass of water and a glass of tea for the lunch meal.
On 10/15/24 at 1:45 PM R260 stated no staff offered him any alternatives for lunch.
On 10/16/24 at 1:02 PM R260 stated he has no medical restrictions on his diet and that he does not eat pork due to his religion. R260 stated I just don't eat it if they bring it. I don't ask for anything else.
On 10/16/24 at 3:00 PM V9 Dietary Manager stated all residents should be interviewed to determine their preferences and for any foods that they might not wish to eat based on their religion. V9 stated I have only been here a couple of months and am trying to get everything in order. I had already found that there are problems with these things. There is no list of resident preferences for anyone over the last several months. I am planning on talking to all the residents that admit to the facility and also those that have been here a few months to update their diet slips. Residents should be able to be served foods that they like and they should not be served foods that go against their religion.
The facility policy titled Food and Nutrition Services Dining Services dated 9/1/2021 documents the food preference interview will be entered into the medical record. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, allergies and intolerances, and preferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
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 resident meals consistent with a resident's all...
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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 resident meals consistent with a resident's allergies for one of nine residents (R6) reviewed for meal service in a sample list of 43 residents.
Findings include:
R6's undated Face Sheet documents medical diagnoses as Diabetes Mellitus Type II, Morbid Obesity, Gastroesophageal Reflux Disease (GERD), Spinal Stenosis, Dizziness and Giddiness, Mild Intellectual Abilities, Fusion of Spine, Major Depressive Disorder, Borderline Personality Disorder and Post Traumatic Stress Disorder (PTSD). This same Face Sheet documents R6's allergies as Bupropion, Regadenoson, Tetracycline, Valproic Acid, Buspar, Penicillin and Onion.
R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact.
R6's Physician Order Sheet (POS) dated October 2024 documents a physician diet order for Consistent Carbohydrate (CCHO) diet, regular texture and thin/regular consistency.
R6's undated diet ticket documents R6 is allergic to onions.
R6's Care Plan intervention dated 9/9/2024 documents to provide R6's diet as ordered by Physician.
On 10/15/24 at 12:23 PM R6 was sitting at a dining room table with lunch meal of polish sausage, macaroni salad with pieces of onion, spinach with pieces of onions and chocolate chip cake sitting on table in front of R6. R6's diet slip documents No Brussels sprouts, cabbage, chowder soup and salt. Allergies: Onion. R6 didn't eat the macaroni salad and spinach.
On 10/15/24 at 12:30 PM R6 stated If I eat onions I will go to the hospital. Onions make me throw up and get very sick.
On 10/16/24 at 3:10 PM V9 Dietary Manager stated R6's diet ticket documents R6 is allergic to onions and should not have been served any onions. V9 Dietary Manager stated I am glad to see that (R6) did not eat them or she could have gotten very sick. (R6) had a history of being force fed onions as a child so I think that is why it is listed as an allergy but either way she should not have been served any onions.
The facility policy titled Food and Nutrition Services Dining Services dated 9/1/2021 documents the food preference interview will be entered into the medical record. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, allergies and intolerances, and preferences.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
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 provide foods that were palatable and at appropriate te...
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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 foods that were palatable and at appropriate temperatures, and failed to provide a meal for a resident for five of nine residents (R8, R20, R30, R53, R163) reviewed for dining in a sample list of 43 residents.
Findings include:
The facility Resident Council Minutes for the Month of July, 2024 document resident concerns of the food being served cold.
The facility Resident Council Minutes for the Month of August, 2024 document resident concerns of the ''food temperatures not being warm enough and food sometimes comes out burned.
The facility Resident Council Minutes for the Month of September, 2024 document resident concerns that the facility needs to update diet tickets two times a year with likes and dislikes. The facility Resident Council Feedback form dated 9/20/2024 documents Department Response: Tickets will be updated with likes and dislikes twice yearly.
1.) R163's undated Face Sheet documents medical diagnoses as Heart Failure, Pulmonary Edema, End Stage Renal Disease, Chronic Respiratory Failure, Toxic Encephalopathy and Weakness.
R163's admission assessment dated [DATE] documents R163 as cognitively intact.
R163's Physician Order Sheet (POS) dated October 2024 documents a physician diet order of Regular diet, Regular texture, Thin/Regular consistency with Renal precautions.
R163's Care Plan goal dated 10/15/2024 documents R163 receives Hemodialysis due to end stage renal failure.
On 10/15/24 at 12:55 PM the cart carrying the meal trays for 300 hall where R163 resides was delivered to 300 hall. This same cart was not plugged in and was not warm.
On 10/15/24 at 1:10 PM R163 was served his lunch meal in his room. R163's lunch plate was delivered without the cover.
On 10/15/24 at 1:20 PM V9 Dietary Manager obtained temperatures of R163's lunch meal items. R163's macaroni salad had a temperature of 45.2 degrees Fahrenheit (F), Spinach 105.5, pork chop with pork gravy 78.6. F.
On 10/15/24 at 1:15 PM R163 stated I haven't had a warm meal yet. Every single meal is served cold. They (staff) try to warn it up but by the time my food comes back to me it's cold again. I have to order out (pointing at fast food bag on dresser). I am only here to get therapy and then can go home again. Yesterday I had (Renal) Dialysis at 11:30 AM. I was in the chair for four and a half hours and then the drive back here to the facility. I didn't get back until about 5:00 PM. They (facility) didn't give me anything to eat or send any food with me. I was completely worn out by the time I got back. Why can't they (facility) just serve the meals warm and not forget to feed people their meals?
On 10/15/24 at 1:25 PM V9 stated R163 is on a renal diet. V9 stated R163's lunch meal items of spinach and pork chop with gravy were not at a safe temperature. V9 stated R163's food temperatures should have been hotter. V9 stated R163's macaroni salad temperature was too warm. V9 stated the facility does not have warmer plates or carts to serve the resident's food on. V9 stated I know this has been a problem and I have asked for more equipment to be able to serve the resident's warm meals but I only have what I have. We (facility) do the best with what we have. Unfortunately we (facility) just do not have the equipment we need. V9 Dietary Manager stated (R163) did not receive a lunch meal on 10/14/24 and should have. (R163) was served a grilled cheese sandwich when he returned but that was at the same time as supper so in reality he really did miss an entire meal.
2) R53's undated Face Sheet documents medical diagnoses as Severe Protein-Calorie Malnutrition, Nonalcoholic Steatohepatitis, Cirrhosis of Liver, Ischemic Cardiomyopathy, Myocardial Infarction and Chronic Kidney Disease.
R53's Physician Order Sheet (POS) dated October 2024 documents a physician diet order of NAS (No Added Salt) diet, Regular texture, Thin/Regular consistency, Heart Healthy for 2000 milligram (mg) sodium restriction, low fat, low cholesterol diet.
R53's Minimum Data Set (MDS) dated [DATE] documents R53 as cognitively intact.
On 10/15/24 at 1:00 PM R53 was served a polish sausage, spinach, macaroni salad and a full piece of chocolate chip cake. R53 ate 25% of her meal.
On 10/15/24 at 11:40 AM R53 stated The riblets they (facility) served for supper last night (10/14/24) were hard as a brick. I couldn't eat them. I like ribs too. I would have enjoyed even having the fake ribs. It was a real disappointment. Lots of times they (facility) run out of the main meal so they serve us whatever they have in the store room. One time, I was supposed to get the ham and potatoes and they gave me a cold bologna sandwich instead. I am supposed to watch what I eat because of my heart. I am pretty sure bologna is not heart healthy.
3.) R8's undated Face Sheet documents medical diagnoses as Comminuted Fibula Fracture, Morbid Obesity, Diabetes Mellitus Type II, Chronic Respiratory Failure, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominate side, Obstructive Sleep Apnea, Pulmonary Hypertension, Legal Blindness and Dependence on Supplemental Oxygen.
R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact.
On 10/16/24 at 1:00 PM R8 was sitting at her dining room table. R8 had eaten less than 10% of her meal.
On 10/16/24 at 1:15 PM R8 was sitting at the dining room table. R8 had eaten less than 10 % of her meal.
On 10/15/24 at 1:40 PM R8 stated The food is inedible. The ribs they (facility) served last night (10/14/24) were so tough you couldn't even stab a fork in them. They were awful. Many of the meals are so over cooked you can't eat them. The food is cold and awful.
On 10/16/24 at 1:18 PM R8 stated Today's lunch was polish sausage, spinach and macaroni salad. The sausage was greasy and cold, the spinach was cold and the macaroni salad didn't have any flavor. I told them (staff) about it and they brought me a pudding cup. That is not a meal. They (facility) really need to work on their food.
4.) R30's undated Face Sheet documents medical diagnoses as Nondisplaced Fracture of Right Femur, Diabetes Mellitus Type II, Morbid Obesity, Myelodysplastic Syndrome, Chronic Pulmonary Edema, Cardiomyopathy, Pulmonary Hypertension, Benign Paroxysmal Vertigo, Vitamin D Deficiency and Carpal Tunnel Syndrome.
R30's Minimum Data Set (MDS) dated [DATE] documents R30 as cognitively intact.
R30's Physician Order Sheet (POS) dated October 2024 documents a physician ordered diet of Consistent Carbohydrate diet, Regular texture, Thin/Regular consistency
On 10/15/24 at 10:10 AM R30 stated I go to the meeting for residents and complain there too because I am sure I am not the only one who can't eat the food. But what if someone doesn't like the food and just can't speak up for themselves. I feel like I should do that. I have to order out because the food is like dog food. It is never hot. The riblets last night were horrible. I couldn't even cut through them they were so overcooked. They were harder than jerky.
5. On 10/1520/24 at 2:04PM, R20 reported eating all meals in R20's room and reported the facility meals are always cold.
On 10/17/2024 at 12:01PM, dietary staff were assembling resident meals in the facility kitchen on ceramic plates. The plates were stored at room temperature beside the service line and were not held inside of any warming device.
On 10/17/2024 at 12:30PM, a transportation/warming cart containing resident meal trays was located in the 100 hallway. The cart was not plugged into an electrical receptacle and the interior of the cart was room temperature.
Oct 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from sexual abuse by another resident. T...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from sexual abuse by another resident. This failure affects two residents (R1, R2) reviewed for sexual abuse on the sample list of 26.
Findings include:
On 9/25/24 at 1:45 PM, V7 Licensed Practical Nurse, stated, I walked into R1's room and saw R1 with his privates (genitals) exposed and R2 was playing with R1's privates (genitals) with her hand. V7 then stated, I did not do anything about it because everyone tells me they are consensual. V7 concluded by stating, I think both R1 and R2 can form consent, they always sit at the table together and I hear them talking to each other asking if the other wants to come to their room.
R2's Diagnoses List dated 9/25/24 documents R2's medical diagnoses includes Dementia. There were no facility assessments or referenced ability or inability for R2 to consent to sexual relationships documented in R2's medical record. R2's Minimum Data Set (MDS) dated [DATE] documents R2 scored a 2 out of a possible 15 during a Brief Interview for Mental Status, rating R2 as severely cognitively impaired.
R1's Diagnoses List dated 9/25/24 documents R1's medical diagnoses includes Dementia. There were no facility assessments or referenced ability or inability for R1 to consent to sexual relationships documented in R1's medical record. R1's MDS dated [DATE] documents R1 received a score of 7 out of 15 during a BIMS, rating R1 as severely cognitively impaired.
On 9/25/24 at 1:15 PM, V3 Certified Nursing Assistant (CNA), stated she had direct knowledge of R1 and R2 kissing. On 9/25/24 at 1:25 PM, V5, CNA, stated she had seen R1 and R2 hold hands, and R1 hug R2 around the neck. V5 further stated that another resident reported to V5 seeing R1 in R2's room rubbing on R2's private area (genitals) with her hand. V5 stated she did not think R2 had the capacity to consent to sexual activity.
On 9/25/24 at 1:35 PM, V6 CNA, stated she did not think either R1 or R2 had the mental capacity to form consent to sexual activity.
On 9/25/24 at 2:55 PM, V2 Director of Nursing, stated, I do know (R1) and (R2) are friendly, I know they used to be at another nursing home at the same time so they have known each other from back before here, I know they sit together at the same table in the dining room, and (R2) stops by (R1's) room to ask if he is going to the dining room. V2 then stated, I do think they both are able to consent to a sexual relationship. V2 concluded by stating, As far as I know there hasn't been any formal documented evaluation of either one of them for a capacity to consent.
On 9/25/24 at 3:40 PM, V13 Social Services Director, I have not ever evaluated either of the two of them for the ability to consent to a sexual relationship.
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
Based on interview and record review, the facility failed to develop residents care plans to include an intimate relationship and the need for privacy. This failure affects two residents (R1, R2) out ...
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Based on interview and record review, the facility failed to develop residents care plans to include an intimate relationship and the need for privacy. This failure affects two residents (R1, R2) out of 5 reviewed for care plans on the sample list of 26.
Findings include:
On 9/25/24 at 1:45 PM, V7, Licensed Practical Nurse, stated, I walked into R1's room and saw R1 with his privates (genitals) exposed and R2 was playing with R1's privates (genitals) with her hand. V7 then stated, I did not do anything about it because everyone tells me they are consensual. V7 concluded by stating, I think both R1 and R2 can form consent, they always sit at the table together and I hear them talking to each other asking if the other wants to come to their room.
On 9/25/24 at 1:25 PM, V5, CNA, stated, I have seen R1 and R2 hold hands, and R1 hug R2 around the neck. V5 further stated, Another resident reported to me seeing R1 in R2's room rubbing on R2's private area (genitals) with her hand.
The facility policy (undated) on Intimate Resident Behavior, Privacy, and Relationships documents the facility encourages residents to appropriately pull privacy curtains and close doors when engaging in behavior of a sexual nature. This same policy documents, The resident's care plan should document issues or concerns related to intimacy and sexual expression.
As of 9/25/24 at 2:50 PM, neither R1's nor R2's care plan had an intimate sexual relationship and the need for privacy documented on their individual plans of care.
On 9/25/24 at 2:55 PM, V2, Director of Nursing, stated, I can get a care plan fixed for (R1 and R2) about them being in a sexual relationship.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document evaluations to determine cognitively impaired residents' c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document evaluations to determine cognitively impaired residents' capacity to consent to a known sexual relationship, failed to develop their policy on intimate resident behavior to include the criteria for initial evaluation and frequency with which a cognitively impaired resident's capacity to consent to an intimate relationship is to be evaluated, and to specify where and how the evaluations and determinations would be documented and maintained. This failure affects two (R1, R2) residents and has the potential to affect 22 additional cognitively impaired residents (R5 through R26) on the sample list of 26 reviewed for cognitive capacity.
Findings include:
The facility policy (undated) on Intimate Resident Behavior, Privacy, and Relationships, documents the facility may utilize, as appropriate, a mental health practitioner, psychiatrist, clinical social worker, or psychologist, or primary care physician to help in the evaluation and determination of an individual's ability to provide informed consent.
R2's Diagnoses List dated 9/25/24 documents R2's medical diagnoses includes Dementia. R2's Minimum Data Set (MDS) dated [DATE] documents R2 scored a 2 out of a possible 15 during a Brief Interview for Mental Status, rating R2 as severely cognitively impaired.
R1's Diagnoses List dated 9/25/24 documents R1's medical diagnoses includes Dementia. R1's MDS dated [DATE] documents R1 received a score of 7 out of 15 during a BIMS, rating R1 as severely cognitively impaired.
On 9/25/24 at 1:15 PM, V3, Certified Nursing Assistant (CNA), stated she had direct knowledge of R1 and R2 kissing. On 9/25/24 at 1:25 PM, V5, CNA, stated she had seen R1 and R2 hold hands, and R1 hug R2 around the neck. V5 further stated that another resident reported to V5 seeing R1 in R2's room rubbing on R2's private area (genitals) with her hand. V5 stated she did not think R2 had the capacity to consent to sexual activity. On 9/25/24 at 1:35 PM, V6 CNA, stated she did not think either R1 nor R2 had the mental capacity to form consent to sexual activity.
On 9/25/24 at 1:45 PM, V7, Licensed Practical Nurse, stated, I walked into R1's room and saw R1 with his privates (genitals) exposed and R2 was playing with R1's privates (genitals) with her hand. V7 then stated, I did not do anything about it because everyone tells me they are consensual. V7 concluded by stating, I think both R1 and R2 can form consent, they always sit at the table together and I hear them talking to each other asking if the other wants to come to their room.
On 9/25/24 at 2:33 PM, V11, Friend/ Power of Attorney (POA) for R2, stated, I am aware of the situation with (R2) in (R1's) room and playing with (R1's) privates (genitals). I absolutely think she (R1) is aware of what she is doing and I think she has the mental thoughts to be able to do that kind of thing and I don't think that is out of line. On 9/25/24 at 2:47 PM, V12, sister/ POA for (R1), stated, Well (R1) was capable of making that kind of decision (whether to engage in an intimate relationship) before he went into the nursing home so I would say he still is capable of making that kind of decision now.
On 9/25/24 at 2:55 PM, V2, Director of Nursing, stated, I do know (R1) and (R2) are friendly, I know they used to be at another nursing home at the same time so they have known each other from back before here, I know they sit together at the same table in the dining room, and (R2) stops by (R1's) room to ask if he is going to the dining room. V2 then stated, I do think they both are able to consent to a sexual relationship. V2 concluded by stating, As far as I know there hasn't been any formal documented evaluation of either one of them for a capacity to consent.
On 9/25/24 at 3:40 PM, V13, Social Services Director, I have not ever evaluated either of the two of them for the ability to consent to a sexual relationship.
On 9/25/24 at 3:40 PM, V14, Regional Director of Operations, stated, There should have been some documentation of both resident's capacity to consent to sexual activity. Going forward, we will make it as right as we can. On 9/27/24 at 10:27 AM, V14 stated, Absolutely (we should have been able to put all of the documentation of the evaluations of R1 and R2's capacity to consent to a sexual relationship in your hand when you came in to do this survey).
The facility policy (undated) on Intimate Resident Behavior, Privacy, and Relationships did not include where and how the results of an evaluation of a resident's capacity to consent to a sexual relationship are to be maintained, nor was there a time interval for the evaluations to be conducted.
On 9/27/24 at 2:20 PM, V14, Regional Director of Operations, stated, I don't see that our policy specifies where we would document or maintain the evaluations (of a resident's capacity to consent to an intimate relationship) but going forward we would scan them into the resident's chart. V14 further stated, We would do the evaluations quarterly, we need to set up the form in the PCC (electronic medical record format).
On 9/27/24 at 2:20 PM, V17, Regional Director, stated, For now we would just have to scan the evaluations into the medical record. V17 then stated, All I see as far as frequency is as appropriate which isn't very specific. The portion of the policy which V17 referred to documents The facility will record assessment findings in appropriate documentation. There is no mention of the frequency of the assessments or evaluations.
Additional residents potentially affected include:
R5's MDS dated [DATE] documents R5 received a score of 3 out of 15 during a BIMS, indicating severe cognitive impairment.
R6's MDS dated [DATE] documents R6 received a BIMS score of 10 out of 15, rating R6 as moderately cognitively impaired.
R7's MDS dated [DATE] documents R7 received a BIMS score of 2 out of 15 during a BIMS, rating R7 as severely cognitively impaired.
R8's MDS dated [DATE] documents R8 received a BIMS score of 11, indicating moderate cognitive impairment.
R9's MDS dated [DATE] documents R9 received a BIMS score of 4 out of 15, indicating severe cognitive impairment.
R10's MDS dated [DATE] documents R10 received a score of 3 out of 15 during a BIMS, rating R10 as severely cognitively impaired.
R11's MDS dated [DATE] documents R11 received a score of 6 out of a possible 15 during a BIMS, rating R11 as severely cognitively impaired.
R12's MDS dated [DATE] documents R12 could not complete a BIMS interview and was assessed by staff to be severely cognitively impaired.
R13's MDS dated [DATE] documents R13 received a score of 11 out of 15 during a BIMS, rating R13 as moderately cognitively impaired.
R14's MDS dated [DATE] documents R14 received a score of 11 out of 15 during a BIMS, rating R14 as moderately cognitively impaired.
R15's MDS dated [DATE] documents R15 received a score of 11 out of a possible 15 during a BIMS, rating R15 as moderately cognitively impaired.
R16's MDS dated [DATE] documents R16 could not complete a BIMS interview and was rated by staff to be severely cognitively impaired.
R17's MDS dated [DATE] documents R17 received a BIMS score of 3 out of 15, rating R17 as severely cognitively impaired.
R18's MDS dated [DATE] documents R18 received a score of 7 out of 15 during a BIMS, rating R18 as severely cognitively impaired.
R19's MDS dated [DATE] documents R19 received a score of 9 out of 15 during a BIMS, rating R19 as moderately cognitively impaired.
R20's MDS dated [DATE] documents R20 received a BIMS score of 7 out of 15, rating R20 as severely cognitively impaired.
R21's MDS dated [DATE] documents R21 received a BIMS score of 6 out of 15, rating R21 as severely cognitively impaired.
R22's MDS dated [DATE] documents R22 received a score of 3 out of 15 during a BIMS, rating R22 as severely cognitively impaired.
R23's MDS dated [DATE] documents R23 received a score of 7 out of 15 during a BIMS, rating R23 as severely cognitively impaired.
R24's MDS dated [DATE] documents R24 received a score of 9 out of 15 during a BIMS, rating R24 as moderately cognitively impaired.
R25's MDS dated [DATE] documents R25 received a score of 10 out of 15 during a BIMS, rating R25 as moderately cognitively impaired.
R26's MDS dated [DATE] documents R26 received a score of 7 out of a possible 15 during a BIMS, rating R26 as severely cognitively impaired.
Feb 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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide denture care assistance for two (R1 and R3) of ...
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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 denture care assistance for two (R1 and R3) of three residents reviewed for activities of daily living from a total sample list of seven residents reviewed.
Findings include:
The undated facility policy documents that denture care is to be provided before breakfast and at bedtime. The resident is to be encouraged and assisted as needed. As denture care is provided, examination of the resident's mouth and gums for paleness, mouth sores, bleeding or areas of discoloration should be done. Encourage the resident to perform as much of the procedure as possible.
1.) R1's admission assessment dated [DATE] documents that R1 admitted to the facility with upper and lower dentures.
R1's updated care plan does not document denture care.
On 2/26/24 at 8:50AM, V4 Certified Nursing Assistant (CNA) stated that morning cares consist of washing (the residents) up, making sure they have their call lights, brushing their teeth, cleaning their dentures, and brushing their hair and if they can do it on their own, we still take a look and to make sure that it was done.
On 2/26/24 at 8:45AM, R1 was sitting in his room in a wheel chair eating his breakfast while wearing dentures. A denture cup was sitting on his bedside table.
On 2/26/24 at 9:30AM, R1 stated, They don't clean my dentures here. I usually leave them in all the time. When I was at the hospital, they told me that I have to take them out and clean them once in awhile. They cleaned them when I was in the hospital and they haven't been cleaned since.
On 2/26/24 at 8:55AM, V5 CNA stated that she usually works on the 200 hall and that she didn't help R1 with his dentures today because he doesn't have dentures.
On 2/26/24 at 8:56AM, V4 stated that she usually works the 200 hall and that she has never reminded R1 to clean his dentures because he doesn't have dentures.
On 2/26/24 at 8:57AM, V6 Licensed Practical Nurse stated that she was R1's nurse and that she was not aware that R1 had dentures.
On 2/26/24 at 9:04AM, V3 Assistant Director of Nursing stated that she expected oral and denture care to be done daily and as needed but that she did not think that R1 had dentures. I think that he is just edentulous.
On 2/26/24 at 9:15AM, V3 Assistant Director Of Nursing confirmed that R1 has a full set of dentures in his mouth with one front denture tooth missing and that she took them out and rinsed them off once moments ago, when she found out that he had dentures.
2.) On 2/26/24 at 11:42AM, R3 stated that he has been edentulous since 2013, and has had the same pair of dentures since 2013. R3 stated that they fit well and that he primarily wears them when he leaves the facility to go out into public.
On 2/26/24 at 1:15PM, R3's dentures were soaking in a denture cup in his room. The water had mold floating on/in the water.
R3' medical record does not document R3 having dentures.
On 2/26/24 at 3:15PM, V2 Interim Director of Nursing stated, It is basic CNA care to be looking at those (dentures) and the water that they are in at least daily. We will correct this.
On 2/26/24 at 4:00PM, V11 Director of Nursing 4:00PM stated, Even if a resident is independent, we are still responsible for making sure that they are being taken care of including having their denture care completed.
Jan 2024
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a safe, sanitary, and comfortable environment...
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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 a safe, sanitary, and comfortable environment by failing to prevent ongoing water leakage through the roof and mold-like growth in the shower rooms and on ceiling tiles. This failure has the potential to affect all 62 residents residing in the facility.
Findings Include:
On [DATE] at 9:35 AM there was black mold-like substance on the East Hall shower room ceiling vent grate. There was also black and orange mold-like substance on the shower stalls wall and floor. The caulk was peeling off and the black mold like substance was growing underneath.
On [DATE] at 9:40 AM one 2'x2' ceiling tile in front of room [ROOM NUMBER] and 106 was missing and the tile next to that spot appeared to have been saturate with water at one point, was bulging downward towards the floor and was discolored and brown.
On [DATE] at 9:46 AM two 2'x2' ceiling tiles in front of room [ROOM NUMBER] and 108 were missing and four ceiling tiles around that spot had brown water-like spots on them.
On [DATE] at 9:54 AM two 2'x2' ceiling tiles in front of room [ROOM NUMBER] were completely missing.
On [DATE] at 9:57 AM there was black mold-like substance on both of the [NAME] Hall shower room ceiling vent grates. There was also black and orange mold-like substance on the shower stalls wall and floor. The caulk was peeling off and the black mold like substance was growing underneath.
On [DATE] at 10:01 AM one 2'x2' ceiling tile was missing by the [NAME] Hall nurses station.
On [DATE] at 10:03 AM one 2'x2' ceiling tile was missing in front of room [ROOM NUMBER] and 213 and the surrounding tiles had brown water-like spots on them.
On [DATE] at 10:06 AM one 2'x2' ceiling tiles at the end of the [NAME] Hall by the exit door had brown water-like spots on them and one corner had black and pink mold-like substance growing on it.
The facility Resident Council Minutes for the month of [DATE] document resident complaints of the roof leaking and needs fixed.
On [DATE] at 10:10 AM both R2 and R3 stated the roof had been leaking in the facility for a couple months. Both R2 and R3 stated they think V7 Maintenance was trying to patch it but it was not working and only getting worse. Both R2 and R3 stated they had used their own trash can once the week before when it was leaking to help catch the water so it didn't get all over the floor and create a hazard. Both R2 and R3 stated they had seen mold-like substances growing in the shower rooms. Both R2 and R3 agreed that these issues needed to be addressed in a more thorough fashion.
On [DATE] at 8:05 AM V3 Licensed Practical Nurse stated the roof has been leaking for a couple of months but has gotten worse. V3 stated the leaking is happening down the East and [NAME] Hallways and is not getting fixed properly. V3 stated staff put out buckets to catch the water when it leaks.
On [DATE] at 8:15 AM V4 [NAME] stated the roof has been leaking for a few months. V4 stated the maintenance department tries to repair it but it is not working and they need a professional roofing company.
On [DATE] at 8:30 AM V5 Licensed Practical Nurse stated the roof is leaking but she does not know for how long. R5 stated the staff set out buckets to catch the water.
On [DATE] at 8:47 AM V6 Certified Nurses Assistant stated the roof has been leaking for a couple of months but has gotten worse. Staff put out buckets to catch the water.
On [DATE] at 9:30 AM V8 Housekeeper stated the roof has been leaking for a few months on East and [NAME] halls. V8 confirmed she has seen a mold-like substance in the [NAME] Hall shower room stall and has tried to clean it but it does not get rid of it for good.
On [DATE] at 9:43 AM V9 Activities Assistant stated the roof has been leaking and staff use trash cans to catch the water.
On [DATE] at 10:01 AM V10 Licensed Practical Nurse and V11 Certified Nurses Assistant stated the roof has been leaking pretty badly down [NAME] Hall and on East Hall. Staff use buckets to catch water and try to prevent water hazards.
On [DATE] at 8:50 AM V1 Administrator confirmed the roof has been leaking. V1 was not sure about a time frame but felt a couple months sounded accurate. V1 stated the roof leaks down the East and [NAME] Halls. V1 Administrator confirmed the facility census was 62.
On [DATE] at 8:58 AM V7 Maintenance Director stated the roof has been leaking for about a year. V7 stated it has gotten worse in the last few months. V7 stated he has patched it several times however it is not working. V7 confirmed the leaking occurs down the East and [NAME] hallways and is a steady drip when it is raining. V7 confirmed the removed ceiling tiles in the building are areas where water has been leaking through. V7 confirmed some tiles have water spots from getting wet. V7 confirmed the shower room stalls need to be cleaned more thoroughly and currently have a black and orange mold-like substance growing on them. V7 confirmed the shower room vent grates also have a black mold-like substance on them. V7 stated the facility does have a plan to have a roofing company come and do professional repairs but is not sure when that will be exactly.
On [DATE] at 10:57 AM V12 Corporate Maintenance Director stated the facility has been struggling with it's roof leaking for quite some time and the issues is ongoing. V12 confirmed the issues has gotten worse as of recently with all of the rain and snow. V12 stated the facility just had a professional roofing company come out to do an estimate for repairs or replacement. V12 stated the plan is to get the roof repaired or replaced by this Spring. V12 stated the facility's housekeepers have the right products to properly clean the showers and if done correctly the facility should not have any mold-like substances growing in the shower stalls. V12 confirmed he would be talking with facility maintenance and housekeeping in order to get the items cleaned or replaced if needed. V12 confirmed the staff should have remedied these issues.
Dec 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide individualized fall interventions and provide...
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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 individualized fall interventions and provide safe access for communication/response to resident's requests for care. This failure affects one resident (R5) of five residents reviewed for fall interventions in the sample of five.
Findings include:
The facility's Fall Prevention Program/Protocol dated Revised 2/1/23, documents based on previous evaluations and current data, staff will identify interventions related to resident's specific risks to prevent resident from falling; new admissions will be reviewed for fall history and interventions put in place prior to admission to the facility; and rounds will be completed at least daily to ensure fall intervention remain in place.
R5's Nursing Progress Notes dated 11/15/23 at 7:20 PM, documents R5 arrived to the facility by ambulance from the hospital, oriented to self only, resident up walking in halls, gait unsteady. This same progress note documents significant physical therapist findings for R5 which include: weakness, decreased endurance, decreased strength, decreased cognition, impaired balance and impaired gait that leads to impaired ability to perform functional transfers and ambulation.
R5's undated Face Sheet documents R5's diagnoses as: Metabolic Encephalopathy, Alcoholic Cirrhosis of Liver with Ascites, Unspecified Dementia, unspecified severity, without Behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, [NAME] Matter Disease, unspecified, Fracture of one rib, left side, subsequent encounter for fracture with routine healing, Emphysema, unspecified, Moderate protein-calorie Malnutrition, Pulmonary Fibrosis, unspecified.
R5's Minimum Data Set (MDS) dated [DATE], documents R5 is not cognitively intact with inattention and disorganized thinking.
R5's Post Acute Care Transition Document dated 11/15/23, documents Lovenox (anticoagulant injections) through 11/15/23 and R5 needs Fall Precautions at the Skilled Nursing Facility.
R5's Care Plan dated 11/29/23, documents R5 has impaired cognitive function/dementia related to Dementia and impaired decision making. This same care plan documents R5 is at risk for falls related to cognitive impairment, dementia, unsteady gait, pain, weakness, history of falls prior to admission.
On 11/29/23 at 11:35 AM, R5 lying in bed. When asked R5 question R5 would say okay and then repeated the question, being unable to communicate relevant responses. Call light at the end of R5's bed hanging towards the floor, not within R5's reach. No other fall interventions observed in R5's room. On 11/29/23 at 1:05 PM, R5 lying in bed, R5's call light, appears in the same place as when observed at 11:35 AM, not within R5's reach. On 11/29/23 at 2:49 PM, R5 lying in bed, R5's call light, appears in the same place as when observed at 11:35 AM. R5 lying in bed, call light not within R5's reach. On 11/29/23 at 11:35 AM, 1:05 PM, and 2:49 PM, R5's room was observed having one bed, one bedside table, one chair, and a walker in R5's room. No other devices, accessories, or appliances observed in R5's room. At these same times, R5's call light was at the end of R5's bed hanging towards the floor, not within R5's reach.
On 11/29/23 at 1:53 PM, V7 Registered Nurse (RN) stated there are no fall interventions in place in R5's room. On 11/29/23 at 1:59 PM, V6 Licensed Practical Nurse (LPN) stated there are no fall interventions in place in R5's room. There were no fall interventions documented in R5's medical record related to specific risks to prevent R5 from falling.
Nov 2023
21 deficiencies
1 Harm
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** 2.) R18's care plan with a revision date of 10/30/23 documents R18 is at risk for falls and injuries related to impaired balance...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R18's care plan with a revision date of 10/30/23 documents R18 is at risk for falls and injuries related to impaired balance and mobility. This care plan includes an intervention for a mechanical lift.
On 10/30/23 from 12:12 PM to 12:29 PM, R18 was sitting in the dining room. R18 complained multiple times that he was sliding down in the wheelchair. R18 was noted to be sitting on a pressure relief cushion. A mechanical lift sling was positioned under R18's buttocks and on top of the pressure relief cushion. The sling was noted to be bunched in places. V6 Certified Nurse's Assistant assisted R18 with re-positioning in the wheelchair.
On 11/01/23 at 2:51 PM, V6 stated she helped R18 with repositioning in the dining room on 10/30/23. V6 stated the mechanical lift sling lying on top of the pressure relief cushion did cause sliding of the sling.
The facility's mechanical lift policy with a revision date of 1/23/23 documents instructions to remove the mechanical lift sling from underneath the resident after transferring the resident.
On 11/1/23 at 11:40 AM, V19 Director of Operations stated she thinks the mechanical lift sling is supposed to be removed after transfer for the prevention of pressure. When asked if it was also to prevent residents from slipping out of the wheelchair, V19 stated yes. At 11:50 AM, V19 stated she called the person who made the policy and they have now amended the policy a few minutes ago to state that they only remove the sling when transferring to bed. V19 verified that the amended policy was not changed until it was questioned and that it used to say to remove the sling after transfers.
Based on observation, interview and record review the facility failed to provide adequate supervision to prevent a resident from leaving the building resulting in a fall outside on the sidewalk (R52) and failed to remove a mechanical lift sling from underneath a resident to prevent sliding in the wheelchair (R18) for two of eight residents (R52, R18) reviewed for accidents in the sample list of 34. This failure resulted in R52 exiting the building unaccompanied and falling resulting in abrasions to R52's face, hand and knee and a bruise to R52's face.
Findings include:
The facility's Accidents and Incidents policy with a revised date of 9/7/23 documents, Purpose: To provide staff with guidelines for investigating, reporting, and recording Accidents and incidents. Policy: All accidents/incidents involving a resident shall require an incident report. The interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions.
1.) R52's Order Summary Report dated 10/31/23 documents diagnoses including Orthostatic Hypotension, Personal History of Transient Ischemic Attack, Other Specified Disorders of the Brain, Vascular Dementia, Adjustment Disorder With Depressed Mood, Suicidal Ideations, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Auditory Hallucinations, Other Seizures, Mild Cognitive Impairment of Uncertain or Unknown Etiology and Repeated Falls. This Order Summary documents an order for an electronic alert device placement every shift for monitoring and an order to check the function of the device every shift with an order date of 10/10/23.
R52's Nurse's Note dated 9/5/23 at 9:27 AM documents R52 was exit seeking and electronic alert device was placed to R52's left leg. This note documents R52 stated R52 wanted to walk outside.
R52's Nurse's Note dated 9/6/23 at 8:43 AM documents R52 removed the electronic alert device at breakfast and Social Services was made aware.
R52's Nurse's Note dated 10/10/23 at 9:47 AM documents that staff noticed R52's electronic alert device sitting on the bedside stand. This note documents R52 stated R52 bit it off of R52's wrist. This note then documents the Social Services Director was able to talk R52 into putting the electronic alert device back on R52's wrist.
R52's Nurse's Note dated 10/26/23 at 2:00 PM documents the nurse was alerted by staff that R52 was outside on the ground by the smoking area. R52 was non-compliant with fall alarm and electronic alert device and was walking without assistance resulting in a fall. Assessment showed abrasion to the right knee, a bruise to the left middle back, a skin tear to the right great toe and right hand, and bruising and an abrasion to the left temple and cheek.
R52's Minimum Data Set (MDS) dated [DATE] documents R52 is moderately cognitively impaired and requires assistance of one staff member for ambulation. This MDS documents that R52's balance is not steady when walking, that R52 can only be steady with staff assist.
R52's Care Plan dated 9/5/23 documents R52 has a potential risk of elopement, cognitive deficit, exit seeking behavior (with purpose to leave), history of elopement, history of wandering, repetitive pacing (ambulatory), walks or wheels about aimlessly w/o (without) purpose. This Care Plan has interventions dated 9/5/23 to place an electronic sensor device to alert staff of exit attempt (or if unavailable place on 1:1 observation), check placement device, check battery function and evaluate effectiveness. Monitor whereabouts regularly, recognize any unsafe conditions or escalating patterns and respond to any alarm activation promptly.
On 10/30/23 at 9:55 AM, R52 was in R52's bed sleeping. R52 had a bruise on R52's left eye. There was a mat on the floor and a pressure alarm on the bed.
On 10/30/23 at 3:01 PM, R52 was in R52's wheelchair outside smoking. There was a staff member outside with R52. On 10/31/23 at 12:35 PM, R52 was in R52's bathroom with the door open. R52's wheelchair was sitting outside of the bathroom door and the pressure alarm was sitting in the wheelchair not sounding. V6 Certified Nursing Assistant was notified and immediately went to assist R52. V6 stated that R52 turns off the pressure alarm so they do not know when R52 gets up.
R52's Fall report dated 10/26/23 documents the nurse was notified of R52 being found on the ground face first. Nurse assessed R52 and addressed skin impairments and applied first aid. Nurse located electronic alert device and placed it to R52's right ankle and all staff were notified to check the placement of the electronic alert device.
On 10/31/23 at 3:05 PM, V26 Certified Nursing Assistant stated that when R52 fell on [DATE] V26 was the only CNA working on R52's hall and V26 did not see R52 leave. V26 stated that R52 removed the electronic alert device and left it in R52's room and rolled the wheelchair to the front door, stood up and pushed the button to turn off the door alarm and walked out the door. V26 stated that R52 walked around the building to the smoking area and R52's shoe slipped off when R52 got to the grass area and R52 fell face first into the concrete. V26 stated that another resident's family was outside with that resident and found R52. V26 stated no one in the facility knew that R52 had gotten outside alone. V26 stated that if that family hadn't found R52 who knows how long R52 would have laid out there.
On 11/1/23 at 2:52 PM, V2 Director of Nursing stated regarding R52's fall on 10/26/23 that V2 can't speak to the fact of whether R52 had the electronic alert device on or not as V2 was not in the building at the time of the fall. V2 confirmed that R52 exited out the front door and got out without anyone knowing R52 left the building. V2 confirmed R52 should not have been outside by R52's self. V2 confirmed that R52 has removed the electronic alert device multiple times and they replace it when they find it.
On 11/1/23 at 2:58 PM, V1 Administrator confirmed that another resident's family found R52 outside after R52 had gotten out of the building and fell. V1 confirmed that R52's current black eye is from the fall on 10/26/23 and V1 confirmed that R52 was not supposed to be outside alone.
On 11/1/23 at 3:04 PM, R52 stated on 10/26/23 when R52 fell, R52 went out the front door of the facility and walked through the parking lot to the smoking area and when R52 got to the grass area R52's shoe got caught on the grass and R52 tripped and fell and hit R52's face on the concrete sidewalk.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a call light was in reach for one resident (R213) of 16 residents reviewed for call lights in a sample list of 34.
Find...
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Based on observation, interview, and record review the facility failed to ensure a call light was in reach for one resident (R213) of 16 residents reviewed for call lights in a sample list of 34.
Findings Include:
R213's Order Summary Report printed 11/1/23 at 3:10PM documents R213 was admitted to the facility 10/21/23 with diagnoses of Extensive Heart and Lung Disease and chronic Kidney Disease for Hospice care.
On 10/30/23 at 3:20 PM R213 was resting in her bed. R213 stated I can't get to my call light. I'm thirsty, I want some ice, and I need straightened out in bed and I can't reach my call light. R213's call light was observed on the floor between the left side of the bed and the wall. No staff were observed in the room or the hall outside R213's room.
On 10/31/23 at 3:15 PM R213 was resting in her bed. R213's call light was observed lying on the floor between the left side of the bed and the wall. V27, Certified Nurse's Aide (CNA) entered the room. V27 stated The call light fell off. All residents should have a call light in reach at all times.
On 10/31/23 at 11:00AM V2, Director of Nursing stated that while the facility doesn't have a specific written policy for call lights, All residents should always have a call light within reach.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
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 notify the resident's representative of a change in condition for on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the resident's representative of a change in condition for one resident (R20) of 16 residents reviewed for condition change in a sample list of 34 residents.
Findings include:
R20's Care Plan revised 10/11/23 includes the following diagnoses: Type II diabetes Mellitus, Heart Disease, Anxiety, Dementia, Psychotic Disturbance, Mood Disorder, and Chronic Kidney Disease.
R20's Minimum Data Set, dated [DATE] documents R20 is severely cognitively impaired.
R20's Face Sheet reviewed 10/30/23 documents V28 is R20's resident representative and Power of Attorney.
On 10/30/23 at 12:37 PM V28 stated (R20) had diarrhea and black stool in July and the facility did not notify me. It turned out to be C-Diff (Clotridoides difficile) and they didn't let me know that either.
R20's Progress note dated 7/4/23 at 11:15PM documents (R20) has large black foul smell stool. (R20) lethargic with temperature of 100.4, blood pressure 106/50,16 respirations, and 110 pulse. (R20) refuses to go to the hospital at this time for further evaluation. There is no documentation to support V28 was notified of this change in condition.
R20's Progress note dated 7/5/23 at 12:00AM documents (R20) has another large black foul loose stool. Temperature 100.5, blood pressure 107/48, pulse 109, respirations 15. (R20) lethargic. Sending (R20) out to (Local hospital) for further evaluation. There is no documentation to support V28 was notified of this change in condition.
R20's Progress note dated 7/5/23 at 3:12AM documents, Nurse from (local hospital) called with update. Going to admit (R20) with elevated troponin level and Potassium of 2.7, called (V28) POA (Power of Attorney) No answer at this time. There is no documentation to support any message was left or additional attempts were made to notify V28.
R20's Progress note dated 7/10/23 at 3:51PM documents Report from (local hospital) given to this writer. Nurse (from hospital) stated (R20) tested positive for C Diff and a Urinary Tract Infection. (R20) placed on oral vancomycin. (R20) had urinary retention and was straight cathed (catheterized) there twice. There is no documentation to support the facility attempted to notify V28 of this information.
The facility policy Acute Change in Condition revised 1/23/23 does not address the requirement to notify resident representative of condition change.
On 11/1/23 at 1:00PM V1, Administrator stated It is my expectation we will always notify family or resident representative of any change in our resident's condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to notify the resident's representative of a transfer to the hospital for one resident (R20) of 16 residents reviewed for condition change in a...
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Based on interview and record review the facility failed to notify the resident's representative of a transfer to the hospital for one resident (R20) of 16 residents reviewed for condition change in a sample list of 34 residents.
Findings include:
R20's Care Plan revised 10/11/23 includes the following diagnoses: Type II diabetes Mellitus, Heart Disease, Anxiety, Dementia, Psychotic Disturbance, Mood Disorder, and Chronic Kidney Disease.
R20's MDS (Minimum Data Set) dated 9/27/23 documents R20 is severely cognitively impaired.
R20's Face Sheet reviewed 10/30/23 documents V28 is R20's resident representative and Power of Attorney.
On 10/30/23 at 12:37 PM V28 stated (R20) had diarrhea and black stool in July and the facility did not notify me. It turned out to be C-Diff (Clostridium difficile) and they didn't let me know that either. I didn't even know they sent (R20) to the Emergency Room.
R20's Progress note dated 7/5/23 at 12:00AM documents (R20) has another large black foul loose stool. Temperature 100.5, blood pressure 107/48, pulse 109, respirations 15. (R20) lethargic. Sending (R20) out to (Local hospital) for further evaluation. There is no documentation to support V28 resident representative was notified when R20 was sent to the hospital.
The facility policy Acute Change in Condition revised 1/23/23 does not address the requirement to notify resident representative of condition change.
On 11/1/23 at 1:00PM V1, Administrator stated It is my expectation we will always notify family or resident representative of any change in our resident's condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) l...
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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 Preadmission Screening and Resident Review (PASARR) level I screening was completed for two (R24 and R37)of two residents reviewed for PASARR level I screenings with serious mental illnesses and prescribed anti-psychotic medication from a total sample list of 34 residents reviewed.
Findings Include:
1. R24's level I PASARR dated 7/1/19, documents that a level II PASARR is not required due to R24 not having a SMI (Severe Mental Illness) diagnosis upon admission to the facility on 7/2/19.
R24's diagnosis sheet dated 11/20/20 documents a new diagnosis of Psychosis.
R24's diagnosis sheet dated 1/5/23 documents a new diagnosis of Schizoaffecive disorder.
R24's October 2023 physician order sheet documents Olanzapine 2.5 milligrams (mg) daily for schizoaffective disorder, Lorazepam 0.5mg for anxiety twice daily and Zoloft 25mg daily for depression.
On 11/1/23 V19 Director of Operations said that another PASARR level one screening had not been obtained by the facility since the new psychiatric diagnoses and antipsychotic medication had been prescribed for R24 and that it should have been done.
2. R37's Electronic Health Record documents R37 was admitted to the facility on [DATE]. R37's medical record does not include a level II PASARR screening.
R37's OBRA (Omnibus Budget Reconciliation Act) Initial Screening dated 10/5/20 documents there is no reasonable basis to suspect R37 has a mental illness.
R37's History and Physical dated 12/14/22 written by V25 Physician documents, Over the last several months (R37) has become paranoid and delusional to the point where he is now refusing to take any medications. Psychiatry recently evaluated him as having Paranoid Schizophrenia, but no medication is being used at this time.
On 10/31/23 at 9:18 AM, V1 Administrator stated R37 did not require a level II PASRR when his original screening was completed. V1 stated R37 was diagnosed with Schizophrenia after being seen by his physician (V25) on 12/14/22. V1 stated it was added to his diagnosis list on 12/28/22.
On 10/31/23 at 1:30 PM, V11 [NAME] President of Resident Services stated the facility should have obtained a new PASARR with a level II when the diagnosis of Schizophrenia was added.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R20's Care Plan revised 10/11/23 includes the following diagnoses: Type II diabetes Mellitus, Heart Disease, Anxiety, Dement...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R20's Care Plan revised 10/11/23 includes the following diagnoses: Type II diabetes Mellitus, Heart Disease, Anxiety, Dementia, Psychotic Disturbance, Mood Disorder, and Chronic Kidney Disease.
R20's MDS (Minimum Data Set) dated 9/27/23 documents R20 is severely cognitively impaired.
R20's weight tracking documents on 05/02/2023, (R20) weighed 168 lbs and on 10/23/2023, (R20) weighed 144 pounds which is a -14.29 % Loss There is no documentation to support (R20's) care plan was updated to reflect actual significant weight loss.
On 10/30/23 at 11:00AM V12, Care Plan Coordinator stated When (R20) was determined to have experienced a significant weight loss it should have been updated on (R20's) care plan.
Based on interview and record review the facility failed to update a care plan with resident's significant weight loss for two of 16 residents (R11, R20) reviewed for care plans in the sample list of 34.
Findings include:
The facility's Care Plan policy with a revision date of 1/11/23 documents, Purpose: To provide guidance to the facility in developing, implementing and communicating the individualized plan of care of residents. Policy: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.
1.) R11's Order Summary Report dated 11/1/23 documents diagnoses including Hemiplegia following a CVA (Cerebrovascular Accident), Dysphagia Oral Phase, Unspecified Protein-Calorie Malnutrition and Vitamin B12 Deficiency Anemia.
R11's Weight Summary dated 11/1/23 documents R11's weight on 7/12/23 as 142.5 pounds, 8/14/23 as 134.0 pounds, 9/11/23 as 125.0 pounds and 10/16/23 as 120.0 pounds. That is a significant weight loss of 15.79 % (percent) from 7/12/23 to 10/16/23.
V21 Dietician's Nutritional Risk assessment dated [DATE] documents R11 had a 13.7 % (percent) weight loss in three months and an 18.5 % weight loss in six months which is undesirable. V21 documents R11 was previously on a pureed diet with poor intake related to not liking the texture of the pureed food. V21 documents that R11's diet was changed to mechanical soft and R11's intake has improved some. V21 recommended adding ice cream for weight support.
R11's Care Plan dated 1/3/23 documents a risk for altered nutrition and hydration related to Heart Disease, Hypertension, and refusing to eat at times. R11's Care Plan does not document the significant weight loss for the last six months.
On 11/1/23 at 12:57 PM, V21 Dietician confirmed R11's significant weight loss and confirmed that should be on R11's Care Plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assist with/provide ADL (Activities of Daily Living) ca...
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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 with/provide ADL (Activities of Daily Living) care for two of three residents (R11, R50) reviewed for ADLs in the sample list of 34.
Findings include:
The facility's ADL Support policy with a revised date of 5/2/23 documents, Residents will be provided with care, treatment, and service as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).
1.) R11's Order Summary Report dated 11/1/23 documents diagnoses including Hemiplegia following a CVA (Cerebrovascular Accident), Other Idiopathic Peripheral Autonomic Neuropathy and [NAME] Matter Disease.
R11's Minimum Data Set (MDS) dated [DATE] documents R11 has moderately impaired cognition and requires assistance with ADLs.
On 10/30/23 at 9:47 AM, R11 was in bed and R11's fingernails on the right hand had a dark brown substance underneath them and they were long, extending over the end of the fingers approximately 1/8 to 1/4 inch. R11 has approximately 1/8 inch of facial hair outgrowth.
On 10/31/23 at 10:32 AM, R11's fingernails were still long and still had a dark brown substance underneath the right hand fingernails. R11 also still had outgrowth of facial hair.
On 11/1/23 at 8:52 AM, R11 was in bed and still not shaved and R11's fingernails were still long and appeared dirty underneath them. The right hand fingernails still had a dark brown substance underneath them. At this time R11 stated that R11 needs to be shaved and needs to have R11's nails cut.
2.) R50's Order Summary Report dated 10/30/23 documents diagnoses including Neurocognitive Disorder With Lewy Bodies and Unspecified Osteoarthritis.
R50's MDS dated [DATE] documents R50 has severe cognitive impairment and requires extensive assistance of one staff for ADLs.
On 10/31/23 at 12:05 PM, V6 and V7 Certified Nursing Assistants completed incontinence care for R50. During care R50 was pinching R50's arms with R50's long nails. V7 stated that R50's nails were sharp and V7 stated that V7 was afraid that R50 was going to tear R50's own skin by pinching R50's self.
On 11/1/23 at 9:02 AM, V2 Director of Nursing stated males faces should be shaved as they desire but typically on their bath days and as needed throughout the week. V2 stated that the fingernails should be done on bath days and when needed except for Diabetic residents. For Diabetic residents the nurses need to assist with those. V2 stated that V2 expects the resident's fingernails to be clean.
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 provide pressure ulcer treatments and relieve pressure while up in the wheelchair for one (R18) of four residents reviewed for...
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Based on observation, interview, and record review the facility failed to provide pressure ulcer treatments and relieve pressure while up in the wheelchair for one (R18) of four residents reviewed for pressure ulcers on the sample list of 34.
Findings include:
On 10/31/23 at 2:00 PM, R18 had a dime sized pressure ulcer to the left upper thigh.
R18's wound assessment and plan dated 10/18/23 documents R18's wound to the left upper thigh as a pressure injury measuring 0.5 centimeters by 1.1 centimeters by 0.1 centimeters.
On 10/30/23 from 12:12 PM to 12:29 PM, R18 was sitting in the dining room. R18 complained multiple times that he was sliding down in the wheelchair. R18 was noted to be sitting on a pressure relief cushion. A mechanical lift sling was positioned under R18's buttocks and on top of the pressure relief cushion. The sling was noted to be bunched in places. V6 Certified Nurse's Assistant assisted R18 with re-positioning in the wheelchair.
On 11/01/23 at 2:51 PM, V6 stated she helped R18 with repositioning in the dining room on 10/30/23. V6 stated the mechanical lift sling lying on top of the pressure relief cushion did cause sliding of the sling.
The facility's mechanical lift policy with a revision date of 1/23/23 documents instructions to remove the mechanical lift sling from underneath the resident after transferring the resident.
On 11/1/23 at 11:40 AM, V19 Director of Operations stated she thinks the mechanical lift sling is supposed to be removed after transfer for the prevention of pressure. At 11:50 AM, V19 stated she called the person who made the policy and they have now amended the policy a few minutes ago to state that they only remove the sling when transferring to bed. V19 verified that the amended policy was not changed until it was questioned and that it used to say to remove the sling after transfers.
R18's treatment record documents an order dated 9/28/23 to 10/3/23 to apply medical honey with calcium alginate to left posterior medial thigh topically one time a day. This treatment record does not document that the treatment was completed on 10/1/23, 10/2/23, or 10/3/23.
R18's treatment record documents an order dated 10/3/23 to 10/6/23 to apply medical honey with calcium alginate to left posterior medial thigh topically one time a day. This treatment record does not document that the treatment was completed on 10/5/23 or 10/6/23.
R18's treatment record documents an order dated 10/6/23 to 10/18/23 to apply medical honey with calcium alginate to left posterior medial thigh topically one time a day. This treatment record does not document that the treatment was completed on 10/11/23.
R18's treatment record documents an order dated 10/18/23 to apply medical honey with calcium alginate to left posterior medial thigh topically one time a day. This treatment record does not document that the treatment was completed on 10/25/23, 10/26/23, 10/27/23 or 10/29/23.
On 11/1/23 at 3:00 PM, V19 stated in regards to the days that R18's treatment are not signed off (10/1/23, 10/2/23, 10/3/23, 10/5/23, 10/6/23, 10/11/23, 10/25/23, 10/26/23, 10/27/23 and 10/29/23) that, If they aren't signed off that means that they weren't done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to perform complete incontinence care for one of two resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to perform complete incontinence care for one of two residents (R50) reviewed for incontinence care in the sample list of 34.
Findings include:
The facility's Incontinence Care Policy with a revised date of 5/16/22 documents, All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination.
R50's Order Summary Report dated 10/30/23 documents diagnoses including Neurocognitive Disorder With Lewy Bodies and Unspecified Osteoarthritis.
R50's MDS dated [DATE] documents R50 has severe cognitive impairment and requires extensive assistance of one staff for ADLs.
On 10/31/23 at 12:05 PM, V6 and V7 Certified Nursing Assistants completed incontinence care for R50. V6 washed R50's front side and they rolled R50 onto R50's side and removed the urine saturated incontinence brief from underneath R50. V6 washed R50's right buttocks and anal area and dried the same area. V6 and V7 rolled R50 back to the other side and placed a clean incontinence brief underneath R50. V6 applied a barrier cream to R50 and closed the brief and covered R50 with the blankets. V6 did not wash R50 left buttocks even though the incontinence brief was saturated with urine and R50 had been laying in bed for over an hour and a half.
On 11/1/23 at 8:40 AM, V2 Director of Nursing stated that V2 expects staff to wash the entire buttocks of the residents not just one side.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 nutritional interventions for a resident with...
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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 nutritional interventions for a resident with significant weight loss for one of four residents (R11) reviewed for weight loss in the sample list of 34.
Findings include:
The facility's Weight Assessment and Intervention policy with a reviewed date of 11/2/21 documents, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Interventions for undesirable weight loss shall be based on careful consideration of the following: choices, preferences, nutrition and hydration needs, functional factors, environmental factors, chewing and swallowing abnormalities, medications, supplemental feeding and end of life decisions.
R11's Order Summary Report dated 11/1/23 documents diagnoses including Dysphagia Oral Phase, Unspecified Protein-Calorie Malnutrition, Gastro-Esophageal Reflux Disease, Hypokalemia and Vitamin B12 Deficiency Anemia.
R11's Weight Summary dated 11/1/23 documents R11's weight on 7/12/23 as 142.5 pounds, 8/14/23 as 134.0 pounds, 9/11/23 as 125.0 pounds and 10/16/23 as 120.0 pounds. That is a significant weight loss of 15.79 % (percent) from 7/12/23 to 10/16/23.
On 11/1/23 at 12:44 PM, R11 was in bed and had just received R11's lunch tray. R11 had ground meat and mashed potatoes with gravy and a chocolate brownie. R11 had built up silverware and was feeding R11's self. There was no nutritional supplement on R11's lunch tray.
R11's Nutritional Risk assessment dated [DATE] by V21 Dietician documents R11 had a significant weight loss which was undesired. V21 recommended adding ice cream twice a day at lunch and dinner.
R11's diet tray card does not document the recommendation of ice cream at lunch and dinner.
On 11/1/23 at 12:48 PM, V22 Dietary Manager stated if the Dietician puts in a recommendation that it goes to nursing and they put the order in the computer system and then give V22 a diet communication card. Then V22 puts the recommendation on the tray card. V22 stated that it should happen within 24-48 hours. V22 stated V22 would assume R11 should be getting ice cream at lunch and dinner. V22 confirmed that ice cream was not on R11's tray card.
On 11/1/23 at 12:57 PM, V21 Dietician stated when V21 writes a recommendation V21 expects the order to be put in place within 48 hours. V21 stated R11 should be getting ice cream at lunch and dinner. V21 stated that V21 can see in the computer system that the order has not been put in place. V21 stated V21 is going to send another recommendation to nursing for the addition of the ice cream for R11.
On 11/1/23 at 3:15 PM, V13 Corporate Nurse provided documentation that the Nurse Practitioner decided to order 4 oz (ounces) of a protein shake instead of the ice cream on 10/16/23.
R11's Medication Administration Record dated 10/1/23 through 10/31/23 does not document an order for the protein shake. R11's medical record contains no documentation that R11 received any nutritional supplement after V21 Dietician recommended one on 10/11/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to provide oxygen therapy as ordered and failed to change oxygen tubing weekly for one (R17) of one residents reviewed for oxygen ...
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Based on observation, interview and record review the facility failed to provide oxygen therapy as ordered and failed to change oxygen tubing weekly for one (R17) of one residents reviewed for oxygen therapy from a total sample list of 34 residents.
Findings include:
The facility Oxygen Administration policy dated 3/17/22 documents that it is the responsibility of the charge nurse to ensure that residents who have an order for oxygen are receiving it properly. Additionally, the tubing will be changed and dated weekly.
R17's undated diagnosis sheet documents Acute and Chronic Respiratory Failure, Chronic Pulmonary Edema and Chronic Obstructive Pulmonary Disease.
R17's October physician order sheet documents oxygen to be administered at 2-4 liters per nasal cannula to maintain oxygen above 90 percent.
On 10/30/23 at 11:58AM, R17 was wearing oxygen while working a puzzle. R17's portable tank was empty and the nasal cannula tubing was dated 10/23/23, confirmed by V2 Director of Nursing.
On 11/1/23 at 11:30 AM, R17's oxygen was running at three liters per nasal cannula with the tubing dated 10/23/23.
On 11/1/23 at 11:40AM, V4 Licensed Practical Nurse stated that R17 wears oxygen at all times and that the tubing is supposed to be changed weekly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to assess the risk for entrapment for the use of a bed rail for one of one resident (R18) reviewed for bed rails on the sample li...
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Based on observation, interview, and record review the facility failed to assess the risk for entrapment for the use of a bed rail for one of one resident (R18) reviewed for bed rails on the sample list of 34.
Findings include:
On 10/31/23 at 9:12 AM, R18 was lying in bed. The bed was positioned along the wall. A half bed rail was elevated on R18's right hand side of the bed.
R18's medical record did not contain documentation that R18 was assessed for the risk of entrapment for the use of the bed rail.
On 11/01/23 at 10:35 AM, V1 Administrator stated there is not an assessment for the use of R18's bed rail.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to securely store a schedule four medication and failed to dispose of undated insulin for three (R4, R47 and R213) of three reside...
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Based on observation, interview and record review the facility failed to securely store a schedule four medication and failed to dispose of undated insulin for three (R4, R47 and R213) of three residents reviewed for medication storage from a total sample list of 34 residents.
Findings include:
The facility Medication Storage policy dated 7/11/21 documents that all drugs will be stored in a safe, secure and orderly manner in accordance with state and federal regulations. Additionally, schedule 2-4 controlled medications will be stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medication.
The facility provided insulin drug manufacturer instructions document that multidose, Lantus and Humalog Insulin vials must be disposed 28 days after opened.
The facility provided insulin drug manufacturer instructions document that a multidose, Levemir Insulin vial must be disposed 42 days after opened.
On 10/30/23 at 3:51PM, V5 Registered Nurse (RN) confirmed that R4's open Lantus Insulin, nor open Humalog Insulin were dated with an opened on date.
On 10/30/23 at 3:51PM, V5 RN confirmed that R47's Levemir Insulin was not dated with an opened on date.
On 10/30/23 at 3:55PM, V5 RN stated that all insulins are to be dated when opened so that they are not used after their disposal date.
On 10/31/23 at 10:24AM, the Core Medication Room refrigerator did not have a lock on the refrigerator and the refrigerator contained Lorazepam (Schedule IV Controlled Medication) for R213, confirmed by V5 RN.
On 11/1/23 at 12:15PM, V10 Chief Operating Officer confirmed that all Insulin should be dated upon opening.
On 11/1/23 at 1:20PM, V13 Corporate Nurse said that Lorazepam is supposed to be locked behind two locks.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
5.) R24's October 2023 physician order sheet documents Olanzapine 2.5milligrams (mg) daily for schizoaffective disorder, Lorazepam 0.5mg for anxiety twice daily and Zoloft 25mg daily for depression.
R...
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5.) R24's October 2023 physician order sheet documents Olanzapine 2.5milligrams (mg) daily for schizoaffective disorder, Lorazepam 0.5mg for anxiety twice daily and Zoloft 25mg daily for depression.
R24's medical record did not contain initial assessments for the use of Olanzapine, Lorazepam and Zoloft.
On 11/1/23 at 8:45AM, V13 Corporate Nurse stated that there are no initial assessments for psychotropic medications for R24.
On 11/1/23 at 8:00AM, V10 Chief Operating Officer stated that the facility did not obtain initial assessments for psychotropic medications and that they would be changing their practice.
4.) R18's Medication Administration Record dated 10/1/23 to 10/31/23 documents an order dated 4/20/23 for Bupropion 150 milligrams (antidepressant) one tablet once a day for depression 4/20/2023.
R18's medical record does not include an assessment for the use of Bupropion.
On 11/1/23 at 8:00 AM, V10 Chief Operating Officer stated that the facility did not obtain initial assessments for psychotropic medications.Based on interview and record review the facility failed to assess the need for Psychotropic medications for five of five residents (R52, R9, R50, R18, R24) reviewed for unnecessary medications in the sample list of 34.
Findings include:
The facility's undated Psychotropic Medication Protocol documents, Purpose: To provide guidance to facility staff in the implementation, monitoring and gradual dose reductions of psychotropic medications. Initiate GDR (Gradual Dose Reduction) monitoring flow sheet. Within 30 days of Initiation Discuss at weekly risk meeting, potential GDR evaluation (Complete assessment and update GDR monitoring flow sheet), AIMS (Abnormal Involuntary Movement Scale) (if antipsychotic). Quarterly Initiate potential GDR (complete assessment and update GDR monitoring flow sheet).
1.) R52's Order Summary Report dated 10/31/23 documents diagnoses including Generalized Anxiety Disorder, Bipolar Disorder, Vascular Dementia, Adjustment Disorder with Depressed Mood, Suicidal Ideation, Auditory Hallucinations, Mild Cognitive Impairment and Major Depressive Disorder.
R52's Order Summary Report dated 10/31/23 documents orders for Duloxetine HCL (Hydrochloride) 60 mg (milligrams) every morning and at bedtime for Depression with a start date of 8/9/23. Hydroxyzine HCL 10 mg three times a day for Anxiety with a start date of 10/12/23. Nortriptyline HCL 50 mg at bedtime for Depression with a start date 8/14/23.
R52's medical record does not contain an assessment for the use of the Hydroxyzine for Anxiety.
On 11/1/23 at 1:29 PM, V13 Regional Nurse confirmed there was no psychotropic medication assessment for the Hydroxyzine for the Depression for R52.
2.) R9's Order Summary Report dated 10/31/23 documents diagnoses including Borderline Personality Disorder, Post Traumatic Stress Disorder, Major Depressive Disorder, Mild Intellectual Disabilities, Mood Disorder, Suicidal Ideation, Adjustment Disorder with Mixed Disturbance of Emotions and Conduct and Generalized Anxiety Disorder.
R9's Order Summary Report dated 10/31/23 documents order for Aripiprazole ER (Extended Release) (antipsychotic) prefilled syringe 400 mg (milligrams) one dose every 28 days for Depression and Anxiety with a start date of 10/15/23. Benzotropine Mesylate (anticholinergic) 0.5 mg twice a day for Depression with a start date of 10/16/23. Duloxetine HCL (antidepressant) 60 mg once a day for Major Depressive Disorder with a start date of 10/15/23. Hydroxyzine HCL (antihistamine) 25 mg three times a day for Generalized Anxiety Disorder with a start date of 10/14/23. Lamictal (anticonvulsant) 150 mg in the morning for Borderline Personality Disorder with a start date of 10/15/23. Lamictal 200 mg at bedtime for Borderline Personality Disorder with a start date of 10/14/23. Mirtazapine (antidepressant) 15 mg at bedtime for Major Depressive Disorder with a start date of 10/14/23.
R9's medical record does not contain an assessment for the use of Benzotropine Mesylate for the Depression or the Lamictal for the Borderline Personality Disorder for R9.
On 11/1/23 at 1:29 PM, V13 confirmed there were no psychotropic medication assessments for the Benzotropine or Lamictal for R9.
3.) R50's Order Summary Report dated 10/30/23 documents diagnoses including Neurocognitive Disorder with Lewy Bodies, Unspecified Psychosis, Insomnia, Restlessness and Agitation and Major Depressive Disorder.
R50's Order Summary Report dated 10/30/23 documents orders for Paroxetine (Selective Serotonin Reuptake Inhibitor) HCL 10 mg in the morning for Major Depressive Disorder with a start date of 3/3/23. Quetiapine Fumarate (antipsychotic) 25 mg twice a day for Psychosis with a start date of 5/5/23. Trazadone HCL 50 mg at bedtime for Major Depressive Disorder with a start date of 4/20/23.
R50's medical record does not contain an assessment for the use of Paroxetine and Trazadone for Major Depressive Disorder for R50.
On 11/1/23 at 1:29 PM, V13 confirmed there were no psychotropic medication assessments for the Paroxetine or Trazadone for R50.
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 Pneumococcal vaccines for four residents (R23, R29,...
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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 Pneumococcal vaccines for four residents (R23, R29, R8, R49) of five residents reviewed for Vaccines in a sample list of 34.
Findings include:
The facility's Infection Control policy revised 5/21/22 states Each resident will be offered the influenza, pneumonia, and SARs-Co-V2 (COVID) vaccines as directed per CDC (Centers for Disease Control) guidelines, unless medically contraindicated. This shall be documented.
1. R23's Minimum Data Set (MDS) dated [DATE] documents R23 was not offered and did not receive the pneumococcal vaccine. There is no consent or refusal of the pneumococcal vaccine included on R23's electronic medical record. The immunization tracking included in R23's medical records does not document R23 received pneumococcal vaccine(s) according to current guidelines.
2. R29's Minimum Data Set (MDS) dated [DATE] documents R29 was not offered and did not receive the pneumococcal vaccine. There is no consent or refusal of the pneumococcal vaccine included on R29's electronic medical record. The immunization tracking included in R29's medical records does not document R29 received pneumococcal vaccine(s) according to current guidelines.
3. R8's Minimum Data Set (MDS) dated [DATE] documents R8 was not offered and did not receive the pneumococcal vaccine. There is no consent or refusal of the pneumococcal vaccine included on R8's electronic medical record. The immunization tracking included in R8's medical records does not document R8 received pneumococcal vaccine(s) according to current guidelines.
4. R49s Minimum Data Set (MDS) dated [DATE] documents R49 was not offered and did not receive the pneumococcal vaccine. There is no consent or refusal of the pneumococcal vaccine included on R49s electronic medical record. The immunization tracking included in R49's medical records does not document R49 received pneumococcal vaccine(s) according to current guidelines.
On 10/30/23 at 2:30PM V12 Infection Preventionist/Care Plan Coordinator stated If there isn't a consent or refusal for a pneumonia or COVID vaccine in the miscellaneous section of the resident's chart or documentation in the immunization section of the resident's chart then the resident didn't get the vaccine.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to offer/administer Sars-Co-V2 (COVID) vaccines for four residents (R23, R29, R8, R49) of five residents reviewed for vaccines in a sample list...
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Based on record review and interview the facility failed to offer/administer Sars-Co-V2 (COVID) vaccines for four residents (R23, R29, R8, R49) of five residents reviewed for vaccines in a sample list of 34.
Findings include:
The facility's Infection Control policy revised 5/21/22 states Each resident will be offered the influenza, pneumonia, and COVID vaccines as directed per CDC (Center for Disease Control) guidelines, unless medically contraindicated. This shall be documented.
COVID-19 Vaccines for Long-term Care Residents Updated Sept. 25, 2023 documents: CDC recommends everyone aged 5 years and older, including people who live and work in Long-term Care (LTC) settings, get 1 updated COVID-19 vaccine. People who are moderately or severely immunocompromised can get additional updated COVID-19 vaccines. Learn more about additional doses. People who live in LTC settings must give consent, or agree to getting a COVID-19 vaccine.
1. There is no consent or refusal of the current COVID booster included on R23's electronic medical record. The immunization tracking included in R23's medical records does not document R23 received a COVID booster according to current guidelines.
2. There is no consent or refusal of the the current COVID booster included on R29's electronic medical record. The immunization tracking included in R29's medical records does not document R29 received the current COVID booster according to current guidelines.
3. There is no consent or refusal of the current COVID booster included on R8's electronic medical record. The immunization tracking included in R8's medical records does not document R8 received the current COVID booster according to current guidelines.
4. There is no consent or refusal of the current COVID booster included on R49's electronic medical record. The immunization tracking included in R49's medical records does not document R49 received the current COVID booster according to current guidelines.
On 10/30/23 at 2:30PM V12 Infection Preventionist/Care Plan Coordinator stated, If there isn't a consent or refusal for a pneumonia or COVID vaccine in the miscellaneous section of the residents chart or documentation in the immunization section of the resident's chart then the resident didn't get the vaccine.
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 prepare and distribute food under sanitary conditions. This failure has the potential to affect all 61 residents residing in t...
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Based on observation, interview, and record review the facility failed to prepare and distribute food under sanitary conditions. This failure has the potential to affect all 61 residents residing in the facility.
Findings include:
On 10/31/23 at 10:57 AM, V23 [NAME] pureed a pork loin. V23 was wearing a ball cap. V23's hair stuck out of the edges of the ball cap. V23 had a full beard and and was not wearing a face covering over his beard.
On 10/31/23 at 12:11 PM, V23 was serving lunch and was not wearing a face covering or a ball cap.
On 11/01/23 at 1:28 PM, V22 Dietary Manager stated that V23 should have had his beard covered when cooking and serving food on 10/31/23.
The facility's Long Term Care Application for Medicare and Medicaid form dated 11/1/23 signed by V1 Administration documents there are 61 residents residing 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 develop, implement and maintain an ongoing quality assurance performance improvement program over the past 12 months. This failure has the p...
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Based on interview and record review the facility failed to develop, implement and maintain an ongoing quality assurance performance improvement program over the past 12 months. This failure has the potential to affect all 61 residents of the facility.
Findings include:
The Long-Term Care Facility Application For Medicare and Medicaid dated 11/1/23 and signed by V1 Administrator documents 61 residents reside in the facility.
The facility provided Quality Assurance Policy dated 7/20/22 documents that the Quality Assurance Performance Improvement (QAPI) Committee oversees implementation of the QAPI plan, which is the written component of describing the specifics of the QAPI program, how the facility will conduct its QAPI functions and the activities of the QAPI committee.
On 11/1/23 at 11:35AM, V1 stated that she was not aware of any performance improvement projects that had been developed by the quality committee over the past year. Nor was any performance project implemented with the front line staff and evaluated by the quality committee. No tracking and trending of performance goals, monitoring for performance improvement, nor documentation of performance improvement was provided during this survey.
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 hold quarterly quality improvement meetings over the past 12 months. This failure has the potential to affect all 61 residents of the facili...
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Based on interview and record review the facility failed to hold quarterly quality improvement meetings over the past 12 months. This failure has the potential to affect all 61 residents of the facility.
Findings include:
The Long-Term Care Facility Application For Medicare and Medicaid dated 11/1/23 and signed by V1 Administrator documents 61 residents reside in the facility.
The facility provided Quality Assurance Policy dated 7/20/22 documents that the administrator is responsible for insuring that the facility's quality program complies with federal, state and local regulatory requirements.
On 11/1/23 at 11:54AM, V1 Administrator stated that no quality information could be provided prior to August of 2023, including meeting minutes.
On 11/1/23 at 12:00PM, V10 Chief Operating Officer confirmed that no quality information could be located prior to August 2023.
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
A. Based on record review and interview the facility failed to initiate a water management program. This failure has the potential to affect all 61 residents residing at the facility.
B. Based on obs...
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A. Based on record review and interview the facility failed to initiate a water management program. This failure has the potential to affect all 61 residents residing at the facility.
B. Based on observation, interview and record review the facility failed to prevent potential cross contamination during incontinence care for one of two residents (R50) reviewed for incontinence care in the sample list of 34.
Findings Include:
a.) The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 11/1/23 documents 61 residents reside in facility.
The facility's policy Legionella Water Management Program last revised July 2017 (not reviewed annually) states Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. The water management team will consist of at least the following personnel: Infection preventionist, the Administrator, the Medical Director, the Director of Maintenance, the Director of Environmental Services. The purpose of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's Disease.
On 10/31/23 at 3:00PM V1, Administrator stated I will be honest with you we do not currently have a water management program in place. All I have is the policy.
b.) The facility's Incontinence Care Policy with a revised date of 5/16/22 documents, All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination.
On 10/31/23 at 12:05 PM, V6 and V7 Certified Nursing Assistants (CNA) prepared supplies to perform incontinence care for R50. V6 washed V6's hands and donned a pair of gloves. V7 closed the door and pulled the privacy curtain then donned a pair of gloves without performing hand hygiene. V6 and V7 opened R50's incontinence brief and V6 put a wash cloth in a basin of water and sprayed perineal wash on the wash cloth and washed the front creases of R50. V6 proceeded to get another wash cloth and continue to clean the front perineal area of R50. R50's perineal area was reddened. After finishing R50's front side they rolled R50 onto R50's side and without changing gloves or performing hand hygiene V6 got another wash cloth wet and sprayed with perineal wash and proceeded to wash the right buttock. V6 got another wash cloth and washed the anal area then dried with a dry wash cloth. V7 removed the urine saturated incontinence brief and handed it to V6 and V6 threw it in the garbage can. Without changing gloves or performing hand hygiene V6 put a clean draw sheet underneath R50 and laid a clean incontinence brief next to R50. V6 then applied a barrier cream to R50's back side and removed V6's gloves and washed V6's hands and donned new gloves. V7 still donned the same pair of gloves. They put the clean brief under R50 and rolled R50 to straighten the brief and draw sheet. V7 touched the clean brief and clean draw sheet and R50 and R50's bed linens with the same pair of gloves that V7 removed the saturated incontinence brief with. V6 then applied barrier cream to R50's front perineal area and removed V6's gloves. V7 closed the incontinence brief. They repositioned R50 in bed then performed hand hygiene.
On 11/1/23 at 8:40 AM, V2 Director of Nursing stated that the CNAs should be changing their gloves between clean and dirty. They should change gloves after touching anything dirty before touching the resident. V2 confirmed the CNAs should have changed their gloves after removing the urine saturated incontinence brief.
MINOR
(C)
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 staffing. This failure has the potential to affect all 61 residents residing in facility.
Findings include:
The faci...
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Based on observation, interview and record review the facility failed to post daily staffing. This failure has the potential to affect all 61 residents residing in facility.
Findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 11/1/23 documents 61 residents reside in facility.
On 10/30/23 upon entry into the facility there was no posted staffing located anywhere in the lobby or office areas.
On 10/31/23 at 9:00 AM, there is still no posted staffing located anywhere in the lobby or office areas of the facility.
On 11/1/23 at 1:30 PM, V1 Administrator confirmed the daily staffing is not posted. V1 stated V1 doesn't know why it's not posted.
Oct 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain infection control practices for one (R4) resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain infection control practices for one (R4) resident on contact isolation precautions for Extended Spectrum Beta-Lactamase (ESBL) in urine out of three residents reviewed for catheters in a sample list of seven residents.
Findings include:
R4's Undated Face Sheet documents R4 admitted to facility on 8/25/23 with medical diagnoses of Infection and Inflammatory Reaction due to indwelling Urethral Catheter, Urinary Tract Infection, Dementia, Weakness, Spinal Stenosis and Urine Retention. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. This same MDS documents R4 requires extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. R4's current Careplan documents R4 as a high risk for a Urinary Tract Infection (UTI). This same careplan does not include an intervention to maintain contact isolation precautions.
R4's Urine Culture and Sensitivity Results dated 10/12/23 shows results of greater than 100, 000 CFU (Colony Forming Units)/milliliter (ml) of Morganella Morganii, greater than 100, 000 CFU/ml of Klebsiella Pneumoniae and positive for Extended Spectrum Beta-Lactamase (ESBL).
On 10/25/23 at 11:00 AM Observed V10 Physical Therapy Assistant (PTA) assisting R4 out of R4's bed in to wheelchair. R4 used both hands to hold onto V10's forearms. V10's lab coat directly touched R4's jacket. R4's door to room had contact and enhanced barrier precaution signs posted. There was an isolation bin filled with Personal Protective Equipment (PPE) sitting outside of R4's room.
On 10/25/23 at 12:00 PM V10 Physical Therapy Assistant (PTA) stated I should have worn the gown and gloves. V10 also stated, (R4) is on contact isolation for Extended Spectrum Beta-Lactamase (ESBL) in his urine. I saw (R4) trying to get up and told him to wait for staff. I told (R4) a couple of times but he didn't listen. I should have grabbed a gown or at least gloves before going into (R4's) room.
On 10/25/23 at 12:30 PM V2 Director of Nurses (DON) stated (V19) Minimum Data Set (MDS)/Infection Preventionist (IP) is the actual IP for this facility because she has the certificate. I have not been certified. (V19) IP really only has the title of IP, she does not manage the IP program. I do that when I can. (V10) PTA should have worn the proper PPE when entering a resident (R4) room who is on isolation. If (V10) had time to tell (R4) to wait a few times then she had time to put on the right PPE. (R4) is on contact isolation for having ESBL in his urine. ESBL is very contagious and we (facility) need to take that seriously or it could spread to other residents.
The facility policy titled 'Infection Control Policy' revised 5/21/22 documents it is the responsibility of the Licensed Nurse/Nursing Staff to follow the policy to ensure proper identification and containment of infections.
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
Incontinence Care
(Tag F0690)
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 provide appropriate and sufficient services to prevent ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide appropriate and sufficient services to prevent urinary tract infection (UTI) for a resident with an indwelling urinary catheter. The facility also failed to obtain an acceptable urine specimen from a resident with an indwelling urinary catheter from 9/26/23 to 10/11/23(2 weeks) resulting in a delay of treatment. These failures affects one resident (R4) of three residents reviewed for catheter care in a sample list of seven residents.
Findings include:
R4's Undated Face Sheet documents R4 admitted to facility on 8/25/23 with medical diagnoses of Infection and Inflammatory Reaction due to indwelling Urethral Catheter, Urinary Tract Infection, Dementia, Weakness, Spinal Stenosis and Urine Retention.
R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. This same MDS documents R4 requires extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene.
R4's current Careplan documents R4 as a high risk for a Urinary Tract Infection (UTI). This same careplan does not include an intervention to provide catheter care every shift nor to maintain contact isolation precautions.
R4's Electronic Medical Record (EMR) does not document catheter care being provided from 8/28/23-10/10/23.
Facility Resident Council Minutes dated 8/24/23 document nursing concerns Concerns with catheter care.
R4's Physician Order Sheet (POS) documents order physician orders to collect a Urinalysis sample with Culture and Sensitivity on 9/26/23, 10/1/23 and 10/5/23. This same POS documents a physician starting 10/10/23 to provide urinary catheter care every shift and as needed.
R4's Urine Culture and Sensitivity Results dated 9/28/23 shows results of Mixed Flora greater than 100,000 colony (col)/milliliter (ml). This same report documents multiple organisms isolated with no predominant type, consistent with contamination. Consider recollection.
R4's Urine Culture and Sensitivity Results dated 10/4/23 shows results of Mixed Flora greater than 100, 000 colony (col)/milliliter (ml). This same report documents multiple bacterial morphotypes present, possible contamination. Suggest a recollection if clinically indicated.
R4's Urine Culture and Sensitivity Results dated 10/12/23 shows R4's Urinalysis was collected 10/6/23 and received 10/12/23 with results of greater than 100, 000 CFU (Colony Forming Units)/milliliter (ml) of Morganella Morganii, greater than 100, 000 CFU/ml of Klebsiella Pneumoniae and positive for Extended Spectrum Beta-Lactamase (ESBL).
R4's Nurse Progress Notes document:
-9/26/23 at 1:20 PM V8 Nurse Practitioner, Urinary indwelling catheter intact with hazy dark yellow urine with sedimentation. Urinalysis needed to rule out infection.
-9/27/23 at 2:57 PM, (R4's) urine collected per catheter, laboratory contacted for pick up.
-9/29/23 at 1:42 PM V8 Nurse Practitioner (NP), a new urine sample required from urinary catheter from catheter not from drainage bag. Catheter should be changed 10/14/23.
-10/1/23 at 10:15 AM V8 Nurse Practitioner (NP), A new urine sample needed from catheter not from urine drainage bag on 10/1/23 to keep in refrigerator. No indication for blind antibiotic therapy at this time.
-10/1/23 at 11:48 PM, New urine specimen obtained and laboratory notified.
-10/5/23 at 2:33 PM V8 Nurse Practitioner, (R4's) second urine sample also showed mixed flora with possible contamination. Will follow up with third urine sample.
-10/5/23 at 3:19 PM, New urine sample is needed via new bag to collect today and keep in refrigerator.
-10/6/23 at 10:51 AM, Laboratory notified of stat pick up of specimen for Urinalysis with Culture and Sensitivity.
-10/11/23 at 2:59 PM, Urinalysis (U/A) with Culture and Sensitivity (C&S) final report back and faxed to (V20) Physician office. Results positive for Morganella Morganii, Klebsiella Pneumoniae, and Extended Spectrum Beta Lactamase (ESBL). Contact precautions initiated and maintained. New order received for Levaquin 250 milligrams (mg) daily for ten days
On 10/25/23 at 11:10 AM Observed R4 self propelling in wheelchair with catheter drainage bag attached to underside of wheelchair dragging the hallway floor as R4 propelled down hallway approximately 50 feet. Staff present in hall did not adjust R4's urinary catheter drainage bag.
On 10/25/23 at 11:15 AM V2 Observed Director of Nurses (DON) assess R4's catheter insertion site/peri area, small amount of thick yellow drainage noted.
On 10/24/23 at 3:45 PM V8 NP stated (R4's) catheter tubing was very corroded with sediment that had been building up. You could tell that had been there a long time. (R4) did not have orders inputed to provide catheter care until the third Urinalysis came back with infection of Extended Spectrum Beta-Lactamase (ESBL). They (facility) should have been cleaning (R4's) catheter since he admitted to the facility. I(V8) gave actually four seperate orders to obtain Urinalysis' for (R4). I ordered the first Urinalysis (U/A) on 9/26/23 and they (facility) waited an entire day before they even got the specimen. The second U/A was ordered on 9/29/23. They never got this U/A so I re-ordered the second U/A on 10/1/23. They should have got this specimen on 9/29 and not wait two days to obtain the specimen. For some reason the first two, the nurse obtained the urine specimen from the drainage bag and not the correct way. In addition, this altered the results so I had to order a third Urinalysis (U/A). (R4) had a history of Urinary Tract Infections (UTI) and he admitted with the Urinary indwelling catheter. Now (R4) is on antibiotics for ESBL in his urine. That is most likely due to cross contamination, poor infection control practices from the staff and delay in obtaining the urine specimens. This facility does a good job at alot of other things but they are not good at managing resident catheters.
On 10/27/23 at 10:00 AM V2 Director of Nurses (DON) stated Our nurses should not have waited to obtain the U/A's for (R4). I don't know why there was a delay but there definitely was. (R4) has an indwelling urinary catheter so there should be no reason for the delay. Catheter care for any resident with a catheter including (R4) should happen every shift. I don't know why the orders weren't put in when (R4) admitted . I don't have any documentation that the staff provided catheter care for (R4). V2 also stated, the staff should make sure the catheter drainage bags are kept off of the ground.and I don't even think we have a policy for that because it is just the expectation. (R4) is already on contact isolation for ESBL in his urine. That is exactly what we (facility) should not let happen. I will re-educate them (staff) again. We (facility) are working on an extensive training for staff for residents with catheters. (R4's) drainage bag dragging on the floor certainly does not help prevent infections. In fact, it is those types of things cause infections. (R4) has a current Urinary Tract Infection (UTI) for which he is on contact isolation and requires antibiotic treatment.
Sept 2023
4 deficiencies
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 F0804
(Tag F0804)
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 serve foods that were palatable to four (R1, R4, R7, R9...
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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 foods that were palatable to four (R1, R4, R7, R9) residents out of four residents reviewed for Dietary Services in a sample list of eleven residents.
Findings include:
Resident Council Minutes dated 8/24/23 document a new concern of serving times. These same council minutes document the department response as Serving times are set for the building. We (staff) will get meals served on time as close as possible to times that are set.
1.) R1's Minimum Data Set (MDS) dated [DATE] documents R10 as cognitively intact.
On 9/27/23 at 12:35 PM R1 stated I just hope the food is hot today. Most of the time it is lukewarm at best.
2.) R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact.
On 9/26/23 at 12:11 PM Observed V7 Dietary Aide place a quarter pan of barbecued pulled pork on serving line. Observed V7 Dietary Aide obtain temperature of pulled pork which was 119 degrees Fahrenheit. Observed V3 [NAME] plate this same pulled pork for R4.
On 9/26/23 at 12:40 PM Observed V14 Certified Nurse Aide (CNA) serve lunch tray with pulled pork sandwich to R4 in room.
On 9/26/23 at 1:38 PM R4 stated My barbecue sandwich was ice cold. The food is usually cold here. The staff will warm it up if you ask but usually they are in and out so fast you don't have time to ask and just end up eating cold food. The staff are very good at helping but the food is cold. I didn't eat much of that.
3.) R7's Minimum Data Set (MDS) dated [DATE] documents R7 as cognitively intact.
On 9/27/23 at 10:45 AM R7 stated The only real problem is the food. I eat in the dining room and most of the time the food is cold by the time you get it. For some reason the kitchen cooks all the food and then there isn't anyone to serve it.
4.) R9's Minimum Data Set (MDS) dated [DATE] documents R9 as cognitively intact.
On 9/26/23 at 12:39 PM Observed V14 Certified Nurse Aide (CNA) serve a lunch tray to R9 in R9's room.
On 9/26/23 at 12:40 PM R9 stated The food is nothing to write home about. It is usually cold. They (facility) serve me this chicken that is dry as leather and cold.
On 9/27/23 at 11:50 AM V18 Regional Dietary Manager stated I have inserviced all the kitchen staff on the concerns found yesterday (9/26/23). The pulled pork served yesterday was not at the proper temperature. Since it was reheated from the night before, it should have temped (reached a temperature of) at at least 165 degrees Fahrenheit. That might explain why the residents' food is cold. There is a lot of training to do here (facility) but I think the kitchen crew we have is a good one. They just need to be trained properly.
The facility policy titled Safe Food Handling' issued 9/1/2021 documents all foods are prepared in accordance with Food and Drug Administration (FDA) Food Code. The [NAME] will prepare all cooked food items in a fashion that permits rapid heating to appropriate minimum internal temperature. When reheating, foods will be rapidly heated to 165 degrees Fahrenheit for 15 seconds.
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 F0806
(Tag F0806)
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 serve foods timely based on resident preference to four...
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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 foods timely based on resident preference to four (R1, R4, R7, R9) residents out of four residents reviewed for Dietary Services in a sample list of eleven residents.
Findings include:
Resident Council Minutes dated 8/24/23 document a new concern of serving times. These same council minutes document the department response as Serving times are set for the building. We (staff) will get meals served on time as close as possible to times that are set.
1.) R1's Minimum Data Set (MDS) dated [DATE] documents R10 as cognitively intact.
On 9/27/23 at 12:35 PM R1 stated I am sure they (staff) are doing the best they can but it gets tiring to have to wait so long for our meals. My butt gets sore from sitting so long.
2.) R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact.
On 9/26/23 at 12:40 PM Observed V14 Certified Nurse Aide (CNA) serve lunch tray with pulled pork sandwich to R4 in room.
On 9/27/23 at 12:37 PM R4 stated The food is ok. It is just late again today. I don't know why they (staff) are always so late. I see plenty of people running around but no one is helping us. I get hungry. I know they (staff) have others to help but when they aren't helping anyone it makes me upset.
3.) R7's Minimum Data Set (MDS) dated [DATE] documents R7 as cognitively intact.
On 9/27/23 at 10:45 AM R7 stated The only real problem is the food. For some reason the kitchen cooks all the food and then there isn't anyone to serve it. I don't know why people don't help more. They (staff) all know there is a dining room full of residents waiting to get their meals.
4.) R9's Minimum Data Set (MDS) dated [DATE] documents R9 as cognitively intact.
On 9/26/23 at 12:39 PM Observed V14 Certified Nurse Aide (CNA) serve a lunch tray to R9 in R9's room.
On 9/26/23 at 12:40 PM R9 stated I have to wait even longer for them (staff) to get me something else since it took them so long to get me my lunch to begin with.
On 9/27/23 at 12:20 PM Observed dozens of residents in the main dining room sitting at dining room tables with no food or drinks available.
On 9/26/23 at 11:42 AM V5 Dietary Aide stated We (staff) normally serve the dining room first and then the hall trays. Today we have to do it backwards because there is no staff in the dining room to serve all the residents out there. That happens a lot. We have been told we can't serve the residents so we just wait on the nursing staff.
On 9/27/23 at 12:25 PM V6 Dietary Manager in Training stated They (facility) told us we cannot serve the residents so we have to wait for the nursing staff to get up here (kitchen). Lunch is supposed to be served at 12:00 PM. There is no one in the dining room to serve so we (kitchen staff) have to wait it out. I am getting ready to put all this food back in the warmer so it doesn't get too cold.
On 9/27/23 at 11:55 AM V18 Regional Dietary Manager stated I have inserviced all the kitchen staff on the concerns found yesterday (9/26/23). The meals should be served on time. Our kitchen staff have the foods ready but there is no one in the dining room to serve. We (facility) need to come together for the benefit of these residents. I am sure we will be working on teamwork soon.
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
Based on observation, interview and record review the facility failed to employ a qualified director of food and nutrition services. This failure has the potential to affect all 60 residents residing ...
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Based on observation, interview and record review the facility failed to employ a qualified director of food and nutrition services. This failure has the potential to affect all 60 residents residing in facility.
Findings include:
The Facility Midnight Daily Census Report dated 9/26/23 documents 60 residents reside in facility.
On 9/28/23 and 9/29/23 there was no Dietary Manager observed onsite.
On 9/26/23 at 10:15 AM V9 Certified Dietary Manager (CDM) stated I split my time between this facility and another facility. I am not here at this facility full time. I believe we are supposed to have a full time person in this role. I have (V6) who is a dietary manager in training but he is not certified and is not trained yet. We (facility) are working towards that.
On 9/27/23 at 2:00 PM V18 Regional Dietary Manager stated (V9) is a Certified Dietary Manager who does oversee two facilities. (V9) is not at this facility Full-Time but that is our goal.
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 properly label and store refrigerated food products, failed to properly store thawed meat to prevent meat juice from dripping o...
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Based on observation, interview and record review the facility failed to properly label and store refrigerated food products, failed to properly store thawed meat to prevent meat juice from dripping on other foods, failed to ensure cleanliness of food serving area and sanitation of food preparation equipment and failed to ensure the dishwasher was operating as designed to sanitize dishes to prevent potential food borne illness to residents. This failure has the potential to affect all 60 residents residing in facility.
Findings include:
The facility Midnight Daily Census dated 9/26/23 documents 60 residents reside in facility.
1.) On 9/26/23 at 9:25 AM Observed V5 Dietary Aide test the dishwashing machine using a test strip. The test strip turned a light purple color indicating 25 parts per million (ppm).
On 9/26/23 at 9:27 AM V5 Dietary Aide stated That dishwasher is gross. It really needs de-limed. Look at all the buildup (pointing to lime build-up) on the inside of the metal area where the water runs over and back to the dishes. That is nasty The (test) strip should be at least 50 ppm. This thing must not be working right. That could make somebody sick.
2.) On 9/26/23 at 9:20 AM Observed a four inch in diameter and foot long package of small cubed unidentifiable food wrapped in clear plastic wrap with no label and no expiration date sitting on a shelf of reach in the freezer. This same food product package had '9/16' hand written in black marker on outside of clear plastic wrap.
On 9/26/23 at 9:30 AM Observed an opened five pound chub of raw hamburger with no open date but in original packaging. This chub of raw hamburger was wrapped in clear plastic wrap with a small amount of red blood covering outside of plastic wrap. This same chub of raw hamburger was sitting on a wire rack directly above open meat product wrapped in clear plastic wrap and raw eggs on bottom shelf of refrigerator.
On 9/26/23 at 9:32 AM V3 [NAME] stated Someone must have opened something and then put it back. There isn't any way to tell what it is but I think it is some kind of meat. The hamburger should be kept in a sealed container. The blood is coming right through the cracks in the plastic wrap. I couldn't find an expiration or use by date on the hamburger but I am sure it is still good because it doesn't small bad or anything.
3.) On 9/26/23 at 11:34 AM Observed V3 [NAME] lean against metal shelf on serving line. V3's scrub top was directly touching front and top of metal shelf. Observed V3 [NAME] stir gravy with serving spoon and then place serving spoon dripping with gravy directly where V3 had leaned on shelf. V3 did not wipe shelf off after leaning on it. V3 [NAME] then used same contaminated gravy spoon to serve gravy to residents.
On 9/26/23 at 11:40 V3 [NAME] stated I am not really sure what the temperatures of all the foods should be. I know the chicken should be at least 160 degrees but I really don't know about anything else. I am not sure exactly. I put the gravy spoon on the shelf where my shirt had just touched. I didn't realize you can't do that. I cook in this shirt so I should be more careful about cross contaminating my work/serving area.
4.) On 9/26/23 at 9:56 AM Observed facility manual commercial can opener fastened to side of work station in kitchen. This same can opener had a thick layer of built up dark grime covering area that is exposed to food.
On 9/26/23 at 10:30 AM V3 [NAME] stated This can opener is just gross. I know we (staff) have used it plenty of times with it looking like this. It is supposed to be ran through the dishwasher every night after supper but you can clearly see that hasn't been happening by the amount of grime and grossness on this thing.
On 9/29/23 at 9:00 AM V18 Regional Dietary Manager stated The kitchen staff have all been inserviced on the problems in the kitchen. The work areas are supposed to be cleaned. We (facility) have ordered a new can opener because that one was not getting clean in the dishwasher. We (facility) have gone through all of the refrigerators and freezers and dry storage to ensure all of the foods are labeled and stored properly. The dishwasher has been cleaned and is now running at 50 PPM. There is a lot of work to do yet but I believe we (facility) have specific areas to focus on and will achieve our goals.
The facility policy titled 'Safe Storage of Food' issued 9/1/2021 documents all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.
The facility policy titled 'Cleaning and Sanitizing and Proper Hair Restraints' issued 9/1/2021 documents food contact surfaces are properly cleaned and sanitized before and after use, in order to help prevent food-borne illness and minimize bacterial growth. Non-food contact surfaces are cleaned per individual facility cleaning schedule to maintain optimal cleanliness of kitchen equipment.
Jun 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to promptly address pain for one (R1) of three residents reviewed for pain from a total sample list of four.
Findings include:
R1's progress n...
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Based on interview and record review, the facility failed to promptly address pain for one (R1) of three residents reviewed for pain from a total sample list of four.
Findings include:
R1's progress notes document that on 5/27/23 at approximately 10:07AM, R1 fell from her wheelchair onto the floor in her room.
R1's X-ray dated 5/28/23 documents fractures of the right distal tibia, right proximal fibula, and right calcaneus were visualized resulting from the fall.
On 6/6/23 at 12:10PM, V6 (Certified Nursing Assistant/CNA) stated, I helped them get (R1) up with the (mechanical lift) when (R1) fell. She was complaining of pain in her leg.
On 6/6/23 at 1:23PM, V5 (Certified Nursing Assistant/CNA) stated, I helped get R1 back to bed after her fall. I remember that her leg was hurting but it was a hectic morning, I don't know if she got pain med or not.
On 6/6/23 at 12:00PM, V4 (Licensed Practical Nurse/LPN) said that she did not think that R1 was in much pain from the fall, but that the night had been very hectic with other resident issues and needs.
On 6/7/23 at 1:30PM, V2 (Director of Nursing/DON) stated, There was no comprehensive pain assessment completed at the time of the fall and it should have been.
On 6/6/23 at 1:14PM, V8 (Licensed Practical Nurse/LPN) said that she was R1's nurse on the evening of 5/27/23 and that she did not know that R1 had fallen until R1 told her. I remember giving her a pain pill that evening because she was complaining from the ankle down.
R1's medication administration record documents R1's first administered pain control after falling at 10:07AM on 5/27/23 was at 8:16 PM that evening by V8 (LPN).
On 6/6/23 at 9:08AM, R1 stated, I fell out of my wheelchair and broke my leg. I was in pain all day when I fell, and they didn't give my anything and then they found that I had broken in three places.
The facility pain policy dated 5/16/22 documents that pain will be promptly and accurately assessed and diagnosed. Additionally, pain will be assessed upon admission, readmission, and with a change of condition or when new pain or an exacerbation of pain is suspected, the comprehensive Pain Assessment will be completed.
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 F0777
(Tag F0777)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain an order for an X-ray promptly and notify the physician of the X-ray results promptly in one (R1) of one resident reviewed for radio...
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Based on interview and record review, the facility failed to obtain an order for an X-ray promptly and notify the physician of the X-ray results promptly in one (R1) of one resident reviewed for radiology services from a total sample list of 4.
Findings include:
R1's facility investigation file documents that R1 fell out of her wheelchair on 5/27/23 at approximately 10:07AM. R1's medication administration record documents pain on the day and evening shift on 5/27/23 and that Norco 5-325 milligrams was provided for pain. R1's progress notes dated 5/27/23 document an order for X-rays obtained at 10:51PM and that R1 is taking Norco 5-325 milligrams for pain.
R1's X-ray report documents X-rays performed on 5/28/23 at 6:05AM. R1's progress notes dated 5/28/23 document X-rays resulted at 6:48PM. R1's X-ray report dated 5/28/23 document the facility received the results by fax at 6:59PM.
R1's progress notes dated 5/29/23 document X-rays were first reviewed by the facility at 2:52AM and shortly afterward, V12 (Nurse Practitioner/NP) was notified and ordered R1 to be sent to the emergency room for evaluation and treatment immediately.
On 6/6/23 at 9:08AM, R1 stated, I fell out of my wheelchair and broke my leg. I was in pain all day when I fell, and they didn't give my anything, and then they found that I had broken in three places and finally sent me to the hospital a couple of days later.
On 6/6/23 at 2:25PM, V2 (Director of Nursing/DON) stated, I worked the next night, and I looked on the computer and saw that she was broken in 3 places. That's when I called V12 (Nurse Practitioner/NP) and was told to send her out. I don't know where that fax was.
On 6/7/23 at 2:18PM, V12 (NP) stated, There should be a system to notify the facility, or the facility should obtain results sooner than the ones for (R1) were obtained, so that the physician or myself can act. We would have sent her to the hospital sooner, had we been notified of the results sooner.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to document complete and accurate information in the medical record of one (R1) of four residents reviewed for medication administration.
Findi...
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Based on interview and record review the facility failed to document complete and accurate information in the medical record of one (R1) of four residents reviewed for medication administration.
Findings include:
The facility policy, Medication Administration Policy/Procedure dated 9/27/22 documents that medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required. Medication will be administered on the electronic medication administration record and when giving narcotics, in addition, the narcotic sheet will be signed ensuring date, time, amount previous and amount remaining are correct.
R1's controlled drug record for Norco 5-325 milligrams documents that R1 was given Norco 5-325 milligrams on 5/27/23 at 10:15AM by V4 (Licensed Practical Nurse/LPN). R1's medication administration record does not document this administration.
On 6/6/23 at 1:30PM, V7 (Registered Nurse/RN) stated, The process for medication administration is supposed to be that you check the medication administration record, sign the medications out on the medication record and sign the narcotics out on the narcotic book.
On 6/6/23 at 1:00PM, V2 (Director of Nursing/DON) stated, We are supposed to document in the (medication administration record) all medications that are given including narcotics. I need to do some training; they are my staff.
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 F0919
(Tag F0919)
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 accessible call light assistance to one (R1) of three resi...
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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 accessible call light assistance to one (R1) of three residents reviewed for call lights from a total sample list of four.
Findings include:
The facility policy dated 8/20/22 documents, A call light activation device shall be kept within resident reach while in resident rooms and bathrooms.
R1's Minimum Data Set, dated [DATE] documents R1 requires a wheelchair with an assist of one to move in the wheelchair.
R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact.
On 6/6/23 at 9:08AM, R1 stated, I fell out of my wheelchair and broke my leg. I couldn't reach the call light and so I yelled for the nurse. The light was over by my bed, and I was going through my purse next to the other bed. She didn't come in for a while. I worry that if I fall again, they won't come in to help me.
On 6/6/23 at 1:23PM, V5 (Certified Nursing Assistant/CNA) stated, R1 didn't have her call light on when I went into the room. I saw her laying on the floor in front of the other bed with her wheelchair pushed backward and her feet by the pedals. Where she was at, she couldn't reach (the call light). She told me that she was going through her purse.
On 6/6/23 at 12:00PM, V4 (License Practical Nurse/LPN) stated, V5 let me know that R1 had fallen because I was at the other end of the hall passing meds. R1 didn't have a call light on. She couldn't have reached it anyway, given where she was at in the room. She was not able to wheel herself on her own, so she would have been put there.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 ensure that a resident's (R1) medication was administered as ordere...
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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's (R1) medication was administered as ordered by the physician upon admission to the facility. R1 is one of three residents reviewed for medications in the sample of six.
Findings include:
R1's Physician Order Sheet dated January 2023 includes the following diagnoses: Cellulitis of the Abdominal Wall, Syncope and Collapse, Hyperlipidemia, Anxiety and Asthma.
R1's Hospital Discharge Orders for admission to the facility dated 1/9/23 include the following medications:
1. Carbamazepine 200 milligrams (mg) Extended Release (ER) capsule, take two capsules (400 mg total) by mouth every 12 hours for 14 days, THEN 1 (one) capsule (200 mg total) every 12 hours. Next Dose Due Tonight (1/9/23)
2. Clobetasol 0.05% topical solution, Apply to affected area 2 (two) times daily. Next Dose Due Tonight (1/9/23)
3. Diclofenac 1% topical gel, Apply to affected area 4 (four times daily. Next Dose Due Tonight (1/9/23).
4. Melatonin 10 mg Cap (capsule), take 1 (one) capsule by mouth at bedtime. Next Dose Due Tonight (1/9/23).
5. Pregabalin 50 mg capsule, Take 5 capsules (250 mg total) by mouth in the morning and at bedtime for 7 days, THEN 3 capsules (150 mg total) in the morning and at bedtime for 7 days, THEN 1 capsule (50 mg total) in the morning and at bedtime for 7 days. Next Dose Due: Continue Tonight (1/9/23) as directed. Last dose @ 10:06 am.
6. Simvastatin 20 mg tablet, Take 1 tablet (20 mg) by mouth daily at bedtime. Next Dose Due Tonight (1/9/23).
7. Tamsulosin 0.4mg ER Capsule, Take 1 capsule (0.4 mg) by mouth daily at bedtime. Next Dose Due Tonight (1/9/23).
These same Hospital Discharge Orders document a time stamp they were sent and printed at the facility on 1/9/23 at 10:49 am.
R1's admission assessment dated [DATE] at 8:15 pm documents R1 being in the facility.
R1's Medication Administration Record dated January 2023 documents the above medications, but are not signed off as given per physician orders for the night of 1/9/23.
On 2/16/23 at 10:45 am, V1 (Administrator) confirmed that the above discharge orders for R1's admission were received by the facility at 10:49 am on 1/9/23. V1 also confirmed the orders did not get in the system in time for R1's medication to arrive at the facility, and therefore R1 did not receive the medications that were due on the night of 1/9/23.
Dec 2022
6 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 provide care and services to promote healing of pressu...
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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 care and services to promote healing of pressure sores. The facility failed to transcribe and implement physician orders, failed to implement care plan interventions for pressure sore prevention, and failed to obtain physician orders for skin issues and ensure pressure wound treatments were being completed as ordered for three of three residents (R29, R56, R259) reviewed for pressure sores in a sample list of 27 residents. The facility failed to promote healing of R259's pressure sore by failing to implement pressure relieving interventions for R259's left foot pressure sore which subsequently progressed from a stage three to a stage four pressure sore.
Findings include:
1.) R259's undated Face Sheet documents R259 was admitted to facility on 10/20/22 with medical diagnoses of Anemia in Chronic Kidney Disease, Atrial Fibrillation, Idiopathic Peripheral Autonomic Neuropathy and Osteomyelitis of the Left Foot and Ankle.
R259's Electronic Medical Record (EMR) does not document R259 was admitted to the facility with a Left Medial Foot pressure ulcer.
R259's Minimum Data Set (MDS) dated [DATE] documents R259 as cognitively intact. This same MDS documents R259 as requiring extensive assistance of two people for bed mobility, transfers, dressing and personal hygiene.
R259's Initial Wound Evaluation and Summary report dated 10/26/22 documents R259's Left Medial Foot Pressure Ulcer as a Stage 3.
R259's Wound Evaluation and Management Summary dated 11/8/22 documents R259's Left Medial Foot Pressure Ulcer as a deteriorated Stage 3 due to larger size.
R259's Care Plan dated 11/8/22 documents heel protectors at all times. This same Care Plan documents to float R259's heels. This same care plan documents an intervention for a pressure redistribution mattress and to assess pressure ulcer weekly by licensed nurse.
R259's Wound Evaluation and Management Summary dated 11/16/22 documents R259's Left Medial Foot Stage 4 Pressure Ulcer as deteriorated due to larger size. This same report documents a physician order to cleanse R259's Left Medial Foot Stage 4 Pressure Ulcer and apply Calcium Alginate, absorbent pad and gauze wrap twice daily. This same report documents a physician order for R259 to wear calf high heel protectors at all times.
R259's Wound Evaluation and Management Summary dated 11/29/22 documents R259's Left Medial Foot Stage 4 Pressure Ulcer as deteriorated due to larger in size. This same report documents a physician order to cleanse R259's Left Medial Foot Stage 4 Pressure Ulcer and apply Calcium Alginate, absorbent pad and gauze wrap twice daily. This same report documents a physician order for R259 to wear calf high heel protectors at all times.
R259's Physician Order Sheet (POS) dated December 1-31,2022 does not document a physician order for R259's Left Medial Foot Stage 4 Pressure Ulcer from 12/2/22-12/8/22.
On 12/06/22 at 2:22 PM R259's Left Foot was covered with a white gauze bandage not dated or initialed. R259 was not wearing heel protectors. R259's heels were not floated. R259's bed did not have a low air loss mattress.
On 12/07/22 at 2:00 PM, V4 (Licensed Practical Nurse/LPN) completed the dressing change for R259's Left Medial Foot Stage 4 pressure ulcer. R259's wound had a red wound base with approximately 50 percent yellow slough covering base of wound. The peri wound area was dry with moderate dark red color. R259's wound had a previously applied Calcium Alginate dressing well adhered to wound. V4 (LPN) spent several minutes soaking the prior dressing off of R259's wound. R259 showed facial grimacing as V4 LPN was attempting to remove the prior dried on dressing. R259 was not wearing heel protectors. R259's heels were not floated. R259's bed did not have a low air loss mattress.
On 12/8/22 at 10:30 AM, R259 was laying on R259's back in bed with both heels laying directly on the sheets. R259 was not wearing heel protectors. R259's heels were not floated. R259's bed did not have a low air loss mattress.
On 12/9/22 at 10:30 AM, R259 was sitting up in the wheelchair with R259's Left foot on the foot pedal and Right foot resting on the floor. R259 was wearing ankle high heel protectors. R259's Right foot was dark purple colored and Left foot was purple and white colored.
On 12/07/22 at 2:10 PM, V4 (Licensed Practical Nurse/LPN) stated prior to changing R259's Left Medial Foot Stage 4 Pressure Ulcer dressing, V12 (Wound Physician) changed R259's Pressure Ulcer dressing orders 12/6/22 but new order has not been entered into Electronic Medical Record (EMR).
On 12/8/22 at 1:00 PM, V2 (Director of Nursing/DON) stated R259 is to be seen weekly by V12 (Wound Physician). V2 stated R259 was not seen by V12 on 11/23/22 due to the holiday. V2 stated We (facility) did not assess R259's Left Medial Foot Stage 4 Pressure Ulcer that week. R259 went from 11/16/22-11/29/22 without having (R259's) wound assessed. That is unacceptable. It had gotten worse again on 11/16 so that is even more reason to keep an eye on that wound. I wasn't aware of (V12's) physician order for the calf high heel protectors so that is why R259 has not had them on. If the previous dressing was that difficult to remove, I am sure it had been on for more than one shift. That dressing was most likely put on by V12 on V12's 12/6/22 rounds. That would make the most sense since V12 saw R259 and treated R259's Left Medial Foot wound that day. V2 (DON) stated R259 should have heels floated, calf high heel protectors in place and have a low air loss mattress. V2 stated Anyone with a Stage 4 pressure ulcer should automatically be on a low air loss mattress. (R259) is on a pressure reducing mattress, but they are not the same. (R259) needs the low air loss mattress. I don't know how we missed that.
On 12/9/22 at 9:30 AM, V13 (Regional Clinical Nurse) confirmed the facility did not enter V12's (Wound Physician) treatment orders for R259's Left Medial Foot wound. V13 stated There are no orders entered into the Electronic Medical Record (EMR) for R259's Left Medial Foot pressure ulcer from 12/2/22 through 12/9/22. The staff should have entered those orders into the EMR. I do not know why the orders did not get entered but we (facility) will get it taken care of today.
On 12/9/22 at 10:35 AM, R259 stated, They (staff) just dragged those things (heel protectors) in here this morning. I have not had them since I have been here. I want to go home but first I have to get these sores healed up. I will do what the doctor says so that I can get home. R259 confirmed R259 had not been offered or given any style of heel protectors, or air mattress since admission.
The facility policy titled 'Prevention of Pressure Injuries' revised 1/10/22, documents the following: Provide a low air loss or other similar surface to those residents who are at high risk according to the Skin Risk Assessment. Low air loss systems will be inflated based on resident's weight, tolerance and functional status with that inflation rate marked on the control unit and checked each shift for correct settings. Residents on low air loss mattresses require the assistance of two staff for repositioning, turning, perineal care, bathing, transfer or other process where the resident may need support. Complete a skin inspection assessment in EMR approximately weekly for the duration of the resident's stay.
The undated facility policy titled 'Dressings, Dry/Clean' documents the following: Preparation: Verify that there is a physician's order for this procedure. Label tape or dressing with date, time and initials.
The facility's undated Dressings, Dry/Clean Policy, documents the purpose is to provide for the application of dry, clean dressings. This policy also documents to verify a physician's order for the dressing, check the treatment record, clean the wound, apply the dressing.
2.) R29's Physician Order Sheet (POS), dated 11/2022, documents R29's diagnoses as: Morbid (Severe) Obesity due to excess calories, Excoriation (skin picking) Disorder, and Paresthesia of Skin.
R29's Care Plan dated 12/7/22, documents potential for pressure ulcer development related to history of pressure ulcer, impaired mobility, and morbid obesity.
R29's Minimum Data Set (MDS) dated [DATE], documents R29 is cognitively intact.
R29's Skin & Wound Evaluation V5.0 dated 10/20/22, documents a venous skin issue on the left medial malleolus.
R29's Wound Evaluation & Management Summary dated 11/16/22, documents stage 4 pressure wound of the left lateral ankle, dressing treatment plan, Alginate calcium, apply three times per week for 22 days, foam dressing apply three times per week for 22 days, peri wound skin prep apply three times a week for 22 days.
R29's Medication Administration Record (MAR) and Treatment Administration Record (TAR) both dated November 2022, have no documented treatment order for R29's left lateral ankle wound since 11/18/22. R29's Progress Notes dated 11/29/22, documents R29 was taken to the Emergency Room.
On 12/7/22 at 1:54 PM, V17 (Nurse Practitioner/NP) stated R29 came to the emergency room on [DATE] and had a dressing on R29's ankle with the date written on the dressing as 11/18/22.
On 12/9/22 at 12:31 PM, V1 (Administrator) stated there are no orders documented for treatments for R29's ankle after 11/18/22.
On 12/9/22 at 2:48 PM, V15 (Nurse Practitioner/NP) stated the dressing for R29's ankle should have been changed three times a week according to the wound doctor's orders, and there are no orders for R29's dressing changes since 11/18/22. V15 stated there is no excuse for these bandages not being changed.
3.) R56's undated Face Sheet, documents R56's diagnoses as: Chronic Kidney Disease, Peripheral Vascular Disease (PVD), Kidney Transplant Status, Infection of Amputation Stump right lower extremity, Acquired Absence of Right Leg Below the Knee, and Absence of Left Leg Below the Knee.
R56's Care Plan dated 12/5/22, has no documentation of pressure areas on the stump of the right leg.
R56's MDS dated [DATE], documents R56 is moderately impaired cognition, has medically complex conditions including Coronary Artery Disease (CAD), Heart Failure, Renal Insufficiency, Rhabdomyolysis, Occlusion and Stenosis of Left Carotid Artery. This same MDS documents R56 requires extensive assistance for bed mobility, dressing, and toilet use. Also, the MDS documents R56 has functional limitation in range of motion due to lower extremity impairment on both sides and uses a wheelchair and limb prosthesis.
R56's Progress Notes, dated 11/21/22, document R56 returning to the facility with right area on right stump. R56's November 2022 POS has no orders for treatment for R56's right stump area, and there is no treatment documented for R56's right stump on the November 2022 Treatment Administration Record.
The Hospital Note dated 11/27/22 documents R56 was admitted to the hospital on [DATE].
The Hospital Note dated 11/28/22 documents R56 has a pressure sore to the right residual limb measuring eight centimeters by six centimeters with sanguineous drainage.
R56's Discharge summary, dated [DATE], documents a primary discharge diagnosis as Infected Right Stump with Osteomyelitis. This same summary documents findings as changes of below the knee amputation, edema and bone marrow edema enhancement of the distal most tibia and fibula consistent with osteomyelitis, overlying soft tissue edema and enhancement consistent with cellulitis. The summary documents there is skin ulceration.
On 12/9/22 at 2:03 PM, V2 (Director of Nursing/DON) stated we don't have documents or orders for R56's stump treatment only orders from 12/1/22, when R56 returned from the hospital.
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** Based on observation, interview and record review, the facility failed to supervise and implement fall interventions for a resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to supervise and implement fall interventions for a resident (R45) resulting in a fall with major injury. The facility also failed to maintain safe positioning of a resident's (R10) wheelchair during transfer. This failure affects two residents (R45, R10) of seven residents reviewed for accidents in a sample list of 27 residents. R45 sustained contusions (bruises) and a scalp laceration requiring 12 sutures from an unsupervised fall at the facility.
Findings include:
1.) R45's undated Face Sheet documents medical diagnoses of Dementia without Behavioral Disturbance, Metabolic Encephalopathy and History of Falling. R45's Minimum Data Set (MDS) dated [DATE] documents R45 is moderately cognitively impaired. This same MDS documents R45 requires extensive assistance of two people for bed mobility, transfers, dressing and toileting. R45's Fall Risk assessment dated [DATE] documents R45 as a high fall risk.
R45's Care Plan intervention dated 7/13/22 documents keep personal belongings within reach.
R45's Nurse Progress Note dated 11/13/22 at 11:24 AM documents R45 observed on the floor bleeding from the head. R45 stated that R45 was sitting on the bed and leaned over and fell. Per R45's roommate (R42), R45 was sleeping on the side of bed and fell over. Emergency services were called immediately. Noted laceration on top of scalp and abrasion. Pressure applied to stop the bleeding. Emergency services arrived and R45 sent to emergency room.
R45's emergency room discharge instructions, dated [DATE], documents R45's diagnoses as: Fall, Head Injury, Contusion of Right Eye, Scalp Laceration and Shoulder Contusion.
R45's Fall Investigation dated 11/13/22 documents R45 observed on floor with bleeding from scalp. Upon entering room, R45 sitting with back against the bed, legs extended. This same report documents R45 stated 'was sitting on bed, leaned over to grab something and fell over hitting head'. This same report documents injury type: laceration to top of scalp. This same report documents R45 has intermittent confusion at times and was sent to emergency room for evaluation and treatment. This same report documents R45 obtained 12 sutures to top of head from a fall.
On 12/6/22 at 12:30 PM, R45 sitting on side of R45's bed looking down at box of tissues sitting on floor. R45 had facial bruising on forehead and under both eyes that was gray and yellow colored.
On 12/7/22 at 1:00 PM, R45 sitting on side of bed with no shoes or socks on feet. R45 did not have a bedside table in the room. R45's personal belongings were placed in an open closet and in a chair sitting next to the bed.
On 12/7/22 at 2:20 PM, V7 (Certified Nurse Aide/CNA) stated R45 falls frequently. V7 stated, Sometimes R45 knows what is going on but most of the time (R45) needs a lot of supervision and reminders to not fall.
On 12/8/22 at 10:00 AM, V2 (Director of Nursing/ DON) stated, We (facility) are really unsure how R45 fell. R45'snfall on 11/13/22 was unwitnessed by staff. R45's roommate (R42) stated (R45) was sitting on the side of (R45's) bed, fell asleep and then fell over hitting his head. R45 told us (facility) that he was sitting on the side of his bed, leaned over to pick something up off of the floor and fell over. Either way, R45 ended up with 12 sutures in R45's head. This fall could have been prevented if the staff were watching (R45) closer. We (facility) should have seen that R45 was either falling asleep on the side of the bed which is dangerous or that R45 should have had all the personal items within (R45's) reach. We (facility) do not know when the last time (R45) was checked on prior to the fall. (R45) has had a ton of falls, so we (facility) need to be watching R45 like a hawk.
On 12/9/22 at 11:00 AM, V6 (Licensed Practical Nurse/LPN) stated I was R45's nurse the day he fell and got stitches in his head. R45 is supposed to have all of his belongings within reach, and he did not because he does not have a bedside table. R45 did reside on another hall and had a bedside table but for whatever reason R45's bedside table did not get transferred over here with him. R45's orientation is come and go. Some days (R45) is sharp and other days he needs a lot of supervision. I had several other very ill residents that day and was not able to keep close supervision of R45 like he needs. The staff are very good, but they (CNA's) were busy helping me with the other ill residents when this happened.
2.) R10's undated Face Sheet documents medical diagnoses of Emphysema, Dysphagia, Vascular Dementia, Restless Leg Syndrome and Chronic Pain.
R10's Minimum Data Set (MDS) dated [DATE] documents R10 is moderately cognitively impaired. This same MDS documents R10 requires extensive assistance of one person for transfers, bed mobility and personal hygiene.
R10's Care Plan dated 10/27/22 documents a bruise to Left Lower Extremity with intervention to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. This same care plan documents an intervention to keep environment clutter free.
R10's Facility Incident Investigation dated 10/27/22 documents, V16 (Certified Nurse Aide/CNA) reported to nurse that R10's wheelchair fell over and hit R10's left lower extremity. Noted bruise to area. (R10) stated 'the wheelchair fell on my leg when I was sitting in recliner.' This same report documents root cause: R10 was putting recliner footrest down and hit the wheelchair, which tipped and fell on R10's feet. Intervention: encourage (R10) not to leave wheelchair next to the recliner.
R10's Nurse Progress Noted dated 10/28/22 at 2:02 PM, documents V15 (Nurse Practitioner/NP) came to see R10 regarding wheelchair bumping R10's leg when it fell over and bruise to Left Lower Extremity (LLE). New order received to obtain Left Ankle X-Ray complete.
On 12/7/22 at 11:30 AM, R10 stated That girl V16 (Certified Nurse Aide/CNA) was trying to help me get out of my recliner. V16 did not watch where my wheelchair was. V16 just came in and pushed my recliner footrest down and it made the wheelchair fall on my legs. It hurt a bit and left a small bruise. V16 should have been more careful.
On 12/8/22 at 10:30 AM, V6 (LPN) stated R10 was sitting in R10's recliner when the (V16) Certified Nurse Aide (CNA) pushed down on the footrest of R10's recliner chair. This made the wheelchair tip over onto V16 and R10' legs and feet. The handle of the wheelchair is what hit R10's legs and feet. There was a bruise on R10's left lower leg. V16 should have been more careful and made sure the wheelchair was out of the way so R10 would not have gotten hurt.
On 12/8/22 at 2:30 PM, V2 (DON) stated that R10 did not push down her own footrest as the fall investigation documents. V2 stated, V16 (CNA) actually pushed down the footrest, not (R10). The fall investigation report should have been modified. V16 should have made sure to move the wheelchair out of the way of the footrest. That would have solved the problem. Instead, R10 ended up with a bruise because V16 did not think ahead and try to protect the resident.
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 potential verbal abuse to the Administrator. This failure af...
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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 potential verbal abuse to the Administrator. This failure affects one of two residents (R31) reviewed for abuse on the sample list of 27.
Findings include:
R31's Progress Note dated December 2022 documents R31 is diagnosed with Bipolar Disorder, Anxiety Disorder, Major Depressive Disorder, and Factitious Disorder Imposed on Self.
R31's Minimum Data Set, dated [DATE] documents R31 is cognitively intact.
R31's Care Plan dated 10/7/21 documents R31 has a potential for abuse related to her low self-esteem, anxiety, and attention seeking behavior. Staff are to monitor, document, and report any signs or symptoms of R31 posing a danger to herself or others. R31 also displays negative verbalizations towards staff and other residents and can be disruptive, insensitive, and disrespectful.
R31's Progress Note dated 5/12/22 documents V11 (Activities Staff) (no longer a facility employee) witnessed R31 screaming and cursing at three other residents that were in line to smoke, which caused a commotion and upset other nearby residents.
On 12/8/22 at 11:02 AM, V2 (Director of Nurses/DON) confirmed there is no record that R31's behavior on 5/12/22 was reported to the Administrator and should have been reported as potential verbal abuse and investigated as such.
On 12/08/22 at 3:30 PM, V1 (Administrator) confirmed that there is no evidence R31's behavior on 5/12/22 was reported to the Administrator at the time and should have been reported immediately as potential verbal abuse.
The facility Abuse Policy and Procedure dated 9/26/22 documents staff will recognize and report occurrence of abuse, neglect, exploitation, and misappropriation of property. Employees are required to report any allegation of potential abuse they observe, hear, or suspect to the Administrator immediately. These reports will be documented, and a record shall be kept of the documentation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure required personnel attended the required quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the p...
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Based on interview and record review, the facility failed to ensure required personnel attended the required quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 53 residents in the facility.
Findings include:
The undated Quality Assurance Performance Improvement Program documents the facility QAA Committee consists of the Director of Nurses, the Medical Director, the Administrator, at least two other members of the facility staff, and the Infection Control staff member.
On 12/8/2022, V1 (Administrator) provided five QAA Meeting Verification Sheets (3/3/2022, 4/27/22, 5/25/22, 6/29/22, and 9/28/2022) for the previous year's QAA meetings.
The March, April, May, and September 2022 QAA Meeting Verification Sheet sheets do not document the facility Director of Nursing was present at the meetings.
On 12/8/22 at 3:30 PM, V1 (Administrator) confirmed all required members of the QAA committee including the Director of Nurses should be present at all quarterly QAA meetings.
The facility Resident Census and Conditions of Residents report (12/6/2022) documents 53 residents reside in the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow hand hygiene practices to prevent potential cro...
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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 hand hygiene practices to prevent potential cross contamination during urinary catheter care for one (R45) resident out of one resident reviewed for catheter care in a sample list of 27 residents.
Findings include:
The undated facility policy titled 'Handwashing/Hand Hygiene' documents the following: This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub (ABHR) containing at least 62% alcohol; or, alternatively, soap (Antimicrobial or non-Antimicrobial) and water for the following situations: before and after direct contact with residents, before and after handling an invasive device (urinary catheter) and before moving from a contaminated body site to a clean body site during resident care.
R45's undated Face Sheet documents medical diagnoses of Dementia without Behavioral Disturbance, Urinary Retention, Metabolic Encephalopathy and History of Urinary Tract Infections (UTI).
R45's Minimum Data Set (MDS) dated [DATE] documents R45 is moderately cognitively impaired. This same MDS documents R45 requires extensive assistance of two people for bed mobility, transfers, dressing and toileting.
On 12/07/22 at 2:20 PM, V7 (Certified Nurse Aide/CNA) completed urinary catheter care for R45. R45's urinary catheter was not secured to R45's thigh area. R45 was not wearing any type of urinary catheter securement device. R45's urinary catheter drainage bag was attached to R45's bedframe as V7 assisted R45 in rolling over, R45's urinary catheter tubing became very taunt, pulling on R45's urinary catheter. V7 untangled R45's urinary catheter tubing from R45's Right leg and shoe. V7 then provided urinary catheter care and applied a new incontinence brief. V7 did not provide a urinary catheter securement device for R45. V7 tossed soiled linen directly on floor next to R45's bed after cleansing R45's perineal area. V7 did not change gloves, wash hands, or use hand sanitizer during entire procedure.
On 12/07/22 at 2:40 PM, V7 (Certified Nurse Aide/CNA) stated all soiled linen should be placed in a plastic bag and not placed on R45's floor. V7 stated R45 came from the hospital with that catheter, and he had a leg strap on when he came back from the hospital. It must have not gotten replaced. It would sure help from stretching that urinary catheter tubing. V7 (CNA) stated gloves should be changed whenever they become contaminated.
On 12/7/22 at 4:00 PM, V2 (Director of Nurses/DON) stated staff should use good hand hygiene practices whenever providing direct care to all residents. V2 stated (V7) CNA should have had a second staff member to help, should have changed gloves and should never just toss down the soiled linens on the floor. V2 stated the facility does not have a policy for providing urinary catheter care.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure the Infection Preventionist had completed mandatory training in Infection Control and Prevention per the Centers of Disease Control ...
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Based on interview and record review, the facility failed to ensure the Infection Preventionist had completed mandatory training in Infection Control and Prevention per the Centers of Disease Control (CDC). This failure has the potential to affect all 53 residents residing in facility.
Findings include:
The Facility Census and Condition Report dated 12/6/22 documents 53 residents reside in facility.
On 12/8/22 at 2:30 PM, V2 (Director of Nursing/DON) stated, I am the Infection Preventionist for the facility. I have completed all of the modules but unable to provide documentation of the completion of the course.
On 12/9/22 at 1:00 PM, V1 (Administrator) stated, I am an Infection Preventionist but do not have my certificate at facility and unable to provide the necessary documentation. V1 (Administrator) confirmed facility is unable to provide documentation of Infection Prevention completion for any other staff members.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 3 harm violation(s), $216,048 in fines, Payment denial on record. Review inspection reports carefully.
- • 54 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
- • $216,048 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (5/100). Below average facility with significant concerns.
Bottom line: Trust Score of 5/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Hilltop Skilled Nsg & Rehab's CMS Rating?
CMS assigns HILLTOP SKILLED NSG & REHAB an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Hilltop Skilled Nsg & Rehab Staffed?
CMS rates HILLTOP SKILLED NSG & REHAB's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 56%, which is 10 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 73%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Hilltop Skilled Nsg & Rehab?
State health inspectors documented 54 deficiencies at HILLTOP SKILLED NSG & REHAB during 2022 to 2024. These included: 3 that caused actual resident harm, 50 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Hilltop Skilled Nsg & Rehab?
HILLTOP SKILLED NSG & REHAB is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CREST HEALTHCARE CONSULTING, a chain that manages multiple nursing homes. With 108 certified beds and approximately 59 residents (about 55% occupancy), it is a mid-sized facility located in CHARLESTON, Illinois.
How Does Hilltop Skilled Nsg & Rehab Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, HILLTOP SKILLED NSG & REHAB's overall rating (1 stars) is below the state average of 2.5, staff turnover (56%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Hilltop Skilled Nsg & Rehab?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Hilltop Skilled Nsg & Rehab Safe?
Based on CMS inspection data, HILLTOP SKILLED NSG & REHAB has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Hilltop Skilled Nsg & Rehab Stick Around?
Staff turnover at HILLTOP SKILLED NSG & REHAB is high. At 56%, the facility is 10 percentage points above the Illinois average of 46%. Registered Nurse turnover is particularly concerning at 73%. 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 Hilltop Skilled Nsg & Rehab Ever Fined?
HILLTOP SKILLED NSG & REHAB has been fined $216,048 across 4 penalty actions. This is 6.1x the Illinois average of $35,239. 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 Hilltop Skilled Nsg & Rehab on Any Federal Watch List?
HILLTOP SKILLED NSG & REHAB is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.