CHICAGO RIDGE SNF
For profit - Limited Liability company
231 Beds
SABA HEALTHCARE
Data: November 2025
10 Immediate Jeopardy citations
Trust Grade
0/100
#492 of 665 in IL
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Chicago Ridge SNF has received a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #492 out of 665 facilities in Illinois, placing them in the bottom half, and #161 out of 201 in Cook County, meaning only 40 local facilities are worse. The facility is currently on an improving trend, reducing issues from 30 in 2024 to 24 in 2025, but it still faces serious challenges, including $597,937 in fines, which is higher than 92% of Illinois facilities. Staffing is a concern, with a low rating of 1 out of 5 stars and a turnover rate of 52%, which is near the state average. Specific incidents highlight serious safety issues, such as two residents testing positive for fentanyl and opiates, one requiring Narcan after slumping in a wheelchair and needing emergency care. Additionally, another resident suffered a drug overdose due to inadequate supervision, further emphasizing the need for better oversight. While the facility has more RN coverage than average, the overall quality of care remains poor, with 131 total issues found, including 10 critical and 18 serious deficiencies. Families should weigh these significant safety concerns against any potential strengths when considering this nursing home.
- Trust Score
- F
- In Illinois
- #492/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $597,937 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 131 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 27%
Review needed
30 → 24 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 30 issues
2025: 24 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: 52%
Near Illinois avg (46%)
Higher turnover may affect care consistency
Federal Fines: $597,937
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: SABA HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 131 deficiencies on record
10 life-threatening 18 actual harm
Sept 2025
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have an effective contraband policy to prevent illicit drugs from be...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have an effective contraband policy to prevent illicit drugs from being brought into the facility, distribute and used by the residents. The facility failed to develop a plan to determine how the illicit drugs are coming into the facility. This affects 2 of 2 (R7 and R14) residents that tested positive for fentanyl and opiates and had the potential to affect all 13 (R3, R4, R6, R7, R8, R14, R16, R17, R18, R19, R20, R22, and R23) residents reviewed for illicit substance/contraband within the facility. R7 was observed slumping forward in the wheelchair, fell to the floor, was cyanotic and required Narcan (opioid antagonist/opioid reversal agent) to be given. R14 was transported to local hospital emergency room for a change in condition. R14 tested positive for fentanyl and opiates metabolites.Findings include:
The immediate jeopardy which began on [DATE] when R7's urine test was positive for opiates, R7 later was observed slumping forward in wheelchair, R7 fell to the floor, vital signs were very low, R7 was cyanotic, code blue announced, Narcan given. On [DATE] R7 complained of suicidal ideations, sent to hospital tested positive for fentanyl. On [DATE], R14 observed drowsy, opening his eyes and then closing them, 911 summons, R14 tested positive for fentanyl, and opiates metabolites in the emergency room.
On [DATE] at 9:53 am, V12 (Corporate Nurse Consultant) was informed of the immediate jeopardy that began on [DATE].
The immediacy was removed on [DATE] after the facility provided an acceptable removal plan on [DATE]. On [DATE] and [DATE] the surveyor was onsite to confirm the removal plan was implemented. Although the immediacy was removed, the deficiency remains at the Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
Local police report, dated [DATE] at 2:53pm report number xxxx-xxxxx, denotes in-part: on [DATE] at approximately 253hrs, Reporting Officer (R/O) #XXX was dispatched to Chicago Ridge Nursing Home located at (facility address) reference a report of narcotics inside of the facility. Upon arrival, R/O made contact with the social worker for the nursing home, V13 (Social Service consultant). V13 advised that staff had interviewed three people who advised the following. V13 advised an unknown female nighttime worker at the facility is bringing in narcotics and selling them to a resident named R6. These narcotics are believed to be Cannabis, Methamphetamine, and Heroin. R6 is then selling the narcotics to two other residents: R3 and R8. R3 and R8 are then distributing narcotics to six other residents: R23, R20, R16, R22, R17, and R19. V13 advised that R6, R3, R8, and R23 are being Involuntarily discharged from the facility due to their involvement. V13 advised all of the other above listed subjects are able to stay, for now. V13 then handed R/O a garbage bag containing drug paraphernalia. R/O discarded the garbage bag when he returned to (Police Department). The nursing home is going to continue to attempt to identify the worker who is providing the narcotics to the patients; therefore, this case is to be considered open at this time. Nothing further.
On [DATE] at 12:16pm V2 (Administrator) said the facility was cited for a drug overdose in [DATE] and was cleared on [DATE]. V2 said on [DATE] she was made aware that R3, R6 and R8 was involved with selling drugs in the facility. During a follow up interview on [DATE] at 11:11am V2 said, no residents have been transferred to the hospital for illicit drug overdose, suspicion of illicit drug over, or illicit drug related issues.
On [DATE] at 2:06pm V13 (Social Services Consultant) said on [DATE] the maintenance staff informed her that when he was routinely changing a ceiling tile in a resident room, he found some items in the ceiling. V13 said the items was identified as drug paraphernalia. V13 said the police was called and all the ceilings in the rooms on the first floor was searched. V13 said, Residents were interviewed, and a male resident informed her that a female staff with burgundy hair that works the night shift was bringing the drugs into the facility and selling them to the residents. V13 said she informed the police of the description of the female staff. V13 said she can't recall who the male resident is, who informed her of the description of the female staff. V13 said she will go and review her information and follow up with the surveyor. V13 said she can't recall the description of the male resident that informed her of the female staff. V13 said she informed the V2 (Administrator) of the description of the alleged female staff supplying the residents with drugs, and allegedly the administrator said that could be anybody.
During this survey V13 did not follow up with the surveyor regarding who is the identified resident that gave the description of the female staff with burgundy hair.
Review of the police report filed by V13 dated [DATE], there is no documented description of female staff with burgundy hair in the police report, only description given is a female night staff.
On [DATE] upon entrance to the facility, the posted notice was observed to be updated to include staff belongings will be searched. On [DATE] and [DATE], the posting did not include search of staff belongings, observed by multiple surveyors.
1.R7 MDS dated [DATE] denotes BIMS score of 15 (cognitively intact). R7 face sheet shows diagnosis of anxiety, depression, presence of pacemaker, chronic atrial fibrillation.
On [DATE] at 1:30pm, R7, observed alert to person, place, and situation. R7 stated that he was given cocaine on [DATE], stated that he was hospitalized on [DATE]. R7 said he thought he was purchasing cocaine, and not fentanyl. R7 said he doesn't want to name the female resident that gave him the drug, he doesn't want to get her in trouble because she doesn't have anyone. R7 said he used cocaine in the past, stated that once he took the cocaine that he got from the female he knew it wasn't cocaine, it was different. R7 said he does remember he went to the hospital the next day. R7 said the female resident still resides at the facility. R7 declined to give description of the alleged female resident.
[DATE] at 3:40pm V11 (Licensed Practical Nurse/LPN) said she was working on evening shift [DATE], R7's speech was slurred. V11 said it was reported by the day shift Nurse that R7 needed to provide a urine specimen and R7 was unable to provide it during the day shift. V11 said she assumed that R7 was behaving suspiciously on day shift; that's the only reason why staff would collect a urine drug screen. V11 said when R7 was giving the urine sample, R7 kept standing and sitting. V11 said R7's urine specimen tested positive for opiates. V11 said when R7 came out of room after eating dinner, R7 was in a wheelchair. R7 was slumping forward in the wheelchair, then fell to the floor. V11 said R7 vital signs were very low, oxygen was applied to his face, R7 was cyanotic. V11 said she called a code blue. V11 said she administered two doses Narcan. The medical doctor said to monitor R7, neuro checks are scheduled in (electronic records) and vs (vital signs) were done every two hours. V11 said she asked R7, who gave him the illicit drugs? R7 responded, I don't know, I only take my scheduled medications. V11 said she documented the code blue in risk management and the vitals were documented in the records.
On [DATE] at 12:38pm V4 (Substance Abuse Coordinator) said R7 did not have a community pass on [DATE] or [DATE] and does not recall him visiting with his family on [DATE] or [DATE]. V4 said she signs and gives the residents community access passes.
On [DATE] at 3:01pm V10 (Director of Nursing/DON) said R7 informed him that he got cocaine from a resident but refused to talk about it and give information on the resident.
R7's care plan with initiate date of [DATE] denotes in-part, the resident has a history of substance abuse chemical dependency related to clinical depression and anger history of mental illness severe mental illness, poorly developed ability to control impulse, allowing negative inappropriate persons to influence his use of substance. Problem and symptoms are manifested by going into the community to become intoxicated, problems and symptoms are manifested by failure to accept responsibility for actions and to be honest with oneself. The drug of choice is opioids. Date initiated [DATE]. Goals, I will refrain from using non prescribed substance through the next review date. Resident will attend substance abuse group two times a week to address issues of addiction. Staff will conduct random room searches provide supervised visits, and search residents belongings as needed as it relates to substance use. Staff will perform random drug screening to assess for substance use. Upon suspicion that resident has illicit drugs or used illicit drugs they will be placed on one-to-one monitoring/supervision. Work with the resident to establish a verbal or written behavior contract; specify what is and what is not allowed. Make sure the resident is aware of rules prohibiting use of alcohol, illicit substance and intoxication. Meet with the ID team to discuss the extent of the resident's illness the physician may consider a referral for psychiatrist spam or write borders restricting pass privileges. Provide leisure counseling to the resident to help him use free time and productive nondestructive ways.
R7's progress note dated [DATE] completed by V11 (LPN) denotes in-part resident was observed with signs and symptoms of substance abuse, Physician notified obtained order for drug screen. Resident tested positive for opioids; order received to monitor vs (vital signs) every 4 hours x 72hours. Restrict pass, supervised pass until further notice. Okay to give scheduled medications. Notify MD (medical doctor) of any additional changes or AMS (altered mental status). Administrator, DON (Director of Nursing), and family member notified.
R7's progress note dated [DATE] at 9:27am completed by V4 (Substance Abuse Counselor/SAC) denotes in-part: it was brought to SAC (substance abuse counselor) & SS (social service) attention that the Resident was presenting suspicious behavior affiliated with Substance Abuse. The Resident was showing oddly behavior such as anxiety, sweating, showing a red complexion, and fidgeting with his nose as well as mumbling to himself. The Resident was asked to complete a drug screening whereas at the time stated he cannot go due to using the washroom ten minutes ago. The Resident was present during the room searched and no contraband was found. The Resident was placed on 1:1's with SAC & SS and later with SSA's (social service assistant). This took place on [DATE] at 1:00pm. It was brought to SAC & SS attention that the Resident completed the drug screening, and it was positive for opioids, which the Resident does take Hydrochlorothiazide; a form of the opioids family. SAC spoke with the Resident whereas he stated he did not take any illicit substance and was very adamant on not letting his sister know of what's going on because it's not true. The Resident also was asked; what happened yesterday during the time the Narcan was used, he stated he does not remember. The Resident explained why his test results were positive for Opioids and began mentioning SI (suicidal ideations), which he was placed on 1:1 monitoring until being D/C (discharged ) to the hospital. SAC will update the Resident care plans, assessments, and will upload signed documentation to (electronic records).
R7's hospital/emergency room records dated [DATE] denotes in-part chief complaint AMS (Altered Mental Status), elevated blood pressure, and noncompliance. Social history positive for opioid use, urine drug screen is positive for fentanyl, also on prescription narcotic pain medication, smoking positive although unable to quantify, nursing home resident, issues of compliance with medication. Treatment plan hypertension, atrial fibrillation, history of pacemaker placement, peripheral neuropathy chronic low back pain, seizure disorder, hypothyroidism, fentanyl abuse and intoxication, psychosis. Labs collected on [DATE] at 2:36pm urine opiates screen; positive- reference range; negative. Urine fentanyl collected [DATE] at 2:36pm positive, reference range; negative.
Review of R7's physician order sheet there are no active or discontinue orders for fentanyl.
2. R14's MDS dated [DATE] denotes BIMS score of 15 (cognitively intact). R14's face sheet shows diagnosis of hemiplegia following cerebral infraction affecting left dominate side, chronic obstructive pulmonary disease, psychoactive substance abuse, pulmonary embolism.
On [DATE] at 1:35pm R14 observed alert to person, place time and situation, sitting in wheelchair, able to self-propel. R14 said he purchased twenty dollars' worth of heroin from R3 on [DATE]. R14 said he was sent to the hospital, and the hospital told him that he tested positive for fentanyl. R14 said he didn't know that fentanyl was in the heroin. R14 said, that was not the first-time buying drugs from R3. R14 said the hospital doctor told him he could have died from fentanyl drug overdose.
[DATE] at 12:38pm V4 (Substance Abuse Coordinator) said she was not aware that R14 was sent to the hospital and returned with diagnosis of poly substance abuse on [DATE]. V4 said she should have been made aware. V4 said she was not aware that R14 used illicit drugs on [DATE], no one informed her. V4 said R14 does have a substance abuse history. V4 said R14 was readmitted to the facility after relapsing at home. V4 said R14's sister did not visit him on [DATE]. V4 said she is not aware that R14 went out on a community pass on [DATE]. V4 said she signs and gives the residents community access passes.
On [DATE] at 3:45pm V17 (LPN) said he was the Nurse on duty on [DATE], when a female staff got off the elevator with R14 and said, “this is your resident”. V17 said he didn't assess R14 at that time. V17 said he don't recall who the Aide was. V17 said he was passing medications, and a resident approached him and said, “there's something wrong with R14”. V17 said that's when he assessed R14 by calling his name, checking R14's vitals, continuing to call R14's name and doing a knuckle rub to R14's chest. V17 said R14 was drowsy, opening his eyes and then closing them. V17 said he called 911, when 911 arrived R14 was more alert. V17 said he did not give R14 any medication that would make him drowsy or any medications after observing R14 drowsy. V17 denied giving R14 Narcan and denied that any other staff gave R14 Narcan. V17 said he was the receiving Nurse upon R14's return to the facility. V17 said he reviewed the after-visit summary from the hospital, and it was documented that R14 diagnosis was transient alteration of awareness, polysubstance abuse, and dyspnea. V17 said he understands polysubstance abuse is when the resident is using medications and illicit substance together. V17 said he notified the Director of Nursing of R14's return and diagnosis. V17 said he doesn't recall if the Director of Nursing gave him any directives for R14. V17 said if the facility gave an in-service on when to administer Narcan, he was not at the facility. V17 said Narcan is used to reverse the effects of illicit drugs. V17 said R14 symptoms was different from someone that's overdosing on drugs. V17 declined to give the signs and symptoms of someone overdosing on drugs. V17 denied having knowledge if R14 has a substance abuse history. V17 did not give a response when asked should he have documented R14's presenting condition on [DATE] or the language “change in condition”. V17 said he don't know what the progress notes show. V17 was presented with R14's progress note that was presented by the facility. V17 said he could see the document.
On [DATE] at 3:01pm V10 (Director of Nursing) said he was made aware that R14 tested positive in the hospital for fentanyl. V10 did not respond when asked; when was he was made aware of R14 testing positive for fentanyl. V10 said he was concerned because R14 does not have a physician order for fentanyl. When asked how did R14 say he ingested the fentanyl, V10 said that's a good question. V10 said R14 mentioned that he purchased the heroin from R3, he didn't know fentanyl was in it. V10 said he did not inform the administrator that R14 test positive for illicit drug fentanyl and opiates. V10 decline to answer when asked when the staff should administer Narcan.
R14's progress note dated [DATE] completed by V17 (LPN) denotes in-part during routine rounds, resident was observed with a change in condition. Assessment was conducted, and resident was found unresponsive and unable to be aroused. With knuckle rub stimulation, the resident was able to open eyes briefly for a few minutes. Vital signs were as follows: BP: 139/83, Pulse: 116, Respirations: 20, Temperature: 98.2°F, O2 Saturation: 97%. 911 was called, and the resident was transported to (Hospital name) for further medical evaluation. MD (medical Doctor), family member, and ADON (Assistant Director of Nursing) were notified.
R14's baseline care plan dated [DATE] denotes in-part, I will comply with the intake procedures of substance abuse treatment program by the next care plan review date. I will refrain from using non-prescribed substance through the next review date. I will behave in a safe manner consistent with resident conduct policies through the next review date.
R14's emergency room after visit summary dated [DATE] denotes in-part chief complaint, altered mental status, fatigue. Visiting diagnosis: transient alteration of awareness, polysubstance abuse, and dyspnea. Medications given furosemide, naloxone (Narcan) and sodium chloride. Instructions stop using any drugs that are not prescribed to you or any street drugs at all.
Review of R14's physician order sheet there are no active or discontinue orders for fentanyl.
3. On [DATE] at 10:37am R4 observed to person, place, time and situation. R4 said the last time he used drugs was on [DATE]. R4 said he got the crack from R3. R4 said he doesn't have money to buy the drugs and R3 was giving him drugs to keep his mouth shut because he was aware of what was going on. R3 said, he told the administrator at the facility everything. R4 said R3 removes the drugs from under his testicles or from between his butt cheeks when a resident wants to buy it. R4 said a staff member was involved with R3 getting drugs into the facility, and that's why R3 was giving him drugs to keep quiet about it. R4 said when he reported the female staff, the administrator didn't want to hear what he had to say and asked him to leave the office.
On [DATE], V2 (Administrator) made aware of the specific name of the alleged staff member given by R4.
4. R3's progress note dated [DATE] at 4:31pm denotes in-part resident present as a risk to himself and others as evidenced by using and selling illicit substance in the facility. Resident is a danger to himself and others due to providing drugs to residents with medical and psychiatric issues. Resident has been placed on one to one with staff until local police and EMT's arrived at the facility. Per peer report, resident had a visitor who dropped off the illegal substance to the resident and he was hiding the items in his body cavity. The resident was immediately notified and given a notice of the need to conduct a room search, resident agreed. Upon room search, staff found a crack pipe. In the search contraband was recovered and discarded. The resident declined to a drug screen. Social service staff offered the resident another level of treatment such as inpatient or residential treatment for his substance use disorder. Resident decline. Resident was counseled on the safety risks associated with bringing in contraband. The resident was interviewed to obtain information on where contraband was coming from. At this time the resident will not identify the person who brought the contraband. The physician has been notified, and assessments have been updated as well as care plan. The resident has been given IVD (involuntary discharge) due to noncompliance related to contraband.
R3's progress note dated [DATE] at 4:29pm denotes in-part writer spoke with resident regarding discharge planning to another facility or a shelter. The resident was given a list of shelters that were accepting males. The resident refused help with discharge planning and stated that he is not going anywhere. Resident was educated on the facility rules and substance abuse policy and continues to not sign behavior contract. Resident is currently on one-to-one staff will continue to monitor behavior as needed.
On [DATE] the V14 (Assistant Director of Nursing) presents a “investigation” witness statement dated [DATE], statement completed by V4 (Drug Abuse Counselor) denotes in-part resident/staff involved R3, R6, and R8 name is listed. “I conducted multiple residents' room for contraband, and nothing was found”. Review of this “investigation”, there is no information documented that R3, R6, and R8 was interviewed about selling drugs in the facility, this investigation does not denote what areas of the room was searched.
Witness statement dated [DATE] completed by V3 (Social Service) denotes in-part resident/staff involved R3, R6, and R8 name is listed. “I conducted a room search that (state surveying agency) mentioned, no contraband found”. Review of this investigation, there is no information documented that R3, R6, and R8 was interviewed about selling drugs in the facility, this investigation does not denote what areas of the room was searched.
R22's witness statement dated [DATE] documents: Resident involved R8. R8 came to my (R22) room yesterday and sold me twenty dollars' worth of crack and heroin.
V6's (Maintenance Staff) witness statement dated [DATE] documents: I was changing the ceiling tiles in room xxxb, contraband was in the ceiling, suspected illicit drugs. Police report xxxx-xxxxx.
R16's witness statement dated [DATE] documents: Resident involved (R6). I was given heroin over the weekend by R6.
R20's witness statement dated [DATE] documents: Resident involved (R8). Last week when I got caught on the patio smoking cigarettes during fresh airtime. I was given a cigarette that was laced with crack cocaine by (R8).
R19's witness statement dated [DATE] documents: Resident involved (R3 and R8). R3 and R8 sell me drug when I have money. They will sell me crack cocaine and marijuana.
R17's witness statement dated [DATE] documents: Resident involved R3. R3 sell cocaine and he has a person who gives him the drugs. He gave me crack cocaine on [DATE]. I told them a letter of a name.
R4's witness statement dated [DATE] documents: Resident involved R3, R6, R8. I (R4) witnessed R8, R3, and R6 sell drugs in the facility. They will sell heroin, crack cocaine and marijuana to resident.
R20's witness statement dated [DATE] documents: Resident involved (R8). Last week, when I got caught on the patio smoking cigarettes during fresh air time. I was given a cigarette that was laced with crack cocaine by R8.
R18's witness statement dated [DATE] documents: Resident involved (R3). R3 sold me crack cocaine [DATE].
R14 witness statement dated [DATE] documents: Resident involved (R3). The man in xxxB gave me fentanyl at 10:30pm.
Facility policy titled policy on “Contraband Materials and Inspection of Rooms”, this organization follows federal standards concerning removal of contraband. If the suspected contraband is in plain sight, it shall be promptly removed. If there is reason to suspect/believe that a resident has contraband items/materials in his /her possession the individual will be asked to provide permission to search. If permission is not forthcoming, the individual may be notified that the local police will be notified and asked to complete a search, at the discretion of administration. The following items are NOT ALLOWED in the resident rooms at any time and are not allowed in the resident person. Drugs deemed illegal by federal and state government, prescription medication in the possession of someone to which they were prescribed, alcohol. The organization will try to balance individual rights against the safety needs of peers, visitors, and staff members in making decisions about further investigation of contraband. In situations where illegal activity appears to have taken place appropriate authorities will be notified. Again, safety and security are of the utmost concern.
During this survey the facility failed to present witness statements/investigation from female staff with description of burgundy hair. Per V13's (social service consultant) interview, a male resident described a female staff with burgundy hair, selling illicit drugs to residents.
During this survey there were multiple staff members observed with hair color hue of burgundy.
Upon exit of this survey, the facility failed to present policy/practice related to when to administer Narcan. During this survey V12 (Consultant) was asked, and V10 (Director of Nursing) was asked. It is not clear to surveyor as to when the staff should administer Narcan to a resident. The facility has resident residing that is identified with illicit substance abuse issues.
The Immediate Jeopardy began on [DATE]. The immediacy was removed on [DATE]. The surveyor on [DATE] and [DATE] via observation, interview and record review confirmed the following removal plan was implemented by the facility to remove the immediacy:
The Chicago Ridge Nursing & Rehabilitation Center outlines its plan to prevent illicit drug use and possible drug overdose among residents. The facility has implemented various measures to monitor residents to ensure a safe environment.
R3 no longer resides in the facility.
R6 is currently in the facility and is in stable condition. Remains under increased staff supervision. 1:1 supervision with a minimum of 3 days based on compliance with the plan-of-care.
R7 is currently in the facility and is in stable condition. Remains under increased staff supervision. 1:1 supervision with a minimum of 3 days based on compliance with their plan-of-care.
R8 is currently in the facility and is in stable condition. Remains under increased staff supervision. 1:1 supervision with a minimum of 3 days based on compliance with their plan-of-care.
R 14 is currently in the facility and is in stable condition. Remains under increased staff supervision. 1:1 supervision with a minimum of 3 days based on compliance with the plan-of-care.
· Immediate health assessments were performed by facility staff and hospital staff on R7 and R14.
· Immediate increased supervision was initiated for R3, R6, R7, R8, and R14.
· The facility initiated an investigation into the allegation of staff involvement and had no credible evidence that staff had any involvement in the distribution of illegal substances.
· The facility conducted a comprehensive search of the facility to locate and remove any illicit drugs or paraphernalia.
· The facility enlisted the involvement of external authorities, the (local) Police Department, and the Mayor's Office for assistance and support.
· The facility increased surveillance in key areas identified as potential points of vulnerability, such as the residents' rooms, patio area, and facility entrance.
Compliance Oversight and Documentation Plan for 1:1 Supervision
The following measures will be implemented to support the effectiveness and accountability of the Removal Plan:
Responsible Parties for Compliance
Administrator: Oversees overall implementation and ensures regulatory compliance.
Director of Nursing (DON) and Assistant Director of Nursing (ADON): Responsible for clinical oversight, staff supervision, and adherence to 1:1 monitoring protocols.
Social Services Director: Ensures proper assessment, documentation, and coordination of care for residents with substance use history.
Interdisciplinary Team (IDT): Reviews resident progress and adjusts care plans accordingly. IDT members include: MDS, Social Services, Wounds, Restorative, Dietary, Activities, DON and ADON.
Documentation of 1:1 Supervision, Compliance, and Outcomes Start Date 08-22-205 (ongoing).
Daily Logs: Staff assigned to supervision 1:1 will complete detailed logs documenting:
Start and end times of supervision: See Exhibit 1
Resident behavior and interactions
Any incidents or concerns
Compliance with plan-of-care
Electronic Health Record (EHR): All 1:1 supervision entries will be uploaded to the resident's EHR, including rationale for initiation, duration, and outcome.
Weekly Review: The Administrator or DON will conduct weekly audits of 1:1 supervision documentation to ensure accuracy and completeness.
Outcome Tracking: Residents will be assessed based on behavioral changes, adherence to care plans, and preparedness for transitioning out of 1:1 supervision.
Enhanced Monitoring Measures started 08-22-2025 (ongoing).
· Resident Rooms: Random room searches will continue as part of ongoing surveillance efforts to ensure safety and compliance.
· Patio Area: During the resident patio period, at least two staff members will be assigned to observe and supervise the area.
· Facility Entrance: Monitoring at the main entrance will be increased, and two employees will be assigned to supervise access and activities from 8 am until 8 pm.
· Any staff member suspected of involvement in the trafficking or distribution of an illicit substance will be immediately suspended pending investigation. An internal investigation will begin, and an external investigation may occur if appropriate.
· Initiation of random drug urine tests was implemented for residents at risk for drug use.
· All facility staff have been in-service in person or via telephone. Staff who have received training via telephone will be required to attend in-person training before the start of their shift. Upon completion of the in-person in-service, the staff will sign the in-service sheet. The administrator and/or social service director will conduct weekly spot checks to ensure the facility staff are knowledgeable of the content. Any staff who were unable to attend the in-service due to a planned vacation or leave of absence will be in-serviced on their next workday before the start of their shift. This in-service training will be conducted by the Administrator, Social Services Director, Director of Nursing (DON), or Assistant Director of Nursing (ADON), with an initial completion date of [DATE]. Ongoing training will be provided for all new hires, and
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to follow its medication administration policy and consistently monitor the effectiveness of pain medication. The facility also failed to ac...
Read full inspector narrative →
Based on interviews and record reviews, the facility failed to follow its medication administration policy and consistently monitor the effectiveness of pain medication. The facility also failed to accurately document the administration of controlled substances for 1 resident (R7) out of 3 reviewed for receiving high alert medications in a sample of 22.Findings include:
On 8/15/25 at 10:27 AM, V14 (Assistant Director of Nursing) stated that when a controlled substance medication (hydrocodone-acetaminophen) is administered, the nurse is expected to document in the resident's MAR (Medication Administration Record) at the same time. V14 stated that it is important to document in the MAR when an as needed medication is administered so the nurse will know what time the medication is administered and when the next dose can be administered. V14 stated that the nurse is expected to assess the resident for the effectiveness of the medication and document the resident's response in the MAR. V14 reviewed R7's controlled substance sheet for hydrocodone-acetaminophen. V14 reviewed R7's August MAR. V14 stated staff are not documenting when the medication was administered in R7's MAR. V14 acknowledged that nurses are not documenting accurately when controlled substance is given.
On 8/19/25 at 11:00 AM, V16 (Licensed Practical Nurse) stated that the nurse is expected to document on the controlled substance sheet and the resident's MAR when administering a controlled substance. V16 reviewed R7's MAR and controlled substance sheets for July and August 2025. V16 acknowledged that she did not document in R7's MAR every time she signed out hydrocodone-acetaminophen on the controlled substance sheet. V16 is unable to give reason why she did not chart in MAR.
R7's POS (physician order sheet), dated 8/31/24, notes an order for hydrocodone-acetaminophen 7.5-325mg (milligrams) give one tablet by mouth every 12 hours as needed for pain.
R7's MAR, dated July and August 2025, notes R7 received hydrocodone-acetaminophen on the following dates and times:
On 7/18 at 6:00 PM, pain 6 out of 10 generalized pain.
On 7/19 at 6:36 AM, pain 5 out of 10, back pain.
On 7/31 at 8:07 PM pain 8 out of 10, back pain.
On 8/1 at 8:32 AM, pain.
On 8/3 at 9:24 AM, pain 6 out of 10, back pain.
On 8/4 at 9:50 AM, back pain.
On 8/5 at 9:08 AM, pain 6 out of 10, back pain.
On 8/6 at 9:29 AM, pain 6 out of 10, back pain.
On 8/8 at 9:23 AM, pain 6 out of 10, back pain.
On 8/12 at 9:18 AM, pain 6 out of 10, back pain.
R7's controlled substance sheets, dated July and August, notes that hydrocodone-acetaminophen was signed out by the nursing staff twice a day.
There is no documentation found in R7's medical record noting the nursing staff monitored the effectiveness of R7's pain medication consistently.
R7's pain care plan, initiated 5/5/23, notes R7 is at increased risk for alteration in pain/discomfort related to general aches/pains. Interventions include but not limited to administer analgesic medication as ordered per plan of care, observe resident for effectiveness of pain relief, notify physician for any new resident complaints of pain or signs/symptoms of pain to obtain new order for medication regimen or break-through pain management, offer as needed analgesic medication as indicated for pain management.
The facility's administering medications policy, dated 1/1/2020, notes the individual administering the medication shall initial the resident's medication administration record (MAR) before administering the medication. The director of nursing is responsible for the supervision and direction of all personnel with medication administration duties and functions. If it is discovered the person administering medications has forgot to initial on the MAR, the supervisor shall notify that person to investigate if the medication has been administered. If the response indicates the medication was administered, the staff member shall return to the facility and document in the MAR as a late entry.
Aug 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent incident of resident-to-resident physical assa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent incident of resident-to-resident physical assault. This affected three of three residents (R1-R3) reviewed for physical abuse/assault. This failure resulted in R1 physically assaulting R2 and R3, however as a result of the assault, R1 sustained bilateral nasal bone fracture and blunt abdominal trauma. The findings include:On entry to the facility R1 had been hospitalized on [DATE]. According to progress notes, R1 returned to the facility on 8/7/25 at approximately 8:00PM. On 8/8/25 at 9:44AM R1 on patio, sitting, smoking. R1 looking down, away from surveyor, not making eye contact, did not interact or greet surveyor. R1 kept looking away. Observed under eyes swollen, light purple crescent shape under each eye, flat scratches/abrasions on right side of nose along bridge. R1 would not speak to surveyor.On 8/8/25 at 10:55AM R1 her room, no visible injury on hands or face. Ambulates freely. R1 said I was sitting outside having a smoke and that lady (R1) came up to me, got in my face and tried to hit, I hit her back. R2 said I'm not hurt. R1 said she not my friend I don't know why she wanted to fight me. R1 said yeah, we were fighting. R1 said V2 (Social Service Aide) was there she saw it. R1 said then R1 got in a fight with another lady; I just came inside. R2 said we was outside on the smoking patio.R1's diagnosis includes but are not limited to Anxiety Disorder, Cognitive Communication Deficit, and Unspecified Psychosis. R1's cognitive assessment dated [DATE] identifies she is cognitively intact. R1's behavior assessment dated [DATE] identifies delusions for potential indicators of psychosis.Witness statement with R1's name with no signature or date states I ran up to (R3) and attempted to hit (R3) and she hit (back). I got in (R2's) face and (was) trying to fight her.Witness statement with R3's name and signature states (R1) hit me and (I) hit her back and we started fighting.Witness statement with R2's name and signature states (R1) came in my face and R1 hit me, and I defended myself. I hit, grabbed her hair, and kicked her.On 8/7/25 at 11:22 V2 (Social Service Aide) said R1, R2, and R3 were outside on the smoking patio. V2 said V2 was inside, and one monitor was outside. V2 said V2 heard arguing and walked out, and saw staff try breaking up the fight. R1 and R2 were yelling at each other, and they were swinging at each other. R1 hit R2 first. R2 was sitting and R1 was standing over R2. V2 saw that R1 and R2 were getting separated. V2 said during that time R1 got away and hit R3, and then they start fighting. V2 said V2 saw R3 swinging at R1. V2 said as we were walking away, I saw R1 had blood on her nose. V2 said R1 came out, she looked frustrated and mad when she came outside, that is usual for her. At 2:11PM V2 said when R1 came down, V2 told her she could not go outside. V2 said I kept redirecting her and R1 took it upon herself to go outside anyway. V2 said V2 did not give her a cigarette. V2 said R4 said R1 woke up mad and irritated. V2 said when a resident is on restriction, Social Service Staff will give us the list, I was told the day before that R1 was on restriction. V2 said V2 told R1 she could not go out, she continued to walk past me, she said she wanted to go out. V2 said when R1 got out there, they started arguing. V2 said it was not reported to anyone that R1 was on the patio until after the fight had occurred.V2's witness statement signed and dated 8/5/25 states R1 went out the door and (V2) heard arguing. I saw V5 (Social Service Assistant) was trying to break up a fight between R2 and R1. I went to help and R1 ran to R3 and hit her, then they started fighting.On 8/7/25 at 12:23PM V3 (Licensed Practical Nurse/LPN) stated R1 was brought to the unit and V3 was notified she had been in altercation with another resident. V3 said V3 assessed her and cleansed her nose. V3 said V3 put an ice pack on her nose. V3 said she was not aware if R1 was on a smoking restriction.On 8/7/25 at 12:47PM R4 said on 8/5/25 R4 was on the patio smoking with R1. R4 said R1 was upset because the smoke girl had told her she can't come out and smoke the rest of the day. R4 said the other lady, lives on the first floor (R3) told her to mind her business. R4 said that made R1 mad and I told R1 to stay here, finish your smoke, be good, and then come back in. R4 said I came inside to talk to the smoke monitor inside. R4 said then I saw V2 run outside, and I just knew it was R1. R4 said when R1 came inside I saw blood on her nose and her cheek. R4 said R1 said she got in a fight. R4 said I spoke to R1 on the phone today, she said they were checking her out because she had blood on the brain.On 8/7/25 at 1:32PM V5 (Social Service Assistant) said R1 and R2 were arguing and then R1 hit R2. They were fighting. V5 said V2 (Social Service Aide) came to help me break up the fight. Then R1 went and hit R3. V5 said I was outside on the patio when the fight happened. V5 said R2 was sitting on the bench near where I was and then R1 walked up to R2, and they were arguing and then they were hitting (each other). V5 said R1 and R2 exchanged some words and R1 was mad. R1 had an attitude the whole time she was there. V5 said I sensed she was angry when she came out. V5 said R1 was on smoke restriction and was not supposed to be on the smoking patio.On 8/7/25 at 1:55PM V1 (Social Services) said R1 was on smoking restriction because she had got caught smoking in her room. V1 said R1 was on restriction for 30 days. V1 said R1 can go outside for fresh air but she can't be out there for smoking time. V1 said R1 wasn't supposed to be down there on 8/5/25. V1 said the V2 (Social Service Aide) should have stopped R1. V1 said V2 was trying to stop her from going out. On 8/7/25 at 2:24PM V6 (Director of Nursing) said R1 became aggressive with one resident and another resident jumped in and separated them. V6 said R1 had scratches on her face, and she was the aggressor. She tried to beat up 2 people at the same time. V6 said if a resident is on restrictions, they should not be on the patio with the smokers. V6 said we need to be vigilant to make sure to not allow the person to be outside. The surveyor asked V6 if not smoking can cause a smoker to be cranky. V6 replied absolutely can be cranky. V6 said for nicotine withdrawal we can offer them something else. V6 said I am not sure if R1 was offered something. V6 said I did not know R1 was on restriction until after the incident happened. V6 said R1 was not even supposed to be down there, on the smoking patio. V6 said if the smoke monitors cannot redirect the resident, they should call the nurse and social services for direction to ensure R1 did not violate her restriction. V6 said the staff did not tell anyone R1 was outside.Review of R1 progress notes include screaming and cursing at staff and punch and choke staff on 1/30/25. On 5/12/25 progress notes states R1 presented verbal inappropriate behavior with obscene language to the writer.On 8/8/25 at 1:17PM V7 (Physician) said I was notified that R1 was attacked by 3 others. V7 said I know I got a call about R1 having been attached by 3 other residents. V7 said I was told she was bleeding, but not from where. I told them to send her out for an evaluation. V7 said they're supposed to have a staff on the balcony (smoking area) watching the residents. V7 said the purpose for them to be watching is for safety. V7 said nasal fractures and blunt abdominal trauma can be a result of trauma or impact. V7 said they didn't tell me where she was hit when they called me.R1's Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors dated 6/7/25 states history or recent episode of aggressive/agitated behavior is substantial or significant problem. It was reported R1 was allegedly involved in inappropriate interaction with peer. assessment dated [DATE] states R1 has history of aggression.Smoking Risk review dated 7/24/25 documents R1 was smoking in room with peer. R1 presented with verbal inappropriate behavior. Smoking Risk review dated 4/24/25 documents R1 smoking in hall bathroom. R1 refused to sign smoke contract and not receptive. Smoking Risk review dated 4/22/25 documents R1smoking in peer's room. R1 counseled on facility policy and safe smoking. R1 not receptive. R1 smoking contract dated 7/24/25 states verbalized to resident, R1 refused to sign.R1's care plan dated 7/24/25 states R1 demonstrates non-compliance with safe smoking regulations by smoking in rooms, bathrooms, halls, stairways, elevators, and other non-designated areas. Smoking at non designated times. Interventions include explaining the safe smoking policy and policy for non-compliance. R1's care plan dated 8/5/25 (revised date) states history of aggressive, inappropriate behavior, includes conflicts/altercations with others, threatening behavior, verbal or physical aggression. Intervention includes intervene when inappropriate behavior is observed.R1's progress notes dated 8/5/25 states involved in social inappropriate interaction. R1 in altercation on patio during smoke break. Skin tear to her face, redness near right side of her face and bridge of her nose. R1 sent to hospital for evaluation.Progress notes dated 8/6/25 state R1 transferred to hospital with diagnosis of Assault & Fracture Nasal bones.R1's facility obtained medical records dated 8/7/25 stated schedule this patient for follow up in plastic surgery clinic to discuss her recent bilateral nasal bone fractures. Hospital discharge diagnosis includes Abdominal pain, Blunt Abdominal Trauma.R3's diagnosis includes anxiety disorder and Psychoactive Substance Abuse. R3's cognitive assessment dated [DATE] identifies cognitive intact. Behavior assessment dated [DATE] identifies no potential indicators of psychosis.Progress notes 8/5/25 document R3 involved in social inappropriate interaction with peer. R3 sent to hospital for psych evaluation. (R3 remained hospitalized upon exit of survey.)R3's care plan includes history of aggression, inappropriate behavior, conflicts/altercations with others, verbal or physical aggression. R3 has severe, chronic persistent mental illness. At times shows aggression. Physically abusive behavior when agitated.R2's diagnosis includes but are not limited to Schizoaffective Disorder, Altered Mental Status, Violent Behavior, and bipolar disorder. R2's cognitive assessment dated [DATE] identifies she is cognitively intact. R2's Behavior assessment dated [DATE] identifies delusions for potential indicators of psychosis.Progress notes dated 8/5/25 states R2 involved in social inappropriate interaction with peer. R3 said another resident approached and attempted to make contact with her and she defended herself. Progress noted dated 8/5/25 at 1:14PM states R1 has been arrested two times for domestic battery.The facility behavior management policy and procedure dated 11/22 states it is the policy of the nursing department to determine the cause of behaviors when possible and initiate interventions to reduce control or prevent identified behaviors. In the event the behavior cannot be managed staff will implement protocols to prevent the residents from harming self or others. The purpose is to prevent the residents from harming self or others. Procedure: notify social service of any behaviors as soon as possible initiate behavior monitoring and recording to provide pattern of behaviors and response to planned interventions when applicable. Targeted behavior agitated behavior which represents a danger to self and others. Preventative measure observe residence for behavior escalation of anxiety aggression such as loud voice tone handwringing swear and yelling and other irritability. Removed from problem area. Allow time for the resident to voice feelings and frustration.
Jul 2025
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to have a policy to ensure a resident is supervised and monitored to prevent resident from leaving the facility unauthorized or ...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to have a policy to ensure a resident is supervised and monitored to prevent resident from leaving the facility unauthorized or without staff knowledge. These failures affected one (25) of one resident reviewed for supervision to prevent an unauthorized exit from the facility. This failure resulted in R25 leaving the facility through a window unauthorized or unknowingly to facility staff. Findings include:R25's medical record notes R25 was admitted to this facility on 6/4/25 with diagnoses including but not limited to opioid abuse, cocaine abuse.R25's social service initial interview for substance abuse disorder, dated 6/9/25, notes R25's drug of choice is cocaine and alcohol.R25's admission BIMS (brief interview of mental status), dated 6/11/25, notes R25's BIMS score is 15 out of 15. R25 is cognitively intact.R25's community survival assessment, dated 6/11/25, notes R25 does not appear to be capable of unsupervised outside pass privileges at this time.R25's discharge planning review, dated 6/11/25, notes R25's discharge potential is fair. Barriers to discharge include R25 has had problems complying with his psychiatric treatment regimen (including taking medications as ordered, following up with mental health/psychiatric counseling and case management recommendations); and R25 has had problems complying with substance abuse treatment and after care (has returned to chemical dependence once out of a structured setting, diminished ability to avoid self-neglect). Discharge status nursing facility required to help R25 attain or maintain highest practical health status. Discharge plan - do not initiate discharge planning.R25's screening assessment for indicators of aggressive and/or harmful behaviors, dated 6/11/25, note R25 is at minimal risk.R25's POS (Physician Order Sheet) notes last order documented on 6/26/25.R25's MAR (Medication Administration Record), dated July 2025, notes the last time R25 received any medication was on 7/7/25 at 4:00 PM.R25's POC (Point of Care), dated 7/7/25, notes R25's last documented meal was at 8:42 AM.R25's medical records notes R25 had an appointment with an outside physician at an outpatient clinic on 7/8/25 at 8:15 AM.There is no documentation noted in R25's medical record noting V17 (Licensed Practical Nurse/LPN) tried to keep R25 in the facility so R25 could go to appointment scheduled on 7/8/25.On 7/22/25 at 10:50 AM, the surveyor entered the smoke room and observed wires broken on three windows. The surveyor was able to exit the smoke room and enter the smoking patio. There is a metal fence surrounding the patio and a pad lock on the gate. The fence is 7 feet 9 inches high.On 7/26/25 at 8:45 AM, this surveyor observed the main entry door to facility unlocked. The entry door to the nursing units from the main lobby is locked. Staff at the first-floor nurses' station and the receptionist at the main desk can remotely unlock this door by pressing a buzzer. Residents were observed not having access to open this secured door. Only staff, visitors, and residents with a community pass are allowed to enter and exit the facility.On 7/26/25 at 10:11 AM, V1 (Psychosocial Aide) stated that the smoke times at this facility are 9:00 AM - 10:00 AM, 1:00 PM - 2:00 PM, and 5:30 PM - 6:30 PM. V1 stated that the smoke room door is kept locked.On 7/26/25 at 1:10 PM, V5 (Director of Nursing/DON) stated that one resident attempted to exit the facility through the window in the smoke room. V5 stated that R25 broke the wires securing the window. V5 stated that he does not know where R25 is or what happened to R25. V5 stated that there is only one smoke room, and it is kept locked unless it is smoke time.On 7/26/25 at 1:10 PM, V7 (Maintenance Director) stated that he is on call 24/7 for the facility. V7 stated that residents breaking the wires that prevent the windows from opening more than five inches is a common occurrence at this facility. V7 stated that a resident broke the wires recently. V7 stated that when he came into work, he was informed by a staff member that the wires were broken on three windows in the smoke room. V7 stated that staff did not notify him that the wires were broken. V7 stated that he should have been notified immediately. V7 stated that staff locked the windows, but anyone can unlock and open window. V7 stated that he placed screws in the window frames to prevent windows from opening. V7 stated that each window opening measures 24 inches x 48 inches. V7 stated that when the wires are broken the window will completely open. V7 stated that a resident did exit the facility via the window but does not know resident's name. V7 stated that the smoke room door is locked when it is not a scheduled smoke time.On 7/26/25 at 2:40 PM, V2 (Psychiatric Rehabilitation Service Coordinator/PRSC) stated that she is the social worker for all residents on the second-floor nursing unit. V2 stated that she was not present in the facility when R25 left and is unaware what happened to R25. V2 stated that R25 may have gone AMA (against medical advice). V2 stated that when she came in R25 was gone. V2 denied asking any staff where R25 was. V2 stated that R25 did not request a community pass from her. V2 stated that the smoke room door is supposed to be locked at all times except during smoke times.On 7/28/25 at 10:15 AM, V11 (Nurse) stated that on 7/7/25, R25 was usual self, self-propelling in wheelchair throughout facility. V11 stated that she administered morning medications to R25. V11 stated that her shift ends at 3:00 PM and R25 was present in this facility at that time. V11 stated that she found out R25 eloped over the fence on the smoking patio when she came in to work the following Monday, 7/14/25. V11 stated that the protocol is to call a code pink (changed to code yellow), each nurse does a head count of his/her assigned residents, one nurse from each floor, social services, and activity aides are expected to go into the community and search for resident. V11 stated that V14 (Administrator) is notified. V11 stated that the police are notified if assistance is needed to locate the resident. V11 stated that staff are expected to call hospitals to see if resident admitted , notify physician, and notify resident's family. V11 stated that this is to be documented in the resident's record. V11 stated that the nurse assigned to that resident is expected to search for resident with the other staff members. On 7/28/25 at 10:31 AM, V6 (PRSC) stated that she was not present in facility when R25 left. V6 stated that the elopement protocol is to call a code yellow overhead, staff are to go out into the community and look for resident, perform a head count on residents, call V14 (Administrator). V6 stated that R25 telephoned V6 on 7/10/25 and informed V6 he wanted to return to this facility. When questioned what phone number R25 was calling from, V6 responded she did not know because facility does not have caller ID. V6 stated that V6 instructed R25 to inform the hospital social worker to contact facility to assist with R25's transfer back to facility. V6 was questioned why the telephone conversation with R25 was not documented in R25's medical record until 7/26/25 at 6:13 PM. V6 stated that she forgot about the phone call until this surveyor was present in the facility asking about elopement on 7/7-7/8.A late entry created on 7/26/25 at 6:13 PM in R25's medical record by V6 for 7/10/25 noting R25 called V6 verbalizing that he was in the hospital. V6 redirected R25 to verbalize to the social worker at the hospital that he would like to return back to the facility. R25 was receptive and stated okay. Will document as needed.On 7/28/25 at 10:55 AM, V13 (R25's emergency contact) stated that V13 knows R25 was at this facility and then left. V13 stated that she does not know where R25 is currently. V13 stated that it has been three weeks since V13 has heard from R25. V13 stated that R25 has a text app. R25 does not have a cellular phone. On 7/28/25 at 11:05 AM, V10 (Assistant Administrator) stated that V10 learned of R25's absence on 7/9/25. V10 stated that V14 (Administrator) would have been the one staff notified. V10 stated that code pink was changed to a code yellow a month or two ago. V10 stated that the protocol is the receptionist calls a code yellow 2 times, staff pull everyone in that is outside, staff get a census, conduct a head count; staff go into community and search for resident. V10 stated that she was not made aware if police were called. On 7/28/25 at 11:33 AM, V5 (DON) stated that R25 is alert and oriented x 4. V5 stated that R25 left the faciity on an unauthorized pass, R25 left without permission. When questioned if this is known as an elopement, V5 stated no because he was alert and oriented x 4 and we knew he left. V5 stated that elopement refers to when we can't find a resident. V5 stated that V5 found out R25 was at a hospital in Chicago and has since been discharged . V5 does not know when R25 was admitted to the hospital, when R25 was discharged , or where R25 was discharged to.On 7/28/25 at 1:00 PM, V15 (Regional Consultant) stated that the police told social services today that R25 is not missing. The police officer called the hospital and learned R25 was discharged on 7/18/25 and did not want his family notified of his whereabouts. V15 stated that the police said R25 is not missing, and no report will be filed. V15 is unable to articulate a reason the police were not notified immediately on 7/8/25 when R25 exited the facility via the smoke room window. V15 stated that she spoke to R25 on 7/8/25 or 7/9/25 and R25 wanted to leave. When V15 was questioned what phone number she called to speak with R25, she responded the number on his face sheet. This surveyor informed V15 that there is no phone number listed for R25. V15 stated that the contact phone number had area code 312 on R25's face sheet. This surveyor informed V15 that there is no contact phone number with area code 312 on R25's face sheet. V15 stated to talk to social services.There is no documentation found in R25's medical record by V15 on 7/8/25 or 7/9/25.On 7/28/25 at 1:10 PM, V6 (PRSC) stated that she called the police regarding R25 missing. V6 stated that the police called the hospital and was informed that R25 left hospital on 7/18/25 and that R25 did not want his family to know. V6 stated that R25 hadn't expressed a desire for a community pass, to go AMA, or discharge home to her or anyone in social services. V6 stated that if a resident wants to leave AMA, V6 will discuss with V5 (DON) and/or family to set up proper discharge to ensure a safe discharge for the resident.On 7/28/25 at 3:55 PM, V17 (Licensed Practical Nurse/LPN) stated that V17 worked overnight 7/6-7/7/25. V17 stated that when he made his rounds at 6:00 AM or 7:00 AM, R25 stated that R25 wanted to smoke. V17 stated that he informed R25 that the smoke patio is locked. V17 stated that the smoke room has vending machines in it and this door is unlocked for residents to use. V17 stated that just prior to the end of his work shift he was called, and it was reported that R25 was trying to forcefully open windows in the smoke room. V17 stated that he went to the smoke room, R25 was agitated so V17 left R25 in there unsupervised. V17 stated that he worked 3:00 PM to 11:00 PM shift and 11:00 PM -7:00 AM shift 7/7-7/8/25. V17 stated that the last time V17 saw R25 was at 10:00 PM in his room speaking with friends. V17 is unable to articulate a reason he did not chart in R25's MAR (Medication Administration Record) after 4pm on 7/7/25. The MAR for night shift is blank. V17 stated that R25 is alert and oriented x 4.On 7/29/25 at 8:40 AM, V17 (LPN) stated that on 7/8/25 at 3:00 AM, R25 went down to the vending machine in the smoke room. V17 stated that he did not check to make sure R25 returned to his room. V17 stated that between 3:00 AM and 4:00 AM, there was a code paged overhead. V17 stated that he did a head count of residents but knew the code was for R25. V17 stated that he called V14 (Administrator) and was informed that she would arrange for search of resident. V17 stated that he did not go outside to search for R25 because he did not want to get shot. V17 stated that he did not inform V14 he would not go outside of building to search for R25. V17 stated that he did not call the police, R25's physician, or R25's family. When questioned about what the facility's protocol/policy is, V17 responded he did not know that he was just following instructions.Late entry created on 7/26/25 at 5:29 PM by V5 (DON) in R25's medical record entered for 7/10/25 at 11:30 AM. V5 noted V15 (Nurse Consultant) spoke with R25, second day of him being out on pass. R25 asked if the facility can pay for transportation and he was asked where he was and informed V15, that he was at the hospital and R25 was told the hospital will provide transportation for his return. R25 is currently at the hospital. Late entry created on 7/26/25 at 5:53 PM by V5 (DON) in R25's medical record entered a second note for 7/10/25 at 11:50 AM. V5 noted R25 at the hospital, physician/nurse practitioner notified. Significant other called, no answer, message left on the voicemail. Late entry created on 7/28/25 at 10:20 AM by V5 (DON) in R25's medical record entered a third note for 7/11/25 at 12:15 PM. V5 noted hospital called to inquire about R25's status and was informed R25 is discharged .R25's medical record notes facility staff were informed on 7/10/25 that R25 was in the hospital. There is no documentation found in R25's medical record noting the whereabouts of R25 from 7/8/25 about 4:00 AM until 7/10/25.On 7/31/25 at 2:10 PM, V14 (Administrator) stated that R25 left facility on an unauthorized pass. V14 stated that V17 (LPN) notified her in the middle of the night informing her that R25 left facility. V14 stated that V17 informed her that he contacted R25's physician and family, he looked outside in the community for R25 and attempted to re-direct R25 back into the facility. V14 was informed V17 denied notifying physician, family member, or looking for R25. V14 was informed that in interview with V17, V17 stated that V14 was going to arrange for the search of R25. V14 stated the staff present in the facility are expected to search community for resident. V14 stated how are you going to wait to search for a resident for 3-4 hours.The facility's supervision and safety policy dated 03/2025 notes resident supervision is a core component to resident safety.This facility's discharge against medical advice (AMA) policy, revised 07/2024, notes it is the policy of this facility to provide medical and psychosocial care to residents of the facility. The staff shall provide appropriate attention and make a reasonable effort to prevent a resident from leaving AMA. Call the physician and administrator to notify them of the pending AMA discharge. Assess the resident's competence to make the AMA decision (vital signs, mental status). Explain and document a discussion of the reasons to remain in the facility and all potential serious risks associated with leaving. Explain and document efforts to persuade the resident to remain in the facility. Explain and document ongoing concern for the resident and his/her well-being. Use all available resources to prevent a resident from leaving AMA. Negotiate and compromise with the resident. Assess what is bothering/upsetting the individual and attempt to find an equitable solution (perhaps he/she can enjoy a cigarette on the patio).
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to maintain a homelike environment and ensure that the window drapes were not falling off the curtain rod/track/hooks for 10 of 10...
Read full inspector narrative →
Based on observation, interview and record review the facility failed to maintain a homelike environment and ensure that the window drapes were not falling off the curtain rod/track/hooks for 10 of 10 residents (R1, R7, R8, R9, R10, R11, R12, R13, R14, and R15) reviewed for homelike environment.Findings include: On 7/26/25 at 9:47 am during facility tour, the window drapes in R1, R7, R8, R9, R10, R11, R12, R13, R14, and R15's rooms were observed falling from the curtain rod/track. R7 and R8's room window was also observed to have towels hanging where there is an opening from the falling window drapes.On 7/26/25 at 11:58 am V7 (Maintenance Staff) was made aware and observed the drapes falling from hooks/rods. V7 said the falling drapes are a housekeeping issue, and he will make note of it.On 7/26/25 at 12:45 pm the window drapes remain falling from the curtain rod/track/hooks.On 7/26/25 at 1:40 pm R1 said she has been asking social services to have someone wash her curtains and hang them because they are falling.On 7/26/25 3:04 pm V5 (Director of Nursing) said the resident room should be clean, sanitary and home like, the window drapes should not be falling from the curtain rod.Facility Housekeeping guideline policy, no date noted denotes in-part to provide guidance to maintenance a safe and sanitary environment for resident, facility staff and visitors. Housekeeping personnel shall adhere to a daily cleaning assignment developed so to maintain the facility in a clean and orderly manner.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Room Equipment
(Tag F0908)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure that all elevators were working in the facility. This affects 4 residents (R1, R2, R9, and R24) that require services/c...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to ensure that all elevators were working in the facility. This affects 4 residents (R1, R2, R9, and R24) that require services/care in the facility. Findings Include: On 7/26/25 during the survey tour one of the two elevators in the facility was observed not working. The elevator, to the left (front facing), was observed with a number one in the display box, the number did not change when the call button was pressed. On 7/26/25 at 1:37pm V7 (Maintenance staff) said the elevator company repaired the elevator yesterday 7/25/25. He was notified last night that the elevator went out again. V7 said the elevators breaking down has been an ongoing issue at the facility. V7 denied knowing what the elevator service company mention as the problem for the continue breakdown of the elevator. V7 said it is his opinion that the entire elevator system should be replaced because it is an old facility. Facility service record denotes service was performed on an elevator on 7/25/25, documentation shows car 2. V7 failed to identify which of the two elevators was serviced (car 1 or car 2). There is a certificate in the elevator right side (front facing showing that the elevator is car 2). R1 said it takes a long time for the elevator to arrive because there only one working. R2 said it takes a long time for the elevator to arrive because there only one working. R9 said it takes a long time for the elevator to arrive because there only one working. R24 said it takes a long time for the elevator to arrive because there only one working. On 7/26/25 the facility census report shows 191 residents reside in the facility. On 7/28/25 at 11:05am V5 (Director of Nursing) said the facility use the elevators for transporting the lunch tray to the different floors, resident/staff and visitors use the elevators for going between floors. V5 stated the laundry staff, and housekeeping staff utilized the elevators. Providers also use the elevator when visiting the residents. The facility policy for building maintenance does not denote information / protocol for the facility elevators.
Jun 2025
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their stated protocol for signing residents out on community...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their stated protocol for signing residents out on community pass by not verifying the identity of the individual who signed out a resident (R11). The facility did not have an effective supervised community pass protocol in place. This failure applied to one (R11) of two residents reviewed for community pass and resulted in R11 leaving the facility on pass on 4/30/2025 and not returning. R11 has a significant history of substance abuse disorders and R11's whereabouts are currently unknown.
Findings include:
R11 is a [AGE] year-old female who originally admitted to the facility on [DATE]. R11 has multiple diagnoses including but not limited to the following: multiple orbital fractures, nasal bone fracture, psychoactive substance abuse, opioid dependence, and alcohol abuse.
R11's BIMS (Brief Interview for Mental Status) Score is 15.
Community Survival Skills assessment dated [DATE] shows that R11 is not capable of unsupervised outside pass privileges at this time. R11's care plan states in part but not limited to the following: Interventions: A community survival skills assessment will be conducted to reasonably determine the person's ability to safely and respectfully negotiate within the outside community.
Progress note dated 4/29/2025 states in part that V21 (R11's Friend) will be taking R11 on a day pass on 4/30/2025 from 5PM-7PM.
Pass Request Form states in part but not limited to the following: Pass to begin on 4/30/2025 at 5PM and end on 4/30/2025 at 7PM and accompanied by V21.
It is to be noted that the ID scanned and attached to the community pass is not the same name/person listed on the Community Pass Request Form (V21).
On 6/3/2025 at 9:40AM, V7 (Psychosocial Rehabilitation Services Clinician/PRSC) said our process for the facility is that when a resident needs a supervised pass: the family/friend they are going out with requests to take them out. We get the name and phone number of this person. We document where they are going, when they are leaving, and when they will return. When the date and time comes, the visitor takes the pass, the nurse signs off on it, then the receptionist makes a copy of the ID of the individual taking them out. The copy of the ID is done to ensure the person taking the resident out on supervised pass is the same individual listed on the pass request form. We explain the rules to them and to ensure they are safe that way.
On 6/3/25 at 1:30PM, V22 (R11's Family Member) said R11 is constantly drug seeking. Before she came to the facility, she was in the hospital due to someone assaulting her. She is unsafe to herself and others when in the community. I have an order of protection against her for me and my family's safety. R11 is very manipulative.
On 6/3/25 at 1:50PM, V16 (Licensed Practical Nurse) said I was the nurse on duty on 4/30/2025 when R11 said she had a pass to go out to the grocery store for a couple hours. A friend came and picked her up, I scanned the ID. I then gave the pass and the copy of the ID to the receptionist. After 7PM came and went, I called to follow up. R11 never came back to the facility, to my knowledge.
On 6/3/25 at 3:00PM, V6 (Social Service Aide) said I was the receptionist on 4/30/25 when R11 went out on pass. However, I was passing out cigarettes and not at the front desk at the time R11 left. The receptionist usually scans the ID of the person taking the resident out on pass, but I was busy. I never spoke with the person that took R11 out. The reason we scan the ID is to ensure that the ID matches the name on the pass request form. This is for the resident's safety, in case of an emergency where we would have to call the police or if the resident does not come back to the facility.
On 6/4/2025 at 11:45AM, V1 (Administrator) said when a resident has a supervised pass, a pass request form is filled out listing the name of the person taking the resident out including the date and time the resident is leaving and when they will return. The person's ID is scanned to ensure that the pass and the ID match. V1 said when R11 did not return to the facility, we did not notify the police. I do not consider this elopement.
It is to be noted that facility policy titled Community Pass does not lay out the procedure of the facilities supervised pass system.
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 F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to timely provide foot care treatment and ensure that ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to timely provide foot care treatment and ensure that residents received follow up visits per physician orders and recommendations for residents at risk for foot disorders. This failure applied to two (R5, R6) of three reviewed for podiatrist services.
Findings include:
1.) R5 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: diabetes, hypertension, depression, and gastroesophageal reflux disease.
(MDS) Minimum Data Set assessment of 4/8/2025 section C the BIMS (Brief Interviewed Mental Status) score was 15/15 and indicates cognitive intact.
6/4/2025 at 10:20 AM, R5 said, I have not seen a foot doctor for a long time. R5 removed his shoes and showed the surveyor his toenails. The toenails were long, discolored, and thick. R5 said, I need to see a foot doctor because I have diabetes and I want my nails cut. I don't want any problems with my feet. I requested to see a doctor a long time ago, and I am still waiting.
Review of physician orders dated 1/17/2025 read: May see a podiatrist.
Facility provided visit notes from Podiatrist for R5 dated 01/03/24, 03/06/2024, and 08/12/2024. Note dated 08/12/2024 documents .feet at risk PVD (peripheral vascular disease) .follow up visit 9 weeks. There was no additional information provided by the facility indicating that R5 was seen by the podiatrist after 08/12/2024.
2.) R6 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: diabetes, hypertension, acute kidney disease, and hyperlipidemia.
(MDS) Minimal data Set assessment of 4/4/2025 section C the BIMS (Brief Interviewed Mental Status) score was 15/15 and indicates cognitive intact.
6/4/2025 at 10:25 AM R6 removed shoes and showed toenails to the surveyor, which were long thick discolored nails on both feet. Both big toenails and second toenails were curling up. R6 said, I am a diabetic and I do not recall the last time I had a podiatrist cut my nails. They are too long and I need them cut. R6 verbalized requesting to see a podiatrist but has not seen one for a long time.
Reviewed physician orders for R6 dated 4/16/2023, which read: May see podiatrist, and Podiatry consult due to diabetes, annual foot exam dated 10/31/2023.
6/4/2025 at 11:05 AM V5 (Social Service Director) said, for residents that require podiatry services, the only thing that I do is to add their names to the list and send the list to the podiatrist's office. The podiatrist will come to the facility and see residents in the units.
6/4/2025 at 2:47 PM V3 (Director of Nursing) said, I expect residents to be seen by the podiatrist as needed when residents request to be seen. The podiatrist provider will come to the facility once a month and will go to the units and see residents on the list but will not see all residents at one time. The surveyor requested to see the list of residents and asked V3 when R5 and R6 were seen last time. V3 responded that only residents who requested services are on the list. V3 did not provide a list of residents when requested.
Facility provided visit notes from podiatrist for R6 dated 04/01/2024 and 09/24/2024. Note dated 09/24/2024 documents .feet at risk patient is diabetic .follow up visit 9 weeks. There was no additional information provided by the facility indicating that R6 was seen by the podiatrist after 09/24/2024.
On 6/5/2025 at 10:06 AM V1 (Administrator) provided policy titled, Policy & Procedure Foot Care Assessment (reviewed date 11/2022), which includes:
Policy
It is the policy of the nursing department to perform an assessment of the resident's feet at the time of admission, updated quarterly, and when significant changes occur.
Purpose
To identify treatable conditions, prevent infections, provide treatment, and comfort.
Procedure:
8. Follow physician's orders. Refer to a podiatrist if needed.
9. Refer all diabetics to podiatrist for follow-up
Jun 2025
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to have a system in place for monitoring and investigating how illici...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to have a system in place for monitoring and investigating how illicit drugs got into the facility, to be alerted when illicit drugs enter the facility and to prevent resident use and possible drug overdose. This failure applied to one (R12) of three residents reviewed for supervision and resulted in R12 obtaining and using illicit drugs while in the facility, that led to a drug overdose, requiring the administration of Narcan (opioid reversal agent) and emergent hospital transfer.
Findings include:
The Immediate Jeopardy began on [DATE] when R12 was administered Narcan for drug overdose while in the facility. V32 (Assistant Administrator) was notified on [DATE] at 1:00PM of the Immediate Jeopardy.
The immediacy was removed on [DATE] but noncompliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
1.) On [DATE] 10:48 AM R7 stated he knows other residents are using drugs in the facility because he recognizes the abnormal behaviors from drug use. R7 stated he recognizes these behaviors because he used to be a drug addict. R7 stated when he sees this it does tempt him to abuse drugs.
R7 is a [AGE] year-old male with diagnosis not limited to history of Schizophrenia, Depression, Suicidal Ideations, a History of Suicidal Behavior, Crohn's Disease, Blindness of Left Eye, and Encounter for Palliative Care. R7 was admitted to the facility [DATE].
2.) R12 is a [AGE] year-old female with diagnosis not limited to history of Epilepsy, Restlessness and Agitation, Psychotic Disorders with Delusions, Paranoid Schizophrenia, Bipolar Disorder, Generalized Anxiety Disorder. Recurrent Major Depressive Disorder, Psychoactive Substance Abuse Disorder. R12 was admitted to the facility [DATE].
R12's Hospital Record dated [DATE] documents she is a [AGE] year-old female with a past medical history of depression who presents to the emergency department from a Behavioral Health/Substance Abuse Treatment Center for evaluation of a seizure sensation. R12 is at the Treatment Center for a history of drug, alcohol, and marijuana use. R12 reports last using cocaine 15 days ago.
R12's Facility admission Contract includes a Social Services Quick Reference Interview form that documents she was admitted to the facility on [DATE] and in response to the question do you have a history of substance abuse? She answered yes and in response to the to the question which one? Regarding substance use she answered, all of them.
R12's Nurse Practitioner Progress note dated [DATE] documents she is a [AGE] year-old woman admitted to the facility on [DATE], with chronic diagnoses of Drug Use Disorders and Depression.
R12's Preadmission Screening and Resident Review dated [DATE] documents she has been to the Behavioral Health/Substance Abuse Treatment Center for cocaine detox and rehab.
R12's progress note dated [DATE] created by V21 (Licensed Clinical Social Worker) documents resident has a history of alcoholism and drug addiction (marijuana and cocaine).
On [DATE] at 1:36 PM V18 (Licensed Practical Nurse/LPN) confirmed she responded to R13's room on [DATE] when R13 informed her that something was wrong with R12. When V18 arrived at the room, she observed R12 was unresponsive, laying across R13's bed and V23 (Certified Nursing Assistant/CNA) helped get R12 to the floor. V18 stated she performed a sternum rub on R12, R12 still had a pulse and was slowly trying to open her eyes but she still wasn't responding as normal. V18 stated R12's oxygen levels were dropping so we applied oxygen and once she placed the non-rebreather mask on R12 she had already grabbed Narcan (Opioid Antagonist) just in case. V18 stated she had just talked to R12 at 8:30 or 9 o'clock PM and she wasn't in that condition. V18 stated R12's eyes were rolling into the back of her head and R13 said he thought she had something. V18 stated R12's oxygen level was at like 82%. V18 said she used Narcan because one of the residents said they saw R12 coming out of another resident's room, and she doesn't visit everyone. The only room she ever sees R12 in is her room or in the resident's room she calls her boyfriend. V18 stated when the first Narcan dose was administered R12 slowly came back but not right away. Then when she gave R12 the second dose, her eyes opened, and she came back to us. V18 stated she still had oxygen on R12. By that time the paramedics arrived, and the police came, and they asked R12 in the presence of the paramedics did she take anything or have anything, and she said no it wasn't a pill. V18 stated R12 was asked if it was it a powdery substance that she took and she told the paramedics yes and began throwing up. V18 stated R12 gave the police the name of the resident's room she was in. V18 stated she went with the police to that resident, and he denied having anything. V18 stated the resident was R8 and the police advised they could not search his room because it was illegal. When asked by the surveyor if she or anyone else had R8 tested for drugs V18 stated that on the day of the incident she called V2 (Director of Nursing) and was told the social worker will follow up with R8 in the morning. When asked by the surveyor if any of the administrative or management staff followed up with her and asked any questions about the incident V18 stated on the day of the incident she called and spoke with V2 and called V1 (Administrator) who advised her to notify V24 (Nurse Consultant) and she then notified V24. When asked again by the surveyor if any of the administrative or management staff followed up with her and asked her any questions about the incident V18 stated all three managers did check on her and V23 about their well-being soon after the incident because it was a traumatic experience that she had never been through. V18 stated they gave her the next day off. V18 stated R13 is always in his room, and she has never seen him go out of the facility. V18 stated on that night that R8 was in his room the majority of the night. V18 stated this incident happened at approximately 9:40 PM. V18 stated she had not observed any abnormal behaviors from R8, R12, or R13 that night prior to the incident. V18 stated she is unaware if any drug testing was done on R8. V18 stated V25 (Registered Nurse) was also working during the incident and assisted her.
R12's progress note dated [DATE] at 9:42PM created by V18 (LPN) documents she was visiting with a friend in his room, peer came to desk to get nurse stating, She's not responding to me. Writer entered peers room noticed a change of condition with patient not responding appropriately. Vital Signs noted oxygen at 82%. Writer applied oxygen at 5L via non-rebreather mask. Oxygen saturation increased to 92%. Narcan (Opioid Antagonist) administered twice, 911 called. Fellow co-workers assisted with patients care. At 9:50 PM it was documented that 911 paramedics arrived at facility to assess patient's status and scenario. 911 took over CPR (Cardiopulmonary Resuscitation). At 10:00 PM a late entry documented R12 discharged to the hospital on [DATE] at 9:42 PM; Reason for transfer: Patient not responding appropriately at her normal. At 10:10 PM it was documented patient being transported to the Hospital emergency room for further evaluation.
R12's progress note dated [DATE] created by V31 (LPN) documents resident admitted to the Hospital with diagnosis of Overdose and Pneumonia.
On [DATE] at 10:04 AM R13 stated on the day when R12 was sent to the hospital when he reported to V18 (LPN) that something was wrong with R12. R12 was sprawled out on the floor in his room and when she was revived there were multiple people standing around her and he asked her if someone gave her something. R13 stated R12 initially said she couldn't remember but then he pressed her further she finally admitted she got it from R8. R13 stated he went down to R8's room and asked him if he gave R12 anything and he denied it, however R13 stated he saw the bag in R8's hand. R13 stated he saw a dope bag in R8's hand with some of the substance in it and he was nodding off in his wheelchair. R13 stated he sometimes sees R8 nodding off in a way the indicates he may have used drugs. When asked by the surveyor if V1 (Administrator), V32 (Assistant Administrator), V2 (Director of Nursing) or V19 (Assistant Director of Nursing) came and asked him any questions about the incident after it happened R13 said no. R13 stated the next night after the incident V18 worked and she asked him if knew where R12 got the drugs from, and he told her R8. R13 stated V18 told him they would get R8 out of the facility. R13 stated the police came and didn't do anything and R8 is still here.
R13 is a [AGE] year-old male with diagnosis not limited to history of Stroke, Dependence on Renal Dialysis, and End stage renal disease. R13 was admitted to the facility [DATE].
R12's progress note dated [DATE] documents resident is readmitted to the facility day 1 of 3. Resident transferred from Hospital related to overdose and pneumonia.
On [DATE] at 12:21 PM, observed R12 in her room handling her belongings showing no signs of distress, illness, or injury. When asked by surveyor about her being hospitalized on [DATE] R12 confirmed she was hospitalized for an overdose. R12 stated she has a habit of roaming around and going in and out of rooms and on that day, she had been wandering in and out of rooms and when she arrived to R8's room she saw him snorting heroin. R12 asked if she could join him and she snorted heroin six times, then went to her boyfriend (R13's) room and passed out. R12 stated was told she was given CPR (Cardiopulmonary Resuscitation) because she was not responding. R12 stated she told them in the hospital she was suicidal. R12 stated while in the hospital, she was told she that she has a heart murmur and pneumonia and that if she has another incident she could end up in the ICU (Intensive Care Unit).
R12's Community Survival Skills Assessments dated [DATE], [DATE], [DATE], and [DATE] documents that R12 does not appear to be capable of unsupervised outside pass privileges at this time.
R12's current care plan does not include interventions for monitoring for drug seeking behaviors.
The surveyor reviewed the facility's reportable investigations from May and [DATE]. There were no reports of an investigation of R12's overdose.
On [DATE] at 4:59 PM V27 (Family Member) stated peer pressure, and the environment are triggers for R12's drug use. V27 stated she doesn't know how but R12 will be in the company of not good people and monkey see monkey do with her. V27 does go out with R12, and she monitors her closely and R12 does not use drugs when she's with her. When R12 was in the hospital after her ordeal on [DATE] she received a phone call from the hospital physician that was treating R12, and he said they found her unresponsive. She doesn't know what kind of drug R12 does or how much or what she does. The hospital physician may have mentioned what kind of drug R12 used but V27 couldn't recall. V27 stated the hospital physician informed her that R12 overdosed. R12 was nonresponsive, the paramedics were called, and they had to detox her. No one from the facility contacted V27 to ask any questions about R12's overdose incident. V27 confirmed she found out from the hospital that R12 was there and doesn't recall receiving a phone call from the facility notifying her of R12 being admitted to the hospital. V27 stated she asked R12 how she was able to get drugs while in the facility and R12 sometimes can deflect and not answer questions directly but from what R12 told her it sounds like one of the residents in the facility was able to bring in the drug. V27 stated she is not sure what drug, but she thinks it was heroin. V27's greatest concern is that R12 was unresponsive, it could have been a matter of moments, and if she took just a little bit more of the drug or there was a delay in getting to her, she could have been lights out meaning passed away. V27 stated her concern is she could have lost R12 and if there's a way to prevent drugs from coming in, she would want that. V27 stated R12 said they had to do electric shocking to resuscitate her. V27 stated thankfully R12 didn't die but hopefully it doesn't happen to someone else or another resident's family. V27 stated R12's overdose caused her and V33 (Family Member) a lot of distress. V27 asked what if the nurse hadn't gotten to R12 at the time she did or if there was a minute delay? V27 stated every moment or second is imperative to life in that situation.
3.) On [DATE] at 11:09 AM R8 stated a few weeks ago he was threatened to be put out by V16 (Substance Abuse Coordinator/Psychosocial Rehabilitation Services Coordinator) because he had a verbal altercation with her about not letting him go out on pass. R8 stated V16 told him he was going to be put out.
R8 is a [AGE] year-old male with diagnosis not limited to history of Recurrent Major Depressive Disorder, Bipolar Type Schizoaffective Disorder, Psychoactive Substance Abuse, COPD, Peripheral Vascular Disease, and Prostate Cancer who was admitted to the facility [DATE].
On [DATE] at 1:15 PM V17 (Receptionist) stated R8 had an outside pass and was going out regularly. When asked by surveyor was R8's outside pass privileges removed in the past few weeks, V17 stated R8's outside pass was revoked and she isn't sure why. V17 stated residents are supposed to sign in on a log at the front desk whenever they go in and out of the facility. V17 stated R12 never had an independent pass and always goes out of the facility with family or friends.
On [DATE] at 1:23 PM V16 (Substance Abuse Coordinator) initially stated R8's outside pass privileges were revoked due to suspicious behaviors of hanging around other residents. V16 could not provide information on when these behaviors were reported. When asked by surveyor if suspicious behavior is documented, V16 stated it depends on if a resident's name keeps coming up or if she keeps hearing their name brought up involving behaviors. V16 stated she followed up on the report about R8's suspicious behavior of hanging around people by asking him what's going on and who he's been hanging around etc. and his response was nothing was going on.
At the time of the survey R8's progress notes from [DATE] did not include any behavioral documentation concerning drug use.
R12's progress notes from [DATE] and the facility's resident reception log dated [DATE] do not document any record of R12 leaving the facility on that date. However, the resident reception log dated [DATE] does document that R8 left the faciity on [DATE] shortly after 9AM.
On [DATE] at 1:47 PM V10 (Psychosocial Rehabilitation Services Director) stated when residents leave the facility independently it is documented in the resident log kept at the front desk. V10 stated if Narcan (Opioid Antagonist) is used on a resident, and it is effective or if they were hospitalized related to an overdose that should be communicated to the Director of Nursing and V16 (Substance Abuse Coordinator) because she is the substance abuse coordinator. V10 stated she is not aware of R12 engaging in any substance use while in the facility.
On [DATE] at 2:44 PM when asked by the surveyor if there was an investigation regarding staff's documented report of R12 being hospitalized for an overdose, V2 (Director of Nursing) stated he doesn't have an investigation for R12's overdose incident because they said she overdosed but couldn't specify what it was. V2 stated that he did not see the paperwork from the hospital with any information on what substances were involved. V2 said you can talk to the patient and ask about the overdose, but you can't just accuse people based on allegations; and you have to be careful to accuse people. If an overdose is an admitting diagnosis for a resident this should be investigated. People overdose on a lot of stuff but most commonly drugs. The facility should follow up and ask for the toxicology result if there is a report of an overdose for a resident. V2 agreed it is standard practice to obtain hospital paperwork when residents return from the hospital. It is important to follow up on this situation to ensure the patient is safe and possibly remove the source to prevent reoccurrence.
On [DATE] at 4:10 PM R8 stated he was drug tested within a day of a female resident reporting that he gave her some drugs.
On [DATE] at 2:11 PM V2 (Director of Nursing) stated Narcan (Opioid Antagonist) is used when there is a suspected overdose. V2 stated Narcan will revive someone even if they don't have drugs in their system. V2 stated Narcan is also effective for Catatonia. V2 stated there are 9000 reasons that someone could become unresponsive and that the use of Narcan depends on the assessment of the patient and it's better to be safe than sorry. V2 stated that in his opinion; in order to suspect someone is under the influence of a substance you have to have the toxicology. If there were any investigations of any incidents they would be included with the reportable investigations, and he doesn't believe there were any reportable investigations for R12 in the month of May.
The National Institute on Drug Abuse's Drug Facts page accessed [DATE] documents Narcan (Brand name for Naloxene) is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. Naloxene has no effect on someone who does not have opioids in their system. Examples of opioids include heroin.
On [DATE] at 3:25 PM, when asked by the surveyor how the facility responds if a resident experiences an overdose while in the facility V26 (Medical Director) stated the facility performs random routine drug testing, they are more vigilant with vitals, and if there are any signs of intoxication, they will drug test them. V26 stated he heard some sort of rumor about residents bringing recreational drugs in the facility and selling it to other residents. V26 stated he met with the administrator last week and discussed this issue and as a result they planned to work on fixing the cameras and doing some undercover investigating to get to the bottom of this. When informed by the surveyor that she was inquiring about a specific resident who was documented as being hospitalized for an overdose incident that occurred while in the facility V26 stated he didn't hear about a specific resident having an overdose otherwise they would have been kicked out of the building or it would have been investigated further. When asked by the surveyor if any report of a resident overdosing while in the facility should be investigated, V26 stated 100% this should have been investigated and that's common sense. V26 stated he doesn't know how drugs got in the facility in the first place, and he doesn't expect drugs to be inside the facility. Narcan is just a reversal agent and reverses an opioid overdose and won't do anything for an infection, or pneumonia, or sepsis. If the facility is not investigating an overdose incident that is unacceptable because the facility should be, and something should be done about it. When asked by the surveyor why would it be important to investigate such incidents V26 stated, the facility is a place of rehab, and they should try to prevent these incidences for the purpose of the safety of the residents and the staff.
On [DATE] at 10:28 AM V1 (Administrator) stated she did participate in an unscheduled meeting with V26 (Medical Director) and V2 (Director of Nursing) a week ago because they wanted to discuss workflow. V1 stated V26 provided suggestions on how to improve the workflow by asking them to prioritize a list on the residents he needs to see when he comes in. V1 stated V26 did not discuss anything during that meeting about residents bringing drugs in the facility. V1 stated she had not received any concerns about residents having drugs in the facility. V1 stated there's always a speculation about this because of the type of population of residents we have in the facility.
On [DATE] at 12:26 PM and 4:07 PM the surveyor requested confirmation as to whether V25 (Registered Nurse) or any other nurse performed drug testing on R8 on [DATE]. On [DATE] at 4:40 PM V32 (Assistant Administrator) advised that V2 (Director of Nursing) would provide this information. As of the time of the survey exit [DATE] the facility had not provided this information.
On [DATE] at 11:00 AM
R8 stated the next day after R12 alleged he gave her drugs V2 (Director of Nursing) and V16 (Substance Abuse Coordinator) asked him if he gave R12 anything and he told them no. R8 stated he told them R12 asked him for an ice cream sandwich, and he didn't have one and she left.
On [DATE] at 11:02 AM V31 (LPN) stated she didn't know much about R12's incident on [DATE] that involved her being hospitalized . V31 stated it happened after she left for the day. V31 stated the next morning she contacted the hospital and was informed that R12 was admitted for an overdose and pneumonia. V31 stated she did not attempt to perform drug testing on R8. When asked by the surveyor if V1 (Administrator), V32 (Assistant Administrator), V2 (Director of Nursing) or V19 (Assistant Director of Nursing) came and asked her any questions about the incident V31 said no.
On [DATE] at 2:55 PM V16 (Substance Abuse Coordinator) stated she doesn't recall asking R8 on [DATE] about whether he had any drugs in the facility. When asked by the surveyor if she was involved in any investigation regarding R12 being hospitalized on [DATE], V16 stated she heard bits and pieces about it and spoke with R12 about coping skills and provided her with some which was documented but that's all.
4.) On [DATE] at 11:14 AM R14 stated he has heard about other residents using drugs and 3 or 4 months ago he heard about residents overdosing.
R14 is a [AGE] year-old male with diagnosis not limited to history of Single Episode Major Depressive Disorder, Generalized Anxiety Disorder, Opioid Use, and Accidental Poisoning by Unspecified Narcotics who was admitted to the facility [DATE].
On [DATE] at 12:35 PM V16 (Substance Abuse Coordinator) confirmed R12 was admitted with a substance abuse history and was referred to her. V16 stated she sometimes hears about R14 being under the suspicion of bringing drugs in the facility and supplying it. V16 stated approximately 3 months ago a resident who was discharging informed them that there is a resident who grabs drugs that you want and gave a description of a tall dark resident who fit R14's description. V16 stated she overheard this conversation while in the social services office when the resident was on the phone with one of the social-services staff, however she couldn't recall which staff were taking this phone call. V16 stated the resident said he would call back and give a name, but they never called back. V16 stated she is unsure of the resident's name because they were only in the facility for one or two days. V16 stated she doesn't believe she reported this to any of the management staff and they were just waiting on the resident to call back. When asked by the surveyor if there was anyone that should be notified if they received information about residents allegedly bringing in drugs V16 stated the abuse coordinator. When asked by the surveyor if she knows what triggered R12 to use drugs in the past V16 stated R12 just said if she's around certain people or gets involved at parties; and V16 believes that's what lead up to R12 using substances in the past.
The facility's list of residents receiving treatment for substance abuse disorders printed [DATE] documents there are currently 52 residents in the facility with active substance abuse disorders receiving treatment including R8, R12, R13, and R14.
The facility's Alcohol/Substance Use/Abuse Policy received [DATE] states:
It is the policy of the nursing facility to provide a safe and healthy living environment. The use of drugs that are not prescribed by the physician are not allowed in this facility or on the facility campus. Illicit drugs may not be brought inside the facility.
Documentation should include the resident's own admission of drug use.
The facility's Incident/Accident Reports Policy received [DATE] states:
The accident report is completed for all accidents where there is injury or the potential to result in injury.
The purpose of the policy is To report, record, and investigate all accidents. To provide a process for monitoring of planned corrective actions to prevent or reduce the risk of reoccurrence of reported accidents.
An accident is defined as any happening, unexpected, unintended event not consistent with the routine operation of the facility that can result in bodily injury other than abuse.
An accident report will be completed for: All serious accidents of residents; All accidental unusual occurrences; All accidental situations requiring the emergency services of a hospital or police; All unexpected events that occur that cause actual or potential harm to a resident.
An accident report is to be completed by a Licensed or Registered Nurse and is to include date and time of accident, full written statement and possible cause of incident, and notification of appropriate parties.
The Administrator, Director of Nursing, Assistant Director of Nursing, or Nursing Supervisor must notify the following if a serious injury occurs: The Illinois Department of Public Health as soon as possible within 24 hours of the occurrence.
Public Health is to be notified of incident resulting in emergency services provided by the police (911), accidents resulting in serious injury requiring hospitalization, or any accident which has or is likely to have a significant effect on health, safety, or welfare of a resident.
All accident reports are reviewed, signed, and investigated by: The Administrator and The Director of Nursing or the Assistant Director of Nursing.
Results of investigations are analyzed, and findings discussed in safety meetings.
The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. On [DATE] the survey team verified by observation, interview, and record review, that the facility implemented the following to remove the immediacy.
Removal Plan:
The Chicago Ridge Nursing & Rehabilitation Center outlines its plan to prevent illicit drug use and possible drug overdose among residents. The facility has implemented various measures to monitor residents to ensure a safe environment.
R12 currently resides in the facility and remains in stable condition. R12 has had no ill effects from the alleged deficient practice.
Education was initiated on [DATE] by the DON, ADON, and Social Service Director and is ongoing.
All facility staff have been in-service in person or via telephone. Staff who receive training via telephone will be required to attend in-person training before the start of their shift. Upon completion of the in-person in-service, the staff will sign the in-service sheet. The administrator and/or social service director will conduct weekly spot checks to ensure the facility staff are knowledgeable of the content. Any staff who were unable to attend the in-service due to a planned vacation or leave of absence will be in-serviced on their next workday before the start of their shift. The administrator, social service director, DON, or ADON will lead this in-service [DATE], ongoing.
Upon hire new staff are educated by social service and sign the in-service sheet ongoing
The Facility does not contract with agency staffing.
Education includes:
All staff ' s education will be ongoing.
Monitoring and investigating includes the steps to determine how illicit drugs got into the facility, prevent illicit drugs from entering the facility, are alerted when an illicit drug enters the facility and prevention of resident ' s use of illicit drugs and possible drug overdose.
Substance abuse and prevention is a process that attempts to prevent the onset/relapse of substance use.
Staff ensure the safety of residents and monitor the residents by conducting random room searches, supervised visits, and searching the residents' belongings.
Anyone who appears under suspicion of illicit drugs are placed under 1:1 supervision, notifications will be made to the administrator, DON, family, and MD. Narcan will be administered per the physician's orders.
The facility staff is responsible to reasonably prevent the entry of contraband into the facility and removing it from any resident who has it on them, including calling the police if applicable.
Upon admission/re-admission to the facility, the resident ' s packet and PASSR screen is reviewed by the social services director. The social service director has re-educated the social service department on the resident ' s diagnosis and discuss therapeutic programming and care plan development.
The resident's SMI/substance abuse disorder assessment was initiated, and care plan interventions updated 6-4-2025 to allow staff to adequately supervise and provide care to reduce the risk of substance use/ overdose.
Education is covered in annual competency for all facility staff.
Education on signs and symptoms of substance abuse and reporting signs and symptoms to the charge nurse.
Educated on confiscation of contraband and labeling non-contraband items.
The police department will be called immediately if contraband or illicit drugs are discovered, suspicious packages are delivered, or visitors bring them in. Or if a visit or resident refuses to have their packages searched.
Prevention of illegal substances in the facility:
The facility has posted signage in the lobby on 6-3-2025 alerting staff, residents, and visitors to the facility's policy of searching for contraband. This information has been provided to each resident in writing 6-4-25 and ongoing.
Mouth checks on residents will be performed on residents with a history of substance abuse and residents who receive scheduled control medications. This will be performed to ensure medications are being taken when administered. This will be performed by licensed nurses. 6-4-2025 (ongoing).
Upon admission/re-admission, the receptionist or designee will obtain the resident ' s belongings to be searched and inventoried before items are taken to the unit. 06-3-2025 and ongoing.
Residents who refuse to be searched will be placed on 1:1 supervision, notifications will be made to the family, local police, and the physician, and the resident will be petitioned to t[TRUNCATED]
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0745
(Tag F0745)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policies and procedures for providing services and su...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policies and procedures for providing services and supports for chemical dependence and substance abuse by not offering substance abuse group programming to a resident who reported a history of substance abuse and not ensuring a resident with a diagnosis history of Psychoactive Substance Abuse Disorder received psychiatric, group, or behavioral health counseling and services for two (R7, R12) of three residents reviewed for behavioral health services. These failures resulted in R12 using illicit substances in the facility and requiring emergent transfer to local hospital for overdose.
Findings include:
1. R7 is a [AGE] year-old male with diagnosis not limited to a history of Schizophrenia, Depression, Suicidal Ideations, a History of Suicidal Behavior, Crohn's Disease, Blindness of Left Eye, and Encounter for Palliative Care. R7 was admitted to the facility [DATE].
On [DATE] at 10:48 AM observed R7 sitting in the hallway in his wheelchair. R7 stated the facility does have a substance abuse group however, he was told he is not allowed to attend the substance abuse group because in order to attend he had to have a substance abuse history when he was admitted to the facility. R7 stated he knows other residents are using drugs in the facility because he recognizes the abnormal behaviors from drug use. R7 stated he recognizes these behaviors because he used to be a drug addict. R7 stated when he sees this it does tempt him to abuse drugs. R7 stated he uses a substance abuse program app on his phone for drug counseling and showed the app to the surveyor. R7 stated it would be helpful if he was able to attend substance abuse counseling groups at the facility or receive some substance abuse counseling at the facility.
R7's Current Care Plan initiated [DATE] documents he has a substance use disorder with interventions including involve him in individual counseling as appropriate and it does not include attending substance abuse groups.
Substance Abuse Group Attendance Sheets from April - [DATE] did not include R7's signature in the attendance sheets for the substance abuse group meetings.
On [DATE] at 1:59 PM V10 (Psychosocial Rehabilitation Services Director) stated V16 is the Substance Abuse Coordinator and conducts substance abuse groups 3-4x week. V10 stated V20 (Psychologist) also conducts Psychosocial programming every Tuesday and Thursday which includes three different groups on those days, and he also comes on Fridays. V10 stated V21 and V22 are Licensed Clinical Social Workers who see residents Monday - Friday and social services staff also meet with residents. V10 stated none of the current residents want to go to outside day programs and the few that do are in wheelchairs and those programs don't accept them.
On [DATE] at 2:54 PM V16 (Substance abuse Coordinator) stated she conducts substance abuse classes twice weekly on Mondays and Wednesdays for two half hour sessions between 11AM - 12PM; Residents attend the substance abuse groups based on their hospital documentation upon admission, and she did not find any documentation of a history of substance abuse in R7's records. V16 stated she reviews all resident referrals and hospital packets on admission and if it specifies a substance use history she will complete an admission packet for the substance abuse department, offer the programming, and if they decline, she has a one-to-one session with them on Tuesday. V16 stated she will encourage residents to come to the Groups during the one-to-one sessions. V16 stated approximately three months ago R7 mentioned to her he had a substance abuse background, and she told him she would have to review his admission packet and would get back to him. V16 stated when R7 returned from going in and out of the hospital for health issues he brought to her attention that he was enrolled in a substance abuse program online. V16 stated this was the second time he mentioned this, and she encouraged him to stay on the online program and advised it was really good. When asked by surveyor would a resident be invited to the substance abuse group program based on informing her of having a history of substance abuse or of her becoming aware of this information V16 stated she reviewed R7's admission packet and didn't find anything in his history and they must have this history in order to attend the group.
On [DATE] at 1:47 PM V10 (Psychosocial Rehabilitation Services Director) stated R7 should not be restricted from attending the substance abuse groups based on a substance abuse history not being identified on admission. V10 stated V16 should initiate a care plan and document on his history of substance use. V10 stated residents with a substance abuse history should receive services to address whatever behaviors or issues they have.
On [DATE] at 2:44 PM V2 (Director of Nursing) stated once a substance abuse history is identified for a resident, they should immediately be enrolled in the substance abuse group unless they decline. V2 stated this is important because you want to initiate the treatment protocols that are available to the patient.
On [DATE] at 3:25 PM V26 (Medical Director) stated the facility wouldn't treat residents with a substance abuse history any differently than any other patient, all the residents have medical conditions and substance abuse is just another type of medical condition. When asked by the surveyor should the facility monitor or be aware of a resident's triggers for substance use for residents with a substance abuse history V26 stated the facility has psychiatry that sees the residents to make sure they don't have any symptoms or withdrawals. V26 stated assessing triggers and monitoring the residents desire for drug use is part of the psychiatry evaluation and residents with a substance use history are managed by a psychiatrist for their addiction problems.
2. R12 is a [AGE] year-old female with diagnosis not limited to history of Epilepsy, Restlessness and Agitation, Psychotic Disorders with Delusions, Paranoid Schizophrenia, Bipolar Disorder, Generalized Anxiety Disorder. Recurrent Major Depressive Disorder, Psychoactive Substance Abuse Disorder. R12 was admitted to the facility [DATE].
On [DATE] at 12:21 PM observed R12 in her room handling her belongings. When asked by surveyor about her being hospitalized for drugs on [DATE] R12 confirmed she was hospitalized for an overdose. R12 stated she has a habit of roaming around and going in and out of rooms and on that day, she had been wandering in and out of rooms and when she arrived to R8's room she saw him snorting heroin. R12 stated she asked if she could join him and she snorted heroin six times, then went back to her room then to her boyfriend R13's room and passed out. R12 stated she heard that she was given CPR (Cardiopulmonary Resuscitation) because she was not responding. R12 stated she was told while in the hospital if she has another incident she could end up in the ICU (Intensive Care Unit).
R12's Hospital Record dated [DATE] documents she is a [AGE] year-old female with a past medical history of depression who presents to the emergency department from a Behavioral Health/Substance Abuse Treatment Organization for evaluation of a seizure sensation; she is at the Behavioral Health/Substance Abuse Treatment Organization for a history of drug, alcohol, and marijuana use; she reports last using cocaine 15 days ago.
R12's admission Contract includes a Social Services Quick Reference Interview form that documents she was admitted on [DATE], and in response to the question do you have a history of substance abuse? She answered yes and in response to the to the question which one? Regarding substance use she answered, all of them.
R12's Nurse Practitioner Progress note dated [DATE] documents Chief Complaint is to Establish care. This is a [AGE] year-old woman admitted to the facility on [DATE], with chronic diagnoses of Drug Use Disorders and Depression.
R12's (PASRR) Preadmission Screening and Resident Review dated [DATE] documents she has been to a Behavioral Health/Substance Abuse Treatment Organization for cocaine detox and rehab.
R12's Social Service Initial Interview for SMI (Severe Mental Illness) Substance Abuse Disorder dated [DATE] completed by V16 (Substance Abuse Coordinator) documents and answer of no in response to the question have you been in treatment for substance abuse?
R12's progress note dated [DATE] documents V16 (Substance Abuse Coordinator) spoke with her about the Substance Abuse admission whereas she received the Addiction & Diagnosis contracts. She is strongly encouraged to participate in Substance Abuse groups which will result in a 1:1 if a group is missed. Substance Abuse Counselor will assist as needed. R12's drugs of choice are Alcohol, Marijuana, and Cocaine.
R12's Current Care Plan initiated [DATE] documents her Comprehensive Assessment reveals a history of suspected Substance Abuse whereas the Resident is placed in the Substance Abuse Counseling group held on Mondays & Wednesday at 11 AM and alcoholics group which is held on Fridays at 11 AM. Her Drugs of choice are Alcohol, Marijuana, & Cocaine with interventions including emphasize treatment of causal factor and/or intervention designed to moderate/reduce symptoms (make treatment of compulsive behavior, Substance abuse, anger, and mental health issues available to the Resident, as indicated). R12 has a history of substance abuse/chemical dependency related to: Clinical depression and anger (substance abuse often indicates an attempt at self-medicating depression and disturbing thoughts), History of mental illness/severe mental illness, poorly developed ability to control impulses, and Allowing negative, inappropriate persons to influence his/her use of substances with interventions including: The physician may consider a referral to the psychiatrist. Provide leisure counseling to the resident to help him/her use free time in productive, not destructive ways.
R12's Psychiatric Progress Note dated [DATE] documents the type of visit as acute and she was seen for a chief complaint of assessment after admission from other facility. History of present illness includes recently using crack cocaine which may have precipitated either a seizure or behavioral disinhibition. She reports a history of mixed substance abuse before coming to Chicago Ridge at the end of [DATE]. Diagnosis Assessment and Plan includes Alcohol dependence.
R12's progress note dated [DATE] documents a referral packet was sent to V20 (Psychologist) for group therapy. R12 was denied for V20's services. R12 was referred to (another provider).
R12's Psychiatric Progress Notes dated [DATE] do not include substance abuse counseling.
R12's progress note dated [DATE] created by V21 (Licensed Clinical Social Worker) documents Reason for Referral as Comprehensive biopsychosocial assessment for initial psychiatric diagnostic evaluation as per referral by the Director of Social Services. Resident has a medical diagnoses history of Uncomplicated Other Psychoactive Substance Abuse. Resident has a history of alcoholism and drug addiction (marijuana and cocaine). Drug Use: Remote.
R12's Psychiatric Progress Note dated [DATE] created by V29 (Addiction and Psychosocial Nurse Practitioner) documents the type of visit as addictions program follow up and she was seen for a chief complaint of assessment of current alcohol use. Substance use history includes her reporting a history of using heroin and cocaine for 1-2 years. Reports alcohol is a problem for her and refused to discuss her history with alcohol. Patient reports she would like to think about it regarding MAT (Medication-Assisted Treatment - a comprehensive approach to treating substance use disorders that combines medications with counseling and behavioral therapies). Per chart review patient was previously on an alcoholism medication although she can't recall this. Relapse prevention discussed.
R12's Psychiatric Progress Notes dated [DATE] created by V28 (Psychiatric Nurse Practitioner) do not include substance abuse counseling.
R12's progress note dated [DATE] documents resident is seen by the facility Psychiatrist once a month.
R12's progress notes from April and [DATE] document she attended substance abuse group once on [DATE] and does not include any notes of one-to-one substance abuse counseling.
R12's Psychiatric Progress Notes dated [DATE] created by V28 (Psychiatric Nurse Practitioner) do not include substance abuse counseling.
R12's progress note dated [DATE] at 9:42PM created by V18 (Licensed Practical Nurse) documents she was visiting with a friend in his room, peer came to desk to get nurse stating, She's not responding to me. Writer entered peers room noticed a change of condition with patient not responding appropriately. Vital Signs noted oxygen at 82%. Writer applied oxygen at 5L via non-rebreather mask; Oxygen saturation increased to 92%. Narcan (Opioid Antagonist) administered twice, 911 called. Fellow co-workers assisted with patients care; at 9:50 PM it was documented that 911 paramedics here at facility to assess patient's status and scenario. 911 took over CPR (Cardiopulmonary Resuscitation); at 10:00 PM a late entry documented R12 discharged to: the hospital on [DATE] at 9:42 PM; Reason for transfer: Patient not responding appropriately at her normal; at 22:10 it was documented patient being transported to the Hospital emergency room for further evaluation.
R12's progress note dated [DATE] created by V31 (Licensed Practical Nurse) documents resident admitted to the Hospital with diagnosis of Overdose and Pneumonia.
R12's Physician Order History documents an order effective [DATE] for being able to be seen by a psychiatrist or psychologist. R12's Physician Order History does not include any previous orders for seeing the psychiatrist.
R12's progress note dated [DATE] documents resident is readmitted to the facility day 1 of 3. Resident transferred from Hospital related to overdose and pneumonia.
On [DATE] at 12:35 PM V16 (Substance Abuse Coordinator) confirmed R12 was admitted with a substance abuse history and was referred to her. V16 stated R12 attends every group. V16 stated on admission she does ask residents what their current drug use is and if they have cravings. V16 stated she completes the substance abuse assessments yearly or whenever the residents get into trouble she revises them. When asked by the surveyor what are R12's triggers for drug use V16 stated she just told me she needed some coping skills. When asked by surveyor to specify what coping skills R12 needed V16 stated R12 was struggling with coping skills regarding sex, it's like difficult to explain, she needs something to keep her mind off things, so she gave her coping skills suggestions of meditation and finding inspirational speakers online. V16 stated R12 also received a paper with coping skills suggestions from V3 (Psychiatric Rehab Services Coordinator) her social worker. V16 stated residents receive coping skills guidelines through the documentation she provides during substance abuse groups. V16 stated every Tuesday she provides one to one substance abuse counseling for all the residents that don't attend the substance abuse groups which include for gambling, for alcoholics, and for narcotics and cocaine. V16 stated the residents are referred to groups based on their drug of choice. V16 stated R12's substance abuse care plan should include gambling and alcoholics and now she is interested in all three groups.
On [DATE] at 11:09 AM V10 (Psychosocial Services Director) stated (provider name) is the program that V21 and V22 the LCSW's (Licensed Clinical Social Workers) work from. V10 stated V20 (Psychologist) provides psychosocial groups and one to one counseling. V10 stated R12 was denied V20's program due to insurance.
On [DATE] at 11:23 AM V1 (Administrator) stated it's not part of their process to acquire any information from the substance abuse treatment center where R12 was being treated in just prior to her admission to the facility, however it's a good idea.
On [DATE] at 12:10 PM V30 (Psychiatrist) stated R12 is seen once per month for schizophrenia by V28 (Psychiatric Nurse Practitioner) and seen once per month by the addiction provider V29 (Addiction and Psychiatric Nurse Practitioner). V30 stated V29 last saw R12 in March and believes this was the first time she saw her. V30 stated R12 has a history of alcohol use and was evaluated by V29 for this. V30 stated it looks like R12 also reported a history of cocaine for 1-2 years and said she would think about MAT (Medication Assisted Treatment). V30 stated he isn't sure if there was any discussion with R12 and V28 regarding using cocaine or heroin but there is no documentation of it in V28 notes. V30 stated R12 was seen by the psychiatric nurse practitioner once monthly and V29 was seeing her parallel to that. V30 stated he's not sure if R12 was in the hospital when V29 was rounding at the facility. V30 stated V29 comes to the facility approximately every two weeks and R12 would have been seen during those visits. V30 stated V29 was at the facility [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. V30 stated he did not find any notes from V29 for R12 other than on [DATE]. V30 stated R12 was on the list to be seen on 04/18 however there was no notation as to why she wasn't seen. V30 stated V28 is seeing R12 more for hallucinations, anxiety, and schizophrenia symptoms.
On [DATE] at 2:23 PM V28 (Psychiatric Nurse Practitioner) stated the last time she saw R12 was [DATE] and she sees her monthly. V28 stated there has been no discussion about R12's use of cocaine or heroin during their meetings. V28 stated during her meetings with R12 she addresses her mental health and R12 is being seen by an addiction specialist as well.
On [DATE] at 3:55 PM when asked by surveyor if during his meetings with R12 there is any discussion about her use of heroin or cocaine V21 (Licensed Clinical Social Worker) stated no, he lets V16 (Substance Abuse Coordinator) do that with R12 during her groups.
The facility's Chemical Dependency and Relapse Prevention Support Group Policy received [DATE] states:
The purpose of the policy is To help the resident with a substance abuse diagnosis and/or history remain (clean) in the least restrictive setting. The group is an adjunct support in the patient's effort to decrease and eliminate the role and influence of chemical dependency in his/her life.
Referral Criteria:
History/Diagnosis of substance abuse and some desire to achieve sobriety or remain sober.
History of in-patient substance abuse treatment and need for aftercare.
The facility's Alcohol/Substance Use/Abuse Policy received [DATE] states:
It is the policy of the nursing facility to provide a safe and healthy living environment. The facility recognizes that persons requiring long-term care present with significant physical and mental health problems.
The facility shall work with the individual to provide appropriate treatment referrals to enable the individual to work on abstinence, sobriety, personal improvement and reducing chances of recidivism.
Appropriate interventions are strongly recommended to persons with substance abuse problems.
Persons assessed with an active substance abuse problem are offered appropriate treatment and rehabilitative services.
Follow-up interventions and treatment recommendations will be communicated to the resident and documented in the medical record. Outside treatment sources will be utilized as appropriate.
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to follow professional standards of care to transcribe and follow the physician orders for one of one resident (R1) to monitor the right foot f...
Read full inspector narrative →
Based on interview and record review the facility failed to follow professional standards of care to transcribe and follow the physician orders for one of one resident (R1) to monitor the right foot for increased discoloration, to assess pedal pulse, and monitor for temperature changes. This affects one of three residents reviewed for professional standards.
Findings include:
R1 face sheet shows diagnosis of occlusion and stenosis of right carotid artery, essential hypertension, and anemia.
On 4/23/25 at 11:50am V11 (Nurse Practitioner) said R1 complained of discoloration to her right foot, and she ordered a doppler ultrasound for R1's feet bilaterally. V11 said she assessed R1 foot, R1 denied pain. V11 said she observed R1 right foot to be cool to touch (cooler than the left foot) and R1 had edema bilaterally to the feet. V11 said the doppler results was negative for deep vein thrombus (DVT). V11 said she was not concerned for ischemia because the doppler was negative for DVT. V11 said although the doppler was negative, the plan of care was to monitor R1's foot due to the lateral discoloration. V11 said the plan was to monitor for increased discoloration, monitor the pedal pulse and assess the temperature of R1's foot. V11 omitted the time frame for monitoring R1's foot. V11 said she gave a verbal order to the Nurse. V11 said she don't recall the Nurse's name, she recalls giving the verbal order to a female Nurse.
On 4/23/25 at 12:29pm, V12 (Licensed Practical Nurse/LPN) said she sent R1 to the hospital after the fall on 4/6/25. V12 said she did not assess R1's feet after the unwitnessed fall. V12 said she was not aware of any orders to monitor R1's right foot for increased discoloration, assess the pedal pulse and assess the temperature of R1's foot. V12 said she was aware that R1's right foot was darker than the left foot and that there was a doppler ordered and completed for R1. V12 said she should have assessed R1 from head to toe. V12 said she was educated to assess the resident from head to toe after an unwitnessed fall. V12 said she would have notified the physician, Director of Nursing, and administrator of the changes to R1's foot had she assessed R1's foot.
On 4/23/25 at 1:53pm V13 (Certified Nursing Assistant/CNA) said she was R1's aide before her assignment of R1 switched. V13 said R1 had a bandage on her right foot, V13 said she was made aware days prior that R1 had a blister on her foot, and it had burst. V13 said the Nurse wrapped R1's foot.
4/25/25 at 11:31am V17 (Medical Doctor) said R1 has history of chronic ischemia, the blister to the right foot is due to poor perfusion and ischemia, the blister is a result of vascular disease. V17 said ischemia to R1 foot is not a result of the facility, R1 has chronic comorbidities, including cardiovascular issues, poor perfusion, and she smoke. V17 said the Nurse was correct to wrap the foot when she observed the blister. V17 said he may have been notified, he would have order to wrap the foot and to monitor the foot. V17 said he agrees with the orders from the Nurse practitioner for monitoring for discoloration, checking the pulse, and monitoring the temperature. V17 said R1 decline treatment in the hospital for the ischemia. V17 said the blister is a result of the poor perfusion, the blister would be expected, V17 said the blister is fluids. V17 said the blister was observed on the 4th, and R1 was sent to the hospital on the 6th, one day would not have changed R1 outcome for the chronic ischemia.
On 4/25/25 at 12:05pm V16 (LPN) said V11 gave her the orders to monitor R1's foot. V11 said she forgot to transcribe the orders. V11 said she's the Nurse that wrapped R1's foot with the bandage.
Review of R1's physician order sheet, there are no orders noted for monitoring of R1's right foot for increase in discoloration, assessment of the pedal pulse, nor monitoring the temperature of R1's foot.
Review of R1's progress notes there are no documentation denoting that R1 foot or feet were monitored/ assessed for increased discoloration on 4/4/25 all shifts, 4/5/25 all shifts and on 4/6/25.
R1 emergency room records dated 4/6/25 denotes in-part diagnosis lower limb ischemia, open wound of right foot, anasarca.
Facility physician orders policy dated 1/2024 denotes in-part policy and procedures physician orders, purpose to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards. All orders (telephone, verbal, written) shall be provided by licensed practitioners (physician, nurse practitioner, or physician assistant) authorized to prescribe such orders. Orders must be recorded in the medical records by the licensed nurse authorized to transcribe such orders. Physician orders must be documented clearly in the medical record (PCC). Clear and complete orders will be transcribed to the appropriate administration record ( MAR/TAR) Medication administration record/treatment administration record).
Apr 2025
3 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
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect a resident's right to be free from physical abuse from ano...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect a resident's right to be free from physical abuse from another resident for one (R5) of five residents reviewed for abuse in a sample of 14. This failure resulted in R5 being physically assaulted and emergently transferred to the hospital for evaluation of facial trauma.
Findings inlcude:
R5 was dmitted to the facility on [DATE] with diagnosis including but not limited to Gout, Unspecified; Hypothyroidism, Unspecified; Chronic Obstructive Pulmonary Disease, Unspecified; Essential (Primary) Hypertension; Hyperlipidemia, Unspecified; Other Muscle Spasm; and Nondisplaced Fracture of Cuboid Bone Of Right Foot, Subsequent Encounter For Fracture With Routine Healing.
According to R5's MDS (Minimum Data Set) assessment dated [DATE] under section C, R5 has BIMS (Brief Interview of Mental Status) score of 15 indicating, indicating intact cognition.
Prior to 03/02/2025 absent are any care plans related to R5's susceptibility to abuse.
R6 was admitted to the facility on [DATE] with diagnosis including but not limited to Schizophrenia, Unspecified; Primary Insomnia; Opioid Dependence with Withdrawal; Chronic Obstructive Pulmonary Disease, Unspecified; Chronic Viral Hepatitis B Without Delta-Agent; Unspecified Viral Hepatitis C Without Hepatic Coma; Essential (Primary) Hypertension; and Opioid Dependence, Uncomplicated.
According to R6's MDS (Minimum Data Set) assessment dated [DATE] under section C, R6 has BIMS (Brief Interview of Mental Status) score of 14 indicating, indicating intact cognition.
Prior to 03/02/2025 absent are any care plans related to R6's predisposition to abuse.
R10 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Unspecified; Edema, Unspecified; Hypotension, Unspecified; Hypertensive Heart Disease Without Heart Failure; Type 2 Diabetes Mellitus Without Complications; Hypokalemia; Major Depressive Disorder, Single Episode, Unspecified; and Schizoaffective Disorder, Unspecified.
According to R10's MDS (Minimum Data Set) assessment dated [DATE] under section C, R10 has BIMS (Brief Interview of Mental Status) score of 15 indicating, indicating intact cognition.
On 04/02/2025 at 1:27 PM Surveyor observed 19 residents in the third-floor dining room, no monitoring staff present.
On 04/02/2025 at 1:36 PM Surveyor observed 11 residents in the second-floor dining room, no monitoring staff present.
On 04/07/2025 at 10:57 AM Surveyor observed 3 residents in the second-floor dining room, no monitoring staff present.
On 04/02/2025 at 12:23 PM, R5 stated, On 03/02/2025 around 7:00 PM, I was sitting in the dining room (third-floor unit). (R6) came up to me and wanted to grab a chair that I was using to keep my leg elevated. My right ankle was fractured at that time. There were multiple empty chairs in the dining room. I told (R6) to leave it and then he just punched me. I had a black eye out of that, but it healed. I was sent out to the hospital after the incident. There was no staff in the dining room at the time of the incident. (R10) was there, he can confirm there was no staff monitoring. Surveyor asked if R5 feels safe in the facility, R5 said apprehensively, I feel safe in the facility. This is what I think, if I stay in my room, nothing is going to happen, right? Surveyor did not observed trauma on R5's face at this time.
On 04/02/2025 at 12:39 PM, R6 said, I had no altercation with no other residents.
On 04/02/2025 at 12:41 PM, R10 said, I saw when (R6) hit (R5). It was in the dining room. There was no staff monitoring the dining room. All staff came in after they heard the commotion; otherwise, they're never there.
On 04/08/2025 at 12:06 PM, V22 (Social Service Assistant Director) said, The altercation between (R5) and (R6) happened on the evening of 03/02/2025, which was Sunday. I don't work on Sundays, so I was notified the following day. I was told that (R6) was the aggressor, and both residents were sent out, (R5) due to injury and (R6) for behavioral evaluation. I don't remember why they got into a fight.
On 04/08/2025 at 2:35 PM, V26 (Licensed Practical Nurse/LPN) said, I worked on 03/02/2025 3:00 PM - 11:00 PM. (R5) came to the nursing station in the evening and complained about being hit by (R6). We notified (V1 (Administration/Abuse Prevention Coordinator)) and (V3 (Director of Nursing)). We assessed (R5)'s face. (R5) had swelling to the left side. (R5) said Don't worry about it, but I told him that the (V1) had to be notified. The doctor and the family were notified as well, and I received an order to send (R5) out for evaluation. We went and looked for (R6). (R6) was smoking on the smoking patio. We brought (R6) back to the third-floor unit. (R6) had no injuries and was sent out later in the evening for behavioral evaluation. We usually have, 1 to 2 CNAs on afternoon shifts on weekends and sometimes weekdays. 1 nurse passes medications and another nurse along with the CNA monitors. Some of the residents stay in the dining room to watch TV but we don't have to monitor all the time.
On 04/08/2025 at 3:22 PM, V27 (Certified Nurse Assistant?CNA) said, I worked on 03/02/2025 from 3:00 PM to 11:00 PM. I was the only CNA on duty on the third-floor unit that evening. I was staying in the dining room for 30 to 35 minutes at the time and alternating with one of the two nurses who worked with me that evening. Towards the end of my shift, (R5) came up to the nursing station. (R5)'s face was red; you could see right away that something happened. (R5) said that (R6) punched him when they were in the dining room. No one was monitoring the dining room at that time, so I didn't see the altercation. Both nurses were charting, and I was completing my forms at that time, it was almost the end of the shift. I know that (R10) was there and saw what happened. I was assigned to watch (R6) after the altercation. (R6) told me that (R5) is just exaggerating. (R6) was pacing around the unit, so I just followed him around. At some point, (R6) went into his room and fell asleep.
On 04/09/2025 at 2:51 PM, V28 (Psychiatric Nurse Practitioner) said, Residents with psychiatric diagnosis should be monitored, especially, if they are in the common area with other residents. Safety is a major reason to monitor residents with psychiatric diagnosis.
On 04/14/2025 at 10:07 AM V1 (Administrator/Abuse Prevention Coordinator) said, I was notified of the incident on the same evening (03/02/2025). I was told that there was an altercation between (R5) and (R6) and that they were separated immediately. (R5) and (R6) were arguing over a chair. It happened in the dining room; (R5) and (R6) may have been left alone at the time of the incident. All residents should be monitored while they're in the dining room. However, the investigation revealed that R6 denied hitting R5 and there were no witnesses who witnessed the incident; therefore, the incident was unsubstantiated. The investigative process is always the same. We obtain involved residents' statements, staff, and other residents who may have witnessed the incident. We always make a police report and send residents out if ordered by the physician. I send an initial report to (regulatory agency), inform responsible parties for the residents' and then continue with the investigation until concluded what happened.
Progress note dated 03/02/2025 at 8:50 PM written by V26 (LPN) reads in part, Writer was informed via staff member that resident (R5) was hit by co-resident (R6). Head to toe assessment completed with slight swelling noted to left eye. First aid rendered, denies pain at present time. VSS. Residents separated and in close observation with staff. Administrator, MD, Family member made aware. Obtained order via MD to send pt out to hospital for medical and psychiatric eval.
R5's hospital record dated 03/02/2025 reads in part, (R5) reports he got an argument with another resident (R6). (R5) had a chair, other resident (R6) tried to take the chair from him. The other resident (R6) punched him in the face. Differential diagnosis includes but not limited to Blunt trauma, contusion, assault.
Police report dated 03/02/2025 8:16 PM reads in part, Physical altercation between two residents in the day room; event number provided over the phone; both parties separated.
Facility staffing for 03/12/025 3:00 PM to 11:00 PM shows V27 (CNA) as the only aid working on the third-floor unit housing 75 residents.
The facility Abuse Prevention Program last reviewed 01/04/2019 reads in part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident Assessment; Staff Supervision.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to assess and identify resident's new onset of right hip pain and adm...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to assess and identify resident's new onset of right hip pain and administer PRN (as needed) pain medications for one (R8) of three residents reviewed for pain in a sample of 14. This failure resulted in R8 having increased pain level for 24 hours before R8 was hospitalized for pain management and later surgery of the right hip fracture.
Findings include:
R8 was admitted to the facility on [DATE] with diagnosis including but not limited to History Of Falling; Epilepsy, Unspecified, Not Intractable, Without Status Epilepticus; Restlessness And Agitation; Paranoid Schizophrenia; Hypertensive Heart Disease Without Heart Failure; Cognitive Communication Deficit; Need For Assistance With Personal Care; and Other Abnormalities Of Gait And Mobility.
On 04/02/2025 at 1:31 PM, Surveyor attempted to interview R8, R8 answered surveyor's questions unintelligibly. Surveyor unable to interview R8.
On 04/07/2025 at 12:41 PM, V19 (Therapy Director) said, (R8) was seen by therapy 2/14/2025, 2/18/2025, 2/19/2025, and 2/20/2025. (R8)'s pain to the legs was first documented by me on 2/19/2025. I reported the pain in the IDT (interdisciplinary team) meeting later in the day on 2/19/2025, nursing staff was notified. I also noticed change in (R8)'s condition, most of all, (R8) became not ambulatory. (R8) was then hospitalized on [DATE]. During the hospitalization (R8) had ORIF (open reduction internal fixation) of right hip.
On 04/08/2025 at 12:40 PM, V4 (Assistant Director of Nursing) said, On 2/19/2025, (V19 (Therapy Director)) notified me that (R8) was complaining of pain to his right hip. I went and talked to (R8), and he said that he has pain in the right leg. I asked (R8) about the number on pain scale but (R8) didn't give me a number. I tried to do ROM (range of motion) but (R8) refused. I notified (V23 (Licensed Practical Nurse)) and (V24 (Family Nurse Practitioner)). (V24) placed an order for x-ray. X-ray service came in late that night and results were reported on 2/20/2025 around 3:25 AM. X-ray showed fracture in the right hip and (R8) was sent out to the hospital on 2/20/2025 around 10:15 AM. (V23) was told to give (R8) pain medication. I didn't give (R8) anything for pain after my assessment.
On 04/08/2025 at 12:56 PM, V24 (Family Nurse Practitioner) said, I was in the facility on 02/19/2025 when (V23) told me about (R8)'s pain. I went to assess (R8), and he said he's scared to move his right leg due to pain. I ordered an x-ray and told the nurse to offer (R8) pain medication. I reviewed the x-ray on 2/20/2025 at 9:57 AM, it showed right femoral neck fracture, and R8 was sent out to the hospital shortly after. As far as pain, nurses were supposed to give (R8) his PRN (as needed) pain medication, there was already order for that. When a resident complains of pain, nurses should do assessment first, and give pain medication. Pain medication administration is important to prevent any additional physical symptoms, such as elevated blood pressure, stress, tachycardia, or even depression. (R8) stated his pain was 6/10 on the pain scale and it was definitely appropriate for nurses to administer pain medications.
On 04/08/2025 at 3:58 PM, V25 (Registered Nurse) said, I worked on 2/19/2025 from 3:00 PM to 11:00 PM. I never heard (R8) complain of pain on my shift, so I didn't give (R8) any pain medications. I knew (R8) was waiting for an x-ray due to pain in his leg, but that's all I know.
On 04/09/2025 at 11:37, AM V23 (Licensed Practical Nurse) said, I worked on 2/19/2025 and 2/20/2025 from 7:00 AM to 3:00 PM. I know (R8) very well, I take care of him almost every day. I was doing my morning medication pass on 2/19/2025 when (V4 (Assistant Director of Nursing)) told me that (V19 (Therapy Director)) notified her of (R8)'s pain in the hip and asked me to give (R8) pain medication. I went to get pain medication and gave it to (R8). I didn't document it. (R8) was complaining of hip pain on 2/19/2025 but never gave me a number on the pain scale. I did not document any pain assessments for (R8). I didn't give (R8) any additional pain medications after the morning of 2/19/2025 nor before (R8) was sent out to the hospital (2/20/2025 10:15 AM). I noticed that (R8) wasn't getting out of bed few days prior to 2/19/2025. It was a pretty big change for (R8) because normally he would walk around but I didn't ask him why (R8) is not himself, I thought he was just not in the mood to get out of bed.
On 04/09/2025 at 2:24 PM, V3 (Director of Nursing) said, If a resident complains of pain, nurses should first assess a resident to determine location, intensity, and number on the scale related to pain. Nurse should document a pain review. Nurses should then administer pain medication if there is an existing order for PRN (as needed) pain medication. The pain review should be completed with any change in resident's condition, new pain, or fall.
Absent are any progress notes or pain reviews related to R8's new onset of pain in the right hip on 2/19/2025.
R8's physician order dated 02/12/2025 reads in part, Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for pain.
R8's Medication Administration Record for February 2025 does not show any pain medication given to R8 on 02/19/2025 nor 02/20/2025.
Progress note dated 02/19/2025 written by V19 (Therapy Director) reads in part, Response to session interventions: (R8) required max encouragement to participate with skilled interventions. (R8) c/o BLE (bilateral lower extremities) discomfort during functional bed mobility performing self-care tasks, nursing notified.
Progress note dated 02/19/2025 1:35 PM written by V24 (Family Nurse Practitioner) reads in part, HPI: (R8) seen for complaints of right hip and thigh pain. (R8) was found lying in bed stated he is scared to move his right leg, rated pain 6/10. Assessment/Plan: Localized pain, continue pain management, 3 views x-ray of right hip and thigh.
R8's x-ray physician order dated 02/19/2025 1:53 PM reads in part, Right hip and thigh x-ray, 3 views; standard diagnostic.
R8's Radiology Results Report read sin part, Examination date: 02/19/2025; Reported date: 02/20/2025 3:25 AM' reviewed by V24 (FNP) on 02/20/2025 9:57 AM. Clinical information: Post Fall, r/o, Fracture. Findings Right Hip: Examination reveals impacted subcapital fracture of the right femoral neck with varus deformity and no significant displacement.
R8's hospital record dated 02/20/2025 reads in part, (R8) was sent form his (facility) to outpatient XR which showed right hip fracture and was send to ED for further evaluation. (R8) states he fell out of bed a couple of days ago, he says he does not know why he didn't come after his fall. (R8) says that his pain 8/10.
R8's Operative Notes dated 02/21/2025 read sin part, Procedure: Right Hip Anterior Hemiarthroplasty.
The facility Pain Management and Assessment policy last reviewed 11/2022 reads in part, It is the policy of the facility to assess the resident for the presence of pain in order to determine the appropriate interventions. Assess and document pain including onset and duration, location, severity, alleviating, and aggravating factors, possible causes, and accompanying signs and symptoms. Identify the pain rating scale used for consistency with subsequent assessments. Routine pain assessment reviews will be conducted quarterly, upon significant change in condition, and more frequently as necessary to evaluate the effectiveness of the individualized pain management program and comfort level of the resident.
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 interviews and record review, the facility failed to notify a physician of a resident refusing psychotropic medication ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify a physician of a resident refusing psychotropic medication for one (R7) of three residents reviewed for quality of care in a sample of 14.
Findings include:
R7 was admitted to the facility on [DATE] with diagnosis including but not limited to Schizoaffective Disorder, Unspecified; Hyperlipidemia, Unspecified; Paranoid Schizophrenia; Brief Psychotic Disorder; Restlessness And Agitation; Anemia, Unspecified; Body Dysmorphic Disorder; Gastro-Esophageal Reflux Disease Without Esophagitis; Other Specified Phobia; Obsessive-Compulsive Disorder, Unspecified; and Other Schizoaffective Disorders.
According to R7's MDS (Minimum Data Set) assessment dated [DATE] under section C, R7 has BIMS (Brief Interview of Mental Status) score of 15 indicating, indicating intact cognition.
According to R7's MDS (Minimum Data Set) assessment dated [DATE] under section E, R7 has a history of refusing of care, including refusing taking medications.
R7's care plan (R7) requires psychotropic medication to help manage and alleviate: OCD, Suicidal ideation, Schizophrenia, Schizoaffective Disorder dated 01/04/2022 reads in part, Carry out the medication management regiment as prescribed. Report changes, complications to the doctor.
On 04/02/2025 at 1:24 PM, Surveyor attempted to interview R7, R7 refused to talk to the surveyor.
On 04/08/2025 at 10:58 AM V9 (Licensed Practical Nurse) said, I worked on 03/05/2025 from 7:00 AM to 3:00 PM on the third-floor unit. At the start of my shift, (R7) was already spiraling down. (R7) can be very manic at times and wants to do things when she wants them done. I suspect (R7) didn't get what she wanted on a previous shift and that's why she spiraled down on my shift. (R7) doesn't often need PRN psychotropic medication, but when she needs them, she needs them. You can tell when (R7) spirals down, she starts to pace, sorts through clothes, wants only specific garments, and wants to bathe. There are definitely signs based on which you can tell (R7) is spiraling down. Not sure why other staff don't recognize those signs, I think I work with (R7) the most, that's why I can see when she needs intervention. On the morning of 03/05/2025, (R7) went to the first-floor unit and was trying to go to (R12)'s room to use a bathroom. I followed (R7) to give her PRN (as needed) psychotropic medication. (R7) was having a behavioral crisis. Before I was able to bring (R7) back to the third-floor unit to administer the medication, (R7) hit (R12). I witnessed what happened. I was the one who separated both residents. I was then able to bring (R7) back to the third-floor unit and give her the medication. I then assessed (R7), notified the doctor, (V3 (DON)), and guardian. The doctor gave an order to send (R7) out to the hospital for behavioral assessment. I don't remember if I gave (R7) her scheduled psychotropic medication on 03/02/2025, (R7) might have refused. I didn't have a chance to document or let anybody know that (R7) refused her scheduled psychotropic medication.
On 04/09/2025 at 2:51 PM V28 (Psychiatric Nurse Practitioner) said, I am familiar with (R7). We usually see residents on monthly basis, last time I saw (R7) was 03/24/2025. From what I'm told by the nurses, (R7) doesn't have a lot of behavioral episodes. I was not aware that (R7) hit another resident on 03/05/2025. (R7) is on scheduled long-acting injectable psychiatric medication. I was not aware that (R7) refused her long-acting injectable psychiatric medication scheduled to be given on 03/02/2025. Nurses should notify me if that happens. If resident a resident misses a dose of scheduled medication, they can become delusional, psychotic, or even aggressive. It is possible that missing a dose of the scheduled medication led to (R7)'s behavioral decline on 03/05/2025, it is definitely possible. Some of the behavioral clues that a resident's behavior is declining, and they may need interventions, or that a resident needs a PRN (as needed) medications are delusions, psychosis, or aggression.
On 04/09/2025 at 2:24 PM V3 (Director of Nursing) said, If a resident refuses psychotropic medication scheduled every 30 days, the nurse should offer it again, even the next day. If a resident still refuses, the nurse should let the doctor know. Medication refusal should also be documented in the resident's chart.
Absent are any progress notes showing (R7) refused scheduled medication and a physician was notified on 03/02/2025.
R7's physcian order dated 11/02/2024 [NAME] in part, Haloperidol Decanoate Solution 100 MG/ML Inject 100 milligram intramuscularly one time a day every 30 day(s) for agitation.
R7's Medication Administration Record for March 2025 shows that R7 refused scheduled long-acting injectable psychiatric medication on 03/02/2025.
The facility Charge Nurse job description read sin part, Main Duties: Administer all parenteral, intramuscular, and sub-cutaneous injections; Administer all medications; Direct charting in his/her shift and make monthly detailed evaluation of all resident charting so that charts reflect progress and condition of residents in the EMR system.
Feb 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep a resident free from verbal abuse from a staff member. This fa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep a resident free from verbal abuse from a staff member. This failure applied to one (R1) of one resident reviewed for abuse.
Findings include:
R1 originally admitted to the facility on [DATE] and discharged AMA (Against Medical Advice) on 2/26/2025. R1 has multiple diagnoses including but not limited to the following: multiple puncture wounds, pain, mental and behavioral, anxiety, and depression.
MDS (Minimum Data Set) dated 2/28/2025 shows R2 has a BIMS (Brief Interview for Mental Status) of a 15 meaning R2 is cognitively intact. MDS dated [DATE] shows R1 has a BIMS of 15 also meaning R1 is cognitively intact.
Initial facility reported incident dated 2/23/2025 states in part but not limited to the following: R1 reported V3 (Former Social Service Aide/Smoking Monitor) was verbally inappropriate with residents.
R1's witness statement dated 2/23/2025 states in part but not limited to the following: R1 requested a cigarette from V3 during smoking time. V3 refused to give R1 a cigarette and I told her I am a grown man. V3 then told R1 B**ch, you are not getting one.
R2's witness statement dated 2/23/2025 states in part but not limited to the following: R1 asked V3 for a cigarette and V3 said no, b**ch.
2/27/2025 at 11:35AM, R2 said I was present on 2/23/2025 when R1 was asking V3 for a cigarette. V3 was standing inside the facility by the cart that contains the resident cigarettes and smoking her own cigarette. V3 was not letting me or R1 smoke. R1 was upset that V3 would not give him a cigarette. They were arguing about it and V3 called R1 'a b**ch.'
At 11:13AM, V2 (Licensed Practical Nurse) said after the 1:00PM smoking time on 2/23/2025, R1 came back up to the third floor and told me that V3 was talking to him in an inappropriate way and called him 'a b**ch.' R2 said he was present also at the time and he heard V3 use inappropriate language to R1 as well. R1 was very upset and I brought him to his room to calm down. I called V1 (Administrator/Abuse Coordinator) and a police report was filed.
Police Report dated 2/23/2025 states in part but not limited to the following: Complainant needing to document a verbal aggression towards patient.
V3's personal file included a disciplinary action dated 7/3/2023 which read: Employee are presented with unsatisfactory work and/or attitude. Employee noted with dishonest practice regarding the handling of smoking materials.
Abuse Prevention Program facility policy and procedure with last review date of 1/4/2019 states in part but not limited to the following: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, etc.
Feb 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to follow Care Plan interventions and implement appropriate fall preven...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to follow Care Plan interventions and implement appropriate fall prevention interventions to prevent repetitive falls for one of three Residents (R2) reviewed for falls in a sample of four.
Findings include:
Facility Fall Prevention Program Policy, dated 2/28/14, documents: it is the policy of the Facility to have a fall prevention program to assure the safety of the all residents in the facility; the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary; and the fall prevention program includes methods to identify risk factors, identify residents at risk, use and implementation of professional standards of practice, changes in interventions that were unsuccessful, documentation requirements and Care Plan incorporates identification of all risk/issue and interventions with each fall.
R2's Minimum Data Set/MDS, dated [DATE], documents a Brief Interview for Mental Status of mild cognitive deficit (score 12/15) and that R2 requires substantial staff assistance with sit-to-stand, standing, sitting in a chair or side of the bed.
R2's current Care Plan documents R2 has diagnoses including Cerebral Vascular Attack and Hemiplegia. The Care Plan also documents that R2 has had multiple falls related to general weakness, poly-pharmacy, poor coordination, use of anti-hypertensive's, use of psychotropic medications, and a history of falls, incontinence of bowel and bladder.
R2's Care Plan interventions include: call light within reach and remind to ask for staff assistance with all transfers (date initiated 01/19/2024); remind to use the Call light for assistance with transfers and Physical Therapy evaluation (date initiated 03/10/2024); footwear checked to insure proper fitting (date initiated 06/08/2023); will be placed on the early get-up list (date initiated 11/29/2024); Physical Therapy evaluation and non-slide padding placed in wheelchair for safety (date initiated 10/17/2024); Physical Therapy evaluation and frequent rounds to assist with activity of daily living and transfers (date initiated 02/06/2024); Physical Therapy evaluation and an extension piece to assist with left wheelchair brake (date initiated 11/06/2024); Physical Therapy evaluation, restorative evaluation and call light placed in reach and encouraged to use for all transfers (date initiated 05/15/2024); reminded to lock brakes prior to transfers (date initiated 11/13/2023); room change, closer to the nursing station (dated initiated 02/07/2024); gather information on past falls and attempt to determine the root cause of the fall; anticipate and intervene to prevent recurrence (date initiated 06/08/2023; be sure call light is within reach and encourage to use it for assistance as needed and staff to respond promptly to all requests for assistance (date initiated 06/02/2023); and anticipate and meet individual needs of the resident.
R2's Physician Order Sheet/POS, dated 2/22/25, documents an order (dated 10/17/24) for Physical Therapy evaluation on admission, re-admission, and/or as needed and may evaluate as needed. The POS also documents a specific Physical Therapy order, dated 10/17/24, for Physical Therapy for three to four times a week for balance and gait training. The POS does not document Physical Therapy orders for 11/6/24, 1/5/25 or 2/13/25.
R2'S Electronic Medical Record does not document Physical Therapy evaluations for 11/6/24, 1/5/25 or 2/13/25.
R2's Fall Report (Fall #1143), dated 11/6/24, documents R2 fell on the floor in R2's room, during an unassisted transfer from R2's bed to R2's wheelchair. No injuries were noted. The intervention was for a Physical Therapy evaluation and to place an extension piece to R2's left wheelchair brake.
R2's Fall Report (Fall #1207), dated 1/5/25, does not document a mental status for R2. The Fall Report documents R2 fell on the floor in R2's room, during an unassisted transfer from R2's bed to R2's wheelchair. No injuries were noted. The Fall Report documents that R2 had on improper footwear and had predisposing fall factors (impulsive, resistive to cares, gait imbalance, weakness and receives anti-psychotic medications). The intervention documents a Physical therapy evaluation and to remind R2 to use the call light.
R2's Fall Report (Fall #1239), dated 2/13/25, documents R2 fell on the floor in R2's room, during an unassisted transfer from R2's bed to R2's wheelchair. No injuries were noted. The Fall Report documents that R2 had on improper footwear and had predisposing fall factors (incontinent and decreased safety awareness). The intervention documents for staff to ensure call light in place, a Physical Therapy evaluation and to continue interventions.
On 2/22/25, the Facility could not provide Physical Therapy evaluations or treatment for 11/6/24, 1/5/25 or 2/13/25 fall.
On 2/22/25 at 12:30 pm, V2 (Director of Nursing/DON) stated, Fall interventions should be followed and should be appropriate. V2 verified that R2's 11/6/24, 1/5/25 and 2/13/25 falls all occurred in R2's room, during unassisted self transfers from R2's bed to the chair and the Care Plan interventions and proper footwear should have been followed.
On 2/24/25 at 9:47 am, V1 (Administrator) stated, Our Director of Nursing (DON) is new, my old DON and Restorative Nurse, they used to be responsible for fall interventions and review of Resident falls. (R2) is a challenge and non-compliant. V1 verified that interventions need to be Resident specific and fall interventions need to be followed.
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 F0925
(Tag F0925)
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 an effective pest control program to effective...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to maintain an effective pest control program to effectively exterminate pests (cockroaches) in the Facility. This failure has the potential to affect all 205 Residents residing in the Facility.
Findings include:
Facility Midnight Census Report, dated 2/22/25, documents 205 Residents residing in the Facility.
Facility Resident Rights for People Living in Long-Term Care Facilities Policy, revised 11/2018, documents your Facility must be safe, clean, comfortable and homelike.
The Facility Pest Control Agreement, dated 12/1/2002, documents targeted pest control for roaches and twice a month service, with additional services at a cost.
Facility Grievance Opportunity Resolution Form, dated 1/7/25, documents concerns of a pest problem and the action taken was to deep cleaning.
Facility Grievance Opportunity Resolution Form, dated 2/4/25, documents concerns of a would like pest control to spray his room and the action taken was pest control will be out on 2/10/25.
Facility Grievance Opportunity Resolution Form, dated 2/11/25, documents concerns of a pest control to treat room and the action taken was the room was treated on 2/12/25.
On 2/22/25, at 11:22 am, a live cockroach was observed on the floor, by a dresser in room [ROOM NUMBER] and on 2/22/25 at 11:26 am, a live cockroach was observed on the floor near the corner of the wall in room [ROOM NUMBER].
On 2/22/25 at 8:40 am, R9 stated, I had a cockroach in my room last night.
On 2/22/25 at 8:42 am, R10 stated, I see roaches once in a while.
On 2/22/25 at 9:04 am, R11 stated, I see roaches occasionally. A few days ago, I told them and they came in and killed them.
On 2/22/25 at 9:08 am, R13 stated, Oh they know about the cockroaches. I see cockroaches every day.
On 2/22/25 at 11:02 am, V8 (Third Floor Housekeeping) stated, I see cockroaches every day and they are alive and moving. I see them in bathrooms and rooms. I sweep them up.
On 2/22/25 at 11:18 am, V9 (Second Floor Housekeeping) stated, I see live roaches every day.
On 2/22/25 at 10:22 am, V4 (Activity Director) stated, There are complaints about roaches, a couple times a week. Its not one particular Resident complaining, they all complain. I do report the concerns to management, and I think pest control comes out, but I am not sure they are getting rid of all of them.
On 2/24/25 at 9:47 am, V1 (Administrator) stated, Our pest control comes every time we call them and on scheduled visits, but I have no answer why they are not getting rid of the roaches.
Jan 2025
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a system in place to ensure that a resident who ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a system in place to ensure that a resident who was assessed to not be able to navigate safely and independently in the community, leave the facility unsupervised. This failure applied to one (R1) of one residents reviewed for supervision and resulted in R1 eloping from the facility on 01/10/25 with no access to ordered medical care and was subsequently found (at an undetermined date) intoxicated by local police and taken to local hospital.
The Immediate Jeopardy began on 01/10/25 when R1 eloped from the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 01/22/2025 at 3:39 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 01/28/25 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
Findings include:
R1 is a [AGE] year-old male who was admitted to the facility on [DATE], past medical history includes, but not limited to other seizures, unspecified psychosis it due to a substance or known physiological condition, gastroesophageal reflux disease, chronic obstructive pulmonary disease, encephalopathy, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, essential primary hypertension, encounter for general psychiatric examination requested by authority, suicidal ideation, depression, etc.
Community survival skills assessment dated [DATE] documented that R1 does not appear to be capable of unsupervised outside pass privileges at this time. Discharge planning review dated 12/31/2024 documented resident's discharge potential as fair, nursing facility required to help resident attain or maintain highest practical health status. Minimum Data Set (MDS) assessment dated [DATE] section C (cognitive) scored resident with a BIMS (Brief Interview of Mental Status) score of 12, section GG (functional) of the same assessment coded R1 as requiring staff supervision for all Activities of Daily Living (ADLs) including ambulating within the facility. Section P (alarms and restraints) documented that R1 does not use any restraints or alarms.
It is to be noted that the facility is located on a busy highway, in a high traffic area.
Care plan initiated 12/23/2024 documented that R1 is at increased risk for alteration in pain and discomfort related to diagnosis of GERD. R1 is at risk for seizure activity related to seizure disorder, has a diagnosis of severe mental illness and significant mood distress related to a diagnosis of depressive illness. R1 is also care planned as requiring supervised smoking and community access.
Police report number ****** dated 01/11/2025 17:23 stated in part: On 11 [DATE] at approximately 1723 hours, responding Officer received a call from Southwest Central Dispatch (SWCD) regarding a missing person at a nursing home (address). SWCD advised that a patient left yesterday without permission and still has not returned. Responding officer arrived on scene at the Nursing Home and spoke with Staff Director V3, she related that on 10 [DATE] at approximately 1830 hours, the bed alarm in room (#). V3 related that her staff conducted a headcount immediately after the bed alarm went off and realized that the patient in room (#), (R1), was missing. V3 advised that R1 was last seen wearing a winter hat, jeans, and a winter jacket. V3 stated that she contacted R1's only emergency contact that she has listed in their computer system, (V6) several times with negative results. V3 related that R1 has been a patient at the nursing home since November 2024 and is unsure where he could be. V3 advised responding officer that R1 has dementia and has never left the Nursing Home since he`s been a patient there. V3 also stated that R1 does not have a cell phone.
On 1/15/2025 at 4:46PM, V3 (Social Service Director) said that a staff reported to her that R1 was not in the facility, she asked other staff, (a nurse and smoking monitor) and they said that he did not come out for the morning and afternoon smoke breaks. V3 said that she did not see R1 leave the building, did not speak to the assigned nurse, she called the police because the administrator instructed her to do so, V3 filed a report, the police told her that it was a missing person report and gave her the report number. V3 said that R1 does not have an independent pass, can only go out with supervision, he has never tried to leave the facility before and does not have any behaviors.
On 1/22/2025 at 10:39 AM, V3 (Social Service Director) was interviewed again regarding the bed alarm mentioned in the police report and she said that she does not recall starting that a bed alarm went off, or mentioning the exact day and time the resident left the facility, she just told the police that it was reported to her on Saturday.
1/16/2025 at 9:47AM, V6 (Family Member) said that she does not know where resident is, the facility called her on Saturday morning around 6:30AM, stating that the resident left the facility yesterday and had not returned. V6 said that the facility did not call her till 6:30AM the following day, she cannot get in touch with R1 because he does not have a phone, he does not have any other family and V6 is worried that he might be in danger.
1/15/2025 at 4:59PM, V4 (Licensed Practical Nurse - LPN) said that R1 is pleasant, he walks around the facility, V4 did not see resident leave the facility, she documented that he was appropriately dressed for the weather because that's what the roommate told her.
1/15/2025 at 5:10PM, V5 (Certified Nursing Assistant - CNA) said that she was the person that reported resident missing, she saw the resident on Friday around 8:00PM, when V5 came back to work on Saturday around 3:00PM, she was hearing people saying that R1 is not in the facility, the CNA she took over from said that she did not see resident all day, he did not eat breakfast or lunch. V5 said she reported to social services after searching the rooms on every floor, they thought he was out on pass.
1/15/2025 at 6:00PM, V1 (Administrator) said that they were made aware that resident left the facility, they spoke to the roommate, and he told them that resident said he was leaving, and he left. V1 said that there is only one main entrance and a back door through which they get supplies. V1 was asked why resident was discharged in the system and she said, if a resident leaves unauthorized, we call the police, and they consider it the same as going against medical advice (AMA). V1 was asked if residents are required to sign an AMA form when going AMA and she said yes, she was asked if R1 signed any papers and she said no.
1/23/2025 at 2:05 PM, V12 (Local Police Detective) called surveyor and stated that R1 had been located. V12 did not know all the details surrounding the whereabouts of R1 but said that R1 had been found in (Nearby Town) (which is over 30 miles away from the facility). V12 added that R1 was intoxicated when found and taken to a local hospital. V12 did not know which hospital but gave surveyor the report number. Surveyor attempted to contact (Nearby Town) police department for more details and left several messages with no call back.
Requested for an authorized pass policy but the facility did not have one to provide during the course of this survey.
Supervision policy (undated) presented by V1 (Administrator) states in part, our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility-wide priority. The same document also stated: Our facility oriented approach to safety addressees risk for group of residents such as wanderers, behaviors, aggressiveness, confusion, etc. Resident supervision is a core component to resident safety.
Discharge against medical advice policy revised 7/2024 states in part, It is the policy of this organization to provide medical and psychological care to residents of the facility. In the majority of the situations, it is not in the resident's best interest to leave against medical advice (AMA). Staff to utilize good public relations to .Contact the attending physician and notify psychiatrist and administrative representative prior to allowing the individual to leave the premises .2. Carefully document when a resident leaves AMA. Make sure that the physician, and administrator designee agree that the person is competent to leave. 3. Require resident to sign the AMA form. 6. Scan the AMA form into the electronic medical record (EMR).
The Immediate Jeopardy that began on 01/10/25, was removed on 01/28/25, when the facility took the following actions to remove the immediacy:
The facility will continue to provide a safe environment for the residents through written policies and procedures to prevent elopement and to use as a baseline to maintain a secure resident environment.
Corrective action that will be accomplished for those residents found to have been affected by the deficient practice.
R1 no longer resides in the facility.
Investigation: The facility initiated an investigation on 1/11/2025. It has been determined that the resident exited the facility from the basements back door. As a system revision, the facility has implemented the following measures.
How the facility will identify other residents having the potential to be affected by the same deficient practices.
All residents who reside in the facility have the potential to be affected by this alleged deficient practice.
Measures the facility has taken or systems the facility will alter to ensure the problem will be corrected and will not recur.
Director of Social Services, Assistant Director of Social Services and PRSCs has re-assessed facility residents' elopement risk assessment and community survival skill assessments.
Initiated: 1/11/25 Completed: 1/13/25
The facility has provided an elopement binder to all facility units with pictures identifying residents at risk for elopement. (Exhibit 1)
Initiated: 1/11/2025 Completed: 1/13/2025
Director of Social Services, Assistant Director of Social Services and PRSCs have re-screened and assessed All residents to determine any factors that would put them at risk for elopement. Factors including History of elopement (prior to admission), exit seeking behaviors, attempts at elopement, hanging around exit doors, wandering between units, verbalizing a strong desire to leave.
Initiated: 1/11/2025. Completed: 1/13/2025
Director of Social Services, Assistant Director of Social Services and PRSCs will continue to meet and assess all residents upon admission, quarterly, annually, and with change in condition or behavioral observations that may put the resident at risk for elopement. All residents that were assessed with indicators of history of elopement will be considered high risk for elopement, in addition to those that score 6 or more. (Exhibit 2)
Initiated: 1/11/2025. Completion: Ongoing
Administrator, Director of Social Services and all staff will continue to monitor residents for potential signs of elopement.
Initiated: 1/11/25. Completion: Ongoing
o Staff were re-educated but not limited to the facility elopement policy and procedures. The re-education emphasized identifying residents at risk for elopement and providing a safe environment. This re-education provided a return verbalization and understanding. This education was completed by the Regional Nurse Consultant and Director of Social Services.
Initiated on 01/17/2025. Completion: Ongoing.
o DON/Designee will in-service all newly hired staff at the time of hire on the facility's elopement policy.
Initiated: 1/23/2025. Completion: Ongoing
o DON/Designee will in-service staff out on leave or on vacation upon their return to work.
Initiated: 1/23/2025. Completion: Ongoing
o Additionally, elopement binders have been placed on all facility units including the front reception area.
Initiated: 1/11/2025. Completion: Ongoing
o All exit doors have been rechecked to ensure all alarms are functioning properly and to check staff response time. Initiated and Completed on 1/17/2025.
o The facility Assistant Administrator conducted an ad hoc QA meeting on 0/15/25 which reviewed the facility elopement policy as it relates to safeguarding current and future residents from elopement.
Quality Assurance plans to monitor the facility's performance to make sure that the corrections are achieved and are permanent.
o Quality Assurance will audit 5 random resident files to ensure the risk for elopement has been properly assessed and care planed. This audit was initiated on 1/23/2025 and will occur weekly for a period of two months. Completion: 3/28/2025
o The Administrator/Designee will perform weekly audits will be performed on all newly admitted and re-admitted residents to ensure the risk for elopement has been properly assessed and care planned. The Administrator/Designee will conduct this audit weekly for 2 months and present its audit to the QA Committee.
Initiated: 1/23/2025. Completion: 3/28/25
o As part of the Quality Assurance Committee the Administration/DON will in-service all staff monthly on the elopement policy for a period of two months. The in-servicing and any allegations of elopement will be monitored by the Regional Nurse Consultant.
Initiated: 1/23/2025. Completion: 3/28/25
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their grievance policy and procedures by not ensuring that ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their grievance policy and procedures by not ensuring that a concern reported to staff regarding assistance with activities of daily living was documented, investigated, followed up on, and resolved. This failure applies to one of fifteen residents (R7) reviewed for grievance procedures.
Findings include:
R7 is a [AGE] year-old female with a diagnoses history of Polyneuropathy, Reduced Mobility, and Chronic Embolism and Thrombosis who was admitted to the facility 06/08/2023.
On 01/22/2025 at 10:09 AM, V10 (Assistant Director of Nursing) stated about a week ago there was an incident of one of the mechanical lifts not working because it needed to be charged.
On 01/27/2025 at 9:35 AM, R7 stated V27 (Family Member) filed a grievance with the facility regarding her being left in the chair for 17 hours. R7 stated in response to V27's report about her being left in the chair the facility explained it takes at least two hours for the mechanical lift to partially charge and this may not be enough of a charge to transfer her. R7 stated the mechanical lift had not been charged on the day she was left in the chair for 17 hours and no one had offered to ask for assistance from other staff to help transfer her out of the chair. R7 stated this incident happened approximately one and a half to two weeks ago.
On 01/28/2025 at 9:48 AM, V27 (Family Member) stated lately they'll get R7 out of bed but then say they don't have anybody there to place her back in bed and the mechanical lift isn't working. V27 stated approximately two weeks ago R7 was left sitting for over 8 hours and the next day she formally reported this grievance to V25 (Psychosocial Rehabilitation Services Coordinator).
On 01/27/2025 at 10:04 AM, V10 (Assistant Director of Nursing) stated she had not received any complaints from regarding R7 being left in a chair for several hours.
On 01/27/2025 at 10:40 AM, V25 (Psychosocial Rehabilitation Services Coordinator) stated V27 (Family Member) called a couple of weeks ago and reported a complaint to her that over the weekend R7 was in the chair and V27 was trying to call the nurses station about this and couldn't get a hold of anyone. V25 stated she reported this information to V2 (Director of Nursing) or V10 (Assistant Director of Nursing) at the front office.
On 01/28/2025 at 2:56 PM, V10 (Director of Nursing) stated if a grievance is reported it should be documented on a grievance form and turned in to the proper head of the respective department.
The facility's Grievance Forms from January 2025 reviewed by surveyor from 01/22/2025 - 01/23/2025, and on 01/28/2025 did not include documentation regarding R7 being left in a chair for several hours.
The facility provided a Grievance form to the surveyor on 01/29/2025 dated 01/28/2025 documenting V27 (Family Member) reported that R7 was up in chair for almost 7 hours.
The facility's Grievance Policy received 01/27/2025 states:
All concerns will be documented in writing.
The Director of Social Services will review and maintain concern through resolution.
All departments and facility staff members are required to participate in the investigation and follow up that is required to resolve each concern.
Concern resolutions are expected within 72 hours.
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their call light policy and procedures by no...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their call light policy and procedures by not promptly answering residents call lights. This failure applies to five (R6, R7, R13, R14, R15) of 15 residents reviewed for call light response.
Findings include:
R6 is a [AGE] year-old female with a diagnoses history of Schizoaffective Disorder, COPD, and Stage 3 Chronic Kidney Disease, who was admitted to the facility 11/20/2024.
On 01/27/2025 at 9:35 AM, R6 stated during nights it has taken an hour for staff to respond to her call light. R6 stated as a result of this she has trouble getting water or being dried at night and has experienced some itchiness and burning in her peri area from being left wet for too long.
R7 is a [AGE] year-old female with a diagnoses history of Polyneuropathy, Reduced Mobility, and Chronic Embolism and Thrombosis who was admitted to the facility 06/08/2023.
R7 stated during nights it has taken an hour for staff to respond to her call light. R7 stated if she is left in a wet diaper for too long she can get urine burns.
R13 is a [AGE] year-old male with a diagnoses history of Chronic Pain Syndrome, Chronic Congestive Heart Disease, Acquired Absence of Left Toe and Right Leg Below Knee, Dependence on Supplemental Oxygen and Renal Dialysis who was admitted to the facility 11/26/2024.
R14 is a [AGE] year-old female with a diagnoses history of Schizophrenia, Schizoaffective Disorder, COPD, Seizures, Edema, and Need for Assistance with Personal Care who was admitted to the facility 11/22/2024.
R15 is a [AGE] year-old female with a diagnoses history of COPD, Pulmonary Embolism, Congestive Heart Failure, and Dependence on Enabling Machines and Devices who was admitted to the facility 05/08/2023.
On 01/28/2025 from 11:45 AM - 12:00 PM Observed R13's call light activated and V30 (Licensed Practical Nurse) working right outside R13's room and did not respond to his call light. V30 walked to the nurses station and sat down alongside V29 (Wound Nurse/Licensed Practical Nurse). At nurses station, R13, R14, and two other room call lights were activated. V29 and V30 remained sitting at the nurses station while the four room call lights were activated and did not respond. V32 (Certified Nursing Assistant) walked near the nurses station, around the floor, and past R13's room without responding to his activated call light. V31 (Restorative Nurse) walked past R13's room with his call light activated and did not respond to his call light.
On 01/28/2025 at 12:00 PM, V31 (Restorative Nurse) stated she answers call lights quite frequently and had not noticed that R13's call light was activated when she walked past.
On 01/28/2025 at 12:03 PM, V31 (Restorative Nurse) respond to R13's call light after being made aware of it by the surveyor and R13 informed V31 that he wished to be transferred from his bed.
On 01/28/2025 at 12:05 PM, R14 and R15's call light were still activated at the nurses station while V29 (Wound Nurse/Licensed Practical Nurse) and V32 (Certified Nursing Assistant) were present and neither of them responded to the call light.
On 01/28/2025 at 12:07 PM, R14 and R15's call light was finally deactivated. R15 stated R14 had pressed the call light and was now in the restroom.
On 01/28/2025 at 2:56 PM V10 (Director of Nursing) stated when call lights are on any staff should respond immediately even if it's not their resident.
The facility's Call Light Policy received 01/27/2025 states:
Purpose: To respond to resident's requests and needs in a timely and courteous manner.
All call lights will be answered by any staff within their scope of practice.
All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered.
Answer light (signal) promptly.
Jan 2025
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
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 prevent and protect a resident (R2) from resident-to-resident physi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent and protect a resident (R2) from resident-to-resident physical abuse. This failure affected one (R2) of four residents reviewed for abuse.
Findings include:
R2's face sheet dated 01/12/2023, initial admit date [DATE] documents that R2 is a [AGE] year-old male with diagnoses including but not limited to: unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, anxiety disorder due to know physiological condition, bipolar disorder, major depressive disorder, unspecified dementia.
R2's Minimum Data Set (MDS) dated [DATE] documents: Brief Interview for Mental Status (BIMS) score of 00/15, which suggests severe cognitive impairment.
Minimum data set (MDS) section GG dated 10/22/2024, R2 is dependent for toileting, shower/bathe, lower body dressing, putting/taking off footwear, personal hygiene. R2 requires partial/moderate assistance for eating and oral hygiene. Walk 10 feet - Not attempted due to medical condition or safety concerns.
On 12/30/2024 at 10:10 AM, R2 stated, my roommate punched me in the chest, 4 punches. I had to go to the hospital, by an ambulance. I don't know his name. He punched me because of hurt feelings. I didn't do anything to him. I told the nurse. Resident was clean and well groomed. No foul odors. Resident was sitting in wheelchair.
On 12/31/2024 at 11:51 AM, R2 stated, I'm doing good today. R3 punched me. It happened last week, at 2 o'clock in the morning. I did not tell anyone. When I came back from the hospital, I told them that he (R3) punched me. No, I did not tell them I bumped my chest. No, I did not bump my chest against the sink.
R2's nurses' progress note dated 12/23/2024 at 07:21 documents: Note Text: CNA (Certified Nursing Assistant) notified the writer that the resident has discoloration on the left side of the chest. the Writer and CNA intervened and separated both parties. Writer assessed the resident from head to toe. Discoloration is noted on the left side of the chest. NP (Nurse Practitioner) was called, awaiting callback. family was left a message to give the facility a callback. all departments made aware.
R2's nurses' progress note dated 12/23/2024 at 17:56 documents: Note Text: Resident was involved in an inappropriate interaction with roommate earlier today. He has redness/bruising to the left side of his chest. Resident c/o of no pain, vitals are stable and he is calm. Physician is made aware and orders to be sent to (Local) hospital have been carried out. ADON (Assistant Director of Nursing) and DON (Director of Nursing) made aware. Phone call to family made around 6pm. (Transportation) to pick resident in 60-90 minutes.
R2's social service note dated 12/23/2024 documents: Late Entry: Note Text: Resident with the psych diagnosis of Unspecified Dementia, unspecified Severity, With Other Behavioral Disturbance, Anxiety Disorder Due to Known Physiological Condition, Dipolar Disorder, Unspecified, Post-Traumatic Stress Disorder, Unspecified, Other Psychoactive Substance Abuse with Psychoactive Substance-Induce Psychotic Disorder, Unspecified, Unspecified Psychosis Not Due To A Substance or Known Physiological Condition, Major Depressive Disorder, Recurrent, Unspecified, with other medical diagnosis. Resident alert, responsive and able to make needs known at this time. Resident BIMs 0 at this time. It was reported to writer that resident allegedly had a disagreement with peer. Both peers were separated immediately. Resident was taken to a quiet place to vent and was reminded he lives in a safe facility. Resident did verbalize feeling safe in the facility at this time. Resident was counseled on conflict resolution skills. Resident was encouraged to utilize appropriate language and communication. Resident was educated to utilize coping strategies for managing heightened anxiety. Resident was encouraged to report all discourteous behavior to staff immediately. Resident was receptive to counseling at this time. DON, MD (Medical Doctor), Admin, Family and (Local Police Department) notified. Care plan and assessment updated accordingly. SS (Social Services) will continue to monitor and assist.
R2's care plan dated 7/20/2023 documents (in part): Focus: The resident demonstrates behavior symptoms concerning inappropriate personal boundaries due to: A diagnosis of severe mental illness., A personality disorder diagnosis., A substance abuse disorder., Cognitive impairment secondary to Alzheimer's disease or a related dementia., These symptoms are manifested by: inappropriate touching (i.e., attempting to rub another person's back, reaching for a leg), shoulder rubbing or bump, These symptoms are manifested by: other: Goals: The resident will: ask appropriate questions. The resident will: not pry into another's persons situation. The resident will demonstrate respect for personal boundaries during interaction w/ staff & peers through the next review. The resident will: behave with respect towards staff & peers. Interventions: Staff need to be assertive when interacting with persons who do not respect boundaries. It is important to: (A) establish clear boundaries, (B) reinforce the boundaries, do not waiver, do not show flexibility; enforce strict limits, (C) communicate how to set these limits with fellow staff members & (D) communicate how to handle this behavior to residents who are approached by peers who do not respect boundaries. Document, as appropriate, behavior symptoms such as disrespecting boundaries & assertively communicate to the resident that each person is expected to behave with dignity & respect. Use phrases to clearly communicate what behavior is unacceptable & inappropriate, for example: You & I have a professional relationship. We do not have a romantic relationship. Use phrases to clearly communicate what behavior is unacceptable & inappropriate, for example: I do not discuss my personal life at work. Use phrases to clearly communicate what behavior is unacceptable & inappropriate, for example: Use phrases to clearly communicate what behavior is unacceptable & inappropriate, for example: I am concerned about your well being & I will help you function your best.
R2's hospital records dated 12/24/2024 documents diagnoses as: Contusion of left chest wall and possible assault. Police Incident report dated 12/23/2024 stated, R2 alleged that his roommate, R3, struck him in the chest.
R3's face sheet dated 11/20/2024 documents that R3 has a diagnoses including but not limited to: unspecified systolic heart failure, opioid dependence, chronic kidney disease.
R3's Minimum Data Set (MDS) dated [DATE] documents: BIMS score of 15/15, which suggests that cognition is intact.
R3's nursing progress note dated 12/232024 at 7:51 am, documents: Note Text: the writer observed the resident lying in bed resting. the writer asked the resident what happened and he stated, he didn't see anything. the Writer and CNA intervened and separated both parties. The writer assessed the resident from head to toe w/ no injuries noted. the resident was put on a 1 on 1 supervision and the (local police department) was called. the resident is his own responsible party. MD and all department heads notified.
R3's social service progress note dated 12/23/2024 documents: Late Entry: .It was reported to writer that resident allegedly had a disagreement with peer. Both peers were separated immediately. Resident was taken to a quiet place to vent and was reminded he lives in a safe facility. Resident did verbalize feeling safe in the facility at this time. Resident was counseled on conflict resolution skills. Resident was encouraged to utilize appropriate language and communication. Resident was educated to utilize coping strategies for managing heightened anxiety. Resident was encouraged to report all discourteous behavior to staff immediately. Resident was receptive to counseling at this time. DON, MD, Admin, Family and (Local Police Department) notified. Care plan and assessment updated accordingly. SS will continue to monitor and assist.
R3's nursing progress note dated 12/23/2024 at 12:10 pm, documents: Note Text: transportation arrived X2 via stretcher for Resident who is AOX4 (Alert and Oriented). Face sheet, medication list and petition all sent with resident. Morning and all afternoon medication was given.
R3's petition for involuntary/judicial admission dated 12/23/2024 documents: Resident presents with social inappropriate encounter with peer. Care Plan dated 11/27/2024 documents: Focus: I demonstrates mood distress & anxiety related to: A diagnosis &/or h/o (history of) depressive illness., Problems/needs are manifested by: voicing repetitive health complaints-e.g., persistently seeks medical attention, obsessive concern with body function, Problems/needs are manifested by: voicing repetitive anxious complaints/concerns (non-health related) e.g., persistently seeks attention/reassurance, Problems/needs are manifested by: voicing distressful complaints r/t (related to) exaggerated demands/expectations that do not afford an easy solution. Goals: I will work cooperatively with staff to resolve my complaints in a fair/reasonable manner by the next review. Interventions: o Listen carefully to the resident's description of his/her concerns. Assure the resident that his/her satisfaction is important. Work cooperatively w/ the individual to resolve the complaint. Inform the resident of the steps being taken to improve satisfaction. Evaluate/assess whether other factors underlie frequent complaints. For example, complaints about food may be legitimate but may also be a person's way of saying, I am upset about living in this type of environment & facing multiple health issues.
On 12/30/2024 at 10:35 AM, R3 stated, I have lived here for about a month. Nothing happened between me and R2. I used to be his roommate. I didn't punch him. I barely spoke to him. I was moved out of the room. They said because I got into it with him (R3). They sent me to the hospital and the hospital sent me right back. I had no physical interaction. The guy doesn't talk. He doesn't talk, period. I was in the middle bed. Resident appeared well groomed. Items in room well organized. No foul odors.
On 12/30/2024 at 2:35 PM V12, CNA (Certified Nurse Assistant) stated, I have worked here about 9 years. I just know what R2 told me. No, I did not witness the incident. It was Monday morning, when I went about in about 5:00AM to do AM care. I was going to change his clothes. AM care involves bed bath, change clothes get them dressed. When I was going to remove his gown, I noticed a bruise mark on his chest, right over his breast, it covered his breast. I asked him what happened, and he just said punch, punch, punch and he pointed to his roommate in the middle. His roommate was in bed, sleeping. I did not wake up the roommate. When I performed Sunday morning care, I did not see that bruise. The roommate was sleeping when I did the assessment. He did complain of pain. He said it hurts; it hurts. I went to the nurses' station to let the nurse know. When I let her know, she said she was going to go look at the bruise. I stayed in front. When the nurse came back, I went in to finish the AM care. I have not noticed any previous incidences like that.
On 12/30/2024 at 3:16 PM V6 (DON) stated, I have been the DON since 12/4/2024. I saw R3 on the way out and he said he had no interaction with his roommate. The typical head to toe assessment, pain assessment was done; they notified the physician and family member. The altercation was not noticed by any staff. They were separated by putting them into separate rooms. R3 was sent out. Safety precautions are: When they return to the facility they go to separate rooms. Social Service also intervenes, do some education on conflict resolution, groups, anger management if necessary.
On 12/31/2024 at 10:47 AM V14, (Assistant Director of Social Services) stated, I was not present. The incident was reported to me the following day, I believe Christmas Eve. I don't believe R2 has ever had an altercation with anyone. Interventions implemented include reminding him that he is in a safe environment and counseling. He reported he felt safe.
On 12/31/2024 at 1:12 PM, V1, (Administrator) stated, I was informed of the incident. R2 was found with bruise on chest. He said he was punched on the chest by R3. He said the roommate hit him in the chest. We sent them both to the hospital. R3 said he never put his hands on him.
On 1/2/2025 at 1:15 PM, V1 stated, I (V1) am the abuse coordinator. V1 stated, R3 was sent out for psych evaluation because that is who R2 said hit him.
On 12/31/2024 at 1:53 PM V16, LPN (Licensed Practice Nurse) stated, I have worked here for 2 months. I had gotten report from the CNA that the R2 had bruise on his chest. So, I went to check on the bruise. The bruise covered the whole left side of his chest. Dark red mark, no imprints. So, when I saw it, I asked him what happened and R2 said: he (R3) hit me, several times and he pointed to his roommate on bed 2. I asked the CNA to help me move R2 out of the room to the nurses' station and I did a set of vitals. He didn't complain of pain to the site. R2 didn't put a call light to report the incident. I do not know if he pushes himself to the bathroom. He receives incontinence care. R3 denied any encounter with R2. He was calm. The second time I questioned R3 he said R2 told him that another resident came in and punched him. R2 was consistent with his story that he was punched by his roommate. After his vitals were done, I notified V1, V6 and Nurse consultant, his doctor and left message for his family member. They told me to call 911.
Abuse Prevention Program/Facility Policy and Procedure - (State) Policy dated 11/18/2016 and review dated 01/04/2019 documents (in part): Abuse is defined as the willful infection of injury, resulting physical harm, pain, or metal anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, to inflict injury or harm. Relevant Regulatory Standards (revised November 28, 2017) F600 Free from abuse and neglect.
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 F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient nursing staff were available to ensure medication...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient nursing staff were available to ensure medications were administered as ordered to 34 residents (R1, R4, and R6-R37). This failure has the potential to affect 34 residents ordered to received medication from third floor front cart.
Findings include:
The 3rd floor (12/25/2024) census of 72 residents was provided to surveyor by V1 administrator.
R1's face sheet dated 12/30/2024 documents that R1 is a [AGE] year-old resident with diagnoses including but not limited to: unspecified dementia, unspecified psychosis, seizures, depression, encephalopathy, essential hypertension, and chronic obstructive pulmonary disease.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 12, which suggests that R1 is moderately cognitively impaired.
Medication Administration Records (MAR) for December 2024 for (R1, R4, and R6- R37) all document that medications were not given 12/25/2024, day shift.
On 12/30/2024, at 10:06 am, R4 stated we always have a nurse on shift to give medications except on Christmas Eve or Christmas Day that morning I did not get my medications.
On 12/30/2024, at 10:30 AM V7, Licensed Practical Nurse (LPN), stated, we are supposed to have two nurses on each floor for day (7am - 3:30pm) and evening (3:00pm - 11:30pm) and just one for nights (11:00pm-7:30am). Two nurses on nights on second floor only and one nurse on nights for 1st and 3rd floors.
On 12/30/2024, at 11:03 AM, R1 stated, we did not have a nurse on the 3rd floor day of Christmas on day shift. So, we did not get medications for the day. Someone came up from another floor about 5:00 pm and gave medications then, just the evening medications.
On 12/31/2024, at 9:35 AM, V7 (LPN) stated, I worked Christmas Day (12/25/2024) by myself up on third floor. I did not give medications to the whole floor. I just gave medications to my side which was the back hall 312-325. The other cart covers rooms 301-311 and 326-334. Management knew I was not giving medication to the whole floor. V6 DON (Director of Nursing) knew that I wasn't going to be giving medication to the whole floor because she was looking for a nurse. She said, they were missing a nurse on first floor as well and the nurse down there was getting a bonus to pass meds for the whole floor. I told her I would not pass meds for the whole floor bonus or not. The other residents on the floor did not get their medications. V6 did not come up and pass meds for the other residents. There are 77 residents on this floor right now. I did not accept keys for that cart or anything. I came in and did my residents, passed medications, and did make sure everyone was safe and taken care of but did not pass medications for the other half of residents. This was the only time this happened that I am aware of. V6 was well aware that I was not passing medications on the other cart. ADON (Assistant Director of Nursing) is on vacation and was on vacation at that time.
On 12/30/2024, at 12:27 PM, Surveyor Reviewed Daily Staffing sheets from 11/6/2024 - 12/30/2024. Date of 12/25/2024 is missing. All other dates show 2 nurses on dayshift per floor, 2 on pm shift per floor and 1 nurse on night shift for 1st and 3rd floor and 2 on 2nd floor except for the following dates:
11/8/2024 only 1 nurse on nights on 2nd floor
12/6/2024 only 1 nurse on nights on 2nd floor
12/20/2024 only 1 nurse on pms on 2nd floor
12/29/2024 only 1 nurse on nights on 2nd floor
12/30/2024 only 1 nurse on pms on 2nd and 3rd floor and 1 nurse on nights on 2nd floor.
On 12/31/2024, at 11:36 AM, Schedule was provided to surveyor for 12/25/2024. Schedule documents only one nurse assigned to day shift on 3rd floor and only one nurse assigned to 1st and 3rd floor on second shift.
On 12/30/2024, at 3:20 PM V6 (DON) stated I have been the DON since December 4th, 2024. I am not aware of any issues with medications not being delivered by pharmacy or residents not getting medications. R1 has not complained to me about not getting his medication. My expectation of my staff is that residents get their medications as ordered. If they run into any issues, to please let me know. I am aware of not having a second nurse up on 3rd floor on Christmas day. There was a call off. I have not had anyone come to me to say they did not receive their medications on that day. I did only have one nurse up on 3rd floor. I have worked this floor by myself and that is not how we typically want it, but it can be done. I have not been made aware of anyone missing medications.
On 12/31/2024, at 11:52 AM surveyor interviewed V6 and V7 together. V6 stated, I would come in if we do not have enough nurses on the floor. Wound nurse, restorative nurse, IP (Infection Preventionist) nurse, ADON, MDS nurses and I can all fill in on the floor. Other nurses have come up on different occasions to help pass medications. I was trying to get help to get some nurse to come in to help pass medications. It was a holiday. (ADON) was on vacation. I was given schedules as if it was staffed. Someone quit on me. I was working at another job and could not get a replacement for myself. I was under the impression that V7 was going to pass medications for the whole floor. A resident called the administrator and said V7 told resident she wouldn't give her medications. V6 stated, I called (V7) and (V7) stated she was in process of passing medications and did not say that. V7 stated, I did not accept the keys for the other cart and made it clear I would not pass medications for whole floor. V6 stated, (V7) did say she would not accept a bonus to do the medications on the other half of the floor. V7 stated, I did not say I was passing medication all morning on the other side of the floor. V7 stated, I passed my medications to my residents, on my cart, made sure people were safe and cared for. V6 stated, I understand it is a lot, I am new, and I am accepting responsibility for this. I understand approximately 77 residents is a lot and I was continuing to look for another nurse. This was an isolated incident. These are routine residents that the nurses are used to working with. I am not an office DON. I come in here in uniforms and I work the floors. The conversation was different, I take responsibility for the situation. Not one time did (V7) say she would not pass the medications for the other residents. I still pick up at my other job. My administrator is aware that I have another job and I just pick up as needed. I have not picked up anymore because my ADON is on vacation. I had promised to work at the other job months ago prior to taking this job. We staff two nurses on day shift and pm shift for all three floors. On nights it is only one nurse for first and third floors and two nurses on second floor.
On 1/2/2025, at 9:33 AM, V7 (LPN) stated I did not call the doctors for the residents that I did not pass medications to on 12/25/2024 and let them know that the residents did not get their medications. I was not the nurse for that med cart. I did not accept keys for that cart. Management knew I was not passing medications on that cart.
On 12/30/2024, at 1:18 PM, V3 (Nurse Practitioner) stated, I did not get a call regarding Christmas Day or any residents not receiving their medications that morning. I am a contractor here. I do see the residents here. I was not here Christmas day.
On 12/31/2024, at 1:19 PM V1 (Administrator) stated, my expectation of staff is that staff completes medication pass and documents it. I do not know the answer to if V6 is allowed to have another job. We are going to have to try to create a holiday rotation. We do not have a holiday rotation set right now. The impression I was under was that V7 (LPN) was going to pass the medications for the whole floor of about 77 patients. I did not know anything about the bonus until after the fact. I do not have to approve the bonuses. We don't give too many out. If it got crazy, yes but not in this case. We will have to come up with a holiday plan and whoever is on call for the holiday is going to have to come in and cover any call offs. My expectation is that medications are given as ordered to the residents. It could have been not so good of turnout as a lot of residents are on seizure medications, psych medications, etc. Thank God it wasn't. I am not aware of any other complaints of medications not being given as ordered except for now the issue with Christmas day on day shift.
On 12/31/2024, at 11:36 AM, nursing schedule provided to surveyor for 12/25/2024. Schedule documents only one nurse assigned to day shift on 3rd floor and only one nurse assigned to 1st and 3rd floor on second shift.
On 1/2/2025, at 12:05 PM, V1 Administrator stated, facility does not have a staffing policy.
On 1/2/2025, at 12:16 PM, V1 Administrator stated there were 72 residents total on third floor on 12/25/2024.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide medications to 34 residents (R1, R4, and R6-R37) as ordered...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide medications to 34 residents (R1, R4, and R6-R37) as ordered by the prescriber to meet the needs of each resident. This failure has the potential to affect thirty-four residents receiving medication from third floor front cart.
Findings include:
R1's face sheet dated 12/30/2024 documents that R1 has a diagnoses including but not limited to: unspecified dementia, unspecified psychosis, seizures, depression, encephalopathy, essential hypertension, and chronic obstructive pulmonary disease.
R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has a Brief Interview for Mental Status (BIMS) score of 12, which suggests that R1 is moderately cognitively impaired.
Medication Administration Records (MAR) for December 2024 for (R1, R4, and R6- R37) all document that medications were not given 12/25/2024, day shift.
On 12/30/2024, at 10:06 am, R4 stated, we always have a nurse on shift to give medications except on Christmas Eve or Christmas Day that morning I did not get my medications.
On 12/30/2024, at 11:03 AM, R1 stated (in part), we did not have a nurse on the third floor day of Christmas on day shift. So, we did not get medications for the day. Someone came up from another floor about 5:00 pm and gave medications then, just the evening medications.
On 12/31/2024, at 9:35 AM, V7, Licensed Practical Nurse (LPN), stated I worked Christmas Day by myself up on 3rd floor. I did not give medications to the whole floor. I just gave medications to my side which was the back hall (third floor). The other cart (front) covers residents (R1, R4, and R6-R37). Management knew I was not giving medication to the whole floor. V6 Director of Nursing (DON) knew that I wasn't going to be giving medication to the whole floor because she was looking for a nurse. She said that they were missing nurse on 1st floor as well and the nurse down there was getting a bonus to pass meds for the whole floor. I told her I would not pass meds for the whole floor bonus or not. The other residents on the floor did not get their medications. The DON did not come up and pass meds for the other residents. There are 77 residents on this floor right now. I did not accept keys for that cart or anything. I came in and did my residents, passed medications, and did make sure everyone was safe and taken care of but did not pass medications for the other half of residents. This was the only time this happened that I am aware of. The DON was well aware that I was not passing medications on the other cart. The ADON (Assistant Director of Nursing) is on vacation and was on vacation at that time.
On 12/30/2024, at 3:20 PM V6 (DON) stated (in part), I have been the DON since December 4th, 2024. I am not aware of any issues with medications not being delivered by pharmacy or residents not getting medications. R1 has not complained to me about not getting his medication. My expectation of my staff is that residents get their medications as ordered. If they run into any issues, to please let me know. There was a call off. I have not had anyone come to me to say they did not receive their medications on that day. I did only have one nurse up on 3rd floor. I have not been made aware of anyone missing medications.
On 12/31/2024, at 11:52 AM, surveyor interviewed both V6 (DON) and V7 (LPN) together. I (V6) was trying to get help to get some nurse to come in to help pass medications. It was a holiday. I was under the impression that (V7) was going to pass medications for the whole floor. Another (resident) called administrator and said (V7) told resident she wouldn't give her medications. I called (V7) and (V7) stated she was in process of passing medications and did not say that. V7 stated she did not accept the keys for the other cart and made it clear she would not pass medications for whole floor. V6 stated, V7 did say she would not accept a bonus to do the medications on the other half of the floor. V7 stated she did not say she was passing medication all morning on the other side of the floor. V7 stated I passed my medications to my residents, on my cart, made sure people were safe and cared for. V6 stated Not one time did (V7) say she would not pass the medications for the other residents.
On 1/2/2025, at 9:33 AM, V7 (LPN) stated, I did not call the doctors for the residents that I did not pass medications to on 12/25/2024 and let them know that the residents did not get their medications. I was not the nurse for that med cart. I did not accept keys for that cart. Management knew I was not passing medications on that cart.
On 12/30/2024, at 1:18 PM, V3 (Nurse Practitioner) stated, I did not get a call regarding Christmas Day or any residents not receiving their medications that morning. I am a contractor here. I do see the residents here. I was not here Christmas day.
On 12/31/2024, at 1:19 PM V1 (Administrator) stated, the impression I was under was that V7 (LPN) was going to pass the medications for the whole floor of about 77 patients.
Administering Medications Policy & Procedure dated 1/1/2020 documents (in part): Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations.
2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications shall be administered in physicians written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the residents identity when no contraindications are identified and the medication is labeled according to accepted standards.
8. The individual administering the medication shall initial the resident's medication administration record (MAR) on the appropriate line and date for that specific day before administering the medication.
10. If it is discovered the person administering medications has forgot to initial in the appropriate space, the supervisor shall notify that person to investigate if the medication/treatment has been administered/performed.
If the response indicates the medication/treatment was administered the staff member shall return to the facility, initial and circle the MAR to indicate a late entry. A late entry note will be documented indicating the administrateion of the medication. If the medication was not administered the missed dose/medication error protocol shall be followed.
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 F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide significant medications to five residents (R1, R16, R26, R3...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide significant medications to five residents (R1, R16, R26, R33 and R37) on 12/25/2024 on day shift. This failure affected five of thirty-four residents reviewed for significant medication.
Findings include:
Complaint dated 12/25/2024 alleges R1 is missing medications, given wrong medications and at times not all the medications due to no nurse.
R1's face sheet dated 12/30/2024 documents that R1 is a [AGE] year-old resident with diagnoses including but not limited to: unspecified dementia, unspecified psychosis, seizures, depression, encephalopathy, essential hypertension, and chronic obstructive pulmonary disease.
R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has a Brief Interview for Mental Status (BIMS) score of 12, which suggests that R1 is moderately cognitively impaired.
Medication Administration Records (MAR) for December 2024 for (R1, R16, R26, R33 and R37) all document that seizure medication were not given on on 12/25/2024, day shift.
On 12/25/2024 R1's December MAR documents (in part) Divalproex Sodium Oral Tablet Delayed Release 250 mg - Give 1 tablet by mouth two times a day for treat seizures was not given on at 8:00 AM. and Levetiracetam Oral Tablet 250 mg - give 3 tablets by mouth two times a day for seizures was not given at 8:00 AM
On 12/25/2024 R16's December MAR documents (in part) Keppra Oral Tablet 250 mg (milligram) - give 5 tablet by mouth two times a day for seizure was not given on at 8:00 AM and Lacosamide Oral Tablet 100 mg - give 1 tablet by mouth every 12 hours for seizures was not given at 8:00 AM.
On 12/25/2024 R26's December MAR documents (in part) Depakote Tablet Delayed Release 500mg - give 1 tablet by mouth two times a day for anticonvulsant was not given at 8:00 AM.
On 12/25/2024 R33's December MAR documents (in part) Depakote Tablet Delayed Release 500 mg - give 1 tablet by mouth three times a day for prevent seizures was not given at 8:00 AM nor at 12:00 PM.
On 12/25/2024 R37's December MAR documents (in part) Keppra Oral Tablet 1000 mg - give 1 tablet by mouth one time a day related to other generalized epilepsy and epileptic syndromes was not given at 8:00 AM.
On 12/30/2024, at 10:06 am, R4 stated, we always have a nurse on shift to give medications except on Christmas Eve or Christmas Day that morning I did not get my medications.
On 12/30/2024, at 11:03 AM, R1 stated, I have not had my seizure medicine for about 4 days. I take Keppra twice a day 750 mg. The facility ran out. I think it is an insurance issue. I had an issue when I was not here of not taking my medications when I was supposed to. I should have 90-day supply of Keppra here that I came in with, but because I came in with it, I don't think the facility will give it to me because they can't verify what the pills are. They were giving me Depakote from a previous facility and this facility continued it here until I refused to take it. We did not have a nurse on the 3rd floor day of Christmas on day shift. So, we did not get medications for the day. Someone came up from another floor about 5 pm and gave medications then, just the evening medications.
On 12/30/2024, at 2:27 PM, surveyor asked V8 (Licensed Practical Nurse/LPN) to see R1 medication cards for Keppra. V8 stated, he took his last dose on the card this morning. I already reordered it. When he needs it, we can get it out of the (Medication Storage System) downstairs. Electronic medical record shows it was reordered 12/29/2024. V8 stated, she is going to call pharmacy right now to see when it is coming in. Surveyor stayed and V8 put phone on speaker. Pharmacy stated, there is an issue with insurance. The last time we sent was November 20th for 30 days. It was a 750 mg tablet and then it changed to 250 mg tablets x 3 tabs. That may be the issue. They are stating that they can send 500 mg tablet and a 250 mg and will send it tonight and update the (Medication Storage System) for it to be pulled with new order this evening. Pharmacy needs new order sent over.
On 12/30/2024, at 4:05 PM, V8 (LPN) showed surveyor 3 tabs of Keppra 250 mg pulled from (Medication Storage System) for evening dose for R1. She stated, the order was approved by pharmacy for the 750 mg oral tablet twice a day and will be delivered tonight.
On 12/31/2024, at 9:32 AM, V9 (LPN) showed surveyor the two medication cards for R1 that came in of Keppra 750 mg of 30 pills each. She also showed surveyor the bottle of Keppra 750mg that R1 came in with. Bottle is over half full approximately 75% full. V9 stated, I have not been made aware of him missing any medications or Keppra. That bottle has been here since he came.
On 12/31/2024, at 9:35 AM, V7 (LPN) stated I worked Christmas Day by myself up on 3rd floor. I did not give medications to the whole floor. I just gave medications to my side which was the back hall. The other cart covers (R1, R4, and R6-R37). Management knew I was not giving medication to the whole floor. V6 Director of Nursing (DON) knew that I wasn't going to be giving medication to the whole floor because she was looking for a nurse. She said that they were missing nurse on 1st floor as well and the nurse down there was getting a bonus to pass meds for the whole floor. I told her I would not pass meds for the whole floor bonus or not. The other residents on the floor did not get their medications. The DON did not come up and pass meds for the other residents. There are 77 residents on this floor right now. I did not accept keys for that cart or anything. I came in and did my residents, passed medications, and did make sure everyone was safe and taken care of but did not pass medications for the other half of residents. This was the only time this happened that I am aware of. The DON was well aware that I was not passing medications on the other cart.
On 12/30/2024, at 3:20 PM V6 (DON) stated (in part), I have been the DON since December 4th, 2024. I am not aware of any issues with medications not being delivered by pharmacy or residents not getting medications. R1 did have a hospitalization and was out 12/16/2024-12/20/2024. So, he could have gotten his dose for those days at the hospital prior to returning. We do have access to this medication in the (Automated Medication Storage/Dispensing System) and he will get the dose. If there is an insurance issue, we can still get out of the (Automated Medication Storage/Dispensing System), and the facility will cover cost. That is a short-term fix, but we still need to figure out how we can get this medication. Whether it be getting an order for a different medication that does the same thing, or go to a different pharmacy, we just need to figure it out for the patient. He has not complained to me about not getting his medication. My expectation of my staff is that residents get their medications as ordered. If they run into any issues, to please let me know. I have not had anyone come to me to say they did not receive their medications on that day. I did only have one nurse up on 3rd floor. I have not been made aware of anyone missing medications.
On 1/2/2025, at 9:33 AM, V7 (LPN) stated I did not call the doctors for the residents that I did not pass medications to on 12/25/2024 and let them know that the residents did not get their medications. I was not the nurse for that med cart. I did not accept keys for that cart. Management knew I was not passing medications on that cart.
On 12/30/2024, at 1:18 PM, V3 (Nurse Practitioner) stated, regarding R1 is on Keppra 750 mg twice a day. I did not get a call regarding Christmas Day or any residents not receiving their medications that morning. The Keppra is used for seizure. The resident is prone to having seizures. If residents do not get seizure medication that will lower the seizure threshold and make them more susceptible to having a seizure. I am a contractor here. I do see the residents here. I was not here Christmas day.
Facility policy: Administering Medications Policy & Procedure dated 1/1/2020 documents:
Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations.
2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions.
3. Medications shall be administered in physicians written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the residents identity when no contraindications are identified and the medication is labeled according to accepted standards.
8. The individual administering the medication shall initial the resident's medication administration record (MAR) on the appropriate line and date for that specific day before administering the medication.
10. If it is discovered the person administering medications has forgot to initial in the appropriate space, the supervisor shall notify that person to investigate if the medication/treatment has been administered/performed. If the response indicates the medication/treatment was administered the staff member shall return to the facility, initial and circle the MAR to indicate a late entry.A late entry note will be documented indicating the administration of the medication. If the medication was not administered the missed dose/medication error protocol shall be followed.
Dec 2024
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 F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on observation, interviews and record reviews, the facility failed to follow its care plan policy and initiate an individualized falls care plan with interventions, implement fall precautions im...
Read full inspector narrative →
Based on observation, interviews and record reviews, the facility failed to follow its care plan policy and initiate an individualized falls care plan with interventions, implement fall precautions immediately to prevent a fall, and adequately supervise a resident at moderate risk for falls. This failure affected one resident (R2) out of three reviewed for falls in a sample of 18.
Findings include:
On 12/17/24 at 11:15AM, R2 was observed laying in bed. R2's call light cord was observed on the floor under R2's bed and not within reach. R2's left eye was observed to have purple discoloration, left side of face swelling, and R2's left cheek had green-yellow discoloration.
On 12/23/24 at 9:30AM, R2 was observed laying in bed. R2's call light cord was observed on the floor under R2's bed and not within reach.
On 12/17/24 at 11:15AM, R2 stated that she was walking in her room and fell hitting left eye on her roommate's foot board of her bed.
On 12/18/24, V6 (Restorative Nurse) stated that V6 is responsible for investigating resident falls and updating the residents' care plans. V6 stated that V6 did not investigate R2's fall on 12/11/24. V6 stated that R2's fall should have been investigated by a staff member. V6 stated that V6 was informed of the intervention to be put in place post fall. V6 stated that V6 educated R2 on seeking assistance with transfers and physical therapy evaluation. V6 stated that call light use, safe transfers, and locking wheelchair brakes were part of the post fall education but did not note these as interventions in R2's care plan.
R2 transferred from another long term care facility to this facility on 12/10/24. R2's previous medical record, dated 12/10/24, notes R2 with diagnosis of history of falling and generalized weakness.
R2's BIMS (brief interview of mental status) score, dated 12/11/24, notes R2's score is 15 out of 15. R2 is able to make needs known.
R2's care plan does not note a falls care plan was initiated until 12/17/24 and back dated to 12/11/24. R2's post fall care plan notes R2 has had a fall related to unaware of safety as evidenced by falling out of chair after leaning forward. The only interventions identified to prevent further falls is R2 was educated on the importance of seeking staff assist for transfers and physical therapy evaluation.
This facility's care plan policy, dated 04/2014, notes all residents will have comprehensive care plan initiated upon admission within 24 hours.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to follow its fall risk and post fall assessment policy and accurately assess the resident's fall risk upon admission, identi...
Read full inspector narrative →
Based on observations, interviews, and record reviews, the facility failed to follow its fall risk and post fall assessment policy and accurately assess the resident's fall risk upon admission, identify and implement fall prevention interventions immediately to prevent a fall. This failure affected one resident (R2) out of three reviewed for falls in a sample of 18.
Findings include:
On 12/17/24 at 11:15AM, R2 was observed lying in bed. R2's call light cord was observed on the floor under R2's bed and not within reach. R2's left eye was observed to have purple discoloration, left side of face swelling, and R2's left cheek had green-yellow discoloration.
On 12/23/24 at 9:30AM, R2 was observed lying in bed. R2's call light cord was observed on the floor under R2's bed and not within reach.
On 12/17/24 at 11:15AM, R2 stated that she was walking in her room and fell hitting left eye on her roommate's foot board of her bed.
On 12/18/24, V6 (Restorative Nurse) stated that V6 is responsible for investigating resident falls and updating the residents' care plans. V6 stated that V6 did not investigate R2's fall on 12/11/24. V6 stated that R2's fall should have been investigated by a staff member. V6 stated that V6 was informed of the intervention to be put in place post fall. V6 stated that V6 educated R2 on seeking assistance with transfers and physical therapy evaluation. V6 stated that call light use, safe transfers, and locking wheelchair brakes were part of the post fall education but did not note these as interventions in R2's care plan.
There is no documentation found in R2's medical records noting R2 was educated on call light use, safe transfers, and locking wheelchair brakes.
On 12/19/24 at 11:30AM, V7 (Director of Rehabilitation) stated that R2 was screened because R2 was a new admission to this facility. V7 stated that R2 was screened on 12/11/24. V7 stated that R2 has Medicaid insurance and insurance approval is needed before R2 can be seen by skilled therapy. V7 stated that Medicaid residents are placed on a list and are seen based on priority. V7 stated that when R2 was screened, R2 was unable to recall how she had the fall. V7 stated that no further screening was done. V7 presented R2's skilled therapy screening form, dated 12/12, noting R2 unable to recall the fall event from 12/11. When questioned if V7 reads a resident's transfer paperwork, V7 responded that V7 does not read any resident's medical records from hospital or other long term care facility prior to admission. V7 acknowledged that R2's transfer paperwork noting a rehabilitation physician's note that R2 has had a decline in functional abilities and needs skilled therapy to prevent further decline and documentation noting two recent falls prior to R2's transfer to this facility would indicate R2 is a higher priority and should have been seen by skilled therapy. V7 stated that as of today, R2 has still not been evaluated by physical and occupational therapy.
R2 fall incident report for fall on 12/11/24 was requested from V2 DON (Director of Nursing) on 12/18/24 and 12/20/24. R2's fall incident report was requested from V1 (Administrator) on 12/18/24 and from V3 (Nurse Consultant) on 12/20/24. A copy of this incident report was not provided to this surveyor during this survey.
R2's POS (physician order sheet), dated 12/11/24, notes an order for physical therapy and occupational therapy screen on admit, re-admit, and/or as needed. May evaluate and treat if appropriate.
R2 transferred from another long-term care facility to this facility on 12/10/24 and notes R2 had falls on 10/29/24 and 10/31/24. R2's previous medical record, dated 12/10/24, notes R2 with diagnosis of history of falling and generalized weakness. It notes to assist R2 when ambulating, ensure R2 is wearing proper footwear when ambulating, maintain safety precautions when ambulating, and keep call light within reach. R2's gait was noted as unsteady and balance is poor.
R2's BIMS (Brief Interview of Mental Status) score, dated 12/11/24, notes R2's score is 15 out of 15. R2 is able to make needs known.
R2's fall risk review, dated 12/10/24 at 8:37PM, notes no history of falls within the last three months. No noted drop in R2's systolic blood pressure between lying and standing. It also notes R2 does not have any predisposing conditions/diseases.
R2's post fall review, dated 12/12/24, notes no history of falls within the last three months. No noted drop in R2's systolic blood pressure between lying and standing. It notes R2 is not taking any medications currently or in the last 7 days. It also notes R2 does not have any predisposing conditions/diseases.
R2's vital sign documentation, dated 12/10/24, does not note R2's blood pressure was obtained lying and standing to determine if there was a change in R2's systolic blood pressure.
R2's diagnoses on admission include, but not limited to, seizure disorder, primary generalized osteoarthritis, and history of falling.
R2's POS, dated 12/11/24, notes orders for: clonazepam 0.5mg (milligrams) oral every 12 hours for seizures, insulin subcutaneous injections per sliding scale for diabetes, Keppra 250mg oral give 5 tablets oral two times a day for seizures, lacosamide 100mg oral every 12 hours for seizures, and Seroquel 25mg oral three times a day for schizoaffective disorder.
R2's functional score summary, dated 12/10/24, notes R2's energy level fluctuates throughout the day. R2 with fluctuating cognition/safety awareness. It notes supervision/touching assistance needed with ADL (Activities of Daily Living) tasks. There is no documentation noting R2's recent falls prior to admission.
R2's care plan does not note a falls care plan was initiated until 12/17/24 and back dated to 12/11/24. R2's post fall care plan notes R2 has had a fall related to unaware of safety as evidenced by falling out of chair after leaning forward. The only interventions identified to prevent further falls is R2 was educated on the importance of seeking staff assist for transfers and physical therapy evaluation.
The facility's fall risk and post fall assessment policy, dated 06/2014, notes a fall risk will be completed at the time of admission. A post fall assessment will be performed after each fall and additional interventions promptly initiated to prevent further falls. If the fall prevention plan failed initiate an immediate new intervention. Complete an incident report. Revise the care plan to include all new fall interventions
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 F0800
(Tag F0800)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to ensure that there were plates, cups, eating utensils, and napkins available for each resident during the lunch meal servic...
Read full inspector narrative →
Based on observations, interviews, and record reviews, the facility failed to ensure that there were plates, cups, eating utensils, and napkins available for each resident during the lunch meal service. This failure has the potential to affect all 75 residents residing on the third floor nursing unit.
Findings include:
On 12/18/24 at 12:36PM, this surveyor observed the lunch meal service on the third floor nursing unit. There was one member from the kitchen plating the residents' food. There were two staff members handing the meal tray and drinks to residents. Residents were served canned fruit in a Styrofoam bowl. The first forty-five residents received lunch served on a plastic plate.
On 12/18/24 at 12:50PM, the food server ran out of plates. The following thirty residents received lunch on a Styrofoam plate. At the same time, the servers ran out of plastic cups with handles for coffee. Ten residents that were offered coffee, received it in a Styrofoam cup without a handle.
On 12/18/24 at 12:53PM, the food servers ran out of napkins, twenty-five residents were not given a napkin. The staff in the dining room did not notify the kitchen staff to bring more plates, napkins, and coffee cups.
On 12/19/24 at 9:50AM, this surveyor toured the kitchen with V8 (Dietary Manager). In the kitchen storage room, there were two boxes with 48 plates in each. There was a box with 48 plastic cups with handles, and eleven packages of napkins. V8 stated that the number of plastic plates, cups, eating utensils, and napkins sent up to each nursing unit should equal the number of residents residing on that unit. V8 stated that no staff called down to the kitchen to request additional items for the residents.
The resident roster notes there were 75 residents residing on the third floor nursing unit during the lunch meal service.
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to follow the menu and ensure residents received garlic Texas toast with the lunch meal on 12/18/24 and oatmeal and scrambled egg...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to follow the menu and ensure residents received garlic Texas toast with the lunch meal on 12/18/24 and oatmeal and scrambled eggs with cheese with the breakfast meal on 12/20/24 for all 211 residents who receive meals in the facility.
Findings include:
The lunch menu for 12/18/24 lunch noted 1/2 slice of garlic Texas toast was to be served.
On 12/18/24 at 12:45PM, lunch service on the first floor nursing unit was observed. All residents were served one slice of white bread with meal.
On 12/18/24 at 1:10PM, lunch trays on the second floor nursing unit was observed. All residents were served one slice of white bread with meal.
On 12/18/24 at 1:20PM, lunch trays on the third floor nursing unit was observed. All residents were served one slice of white bread with meal.
On 12/20/24 at 8:55AM, breakfast meal service for the third floor nursing unit residents was observed. Residents that use a wheelchair were observed sitting at the dining room tables waiting for breakfast to be served. There were 8 plastic bowls filled with fruit rounds cereal. There were 9 plastic bowls and 6 Styrofoam bowls filled with frosted flakes cereal. There were metal containers with scrambled eggs, cream of wheat hot cereal, and unbuttered toast on the steam table.
On 12/20/24 at 9:16AM, during observation of breakfast meal service, there was no more fruit rounds cereal available for residents. At 9:26AM, there was no more frosted flakes cereal available for residents. R13 requested cold cereal. R13 was informed there was no more cold cereal and R13 would have to have hot cereal. R13 left the dining room without eating breakfast. At 9:32AM, there was no packets of regular sugar available for residents. At 9:34AM, there was no toast available for residents. At 9:45AM, one resident asked for toast and was informed there was none left for him.
The breakfast menu for 12/20/24 notes oatmeal (#8 scoop = 1/2 cup) and scrambled eggs with cheese (#8 scoop = 2 ounces of protein).
On 12/20/24 at 9:45AM, V13 (Kitchen Staff) stated that a six ounce ladle was used to serve the cream of wheat hot cereal and a two ounce ladle was used to serve the scrambled eggs. V13 denied any cheese in the eggs.
On 12/20/24 at 9:50AM, the breakfast trays on the second floor nursing unit was observed. All residents were served cream of wheat hot cereal and scrambled eggs without cheese.
On 12/20/24 at 9:55AM, the breakfast trays on the first floor nursing unit was observed. All residents were served cream of wheat and scrambled eggs without cheese.
On 12/20/24 at 10:15AM, V8 (Dietary Manager) stated that there was additional cold cereal available in the kitchen. V8 stated that staff should have called to have more cold cereal brought up. V8 acknowledged that the residents did not receive garlic toast with their lunch on 12/18/24. When questioned reason residents were not served breakfast per the menu, V8 did not respond.
The resident roster for 12/18/24 notes there are 211 residents currently residing in this facility.
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
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure documented alternate communication methods ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure documented alternate communication methods were used to maintain communication for a resident with a communication barrier. This failure applied to one (R2) of eleven residents reviewed for quality of life and care.
Findings include:
R2 is a [AGE] year-old male with a diagnoses history of Cerebral Palsy, Epilepsy, Other Specified Disorders of the Brain, and Urinary Incontinence who was admitted to the facility 10/10/2024.
On 10/21/2024 at 11:59 AM Observed R2 difficult to understand and with extremely limited speech. Observed there was no communication board available to communicate with R2.
On 10/21/2024 at 12:09 PM observed V16 (Licensed Practical Nurse) respond to R2's call light. V16 stated there is no communication board used for R2, and he understands R2 a little. Observed R2 with a muffled and difficult to understand response when asked by V16 what his needs were. Observed there was no communication board used by V16 when attempting to communicate with R2.
On 10/21/2024 at 1:48 PM V17 (Certified Nursing Assistant) stated there isn't a communication board for use when communicating with R2 and she can understand him a little.
R2's Social Service progress note dated 10/11/2024 documents resident has communication barrier and communication board will be provided for resident.
R2's Social Service progress notes dated 10/15/2024 and 10/16/2024 document he has difficulty making needs known.
R2's Social Service progress note dated 10/17/2024 documents the resident presented an appropriate affect when talking to the writer, but his speaking was a bit muffled making the resident a little difficult to understand. Resident has communication barrier and communication board will be provided for resident.
On 10/23/2024 at 11:20 AM V3 (Director of Nursing) stated usually social services provide residents with communication boards. V3 stated nursing should be asking social services for the communication boards to be able to communicate with the resident when needed.
On 10/23/2024 at 3:00 PM V26 (Social Services Worker) stated she uses a communication board when speaking to R2 because it's difficult for her to understand him because she is hard of hearing. V26 stated however she did not leave R2 with a communication board. V26 stated she hasn't heard anything from any other staff about not being able to understand R2.
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
Safe Environment
(Tag F0584)
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 an environment that was clean and free of perv...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an environment that was clean and free of pervasive odor of urine in residents' rooms, failed to ensure that residents rooms are cleaned, and that garbage is properly disposed, failed to properly dispose of wet, soiled, stained linens from resident's room, and failed to properly clean or replace soiled mattresses. This failure affected seven of seven residents (R1, R4, R5 R6, R7, R8, R10) reviewed for environment and has the potential to affect all 67 residents residing on the third floor of the facility.
Findings include:
1. 10/21/2024 at 10:00am while conducting rounds on the third floor, surveyor noted several rooms to be dirty with garbage all over the floor. Some of the rooms have brownish stains on the floor that looks dark and sticky. There is also a strong urine like smell coming from some of the rooms on the A side of the third floor that can be perceived in the hallway. At 4:30PM, the hallway on the A side of the third floor was still noted with strong urine like smell.
10/21/2024 at 11:50AM, Surveyor noted R1's room and bathroom to be dirty, there were lots of garbage and some brownish material in the bathroom floor, room was noted to have brownish stains on the floor. R1 said that the housekeeper came and took the garbage out because it was overflowing but left lots of garbage on the floor. R1 said that he never stopped anyone from coming in and cleaning his room, his room has not been cleaned for the past 4 days.
10/21/2024 12:20PM, R4 was observed in his room lying in bed, awake and alert and stated that he has been at the facility for over one year, everything is going okay, he does not need staff assistance with any ADL (Activities of Dailey Living) care, takes care of himself. R4 was asked if anyone cleaned his room today and he said no, it has been a couple of days since it was cleaned last. Resident's room was noted to be very dirty with brownish stains on the floor, beds were not made, room looked disorganized with some garbage pieces on the floor.
10/21/2024 at 12:45PM V6 (Housekeeper) said that he is the only one scheduled on the third floor today and he did not clean resident room. V6 said that when they have only one housekeeper, they can only clean the hallways and other pertinent places like the staff bathroom and the nursing station. V6 said that he cannot get into every resident room when he is by himself, he can remove the garbage and give them supplies like toilet paper but cannot clean every single room. V6 was asked if he removed the garbage from R1's room and he said yes. Surveyor took him back to R1's room and presented him with garbage all over the floor. V6 said that he can sweep up the garbage, but it was not like this when he took the garbage, he did not work over the weekend and does not know what happened.
10/22/2024 at 9:55AM, R5 was observed in his room sitting in a wheelchair, resident's bed was noted with no linen and there was a whitish stain in the middle of the mattress. Bed linen was noted folded and in the corner of the room, there was a strong urine smell coming from the corner with the bed linen. R5 was asked what happened to his bed linen and he said that it was wet, and he removed them, he is waiting for someone to make his bed or give him clean linen so that he can make the bed himself. The floor was noted to be dirty with garbage and a used mask in the middle of the floor. R5 was asked if anyone has cleaned his room today and he said no, R5 was asked the last time his room was cleaned and he said he cannot recall, it has been a while.
10/22/2024 at 10:43AM, V7 (CNA) said that she was assigned to R5 and was just going to get clean linen and make his bed, V7 acknowledged that the room smell like urine and the smell was coming from the linen on the floor. V7 stated that staff are supposed to make the bed for residents and remove the dirty linen from the room, V7 added that she will get housekeeping to clean the room.
10/22/2024 at 10:48AM, R6 was observed in her room sleeping but awakes to greeting, stated that she is doing okay, the last time her room was cleaned was last Friday, no one have cleaned her room today. Surveyor noted the floor to be dirty with garbage and a used washcloth on the floor.
10/23/2024 at 12:51PM, V23 (Housekeeping Director), said that V24 is responsible for all the supplies they need in the housekeeping department, she puts in the order but does not get everything she orders. She has explained to V24 that they need bleach to properly clean the rooms and get the stains off the linens, but he sent then baking soda and vinegar to wash with. V23 said that she requested 17 dozen of linen but received only one dozen, requested 5 cases of bleach but received one, last week, she did not receive any and was hoping that it will come this week, but none have been delivered. V23 said that they are short of staff, she used to come in and work overtime when they are short but was told that she will not be paid overtime. V23 said that she is short on weekends and only have 3 housekeepers every weekend, one on each floor. V23 said that when there is one housekeeper on the floor, they were only supposed to remove the garbage in the rooms and touch up the bathroom, probably replace their supplies, and sweep off any debris on the floor. They are not supposed to mop the floors when there is only one housekeeper on the floor, but if a room is visibly dirty, it should be cleaned.
10/23/2024 at 1:18PM, V24 (Owner) said that he is only a part owner to the facility, he is not aware that the facility needs supplies, they have a guaranteed delivery of supplies and places an order for linens once a month. V24 said that he is not aware that the housekeeping department is short of staff, if there is a problem with delivering supplies to the facility, it will be reported to him, and he has not received such complaint. V24 said that he will investigate to find out what is going on.
A document presented by V1 (Administrator) (undated) titled housekeeping guidelines stated its purpose as to provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors. Under standards, the document states in part: #6. Housekeeping personnel shall adhere to daily cleaning assignments developed to maintain the facility in a clean and orderly manner. #11 Cleaning: A. All horizontal surfaces will be cleaned daily and as needed with approved disinfectant. C. All carpets are vacuumed daily. 13. Trash will be removed from all areas of the facility daily and as needed to prevent spillage and odors. 14. All trash collection containers are lined with plastic bags to prevent leakage into primary container.2. R5 is a [AGE] year-old male with a diagnoses history of COPD, Acquired Absence of Left an Right Legs Below Knees, and Atherosclerotic Heart Disease who was admitted to the facility 01/07/2021.
R7 is a [AGE] year-old male with a diagnoses history of Sarcoidosis, Cerebrovascular Disease, Schizophrenia, Schizoaffective Disorder, Anxiety Disorder, Recurrent Major Depressive Disorder, and Spinal Radiculopathy who was admitted to the facility 11/22/2019.
R8 is a [AGE] year-old male with a diagnoses history of Alzheimer's Disease, Paranoid Schizophrenia, Generalized Anxiety Disorder, Recurrent Major Depressive Disorder, Conversion Disorder with Seizures, Presence of Cardiac Pacemaker, and Generalized Muscle Weakness who was admitted to the facility 02/26/2021.
R10 is a [AGE] year-old male with a diagnoses history of Schizophrenia, Hypertensive Heart Disease, and Encounter for Aftercare Following Digestive System Surgery who was admitted to the facility 07/20/2005.
On 10/22/2024 at 9:52 AM Surveyor along with V6 (Housekeeper) observed R7's bed linens to smell of urine, observed R8's bed sheets with a large stain and smelling of urine, observed R8's mattress to appear stained. V6 stated R7's bed sheets were wet. V6 stated there are certain staff who make beds, and he hasn't seen the person assigned to make beds on the floor where R7 and R8's room are in a while. V6 stated the bed linens don't get changed which is why there is a strong smell of urine.
On 10/22/2024 at 12:18 PM Observed R5, R7, R8, and R10's rooms with a strong urine odor.
On 10/22/2024 at 12:43 PM Observed multiple stained sheets and towels in clean linen closet. V18 (Regional Nurse Consultant) stated she will in service staff to replace stained linens and towels and ensure they are replaced.
On 10/22/2024 at 2:29PM Observed R7 sleeping on his mattress and his bed area smelling of urine.
On 10/22/2024 at 1:34 PM V7 (Certified Nursing Assistant) stated R5 and R10's room have a strong urine smell. V7 stated she did wipe down R5 and R10's mattresses, changed their linens, and housekeeping came in and mopped however she believes the smell is in their mattress and their mattresses need to be changed. V7 stated a lot of mattresses need to be replaced. V7 stated many times she has to wait for linens to arrive from laundry before she can change them.
On 10/23/2024 at 11:20 AM V3 (Director of Nursing) stated bed linens should be changed immediately if soiled and are changed by the CNA (Certified Nursing Aides). V3 stated if linens are stained, they should be changed. V3 confirmed a mattress should be replaced if it is observed to be soiled and stained and stated usually the resident or CNA will inform management that a mattress needs to be replaced because its soiled and maintenance will be notified.
On 10/23/2024 at 12:51 PM, V23 (Housekeeping Director) stated that V24 (Facility Owner) is responsible for all the supplies needed in the housekeeping department, and she places a request for what she needs but does not receive everything she orders. V23 stated she has explained to V24 that they need bleach to remove the stains from the linens, but he sent baking soda and vinegar. V23 stated she requested 17 dozen linens but only received one dozen. V23 stated she requested 5 cases of bleach but received only one and last week, she did not receive any and was hoping that it will come this week but has not received it.
The facility's Mattresses - Cleaning/Sanitizing Policy received 10/24/2024 states:
The Purpose of the Policy is: To assure that bed mattresses and non-porous protective mattresses are cleaned and sanitized on a regular or as needed basis.
It is the policy of this facility to weekly or as necessary wash and sanitize mattresses.
A schedule shall be developed by Housekeeping and Nursing to assure beds are stripped and mattresses are cleaned and sanitized.
Nursing Assistants shall be responsible for informing housekeepers (if available) when the bed has been stripped of linens after each episode of incontinency which soils the mattress.
Nursing Assistants shall be responsible for cleaning mattresses which become soiled when no housekeepers are present.
Mattresses shall be inspected for stains and deterioration, and replaced as necessary.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for serving food under sanitary conditions and ensuring residents meals are served in a...
Read full inspector narrative →
Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for serving food under sanitary conditions and ensuring residents meals are served in a manner to maintain appropriate serving temperatures by not covering meal trays with lids during dining service. This failure applied to all (66) residents receiving meals on the 2nd floor of the facility.
Findings include:
On 10/22/2024 at 1:15 PM Observed several food trays on the 2nd floor sitting on skeleton carts with no lids with gnats flying on and around food.
On 10/22/2024 at 1:18 PM Observed the dietary aides food service cart with several unused clean lids.
On 10/22/2024 at 1:22 PM V15 (Certified Nursing Assistant) stated meal trays lids are normally not available V15 stated she didn't see lids on the food service cart which is why she didn't use them.
On 10/22/2024 at 1:26 PM V14 (Certified Nursing Assistant) stated she didn't pay attention that the lids weren't on the meal trays when she was delivering them on the cart from the dining area. V14 stated she normally covers the trays with lids and if the trays are not covered there is a possibility of contamination with germs and of pests.
On 10/23/2024 at 11:20 AM V3 (Director of Nursing) stated food trays should be covered with a lid for infection control purposes, prevent contamination and maintain appropriate temperature.
The facility's Food Handling Policy received 10/24/2024 states:
The Purpose of the Policy is: To establish principles for dietary personnel to minimize or prevent
infections related to food handling in addition to those addressed in other specific infection control procedures.
Food and beverages are to be covered when transporting from the Dietary
Department to the resident.
Oct 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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an altercation between two residents (R1 and R4) was identif...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an altercation between two residents (R1 and R4) was identified and investigated as abuse. This failure applied to two (R1, R4) of three residents reviewed for abuse.
Findings include:
R1 is a [AGE] year-old female who admitted to the facility on [DATE] and continues to reside in the facility. R1 has multiple diagnoses including but not limited to the following: anxiety, depression, COPD, PTSD, and psychoactive substance abuse. Per Minimum Data Set, dated [DATE] states residents has a Brief Interview of Mental Status (BIMS) of 15 meaning resident is cognitively intact.
R4 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R4 has multiple diagnoses including but not limited to the following: hypertension, panic disorder, psychoactive substance abuse, borderline personality disorder, bipolar disorder, and depression.
On 10/7/2024 at 11:50AM, R1 was interviewed regarding incident with R4. R1 said a week or so ago, R4 physically assaulted me and I feel as if the facility is trying to cover it up. R1 said R4 was my roommate at the time and stole a water bottle from me. I called her a liar which made her very angry and she punched me in the chest. R1 said V4 (Registered Nurse / RN) and V9 (Certified Nursing Assistant / CNA) were there when it was going on so they are aware. They tried to send me out to the hospital but I refused to go. They made me and R4 switch rooms and I have seen her since in the hallway.
At 12:25PM, V7 (Social Service Director) was interviewed regarding incident with R1 and R4 and policy regarding abuse allegations. V7 said my understanding was that R1 and R4 got in a verbal disagreement over a water bottle. I was never told that there was a physical altercation. V7 said if there was a physical altercation, we would have put the residents on 1:1 supervision and sent them out to the hospital.
R4's progress note dated 9/30/24 states in part but not limited to the following: R4 sent out via 911 for psych evaluation. R4 was found having an altercation with R1.
R1's progress note dated 9/30/24 states in part but not limited to the following: R1 was found to be in an altercation with R4. R1 refused to be sent out for a psych evaluation. R1 placed on 1:1 supervision.
At 12:39PM, V4 (RN) was interviewed regarding altercation between R1 and R4. V4 said I was the nurse on duty during R1 and R4's altercation. V9 (CNA) was calling my name from their room and when I entered R1 was on the bed pointing her finger in R4's face. They were both yelling at each other. V9 was in the middle of the two residents and it looked as if they were going to lunge at one another. They were being very aggressive. We attempted to separate both of them but anytime they would get back in the vicinity of one another, they would argue again. They were both being very disruptive and I was afraid it would get physical. We placed both residents on 1:1 supervision and attempted to send both of them out for a psych evaluation. R4 went to the hospital via 9-1-1 but R1 refused to go. V4 said, at no point was I made aware of any physical altercation between the two residents, but they were being very aggressive and I feel as if we didn't separate them, there could have been a physical altercation.
On 10/8/24 at 12:04PM, V9 (CNA) was interviewed regarding incident with R1 and R4. V9 said I heard commotion coming from R1 and R4's room. When I walked into the room, R1 was standing on her bed and pointing her finger in R4's face, yelling at her. She was calling R4 a liar and they were both very irritated and yelling at each other. I did not witness any physical altercation, I just heard yelling.
V9 said we placed both residents on 1:1 supervision and attempted to send them both to the hospital. R4 went to the hospital but R1 refused to go.
At 1:35PM, V2 (Assistant Administrator) was interviewed regarding incident with R1 and R4 and abuse investigations. V2 said I was not made aware of this situation until 10/7/24 when this surveyor started asking questions.
V2 said we investigate all the abuse concerns including but not limited to: verbal, mental, physical, etc. Verbal abuse is investigated when the residents want to fight each other or if the conversation is very heated. If the residents are very aggressive, that can be considered verbal abuse.
On 10/9/24 at 11:35AM, V1 (Administrator/Abuse Coordinator) was interviewed regarding incident with R1 and R4 and abuse investigations. V1 said they report all abuse allegations including but not limited to the following: verbal, mental, physical, etc. V1 said verbal abuse would be considered when someone is calling names, cussing, swearing, being intimidating or aggressive. V1 said we did not consider the incident with R1 and R4 to be abuse.
Abuse Policy with last review date of 1/4/2019 states in part but not limited to the following: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Supervisors shall immediately inform the administrator of all reports of incidents, allegations, or suspicion of potential abuse. Upon learning of the report, the administrator shall initiate an incident investigation.
Sept 2024
2 deficiencies
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 follow their policy in alerting a resident's responsible party of a change in condition. This failure affects one (R3) of two residents rev...
Read full inspector narrative →
Based on interview and record review, the facility failed to follow their policy in alerting a resident's responsible party of a change in condition. This failure affects one (R3) of two residents reviewed for notification of responsible party of resident's change in condition in a sample of 35.
Findings include:
On 9/27/2024 at 12:30, surveyor reviewed the documentations for R3 hospitalization on 3/20/2023 and 5/29/2024. No indication that R3 responsible family member was notified of the hospitalizations.
On 9/27/2024 at 12:43 PM, V2 (Director of Nursing) said that the family member should have been notified of the two hospitalizations.
The Facility's Policy: Guideline: Change In Resident's Condition Review Date: 11/2023
General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician/NP and resident's responsible party of a change in condition.
Policy: 4. Communication with the resident and their responsible party as well as the physician/NP will be documented in the residents in the resident's medical record or other appropriate documents.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure transmission-based precaution (PPE, isolation s...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure transmission-based precaution (PPE, isolation signage and set-up, resident/employee/visitor screening) and infection surveillance were implemented during COVID 19 outbreak. These deficiencies affected 14 residents (R5, R7, R38, R64, R69, R90, R99, R114, R147, R148, R150, R155, R158, R142) and has the potential to affect the rest of 180 residents residing in the building.
Findings include:
On 9/24/2024 at 10:30AM V3 (Infection Control Nurse) provided surveyor with COVID 19 resident tracking with names and corresponding room number. During positive COVID 19 room rounds with V3, discrepancies were identified as room number assigned did not matched current residents in the room. One room was identified with positive residents along with previously positive resident whose isolation have ended were all in the same room.
On 9/24/2024 at 10:45AM, V3 said residents identified as COVID positive and resident with discontinued COVID isolation should not be in the same room.
On 9/24/2024 at 12:05PM R158 was in her room, identified as COVID 19 positive room. Observed room without available garbage bin to dispose used PPE.
On 9/24/2024 at 12:05 PM, R158 said facility is not doing a good job controlling the spread of COVID 19. R158 tested positive for COVID on 9/15/2024 and was put on isolation with roommates that also tested positive for COVID.
On 9/24/2024 at 12:32 PM, V2 (Director of Nursing) and V3 said that all positive COVID droplet/contact isolation set up bin should have N95 mask, gloves, face shield, gown, and sanitizer/disinfectant inside the isolation bin drawers readily available for use.
R158's Physician Order: COVID 19 Testing per CDC/IDPH guidelines - 9/5/2023 (Order date)
Care Plan: Focus - Resident is on isolation R/T: COVID.
The facility's Policy and Procedure, Care for Residents with Suspected or Confirmed SARS-CoV-2 Infection or a Close Contact of Someone with Confirmed COVID-19 Infection, revised 5/23, documents,
Purpose: Establish a guideline to help prevent the transmission of SARS-CoV-2 infection.
Procedure: 8. In general, residents should continue to wear source control until symptoms resolve or, for those who never developed symptoms, until they meet the criteria to end isolation. Then they should revert to usual facility source control policies for residents.10. Staff must wear full PPE (N95 respirator, gown, gloves, eye protection) when providing care.
Residents SUSPECTED to have COVID-19
3. Resident placement: single room with door close if safe to do so. Dedicated bathroom when possible.
8. Staff must wear full PPE (N95 respirator, gown, gloves, eye protection) when providing care.
11. Follow the policy on visitation.
On 9/24/2024, at 1:00 PM surveyor observed that R90 who is positive for COVID - 19 infection has no contact/droplet signage on the door and her door was open.
On 9/24/2024 at 1:03PM, V5(Licensed Practical Nurse/LPN) said that V5 notified V3 (Infection Preventionist) that R90 tested positive for COVID-19 on 9/23/24. V5 said that V3 should have placed the contact/droplet signage on R90s door and set up the isolation cart with the PPE by R90's door.
On 9/24/2024 at 1:10 PM, V2 (Director of Nursing) and V3 both said that there should have been a contact/droplet isolation signage at R90's door. V2 and V3 also said that there should have been an isolation bin with proper PPE set up by R90's door.
R90 is a [AGE] year-old female admitted with diagnosis not limited to alcoholic cirrhosis of the liver with ascites, type 2 diabetes, epilepsy, chronic viral hepatitis C, and polyneuropathy.
R90 physician order of start date of 9/23/2024 indicates that R90 has COVID-19 Droplet Precautions/Contact Isolation for every shift for infection control for 10 days. The order also indicates to keep the door to R90 room closed.
On 9/24/24 at 9:40AM Observed red announcement signage posted at the entrance door indicated that facility has COVID infection outbreak. Observed empty box of N95 mask and surgical mask at the front desk. V4 Receptionist said that they have residents with COVID infections in the facility and they required visitors to wear N95 mask. Surveyor informed V4 that both N95 mask and surgical mask are empty. V4 took new boxes and provided surveyors of N95 mask.
On 9/24/24 at 12:32PM, Rounds made with V2 DON (Director of Nursing) to first floor from rooms (AAA to SSS). Observed 6 rooms with isolation set up outside the residents' door. V2 said that those residents have COVID infections and were placed on droplet and contact precautions. Inspected all droplet and contact isolation set up with V2. Observed the following rooms (BBB, GGG, MMM, RRR and SSS) does not have N95 mask in the isolation set up outside the rooms while Room (LLL) does not have gloves in the isolation set up outside the room. All isolations set up does not have sanitizer and disinfectant. All rooms do not have isolation garbage bin. V2 DON said that all COVID infection droplet/contact isolation set up should have PPE (personal protective equipment) such as N95 mask, gloves, face shield, gown, and sanitizer/disinfectant inside the isolation drawers.
On 9/24/24 at 1:09PM, Surveyor and V2 DON informed V3 Infection Preventionist of above observations. V3 said that that isolation garbage bins, and PPE supplies are being ordered. V3 said that COVID isolation set up should have N95 masks, gloves, gowns, face shields, sanitizer/disinfectant available for usage.
On 9/24/24 at 1:30PM, Informed V3 Infection Preventionist that list of residents with COVID infections are not updated. R38 and R155 are not on the facility's list for residents with COVID infection but on COVID infection isolation precaution and both residents have ordered for COVID isolations. Surveyor requested for COVID infection policy.
On 9/25/24 at 9:27AM, Observed V12 Family member of R174 entered the facility without N95 mask waiting for elevator with Surveyor and V4 Receptionist. Staff did not advise the V12 Family member to wear mask. Surveyor asked V12 Family member if she is aware that the facility has a COVID infection outbreak and visitors are required to wear mask. V12 Family member said that she was not told and not offered by V8 Assistant Social Director/Receptionist when she entered the facility. V4 got a N95 mask from the 1st floor nursing station and gave to V12 Family member.
On 9/25/24 at 9:56AM, Informed V2 DON and V3 Infection Preventionist of above observation. Both said that the receptionist should informed all incoming visitors of COVID infection outbreak in the facility and provided N95 mask when entering the facility. V3 IP said that they are performing COVID testing twice a week to residents. V3 said, when resident tested positive, the floor nurse will notify the family and physician. The nurse will obtain isolation order form the physician. The nurse and social service will coordinate for room change. V3 said that she updates COVID infection care plan. Informed V3 that R69 did not have an order for COVID isolation precaution until 9/25/24 and COVID precaution care plan was not formulated until 9/25/24. R69 tested positive for COVID on 9/19/24.
Record review of the following residents:
Room (BBB)
R150 is admitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus, Hypertension. R150 tested positive for COVID infection on 9/16/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift for infection control for 10 days ordered 9/15/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/15/24.
R64 is admitted on [DATE] with diagnosis listed in part but not limited to [NAME] Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Hypertension, Atherosclerotic heart disease, Cerebral infarction. R64 tested positive for COVID infection on 9/24/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift for infection control for 10 days ordered 9/15/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/15/24.
Room (GGG)
R7 is admitted on [DATE] with diagnosis listed in part but not limited to Chronic Obstructive Pulmonary Disease, Personal history of COVID-19, Morbid Obesity, Atherosclerotic heart disease, Cardiomegaly, Acute bronchitis. R7 tested positive for COVID infection on 9/19/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift until 9/28/24 ordered 9/19/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/17/24.
Room (LLL)
R155 is admitted on [DATE] with diagnosis listed in part but not limited to Hypertension, Schizophrenia. R155 tested positive for COVID infection on 9/19/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift until 9/29/24 ordered 9/19/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/24/24.
Room (MMM)
R38 is admitted on [DATE] with diagnosis listed in part but not limited to COVID-19, Hypertensive heart disease, Chronic obstructive pulmonary disease. R38 tested positive for COVID infection on 9/19/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift until 9/29/24 ordered 9/19/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/24/24.
R114 is admitted on [DATE] with diagnosis listed in part but not limited to COVID-19, Obesity, Shortness of breath, Disorder of the kidney and ureter. R114 tested positive for COVID infection on 9/19/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift until 9/29/24 ordered 9/19/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/19/24.
R242 is admitted on [DATE] with diagnosis listed in part but not limited to COVID-19, Hypertensive urgency, Complete atrioventricular block. R242 tested positive for COVID infection on 9/19/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift until 9/29/24 ordered 9/19/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/19/24.
Room (RRR)
R147 is admitted on [DATE] with diagnosis listed in part but not listed to COVID-19, Hypertensive heart disease. R147 tested positive for COVID infection on 9/16/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift for infection control for 10 days ordered 9/15/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/15/24.
R148 is admitted on [DATE] with diagnosis listed in part but not limited to schizoaffective disorder bipolar type, Progressive multifocal leukoencephalopathy, Moderate protein calorie malnutrition. R148 tested positive for COVID infection on 9/16/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift for infection control for 10 days ordered 9/15/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/15/24.
R69 is admitted on [DATE] with diagnosis listed in part but not limited to local infection of the skin and subcutaneous tissue, Pericarditis in disease, Solitary pulmonary nodule. R69 tested positive for COVID infection on 9/19/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift for infection control for 10 days ordered 9/25/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/25/24.
Room (SSS)
R5 is admitted on [DATE] with diagnosis listed in part but not limited to COVID-19, bipolar disorder. R5 tested positive for COVID infection on 9/19/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift for infection control for 10 days ordered 9/15/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/15/24.
R158 is admitted on [DATE] with diagnosis listed in part but not limited to Nontraumatic intracerebral hemorrhage, Solitary pulmonary nodule, Hypertension, Asthma. R158 tested positive for COVID infection on 9/16/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift for infection control for 10 days ordered 9/15/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/15/24.
R99 is admitted on [DATE] with diagnosis listed in part but not limited to Diabetes insipidus, adult failure to thrive, Schizophrenia. R99 tested positive for COVID infection on 9/16/24. Active physician order sheet indicated COVID-19 Droplet precaution/contact isolation every shift for infection control for 10 days ordered 9/15/24. No monitoring of vital signs and symptoms were done and documented in resident's chart. Formulated COVID infection care plan on 9/15/24.
Facility's policy on Source Control revised 5/2024 indicates:
Purpose: Prevent the spread of COVID-19 infection through the proper use of source.
Definition: Source control refers to use of respirators or week fitting face masks to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are breathing, talking, sneezing, or coughing.
4. The facility may choose to offer well fitting masks as a source control option for visitors but should allow the use of a mask or respirator with higher-level protection that is not visibly soiled.
5. It is recommended that residents wear a well fitted mask in common areas when the facility is experiencing an outbreak of COVID-19 or is otherwise recommended by public health
Facility's policy on Personal Protective Equipment (PPE) reviewed 5/2024 indicates:
Purpose: Prevent the spread of COVID-19 infection through proper use of personal protective equipment (PPE)
Procedure:
Universal PPE for HCP (Healthcare Professional):
3. If the facility is experiencing an outbreak of COVID-19 or other respiratory illness, at a minimum, HCP must wear a well-fitted mask while on the unit or floor experiencing an outbreak. In addition, facilities should consider requiring an N95 respirator and eye protection (goggles, or face shield that covers the front and sides of the face) during all resident care, on the affected unit or floor.
Facility's policy on Screening revision 5/2024 indicates:
Purpose: To establish a process of evaluating and monitoring residents according to the COVID-19 hospital admission levels or outbreak status.
Procedure:
2. Residents: When COVID-19 hospital admission levels are high or if the facility is in outbreak, all residents, including new admissions, should be evaluated at least daily for signs and symptoms of COVID-19.
Residents with confirmed COVID-19
5. Monitor the resident every four hours for clinical worsening. Include an assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam to identify and to quickly manage serious infections.
Duration of transmission-based precautions for residents confirmed to have COVID-19
1. Mild to moderate illness
*A minimum of 10 days since symptoms first appear or first diagnostic test.
Sept 2024
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their policy and procedures for internal reporting require...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their policy and procedures for internal reporting requirements of abuse allegations by not reporting a family reported allegation of abuse to the abuse coordinator (Administrator). This failure applied to one of three residents (R2) reviewed for abuse.
Findings include:
R2 is a [AGE] year-old male with a diagnoses history of Schizoaffective Disorder, Adult Failure to Thrive, Dementia, Major Depressive Disorder, Bipolar Disorder, and History of Falling who was admitted to the facility 03/09/2021.
On 09/10/2024 Abuse investigation reports from June - September 2024 were reviewed with no reports included regarding V18's abuse allegation regarding R2.
On 09/11/2024 at 2:06 PM V18 (Family Member) stated on approximately 08/18/2024 or 08/19/2024 at approximately 2 or 3 PM on the second day after R2's admission, V19 (Certified Nursing Assistant) came in with V20 (Certified Nursing Assistant) to change R2's brief and sheets. V18 stated they would turn R2 on his left then right to remove his adult brief and sheet. V18 stated when V19 attempted to turn R2 on his left side and grabbed R2 by his shoulder and back and pushed him over on his side, R2 raised his fist and said don't do that. V18 stated V19 then began yelling at R2 stating uh uh we're not gonna [sic] have that, we are not gonna have that, not today. V18 stated she told V19 R1 doesn't understand, but V19 ignored her. V18 stated she reported to the nurses at the nurses station that day that V19 was rough with her father, and she didn't want him changing R2 anymore. V18 stated there were about 6 or 7 nursing staff present at the nurses station. V18 stated the next day V20 came into R2's room and she told her she's glad V19 is not coming back because he was rough with her father. V20 stated that's ok she can take care of R2 by herself. V18 stated V19 then came into the room, and she said excuse me I'm in the middle of talking, and he responded uh uh, uh uh, hello. V18 stated V19 then yelled at her I'm not gonna put up with that (swear word) today, and told V20 you take care of him then and stomped out of the room. V18 stated she reported how V19 was roughly handling R1 to V22 (Licensed Practical Nurse). V18 stated she also reported this to V2 (Director of Nursing) and she listened then told her ok I will have a talk with V19. V18 stated she advised she doesn't want V19 taking care of R2 anymore and V2 replied ok she'll have a talk with him.
On 09/11/2024 at 4:06 PM V2 (Director of Nursing) stated a couple of weeks ago V18 (Family Member) reported she didn't like the way V19 (Certified Nursing Assistant) was talking to her and in response she had a long conversation with V19. V2 stated V18 did not report to her that V19 handled R2 roughly. V22 (Licensed Practical Nurse) reported by phone to surveyor that V18 did report to her that V19 handled R2 roughly and she did report this to V2. V1 (Administrator) confirmed that based on what V18 reported about V19 handling R2 roughly, an investigation would have to be started. V2 and V1 stated V22 should have reported this to V1 and if it was reported to V2, V2 would have had to report it to V1. V1 stated if this incident would have been reported to her V19 would have been removed from the schedule, she would have reported this to the state within two hours, and initiated an investigation.
The facility's Abuse Prevention Program Facility Policy and Procedure received 09/13/2024 states:
Employees are required to report any allegation of potential abuse they observe or hear about to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence.
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 observations, interviews, and record reviews the facility failed to ensure bed linens were changed as needed for a resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure bed linens were changed as needed for a resident who requires assistance with activities of daily living. This failure applied to one of three residents (R1) reviewed for activities of daily living.
Findings include:
R1 is a [AGE] year-old male with a diagnoses history of Local Infection of the Skin, Rheumatoid Arthritis, Chest Pain, Cellulitis of Right Lower Limb, Non-Pressure Chronic Ulcer of Right Ankle, Pulmonary Nodule, and Pericarditis who was admitted to the facility 04/11/2024.
On 09/10/2024 at 12:35 PM Observed both of R1's hands with contractures. Observed R1's linens and pillowcases with stains that appeared old.
On 09/18/2024 at 12:48 PM Fellow surveyor observed R1's bed linens with stains that appeared old.
On 09/19/2024 at 1:24 PM V17 (Family Member) stated a couple of weeks ago when she and other family member's visited R1 she observed R1's bed linens stained.
On 09/19/2024 at 2:35 PM V17 (Family Member) stated she reported R1's stained bed linens to all the nurses that were present when she and her family visited R1 a couple of weeks ago and to V6 (Social Services Designee). V17 stated she has reported this to multiple people multiple times and was told they would investigate it. V17 stated she submitted a written report regarding R1's bed linens to the state agency and to others as well.
On 09/19/2024 at 3:19 PM V2 (Director of Nursing) stated she was not aware of any reports of soiled bed linens for R1. V2 stated if bed linens are stained the certified nursing assistants should change it. V2 stated to her knowledge there has been no incidents of R1 not allowing staff to change his linens.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for weight manag...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for weight management by not ensuring specialized dietary orders were followed, not following a physician's supplemental recommendations from hospital records, not honoring a residents supplemental preference, not accurately documenting supplement administration, not obtaining dietary preferences, not providing feeding assistance as needed, and not accurately documenting meal consumption for a resident at high risk for and exhibiting signs of severe malnutrition. This failure applied to one of one resident (R1) reviewed for nutrition status.
Findings include:
R1 is a [AGE] year-old male with a diagnoses history of Local Infection of the Skin, Rheumatoid Arthritis, Chest Pain, Cellulitis of Right Lower Limb, Non-Pressure Chronic Ulcer of Right Ankle, Pulmonary Nodule, and Pericarditis who was admitted to the facility 04/11/2024.
On 09/10/2024 at 12:35 PM Observed R1 with multiple missing teeth.
On 09/10/2024 at 1:31 PM Observed both of R1's hands with contractures. Observed V15 (Licensed Practical Nurse) assisting R1 with eating his meal. R1 stated he can't eat everything because some foods are hard to chew or just completely hard. R1 showed surveyor that his chicken was tough by bending it back and forth. Observed chicken to be tough and uncut. R1 stated V17 (Family Member) brings him cereal and soup and things he can chew. Observed V15 did not attempt to cut R1's meat while assisting him with eating then take R1's tray after he said he couldn't eat the meal anymore without encouraging him to eat more or offering him alternative foods. Observed R1's meal tray with leftover food including 2 full chicken tenders, ½ cup of slaw, 1 slice of bread, and approximately 1 Tbsp of apple crisp. Observed R1 ate 15-20% of his meal. Observed R1's meal ticket did not include preferences. V15 stated R1 hasn't been eating so well.
R1's point of care reports for amount of food eaten on 09/10/2024 documents during his lunch meal he ate 75-100% of his meal.
R1's current physician order summary includes an active order effective 08/15/2024 for General Mechanical Soft texture diet with Regular, 1 Scoop (Protein Supplement) two times a day for weight management; and 120 ml Nutritional Protein Supplement two times a day for weight management and does not include nutritional shake.
On 09/10/2024 at 1:54 PM V17 (Family Member) stated R1 has lost weight since he's been in the facility. V17 stated R1 has reported difficulty with chewing food, and she has observed them leaving him with his tray and he needs help with being fed. V17 stated R1 has been at the facility since April and he's going to die there if they are not helping him.
On 09/12/2024 from 9:50 - 10:10 AM V15 (Licensed Practical Nurse) stated R1 refused his ordered protein supplement when she offered it to him this morning and preferred to drink his milk. V15 opened R1's medication administration record at the nurses station computer upon surveyor's request which documented that 1 scoop of protein supplement was administered to R1 during morning medication pass. V15 could not explain why she marked the protein supplement as administered although R1 declined it. Observed V15 attempt again to offer R1 his protein supplement. R1 declined it and asked for Nutritional shake. R1 stated he used to receive a case of nutritional shake through his insurance. V15 stated R1's family sometimes brings him nutritional shake. R1 stated the nutritional shakes comes in different flavors that he likes.
R1's September 2024 Medication Administration Record was reviewed to be inconsistent with surveyors observations on 09/12/2024 from 9:50 AM - 10:10 AM.
R1's Hospital Report dated 07/09/2024 documents he was observed to be underweight and frail, suspected to have inadequate intake, severe muscle and adipose wasting observed upon physical nutritional assessment consistent with severe malnutrition, and a recommendation to provide advanced nutritional shake three times daily to enhance diet.
R1's current care plan initiated 09/10/2024 documents he requires assistance with his meals as evidenced by diagnosis of Rheumatoid Arthritis at multiple sites related to: Contracture of Muscle at multiple sites with interventions including staff to assist with cutting meat and vegetables for all meals; current care plan initiated 08/22/2024 documents his nutritional status is compromised secondary to: Low Body Mass Index, Chronic renal failure with resultant abnormal labs, Present Weight at 90 below Ideal Body Weight of 133-163 lbs. with interventions including prepare/serve R1's nutritional diet as ordered, Determine R1's food preferences through one-to-one interview and/or family interview, and provide dietary supplements as ordered.
On 09/12/2024 at 11:43 AM Observed R1 weighed to be 92.2 lbs.
On 09/12/2024 at 12:20 PM V7 (Dietary Manager) stated R1 did not have any food preferences when she asked him on admission.
On 09/12/2024 at 2:20 PM V21 (Dietitian) stated the facility should be able to order the nutritional shake that R1 prefers. V21 stated R1's ordered nutritional protein supplement is nutritionally similar to the nutritional shake and may be better quality however if he doesn't like it he won't drink it. V21 stated usually the facility can find a way to order the Nutritional shake. V21 stated mechanical soft food is what's ordered for R1. V21 confirmed it is important that R1 receives supplements if he doesn't eat well. V21 stated it is important that R1 is eating regular foods as well. V21 stated 92.2 pounds is definitely low even though R1's Body Mass Index is in a normal range. V21 stated it would be good if R1 gained weight and Body Mass Index doesn't take into account body composition or mass. V21 stated we would want R1 to get enough vitamin C and iron from adequate intake of whole foods as well as supplement intake.
On 09/12/2024 at 3:15 PM V35 (Licensed Practical Nurse) stated R1 doesn't like the 120ml (Milliliter) Nutritional Protein Supplement and usually declines it preferring to drink soda or milk. Observed R1 decline his prescribed 120ml Nutritional Protein Supplement when offered by V35. R1 stated the Nutritional Protein Supplement tastes like medicine and he prefers Nutritional shake which has different flavors and tastes like a shake. R1 stated he drinks milk with no issue and the nutritional shake, but his ordered Protein Supplement and Nutritional Protein Supplement taste like medicine.
On 09/12/2024 at 3:34 PM V2 (Director of Nursing) stated staff should encourage or cue R1 to eat if he is refusing to eat. V2 stated if R1 refuses the protein supplements provided by the facility an alternative should be offered to him.
On 09/12/2024 at 3:56 PM V21 (Dietitian) stated she spoke with V1 (Administrator) and she will work on getting the Nutritional Shake for R1 and the facility should be offering other alternatives if the Nutritional Shake is unavailable such as calorie dense shake, protein enriched frozen dessert, and fortified ice cream. V21 stated if it is not possible to order the Nutritional Shake there should be some other alternatives available.
On 09/17/2024 at 2:24 PM When surveyor asked V7 (Dietary Manger) if she ever asked R1's family about his food preferences she stated she has never met or encountered R1's family but if any dietary issues come up during care conferences, she will address those concerns.
On 09/19/2024 at 8:46 AM V2 (Director of Nursing) stated the facility does use recommendations from hospital records and if necessary, the facility will work with the dietitian to implement any recommended interventions or any alternatives to those recommendations.
On 09/19/2024 at 1:24 PM V17 (Family Member) stated R1 likes to eat chicken nuggets because they're soft, hamburger meat without the bun because it's too hard, French fries, and likes milk shakes a lot. V18 stated R1 previously had a lot of favorite foods and prefers Mexican food such as burrito's, tacos, soups, and beef. V18 stated the facility never asked her about his favorite foods or food preferences and assumes they just provide him whatever is on the menu for all the residents.
The facility's Policy for Weight Assessment and Intervention received 09/13/2024 states:
Interventions for undesirable weight changes may take the following considerations: resident's preferences, rights, and use of supplements, as ordered by the physician.
The facility's Resident Tray Delivery Policy received 09/18/2024 states:
Check name, diet order and preferences on dietary card on tray
Avoids errors in served items, or omissions.
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 F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for providing sp...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for providing specialized diets by not ensuring specialized dietary orders were followed and not providing feeding assistance as needed for a resident who receives a mechanical soft diet. This failure applied to one of one resident (R1) reviewed for specialized diet.
Findings include:
R1 is a [AGE] year-old male with a diagnoses history of Local Infection of the Skin, Rheumatoid Arthritis, Chest Pain, Cellulitis of Right Lower Limb, Non-Pressure Chronic Ulcer of Right Ankle, Pulmonary Nodule, and Pericarditis who was admitted to the facility 04/11/2024.
On 09/10/2024 at 12:35 PM Observed R1 with multiple missing teeth.
On 09/10/2024 at 1:31 PM Observed R1 both of R1's hands with contractures. Observed V15 (Licensed Practical Nurse) assisting R1 with eating his meal. R1 stated he can't eat everything because some foods are hard to chew or just completely hard. R1 showed surveyor that his chicken was tough by bending it back and forth. Observed chicken to be tough and uncut. R1 stated V17 (Family Member) brings him cereal and soup and things he can chew. Observed V15 did not attempt to cut R1's meat while assisting him with eating then take R1's tray after he said he couldn't eat the meal anymore without encouraging him to eat more or offering him alternative foods. Observed R1's meal tray with leftover food including 2 full chicken tenders, ½ cup of slaw, 1 slice of bread, and approximately 1 Tbsp of apple crisp. Observed R1 ate 15-20% of his meal. V15 stated R1 hasn't been eating so well.
On 09/12/2024 at 2:20 PM V21 (Dietitian) stated mechanical soft food is what's ordered for R1. V21 confirmed it is important that R1 receives supplements if he doesn't eat well. V21 stated it is important that R1 is eating regular foods as well. V21 stated 92.2 pounds is definitely low even though R1's Body Mass Index is in a normal range. V21 stated it would be good if R1 gained weight and Body Mass Index doesn't take into account body composition or mass. V21 stated we would want R1 to get enough vitamin C and iron from adequate intake of whole foods as well as supplement intake.
R1's current care plan initiated 09/10/2024 documents he requires assistance with his meals as evidenced by diagnosis of Rheumatoid Arthritis at multiple sites related to: Contracture of Muscle at multiple sites with interventions including staff to assist with cutting meat and vegetables for all meals; current care plan initiated 08/22/2024 documents his nutritional status is compromised secondary to: Low Body Mass Index, Chronic renal failure with resultant abnormal labs, Present Weight at 90 below Ideal Body Weight of 133-163 lbs. with interventions including prepare/serve R1's nutritional diet as ordered.
R1's current physician order summary includes an active order effective 08/15/2024 for General Mechanical Soft texture diet.
R1's Restorative progress note created dated 9/10/2024 documents writer asked out of concern was assistance from staff needed with his meals. R1 stated, at times he does need assistance with cutting his meats and, some vegetables.
The facility's Resident Tray Delivery Policy received 09/18/2024 states:
Check name, diet order and preferences on dietary card on tray
Avoids errors in served items, or omissions.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their environmental policy and procedures by...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their environmental policy and procedures by not ensuring resident living areas were kept free of mold or mold promoting conditions. This failure applied to three of three residents (R1, R13, and R14) reviewed for environment.
Findings include:
R1 is a [AGE] year-old male with a diagnoses history of Local Infection of the Skin, Rheumatoid Arthritis, Chest Pain, Cellulitis of Right Lower Limb, Non-Pressure Chronic Ulcer of Right Ankle, Pulmonary Nodule, and Pericarditis who was admitted to the facility 04/11/2024.
R13 is a [AGE] year-old male with a diagnoses history of Schizoaffective Disorder, Anxiety Disorder, and Benign Prostatic Hyperplasia who was admitted to the facility 10/10/2023.
R14 is a [AGE] year-old male with a diagnoses history of Type 2 Diabetes Mellitus with Hyperglycemia, Atherosclerotic Heart Disease, History of Pulmonary Embolism, and Metabolic Encephalopathy who was admitted to the facility 05/02/2022.
On 09/10/2024 at 12:35 PM Observed 4 large dark discolored stains with a fuzzy growth on the ceiling tiles near R1's bed that appeared to be mold. R1 did not comment on the surveyors observations but did sigh in agreement about the surveyors concerns about the condition of the ceiling tiles.
On 09/11/2024 from 10:19 AM - 11:00 AM V9 (Maintenance Director) stated if water stains sit on ceiling tiles for too long, they can begin to change colors, decay, or turn into mold. V9 stated mold is a fungus and a growth that can be a range of colors depending on what it's growing on. V9 stated mold is also distinguished by shape and texture V9 stated mold can be black, green, or even purple if its sitting on an object of that color. V9 stated if ceiling tiles become discolored, he will change them out. V9 explained that the facility's air conditioning system does cause some moisture to drop onto the ceiling panels. V9 stated this issue is more common in certain areas of the building such as the first-floor area that were observed with discolored and water-stained ceiling tiles. V9 stated if staff observe discolored ceiling tiles, they are trained to document these observations on work order forms which he also tries to address within 24 hours. Observed 4 large dark discolored stains with a fuzzy growth on the ceiling tiles near R1's bed. V9 stated the dark discolored stains on the ceiling tiles near R1's bed appear to be mold. V9 agreed that staff that have entered R1's room should have reported the discolored ceiling tiles. V9 stated if mold is observed in a residents room they would be removed from the room, he would don a mask and gear and remove the panels. V9 agreed that mold is dangerous. Observed a large dark discolored stain with a fuzzy growth on the ceiling tile directly outside of R13's room. V9 stated the dark discolored ceiling tile directly outside of R13's room looks like it's turning into mold. Observed a dark discolored ceiling tile in a non-occupied room. V9 stated he would say that the dark discolored ceiling tile in the non-occupied room is mold. V9 stated no one is currently living in that room but the room is being prepared for admitting residents. V9 stated the ceiling tiles in the non-occupied room would need to be removed. Observed multiple discolored water-stained panels in R14's room and bathroom. V9 stated the multiple discolored water-stained panels in R14's room and bathroom are becoming discolored and should be changed.
The facility's Preventative Maintenance Policy Received 09/13/2024 states:
The purpose of the policy is to:
To conduct regular environmental tours/safety audits to identify areas of concern within the facility.
The responsible parties include:
Maintenance Director and/or Housekeeping Director.
Protocol includes:
Random rounds conducted by the Director of Maintenance and/or Director of Housekeeping Services.
Monitor random rounds in writing to review in the Monthly QA Meeting.
Preventative Maintenance Program will review the following areas during random rounds:
All facility areas are kept clean and in safe condition,
Ceiling tiles are free from watermarks or spots.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedure for wound treatm...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedure for wound treatments by not ensuring residents received wound treatments daily as ordered by the physician, with multiple missed wound treatments. This failure applied to two of three residents (R1 and R3) reviewed for wound care.
Findings include:
1) R1 is a [AGE] year-old male with a diagnoses history of Local Infection of the Skin, Rheumatoid Arthritis, Chest Pain, Cellulitis of Right Lower Limb, Non-Pressure Chronic Ulcer of Right Ankle, Pulmonary Nodule, and Pericarditis who was admitted to the facility 04/11/2024.
On 09/10/2024 at 12:35 PM R1 stated the bandage on his right leg is changed every few days or so and was last changed on Friday or Saturday. Observed R1's bandage on his right leg with some reddish brown stains.
R1's current care plan documents he is at increased risk for alteration in skin integrity related to post surgical wound to his right heel, and right lateral ankle with interventions including Administer Wound Care (Treatments) per physician orders.
R1's current physician order summary includes an active order effective 09/11/2024 for paint right heel with topical anesthetic. Cover with antibiotic pad, and wrap with wound care gauze.
R1's July, August, and September 2024 Treatment Administration Records document missing information on multiple days for wound care treatments as actively ordered.
R1's September 2024 Treatment Administration Record received from the facility 09/13/2024 was modified to fill in the missing information for wound care treatments after the surveyor reviewed it originally on 09/11/2024.
2) R3 is a [AGE] year-old male with a diagnoses history of Dementia, Polyneuropathy, Peripheral Vascular Disease, and Cellulitis of Left and Right Lower Limbs who was admitted to the facility 11/07/2022.
On 09/10/2024 at 10:45 AM R3 stated he called the police on Monday 09/09/2024 because wound care hadn't been provided. R3 stated wound care hadn't changed his bandage and he has a skin ulcer inside the right ankle. Observed R3's ankle covered with a bandage with some reddish-brown stains. R3 stated he was told that on weekends the nurses half to provide wound care and change bandages. R3 stated his bandage was last changed yesterday and prior to that on Friday.
R3's current physician orders document an active order effective 05/31/2024 for apply topical anesthetic to right ankle topically every day-shift for wound healing, cleanse ankle with saline and apply topical anesthetic daily.
R3's August and September 2024 treatment administration record documents missing information for multiple days including Saturday 09/07/2024 and Monday 09/09/2024 for wound treatments as actively ordered.
On 09/12/2024 at 11:45 AM V15 (Licensed Practical Nurse) stated nurses perform wound care on weekends if there is no wound nurse available.
On 09/12/2024 at 3:34 PM V2 (Director of Nursing) stated nurses are responsible to provide wound care on the weekends if there is no wound nurse available.
On 09/19/2024 at 8:46 AM V2 (Director of Nursing) agreed even if a resident has a history of refusing wound treatment the facility should still offer it. V2 stated if there is no documentation in the treatment administration record of the resident receiving wound treatment or refusing it this indicates it was not done.
On 09/19/2024 at 1:53 PM V8 (Wound Nurse/Licensed Practical Nurse) stated she misunderstood the surveyors request to explain the missing entries on R1's September 2024 Treatment Administration Record and thought the surveyor was asking the facility to correct the missing entries. V2 (Director of Nursing) and V8 stated it appears V3 (Assistant Director of Nursing) modified the missing entries in R1's September 2024 Treatment Administration Record the day the surveyor spoke to V8 about this record.
The facility's Wound Care Policy received 09/13/2024 states:
The purpose of the policy is To promote healing of existing pressure and non-pressure ulcers.
The goals of wound treatment are to:
a.
Keep the ulcer bed moist and the surrounding skin dry,
b.
Protect the ulcer from contamination, and
c.
Promote healing.
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 F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for providing ef...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for providing effective pest control interventions by not adequately assisting residents with maintaining a clean environment and not providing pest control treatments consistently. This failure applies to all 202 residents currently in the facility.
Findings include:
R1 is a [AGE] year-old male with a diagnoses history of Local Infection of the Skin, Rheumatoid Arthritis, Chest Pain, Cellulitis of Right Lower Limb, Non-Pressure Chronic Ulcer of Right Ankle, Pulmonary Nodule, and Pericarditis who was admitted to the facility 04/11/2024.
On 09/10/2024 at 12:35 PM Observed gnats flying around R1's room. R1 stated he sees roaches and flying insects in his room.
On 09/10/2024 at 1:54 PM V17 (Family Member) stated she has observed R1's tray to be full of flies and another visiting family member took a video of his tray being left in the room and it being full of flies.
On 09/11/2024 at 11:55 AM Observed gnats flying in first floor hallway.
R2 is a [AGE] year-old male with a diagnoses history of Schizoaffective Disorder, Adult Failure to Thrive, Dementia, Major Depressive Disorder, Bipolar Disorder, and History of Falling who was admitted to the facility 03/09/2021.
On 09/11/2024 at 2:06 PM V18 (Family Member) stated she's seen a roach crawling in R2's room.
R3 is a [AGE] year-old male with a diagnoses history of Dementia, Polyneuropathy, Peripheral Vascular Disease, and Cellulitis of Left and Right Lower Limbs who was admitted to the facility 11/07/2022.
On 09/10/2024 at 10:45 AM R3 stated there are issues with roaches, flies, and gnats.
R8 is a [AGE] year-old male with a diagnoses history of Schizoaffective Disorder and Iron Deficiency Anemias who was admitted to the facility 10/17/2014.
On 09/17/2024 at 1:25 PM R8 reported there was a roach in his coffee this morning. R8 stated he had pictures. Observed a picture in R8's cell phone dated 09/17/2024 at 9:24 AM of a roach in a cup of coffee.
R11 is a [AGE] year-old male with a diagnoses history of End Stage Renal Disease, Dependence on Renal Dialysis, Heart Failure, Convulsions, and Need for Assistance with personal care who was admitted to the facility 03/27/2012.
On 09/11/2024 at 10:12 AM R11 stated the roaches are taking over at night and are all over the building. R11 stated the roaches are just running wild. R11 stated there are a few gnats.
R12 is a [AGE] year-old female with a diagnoses history of Heart Failure, Candidiasis, End Stage Renal Disease, and Asthma who was admitted to the facility 11/04/2022.
On 09/11/2024 at 10:13 AM R12 stated she sees a lot of roaches in her room.
On 09/11/2024 at 11:59 AM V10 (Housekeeping Supervisor) confirmed the facility does have roach problems, and stated once she is made aware of it she notifies the pest control and walks with them to nutritional shake the rooms are treated. V10 stated pest control comes out each time she calls. V10 stated food, wall cracks, and clutter need to be eliminated to eliminate roach problems. V10 stated the pest control rep stated the room walls also need to be kept clean. V10 stated room trays need to be removed timely and rooms kept free of food waste and kept clean. V10 stated while these issues are being addressed the facility should be treated for roaches weekly. V10 stated the pest control rep has observed food on the wall, diapers not in the garbage bag, feces on the wall in the soiled utility room, trays being left in the soiled utility room, food and clutter in the residents room and advised the facility needs to eliminate some of the clutter and food kept in residents rooms. V10 stated they don't call the pest company out for gnat treatment; however, they remove garbage and clean any waste that attracts gnats. V10 stated if residents have concerns about gnats in their room, she'll come into their room and identify any food or waste that are attracting the gnats, she will have the waste removed and have the area cleaned to remove the gnats. V10 stated she would not use fly catchers to remove gnats.
Pest Control Siting Logs from June - September 2024 document multiple reports of roaches throughout the facility.
Pest Control Invoices from June - September 2024 document sightings of roaches in multiple areas of the facility including residents rooms, nurses stations, janitor closet, shower room, utility rooms, offices, library, and kitchen; reports of food, food related items present on walls and on floors, clutter, and wall openings in resident areas reportedly making it impossible to effectively treat roaches with a recommendation to address these issues in order to help keep pest down in residents rooms; and that the facility only received roach treatments every other week.
The facility's Pest Control Policy received 09/13/2024 states:
The purpose of this policy is to prevent or control insects from spreading disease.
The pest control program will be conducted on a regular and as needed basis.
Food will be covered and/or refrigerated as applicable, to prevent pest invasion and spoiling.
Residents shall be allowed to keep limited amount of open food at their bedside in sealed containers.
The facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects.
Jul 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 interview and record review the facility failed to follow the plan of care and provide Activity of Daily Living to a re...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the plan of care and provide Activity of Daily Living to a resident dependent on staff for incontinent care. This affects one of 3 residents (R4) reviewed for activities of daily living care.
Findings include:
R4 MDS (Minimum Data Set) dated 5/18/24 for functional abilities denotes R4 is dependent for toileting. Most recent discharge MDS dated [DATE] for functional abilities denotes R4 is dependent for toileting.
R4 most recent care plan denotes R4 has a self care deficit (ADLs/Mobility) R/T (related /to) generalized weakness and shortness of breath. Resident will improve/maintain highest level of function with participation in therapies and/or restorative programs through next review. One assist with dressing / hygiene tasks; encourage as much self-performance as safely able. Resident is dependent with ADL care; provide total assistance in all aspects of hygiene/dressing. Toilet with two assists.
On 7/30/24 at 10:49am V29 (LPN-Licensed Practical Nurses) said she was the nurse responsible for R4 care on 7/15/24 when R4 was sent to the hospital for change in condition in mental status. V29 said R4 was sent to the hospital for further care on 7/15/24. V29 said she informed the aide that R4 was going out and to clean and change R4. V29 said the next day when she returned to duty, she was informed that R4 was sent to the hospital soiled in urine and was not changed prior to being transferred to the hospital. V29 said the aide should have provided care as directed. V29 said R4 needs assistance with incontinent care.
On 7/30/24 at 12:00pm V26 (CNA) said she did not provide incontinent care to R4 prior to R4 going out to the hospital for a change in condition of mental status on 7/15/24, V26 said she kind of mentioned that she needed help to another aide. V26 said she did not notify the nurse that she needed help with R4 care needs. V26 said she was R4 aide on 7/15/24.
On 7/30/24 at 12:25pm V9 (Director of Nursing) said R4 should have been provided incontinence care prior to being sent to the hospital. V9 said sending a resident out soiled in urine is a dignity issue. V9 said she made aware that R4 was sent to hospital soiled in urine.
On 7/30/24 at 12:33pm V25 (Restorative Nurse) said R4 is dependent of staff for toileting needs (incontinence care).
Facility policy titled activities of daily living dated 9/2023 denotes in-part to preserve ADL function, promote independence, and increase self-esteem and dignity.
Facility incontinence care policy dated 9/22 denotes in-part incontinent resident will be checked periodically every two hours and provided perineal and genital care after each episode.
Jun 2024
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 follow their policy and procedures for behavior Manag...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedures for behavior Management for Agitated Behavior by not providing one to one supervision for a resident, with a history of self-harming behavior, who was threatening and attempting self-harm and being physically aggressive towards staff. This failure applied to one of three residents (R9) reviewed for accidents and injury and resulted in R9 sustaining a fracture to their right arm.
Findings include:
R9 is a [AGE] year-old female with a diagnoses history of Quadriplegia, Multiple Sclerosis, Vitamin Deficiency, Anxiety Disorder, and Recurrent Major Depressive Disorder who was admitted to the facility 03/21/2022.
On 05/28/2024 at 12:23 PM R9 is observed sitting in her wheelchair in her room with a cast and brace on her right arm. R9 stated it was a soft cast and her arm was broken through in 2 pieces. R9 stated one evening between 8-9 PM she blocked her room door from V6 (Licensed Practical Nurse) and V7 (Licensed Practical Nurse) with her wheelchair and told them she wasn't ready to go to bed. R9 stated she was yelling, and they didn't care and put her in bed anyway. R9 stated she was yelling the entire they picked her up from her chair. R9 stated after they left the room, she was being rebellious and tried to get out of bed. R9 stated she swung her feet out of bed first and doesn't recollect how she got her arm caught in the rail, but it makes sense that's how she injured her arm.
R9's progress note created by V6 (Licensed Practical Nurse) on 5/7/2024 at 2:20 PM documents on 05/05/2024 resident was asked can she be assisted to bed, because she was asleep in the wheelchair by the elevator, resident became verbally aggressive and went into her room and tried to block the door with her wheelchair. Staff was able to talk her into opening up the door, resident became very aggressive trying to throw herself out the chair onto the floor. Resident released her seat belt and tried to slide herself out her chair. Writer and the other nurse were able to prevent her from sliding onto the floor. Writer and the other staff transferred resident onto the bed resident and began fighting stating that it's my right to throw myself on the floor. Writer repositioned the resident for comfort. The certified nursing assistant was walking by and noticed the residents legs hanging out the bed, Writer and the other nurse came in and saw that the resident legs and arms were stuck between the chair and the side rail. Resident stated leave me alone it's my right to throw myself on the floor, I don't care. Writer turned and repositioned the resident so she wouldn't fall. Resident stated it's my right leave me alone. Writer explained the importance of not trying to cause harm to herself and that she would cause an injury, resident stated that it's my body and my right.
R9's Progress note created by V6 (Licensed Practical Nurse) dated 5/5/2024 9:07 PM documents resident was being very aggressive trying to take her seat belt off to throw herself on to floor. Resident was swinging and trying to hit writer. Resident's right arm got caught between the bed rail and her motorized wheelchair trying to throw herself out the bed stating that it was her right to harm herself.
R9's Stricken note created by V6 (Licensed Practical Nurse) on 5/5/2024 at 10:28 PM documents resident refused to be changed and she is trying to climb out the bed. Writer entered the room saw resident trying to climb out the bed and she was stuck between the bed and wheelchair. Writer asked a Certified Nursing Assistant to help to get resident back in the bed.
R9's Hospital admission report dated 05/06/2024 - 05/08/2024 documents it was reported she was being moved into bed by nursing staff when her right arm was injured; she was reportedly being combative and was being placed back into bed and apparently forearm got caught in the railing and sustained injury; past medical history includes Multiple Sclerosis; an x-ray of her arm showed a fracture likely due to a combination of trauma and pathological osteoporosis/osteopenia as there was evidence of bone demineralization.
Facility Reported Incident Investigation Reports initiated 05/06/2024 documents on 05/06/2024 R9 reported that V6 (Licensed Practical Nurse) and V7 (Licensed Practical Nurse) were rough while transferring her to her bed causing her to have a bruise on her right arm, upon body assessment staff noted R9's right arm was swelled and bruised; the facility contacted the physician by phone and orders were given to send R9 to local hospital for further evaluation where it was reported that she has a fracture to her right arm; During staff and resident interviews it was noted that R9 was attempting to throw herself on the floor while sitting in the wheelchair; while attempting to throw herself to the floor she started to slide out of the wheelchair when V6 and V7 prevented the fall and assisted R9 to bed; While R9 was in bed and noted to be calmed the CNA (Certified Nursing Assistant) walked by and observed R9 in a prone position on the edge of the bed with her right arm between the rail and wheelchair.
Witness statement dated 05/05/2024 from V45 (Certified Nursing Assistant) documents R9 was sleep in her wheelchair, she heard R9 was asked if she could move from in front of the elevator, R9 became upset, went to her room and blocked the door; V45 was in the room and R9 was yelling at her and telling her to go back to Mexico, R9 moved and V7 and V6 were trying to calm her. R9 kept trying to put herself onto the floor, started sliding out and they stopped her from falling and put her into the bed; All the while R9 was in the bed she was yelling; V45 walked by and R9 's legs were stuck between the wheelchair and turned onto her side trying to move the wheelchair; R9 kept saying she had the right to fall; V45 and others had to move the wheelchair to prevent R9's legs from getting hurt.
Witness statement dated 05/05/2024 from V7 (Licensed Practical Nurse) documents R9 was screaming out loud and using profanity and insisted she has rights; R9 tried to throw herself on the floor, and he stopped her by placing his hand across her chest area; R9 tried to release her seat belt; V7, V6 (Licensed Practical Nurse), V45 (Certified Nursing Assistant) and V39 (Certified Nursing Assistant) placed R9 in the bed and she continued to scream; V7 came back into the room and R9 was trying to reach over and turn her motorized chair on and he moved the chair out of the way.
R9's current physician order documents an active order effective 02/17/2024 for Behavior Monitoring.
R9's current care plan initiated 03/01/2024 documents she has a history of self-harmful ideation
(thoughts) and/or behavior. This appears related to: Evidence of severe mental illness (i.e., active psychosis, major depression, lack of sound judgment, poor contact with reality) with interventions including: as warranted conduct/carry out Behavior monitoring of the resident, look especially for any change.
A safety contract was established with R9 and documents on 03/01/2024 R9 she signed an agreement to not harm herself in any way.
R9's Screening Assessments for Evaluation of Self Harm/Suicide Risk dated 03/01/2024 and 04/24/2024 document she has a history of suicidal ideations and is at risk.
On 05/29/2024 at 10:46 AM V6 (Licensed Practical Nurse) stated on the date of R9's incident at 10:30 PM R9 was being combative. V6 stated R9 was sleeping in her wheelchair at the nurses station and was asked by V27 (Certified Nursing Assistant) if she could ambulate herself in her wheelchair to her room. V6 stated R9 became combative and didn't want to get in her bed and she responded to R9 fine she'll just document that she refused to get in bed. V6 stated R9 started taking her seat belt off and appeared as though she may fall. V6 stated V7 (Licensed Practical Nurse) broke R9's fall by catching her in the front of her chest with his arms. V6 stated V7 then repositioned himself behind R9 and lifted her underneath her arms while she then assisted V7 by grabbing R9's legs and both placed her in bed. V6 stated she and V7 had left the room and a Certified Nursing Assistant walking by R9's room noticed her legs were hanging out of her bed and called her for assistance. V6 stated she then went into the room to assist that CNA (Certified Nursing Assistant) along with V7 and another CNA with getting R9 back into bed and R9 became combative. V6 stated R9 then began fighting, tried to bite V7 multiple times and hit her in the chest with her right arm. V6 stated she believes R9 may have been on smoke restriction and when this happens she becomes combative.
On 05/29/2024 at 11:13 AM V45 (Certified Nursing Assistant) stated on the date of R9's incident V27 (Certified Nursing Assistant) informed her she needed help with R9 because she was partially out of her bed. V45 stated when she entered the room she observed R9 bent over her side rail with her arm pinned underneath her and her legs underneath her wheelchair which was directly next to the bed. V45 stated she, V27, V6 (Licensed Practical Nurse), and V7 (Licensed Practical Nurse) rolled R9 back into her bed and R9 hit V6 in the chest. V45 stated she believes R9's vape was taken and when this happens, she becomes out of control.
On 05/29/2024 at 4:20 PM V7 (Licensed Practical Nurse) stated on the date of R9's incident she was in her chair at the nurses station and he believes there was a conversation about someone getting ready to change her and she wanted to stay in the chair to be changed. V7 stated R9 was told it was not safe to be changed in the chair and needed to be in the bed probably for safety. V7 stated R9 didn't want to be changed, became angry, she ambulated in her motorized wheelchair to her room and then tried to close her door. V7 stated on a previous day R9 closed her room door and tried to place her motorized wheelchair in front of the door to prevent anyone from entering. V7 stated he and V6 (Licensed Practical Nurse) stopped R9 from closing her door during this instance. V7 stated R9 then stated well I'll just throw myself on the floor then took her hand and unbuckled her seat belt. V7 stated R9 then leaned forward as if she was about to throw herself on the floor. V7 stated he then grabbed R9 from underneath her arms from in front of her and the repositioned himself behind R9's wheelchair and V6 grabbed her feet. V7 stated he then grabbed R9 from behind her back underneath her arms and V6 grabbed her feet and both placed her in the bed. V7 stated he and V6 put up the side rail and lowered R9's bed all the way down as low as it can go. V7 stated R9 was still angry and cursing. V7 stated he and V6 left the room and then someone came back to check on R9 five or ten minutes later and she was still in the bed but it was like she was trying to throw herself out of bed. V7 stated R9 was observed lying against the side rail of her bed in a sideways lying position and her feet were still in the bed. V7 stated R9's wheelchair was next to the bed and he thinks she may have tried to turn it on or grab a hold of it to pull herself out of the bed. V7 stated R9 was caught in the side rail, so he came in with two other aides, V45 (Certified Nursing Assistant), V27 (Certified Nursing Assistant), and the Nurse and all of them helped R9 out of the siderail and she was still angry and cursing. V7 stated when R9 is angry she just does things. V7 stated in his time at the facility for the past 2 and a half years R9 has exhibited these behaviors. V7 stated he has documentation of R9 in the past year stating she was going to throw herself on the floor. V7 stated R9 has a history of making verbal threats of self-harm of throwing herself on the floor when something isn't going her way. V7 stated R9 is able to take off her seatbelt and show that she can throw herself on the floor. V7 stated he believes R9 is physically capable of throwing herself out of the chair.
On 05/30/2024 at 12:34 PM V29 (Regional Nurse Consultant) stated during R9's incident on 05/05/2024 she became aggressive, blocked her room door, unbuckled her seat belt, and attempted to throw herself on the floor. V29 stated R9 has a history of this behavior. V29 stated R9 was placed in her bed to prevent her from falling on the floor. V29 stated R9 has a history of osteoporosis and osteopenia and could have had worse than a fracture. V29 stated because of R9's Multiple Sclerosis she couldn't fully place herself on the floor, however R9 obtained a fracture because of her behavior and because of how she was positioning herself out of bed.
On 05/30/2024 at 12:42 PM V2 (Director of Nursing) stated due to R9's condition it's unsafe for her to be alone in her room by herself. V1 (Administrator) stated when R9 declined to have staff in her room the appropriate response would be verbal de-escalation, talking to her through the door to get her to remove her wheelchair. V2 stated after breaking R9's fall from her wheelchair when trying to throw herself on the floor, the nurses should have seen if it's ok to place her in bed, or somewhere they know she would be safe. V2 stated she would expect staff to make a decision of where R9 can be kept safe whether it's place her back in her bed or chair. V2 stated after it was determined R9 would be safer in her bed whomever was in the room should have then placed R9 in the bed and monitored her. V2 stated with the behaviors R9 was exhibiting she would expect staff to implement 1:1 (one to one) monitoring or have someone in the room with R9, then the nurse should have called the doctor and notified the family. V2 stated If R9 was not closely monitored, she could have experienced harm and safety would be a significant concern. V2 stated one to one monitoring was necessary because R9 threatened to place herself on the floor and threatened to harm herself. V2 stated if staff left the room after R9 threatened to place herself on the floor and hear her yelling, they should immediately respond and see what is going on.
On 05/30/2024 at 1:27 PM V44 (Restorative Nurse) stated R9 can slide out of her wheelchair if sitting straight up in it.
Behavior Management for Agitated Behavior Policy received/reviewed 05/30/3034 states:
Observe resident for behavior escalation of aggression such as a loud voice tone, swearing, yelling, and/or other irritability.
Allow time to calm down with 1:1 (one to one) explanation of why behavior is inappropriate and unacceptable in a calm, soft voice.
Allow time for resident to voice feelings and frustration.
If uncontrolled anger, aggression cannot be redirected, i.e. (in other words). the resident is in danger of harming self or others after attempting the above interventions, administer physician ordered medication for anxiety for the symptoms being exhibited.
Document all interventions attempted and administered and the resident's response to medical interventions.
Notify the physician of the resident's signs/symptoms and lack of response to medications and other interventions.
Monitor the response to the drug therapy 1:1 (one to one) until dangerous symptoms are reduced. If the resident responds to the medication by becoming quiet and anxiety free and aggressive acts have minimized, i.e. (in other words) no longer harm to self, 1:1 (one to one) monitoring will be discontinued.
In the event staff needs to physically intervene to prevent the resident from harming self or others, techniques to provide interim control will be implemented which include non-violent crisis intervention.
When interim control is used, the physician will be notified, and a determination made as to the need for acute mental health services.
R9's progress notes and medical records do not include documentation of an attempt to provide medical interventions nor provision of 1:1 (one to one) monitoring during the course of exhibiting self-harming and physically aggressive behaviors.
R9's May 2024 Medication Administration Record does not document any evidence of administration of medication for anxiety, aggression, or self-harming behaviors on 05/05/2024 between 8-10:30 PM.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a re...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident. This failure applied to two of two (R5, R15) residents reviewed for abuse.
Findings include:
R5 [AGE] years old, was initially admitted to the facility 2/1/23 with diagnoses that include Major Depressive Disorder, Anxiety Disorder and Chronic Kidney Disease Stage III.
R15 is [AGE] years old, admitted to the facility from the hospital on 3/11/24 with diagnoses that included Schizophrenia.
The facility reported to IDPH an incident that occurred on 3/11/24 which indicated that R15 found R5 in the hallway and hit them unprovoked. R5 did not sustain any injuries and did not require hospitalization R15 discharged from the facility Against Medical Advice later that evening.
On 5/29/24 at 11:02AM V15 PRSC (Psychiatric Rehabilitative Services Coordinator) said that R15 was in their office while conducting an admission assessment, when all of a sudden, R15 abruptly got up, went into the hall and hit R5, unprovoked. V15 said the residents were immediately separated, and R15 was moved to a different unit. V15 said they didn't know about V15's behavior prior to initiating the assessment and did not probe the hospital records to determine if R15 was at risk for exhibiting abusive or aggressive behaviors.
On 5/30/24 at 12:10PM V29 Regional Nurse Consultant said R15 was admitted to the facility for a seizure disorder, status post craniotomy and it was during med pass that he arrived. The PRSC noted that the nurses were occupied with medication pass and took R15 to their office to complete Social Worker assessments. While they were meeting, R5 knocked on the door to speak with the PRSC and was easily redirected to come back at a later time. R15 finished the interview with the PRSC and was on the way back to the room when they came upon R5 in the hall and hit them. R15 was immediately placed on 1:1 and given a cigarette. Later he discharged home with the father.
Care Plan dated 3/12/24 for R5 includes a focus as stated in part; My comprehensive assessment reveals [history] of suspected abuse &/or neglect or factors that may increase his/her susceptibility to abuse/neglect. Goals of the care plan include I will be treated with respect, dignity & reside in the facility free of mistreatment (i.e., abuse/neglect)
The facility's Abuse Policy, revised 11/2018 states in part:
II. Pre-admission Screening of Potential Residents- This facility shall check and review the criminal history background for any resident seeking admission to the facility in order to identify previous criminal convictions. This facility will: 1. Request a Criminal History Background Check within 24 hours after admission of a new resident, 2. Check for the resident's nae on the Illinois Sex Offender Registration Web site 3. Check for the resident's name on the Illinois Department of Corrections sex registrant search page. 4. While the background from fingerprint checks, and/or identified Offender Report and Recommendations are pending, the facility shall take steps necessary to ensure safety.
IV. Establishing a Resident Sensitive Environment
This facility desires to prevent abuse, neglect, exploitation, mistreatment ad misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident Assessment- As part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or misappropriation of resident property or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis. For residents who are identified offenders, the facility shall incorporate the Identified Offender Report and Recommendations Report into the identified offender's plan of care including the security measures listed.
Apr 2024
3 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** There are two separate deficient practices statements for this citation.
I. Based on interviews and records reviewed the facili...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** There are two separate deficient practices statements for this citation.
I. Based on interviews and records reviewed the facility failed to develop a plan of care to prevent a resident with a history of suicidal ideation from obtaining items that can cause self-harm. This failure affected one of three residents (R4) reviewed for safety and supervision in the sample. This failure resulted in R4 being able obtain a belt and was found hanging from a towel rack on the bathroom floor on 02.29.24.
The Immediate Jeopardy began on [DATE]. V12 and V13 (both Administrators) were notified on [DATE] at 10:53AM of the Immediate Jeopardy. The surveyor confirmed by observation, interview, and record review that the immediate jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
The findings include:
R4 with a diagnosis including, but not limited to: Borderline Personality Disorder, Spondylosis with Radiculopathy, Schizoaffect Disorder, Major Depressive Disorder, Anxiety Disorder, Restless Leg Syndrome, Suicidal Ideations, and Bipolar Disorder, Current Episode Mixed, Severe without Psychotic Features. R4 was admitted to the facility on [DATE]. R4 was assessed on [DATE] to have a BIMS (Brief Interview of Mental Status) of 15 indicating R4 is cognitively intact.
According to the facilities final investigation of incident occurring on [DATE], R4 observed lying on the floor unresponsive, staffed observed a belt around R4's neck and Cardio Pulmonary Resuscitation (CPR) was initiated. R4 was transported to the hospital for evaluation. The facility was informed that R4 died from his self-inflicted injuries.
On [DATE] at 10:25AM, V14, Licensed Practical Nurse (LPN), said (V15, Certified Nursing Assistant (CNA)), came to get me and said (R4)'s roommate, (R8), could not get in the room. I went down to the room. When I got there the Director of Nursing (DON), V15, and I tried to get in the room so we pushed the door in. V14 explained the bathroom door was open against the room door blocking it from opening. V14 said the first person in the room was the Director of Nursing. V14 said When we got the room open and I went in, I saw (R4) half out the bathroom, with his feet out the bathroom, half his body in the bathroom and half out, and he was face down. We flipped him over and saw a belt around his neck, it was buckled on his neck. (V15) took the belt off. I didn't see if (R4) had any marks on his neck. I got the pulse ox (Oximeter) device and I took carotid pulse. (R4) was purple, I don't recall if his eyes were open or closed. (R4) was the only resident in the room and there is no other entrance to the room. It looked like the belt was on one part on the towel rack, the end was tied in a knot. V14 said 911 took R4 to the hospital. V14 said she later found out R4 was on a vent a few days later. V14 said she had seen R4 sitting on his bed talking to R8 and the last time she saw him was around 9:40AM.
On [DATE] at 10:49AM, V6, Psychiatric Rehabilitation Services Coordinator (PRSC), said R4 had a history of homelessness. V6 said R4 said he planned to be here short term. V6 said I did a 1:1 session with (R4) on [DATE], the day before the incident because he was in cigarette room and so was I. V6 said R4 was placed in Symptoms and Behavioral Management because of his history with suicide. V6 said We have a safety contract, I got him to sign it for the suicide and I did the suicide risk assessment. I believe (R4) had been hospitalized before admission for suicide attempt and depression. The information is in the referral packet. I don't recall the method he used.
On [DATE] at 12:09PM, V16, Housekeeping, said (in Spanish, with designated Spanish Speaking Surveyor) The roommate, (R8), called me over to him near the door to his room. The bathroom door was blocking the room door from opening. I peeked around the door and I saw (R4) on the floor. I ran to the CNA and she told the nurse. I thought there was a fabric tied from the towel bar to his body, but I didn't stay to see where it was tied. I saw (R4) was face down. V4 said this was around 12:10PM. On [DATE] at 11:38AM V16 said the police took the towel bar when they came in.
On [DATE] at 12:47 PM, V8, CNA, said I was not assigned to (R4). I had seen him at breakfast. This happened before lunch.
On [DATE] at 1:25 PM. V17, CNA, said I arrived to work at 7:00AM on [DATE]. I did my rounds, (R4) was awake. V17 said R4 went to eat breakfast in the dining room. V17 said I peeked in on (R4) about 11:30 AM, both residents (R4 and R8) were watching television in the room. I then went to break. I was outside and saw the ambulance and police cars. I thought that was crazy, he was just ok, laughing, and making jokes. It's weird that they said he tried to kill himself, I never got that vibe. I'm not sure if he had a history of suicide. If I had known, I may have checked on him more often.
On [DATE] at 2:19PM, V10, DON, said (V15, CNA), came to get me and said (R4) was on the floor. I moved the door a little, (R4)'s legs were blocking the door. I saw on object on his neck. I untied it, it was a belt, it was around his neck and the other end was on the towel bar with 2 knots. V10 said R4 was face down and there was blood on the floor that came from the side of R4's head. V10 said (R4) was bluish- purplish when I saw him. V10 said there is only entrance to the room. V10 said I don't know where (R4) got the belt from. V10 said Cardio Pulmonary Resuscitation was initiated. V10 said 911 arrived and took over. V10 said the police took the belt.
On [DATE] at 10:04AM V4, Psychiatric Rehabilitation Services Director (PRSD), said Social Services does the Cognitive BIMS assessment, Discharge Potential, Community Assessment, Aggression, Suicide Risk, Trauma, Substance Abuse, Social History and level of function for those with SMI (Serious Mental Illness), and Smoking Assessments. V4 said We review the admission packet. The purpose of the assessments are to determine what the patient needs are. V4 said the PASRR are done at the hospital before they are admitted to the facility to determine facility placement. V4 said We use the section of what the patient will benefit from to help determine the type of groups they need. Any abnormal findings on the PHQ9 (Mood assessment) requires updates to the care plan and possibly placement in new groups. We give the, DON, Floor Nurse, and/or the MDS nurse the results if any are abnormal assessment findings. The Care plan should be individualized. If a resident has a plan to use sharp items for self injury, we would remove them and do routine checks. (R4) was on hourly checks, from when he first got here. V4 said the forms are filled out by the social worker. V4 said We complete a belongings inventory. (R4) would not have been allowed a belt and he would not have been able to keep his phone and laptop chargers. I don't know where (R4) got the belt from. Any group, 1:1's or groups refusals should be documented. At 12:12PM V4 reviewed the handwritten Nursing Observation Sheet presented for hourly monitoring on R4. The observation started on [DATE]. V4 said The observation sheets are kept in my office. The Nurse Observations sheets are continued until the resident is stable, then we would stop the nurse observation sheet. We meet twice a day, morning (8:00AM) and afternoon (PM) to discuss if they should continue the observations. The surveyor asked V4 why the observation on [DATE] is not completed for night shift (12AM-6AM). V4 replied I don't know. There is no documentation to say when to stop the hourly monitoring sheets. (R4) was in Symptom and Behavior Management. If any resident has suicide ideation or history they'll be placed in the group. The majority of the time the group topics are not always discussed on 1:1 visit. V4 reviewed R4's Preadmission Screening and Resident Review (PASRR) with the surveyor. V4 read from the PASRR, V4 said R4 should have been placed on 3 group programs. V4 said programs including behavior management, development, maintenance, and consistent implementation across settings of those programs designed to teach daily living skills, grooming, personal hygiene, nutrition, health, and drug therapy. V4 continued reading and said crisis intervention program to keep yourself safe. Individual, group, and family psychotherapy. V4 said R4 could have Psychiatrist and Psychologist services. V4 said the Psychologist comes to the facility every 2 weeks and the psychiatrist comes once a week. V4 said the psychologist had not seen R4 yet. V4 said R4 should have been in Symptom and Behavior management, Traditional Living, and Self Maintenance groups. The surveyor asked for the documentation of the mentioned programs. V4 said I didn't bring those copies of programs or 1:1, I misunderstood what you wanted. I only brought the Symptom & Behavior Management Group records. At 1:26PM V4 provided group confirmation form for R4. V4 said R4 should have received more groups. The surveyor reviewed R4's care plan and V4 said it should state the frequency not just # for days for programs.
On [DATE] at 1:30PM, V12, Administrator, was interviewed regarding R4's (State Agency) final report. V12 said a moderate risk is more severe, it does not mean the same as minimal risk. V12 said the Medical team is the medical nurse practitioner and the psychiatrist, V9, and his Nurse Practitioner. V12 said I wrote the final report based on the progress notes and records I reviewed. V12 Reviewed PASSR and said there is no recommendation for specialized services. V12 said there is a list at each nurse's station of residents with suicide ideation and suicide attempts history. V12 said staff need to make frequent rounds, checking, any signs or symptoms, or if they present with any behaviors staff should notify nurse and social services. V12 said the police took the belt and towel rack. V12 said while hospitalized , R4's plan was to cut himself or walk into traffic. V12 said if staff was supervising R4, then staff should be aware if he had a belt. V12 said V31, Transport CNA, said she saw R4 15 minutes before the code. V12 said we don't have video. V12 said the nurse said 2 hours was when she last saw R4.
On [DATE] at 2:35PM V39, MDS (Minimum Data Set) Nurse, said Social Services does not communicate with me what they do. I don't check their assessments sections, only that is gets done. I just make sure its completed, sections C, D, and E. Each department is responsible for their own assessments and care planning.
On [DATE] at 3:11PM V31, Transport CNA, said I was at the nurses station on [DATE] and I saw (R4) get off the elevator. I was hanging the appointments list. V31 said R4 had books in his hands. V31 said R4 did not say anything. V31 said R4 may have gotten the books form the library or another resident. V31 said Then I got on the elevator and 5 minutes later, I heard them call a code blue. Lunch was maybe 30 minutes to 1 hour after the code happened. I probably seen (R4) between 10:30AM- 11:00AM.
On [DATE] at 11:50AM, V9, Psychiatrist, said the plan for R4 was to monitor him. V9 said R4 had no complaints of depression or anxiety. V9 said regarding R4's symptoms for impulsive and racing thoughts they are part of his diagnosis of Borderline Personality Disorder (BPD). V9 said R4 also had a Bipolar diagnosis. V9 said Bipolar is usually treated with medications and BPD is treated with talking therapy at least monthly. V9 said We did not write an order for him to be in psychotherapy. Usually the providers (facility) provide supportive psychotherapy by way of a trained Nurse Practitioner or Physician Assistant. V9 said R4 can't be held accountable for what he signed on a behavior contract. V9 said the contracts are only a tool used to help to establish rapport with the patient. V9 said behavior contracts are not shown to prevent self harm. V9 reviewed R4's PHQ-9 (mood assessment) on his computer. V9 said of the PHQ-9, I don't know how accurate these are. With a diagnosis of BPD they may have a negative response, maybe they just woke up or are upset about something vs when they are in a good mood all the answers may be positive outlook. I would like to have seen a follow up to this one. V9 said while in the hospital R4 admitted to having chronic Suicide Ideation and racing thoughts but no harming behaviors. V9 said initially what got R4 hospitalized was because he said his plan was to stab himself or walk in front of traffic. V9 said The facility told me (R4) attempted suicide. I am not sure what method he used.
On [DATE] at 10:29AM, V25, Assistant Director of Social Services, said the licensed social worker did not see R4 while he was in the facility.
R4's Screening Assessment for Evaluation Self Harm/Suicide Risk dated [DATE] completed by V6 documents R4 past history of suicidal ideations, history or problems, major depression and personality disorder diagnosis: Significant/Severe problems. Struggling with poor performance, perfectionist personality and/or a negative view of the future: Moderate Problem. Category Score = 11 (6-15) Moderate Risk. Comments: per hospital referral packet, has history of suicide ideation but denies at this time.
R4's Belongings Inventory dated [DATE] documents nothing for possession of belt, no accessories, 1 pair of shoes but no description of the shoes. 1 cell phone with charger and 1 laptop with charger.
Review of Medication Administration Record (MAR) [DATE]-[DATE] notes a list from 0-17 of Behaviors. Interventions are listed 0-9. Outcome results. Documentation prompts list Beh (behavior) Int (interventions) and Out (outcome) for every shift. 2/23-[DATE] on days and evening document 0 (none) behaviors. On 2/28 evening and night shift document NA. Per DON interview indicated Not Applicable. Monitoring of medication side effects on 2/28-2/29 documents NA.
Review of Mood assessment dated [DATE] indicates R4 reported he was feeling down, depressed, or hopeless nearly everyday. R4 reported trouble with sleep nearly everyday. R4 reported feeling tired or little energy half or more of the days assessed. R4 reported feeling bad about self or that he is a failure or have let himself or his family down on several days.
R4's care plan initiated on [DATE] states he has a history of self harm ideation (thoughts) and behaviors related to his mental illness. The intervention prompts what occurred, where, circumstances surrounding the events, precipitants and any current plan to harm. The facility did not documented the information mentioned in the prompt. R4's care plan he resist care related to medication compliance. This was not documented in R4's progress notes or MAR. R4's care plan identifies he has a need for specialized rehabilitation, support, counseling secondary to mental illness. R4's care plan identifies he has coping problems. Group and one to one programing are identified interventions but no specification of frequency or identification of programs R4 was assessed to need.
Nursing Observation Sheet for R4 reviewed. Observation initiated on [DATE] at 12:00AM for every shift. Observation sheet ends on [DATE] with comments and signatures from 8:00AM-11:00AM.
R4's Group Therapy Progress Notes dated [DATE] and [DATE] for Symptom and Behavior Management reviewed. (skill groups indicated on Group Form are Behavior Management, Suicide Prevention Group, Smoking Safety, and Symptoms and
Behavior Management. A progress note written by V6 dated [DATE] states a 1:1 for Symptom and Behavior Management was completed. There is no record R4 participated or was offered a group program or 1:1 for Suicide Prevention.
R4's PASRR Summary dated [DATE] documents if you are admitted to a Medicaid certified nursing facilities what services and supports are nursing facility staff required to provide for you? You made better you may benefit from programs to teach daily living skills to help improve independence. Crisis intervention services or plan. You would benefit from a plan to keep yourself safe. Individual, group, and family psychotherapy. You may benefit from psychotherapy to decrease mental health symptoms and develop healthy coping skills.
R4's Progress Notes dated [DATE] indicated he observed on the floor face down with an object around his neck.
The facility final State Report dated [DATE] states R4 was transported to local hospital for evaluation. The facility was informed R4 passed from his self inflicted injuries.
Fire Department Run sheet dated [DATE] documents onset 12:07PM. Run sheet documents intubation attempted but unsuccessful due to airway obstruction and tracheal trauma. R4 transported to closest facility.
Hospital records states admitted [DATE] after hanging D/C [DATE].
The death certificate was requested on [DATE] and [DATE]. Cause of Death is pending.
The facility Safety and Supervision of residents policy dated [DATE] states safety risk and environmental hazards are identified on an ongoing basis. Our resident oriented approach to safety addresses safety and accident hazards for individual residents. The facility oriented and resident oriented approaches to safety are used together to implement systems approach to safety which considers the hazards identified in the environment and individual risk factors and then adjust interventions accordingly.
The Immediate Jeopardy that began on 02.29.24 was removed 03.29.24 when the facility took the following actions to remove the immediacy.
R4 No longer resides in the facility.
Education was initiated on [DATE] by the Administrator, DON, ADON, and Social Service Director and completed on [DATE]. Education consisted of suicide risk assessment, notifying the physician of any change in condition, a residents score moderate or greater than moderate on the suicide risk assessment, the social service department will create a safety plan with the resident. The resident's plan of care will be updated, and the resident will be contracted to safety. The PRSD and APRSD will create a monitoring schedule and the nursing, activity, and social service department will be in-serviced on a monitoring schedule for the residents. If the resident is noted to have SI (Suicidal Ideations) their physician will be notified, and an order will be obtained to transport them to the local hospital. Staff educated on residents with a history of SI. Residents will attend assigned groups and if refuse MD and family will be notified.
A. Completion of the suicide risk assessment.
B. If a resident scores moderate or greater than moderate on the suicide risk assessment the resident will be presented a safety contract. If the resident refuse to contract to safety, the resident will be transported to the local hospital for a psychiatric evaluation.
C. If the resident has a contract to safety, the resident plan of care will bed updated and the resident will be placed on monitoring: 15 minute check, then will gradually move to 30 minutes checks, to hour checks until the resident has been deemed able to move off of monitoring by the IDT (Interdisciplinary Team).
D. Notifying the physician of any changes in resident condition/mood and if the resident trigger for an alteration in mood based on the PHQ9.
E. If the resident is noted to have SI, the resident's physician will be made aware and the resident will be transported to the local hospital for evaluation.
F. The resident will be encouraged to attend assigned groups and if the resident decline, the physician and family will be made aware and interventions and incentives will be put into place to encourage the resident to attend scheduled groups.
All Staff (Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director, receptionist, dietary aide, Cooks, housekeepers, social service case manager, Social Service Aides, restorative aides, C.N.As, RNs, LPN, activity aides, Laundry aides), including those off duty ( receptionist, Social Service Case Managers, social service assistants, housekeepers, Laundry aides, RNs, LPNs, dietary aides, and cooks) were educated via phone with the same training as the staff educated in person. However, the staff who received the in-service over the phone were notified that they will also be required to attend an in-person training before the beginning of the next shift worked. Upon completion of this in-person training, staff will sign education sheets. Administrator and Social service director will complete weekly spot checks to ensure the facility staff is knowledgeable the informed content: i.e., who are the residents at risk for SI, has there been any mood changes in the resident, was the psychiatrist made aware of the change in mood, does the resident attend group and if not was there interventions in place for refusals. The in-service date of completion is [DATE].
a. Upon admission, a suicide risk assessment will be completed. If a resident scores moderate or greater than moderate on the suicide risk assessment, the social service department will create a safety plan with the resident. The resident's plan of care will be updated, and the resident will be contracted to safety. The PRSD and APRSD will create a monitoring schedule and the nursing, activity, and social service department will be in-serviced on a monitoring schedule for the residents. If the resident is noted to have SI their physician will be notified, and an order will be obtained to transport them to the local hospital.
Prevention of self-harm items:
- Upon admission/readmission residents' belongings will be checked for any self-harm items. i.e.- belts, razors, knives, guns, sharps, and any items that states to keep out of reach from children.
- Searches will be conducted before and after family/friend visits.
- Visitors brining in items will be asked to keep their personal belongings in the car and any items brought into the facility will be check for items of self-harm that places the resident at risk for self-harm.
- Residents will have random room searches to monitor the accessibility of self-harm items.
- Residents will be thoroughly search when they return from out of pass.
B. The facility will ensure residents with history of suicidal ideations are safe by preventing residents from having access to items of self-harm i.e. knife on meal trays, belts, wire hangers, chemicals, items labeled keep out of reach of children.
c. The facility will ensure frequent and consistent rounding is conducted to monitor residents' whereabouts.
d. Upon admission/readmission residents' belongings will be checked for any self-harm items. i.e.- belts, razors, knives, guns, sharps, and any items that states to keep out of reach from children.
e. Searches will be conducted before and after family/friend visits.
f. Visitors brining in items will be asked to keep their personal belongings in the car and any items brought into the facility will be check for items of self-harm that places the resident at risk for self-harm.
g. Residents will have random room searches to monitor the accessibility of self-harm items.
h. Residents will be thoroughly search when they return from out of pass.
- The facility will establish a therapeutic relationship with the resident.
- The facility will monitor for passive statements of wanting to harm them self i.e. I wish I was dead or I'd be better off dead.
- The facility will identify characteristics or behaviors pertaining to suicide ideations.
- The facility assesses for early signs of distress or anxiety and investigates the possible causes.
- The facility staff will assess suicidal intent on a scale of 0 to 10 or by asking the resident directly if they are thinking of harming themselves or has a plan or means to do so.
- The facility will place the resident on 1:1s and notify the psychiatrist and family if the resident is unable to contract to safety and the will then obtain an order to petition the resident out for psychiatric services.
i. The facility will notify the psychiatric MD of mood changes
j. The facility will ensure all staff are aware of a resident with a history of suicidal ideation.
Ongoing education will be provided to all staff on monitoring, preventing residents from having access to items of self-harm, notifying the psychiatrist of any mood changes, and ensuring all staff are aware of a resident who has a history of suicidal ideations. residents at risk for suicide attempts. All staff including Nursing, Certified Nursing Assistants, Housekeepers, Dietary, Activities, Business Office, Admissions, Human Resources, and Social Services. Ongoing education will be provided during the new hire orientation, re-education during all staff meetings for three quarters, and added to the yearly competency program and will be implemented by the PRSD.
On [DATE] the social service staff updated all residents in house suicide with risk assessment. Risk assessments were completed on [DATE].
On [DATE] the social service staff updated all residents' suicide risk care plans with interventions Care plan updates were completed on [DATE].
Facility staff members were re-serviced on residents at risk for suicidal ideations on [DATE]. Staff knowledge will be assessed by random knowledge-based spot checks which will be conducted by the Administrator, PRSD, and APRSD. Any employee who was not able to be in-serviced will be mandated before working their next shift.
No policy changes have been made to the change in condition policies.
The Medical Director was made aware of the IJ [DATE]. On [DATE] the Medical Director reviewed and approved the facilities plan to prevent any recurrence of suicide in the facility.
- The facility will establish a therapeutic relationship with the resident.
- The facility will monitor for passive statements of wanting to harm them self i.e. I wish I was dead or I'd be better off dead.
- The facility will identify characteristics or behaviors pertaining to suicide ideations.
- The facility assesses for early signs of distress or anxiety and investigates the possible causes.
- The facility staff will assess suicidal intent on a scale of 0 to 10 or by asking the resident directly if they are thinking of harming themselves or has a plan or means to do so.
- The facility will place the resident on 1:1s and notify the psychiatrist and family if the resident is unable to contract to safety and the will then obtain an order to petition the resident out for psychiatric services.
Audits to be conducted include did the resident with a history of SI have access to items to self-harm, is there a plan to monitor the resident's whereabouts frequently in place, was the psychiatrist notified of any mood changes, Did the facility staff know the resident who is at risk for SI. Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director. This committee will determine if the audits continue after three months.
II. Based on interviews and records reviewed the facility failed to prevent the use of illicit drug in the facility. This affected two of three residents (R10, R11) reviewed for safety and supervision. This failure resulted in R10 with a history of substance abuse being found unresponsive at the bedside without respiration or pulse on [DATE] at approximately 8:00am. R10 death certificate documented cause of death as Fentanyl Acetyl Fentanyl and 4-ANPP (Despropionol Fentanyl)) toxicity.
The Immediate Jeopardy began on [DATE]. V12 and V13 (Co-Administrators) were notified on [DATE] at 09:09AM of the Immediate Jeopardy. The surveyor confirmed by observation, interview, and record review that the immediate jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
Findings Include:
1. R10, age [AGE], with diagnosis including but not limited to Viral Hepatitis C, Opiod Abuse ([DATE]), and Altered Mental Status. R10 was assessed on [DATE] to have a BIMS (Brief Interview of Mental Status) of 6 indicating R10 has severe cognitive impairment. R10 was initially admitted to the facility on [DATE] with a history of substance abuse.
Progress Notes dated [DATE] states R10 observed unconscious with respiratory distress while in bed. Sternal rub performed; resident difficult to arouse and not responding to stimuli. Writer administered PRN (As Needed) Narcan. The resident became alert and responsive but remained in a mentally altered state. Vitals: T-135/84, P-110, T-98.3F, RR-24, 02 sat (oxygen saturation) 95% via nasal cannula 2 L/min (Liters per minute). Resident sent to Hospital for evaluation via 911. Progress notes dated [DATE] document R10 in his bed at 3:05AM.
On [DATE] at 11:03AM, V34, Registered Nurse, said On ([DATE]), I stopped at (R10)'s room and (R10) was in the bed. I was checking him for breathing or a sign that he is alive. (R10) had labored breathing. I haven't seen too many patients with overdose or using heroine. I was checking (R10)'s vitals and then thought to check the chart and saw his diagnosis of history of drug use. I saw (R10) had an order for Narcan and I administered it. V34 said after administering the Narcan R10 came right out.
On [DATE] at 11:42AM, V41, Licensed practical Nurse (LPN), said On ([DATE]) between 7:30AM and 7:45AM, not after 8:00AM, I saw (R10) was unresponsive and I called for a code blue. I had not done vitals on him prior to this. V41 said R10 was newly moved to her unit. V41 said I found him unresponsive about an hour or little over an hour after I last saw him. V41 said R10 was in his bed when she saw him unresponsive. V41 said I tried calling his name and he was not waking up. I applied the pulse ox (oximeter) device and did not get a reading, I could not feel a pulse and was not able to get a blood pressure. I had heard that (R10) went to the hospital before he came to my unit, but they said his drug test was clean. I was not aware they had given him Narcan in the past. I am not aware of any resident having had drugs or contraband in the facility.
On [DATE] at 2:14PM V30, CNA, said I was here on ([DATE]) and ([DATE]) when (R10) had an unresponsive episodes. I was not assigned to (R10) on ([DATE]), I don't know who had him. At the start of the shift, I saw (R10) in his room and he spoke to me. This was sometime after 7:00AM and breakfast trays had not been passed.
On [DATE] at 2:25PM, V37, CNA, said If someone has a drug use history or recent finding the nurses will let us know to keep a close eye on them. I was not here on ([DATE]), I don't know who worked (R10).
On [DATE] at 2:56PM, V38, CNA, said she was not assigned to R10 on [DATE]. V38 said on [DATE] she was not aware R10 was being sent to the hospital. V38 said she was retuning from break and saw R10 as the ambulance was taking him out.
On [DATE] at 10:20PM, V17, CNA, said I had no interaction with (R10) on ([DATE]). V17 said V30 was assigned to R10 on [DATE]. V17 said I didn't see (R10) before the code blue was called. V17 said the last time she worked with R10 was on [DATE] and he was not on hourly rounding. V17 said R10 did not leave the facility or go outside. The surveyor asked V17 if she was made aware that R10 had been to the hospital on [DATE] with suspicion of drug use. V17 said [TRUNCATED]
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0740
(Tag F0740)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to develop interventions for one resident (R4) with a history of su...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to develop interventions for one resident (R4) with a history of suicide ideation with a plan for skill groups, including suicide prevention group, and failed to provide therapeutic programming. The facility failed to develop a plan for check in to assess daily mood or notify the attending psychiatrist of R4's change in mood which documents feeling down, depressed, or hopeless nearly every day. This failure resulted in R4 found unresponsive hanging from a towel rack in his bathroom. This failure affected 1 of 3 residents reviewed. R4 was pronounced dead in the hospital on 3/5/24.
The Immediate Jeopardy began on 2/29/24 V12 and V13 (both Administrator) was notified on 3/21/24 at 10:54AM of the Immediate Jeopardy. The facility presented an initial removal plan on 3/21/24. The plan was accepted, and 04/03/29 the surveyor conducted an onsite observation, record reviews, and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on 3/29/24. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation
The findings include:
R4 with diagnosis including, but not limited to Borderline Personality Disorder, Spondylosis with Radiculopathy, Schizoaffect Disorder, Major Depressive Disorder, Anxiety Disorder, Restless Leg Syndrome, Suicidal Ideations, and Bipolar Disorder, Current Episode Mixed, Severe without Psychotic Features. R4 was admitted to the facility on [DATE]. R4 was assessed on 2/22/24 to have a BIMS (Brief Interview of Mental Status) of 15 indicating R4 is cognitively intact.
R4's medication administration record dated 2/1 through 2/29/24 includes behavior monitoring every shift with documentation stating the letters NA on 2/28/24 on evening and night shifts. (The two shifts prior to R4 being found.)
On 3/8/24 at 10:25AM V14, Licensed Practical Nurse (LPN), said I saw a belt around R4's neck. (R4) was purple. It looked like one part of the belt was on the towel rack tied in a knot. V14 said 911 took R4 to the hospital. V14 said regarding her charting in the Medication Administration Record (MAR) she charted NA because NA and none basically stand for the same thing.
On 3/14/24 at 12:31 V10, Director of Nursing, said I am not sure what NA means on the MAR. At 12:46PM, V10 said none and nonapplicable are not the same. V10 said NA means that situation does not apply, we should say none not NA.
On 3/8/24 at 10:49AM V6, Psychiatric Rehab Services Counselor, said R4 was calm and there was nothing out of the ordinary. V6 said R4 said he had history of being homeless. V6 said R4 said he planned to be here short term. V6 said R4 had no suicide thoughts. V6 said I did 1:1 session on (2/28/24), the day before the incident, because he was in cigarette room and so was I. V6 said R4 was in Symptom and Behavior management group because of his history with suicide. V6 said I got him to sign the safety contract for suicide. I believe (R4) was hospitalized for suicide attempt and depression. V6 said the information is in the referral packet. V6 said I don't remember his method for attempting.
On 3/8/24 at 1:25PM, V17, Certified Nursing Assistant (CNA) said when she found out about R4, she thought that was crazy. V17 said this was weird that they said R4 tried to kill himself. V17 said I never got that vibe. I am not sure if he had a history of suicide. If I had known, I may have checked on him more often.
On 3/8/24 at 2:04PM, V18, CNA, said some residents are at more risk for suicide. V18 said no one was on suicide risk watch on 2/29/24 on the second floor.
On 3/8/24 at 2:19PM V10, Director of Nursing, said on 2/29/24 V15 knocked on her office door and told her R4 was on the floor. V10 said I went to (R4)'s room and I moved the room door a little, his legs were blocking the door. When I got in the room, I saw an object on (R4)'s neck. I untied it, a belt, it was around (R4)'s neck and the other end was on the bar. V10 said R4 was bluish/purplish. V10 said the towel bar stayed attached to the wall, there were 2 knots on the towel bar. R4 was face down. R4 was dressed. V10 said there was blood on the floor, it came from the side of R4's head. V10 said there is only one entrance to the room. V10 said I don't know where R4 got the belt from. V10 said the belt was black or blue. V10 said the police took the belt.
On 3/14/23 at 10:04AM, V4, Psychiatric Rehab Services Director, said social serviced does a suicide risk assessment and reviews the admission packet. V4 said the purpose of the assessments is to determine what the patient needs are. V4 said the PASRR is done at the hospital before they are admitted to the facility. V4 said We use the section of what the patient will benefit from to help determine the type of groups they need. Any abnormal findings on the PHQ9 (mood indicators) requires updates to the care plan and possibly new groups. We give the Director of Nursing, Floor Nurse, and/or MDS (Minimum Data Set) nurse the results if any are abnormal findings. V4 said the Care plan should be individualized for each resident. V4 said R4 was on hourly checks, from when he first got here. V4 said based on R4's history he would not have been allowed a belt. V4 said R4 would not have been able to keep his phone and laptop chargers. V4 said I don't know where he got the belt from.
On 3/14/24 at 12:28PM, V4 said The nurse observation sheet is stopped once the patient is stable. We meet twice a day, morning (10:00AM) and afternoon (3:00PM) to discuss if they should continue or are stable. The surveyor asked V4 why the observation dated 2/28/24 is not completed for night shift and evening. V4 said I don't know. V4 said there is no documentation to say when to stop the observations. V4 said R4 was in Symptom and Behavior Management group. V4 said if the resident has suicide ideation or history of suicide attempts, they will be placed in Suicide Prevention group. V4 said if a resident does not attend group they will get a 1:1 session. V4 said the group topics are not always discussed the same as during a 1:1 session. V4 a reviewed PASRR with the surveyor. V4 said R4 should be in Group for management and monitoring medication. Development, maintenance, and consistent implementation across settings of those programs designed to teach individuals daily living skills necessary to become more independent and self determining including but not limited to grooming personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of the living environment. You may benefit from programs to teach daily living skills to help improve independence. Crisis intervention services or plan. You would benefit from a plan to keep yourself safe. Individual, group, psychotherapy to develop healthy coping skills. Psychiatrist and psychologist services. V4 said the Psychologist comes every 2 weeks and the psychiatrist comes once a week. V4 said the psychologist had not seen R4. V4 said R4 should be in Symptom and Behavior Management, Traditional Living, and Self Maintenance Groups. V4 said R4 should have been on 3 programs. At 1:26 V4 provided group Confirmation Form for R4. V4 said R4 should have received more groups. Reviewed R4's Care plan with V4, V4 said the care plan should state the frequency not just # for days to attend groups.
On 3/14/24 at 1:30PM, V12, Administrator, said Moderate risk is more severe, it does not mean the same as minimal risk. V12 reviewed R4's PASSR with the surveyor. V12 said it says no recommendation for specialized services. V12 said staff need to make frequent rounds, checking, any signs or symptoms present with any behaviors staff notify nurse and social services. V12 said R4's hospital plan for suicide was to cut him self or walk into traffic. V12 said staff should be aware. V12 said if R4 was being supervised they should know if he had a belt.
On 3/14/24 at 2:35PM, V39, MDS Nurse, said social services does not communicate with me what they do. V39 said I don't check their sections, sections C, D, and E, only that is gets completed. Each department is responsible for their own assessments and careplanning.
On 3/15/24 at 11:50AM, V9, Psychiatrist, said R4's symptoms for impulsive and racing thoughts are part of his diagnosis of Borderline Personality Disorder (BPD) and Bipolar diagnosis. V9 said Bipolar is usually treated with medications and BPD is treated with talking therapy at least monthly. V9 said R4 can't be held accountable for what he signed on a behavior contract. V9 said the contracts are only a tool used to help to establish report. V9 said the contracts are not shown to prevent self-harm. V9 reviewed R4's PHQ-9 on his computer. VI9 said I don't know how accurate (R4)'s answers are. V9 explained with BPD they may have negative response, maybe they just woke up or got upset about something; versus when they are in a good mood, all answers may be positive. V9 said I would like to have seen a follow up to this one (R4's PHQ-9). V9 said on hospital assessment R4 admitted having chronic Suicide Ideation and racing thoughts. V9 said initially, what got R4 hospitalized was R4 said his plan was to stab himself or walk in front of traffic.
On 3/17/24 at 10:29AM V25, Assistant Director of Social Services, said the Licensed Social Worker did not see R4 while he was in the facility.
R4's Preadmission Screening and Resident Review (PASRR) dated 2/12/24 states: mental health disorders: Bipolar disorder. mental health symptoms: suicidal talk. Pharmacotherapy including administration and monitoring of the effectiveness and side effects of medications which have been prescribed to change inappropriate behavior or to alter manifestations of psychiatric illness. You may benefit from programs to teach daily living skills to help improve independence. Crisis interventions or plan. You would benefit from a plan to keep yourself safe. You may benefit from psychotherapy to decrease mental health symptoms and develop healthy coping skills. You are currently in the hospital because you had thoughts of ending your own life. You appear overly tearful to others. You have anxious thoughts.
Nursing Observation Sheet dated 2/28/24 includes documentation from 8:00AM- 11:00AM. There is no documentation prior to that. There is no documentation in the progress notes or care plan to explain the discontinuation of the observation.
R4's Progress note dated 2/15/24 identified as welcome note resident has a BIMS of 15. Per record, resident does have racing thoughts and has sign symptoms of mood distress. Resident has a history of suicide ideation with a plan. Resident was homeless prior to going to the emergency room for suicide ideation with a plan. Per record, resident has auditory hallucinations.
R4's Screening assessment for evaluation self harm suicide risk dated 2/16/2024 past history of suicidal ideations. History of psychiatric mental health problems, major depression and or personality disorder diagnosis significant severe problems. Category score= 11 score indicates 6-15 moderate risk. Her hospital referral packet, resident has a history of suicide ideation but denies at this time.
R4's Belongings inventory dated 2/16/2024 has nothing written for belts, scarves, gloves, mittens, etc. One cell phone with charger and one laptop with charger identified in R4's possession.
R4's mood assessment dated [DATE] states R4 reported feeling down, depressed, or hopeless, nearly every day. Trouble sleeping nearly every day. Feeling bad about himself or that you are a failure or have let yourself or your family down several days.
The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual states the intent of Mood Assessment. The items in this section address mood distress and social isolation. Mood distress is a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. Social isolation refers to an actual or perceived lack of contact with other people and tends to increase with age. It is a risk factor for physical and mental illness, is a predictor of mortality, and is important to assess in order to identify engagement strategies.
Progress note dated 2/28/24 state social service met with R4 to check on his well-being. There is no notation that resident was asked about thoughts of harming himself or if he had a plan to harm himself. A second progress note on 2/28/24 titled skills training participation record states symptoms and behavior management. Willingness motivation to engage in session good compliance progress towards care plan objectives: good. Movement towards positive stages of change: good. Acquiring enhanced life skills: good. Comments: understanding our diagnosis. No mention of questions related to suicide ideation or suicide plan. This is the only skills training participation record found for R4 from 2/15/24 through 2/28/24.
The facility presented two handwritten group therapy progress notes for R4, the first is dated 2/16/2024. Group goals: confronting fears and anxieties. Focus of session: symptom and behavior management. Plan: discuss how to manage stress. There is no discussion of suicide prevention. Group therapy progress note dated 2/20/2024. Discussing techniques on how to manage stress. Plan: enhancing social skills. There is no discussion of suicide prevention.
R4's Care plan initiated 2/16/2024 includes his history of self-harm ideation thoughts and or behavior. Interventions are all dated 2/16/2024. Care plan initiated 2/16/2024 states I am in need of specialized rehabilitation, support, counseling and or psychotherapy services secondary to a mental illness diagnosis, depression diagnosis. All interventions are dated 2/16/2024. Care plan includes demonstrates a pattern of situational and or coping problems in areas such as psychosocial well-being, mood state and or behavior symptoms. This appears related to symptoms are manifested by mood distress, anger, anxiety, sadness, and insomnia. Interventions are dated 2/16/2024. There were no updates or additional interventions added after the completion of the mood assessment completed on 2/22/24.
During the survey the facility provided a list of residents that have a history of suicide ideation slash suicide history (SI/SH) dated 3/1/2024. There are 52 residents named on this list.
The facility policy and procedure for behavior management dated 1/1/2021 states document evaluation of the presence of behavioral symptoms or the potential for behavioral symptoms in the residence medical record and care plan. Document the initiation of behavioral interventions and mental health professional visits in the residence medical record and care plan. Document education provided to resident and or family responsible party. Document nonpharmacological interventions attempted and resident response. Document notification of physician and family member of actions taken to reduce or prevent behaviors.
The Immediate Jeopardy that began on 02/29/24 was removed 03/29/24 when the facility took the following actions to remove the immediacy.
R4 no longer resides in the facility.
Education initiated on 3/1/2024 by the Administrator, DON, ADON, and Social Service Director completed on 3/1/2023.
All Staff (Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director, receptionist, dietary aide, Cooks, housekeepers, social service case manager, Social Service Aides, restorative aides, C.N.As, RNs, LPN, activity aides, Laundry aides), including those off duty ( receptionist, Social Service Case Managers, social service assistants, housekeepers, Laundry aides, RNs, LPNs, dietary aides, and cooks) was educated via phone with the same training as the staff educated in person, however, the staff who received the in-service over the phone were notified that they will also be required to attend an in-person training before the beginning of the next shift worked. Upon completion of this in-person training, staff will sign education sheets. Education Content: staff to ensure residents are placed in therapeutic group programming that was identified on the PASSR screener. Notifying the psychiatrist of any mood changes, and ensuring residents attend skilled group programming indicated or recommended. Ensuring skilled group documentation consists of the frequency/title of the group for all group programming. Make sure that staff documents any refusals of the skilled group and that there are interventions in place to address the refusals. The Administrator, PRSD, and APRSD will conduct weekly knowledge base spot checks to assess the staff's knowledge of the topics for three quarters.
The in-service date of completion is 3/21/2024.
Topic of education:
- Staff to ensure residents are placed in therapeutic group programming that is identified on PASRR Screener.
- Notify psychiatrist of any mood changes based on staff assessment or PHQ9.
- Ensure residents attend skilled group programming indicated or recommended.
- Ensure skilled group documentation is completed and names the topic and frequency of the group programming.
- Staff to ensure they document the any refusals of skilled group and utilize interventions to address refusals.
a. Upon admission, a suicide risk assessment will be completed. If a residents score moderate or greater than moderate on the suicide risk assessment, the social service department will create a safety plan with the resident. The president's plan of care will be updated, and the resident will be contracted to safety. The PRSD and APRSD will assign the resident to a therapeutic. Program based on the resident's assessment. The psychiatrist will be updated on any resident presenting with mood changes identified by staff or based on the PHQ9 in section D of the MDS. The resident will be placed on frequent monitoring i.e. residents will gradually move through the behavior monitoring bases on the severity of the behaviors: 1:1, 15 minute checks, 30 minute checks, 1 hour checks, 2 hour checks and then will be discharged from behavior monitoring once the IDT determination. and asked to sign for safety. An order will be obtained from the psychiatrist to transport the resident to the local hospital for a psychiatric evaluation.
b. The facility social service team will assess admitting residents' PASSR screen and provide therapeutic programming based PASSR recommendations.
c. When mood changes are observed the PRSD/APRSD, PRSC, DON, and ADON will immediately address residents' mood changes by notifying the psychiatrist.
d. The DON, ADON, RN, or LPN will notify the psychiatrist of any mood changes when identified.
e. The PRSD, APRSD, and PRSC will ensure residents attend the skilled group programs indicated/recommended. i.e. Crisis Prevention Intervention, symptom and behavior management, Transitional living, Anger Management and Moving forward programming.
f. The PRSD, APRSD, and PRSC will document the frequency and title of groups and programs including 1:1s.
g. The PRSD, APRSD, and PRSC will ensure residents who refuse groups attend scheduled groups rescheduling the resident's group for a time that better suits the resident and or placing the resident into an incentive program to motivate them to attend the group.
h. Group determination will be based on the resident's admission packet, PASSR screen, resident diagnosis, and behaviors.
i. The facility will complete daily check-ins to assess for any mood, thoughts, and behavioral changes.
Ongoing education will be provided to all staff on ensuring therapeutic programming as assessed on the PASSR screen indicates, identify and notify psychiatrist of any mood changes. Provide skilled group programs as indicated and recommended. Ensure groups, programming, and 1:1s frequency and title are documented. Ensure residents who refuse groups attend scheduled groups. of All staff including Nursing, Certified Nursing Assistants, Housekeepers, Dietary, Activities, Business Office, Admissions, Human Resources, and Social Services.
No policy changes have been made to the change in condition policies.
Ongoing education will be provided during the new hire orientation, re-education during all staff meetings for three quarters, and added to the yearly competency program and will be implemented by the PRSD.
The Medical Director was made aware of the IJ on 3/21/2024 and approved the abatement plan on 3/22/2023. On 3/1/2024, the Medical Director reviewed and approved the facilities plan to prevent any further suicides in the facility.
- Staff to ensure residents are placed in therapeutic group programming that is identified on PASRR Screener.
- Notify psychiatrist of any mood changes based on staff assessment or PHQ9.
- Ensure residents attend skilled group programming indicated or recommended.
- Ensure skilled group documentation is completed and names the topic and frequency of the group programming.
- Staff to ensure they document the any refusals of skilled group and utilize interventions to address refusals.
Weekly audit consists of : was the resident therapeutic programming assessed based on the PASSR screen, did the facility complete a daily check-in to assess the resident's mood, did the facility notify the psychiatrist of any mood changes, did the resident attend a skilled group that's indicated or recommended, does group documentation reflect the frequency and title of the group program or 1:1, are interventions in place to address the refusal of groups.
Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director. This committee will determine if the audits continue after three months.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to provide one resident (R14) with clean and untorn socks at his request. This failure affected one of three residents reviewed for resident righ...
Read full inspector narrative →
Based on observation and interview the facility failed to provide one resident (R14) with clean and untorn socks at his request. This failure affected one of three residents reviewed for resident rights in the sample.
The findings include:
R14's diagnosis include but are not limited to Unspecified Dementia, Polyneuropathy, Right Leg Ulcerations, and Glaucoma.
On 4/4/24 at 10:00AM R14 observed in his room. There is a strong foul odor in the room coming from R14. R14 is wearing torn clothing and is unkempt. R14 is wearing hospital issued socks with torn grips, feet exposed, soil covered, dirty, torn at heel and various areas on the soul. R14 said I've had these socks since October. I want new socks, but they won't give me socks, I asked them.
On 4/4/24 at 10:12AM the surveyor asked V1, Licensed Practical Nurse, if she has seen the condition of R14's socks, with holes, torn, missing bottoms, and dirty. V1 said I was going to get him socks yesterday, but there weren't any. I did not get him any.
On 4/4/24 at 11:46AM V3, Certified Nursing Assistant, said We need to find (R14) bigger socks they in laundry. I haven't given (R14) socks in a long time, I can't remember how long its been. V3 said she last worked with R14 was maybe a month ago.
Jan 2024
7 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision, assistive devices and proper transfer...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision, assistive devices and proper transfer technique to prevent a fall of 1 (R1) of 3 residents reviewed for accident/hazards in the sample. This failure resulted in R1 being emergently transferred to the hospital after a mechanical fall during transfer from bed to chair causing excruciating pain and femoral fracture.
Findings include:
R1 is a [AGE] year old resident with diagnosis of spinal stenosis, lack of coordination, heart failure, end stage renal disease, absence of left leg above knee amputation, absence of right leg below knee amputation, and femur fracture.
MDS (Minimum Data Set) dated 11/1/2023 assessed resident's ability to perform chair/bed-to-chair transfer and states, The ability to transfer to and from a bed to a chair (or wheelchair). Not attempted due to medical condition or safety concern.
Records showed:
On 10/18/23 at 1:14 PM V27 (LPN/Licensed Practical Nurse) wrote, Patient being sent to hospital for x-rays to rule out possible injury for right hip/leg that occurred during transfer from bed to specialty chair. Calls to interview V27 went unanswered and V27 is no longer an employee of the facility.
V2 (Director of Nursing) interview with V11 (CNA/Certified Nurse's Aide) Spoke to (V11) and she stated she transferred (R1) with a bear hug. The resident was complaining of pain prior to transfer. She stated R1 did not hit her leg on the chair nor bed.
Efforts to contact V11 (CNA) on 1/3/24 and 1/4/24 were left unanswered and V11 is no longer an employee of the facility.
Care plan dated 10/13/23 states, Resident is at risk for falls related to falls. Goal: Will have no serious fall related injury through next review. Interventions: Be sure call light is within reach and encourage the resident to use it for assistance as needed. Staff to respond promptly to all requests for assistance. Anticipate and meet individual needs of the resident. Complete the Fall Risk Review per the facility protocol.
A facility fall protocol policy was requested but was never provided during the course of the survey.
R1's fall risk assessment dated [DATE] assessed by V31 (LPN) showed R1 to be a moderate risk for falls.
On 1/8/24 at 11:30 AM, V3 (Assistant Director of Nurses) stated, I remember this resident, but she was not here long. She was being transferred by this CNA (V11) and this CNA wasn't here long either. She was being transferred from bed to chair to get to dialysis and I think she may have fallen but I'm not sure how she got the fracture. Surveyor asked how this resident should have been assisted from bed to chair, V3 stated that the resident required a mechanical lift, so the way this aide transferred her was inappropriate to transfer resident in a bear hug method.
On 10/18/23 at 12:20, V33 (Nurse Practitioner) noted, Nurse approached writer stating patient was being transferred from bed to wheelchair to go to dialysis when patient stated she heard a pop in her right hip and patient screaming in excruciating pain. Patient seen reclined in geriatric chair and crying in pain I heard a pop in my hip, I know it ' s broken. Upon palpation, right hip deformity noted, unclear if patient position in wheelchair/ or due to injury. Initially stat x-ray ordered of right hip, but radiology could not give a timeframe of when x-ray would be completed. Order given to send patient to hospital for further assessment.
On 10/19/23 at 8:20 PM, V34 (RN) noted, Writer called hospital; resident to be admitted with diagnosis of femoral fracture, hepatic lesion, and pleural effusion.
Hospital records dated 10/18/23 authored by V72 (Emergency Department Doctor) reads, This is a [AGE] year old female patient on Eliquis (blood thinner), congestive heart failure with preserved ejection fraction, COPD on home oxygen 3 liters, hyperlipidemia, prior stroke, peripheral artery disease status post right BKA (Below the knee amputation) and left AKA (Above the Knee Amputation) presents to the emergency department today from dialysis center for severe pain and deformity of her right thigh. Patient in excruciating pain so it is somewhat difficult to get the full story of what happened. Apparently, she was being transferred from 1 bed to the dialysis when her right leg was injured. There was immediate deformity of the right femur and pain over the site with tenting of the skin. Patient denies change in temperature or color or paresthesia of the limb distal to the deformity. Patient ultimately was reduced at bedside with orthopedic surgery. Patient received pain dosages of ketamine and fentanyl and tolerated the procedure decently well. Vascular surgery consulted and will follow inpatient but no indication for heparinization at this time. Social work consult placed to assess for safety at nursing home given severe injury with unclear mechanism. Discussed with hospitalist for admission.
Surveyor asked facility for policies related to the safe transfer of residents from bed to chair and was provided an ADL (activities of daily living) policy that reads, Activities of daily living (ADLS) reads in part, Transfers (standing pivot). Apply gait belt per plan of care, position resident to assist with further transfer. Place hands correctly (Do not hold under the arms) Provide cues to resident to let them know what you are doing. Assist resident to stand, using appropriate body mechanics. Pivot resident to the chair or bed, then lower slowly asking them to reach back for the chair.
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
Based on interviews and record reviews the facility failed to follow their abuse policy and procedures by not ensuring a care plan was implemented for a resident when they were initially observed enga...
Read full inspector narrative →
Based on interviews and record reviews the facility failed to follow their abuse policy and procedures by not ensuring a care plan was implemented for a resident when they were initially observed engaging in verbally and physically aggressive behaviors. This failure applies to two of four residents (R11 and R12) reviewed for abuse.
Findings include:
Final Abuse Investigation Report dated 11/05/2023 documents on 11/05/2023 R12 reported that she and her roommate R11 were involved in a verbal disagreement and R11 threw a cup of liquid on her. R11 denied throwing the liquid on R12 and both residents were hospitalized for psychiatric evaluation.
R11's progress note dated 9/15/2023 documents she was observed presenting agitation with verbal aggression with obscene language. R11 was counseled on presenting social and verbal appropriate behavior. Resident was not receptive. Writer counseled the resident on presenting social and verbal appropriate behavior.
R11's progress note dated 9/23/2023 documents she was observed hitting another resident in the face. Per R11 she was in hallway and resident walked past and she called her a profane name and R11 hit her in the face. R11 was separated from peer and put on one-to-one monitoring. Police report filed.
R11's progress note dated 11/5/2023 documents she threw liquids in roommates face, R11 Immediately separated put on one-to-one monitoring and as needed medication was administered. Physician was notified and an order to send R11 to Local Hospital for evaluation was provided.
On 01/08/2024 at 12:28 PM V1 (Administrator) stated he is the abuse coordinator. V1 stated if a resident has known behaviors of aggression the facility tries to address it by care planning to address the behavior. V1 stated if residents are aggressive towards staff, it is possible, they would be aggressive towards other residents.
On 01/08/2024 from 1:08 PM - 1:55 PM V8 (Social Service Worker) stated before R11 became physically aggressive with R12 she had a few incidents of aggression.
R11's current care plan documents an abuse care plan was not initiated until 11/07/2023 and a care plan for aggressive behavior was not initiated until 12/01/2023.
The facility's Abuse Policy reviewed 01/09/2024 states: The facility desires to prevent abuse. This will be accomplished by a comprehensive quality management approach. Through the care planning process, staff will identify and problems, goals, and approaches, which would reduce the chances of abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to prevent the misappropriation and/or diversion of m...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to prevent the misappropriation and/or diversion of medications for two (R2, R17) of three residents reviewed for medication administration; and failed to follow their facility's ordering and receiving of medications policy. This failure resulted in R2's pain medication (ibuprofen) being reordered in excess with minimal documentation of medication being administered to R2; and failed to have both resident's (R2, R17) personal medication supply readily available upon request for administration on numerous occasions.
Findings include:
1. R2's electronic medical record indicated resident is a [AGE] year old male who admitted to facility on 11/07/2022 and has a past medical history not limited to: dementia with behavioral disturbance, hypertensive heart disease, anemia, polyneuropathy, cellulitis of bilateral lower extremities, peripheral vascular disease, glaucoma, and atherosclerosis.
On 01/02/2024 at 2:11 PM, R2 stated that one to two months ago, he had asked for his ibuprofen 800mg and saw that he had a full card of this medication available but a few days later, when he asked for another pill, he was told that he didn't have any tablets left on his card and staff would have to reorder this medication. R2 added that he had asked for an ibuprofen 800mg several times over the last few weeks but doesn't seem to have any of his own supply available and is given the facilities (house stock) medication. R2 then said that he can't understand why his personal medication supply is being reordered so frequently when he himself doesn't take this medication that often.
R2's active physician orders includes but not limited to: one ibuprofen 800 milligram (mg) tablet by mouth every twenty-four hours as needed for severe pain rated between five-eight.
R2's electronic medication administration records (MAR) indicated the following regarding his ibuprofen 800mg medication: January 2023 MAR indicated resident received this medication one time, February 2023 MAR indicated resident received this medication five times, March 2023 MAR indicated resident received this medication two times, April 2023 MAR indicated resident received this medication one time, May 2023 MAR indicated resident received this medication three times, June 2023 MAR indicated resident received this medication four times, July 2023 MAR indicated resident received this medication three times, August 2023 MAR indicated resident received this medication three times, September 2023 MAR indicated resident received this medication five times, and from October 2023 through current, it is not documented that resident was administered this medication during this time period.
R2's pharmacy medication audit log dated 01/10/2023 showed resident's ibuprofen 800mg was reordered in March, April, May, June, August, September, and October of 2023 and again in January 2024 and was dispensed on medication cards in increments of thirty (30) tablets that is inconsistent with the number of documented administrations.
On 01/04/2024 at 11:20 AM, V23 (Licensed Practical Nurse) said R2 has a pain medication order daily as needed that was last documented as being administered on 09/14/2023 at 08:53 AM. When asked to see R2's medication card for ibuprofen, V23 was unable to produce a med card then indicated it was last ordered, dispensed and received on 01/02/2024 and is most likely in the first floor pharmacy box. V23 added that nursing is never allowed to administer a resident's medications to another resident.
On 01/08/2024 at 2:54 PM, observed with V36 (Licensed Practical Nurse) that R2's ibuprofen 800mg tab medication card with dispensed date of 01/02/2024, to have one tablet missing. Reviewed and confirmed with V36 per R2's electronic medication administration record that R2 was last documented as receiving this medication on 09/19/2023 at 08:53 AM. When asked when the current missing tablet was administered and whether it was received by R2, V36 said I don't know because I wasn't here.
On 01/10/2024 at 1:43 PM, V3 (Assistant Director of Nursing) was asked why an as needed medication would be reordered frequently if the resident is rarely being administered this medication, why would the medication need to be reordered so often, V3 said sometimes the pharmacy sends a medication without the facility reordering it then said there would be no other reason for excessive reordering if the medication was not frequently being administered. When asked if there should then be a surplus of this medication available rather than none being available, V3 had no response. When R2's ibuprofen administration records and pharmacy reorder logs were reviewed by surveyor with V3, she was unsure as to why his medication would have been unavailable. V3 then added that her expectation is for nursing staff to document all medication administrations and if not documented, then it would be considered as not given and a medication error.
Ordering and Receiving Non-Controlled Medications From the Dispensing Pharmacy policy with effective date of 10/25/2014 reads in part: Policy: Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. Procedures: Reordering of medications is done in accordance with the order and delivery schedule developed by the pharmacy providers. Reorder medication four (4) days in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand.
R17 is a [AGE] year-old female who has resided at the facility since 2021, past medical history includes, but not limited to Nondisplaced transcondylar fracture of right humerus, subsequent encounter for fracture with routine healing, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, type 2 diabetes, Epilepsy unspecified, etc.
On 1/4/2024 at 10:30AM, R17 was observed in her room, awake and alert with some confusion, stated that she gets aspirin for headache, she got one yesterday. R17 was asked if she gets any other medication for pain and she said, I don't know.
Physician order summary showed the following active order for R17, Ibuprofen tablet 400 MG, give 1 tablet by mouth every 12 hours as needed for Pain, order date 10/17/2022.
Care plan dated 10/14/2022 R17 is at increased risk for alteration in pain/discomfort R/T DX of closed supracondylar FX of RT humerus s/p ORIF 10/14/22. Interventions include: Complete the Pain assessment upon Admission, Re-admission, Quarterly and PRN for new onset of pain, administer analgesic medication as ordered per plan of care, notify MD for any new resident complaints of pain and/or S/S of pain to obtain new order for medication regimen or break-through pain management, monitor for verbal and nonverbal expressions of pain, notify MD if interventions are not consistently effective.
On 1/3/2024 at 3:25PM, observed medication administration with V24 (LPN) for R17, V24 administered three medications to resident and stated that resident has an order for ibuprofen 400mg, she does not have it available, but she will go and pull from the emergency box. Resident stated that she has a headache and rated her pain as a 10 on a scale of 1 to 10. V24 did not come back with the Motrin until 4:20PM, surveyor did not observe V24 administer the medication.
Medication administration record (MAR) for the month of October 2023 shows that resident is on Ibuprofen 400mg to be given every 12 hours as needed, there was no signature indicating that the medication was administered to the resident the whole of October 2023. Review of pharmacy therapeutic report shows that the medication was dispensed in October 2023, has not been reordered until 1/3/2024. Resident is currently missing 3 tablets from the 30 tablets delivered to the facility on 1/3/2024, MAR for January 2024 does not have any documentation that the medication was given to the resident.
On 1/8/2024 at 2:43PM, V3(DON) was asked what happened to the three missing tablets from the bingo card if there is no signature in the MAR indicating that they were given to R17 and she said, I don't know.
Medication administration policy and procedure revised 1/1/2020, presented by V1 (Administrator) states its purpose are to ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Under procedures, the policy states in item 8. The individual administering the medication shall initial the resident's medication administration record (MAR) on the appropriate line and date for that specific day before administering the medication.
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 monitor and assess a resident's (R13) condition who was receiving b...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor and assess a resident's (R13) condition who was receiving blood thinner medication and had previous laceration; and failed to have an active care plan for a resident (R14) for diabetes care and act promptly to provide an intervention for a resident with low blood sugars. These failures involved two residents, R13 and R14. As a result, on 11/10/23 R13 was found lying in a moderate amount of blood in bed and sent to the hospital via 911 emergency. On 11/11/23 R14 was found lying on the floor unresponsive and sent out via 911 after paramedics administered a blood glucose check and which the result of was a hypoglycemic reading.
Findings include:
1. R13 is [AGE] years old and was originally admitted to the facility 6/1/22 and has diagnoses of dementia, history of falling and other mental health disorders. According to the electronic health record, and facility fall reports, R13 had a fall in the facility on 10/25/23. From the fall incident, R13 sustained a laceration to the scalp and was sent to the hospital for evaluation. Physician Order Sheet dated 11/1/23 included order written by the Nurse Practitioner to remove staples. Treatment Administration Record for November 2023 was reviewed and noted that the staple removal order was signed off by a nurse with no further notes or assessment on 11/2/23 at 12:40AM.
On 1/10/24 at 12:10PM V64 Nurse Practitioner explained that when staples are used in a scalp laceration, the purpose is just to hold the skin together to aid the process of healing. V64 went on to say, the scalp is very vascular and heals very quickly, so a laceration that was already treated and closed with staples would typically be healed in 3-4 days unless there was some type of complication such as an infection or reinjury to the site. Because this resident is actively taking a blood thinner medication, such as apixaban 5mg, they are at a higher risk of bleeding should an injury occur.
On 11/10/23 at 8:05AM, V51 LPN wrote a progress note stating Nurse was made aware by therapist that resident needed to be evaluated. Upon entering room resident noted with blood to head and side of face. Resident is alert and oriented x1 which is baseline. Denies pain. [range of motion within normal limits]. [Vital signs assessment] [blood pressure] 102/78, [pulse] 68, [temperature] 97.9 [degrees Fahrenheit] [oxygen saturation] 98% [on room air]. Nurse had staff remain with resident and called 911 for resident to be transported. Resident remains alert and responsive. [Neurological] checks initiated. Noted [within normal limits]. Fire Department on scene and care of resident is transferred. Nurse called the Doctor and made aware .
On 1/3/24 at 11:15AM V68 Fire Department was interviewed and said that when the paramedics arrived to the facility, R13 was in bed and one side of the body was covered in blood. V68 noted that there was also a pool of blood on the floor as well as the bed. Some of the blood was bright red, and some was darker and dried. V64 said, since some of the blood appeared to already be dry, it looked as if R13 had been in that state for a while.
On 1/4/24 at 10:57AM V51 LPN said, I worked 7am-3pm shift on 11/10/23 but earlier that morning, I called someone to let the facility know that I would be coming late. By the time I arrived which was about 8:00AM, the night shift nurse was already gone, and I wasn't able to get report from anyone. Although there was another nurse on the floor, they did not give me a report. When I came in, I didn't do rounds right away, because I went to acclimate myself to the census and residents on the floor. I was printing out my census when the therapist yelled out and I came. When I saw R13 they were lying in a moderate amount of blood. There was so much blood on the body, bed and floor, that I was afraid to touch them too much because I couldn't determine where the blood was coming from. I did a quick assessment asking questions and while R13 was alert, they were confused, didn't know what happened and didn't even know anything was wrong. When the fire department came and took over, I charted the incident in the progress notes.
On 1/4/24 at 1:10PM V69 CNA (Certified Nursing Assistant) said, they were caring for R13 during the night shift and early morning of 11/10/23. V69 said they left early that morning at 6:30AM however before they left, they completed rounds and gave incontinence care to R14 around 5:00AM. V69 said that just as they were completing their care for R13, the nurse on duty came into the room to give medications. V69 said that R13 was left in good condition at that time and did not return to the room before leaving for the day.
On 1/4/24 at 1:26PM V30 RN (Registered Nurse) said, I gave medication to R13 around 5:00AM on 11/10/23 right after V69 finished giving care. I didn't see anything out of the ordinary, R13 was calm and not behaving unusually. After I gave the medications, I didn't return to the room because I finished passing medications, charting, and waited for the morning nurse to come. I waited 30 minutes over to give report to the nurse, but they were not there before I left, so I wrote out a report and endorsed it to the other nurse on the floor.
Medication Administration Record dated 11/10/23 indicates that V30 administered 6am medications including insulin which was signed out at 5:05AM.
On 1/9/24 at 3:10PM V2 Director of Nursing said, they were not made aware of V51 indicating that they would be late, and they were also unaware that the CNA assigned to R13 left before the shift ended at 7am. V2 said that they expect the nursing staff to make rounds on residents prior to leaving and at the beginning of the shift. V2 said that they did not investigate this incident because they didn't feel as if it was needed. V2 did agree however, that staff should have made rounds on R13 from 5am to 8am.
On 1/8/24 at 3:00PM V3 ADON (Assistant Director of Nursing) said nurses and CNAs are expected to make rounds at least every two hours to check on the resident status and needs. V3 also said that the nurses should have been documenting and assessing the laceration with staples and if there is no documentation of the assessments, there is no definitive way to determine if these assessments were being completed.
Care Plan for R13 was reviewed and noted that the plan for falls included updated interventions that were placed 11/13/23.
Hospital records dated 11/10/23 indicated that when R13 arrived to the hospital, there was a blood clot over a preexisting head laceration with staples in place. R13 was treated with intravenous fluids due to dehydration related to blood loss and two additional staples were applied to the wound for closure.
No further documentation of the head laceration was provided by the facility.
2. R14 is [AGE] years old and was admitted to the facility 9/25/23 with diagnoses that included Chronic Obstructive Pulmonary Disorder, Hypertension, Type II Diabetes Mellitus and Kidney Disease and Substance Abuse. Nursing progress note written on 11/11/23 at 1:25AM stated Resident taken by 911 crew to hospital after a fall incident. No further documentation or assessment was noted in the Electronic Health Record regarding this concern.
V68 Fire Department was interviewed 1/3/24 at 11:05AM. V68 said, when his team of paramedics arrived on-scene, R14 was found unresponsive, breathing and lying on the floor. V68 said the nurse on duty refused to render care saying that they were not assigned to R14 and therefore not responsible for R14. V68 said that two facility staff were in the room on arrival, and they were not rendering care but told the paramedics that R14 may have been experiencing illicit drug overdose, as R14 had been previously treated for in the facility prior to this incident. V68 said they administered the antidote naloxone to R14; however, the condition was unchanged. After obtaining vitals and a blood glucose, R14's blood sugar measured 24mg/dl and paramedics administered 25 Grams of Dextrose intravenously. V68 said R14 was arousable after the dextrose, and they transported R14 to the hospital for evaluation. Fire Department Run-sheet was reviewed during this survey which corroborated this interview. V68 named the caller who was later identified by Surveyor to be V71 RN.
V71 RN was listed as the nurse on duty 11/10/23 for the 11PM-7AM shift and was unreachable during this Survey. On 1/8/24 at 3:00PM V3 Assistant Director of Nursing said, I was made aware of the situation when R14 was sent to the hospital. If I remember correctly, the Director of Nursing came in that night due to a call off. I am not sure why the nurses did not assess R14 prior to or after calling 911. I would have expected them to at minimum take vital signs such as blood pressure and blood glucose if the resident was taking insulin. The nurses have medications and equipment to treat residents for hypoglycemia in the facility if needed. If the resident is unconscious or lethargic, the nurses can administer glucagon medication to improve the blood sugar immediately. This medication is specific to the resident meaning it is ordered specifically for each resident and should be available to nursing staff, should be signed out on the Medication Administration Record and reordered after administration.
Medication Administration Record for November 2023 was reviewed and included an order: Glucagon Emergency Injection Kit. Inject as per sliding scale: if 0-60 if less than 60 and unable to swallow give 1mg (milligram) subcutaneous and repeat in 45 minutes if [less] than 60 call [Medical Doctor], Intramuscularly as needed for if blood sugar [less than] 60 Start Date 11/09/2023.
On 1/9/24 at 3:00PM, V2 Director of Nursing said that they were notified around 12:30am that the unit R14 was placed on was short a nurse. V2 said that the shift started at 11:00pm and two nurses should have been on the unit at that time, however the nurse that did not come in was assigned to R14. V2 said that they were informed about R14's condition of being found unresponsive and by the time they arrived at the facility, around 2am, R14 had already transferred to the hospital. V2 said that no further action was taken, and no investigation was completed. When the Medication Administration Record was reviewed, it was noted that evening medications were not signed out for 4PM and 8PM. V2 said, that it was difficult to determine what nurse was assigned to R14 and that since they did not complete an investigation regarding R14's state prior to being found unresponsive and since the medications were not signed out, including insulin, V2 could not determine whether R14 received medications. V2 said that the expectation is for all medications to be signed out as they are given, and all medications should be given as ordered.
On 1/10/24 at 12:04PM V64 Nurse Practitioner said that they assessed R14 on 1/10/24 and was aware that R14 was taking medications for diabetes. V64 explained that a normal blood sugar ranges from 70-90 and that it was very important to correct a low blood sugar quickly before it declines further. V64 said when blood sugar levels are critically low, the patient may have symptoms including becoming incoherent, unconscious, or falling into a diabetic coma. V64 said, in a controlled environment such as in the nursing facility, it is uncommon for this to happen, because the nursing staff is expected to monitor the residents for signs and symptoms before this type of severity takes place.
At the time of this survey, R14 did not have an active care plan for the management of diabetes.
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 F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide sufficient nursing coverage on specific days and shifts, causing call lights not to be answered and not ensuring adequate resident ...
Read full inspector narrative →
Based on interview and record review, the facility failed to provide sufficient nursing coverage on specific days and shifts, causing call lights not to be answered and not ensuring adequate resident care and assistance for three of three residents (R4, R8 and R13) reviewed for staffing.
Findings Include:
Per residents' census report dated 01/02/24, there are 186 residents currently residing in the facility.
On 01/02/24 at 2:23 PM, R4 mentioned during an interview that call lights were not answered by staff in a timely manner. R8 and R13 verbalized concerns regarding staffing in the facility. R4, R8 and R13 stated call light responses, provision of care and necessary support from staff were issues due to lack of staff.
V38 (Staffing Coordinator) was interviewed on 01/08/24 at 9:27 AM regarding staffing. V38 stated, The facility has three floors, first floor is both short term and long term; Second floor is long term. Residents on the second floor all need total care, are dependent on staff for ADLs (activities of daily living), and need constant supervision and monitoring. A lot of residents on the second floor are verbal, some are ambulatory. Third floor is long-term, verbal and ambulatory. V38 was asked regarding number of staff needed on each shift on all three floors. V38 replied, Each shift: first floor needs two CNAs and two nurses; second floor needs five CNAs and two nurses; and third floor needs two CNAs and two nurses. CNAs shift schedules are 7 AM -3 PM; 3 PM - 11 PM and 11 PM - 7 AM. For nurses: it is 6:30 AM - 3 PM, 2:30 PM - 11 PM and 10:30 PM - 7 AM. In cases of call ins, I call staff if someone can pick up. If none, nurse managers, restorative nurses or CNAs pick up. In cases of tardiness, we log and do some disciplinary actions, two tardiness result in disciplinary actions. Each shift requires 6 nurses and at least 9 CNAs in the facility.
On 01/08/24 at 12:05 PM, it was observed that V37 (Certified Nursing Aide) was the only CNA working on the third floor in the facility. V36 (Licensed Practical Nurse, LPN) was asked regarding staffing concern. V36 stated, We only have one CNA today, V37. We usually have two CNAs. We have 59 residents on the floor.
According to the Daily Staff schedule dated 01/08/24, V37 and V54 are assigned to work on the third floor. V54 was absent.
Review of staff weekend time sheets dated November to December 2023 recorded the following numbers of staff worked per shift for the whole facility:
11/5: morning shift had 5 nurses. V31 (LPN) came in at 7:18 AM. V31 was assigned on the second floor. Afternoon shift had 6 CNAs only and night shift had 3 nurses and only one CNA for the three floors.
11/11: 8 CNAs worked during morning shift. Afternoon shift had 10 CNAs, however, V55 (CNA) left at 10:02 PM and V13 (CNA) at 8:02 PM. Night shift had 3 nurses, V58 (LPN) came in at 11:20 PM.
11/12: Afternoon shift had 9 CNAs, but CNAs V39 left at 9:19 PM and V19 at 9:51 PM.
11/18: - Morning shift had 6 CNAs; afternoon shift had 7 CNAs; V46 (CNA) came in at 4:45 PM.
11/19: 8 CNAs worked during morning shift; 7 CNAs worked in the afternoon shift with CNA V43 leaving at 6:37 PM. 5 nurses also worked in the afternoon shift with V9 (LPN) leaving at 8 PM. Night shift had 3 nurses and 3 CNAs.
11/25: Afternoon shift had 9 CNAs, however V46 left at 8:12 PM, V54 (CNA) left at 10:04 PM and V55 worked until 10:05 PM. Night shift had 3 nurses, V58 came in at 11:15 PM.
11/26 - Morning shift had 8 CNAs. 6 CNAs worked in the afternoon shift, V43 left at 9:46 PM and V60 (CNA) worked until 7:52 PM. Night shift had 3 nurses; 6 CNAs. V58 came in at 11:11 PM.
12/2: 8 CNAs worked in the morning shift; 7 CNAs worked in the afternoon shift. Night shift had 1 CNA.
12/3: 6 nurses and 6 CNAs worked during morning shift. However, V31 came in at 7:44 AM, V36 (LPN) also came in at 7:40 AM. V56 (Registered Nurse, RN) left at 1:30 PM. There were 5 nurses who worked during afternoon shift with 7 CNAs. V21 (CNA) left at 8:35 PM. Night shift had 5 CNAs.
12/9: 8 CNAs worked in the afternoon shift, V55 worked until 8:53 PM. Night shift had 3 nurses, V58 came in at 11:31 PM.
12/10: Afternoon shift had 5 nurses and 8 CNAs. V39 left at 10:06 PM and V43 left at 9:30 PM. Night shift had 4 nurses, V58 came in at 11:13 PM.
12/16: Afternoon shift had 7 CNAs, V50 (CNA) worked until 8:52 PM, V39 left at 10:04 PM and V55 left at 9:23 PM. Night shift had 3 CNAs.
12/17: 6 CNAs worked in the morning shift, V62 (CNA) left at 12:55 PM. Night shift had 3 nurses and 4 CNAs.
12/23 - Morning shift had 5 nurses and 8 CNAs. V24 (LPN) came in at 8:02 AM, V36 came in at 10:01 AM. Afternoon shift had 5 CNAs, V13 left at 8:31 PM, V48 (CNA) left at 9:59 PM and V39 worked until 10:30 PM. Night shift had 4 nurses and 5 CNAs.
12/24: Morning shift had 5 nurses. Afternoon shift had 5 nurses. Night shift had 4 nurses, V58 came in at 11:10 PM.
12/30: 5 nurses and 5 CNAs worked in the morning shift. Afternoon shift had 3 CNAs and night shift had 2 CNAs.
12/31 - Afternoon shift had 6 nurses and 9 CNAs. V41 (LPN) worked until 8:03 PM, V31 left at 8:29 PM, V30 (LPN) left at 10:18 PM, V52 (RN) worked until 8:49 PM, V25 (RN) left at 9:11 PM. V48 worked until 9:04 PM. V39 left at 9:19 PM, V19 left at 9:55 PM, V21 left at 8:42 PM and V53 (CNA) worked until 7:32 PM. Night shift had 2 nurses and 1 CNA. The one CNA, V47, worked until 4:51 AM.
Daily nurses' schedule for weekends of November 2023, showed that only one nurse is scheduled on the first floor and one nurse on the third floor during night shift. On 12/02/23 and 12/03/23, one nurse worked on the first floor. On 12/09/23 to 12/31/23, only one nurse worked on the first floor and one nurse on the third floor.
On 01/08/24 at 10:10 AM, V1 (Administrator) was asked regarding staffing issues in the facility. V1 stated, I know that we need to hire nurses and CNAs because there is a turnover of staff, we need to hire and replace staff who have left. Human Resources gets resumes of potential nurses and CNAs, applicants and hiring. Human Resources is responsible for call ins, tardiness. Our DON (V2, Director of Nursing) is still on medical leave.
On 01/08/24 at 10:28 AM, V35 (Human Resources Manager) was interviewed regarding staff absences and tardiness. V35 replied, No, I am not responsible for staff call - ins and tardiness. I am responsible for hiring. I know that they do a lot of call - ins, no call, no show and tardiness. I encouraged department managers to go with the handbook and union handbook regarding disciplinary actions.
V3 (Assistant Director of Nursing) was interviewed on 01/08/24 at 11:20 AM regarding staffing. V3 verbalized, I am responsible for staffing in terms of making sure we have enough staff on the floor. We have staff shortage for both CNAs and nurses. Most of the staff they stay over, they pick up the hours. Some staff stay over if some wants to leave early, they let us know early and we give them permission. Sometimes, we get somebody, ask other staff to come. On weekends, managers come. We know the schedule, we have shortage. The managers know that they have to come to work on the shift.
On 01/09/24 at 9:48 AM, V2 stated during interview, I am not aware of any issues with staffing. We do have normal call offs, but other than that, we don't have any issues. In cases of call ins, I call staff to come in and make sure sufficient number of staff is working on the floor. We try to find somebody to come, we don't use agency staff. For some staff who will be late or will be absent, they inform us, managers or scheduler.
Facility's policy titled, Staffing, undated, stated in part but not limited to the following: Purpose: 1. To have appropriate amount of nursing staff on a daily basis. 2. To render quality nursing care.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide medications and/or biologicals, as ordered by ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide medications and/or biologicals, as ordered by the prescriber to meet the needs of each resident and failed to provide pharmaceutical services to meet each resident's needs which includes acquiring, receiving, dispensing, accurately administering, or disposing of medications. This failure affected one resident (R17) of four residents reviewed for medication administration, causing the resident to endure pain related to not having pain medication available when needed.
Findings include:
R17 is a [AGE] year-old female who have resided at the facility since 2021, past medical history includes, but not limited to Nondisplaced transcondylar fracture of right humerus, subsequent encounter for fracture with routine healing, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, type 2 diabetes, Epilepsy unspecified, etc.
On 1/3/2024 at 3:25PM, observed medication administration with V24 (LPN) for R17, V24 administered three medications to resident and stated that resident has an order for Motrin 400mg, she does not have it available, but she will go and pull from the emergency box. Resident stated that she has a headache and rated her pain as a 10 on a scale of 1 to 10. V24 did not come back with the Motrin until 4:20PM, surveyor did not observe V24 administer the medication.
Surveyor asked V24 why the resident did not have the medication and she said that since it is ordered as needed, sometimes pharmacy will send it and sometimes they do not, V24 did not mention using house stock for resident when they don't have their own. V24 was asked when last resident's Motrin was reordered, and she said in October.
At 3:40PM, observed medication administration with V25 (RN), surveyor asked her if they normally have Motrin house stock and she said, sometimes we do, sometimes we don't.
Physician order summary showed the following active order for R17, Ibuprofen tablet 400 MG, give 1 tablet by mouth every 12 hours as needed for Pain, order date 10/17/2022.
Care plan dated 10/14/2022 states: resident is at increased risk for alteration in pain/discomfort R/T DX of closed supracondylar FX of RT humerus s/p ORIF 10/14/22. Interventions include: Complete the Pain assessment upon Admission, Re-admission, Quarterly and PRN for new onset of pain, administer analgesic medication as ordered per plan of care, notify MD for any new resident complaints of pain and/or S/S of pain to obtain new order for medication regimen or break-through pain management, monitor for verbal and nonverbal expressions of pain, notify MD if interventions are not consistently effective.
On 1/4/2024 at 10:30AM, R17 was observed in her room, awake and alert with some confusion, stated that she gets aspirin for headache, she got one yesterday. R17 was asked if she gets any other medication for pain and she said, I don't know. R17 added that she gets her medications all the time, they sometimes run out of her phenobarbital, but it is not a big deal.
ON 1/4/2023 at 10:25AM, V3 (ADON) said that medications should be ordered when they run out including as need medications. Regarding Ibuprofen, pharmacy sends it for some residents depending on their insurance and for other residents they use the house stock. V3 said that the facility does not have Ibuprofen the Emergency Medication Supply. V3 stated that they were out of the house stock Motrin, they placed an order yesterday, and the administrator went to the store yesterday to buy some after the nurse reported that she does not have any for a resident (R17).
On 1/4/2024 at 10:35AM, V9 (LPN) said that she has Ibuprofen in her medication cart on the first floor, it is a brand-new bottle, she got it and it is not opened yet. At 10:40AM, another nurse on the second floor stated that she has a new bottle of Motrin in her cart, it is brand new and is not opened yet.
On 1/4/2024 at 10:45AM, V26 (LPN) said that pharmacy sends Ibuprofen for residents, they usually have a small bottle of house stock but now she has a brand-new bottle that is not open yet.
Medication administration record (MAR) for the month of October 2023 shows that resident R17 is on Ibuprofen 400mg to be given every 12 hours as needed, there was no signature indicating that the medication was administered to the resident the whole of October 2023. Review of pharmacy therapeutic report shows that the medication was dispensed in October 2023, has not been reordered until 1/3/2024. Resident is currently missing 3 tablets from the 30 tablets delivered to the facility on 1/3/2024, MAR for January 2024 does not have any documentation that the medication was given to the resident.
Medication administration policy and procedure revised 1/1/2020, presented by V1 (Administrator) states its purpose is to ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Under procedures, the policy states in item 3. Medication shall be administered in physician's written/verbal orders upon verification of the right medications, dose, route time, and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standard. 8. The individual administering the medication shall initial the resident's medication administration record (MAR) on the appropriate line and date for that specific day before administering the medication.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to properly prevent and contain the spread of Covid-19 an...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to properly prevent and contain the spread of Covid-19 and other infectious diseases by failing to ensure a posting at the entrance to the facility of active Covid-19 infection; failing to implement source control measures regarding the use of face masks when Covid-19 is present in the facility; failing to ensure alcohol based hand rub was available in the PPE (personal protection equipment) carts for transmission based precaution isolation rooms; failing to ensure dedicated or disposable non critical resident care equipment was available for transmission based precaution isolation rooms; and failing to ensure all residents, their representatives and families were notified following the occurrence of either a single confirmed infection of Covid-19 or three or more residents or staff with new onset of symptoms. This failure has the potential to affect all 187 residents in the facility.
Findings include:
On 1/2/24 at 10:25 AM, upon entrance to the facility there are no signs posted identifying active Covid-19 infection. The receptionist desk has a sign posted on the glass indicating masks are optional. V1 Administrator and V4 Nurse Consultant said, We have Covid residents. V1 Administrator said, We have four residents that are isolated on second floor. Observed multiple residents and staff not wearing face masks or an N95 masks upon entrance to the first floor.
On 1/3/24 at 10:55 AM, R20, R21, and R22 are currently on droplet precaution isolation. The PPE (Personal Protective Equipment) cart at the room entrance does not have alcohol based hand sanitizer to use prior to putting on or removing PPE or dedicated/disposable medical equipment (blood pressure cuff, stethoscope, thermometer) inside the cart for the residents isolated.
At 10:57 AM, V13 CNA (Certified Nurse Assistant) was observed preparing to enter R20, R21, and R22's room. She did not perform hand hygiene prior to donning the isolation gown or gloves. V13 CNA was inquired of isolation precautions. V13 CNA said, There's no hand sanitizer on the cart. They're on the wall but they're a distance away.
At 11:15 AM, R19 is on droplet isolation precautions. The PPE cart at the room entrance does not have alcohol based hand sanitizer to use prior to putting on or removing PPE. There are no N95 masks in the cart.
Multiple residents and staff are not wearing surgical masks or N95 masks on the 1st, 2nd, and 3rd floors.
R18 is on enhanced contact isolation precautions. The PPE (Personal Protective Equipment) cart at the room entrance does not have alcohol based hand sanitizer to use prior to putting on and removing the equipment. There are no gloves in the cart.
At 11:20 AM, R24, R25, and R26 are not wearing face masks while sitting in the hallway at the nurse's station. There are two nurses seated at the nurse's station and neither staff member attempted to encourage the residents to wear a face mask.
On 1/4/24 at 12:34 PM, V28 Infection Preventionist was interviewed regarding infection control and Covid-19 active infections and posting. V28 said, R19 was positive with Covid from the hospital Thursday December 28 when he came back from the hospital. I had the entire facility tested on [DATE]th, staff, and residents. On Monday December 25th R20, R21, and R22 tested positive. Tuesday January 2nd was the next testing day and I got results Wednesday at 1PM with 8 more residents. We don't have a number for an outbreak. The optional mask sign was posted. We have 12 positive residents now. The receptionist should have let visitors know we had residents with Covid. I told the staff myself. The receptionist is not infection control staff. Our receptionist is the only way we inform visitors of Covid. I believe there is an email that goes out to the residents and families. The infection preventionist is responsible for that, that would be me. We are going to initiate that now. R19's family was informed and the staff on his floor. I didn't send any communication to any other family member. There is no documentation in the resident's electronic medical records regarding the notification of the active Covid-19 infection in the building on December 28th. Multiple residents and staff are not wearing surgical masks or an N95 mask on 3rd floor.
At 1:30 PM, V57 CNA (Certified Nurse Assistant) was observed in the 3rd floor hallway not wearing a face mask. V57 was inquired of not wearing a mask. V57 said, I forgot to put one back on. V23 LPN (Licensed Practical Nurse) was observed sitting at the 3rd floor nurse's station not wearing a face mask. V23 was inquired of not wearing a mask. V23 said, I just came back from my break, I haven't put it back on yet.
On 1/8/24 at 9:40 AM, upon entrance to the facility, the receptionist is sitting at the front desk not wearing a face mask.
At 10:28 AM, V28 was inquired the facility's current Covid-19 status. V28 said, Currently we have 26 residents and 1 staff positive for Covid. On Friday we received 14 new residents and 1 staff positive on Friday January 5th. All the residents are on the 2nd floor. I don't have a Covid unit. I'm going to talk to the administrator about that. The regional corporate nurse said the information she gave me was incorrect. The non positive resident's family were supposed to be called.
At 10:34 AM, R23 is getting off the elevator and is not wearing a face mask. R23 was inquired of knowing if she was informed of the need to wear a face mask. R23 said, Everybody is getting Covid. I have one from last time, but I don't know where it is.
At 10:37 AM, V28 Infection Preventionist was inquired of transmission based precautions and infection control related to the current Covid-19 outbreak. On the 2nd floor there are three resident rooms designated as being on droplet precautions with their room doors open to the hallway. V28 confirmed the rooms are being isolated for Covid-19. V28 said, Yes, they're on droplet precautions for Covid; R22, R21, and R20. The room doors should be closed to prevent the droplets from contaminating the hallway.
During observations of the 2nd floor, there are multiple PPE (Personal Protective Equipment) carts for the transmission based droplet precautions without hand sanitizer and dedicated/disposable medical equipment (blood pressure cuff, stethoscope, thermometer) inside the carts for the residents isolated.
At 10:39 AM, V28 was inquired of the components needed for transmission based precaution and dedicated/disposable medical equipment (blood pressure cuff, stethoscope, thermometer) inside the PPE cart for the residents isolated. V28 said, You should sanitize your hands before putting on PPE. They're missing hand sanitizer. I'm missing the stethoscope, blood pressure cuff and thermometers. I'm ordering some, but I didn't order thermometers.
At 10:54 AM, V28 Infection Preventionist was inquired of V32 Receptionist not wearing a face mask. V28 said, V32 is at the desk by herself.
At 1:00 PM, V1 Administrator was inquired of informing residents and visitors of the facility's Covid-19 outbreak status. V1 said, V4 Nurse Consultant worked remotely yesterday. She sent out the communication for Covid to the residents and families.
Review of the 1/7/2024 illness outbreak communications in the electronic medical records indicates the facility has a resident positive with Covid-19. There is no prior documentation of the facility informing the residents, their representatives, and families of the active Covid-19 infection as of December 28, 2023.
At 1:08 PM, multiple residents on the 1st, 2nd, and 3rd floors are not wearing face masks. Staff in the hall and nursing stations are not encouraging the residents to wear face masks related to the Covid outbreak.
At 2:00 PM, V28 was inquired of Covid positive staff. V28 said, I have one staff positive; I got the results last Friday. I'll check if anyone else is positive. V28 was inquired for a copy of the facility's full Covid-19 policy that addresses staff and visitors.
At 2:52 PM, V28 was inquired of current staff positive with Covid-19. V28 said, I have two staff who are positive for Covid-19 now.
On 1/9/24 at 12:44 PM, V28 was inquired of informing staff of the active Covid-19 infections in the facility. V28 said, On December 28th, I started in-services on wearing face masks in the facility because I had 3 positive Covid residents, it was for source control. I did an in-service on Covid testing twice a week for staff and residents. I also did one on hand washing and wearing proper PPE (personal protection equipment) while in isolation rooms. V28 was inquired why there are so many staff not wearing face masks while the facility is having active Covid-19 infections and the facility policy for staff regarding Covid. V28 said, I'm not able to answer that, they knew to wear the masks because I had positive residents. I asked V4 Nurse Consultant and the Covid policy for residents is the only one we have. I can ask for the facility Covid policy.
On 1/10/24 at 10:35 AM, three staff are at the first floor nursing station wearing face masks under their chin. V3 ADON is also at the nursing station and is not encouraging the staff to properly wear their face masks.
At 11:56 AM, V38 Scheduler was not wearing a face mask while in the elevator with a fellow surveyor. Three residents entered the elevator. One resident did not have a face mask on. Two residents were wearing their face masks under their chins. V38 did not encourage the residents to properly wear their face masks.
At 1/10/24 at 1:50 PM, V3 ADON (Assistant Director of Nursing) was inquired of staff inappropriately wearing face masks with active Covid-19 infections in the facility. V3 said, Staff are aware of the Covid positive residents. If I see it, I ask them to wear the mask properly. It's to prevent the spread of the infection. I didn't pay attention to the staff at the desk.
At 3:32 PM, V28 was inquired of any new active Covid-19 infections. V28 said, I have six new residents that tested positive today. I had 4 residents that came off isolation. One came off January 8th and three came off January 9th. I have 27 residents all together with Covid. I checked with V4 Nurse Consultant, and we don't have any other policy for Covid.
Review of the updated Covid-19 line list provided by V28 confirms six additional residents diagnosed with Covid on 1/9/2024.
V28 Infection Preventionist did not provide the copy of the facility's full Covid-19 policy that addresses staff and visitors for review during the survey.
The 11/2022 Infection Control Policy states in part:
Purpose: to establish methods and criteria, necessary within the facility and its operation, to prevent, and control infections and communicable diseases.Responsibility: All employees and Quality Assurance Committee. Policy: It is the policy of this facility to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, and to prevent or eliminate, when possible, the development and transmission of disease and infection. Standards: 14. All facility personnel shall adhere to the Infection Control Program in the performance of their daily assignments. Employees disregarding the facility's policies and procedures shall be retrained as necessary, disciplined, and may be discharged for repeated non-compliance. 16. The facility shall assure that necessary training, equipment, and supplies are maintained to carry out an effective infection prevention program. 18. Hand washing is essential. Alcohol based hand rubs/gels is the gold standard of prevention.
The revised 12/2023 Transmission Based Precautions Policy states in part: Purpose To establish transmission based precautions for residents who are suspected or confirmed to have communicable diseases/infections that can be transmitted to others. Procedure: Droplet precautions. 3. Prior to entering the isolation room, the following steps are required: a. perform hand hygiene and apply gloves and mask prior to entering room.
The 11/8/2022 Care for Residents with Suspected or Confirmed SARS-CoV2 Infection or Close Contact of Someone with Confirmed COVID-19 Infection policy states in part: Purpose: Establish a guideline to help prevent the transmission of SARS-CoV2 infection. Procedure: Residents with Confirmed Covid-19 1. Resident placement: single room with door closed if safe to do so. 3. Isolate using transmission based precautions. 5. Monitor the resident every four hours for clinical worsening. Include an assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam to identify and to quickly manage serious infections. 8. In general, residents should continue to wear source control until symptoms resolve or for those who never developed symptoms, until they meet the criteria to end isolation below. Then they should revert to usual facility source control policies for residents. 9. Use dedicated medical equipment. Resident Placement (Covid Unit): The facility could consider designating entire units within the facility, with dedicated HCP Health Care Providers, to care for residents with SARSCoV2 infection when the number of residents with SARSCoV2 infection is high.
The Department of Health and Human Services Centers for Medicare & Medicaid Services
Ref: QSO-23-13-ALL May 01, 2023
Guidance for the expiration of the Covid-19 Public Health Emergency
Memorandum Summary
Long Term Care and Acute and Continuing Care providers are expected to be in compliance with the requirements according to the timeframes listed below.
Long Term Care Facilities
(Skilled Nursing Facilities (SNFs) and/or Nursing Facilities (NFs)
Requirements for Reporting related to COVID-19
o CMS published an IFC (CMS-5531-IFC) requiring all LTC facilities report COVID-19 information using the Center for Disease Control (CDC) National Healthcare Safety Network (NHSN) (42 CFR 483(g)). Additionally, facilities are required to inform the residents, their representatives and families following the occurrence of either a single confirmed infection of COVID-19 or three or more residents or staff with new-onset of symptoms. This requirement to report information was extended through a final rule (CMS-1747-F) and is set to terminate on December 31, 2024, with the exception of the requirements at § 483.80(g)(1)(viii), which will continue to be in effect as a requirement to support national efforts to control the spread of COVID-19. The reporting requirements referenced above also include provisions for reporting COVID-19 information to residents, their representatives and families (per 42 CFR 483.80(g)(3)). The CMS final rule that set reporting requirements to terminate on December 31, 2024 (CMS-1747) was released in November 2021, and at that time, this type of reporting was necessary. However, CMS is concerned that the effort required to continue this reporting provision may outweigh the utility of the information provided. For example, we have heard that providing families with the total number of cumulative COVID-19 cases (from June 2020) is not useful information. Additionally, this information is now publicly available on CMS' COVID-19 Nursing Home Data Website. Therefore, CMS is exercising enforcement discretion and will not expect providers to meet the requirements at 42 CFR 483.80(g)(3) at this time. All other reporting requirements referenced above remain in effect until December 31, 2024.
Oct 2023
21 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and records reviews the facility failed to ensure to continue to provide substance abuse mainte...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and records reviews the facility failed to ensure to continue to provide substance abuse maintenance medications for one resident admitted with opioid dependency. This failure affected one of three residents reviewed for treatment orders followed in the sample. This resulted in one resident (R372) not receiving her medication for 3 days, following admission to the facility. R372 reported not feeling well, being sweaty, and staff observed R372 to be fidgety. In addition, the facility failed to follow MD orders by not securing an abdominal wound dressing. This affected one of three residents (R222) reviewed for wound dressing in the sample. This failure resulted in R222 not having the dressing change at least twice a day which left the wound and wound packing exposed with noted fecal matter on the wound area.
The findings include:
R372 is a [AGE] year old admitted to the facility on [DATE] from the hospital. Diagnosis include but not limited Type II Diabetes, Asthma, and Psychoactive Substance Dependence.
On 10/15/23 at 10:04AM R372 said I have not received my methadone in 2 days.
On 10/15/23 at 2:55 PM V5, Nurse, checked the medication cart. V5 said no, R372's medications have not been delivered yet. V5 said R372 is on Seroquel and Methadone only. V5 said I am calling the pharmacy about R372's medications.
On 10/16/23 at 9:51AM R372 said I still have not received my Methadone. I'm feeling sick. I don't feel good and I'm all sweaty. The nurse gave me Tylenol this morning, but it's not working. R372 said I need my medications.
On 10/16/23 at 9:53 AM V7, Licensed Practical Nurse said R372 did not get her Methadone. V7 said I gave her Tylenol this morning. At 9:56AM R372 came to the nurses station holding her right side and said to V7 my whole side hurts.
On 10/16/23 at 1:05PM V15, Transportation Scheduler said, R372 has been scheduled to go to the Methadone Clinic for treatment on 10/19/23 (6 days since admission).
On 10/16/23 at 1:15PM V15 said V2, Regional Director, just told me to send R372 to her appointment tomorrow by private transportation. I saw R372 in the hallway and she was looking fidgety in the hallway, I noticed her as I was walking by.
On 10/16/23 at 1:20PM V7 said I assessed R372 this morning, she was fine, no symptoms.
On 10/17/23 at 9:43AM V17, Substance Abuse Counselor, said I saw R372 in group yesterday. R372 is an alcoholic and participated in the group for alcoholism. I got the list yesterday when she came to group. V17 said today I am working on my admission evaluation for R372 with her answering questions personally. V17 said R372 did not report any symptoms of withdrawal to me yesterday. V17 said symptoms can include sick to her stomach, pain, restless anxious, behaviors, disruptive behaviors, shakes, and chills or hot flashes. V17 said for Heroin use the Methadone is used to help the body adjust and may stop the craving. V17 said it will throw the patient off if they are cut off. She did not tell me anything yesterday.
On 10/17/23 at 1:48PM V3, Director of Nursing, said I receive an email when potential new admissions are coming. V3 said I was notified by email (as reading to the surveyor) that R372 is being admitted for Methadone. V3 said when a resident is admitted from the hospital it is important for the residents to get their dosing. V3 said residents should not be waiting 6 days to get their Methadone dosing because they could go into withdrawals.
On 10/18/23 at 12:07PM V28, Nurse Practitioner, V28 said when a resident is admitted I expect them to receive their Methadone within a day.
On 10/18/23 at 12:32PM V3 said the facility does not have a policy to address residents admitted for Methadone Treatment.
Physician order dated 10/14/23 reads Methadone HCl Oral Solution 5 MG/5ML (Methadone HCl), give 18 ml by mouth one time a day for antipsychotic, 18ml daily x7days.
Progress Notes dated 10/15/23 states Methadone HCl Oral Solution 5 MG/5ML, give 18 ml by mouth one time a day for antipsychotic, 18ml daily x7days. On order.
Care plan reviewed on 10/16/23 morning by the surveyor, does not identify R372's history of substance use/abuse. Care plan provided to the facility on the morning of 10/17/23 includes substance abuse.
R372's hospital records dated 10/6/23 state R372 is a heroin and history of cocaine user.
On 10-17-23 at 10:04 AM, surveyor noted R222 lying in bed with abdominal dressing partially open exposing the wound and wound packing. Surveyor noted small amount of fecal matter on the wound dressing with stool visible in the colostomy. R222's abdominal pad was twisted and taped across the top and the right lower corner. The lower left corner of the abdominal pad was not secure, tape was noted on R222 left lower abdomen. R222's wound and abdominal packing could be seen from the entire left lateral side of the dressing.
On 10-17-23 at 10:04am, R222 said, I have been waiting on staff for three hours to change my dressing. My dressing was last changed at 11:00 AM yesterday. My dressing has been open all night.
On 10-17-23 at 10:00 AM, V2 (DON) said R222's TAR documents the wound dressing was done once on 10-14-23, 10-15-23, 10-16-23, and 10-17-23.
On 10-17-23 at 10:09am, V2 (DON) said, R222's dressing is soiled with spots of feces and was not secure. V2 said she expected R222's dressing to be clean and secure. V2 said R222 is at risk for infection related to the wound being exposed, dressing soiled with feces from the colostomy bag, and dressing not being secure and intact.
On 10-17-23 at 11:58 AM, V25 (LPN) said she say R222's abdominal dressing was moderately saturated with drainage and the dressing was partially open. exposing view of the wound and wound packing. V25 said she did not see any fecal matter. During R222's med pass, R222 said he needs a dressing change and dressing was partially open.
R222's treatment administration record documents (dated 10-1-23 to 10-31-23) abdominal treatment was provided once on 10-14-23, 10-15-23, 10-16-23, and 10-17-23.
Physician order sheet dated 10/12/23 documents: Abdomen- Clean with normal saline, then pat dry, then place wet to dry gauze inside wound, cover with ABD pad and secure with tape 2x daily and as needed.
Physician Order Policy (reviewed 11/22) documents Purpose: To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's medication was available for admin...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's medication was available for administration for more than 72 hours following admission. This failure affected 1 (R372) of 2 residents reviewed for missed medication. This failure resulted in R372 reporting they were not feeling well, being sweaty, and staff observing R372 to be fidgety.
The findings include:
R372 is a [AGE] year old admitted to the facility on [DATE] from the hospital. Diagnosis include but not limited Type II Diabetes, Asthma, and Psychoactive Substance Dependence.
On 10/15/23 at 10:04AM, R372 said I have not received my methadone in 2 days.
On 10/15/23 at 2:55 PM V5, Nurse, checked the medication cart. No, R372's medications have not been delivered yet. Surveyor with V5 at the medication cart who said there are no bottles/vials of Methadone on the medication cart.
On 10/16/23 at 9:51 AM R372 said I'm feeling sick they haven't given me my Methadone, I'm feeling sweaty, I need my medications.
On 10/16/23 at 9:53 AM V7, Licensed Practical Nurse said R372 did not get her Methadone.
On 10/16/23 at 1:15PM V15, Transportation Scheduler, said I saw R372 in the hallway and she was looking fidgety in the hallway, I noticed her as I was walking by.
On 10/17/23 at 1:48PM V3, Director of Nursing, said I receive an email when potential new admissions are coming. V3 said I was notified by email (as reading to the surveyor) that R372 was being admitted on [DATE] for Methadone. V3 said when a resident is admitted from the hospital it is important for the residents to get their Methadone dosing. V3 said residents should not be waiting 6 days to get their Methadone dosing because they could go into withdrawals.
Physician order dated 10/14/23 reads Methadone HCl Oral Solution 5 MG/5ML (Methadone HCl), give 18 ml by mouth one time a day for antipsychotic, 18ml daily x7days.
Progress Notes dated 10/15/23 states Methadone HCl Oral Solution 5 MG/5ML, give 18 ml by mouth one time a day for antipsychotic, 18ml daily x7days. On order
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and records reviewed the facility failed to provide clean assistive devices and assistive devices in good working order for one (R102) of three residents reviewed in...
Read full inspector narrative →
Based on observations, interviews, and records reviewed the facility failed to provide clean assistive devices and assistive devices in good working order for one (R102) of three residents reviewed in the sample.
The findings include:
On 10/15/23 at 10:07AM R102 observed sitting in his wheelchair during interview. The surveyor observed the back support of R102's wheelchair is not fully attached and all the way up on the back bars. R102's wheelchair has no foot pedals, is dirty with dried on unidentifiable particles, and both the front rubber wheels are thin and almost not present. R102's wheelchair has a seat and metal frame but without no back support.
On 10/15/23 at 12:44 PM R102 said I would take a new wheelchair if they gave it to me. R102 said I use the wheelchair to get around the facility.
On 10/15/23 at 1:20 PM V5, Nurse, was asked about R102's wheelchair. V5 said he won't let me take his wheelchair, I have tried, he refuses. The surveyor requested documentation specific to R102 wheelchair refusals.
On 10/15/23 at 2:18PM V5, Nurse, said R102 was given a new wheelchair. He is sitting in it.
On 10/16/23 at 2:54 PM R102 observed sitting in a clean wheelchair with good wheels, clean, and back rest and leg rest present.
No documentation of R102's wheelchair refusal was provided. No documentation related to the wheelchair was noted during the surveyors record review.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to clearly document an advance directive status. This affected one of three residents (R89) reviewed for advance directives in the electronic ...
Read full inspector narrative →
Based on interview and record review, the facility failed to clearly document an advance directive status. This affected one of three residents (R89) reviewed for advance directives in the electronic medical record.
Findings include:
On 10/17/23 at 12:55pm, V3(DON) said code status should be on the physician order sheets and located in electronic health record. V3 did not see any code status for R89 when checking the medical record.
R89's practitioner order for life sustaining treatment POLST form documents: Do not attempt Resuscitation dated 9/22/23.
R89's physician order sheet does not document any code status.
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
Based on interviews and records reviewed the facility failed to notify the physician when medications were not available for greater than 72 hours. This affected one of three residents (R373) reviewed...
Read full inspector narrative →
Based on interviews and records reviewed the facility failed to notify the physician when medications were not available for greater than 72 hours. This affected one of three residents (R373) reviewed for notification of missed medications in the sample.
The findings include:
On 10/15/23 at 10:04AM R373 said I have not received my methadone in 2 days.
On 10/15/23 at 2:55 PM V5, Nurse, checked the medication cart. V5 said no, R373's medications have not been delivered yet.
On 10/16/23 at 9:51 AM R373 said I'm feeling sick and sweaty. They haven't given me my Methadone. R373 said I need my medications. The nurse gave me Tylenol this morning, but it's not working.
On 10/16/23 at 1:05PM V15, Transportation Scheduler, said R373 has been scheduled to go to the Methadone Clinic for treatment on 10/19/23 (6 days since admission).
On 10/16/23 at 09:53 AM V7, Licensed Practical Nurse said R373 did not get her Methadone.
On 10/18/23 at 12:07PM V28, Nurse Practitioner, said I was not notified of any concerns related to R373. V28 said if I had been notified that R373 was not scheduled to receive her Methadone until Thursday 10/19/23 then I would have given the order to send her back to the hospital for monitoring and dosing. At 12:23PM V28 said I spoke with the nurse practitioners covering over the weekend and they were not notified that R373 was not receiving her Methadone.
Physician order dated 10/14/23 reads Methadone HCl Oral Solution 5 MG/5ML (Methadone HCl), give 18 ml by mouth one time a day for antipsychotic, 18ml daily x7days. Scheduled at 8:00AM on Medication Administration Record.
The facility policy for Change in Resident Condition dated 2/1/22 states Nursing will notify the resident's physician or nurse practitioner when it is deemed necessary or appropriate in the best interest of the resident.
The facility policy for administering medication dated November 2022 states should a medication be withheld or refused the physician will be notified when 3 consecutive is noted and documented in the medical record.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to prevent the misappropriation and/or diversion of m...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to prevent the misappropriation and/or diversion of medications for two (R2, R17) of three residents reviewed for medication administration; and failed to follow their facility's ordering and receiving of medications policy. This failure resulted in R2's pain medication (ibuprofen) being reordered in excess with minimal documentation of medication being administered to R2; and failed to have both resident's (R2, R17) personal medication supply readily available upon request for administration on numerous occasions.
Findings include:
1. R2's electronic medical record indicated resident is a [AGE] year old male who admitted to facility on 11/07/2022 and has a past medical history not limited to: dementia with behavioral disturbance, hypertensive heart disease, anemia, polyneuropathy, cellulitis of bilateral lower extremities, peripheral vascular disease, glaucoma, and atherosclerosis.
On 01/02/2024 at 2:11 PM, R2 stated that one to two months ago, he had asked for his ibuprofen 800mg and saw that he had a full card of this medication available but a few days later, when he asked for another pill, he was told that he didn't have any tablets left on his card and staff would have to reorder this medication. R2 added that he had asked for an ibuprofen 800mg several times over the last few weeks but doesn't seem to have any of his own supply available and is given the facilities (house stock) medication. R2 then said that he can't understand why his personal medication supply is being reordered so frequently when he himself doesn't take this medication that often.
R2's active physician orders includes but not limited to: one ibuprofen 800 milligram (mg) tablet by mouth every twenty-four hours as needed for severe pain rated between five-eight.
R2's electronic medication administration records (MAR) indicated the following regarding his ibuprofen 800mg medication: January 2023 MAR indicated resident received this medication one time, February 2023 MAR indicated resident received this medication five times, March 2023 MAR indicated resident received this medication two times, April 2023 MAR indicated resident received this medication one time, May 2023 MAR indicated resident received this medication three times, June 2023 MAR indicated resident received this medication four times, July 2023 MAR indicated resident received this medication three times, August 2023 MAR indicated resident received this medication three times, September 2023 MAR indicated resident received this medication five times, and from October 2023 through current, it is not documented that resident was administered this medication during this time period.
R2's pharmacy medication audit log dated 01/10/2023 showed resident's ibuprofen 800mg was reordered in March, April, May, June, August, September, and October of 2023 and again in January 2024 and was dispensed on medication cards in increments of thirty (30) tablets that is inconsistent with the number of documented administrations.
On 01/04/2024 at 11:20 AM, V23 (Licensed Practical Nurse) said R2 has a pain medication order daily as needed that was last documented as being administered on 09/14/2023 at 08:53 AM. When asked to see R2's medication card for ibuprofen, V23 was unable to produce a med card then indicated it was last ordered, dispensed and received on 01/02/2024 and is most likely in the first floor pharmacy box. V23 added that nursing is never allowed to administer a resident's medications to another resident.
On 01/08/2024 at 2:54 PM, observed with V36 (Licensed Practical Nurse) that R2's ibuprofen 800mg tab medication card with dispensed date of 01/02/2024, to have one tablet missing. Reviewed and confirmed with V36 per R2's electronic medication administration record that R2 was last documented as receiving this medication on 09/19/2023 at 08:53 AM. When asked when the current missing tablet was administered and whether it was received by R2, V36 said I don't know because I wasn't here.
On 01/10/2024 at 1:43 PM, V3 (Assistant Director of Nursing) was asked why an as needed medication would be reordered frequently if the resident is rarely being administered this medication, why would the medication need to be reordered so often, V3 said sometimes the pharmacy sends a medication without the facility reordering it then said there would be no other reason for excessive reordering if the medication was not frequently being administered. When asked if there should then be a surplus of this medication available rather than none being available, V3 had no response. When R2's ibuprofen administration records and pharmacy reorder logs were reviewed by surveyor with V3, she was unsure as to why his medication would have been unavailable. V3 then added that her expectation is for nursing staff to document all medication administrations and if not documented, then it would be considered as not given and a medication error.
Ordering and Receiving Non-Controlled Medications From the Dispensing Pharmacy policy with effective date of 10/25/2014 reads in part: Policy: Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. Procedures: Reordering of medications is done in accordance with the order and delivery schedule developed by the pharmacy providers. Reorder medication four (4) days in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand.
2. R17 is a [AGE] year-old female who has resided at the facility since 2021, past medical history includes, but not limited to Nondisplaced transcondylar fracture of right humerus, subsequent encounter for fracture with routine healing, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, type 2 diabetes, Epilepsy unspecified, etc.
On 1/4/2024 at 10:30AM, R17 was observed in her room, awake and alert with some confusion, stated that she gets aspirin for headache, she got one yesterday. R17 was asked if she gets any other medication for pain and she said, I don't know.
Physician order summary showed the following active order for R17, Ibuprofen tablet 400 MG, give 1 tablet by mouth every 12 hours as needed for Pain, order date 10/17/2022.
Care plan dated 10/14/2022 R17 is at increased risk for alteration in pain/discomfort R/T DX of closed supracondylar FX of RT humerus s/p ORIF 10/14/22. Interventions include: Complete the Pain assessment upon Admission, Re-admission, Quarterly and PRN for new onset of pain, administer analgesic medication as ordered per plan of care, notify MD for any new resident complaints of pain and/or S/S of pain to obtain new order for medication regimen or break-through pain management, monitor for verbal and nonverbal expressions of pain, notify MD if interventions are not consistently effective.
On 1/3/2024 at 3:25PM, observed medication administration with V24 (LPN) for R17, V24 administered three medications to resident and stated that resident has an order for ibuprofen 400mg, she does not have it available, but she will go and pull from the emergency box. Resident stated that she has a headache and rated her pain as a 10 on a scale of 1 to 10. V24 did not come back with the Motrin until 4:20PM, surveyor did not observe V24 administer the medication.
Medication administration record (MAR) for the month of October 2023 shows that resident is on Ibuprofen 400mg to be given every 12 hours as needed, there was no signature indicating that the medication was administered to the resident the whole of October 2023. Review of pharmacy therapeutic report shows that the medication was dispensed in October 2023, has not been reordered until 1/3/2024. Resident is currently missing 3 tablets from the 30 tablets delivered to the facility on 1/3/2024, MAR for January 2024 does not have any documentation that the medication was given to the resident.
On 1/8/2024 at 2:43PM, V3(DON) was asked what happened to the three missing tablets from the bingo card if there is no signature in the MAR indicating that they were given to R17 and she said, I don't know.
Medication administration policy and procedure revised 1/1/2020, presented by V1 (Administrator) states its purpose are to ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Under procedures, the policy states in item 8. The individual administering the medication shall initial the resident's medication administration record (MAR) on the appropriate line and date for that specific day before administering the medication.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow their abuse policy by not reporting allegations of abuse for two of three residents (R69, R66) reviewed for abuse reporting.
Finding...
Read full inspector narrative →
Based on interview and record review, the facility failed to follow their abuse policy by not reporting allegations of abuse for two of three residents (R69, R66) reviewed for abuse reporting.
Findings Include:
On 10/15/23 at 10:57am, R69 who was delusional said in 2016, she was raped while she slept. R69 said, when she awoke, she saw R7 walking out of her room in the middle of the night. R69 said, R7 raped her that night. R69 did not recall the act of being raped or when R7 was on top of her but she knew she was raped when she saw R7 walking out of her room. R69 said, she had semen in her vaginal area at that time. R69 also said, the semen is currently still in her vaginal area.
On 10/16/23 at 4:38pm, V2 (regional consultant) said, R69's allegation of sexual abuse should have been reported after her hospitalization. I expect the nurse to review the hospital paperwork for continuity of care.
Nursing note dated 8/27/23 documents: R69 had hallucinations and delusions. R69's petition form completed. Hospital paperwork dated 8/28/23 documents: R69 admitted to ED due to acute psychosis. Per petition from nursing home, R69 has been increasingly delusional with hallucinations. R69 reports being repeatedly raped and tortured at nursing home by staff, thinking a man raped her since she saw him walking out of her room. R69 also stated her mother and daughter tortured her. R69 has been inconsistent with medication recently.
Facility reportable dated 10/16/23 documents: R69 alleged she was raped while in the hospital.
Abuse policy dated 12/21/2019 documents: Residents have the right to be free from abuse. Abuse means any physical or mental or sexual assault inflicted upon a resident other than by accidental means. Immediately protecting resident involved in identified reports of possible abuse. Implement systems to promptly and aggressively investigate all reports and allegations of abuse. Immediately is defined as as soon as possible after being made aware of an allegation of abuse, neglect, misappropriated of resident property or exploitation but is not more than two (2) hours if the events that cause suspicion result in serious bodily injury or involve an allegation of abuse, or not later than twenty-four (24) hours if the events cause the suspicion do not result in bodily injury.
On 10/15/23 10:28am R66 said the devil rapes her stomach by taking her fingers and hands and scratching my stomach.
On 10/15/23 at 10:38am this allegation was reported to V19 (Nurse). Follow up with V19 at 11:13am, V19 said she reported this allegation to V36 (social services).
On 10/16/23 at 2:31pm V1 (Administrator) said no one reported any allegations to him. V1 made aware of the allegation reported by R66.
Facility abuse prevention program policy and procedures dated 1.4.18 denotes in-part internal reporting requirements and identifications of allegations, employees are required to report any incident, allegations, or suspicious of potential abuse, neglect, exploration, mistreatment or misappropriation of resident's policy.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow their abuse policy by not investigating an allegation of abuse for one of three residents (R69) reviewed for abuse reporting.
Findin...
Read full inspector narrative →
Based on interview and record review, the facility failed to follow their abuse policy by not investigating an allegation of abuse for one of three residents (R69) reviewed for abuse reporting.
Findings Include:
On 10/15/23 at 10:57am R69, who was delusional, said in 2016 she was raped while she slept. R69 said, when she awoke she saw R7 walking out of her room in the middle of the night. R69 said, R7 raped her that night. R69 did not recall the act of being raped or when R7 was on top of her but she knew she was raped when she saw R7 walking out of her room. R69 said, she had semen in her vaginal area at that time. R69 also said, the semen is currently still in her vaginal area.
On 10/16/23 at 4:38pm, V2 (regional consultant) said, R69's allegation of sexual abuse should have been investigated after her hospitalization. I expect the nurse to review the hospital paperwork for continuity of care.
Nursing note dated 8/27/23 documents: R69 had hallucinations and delusion. R69's petition form completed. Hospital paper work dated 8/28/23 documents: R69 admitted to ED due to acute psychosis. Per petition from nursing home, R69 has been increasingly delusional with hallucination. R69 reports being repeatedly raped and tortured at nursing home by staff, thinking a man raped her since she saw him walking out of her room. R69 also stated mother and daughter torturing her. R69 has been inconsistent with medication recently.
Facility reportable dated 10/16/23 documents: R69 alleged she was raped while in the hospital.
Abuse policy dated 12/21/2019 documents: Residents have the right to be free from abuse. Abuse means any physical or mental or sexual assault inflicted upon a resident other than by accidental means. Immediately protecting resident involved in identified reports of possible abuse. Implement systems to promptly and aggressively investigate all reports and allegations of abuse. Immediately is defined as as soon as possible after being made aware of an allegation of abuse, neglect, misappropriated of resident property or exploitation but is not more than two (2) hours if the events that cause suspicion result in serious bodily injury or involve an allegation of abuse, or not later than twenty-four (24) hours if the events cause the suspicion do not result in bodily injury.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review the facility failed to follow care plan interventions by not utilizing the communication book for communication for a resident unable to voice thei...
Read full inspector narrative →
Based on observations, interviews, and record review the facility failed to follow care plan interventions by not utilizing the communication book for communication for a resident unable to voice their needs. This affected one of three residents (R147) reviewed for communication in the sample.
The findings include:
R147's diagnosis include but not limited to Altered Mental Status. R147's speech, hearing, and vision assessment notes unclear speech and is sometimes understood and understands others sometimes. R147's cognition notes he is severely cognitively impaired.
On 10/15/23 at 11:25AM the surveyor met R147 in the hallway and attempted to speak to him. R147 only made low grunting sounds and was not able to pronounce his name or identify which bed in the room is his.
On 10/15/23 at 11:39 AM V18, Certified Nursing Assistant (CNA), said reguarding R147, he don't have no communication board he just say yes or no. V18 said R147 can't have a conversation, but he can understand you.
On 10/16/23 at 9:07 AM V6, Assistant Social Service Director said the social service department does the cognitive, hearing, and vision assessments for the residents. V6 said any impairment will be care planned. V6 said if they use the communication devices, we will provide them. V6 said the communication book is used for language and pictures are used for those with cognitive barriers. The surveyor then walked to R147's room with V6. V6 looked and said there is no communication book in R147's room. V6 took the surveyor to the nurses desk and presented the communication book.
R147's care plan was reviewed and it has a communication board as an intervention for impairment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide feeding assistance for one resident identified as needing feeding assistance. This affected one of three residents (R1...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to provide feeding assistance for one resident identified as needing feeding assistance. This affected one of three residents (R160) reviewed for feeding assistance in the sample.
Findings Include:
R160's diagnosis includes unqualified visual loss, both eyes and autistic disorder. Minimal data set section G (functional status) dated 9/7/23 documents: R160 requires supervision with one person physical assist with eating. Physician order sheet dated 8/16/23 documents: for diet need assistance with feeding.
On 10/15/23 at 12:51PM, R160 was assisted by co-peer/another resident who was sitting at R160's table to remove the plastic wrap from a peanut butter sandwich. R160 fed self without any staff assistance. R160's co-peer offered R160 his juice and placed it in R160's hand.
On 10/16/23 at 12:39pm, R160 was given a double cheeseburger from a co-peer. The restaurant sandwich was dropped out of a paper bag on the table in front of R160. Another resident unwrapped the cheeseburger and placed it in R160's hand.
On 10/16/23 at 12:47pm, R160 was given his lunch tray with a peanut butter sandwich, vegetables, fruit and hydration by staff. Staff did not inform R160 of the position of any of the food that was on his tray. R160's co- peer removed the plastic wrap from the sandwich and placed it in R160's hand. R160 ate his sandwich without staff assistant.
On 10/16/23 at 12:53pm, R160 was reaching and searching for his burger which was on the left bottom side of his lunch tray. R160 grabbed his burger and preceded to eat it. R160's co-peer who was sitting at R160's table offered R160 juice. R160's co-peer placed R160's juice in his hand. R160's co-peer asked R160 if he wanted his vegetables to which R160 replied no.
On 10/16/23 at 1:08pm, R160 had scoop vegetables and a bowl of oranges in liquid left on his tray. V27 CNA (Certified Nursing Assistant) sat down at R160's table and asked R160 if he wanted his fruit. V27 preceded to feed R160 the bowl of oranges. V27 said, R160 does not require feeding assistance. V27 said, she just wanted to make sure R160 ate some fruit.
On 10/17/23 at 12:59pm, V3 Director of Nursing (DON) said, she did not know R160. V3 said, if a resident's physician order sheet documents they required feed assistance it means they required assistance with meals from staff. Resident's should not be assisting other residents with their meals.
Feeding policy requested and not provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow their pressure ulcer prevention interventions wh...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow their pressure ulcer prevention interventions which include inappropriate Low Air Loss Mattress pressure setting for residents identified to be at risk for skin breakdown. This affected two of three residents (R62 and R 86) reviewed for pressure ulcer prevention and interventions in a total sample of 36 residents.
Findings Include:
On 10/15/23 at 10:45AM, observed R62 in bed using low air loss mattress. Machine setting is at 350 lbs.
On 10/15/23 at 11:30AM, observed R86 in bed, using low air loss mattress. Machine setting is at 320 lbs.
On 10/15/23 at 11:05 AM, showed V3 (DON) and confirmed that the mattress setting is set on 350 lbs.
On 10/15/23 at 11:30AM, showed V11 (nurse) and confirmed that the mattress setting is set on 320 lbs.
On 10/17/23 at 10:30AM, V3 stated that Low Air Loss Mattress settings need to be set close to the resident's weight. We use Low Air loss Mattress to prevent skin alteration and maintain the integrity of their skin condition.
On 10/17/23 at 2:00PM, V23 (Wound Nurse) stated that R62 and R86 are both on low air loss mattresses, both residents are at risk for developing pressure ulcers due to history of pressure ulcer and their comorbidities. Low air loss mattress is supposed to be set according to residents' weight and nurses should check and adjust the setting as needed.
R62 recorded weight on 10/4/23 is 137.0 lbs.
R86 recorded weight on 10/4/23 is 203.6 lbs.
R86 Braden Scale assessment dated [DATE] shows that R86 is moderate risk for skin alteration.
R62 Braden Scale Assessment date 8/27/23 shows that R62 is high risk for skin alteration.
Operation Manual for low air loss mattress provided by the facility reads in part: The mattress is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with the comprehensive pressure ulcer management plan.
Pressure Ulcer Prevention with a reviewed date 11/2022, reads in part: Purpose is to prevent and treat pressure sores. Pressure reduction mattress will be used for moderate/high risk. Pressure reliving mattress will be used for resident at severe risk for skin breakdown. Rationale: to relieve friction and reduce pressure on bony prominences. Note: pressure relieving mattress will be used for residents who have a Stage III and IV for the trunk area of the body.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
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 one resident with history of mental illness had been assesse...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident with history of mental illness had been assessed by a mental health professional since admission. This affected one of one resident (R167) reviewed for mental health services in the sample.
Findings include:
R167 admitted to the facility on [DATE] with a diagnosis of major depressive disorder severe without psychotic features and psychoactive substance abuse.
R167 Preadmission screening and resident review (PASRR) dated 6/29/23 documents: You have a Level II PASRR condition of Major Depressive Disorder and Anxiety Disorder, which needs routine follow up with a mental health professional and a medication regimen. PASRR dated 9/20/23 under rehabilitative services: A psychiatrist will watch how your respond to your medicine and make changes if needed.
R167's medical record reviewed with no notes from any mental health professionals.
On 10/18/23 at 11:16AM, R167 who was alert and oriented at time of interview, said she has never seen any mental health professional since she has been admitted and would like to see them. R167 said she has told staff her requests with no follow through. R167 said she said she was sent to the facility for those follow up services and is unsure why she has not been seen.
On 10/18/23 at 12:05PM V3 (Director of Nursing) DON said there were no progress notes or visits that documents R167 was seen by mental health professional.
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 follow their medication labeling and storage policy. This affected three of three residents (R472, R473, and R136) reviewed fo...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to follow their medication labeling and storage policy. This affected three of three residents (R472, R473, and R136) reviewed for medication storage in the sample.
Findings Include:
On 10/16/23 at 10:02am, two prescription bottles were observed in a box with old empty pill cards and paper under the 3rd floor nursing station. R472 had a prescribed bottle of amlodipine 5mg dated 7/24/23 (documents: take one tablet by mouth every day) with 22 pills inside the bottle and chlorthalidone 25mg dated 7/24/23 (documents: take one tablet by mouth every day) with 21 pills inside. V16 (ADON) said, there should not be any medication under the nursing station. All medication should be locked in the medication room until disposed of or returned.
R472's physician order sheet dated 10/14/23 documents: Amlodipine 10mg give one tablet by mouth one time a day. Chlorthalidone was not documented as a prescribed medication.
On 10/16/23 at 10:07am, R473 had a Haldol dec medication bottle in the medication room which was dispensed 2/14/23. V16 said, R473 was never a resident in the building. Pharmacy sent R473's medication by mistake. R473's medication should have been sent back to pharmacy.
Facility letter dated 10/18/23 documents we do not have a resident by the name of R473.
On 10/16/23 at 10:40am, during the 3rd floor medication cart inspection, R136 had naloxone hydrochloride nasal spray in the control box. V19 (Nurse) said, R136 is not on naloxone. I am not sure why this medication is on the cart.
On 10/18/23 at 11:35am, V3 (DON) said, medication not prescribed by the doctor should not be on the medication cart.
R136's physician order sheet dated 10/16/23 did not document naloxone as a prescribed medication.
Storage of Medication Policy dated 5/1/2018 documents: Medication and biological are stored safety, securely and properly following manufacturer's recommendation or those of the supplier.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to maintain an effective abuse prevention training policy/practice for reporting allegations of abuse for 1 resident (R66) in sample of 36 revi...
Read full inspector narrative →
Based on interview and record review the facility failed to maintain an effective abuse prevention training policy/practice for reporting allegations of abuse for 1 resident (R66) in sample of 36 reviewed for reporting.
Findings include:
On 10/15/23 at 10:28am, R66 said the devil rapes her stomach by taking her fingers and hands and scratching my stomach.
On 10/15/23 at 10:38am this allegation was reported to V19 (Nurse). Follow up with V19 at 11:13am, V19 said she reported this allegation to V36 (Social Services).
On 10/16/23 at 2:31pm V1 (Administrator) said no one reported any allegations to him. V1 made aware of the allegation reported by R66.
Facility abuse prevention program policy and procedures dated 1/4/18 denotes in-part internal reporting requirements and identifications of allegations, employees are required to report any incident, allegations, or suspicious of potential abuse, neglect, exploration, mistreatment or misappropriation of resident's policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0574
(Tag F0574)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure that residents are aware of where the ombudsmen contact information is posted in the facility. This affects eight of ei...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to ensure that residents are aware of where the ombudsmen contact information is posted in the facility. This affects eight of eight residents (R5, R26, R45, R79, R80, R135, R152, and R274) in the sample of 36 reviewed for residents rights for ombudsmen postings.
Findings include:
On 10.16.23 at 10:27am during the residents council meeting R5, R26, R45, R79, R80, R135, R152, and R274 all asked, what is the ombudsmen. They all asked who is the ombudsmen and said they do not know where the ombudsmen contact information is posted in the facility. They all said they don't know who the ombudsmen is.
On 10.16.23 at 12:36pm there was an 8x10 posting noted on the glass wall near the door exiting into the front lobby. There was not a name listed for the ombudsmen. The posting was posted high on the wall greater than 5 feet 5 inches high. Surveyor had to look up to see the sign.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure that the state inspection is available for the residents to read without having to ask the staff for them. This affected...
Read full inspector narrative →
Based on observation, interview and record review the facility failed to ensure that the state inspection is available for the residents to read without having to ask the staff for them. This affected eight of eight (R5, R26, R45, R79, R80, R135, R152, and R274) residents in the sample of 36 resident reviewed for residents rights.
Findings include:
On 10.16.23 at 10:27am R5, R26, R45, R79, R80, R135, R152, and R274 all asked what is the state inspection. They all said they don't know where to go to read the state inspection.
On 10.17.23 at 4:04pm V1 (Administrator) was asked where is the state inspection? V1 went through the door behind the front desk and pointed to a white binder. V1 was asked if the resident had access behind the front desk. V1 then stated that the inspection report is at each nurse station and pointed to a sign.
On 10.18.23 at 9:05am surveyor stopped at the first floor nursing station and requested to review the state inspection. V12(Nurse) asked what's that. The state inspection was not present at the first floor nurse station.
On 10.18.23 at 9:06am surveyor stopped at the second floor nursing station and requested to review the state inspection. V33 (CNA) asked what's that. A yellow binder with the State inspection was presented. The binder was behind the nurse's station on a bookshelf. V33 said the residents cannot come behind the nurse station.
On 10.18.23 at 9:09am surveyor stopped at the third floor nursing station and requested to review the state inspection. V19(Nurse) asked what's that. The state inspection was not presented at the third floor nurse station.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to follow their Oxygen Equipment Policy. The facility failed to date oxygen tubing and prefilled humidifier. This affected five o...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to follow their Oxygen Equipment Policy. The facility failed to date oxygen tubing and prefilled humidifier. This affected five of five residents (R46, R62, R140, R425 and R427) reviewed for oxygen administration in a total sample.
Findings Include:
On 10/15/23 at 10:45AM, R62 observed to have an oxygen concentrator at bedside, oxygen tubing dated 9/10/23, and empty prefilled humidifier dated 4/9/23.
On 10/15/23 at 10:50AM, R46 observed to have oxygen concentrator at bedside, oxygen tubing and prefilled humidifier not dated, and humidifier bottle is empty.
On 10/15/23 at 11:10AM, R140 observed to have oxygen concentrator at bedside and prefilled humidifier bottle not dated.
On 10/15/23 at 11:15AM, R425 observed to have oxygen concentrator at bedside, oxygen tubing and prefilled humidifier bottle not dated.
On 10/15/23 at 11:20AM, R427 observed to have oxygen concentrator at bedside, oxygen tubing not dated and prefilled humidifier bottle not dated and bottle empty.
On 10/15/23 at 11:05AM, confirmed and verified with V3 (Director of Nursing) R62's oxygen tubing date and humidifier bottle date and empty, and R46's oxygen tubing and humidifier not dated and prefilled humidifier bottle is empty.
On 10/15/23 at 11:25AM, showed V11 (Nurse) R427's oxygen tubing and prefilled humidifier bottle. V11 confirmed that oxygen tubing not dated and prefilled humidifier bottle not dated and bottle empty. V11 verified that humidifier is empty and reported that he will be putting new one and date the bottle also.
On 10/17/23 at 1030am, V3 (DON) stated that humidifier and oxygen tubing are dated so we know when is the date to change them. We change the tubing to make sure there is no build up and the tubing and humidifier is still intact and appropriate to give a constant flow of oxygen to residents.
Oxygen Equipment policy dated 8/14, reads in part: to administer oxygen in conditions in which infection control is maintained. Humidifier bottles: prefilled bottles will be changed and dated when empty. Other bottles will be changed and dated weekly and as needed.
Oxygen tubing/nebulizer masks will be changed and dated weekly and as needed.
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 F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and records reviewed the facility failed to ensure to provide evidence to support sufficient nursing staff based on the facilities staffing numbers. This affected tw...
Read full inspector narrative →
Based on observations, interviews, and records reviewed the facility failed to ensure to provide evidence to support sufficient nursing staff based on the facilities staffing numbers. This affected two of two residents (R138, R222) reviewed for staffing. This has the potential to affect all 191 residents.
The findings include:
According to the CMS 672 dated 10.16.23 there are currently 191 residents.
On 10/15/23 at 11:39 AM V18, Certified Nursing Assistant (CNA), said yesterday (10/14/23) she was the only CNA on the floor. V18 said she is the only CNA on the floor today.
On 10/15/23 at 11:00 AM, R138 said there is not enough staff, and it takes a long time for staff to respond. R138 said he can wait up to an hour for staff to respond to his call light.
On 10/15/23 at 11:04 AM, R222 said there is not enough nurses and there should be 2 nurses on each side instead of 1 nurse. R222 said the nurses and CNA take too long to respond to the lights.
On 10/16/23 11:25 AM V13, Staffing, said we should have 2 CNAs on the 1st floor, 6 CNAs on the 2nd floor and the 3rd floor has 2 CNAs at minimum. V13 said I would say 2 CNAs is the minimum for 3rd floor on day and evening shift. V13 said sometimes 4 CNAs have been working on 2nd floor. V13 said there was only 1 CNA working the third floor unit on 10/14/23 because one of the CNAs went home. V13 said on 10/15/23 there was only 1 CNA on the third because one person was a no call no show.
The surveyor requested day and evening CNA and Nurses timecards from the facility, which were not provided for review, for 10/5/23; 10/6/23; 10/8/23 and 10/14/23.
Review of schedule for Friday 10/6/23 and Sunday 10/8/23, 2nd floor day shift had 4 CNAs listed as working.
Review of schedule for Saturday 10/14/23 and Sunday 10/15/23, 3rd floor has only V18 listed for CNA.
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 ensure the dessert cooler, three compartment sink and ventilation hood were in good working condition. This failure has the po...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure the dessert cooler, three compartment sink and ventilation hood were in good working condition. This failure has the potential to affect all 191 residents at the facility.
Findings include:
According to the CMS 672 dated 10/16/23 there are 191 residents in the facility.
On 10/15/23 at 9:52AM, a tour of kitchen observed dessert cooler temperature reading at 50 degrees Fahrenheit on the inside and outside temperature gauge. V37 (dietary aide) assisted with Food temperatures measurements of food contained within the dessert cooler and said the thermometer was calibrated and ok to measure food temperatures. The following temperatures were recorded: scrambled eggs at 55 degrees; pureed eggs dated 10/14 at 44 degrees Fahrenheit; chicken alfredo pasta dated 10/14/23 measuring 54 degrees Fahrenheit; pureed bread dated 10/14 measuring 42 degrees Fahrenheit and applesauce dated 10/14/23 measuring 51 degrees Fahrenheit.
Temperature log on the dessert cooler for October 2023 documents: Coolers 40 degrees Fahrenheit and below. 10/15/23 was blank upon tour on 10/15/23. On 10/17/23 the same temperature log for the dessert cooler on 10/15/23 documented broken; no entry for 10/16/23.
According to the food safety and inspection service documents bacteria grow most rapidly in the range of temperatures between 40 degrees Fahrenheit and 140 degrees Fahrenheit, doubling in the number in as little as 20 minutes. This range of temperatures is often called the danger zone.
On 10/15/23 at 9:52AM, there was water leaking from a pipe that appears cracked under the three compartment sink and draining into the front of sinks into a floor drain.
On 10/15/23 at 9:52AM the kitchen vent hood was observed without the filter inserts. The inserts were observed in a bin in the kitchen area. V37(dietary aide) said the hood was cleaned yesterday and they had not been placed back.
On 10/15/23 at 12:20pm, V38(dietary manger) said the inserts need to be in the hood when cooking to collect the grease.
On 10/17/23 at 10:58AM, water observed leaking out of 3 compartment sink. V41(Regional Dietary) said it should not be leaking.
On 10/18/23 at 2:50PM, V10 (Maintenance Director) said he was not aware of a water leak in the kitchen until today when surveyor inquired about the plan to fix it.
Facility policy titled Preventative Maintenance Program dated 11/14 documents: to conduct regular environmental tours/safety audits to identity areas of concerns within the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to follow their policy titled food safety and sanitation when handling food during meal service.
Findings include:
Food service ...
Read full inspector narrative →
Based on observation, interview and record review the facility failed to follow their policy titled food safety and sanitation when handling food during meal service.
Findings include:
Food service observation on 10/15/23 from 12:44pm to 1:38pm.
On 10/15/23 at 12:49pm V37 (Dietary Tech) was observed serving lunch meals. V37 approached the metal cart, scratched his left arm with his right hand and V37's arm turned ashy white from scratching and flakes of dead skin were observed. V37 walked back to the serving stove/cart and V37 resumed with meal service. V37 picked up a plate and plated the meal. That plate of food was served to the resident. V37 did not practice any hand washing or hand hygiene with alcohol based hand rub.
On 10/15/23 at 01:39 PM, V37 said he didn't wash his hands after scratching his arms and touching his glasses throughout the meal service. V37 said he washed his hands before he came up the stairs. V37 said he should have practice hand hygiene after scratching his arm and touching his glasses.
On 10/17/23 at 11:56am V38 (Dietary Manager) said hand hygiene and or hand washing should be performed before meal service, and after touching or scratching a body part. V38 said he has in-serviced his staff.
Facility policy titled food safety and sanitation; hand washing dated 4/2017 denotes in-part the facility will practice safe food handling and avoid cross contamination through proper and adequate handwashing techniques. Employees are required to wash hands upon entering the food service area at the beginning of each shift, touching the hair, face or body.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to have an effective pest control program. This failure affected 5 of 5 (R90, R24, R102, R58, R272) in the sample reviewed for p...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to have an effective pest control program. This failure affected 5 of 5 (R90, R24, R102, R58, R272) in the sample reviewed for pest control. This has the potential to affect all 191 residents.
Findings Include:
According to the CMS 672 dated 10/16/23 there are 191 residents in the facility.
On 10/15/23 at 10:17AM, a dead medium size dark brown elongated bug consistent with a roach was seen on its back in the kitchen's dry storage area behind the refrigerator. V26 (Dietary) said, he was not sure what type of bug was dead behind the refrigerator.
On 10/15/23 at 10:28AM, multiple crawling small and medium size brown bugs consistent with roaches were observed in R90 and R24's room and bathroom. R24 said, we have roaches. The roaches are all under our items. Just move anything and they will come out. They live in the walls and in our bathroom. R90 said, we have roaches in our room. V12 (Nurse) said, those bugs are roaches. We have a problem with roaches.
On 10/15/23 at 1:12PM, small brown elongated bugs consistent with roaches were observed running across the dining table where resident's lunch beverages were being served. Resident's cups of coffee, milk cartoons and sandwiches were located on this table.
On 10/15/23 at 1:16 PM, V4 (CNA) said that there was a roach on the table, the roach ran off the table onto the floor and V4 stepped on it.
On 10/15/23 at 12:44PM, R102 said there were two cockroaches in the dining room this morning.
On 10/15/23 at 12:56PM, a brown, long, bug resembling a cockroach was crawling up the wall in the dining room. R58 called out roach and then smashed it on the wall with his fist. R58 remained in the same location and then ate his lunch. R272 is sitting in front of the bug eating his lunch. After finishing his meal, R58 left the dining room.
On 10/15/23 at 1:15 PM, R102 said, see the bug on the wall (the same one R58 smashed). R102 said, the roaches are disgusting.
On 10/15/23 at 1:20 PM, V5 (Nurse) said, that appears to be a squashed dead bug, when the surveyor asked her what is on the wall.
On 10/18/23 at 2:50pm, and V1 (Administrator) and V10 (Maintenance Director) presented a store receipt for roach trays. V10 said they purchased roach trays for the roaches seen in R24 and R90's rooms. The roaches will go into the house/tray eat the poison and take it back to their nest and die.
Store receipt dated 10/18/23 documents a purchase for 12 pack of roach trays.
Pest control policy undated documents: To prevent or control insects and rodents from spreading disease.
Jul 2023
21 deficiencies
5 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Safe Environment
(Tag F0584)
Someone could have died · This affected 1 resident
Based on interview, and record review, the facility failed to develop and implement an effective maintenance plan to ensure the equipment in the kitchen remains in a proper working condition. As a res...
Read full inspector narrative →
Based on interview, and record review, the facility failed to develop and implement an effective maintenance plan to ensure the equipment in the kitchen remains in a proper working condition. As a result, the facility failed immediately to identify and address a gas leak from the kitchen's cooking appliances and to eliminate the threat of carbon monoxide poisoning. This failure has the potential to affect all residents residing within the facility.
The Immediate Jeopardy began on 7/6/23 when the gas leak was identified in the kitchen by the local fire department. V1 (Administrator) was notified on 7/11/23 at 1:28 PM of the Immediate Jeopardy and a template was presented. The facility presented an initial removal plan on 7/12/23. The plan was accepted on 7/13/23. On 7/14/23 the surveyor conducted an onsite observation, record reviews, and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on 7/12/23.
Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation.
Findings Include:
On 7/6/23 at 11:00AM, V86 (Firefighter) came to the library to notify the survey team of the condition of the appliances in the kitchen and that there was a smell of gas. V86 said V88 (Firefighter) tested the gas lines in the kitchen and found 2 separate leaks on separate appliances. V86 reported the gas company found the same gas leaks the fire department did so they shut the gas off and told them they could not use it until it was repaired.
On 7/6/23 at 2:41PM, V16 (Dietary Manager) stated the flat top grill has not been working for about 1 to 2 months, and maintenance has known that it was broken, but they haven't taken it out of the kitchen yet. V16 stated, maintenance has not had time to break it down. V16 reported the wires were exposed and it was past the point of fixing so it just needed to be disposed. V16 said the flat top grill was also not clean. V16 stated staff has not been using the flat top grill but need to turn it on for the gas to light the other two stoves. V16 stated the fire department said there was a gas leak in the kitchen, so the gas company came out and said the facility had to shut the gas off until it was fixed.
On 7/7/23 at 10:25AM, V88 (Firefighter) stated being on an ambulance call when V86 reported smelling gas in the kitchen. V88 stated two gas leaks were found in the kitchen: One on each different appliance. V88 said that the gas line next to the flat top grill and then the stove was also leaking at the control valves, so the gas company was dispatched to verify the findings. V88 stated the gas company found the same issues so the main gas line was shut down. V88 reported the reading was 4500 ppm and a normal range should be zero. V88 endorsed the gas leaks present a hazard risk because if enough gas accumulates it can trigger an explosion. V88 reported the flat top grill isn't being used because it was in a fire a couple months ago when the fire department was there, and a small gas leak was found at that time. V88 endorsed the facility informed the fire department that they would be fixing it and would be on top of it immediately.
On 7/7/23 at 12:55PM, V15 (Maintenance) stated V86 said the flat top grill wasn't in working condition and that they found a gas leak. V15 reported removing the flat top grill from the kitchen yesterday and fixing the gas leaks with sealant. V15 confirmed the fire department said there was a gas leak on a couple different appliances, so the gas company came out and checked and found the same leaks. V15 said the fire department was called out here back in April for that flat top and there was gas leaking where the knobs were at, and it caught fire. V15 stated the flat top grill has just been giving the facility too many problems lately. V15 stated it wouldn't light with the igniters on the grill, so they had to use one of them long lighters, and when staff uses a lighter, the grill went up in flames a little bit. V15 stated, It was like a big whoosh and then the fire went out. V15 said the facility still called the fire department to investigate, and they just told V15 to not turn it on and to get it fixed. V15 reported the flat top grill wasn't being used, but they did have to turn it on because gas goes through that stove to get to the others (cooking appliances) because they are on the same gas line. V15 stated, the life safety (surveyor) was at the facility around the first of the year and the same problems with a gas leak on one of them (appliances) with some exposed wires was noted. V15 confirmed smelling gas in the kitchen. V15 stated, any time you smell it you should test for it.
On 7/7/23 at 3:43pm, V1 (Administrator) stated V86 smelled gas so V86 called some more firefighters, and they found a gas leak. V1 reported the gas company then came out and said that we had a gas leak as well, and they shut down the gas line. V1 said V15 fixed the gas line by unhooking the one line and giving every appliance their own gas line. V1 stated the kitchen (staff) should have notified maintenance about the repairs that need to be done. V1 said V15 should have disposed of the flat top grill if it was not in working condition, and it should've been done the same day that it was brought to their attention. V1 stated, V1 wasn't notified of the gas leak until maintenance told me that the gas company was on their way. V1 said a gas leak is dangerous because it can cause fire.
On 7/13/23 and 7/14/23 the surveyor verified by observation, interview, and record review that the facility implemented the following to removal plan:
-Education initiated on 7/11/2023 by the Administrator, DON, ADON, Social Service Director completed on 7/11/2023. The education was Ensuring the facility has an effective maintenance plan in place by ensuring the kitchen appliances using natural gas are in good working repair and in good working condition to prevent fire hazards.
-All Staff (Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Agency C.N.A(Clipboard) Housekeeping Director, MDS Coordinators and Maintenance Director, receptionist, dietary aide, Cooks, housekeepers, social service case manager, Social Service Aides, restorative aides, C.N.As, RNs, LPN, activity aides, Laundry aides), including those off duty ( receptionist, Social Service Case Managers, social service assistants, housekeepers, Laundry aides, RNs, LPNs, dietary aides, and cooks) were educated via phone with the same training as the staff educated in person, however, the staff who received the in-service over the phone were notified that they will also be required to attend an in-person training prior to the beginning of the next shift worked. Upon completion of this in-person training staff will sign education sheets. In-service date of completion 7/11/2023.
-The flat top grill was removed from the facility on 7/06/2023. Maintenance Director disconnected the flat top from the gas line and redirected the gas line to the working oven.
-The maintenance director was educated by the facility Administrator on 07/11/2023 to ensure an effective plan is in place to ensure the kitchen appliances are maintained without exposing wiring, igniter unit and clean and free of grease and debris to prevent any potential fire hazards.
-A weekly audit was completed by the Maintenance Director to ensure all kitchen appliances are in good working repair, appliances using natural gas are in good working repair and in a condition that will prevent a fire hazard, the kitchen appliances are free from exposed wires, all kitchen appliances are free from dirt/grease/hazardous conditions, the ignitor unit is clean and free from grease and debris, and the appliance has received weekly deep clean. The initial audit was started and completed on 7/11/23 by the Maintenance Director and reviewed by the Administrator. These audits will continue to be completed weekly by the Maintenance Director and audited weekly by the Administrator. Audit tool attached.
-On 07/11/2023 a meeting was held with the facility IDT members. Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director, Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director to discuss the nature of the IJ and the interventions that were put in place to ensure an effective plan is in place to prevent fire hazards.
-A weekly routine equipment inspection will be conducted by the Maintenance Director or the Assistant Director of Nursing.
The Administrator will review the Maintenance Director's audits to validate completion.
-The Maintenance Director will assess gas leaks during weekly inspection.
-The natural gas detector was ordered on 07/12/2023 by the Administrator with an expected delivery date 07/17/2023.
-No policy changes have been changed.
-Medical Director Dr. was made aware of the IJ.
-Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director. This committee will determine if the audits continue after three months.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on interview and record review, the facility neglected to notify the in-house dialysis and nephrologist that a new resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on interview and record review, the facility neglected to notify the in-house dialysis and nephrologist that a new resident was admitted , neglected to assess the resident after an acute change in condition, neglected to notify the physician of an acute change in condition of a resident experiencing shortness of breath, and neglected to round on a resident every two hours per protocol for one (R50) out of three reviewed for change in condition in a total sample of 56.
The Immediate Jeopardy began on 6/5/23 V1 (Administrator) was notified on 6/21/23 at 12:55 PM of the Immediate Jeopardy. The facility presented an initial removal plan on 6/21/23. The plan was accepted, and 6/27/23 and 6/28/23 the surveyor conducted an onsite record reviews and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on 6/21/23.
Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation.
Findings Include:
R50 is a [AGE] year old with the following diagnosis: end stage renal disease, dementia, and congestive heart failure. R50 was admitted on [DATE] and expired in the facility on 6/5/23.
A Nursing note dated 6/4/23 documents R50 had difficulty breathing. The nurse checked the vital signs and they were within normal limits. The oxygen level was 93%. R50 had bronchi and some wheezes noted in the lung sounds. The nurse elevated the head of the bed and the breathing improved. The oxygen level increased to 97%.
A Nursing note dated 6/5/23 at 1:21 AM documents R50 was talking but sounded upset. R50 would not tell the nurse what was wrong. R50 was sitting up in bed. R50 answered being fine. R50's breathing sounded congested but R50 refused to be suction. R50 was assisted to lie back with head part elevated and covered with a blanket to keep warm. The door was left open so the nurse (V56) could hear R50 if help was needed.
A Nursing note dated 6/5/23 at 7AM documents R50 was changed by the CNA at 5:45 AM. R50 was verbally responsive. Around 6:45 AM, the morning nurse (V20) noted R50 unresponsive. R50's arms were cold and clammy. The second nurse (V56) went to assess R50. Vital signs were checked, but none were appreciated. CPR was not attempted since it was a presumptive death.
On 6/8/23 at 2:00PM, R21 was R50's roommate. R21 stated that R50 was screaming and yelling almost all night. R21 reported that R50 was coughing to the point where R50 was almost choking. R21 endorsed the nurse (V56) came in 1 time and told R50 to sit up and drink some water. R21 stated that R50 never got better and continued to scream, I can't breathe. Help me. R21 denied any staff coming to help R50 while R50 was screaming. R21 endorsed telling R50 to shut up after R50 continued to yell. R21 was not able to give a timeframe on how long R50 was yelling before the yelling stopped because R21 fell asleep. R21 stated waking up around 5-6AM because a bunch of people were in the room talking about how he was dead. R21 endorsed R50 was begging for someone to come help and no one ever came back.
On 6/9/23 at 10:16AM, V22 (CNA) stated when I was coming around the corner, the night nurse (V56) was coming down the hall in a panic saying R50 was dead. The night nurse said that the CNA (V79) changed R50 around 5:45AM and was talking with R50 fine. I think it was an agency CNA but I didn't see her that morning.
On 6/9/23 at 10:50AM, V20 (Nurse) stated I came in about 6:30 or 6:45 that morning. I was going around doing my morning rounds and I called R50's name and R50 didn't respond. I started to do a sternal rub and to pinch R50 and R50 was still unresponsive. I called the night nurse (V56) down there and she came to take some vital signs. There were no vital signs. R50's chest was not moving and R50's pupils were dilated and fixed. Since it was both nurses, we presumed R50 dead. The night nurse said R50 was having some trouble breathing and had some secretions in R50's throat, but R50 refused to be suctioned and did not want oxygen. Usually when someone has a lot of sputum you will call the doctor and send them to the hospital. They cannot breathe. We round on residents every two hours to make sure they are OK or see if they need anything. R50 had end-stage renal failure. Those residents you want to check every shift for vital signs, check the catheter site, and check for edema or fluid overload. If someone is having edema, that means they are holding onto the fluid or if they are having trouble breathing.
On 6/9/23 at 12:01PM, V47 (Detective) stated R21 was alert and told me that R50 was screaming all night. R21 said that R50 was saying R50 couldn't breathe and that R50 needed help.
On 6/9/23 at 12:07PM, V2 (DON) stated if R50 was having any trouble breathing, then a doctor should've been called. If they put in orders that should've been completed but if those didn't help, they should've just been sent out to the hospital. When someone is having a change of condition, I expect staff to do a full assessment, so they can have more information on what is going on with the resident. An assessment should always be completed when there's a change of condition. If a resident was refusing oxygen or suctioning, then I would just call 911 to get them out to the hospital where they can do more for them. I know R50 was a dialysis resident so they should've been monitoring R50 for a fluid overload. That happens when you have too much fluid in your body and it backs up into your lungs so you basically drown.
On 6/9/23 at 3:51PM, V13 (Nurse) stated R50 was coughing and spitting up secretions. R50 just kept spitting them out. I adjusted the head of R50's bed so it was more elevated. The first time I checked him it was 93% and then after R50 raised the head of the bed, it came up to 97%. I passed medications in the morning and R50 wasn't really coughing but when I saw R50 in the afternoon, R50 was coughing a lot. I did not listen to R50 with my stethoscope. I was too busy to listen to R50. I told the next nurse just to monitor R50 because R50 was having a lot of coughing with secretions. I never called the doctor. Yes, this would be considered a change in condition because, R50 was having more secretions and R50's oxygen level was lower. I didn't think to call the doctor at that time. I just passed it on to the next nurse.
On 6/13/23 at 11:08AM, V56 (Nurse) stated it was right before 7 AM when V20 came to get me to tell me that R50 was unresponsive. The CNA (V79) told me that V79 changed R50 around 5:45AM, and R50 was talking fine. I checked on R50 at 1 AM. R50 was talking in an angry voice, so I thought R50 was crying. I went to R50's room and R50 told me R50 was fine. I asked if R50 was congested and R50 said no R50 was fine. I didn't hear anything else from R50 that night. R50 sounded congested. When I went to check on R50 at the time (1AM), I could hear R50 congested when R50 talked. I didn't listen to R50 with my stethoscope. It was at the nurse's station so I couldn't listen to R50. I could hear R50 was congested in R50's throat. I elevated the head of R50's bed. I tried to suction R50, but R50 refused. I did not take any vital signs. That was my first time seeing him at 1 AM. It just sounded like R50 had stuff in R50's chest and in R50's throat. The nurse before me said R50 was congested and coughing a lot. R50 did not have any orders. We normally do rounds every two hours. The last time I checked on R50 was at 1 in the morning. I didn't check on R50 after that because I was busy. I think the CNA was checking on R50. When I talked to V79, V79 said V79 checked on R50 at 5:45. I didn't see V79 go in the room. I didn't call the doctor about R50 sounding congested. R50 was new, so I wasn't really sure if that's how R50 normally was. It didn't seem that serious to me. I did hear R50 talking still during the night. I don't know who R50 was talking to and I don't know what R50 was saying. You call the doctor anytime there's a major change in a resident. I don't know why I didn't call the doctor. I was just very busy.
On 6/15/23 at 12:06PM, V66 (Nurse) stated the nurse before me actually admitted R50. I did get R50's medication ordered, but that was the only thing. I didn't order dialysis at that time because that was the only important thing to order because of the time of night it was. I know R50 was getting dialysis. Those residents you have to watch for fluid overload. Fluid overload would be a resident having trouble breathing or needing oxygen when they didn't before. Dialysis isn't there on the weekend, so if any residents are having problems with breathing because their fluid overloaded then you just send them out to the hospital for an extra treatment. I didn't call the doctor for an order for dialysis. I was only able to put in the medication at that time.
On 6/15/23 at 2:16PM, V30 (Dialysis Administrator) stated when the facility is looking over the paperwork and see that they need dialysis, they will send over the referral information to our department. The facility give us an estimated date of arrival and they will let us know when the resident is actually admitted to the facility. The floor nurse will call us if we are here. Otherwise, we get an email from someone in the facility. For dialysis residents, you want to monitor for signs and symptoms of fluid overload, the vital signs, any infections to their access site. Signs of fluid overload would be trouble breathing, swelling anywhere, decreased oxygen saturations, and diminished lung sounds. If a resident is experiencing something like this, the only treatment really for them would be to get dialysis. A doctor should be immediately notified. The breathing treatment and suctioning is not something that would help a resident having respiratory distress if they are getting dialysis. The fluid needs to be removed from buildup in the blood. If they don't send them out 911 at the very least, the physician should be notified that the resident is having changes in the respiratory status. If they're having trouble breathing, then 911 should be called immediately. I have no notification that R50 actually arrived to the facility.
On 6/15/23 at 3:20PM, V69 (Nephrologist) stated I am notified of a new resident in the building by the company contracted for dialysis. I was never notified that R50 was in the facility or that R50 was coming. We never do an extra treatment for a new admission, if anything was off, he would need to be sent to the hospital. Dialysis patients can have very serious situations occur pretty quickly. The most prominent is fluid buildup in the lungs. Since I didn't get a notification that the resident was in the facility, I would expect the nurse to notify the Medical Director or primary physician. These residents can go into respiratory distress fairly quickly and need urgent dialysis. If a resident is unstable, you should default and just call 911. This resident has no IV and dialysis cannot be done in the facility. Oxygen would only be a temporary fix. Suctioning would not help a resident in fluid overload because it would never get the fluid off that needs to come off in certain areas. A physician should be notified immediately that this is going on. If R50's not at the level to be sent out to the hospital yet; then staff need to be keeping a closer eye on R50 to make sure things don't become worse.
On 6/15/23 at 3:47PM, V46 (Nurse) stated R50 was admitted around 7 PM, but at that time we had no Internet. I couldn't complete the admission on the computer. I don't remember anything about dialysis or R50 needing extra dialysis. The admitting nurse will also check the paperwork from the hospital to make sure that all the orders are in place. When the system is working, we normally call the doctor and let them know that they are here and on dialysis. They will put in all the orders regarding dialysis. For those type of residents, you just want to make sure that you were doing assessments for fluid overload. I didn't tell the dialysis company that they were here. If someone is having a change in the respiratory status, you should listen to the lungs and see if they are congested. You should also do their vital signs and notify the doctor. For a dialysis resident any respiratory distress can mean that they have extra fluid in their body. Usually for cases like that they get sent out to the hospital for evaluation and extra dialysis. If you have extra fluid in your body, it usually backs up into your lungs causing you not to be able to breathe better.
On 6/16/23 at 1:40PM, V19 (ADON) stated the nurse will either do the admission or pass it onto the next shift depending on what time the patient comes. Also, the DON and ADON will make sure everything is completed the next time later in the facility. When we are not here, it is just the nurses responsibility to get the orders. If dialysis is in the building, then the nurse will call down to let dialysis know. The nurse will also review the paperwork from the hospital to make sure the orders are correct. If a resident is having any type of change in condition, then the nurse practitioner or physician must be notified. They should call as soon as it is noticed. They either need to get orders for some type of treatment or to be sent out if there's any type of change then they should always call to see what should be done. They should also do another assessment if there's a change. They should check the vital signs, check their mental status, check for pain, and check the area of the complaint. If it is specifically for respiratory distress or shortness of breath, then the head of the bed should be elevated and the oxygen level should be checked. The doctor should immediately be called for a situation like this. If their doctor gave orders and there's no relief, the doctor should be called back or 911 should be called if they get worse. Rounds are done every two hours. This let's us check on the residents to see how they are doing and if they need anything. If a resident is having a change of condition, they need to round every two hours just to make sure it hasn't changed. Dialysis residents can have fluid overload because they cannot urinate. They cannot get the fluid out of their body. This can cause respiratory distress. If there is too much, then they cannot breathe and need a dialysis treatment or to be sent to the hospital.
On 6/20/23 at 12:49PM, V1 (Administrator) stated the Internet went down around 2:30PM that Friday and didn't come back until 1AM on Saturday. The nurses were trying to do all the admissions on their phones. I was asking if anything happened over night and no one could give me an answer that would make me think R50 was going to die. If something crazy happens with a resident where they need attention right away I would expect them to call 911. If it is something they can manage then they should call the doctor first. If they aren't breathing right or they need immediate interventions then 911 should be called immediately. Dialysis gets notified before they get here so they can also approve the patient and have everything set up when they arrive. The order for dialysis should have been put in once R50 arrived. I know the Internet was down so it should have been put up once everything was up and running. I talked with the nurses that admitted R50 and both were kind of blaming each other for all the orders not being put in. Myself, the DON, or our marketer will notify the dialysis center through email when they are arriving. When they arrive to the facility an email is sent when they get here so they can get things set up. I know they knew R50 was coming that day but since the Internet was down I don't know if something got lost in translation. I don't know if they were notified when R50 was actually admitted . The admitting nurse is responsible for going through the paperwork and making sure all the orders from the hospital are carried over and going through them with the doctor.
The Admission/readmission Screen are dated 6/3/23 documents R50 admitted to the facility on [DATE] at 7 PM. R50 was admitted from the hospital. Vital signs were taken and within normal limits. R50 is alert and oriented to person and place. R50 has a regular respiratory rate with no cough. Breath sounds on the left side are clear and on the right side has a slight rhonchi. R50 is able to clear the rhombic. R50 has a dialysis schedule of Monday, Wednesday Friday with a dialysis port to the left upper chest.
Emails between the in-house dialysis and the facility were submitted for review. An email on 6/2/23 at 10:36AM from the in-house dialysis to the facility documents the in-house dialysis was asking for confirmation that R50 was being admitted to the facility that day. The facility replied to this email at 10:37AM confirming R50 is scheduled to arrive on 6/2/23. This is no more email confirmation letting the in-house dialysis what time R50 arrived. There is no email communication on 6/5/23. An email on 6/7/23 at 3:44PM from the in-house dialysis to the facility documents the in-house dialysis asked if the facility was still expecting R50. This confirms the in-house dialysis had no knowledge R50 was admitted to the facility. The facility replied to this email at 10:41PM letting in-house dialysis know R50 expired.
The Physician Order Summary documents a renal diet order was placed on 6/3/23. There are also orders for 11 medications placed on 6/3/23 and 6/4/23. There is no documentation of a dialysis order or anything pertaining to dialysis.
The policy tilted, Dialysis Care, dated 1/1/21 documents, Purpose: To adequately assess residents needs and provide care goals which achieve the highest practicable level of care to residents with end stage renal disease receiving hemodialysis or peritoneal dialysis. Procedure: 1. Arrangements should be made prior to admission for acquisition and storage of supplies, location and type of dialysis and room accommodations.
The policy titled, Supervision and Safety, dated 03/2015 documents, . 10. Staff to make visual rounds on residents minimally every 2 hours and more often if necessary based on resident's assessment needs.
The policy titled, Change in Resident's Condition, dated 2/1/22 documents, General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician/NP, and resident's responsible party of a change in condition. Responsible Party: RN, LPN, Social Services. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. b. There is a significant change in the resident's physical, mental, or emotional status . e. It is deemed necessary or appropriate in the best interest of the resident. 2. Appropriate assessment and documentation will be completed based on the resident's change in condition or indication . 4. The communication with the resident and their responsible party as well as the physician/NP will be documented in the resident's medical record or other appropriate documents.
On 6/27/23 and 6/28/23 the surveyor verified by interview and record review that the facility implemented the following to remove the immediacy:
-Education initiated on 6/21/2023 by the Administrator, DON, Restorative Nurse, Social Service Director, Dietary Manager completed on 6/21/2023.
-Prior to residents being admitted to the facility, the facility (Administrator/DON/ Social Service Director/RN/LPN) team must communicate/coordinate with in-house dialysis that the resident is admitting to the facility.
-During the referral process the facility team (Administrator/DON/Social Service Director) will communicate via email with the Dialysis Director on resident ' s admission/readmission date to the facility.
-DON will notify Team (RN/LPN) via admission Notice of residents scheduled admission.
-The staff nurse (RN/LPN) will contact the Nephrologist upon resident admission to the facility that the resident has arrived and will obtain admission orders and place the orders into PCC.
-Facility staff (RN/LPN) must notify the nephrologist that a resident in need of dialysis has been admitted to the facility.
-The facility nurse (RN/LPN) must assess all residents who are having an acute condition change (shortness of breath).
-The facility nurse (RN/LPN) must notify the physician of any resident having an acute change in condition (having shortness of breath).
-Rounding: Facility staff will obtain their assigned schedule and conduct rounds. Facility staff (RN/C.N.A/Social service aids) will then round every two hours
-All Staff (Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Agency C.N.A(Clipboard) Housekeeping Director, MDS Coordinators and Maintenance Director, receptionist, dietary aide, Cooks, housekeepers, social service case manager, Social Service Aides, restorative aides, C.N.As, RNs, LPN, activity aides, Laundry aides), including those off duty ( receptionist, Social Service Case Managers, social service assistants, housekeepers, Laundry aides, RNs, LPNs, dietary aides, and cooks) was educated via phone with the same training as the staff educated in person, however, the staff who received the in-service over the phone were notified that they will also be required to attend an in-person training prior to the beginning of the next shift worked. Upon completion of this in-person training staff will sign education sheets. In-service date of completion 6/21/2023.
-There were no changes made to the rounding policy.
-Facility staff (RN/LPN/C.N.A/Social Service Aids) will check their assigned group upon arriving to duty.
-Nurse to Nurse rounds will be conducted at shift change then every two hours.
-C.N.A to C.N.A round will be conducted at shift change then every two hours.
-Social Service Assistant will conduct rounds every two hours while on duty.
-Ongoing education will be provided to all staff on notifying the in-house dialysis that the resident was admitted . The facility nurse (RN/LPN) to notify the nephrologist of the resident ' s requiring dialysis has been admitted to the facility, staff nurses (RN/LPN) to follow the facility policy and assess residents who have been identified of having an acute change of condition and to notify the physician immediately. Staff educated on the importance of conducting rounds every two hours. All in services were completed on 6/21/2023.
-A baseline audit was completed by the DON on 6/21/2023 to identify if any newly admitted resident or potential admits that have a diagnosis of ESRD needing dialysis services. The audit will continue weekly for three months by the DON/Restorative Nurse. Audit tool attached.
-On 6/21/2023 a meeting was held with the facility IDT members. Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director.
-RN, LPN, Social Workers, Social Service Assistance, and C.N.As will conduct rounds every two hours.
-No policy changes have been made to the change in condition policies.
-Medical Director was made aware of the IJ.
-Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director. This committee will determine if the audits continue after three months.
2. Based on observations, interviews, and record reviews, the facility neglected to ensure a resident recieved activities of daily living, food and water during a 24 hour period. This failure affected one resident (R18) reviewed for neglect. This failure resulted in R18 family removing R18 from the facility AMA (Against Medical Advise)
Findings include:
On 6/1/23, V1 (Administrator) stated that there is no POC (point of care) charting found in R18's medical record for 3/16/23 or 3/17/23. V1 presented a documented noting no POC documentation.
On 6/13/23 at 3:40pm, V59 CNA (Certified Nurse Aide) stated that he provides care only to his assigned residents. V59 reviewed the assignment sheet for 3/16/23 3:00pm-11:00pm shift. V59 stated that he was assigned to rooms 223A-233B. V59 stated that he was not assigned to provide care to any residents in room [ROOM NUMBER]. V59 stated that he is responsible for completing his charting in this facility's computer system, POC, prior to leaving at end of each shift worked. V59 stated that if he was assigned to R18, he would have documented on him.
On 6/14/23 at 9:40am, V64 CNA stated that V64 does not recall R18. V64 stated that all care she provides to her assigned residents is documented in the resident's electronic medical record, POC charting.
Review of this facility's CNA assignment sheet for 3/16/23 3:00pm-11:00pm, does not note a CNA was assigned to provide care to R18 in room [ROOM NUMBER].
Review of this facility's CNA assignment sheet for 3/17/23 7:00am-3:00pm notes V64 was assigned to R18.
Review of this facility's CNA assignment sheet for 3/17/23 3:00pm-11:00pm, does not note a CNA was assigned to provide care to R18 in room [ROOM NUMBER].
Review of R18's POS (physician order sheet), dated 3/16/23, notes orders for vital sign monitoring every shift for three days then daily; weekly weights; general diet; and Braden score for skin breakdown on admission and weekly x 4.
Review of R18's vital sign documentation notes R18's vital signs were obtained on 3/17 at 00:04am and 8:07am.
There is no documentation noting R18's weight was obtained.
R18's POC (point of care) charting for 3/16/23 and 3/17/23 was reviewed. There is no documentation found noting R18 received morning care, evening care, incontinence care, meals and amount eaten, fluid intake, or bedtime snack.
Review of R18's medical record does not note a Braden score assessment was completed.
Review of R18's progress notes, dated 3/16/23 at 10:43pm, V46 (nurse) noted R18 requires extensive staff assist with ADL's and transfers. Incontinent of bowel and bladder functions. On 3/17 at 00:03am, R18's vital signs were noted. The next documentation in R18's progress notes was 3/17 at 7:30pm when R18's family member removed R18 from this facility against medical advice.
Review of R18's pre-admission hospital record, dated 3/16/23 at 4:29pm, notes R18 requires assistance with ADLs. Review of R18's referral packet, dated 3/10/23, notes R18 with frequent falls secondary to progression of underlying Parkinson's disease. Occupational Therapy noted R18 presents with impaired balance, coordination, and cognitition which limit safety with ADLs.
3.Based on interview and record review, the facility failed to follow their abuse policy, failed to prevent resident to resident abuse both verbal and physical. This affected 4 of 4 (R2-R5) residents reviewed for abuse. This failure resulted in R2 calling R3 a racial slur and R5 punching R4 repeatedly with a closed fist.
Findings Include:
R2 is an [AGE] year old with the following diagnosis: dementia and bipolar disorder. R2 admitted to the facility on [DATE].
R3 is a [AGE] year old with the following diagnosis: bipolar disorder and paranoid schizophrenia. R3 admitted to the facility on [DATE] and discharged on 6/17/23.
On 6/1/23 at 12:08PM, R3 stated that R2 was throwing food out the window so R3 reminded R2 to keep food inside. R3 endorsed R2 became upset at R3 for telling R2 what to do. R3 reported R2 began to yell at R3 and called R3 the N-word. R3 stated everyone started yelling after that so R3 was not able to remember exactly what was said, but knows R2 called R3 the N-word. R3 reported staff then came into the dining room and removed R2.
On 6/1/23 at 12:28PM, R2 doesn't remember the incident with R3. R2 admitted to saying the N-word but not where other people can hear it. When it was brought to R2's attention that R3 heard R2 call R3 the N-word. R2 did not want to speak any more on that incident.
On 6/6/23 at 10:16AM, V3 (Asst Social Service Director) stated I have heard R2 say the 'N word' a few times so I believe that happened. Saying the 'N word' should be considered aggressive behavior. This would be verbal abuse because R2 verbally assaulted R3.
On 6/7/23 at 1:50PM, V35 (Nurse) stated R2 does have a habit of using the N-word. R2 has said it to both residents and staff. Any kind of racial slurs would be considered verbal abuse.
On 6/20/23 at 12:49PM, V1 (Administrator) stated I don't remember this situation. Saying the N-word to someone else would be derogatory and considered verbal abuse.
An Event note dated 4/13/23 documents R2 is alert and oriented times 3. It was reported to staff that R2 had initiated verbal aggression towards R3. Both residents were separated immediately.
The Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors dated 1/8/23 documents a total score of 5 indicating a substantial or significant problem with aggressive behavior for R2.
The Minimum Data Set (MDS) Section B dated 12/31/22 documents R2 has the ability to express ideas and wants and has the ability to understand others with no deficits. Sections C of the MDS documents a Brief Interview for Mental Status score is a 10 (moderate cognitive impairment).
A Care Plan dated 3/4/23 documents R2 displays socially inappropriate and maladaptive behavior due to a diagnosis of dementia, dysfunctional behavior, and mental illness. R2 has periods of anger and agitation. R2 presents with signs and symptoms of persistent anger towards self and others. This problem is manifested by verbal hostility and abuse as well as physical hostility and abuse. R2 makes negative sarcastic remarks with frequent complaints. R2 displays angry outbursts towards staff and sometimes makes racial slurs towards peers. The Care Plan dated 4/13/23 documents R2 has a history of aggressive and inappropriate behavior. The history includes conflict/altercations with others, threatening behavior, verbal or physical aggression, acting impulsively and disrespectful demeaning behavior. R2 has a history of aggressive behavior toward peers and staff.
The Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors dated 1/23/23 documents a total score of a 4 indicating R3 is at a substantial risk for abuse due to an increase in vulnerability, mental health diagnosis, diagnosis of depression, and denial or evasiveness when discussing mental health issues.
The Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score as 14 (no cognitive impairment).
An Event note dated 4/13/23 documents R3 received verbal aggression from a peer. Both residents were separated immediately. R3 was encouraged to utilize coping skills. R3 was receptive to counseling.
The Care Plan dated 4/14/23 documents the comprehensive assessment reveals a history of suspected abuse and/or neglect or factors that increase R3's susceptibility to abuse/neglect. R3 is at risk for abuse and risk factors include history of irritability, delusional thoughts, auditory hallucinations, confusion, poor insight, verbal aggressive behavior, wandering, and dysfunctional behavior.
The Facility Reported Incident dated 4/19/23 documents R3 received verbal aggression from R2 in the first floor dining hall. R3 observed R2 sliding food out of the window. R3 verbalized to R2 to not do this. R2 stated to R3 to mind, your ni**er business. Both residents were separated immediately and counseled on appropriate behavior.
R4 is a [AGE] year old with the following diagnosis: major depressive disorder. R4 admitted to the facility on [DATE].
R5 is a [AGE] year old with the following diagnosis: schizophrenia and dementia. R5
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Employment Screening
(Tag F0606)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its abuse policy and thoroughly review an employee applicati...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its abuse policy and thoroughly review an employee application documenting history of conviction of a crime and child abuse. The facility hired the employee and failed to report with known knowledge of action from the courts to the State Agency. This affected 1 of 60 staff reviewed for background checks. This system failure has the capacity to affect all residents (214) residing in the facility.
The Immediate Jeopardy began on 2/7/23. V1 (Administrator) was notified on 6/21/23 at 12:55 PM of the Immediate Jeopardy. The facility presented an initial removal plan on 6/21/23. The plan was accepted, and on 6/27/23 and 6/28/23 the surveyor conducted onsite record reviews and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on 6/21/23.
Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation.
Findings include:
On 5/31/23 at 10:42 AM, V1 (Administrator) said V27 is currently on hold as an employee and said she received an anonymous call saying V27 is a murderer. V1 said the caller accused the facility does not do background checks. V1 said V27's employee background checks were done and V27 had no disqualifiers noted. V1 said V27 took the CNA class and was ready to become certified however, V1 is unaware of V27 taking the CNA exam. V1 interviewed V27 and was told V27 went to jail for murder in TN. V1 said the employee's daughter is still alive. V1 said V27 is trying to get the conviction expunged from her record. V1 said V27 presented a letter saying the expungement is in process. V1 said the facility is requesting court documents and lawyer paperwork. V1 said V27 has not produced paperwork. V1 said V27's files are sealed, and this may be keeping the documents delayed. V1 said Human Resources Personnel are responsible for reviewing the employee application. V1 said she was not aware of V27's felony conviction. V1 said the facility received an anonymous call and caller told V1 they hired a convict.
On 5/31/23 at 12:48 PM, V8 (Human Resources Personnel/ Assistant Administrator) said she is responsible for reviewing employee applications. V8 said she did not notice the wrongful conviction in the employment application. V8 said she did a background check and found the employee was ok to work per employee background checks. When V8 did the background check they came back as eligible, and she looked no further. V8 said she did not see the felony conviction documented in the employee application. V8 said she would have shown corporate office and they would have done extensive background checks. V8 said if she saw the felony conviction, she would have not hired the employee. V8 said she made the error of scanning margins for no responses and missed the detailed writing stating the felony conviction. V8 said employee started [DATE]th through [DATE]th (date of anonymous call received). V8 said employee applied on 1-30-23. V8 said employee was a Resident Assistant (RA) throughout her employment. V8 said she was unsure if V8 was able to work at the facility and was asking the surveyor to clear V27 to return to work.
On 6/7/23 at 9:01 AM, V1 (Administrator) said V27 applied on 1-30-23, background checks were done on 1-30-23 and started 2-7-23 working as Resident Assistant . V1 said after 30 days, V27 is eligible for CNA training class. V1 said CNA training classes are done in Joliet. V1 said V27 was in CNA classes 3-6-23 to 4-17-23. V1 said CNA class is for 2 months. V1 said V27 started as CNA on 4-5-23. V1 said employee can work as a CNA for 120 days, license pending to sit for exam. V1 said she was not aware of R27's child abuse conviction upon hiring. V1 said if known V27 had a conviction, V27 would have not been hired. V1 said employee does not work here. V1 said facility asked for further documents in regard to expungement and V27 did not provide documentation for over 30 days.
2On 6/7/23 at 10:17 AM, V8 (Human Resources Personnel/ Assistant Administrator) said V27 applied 1-30-23, background checks done on 1-30-23, biometric fingerprint on 1-30-23, orientation and started working on 2-7-23 (as RA). V8 said V27 started working as CNA on 4-5-23. V8 said she is unsure of date of phone call received. V8 said V27 was fired due to not providing documentation 30 days after phone call and no documents provided. V27's Legalaid paper is not clear about V27's conviction expungement. V8 told V27 she had 30 days to provide more documents and V27 has not done so.
On 6/12/23 at 10:29 AM, V27 said she started work in February 2023. V27 said she reviewed her conviction with Human Resources and Scheduler upon hire. V27 said she was removed from the schedule on 4/10/23 and she has not been terminated. V27 said she was not called by anyone at the facility or given a written notice for termination. V27 said she was removed for the schedule after a phone call that reported V27 killed her daughter by V1 (Administrator). V27 said she was placed on hold pending submitting paperwork regarding the conviction. V27 said she was told once everything clears, V27 would be given back pay for the days she was off the schedule. V27 said she was called about the paperwork related to her conviction the day IDPH surveyors walked in the building.
V27's Court Record (dated 9-6-18) documents: Petitioner, (V27), was indicted by the [NAME] County Grand [NAME] for one count of attempted first degree murder. Petitioner pleaded guilty to the amended charge of attempted second degree murder and received a sentence as a Range I offender of eight years in the Tennessee Department of Correction.
V27's Employee File does not show any documentation of termination nor any documentation of reporting conviction to the State Agency.
V1's Timeline (no date) does not document any notification of conviction to State Agency.
Application For Employment (dated 1-30-23) documents: Have you ever been convicted of a crime? Yes. If yes, explain: wrongful conviction pending lawsuit. Have you ever been convicted of, or do you have a prior employment history of child or resident abuse, or mistreatment? Yes, If yes explain: wrongful conviction pending lawsuit. 17. Were you ever convicted of a felony or released from prison after a felony during the year before you were hired? If yes, enter date of conviction: 9-18-15 and date of release: 2-10-21. Was this a federal: No or a State conviction: TN.
Abuse Prevention Program Facility Policy and Procedure (reviewed 1-18) documents: This facility will not knowingly employ any staff convicted of any of the crimes listed in the Illinois Healthcare Worker Background Check Act (unless waivered under the provision of the Act) or with findings of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property listed on the Illinois Health Care Worker Registry.
On 6/27/23 and 6/28/23 the surveyor verified by interview and record review that the facility implemented the following to remove the immediacy:
-V27 no longer works at the facility.
-V8 (HR) was thoroughly trained in an effective application review process, that includes investigating admission of felony conviction on 6/21/2023. This training was completed on 6/21/23.
-The Administrator, DON, and Assistant Social Service Director will continue to educate staff on completing a thorough review of a new employment application with an emphasis on investigating admission of felony convictions. Staff includes Business Office, Admissions, Human Resources, and Social Services.
-Ongoing education will be provided to staff on thoroughly reviewing a new employment application with an emphasis on investigating admission of felony convictions. Staff includes Business Office, Admissions, Human Resources, and Social Services.
-A baseline audit was completed on 6/21/2023 by the Director of Human Resources. This audit included a review of the applications on file for all current staff as well as a review of background checks for all current staff. All current staff includes Nursing, Certified Nursing Assistants, Housekeepers, Dietary, Activities, Business Office, Admissions, Human Resources, Wound Care, Medical Records, Staffing, MDS, Maintenance, and Social Services. Routine audits will be conducted weekly by the HR Director to ensure ongoing compliance.
-On 6/21/2023 a meeting was held with the facility IDT members. Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director. The facility will not hire an employee or engage an individual who was found guilty of abuse, neglect, exploitation, or mistreatment or misappropriation of property by a court of law; or who has a finding in the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, or has a disciplinary action in effect taken against his/her professional license. The facility will report knowledge of actions by a court of law against an employee that indicates the employee is unfit for duty.
-Upon hire the facility will initiate a reference check from previous employers.
-Obtain a copy of state license of any individual being hired for a position requiring a professional license.
-Check the Illinois Heath Care Worker Registry on an individual being hired for prior reports of abuse, neglect or misappropriation of resident property, previous fingerprint check results, and sexual offender Website links on the Registry.
-Initiate an Illinois State Police Livescan fingerprint check for any unlicensed individual being hired without a previous fingerprint check.
-Upon the facility (Administrator/ Assistant Administrator) has known knowledge of action from the court against a new employee, the facility will notify the state nurse aide registry, IDPH, and IDFPR .
-No policy changes have been made to the healthcare worker background check policy.
-Medical Director was made aware of the IJ.
-Audits are being conducted weekly by the HR Director to ensure thorough backgrounds are being checked upon hire, and applications are reviewed for criminal background checks. The QAPI committee determine if the audits will continue after three months.
-Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on interview and record review, the facility failed to notify the in-house dialysis and nephrologist that a new residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on interview and record review, the facility failed to notify the in-house dialysis and nephrologist that a new resident was admitted , failed to assess the resident after an acute change in condition, neglected to notify the physician of an acute change in condition of a resident experiencing shortness of breath, and failed to round on a resident every two hours per protocol for one (R50) out of three reviewed for change in condition in a total sample of 56. This failure caused R50 to have an acute change of condition and subsequently expire.
The Immediate Jeopardy began on [DATE]. V1 (Administrator) was notified on [DATE] at 12:55 PM of the Immediate Jeopardy. The facility presented an initial removal plan on [DATE]. The plan was accepted, and [DATE] and [DATE] the surveyor conducted an onsite record reviews and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on [DATE].
Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation.
Findings Include:
R50 is a [AGE] year old with the following diagnosis: end stage renal disease, dementia, and congestive heart failure. R50 was admitted on [DATE] and expired in the facility on [DATE].
There is one set of vital signs documented for R50's entire stay on [DATE] at 6:34 AM.
A Nursing note dated [DATE] documents R50 had difficulty breathing. The nurse checked the vital signs, and they were within normal limits. The oxygen level was 93%. R50 had bronchi and some wheezes noted in the lung sounds. The nurse elevated the head of the bed and the breathing improved. The oxygen level increased to 97%.
A Nursing note dated [DATE] at 1:21 AM documents R50 was talking but sounded upset. R50 would not tell the nurse what was wrong. R50 was sitting up in bed. R50 answered being fine. R50's breathing sounded congested but R50 refused to be suction. R50 was assisted to lie back with head part elevated and covered with a blanket to keep warm. The door was left open so the nurse (V56) could hear R50 if help was needed.
A Nursing note dated [DATE] at 7AM documents R50 was changed by the CNA at 5:45 AM. R50 was verbally responsive. Around 6:45 AM, the morning nurse (V20) noted R50 unresponsive. R50's arms were cold and clammy. The second nurse (V56) went to assess R50. Vital signs were checked, but none were found. CPR was not attempted since it was a presumptive death.
The Police Report dated [DATE] documents the police were called at 5:15 PM and arrived on scene at 5:51 PM. The family member of R50 wanted documentation due to R50 dying and there were reports of a verbal argument between R50 and R21 the previous night. V1 reported the CNA last checked on R50 around 5:45 AM on [DATE]. The day nurse began the shift at 6:30 AM and checked on R50 around 6:45 AM where R50 was found unresponsive. V1 reported there was a verbal altercation between R50 and R21 the night of [DATE]. R21 complained to staff that R50 was talking to himself loudly making it difficult for R21 to sleep. R21 reported telling R50 to shut up but at no point did they ever make physical contact. Due to nursing staff, not following proper protocol, the police department, fire department, and the on-call detective were not notified of R50's passing for nearly 12 hours.
On [DATE] at 1:42PM, V75 (Family Member) stated I got a phone call at 2 PM from someone at the facility. They told me that R50 had died. I did have a call from a blocked number at about 9 AM. The voicemail said that R50 had gotten into an argument with R21, and they last checked on him around 5:30 AM and R50 was fine. The morning nurse went in there around 6:45am and found R50 unresponsive and tried to resuscitate R50 but couldn't revive R50. They said anything about R50 having a hard time breathing.
On [DATE] at 2:00PM, R50's roommate, R21, stated that R50 was screaming and yelling almost all night. R21 reported that R50 was coughing to the point where R50 was almost choking. R21 endorsed the nurse (V56) came in 1 time and told R50 to sit up and drink some water. R21 stated that R50 never got better and continued to scream, I can't breathe. Help me. R21 denied any staff coming to help R50 while R50 was screaming. R21 endorsed telling R50 to shut up after R50 continued to yell. R21 was not able to give a timeframe on how long R50 was yelling before the yelling stopped because R21 fell asleep. R21 stated waking up around 5-6AM because a bunch of people were in the room talking about how he was dead. R21 endorsed R50 was begging for someone to come help and no one ever came back.
On [DATE] at 10:16AM, V22 (CNA) stated when I was coming around the corner, the night nurse (V56) was coming down the hall in a panic saying R50 was dead. The night nurse said that the CNA (V79) changed R50 around 5:45AM and R50 was talking fine. I think it was an agency CNA, but I didn't see her that morning.
On [DATE] at 10:50AM, V20 (Nurse) stated I came in about 6:30 or 6:45 that morning. I was going around doing my morning rounds and I called R50's name and R50 didn't respond. I started to do a sternal rub and to pinch R50 and R50 was still unresponsive. I called the night nurse (V56) down there and she came to take some vital signs. There were no vital signs. R50's chest was not moving and R50's pupils were dilated and fixed. Since it was both nurses, we presumed R50 dead. The night nurse said R50 was having some trouble breathing and had some secretions in R50's throat, but R50 refused to be suctioned and did not want oxygen. Usually when someone has a lot of sputum you will call the doctor and send them to the hospital. They cannot breathe. We round on residents every two hours to make sure they are OK or see if they need anything. R50 had end-stage renal failure. Those residents you want to check every shift for vital signs, check the catheter site, and check for edema or fluid overload. If someone is having edema, that means they are holding onto the fluid or if they are having trouble breathing.
On [DATE] at 12:01PM, V47 (Detective) stated R21 was alert and told me that R50 was screaming all night. R21 said that R50 was saying R50 couldn't breathe and that R50 needed help.
On [DATE] at 12:07PM, V2 (DON) stated if R50 was having any trouble breathing, then a doctor should've been called and if they put in orders that should've been completed but if those didn't help, they should've just been sent out to the hospital. When someone is having a change of condition, I expect staff to do a full assessment, so they can have more information on what is going on with the resident. An assessment should always be completed when there's a change of condition. If a resident was refusing oxygen or suctioning, then I would just call 911 to get them out to the hospital where they can do more for them. I know R50 was a dialysis resident, so they should've been monitoring R50 for a fluid overload. That happens when you have too much fluid in your body, and it backs up into your lungs so you basically drown.
On [DATE] at 3:51PM, V13 (Nurse) stated R50 was coughing and spitting up secretions. R50 just kept spitting them out. I adjusted the head of R50's bed so it was more elevated. The first time I checked him it was 93% and then after R50 raised the head of the bed, it came up to 97%. I passed medications in the morning and R50 wasn't really coughing but when I saw R50 in the afternoon, R50 was coughing a lot. I did not listen to R50 with my stethoscope. I was too busy to listen to R50. I told the next nurse just to monitor R50 because R50 was having a lot of coughing with secretions. I never called the doctor. Yes, this would be considered a change in condition because, R50 was having more secretions and R50's oxygen level was lower. I didn't think to call the doctor at that time. I just passed it on to the next nurse.
On [DATE] at 11:08AM, V56 (Nurse) stated it was right before 7 AM when V20 came to get me to tell me that R50 was unresponsive. The CNA (V79) told me that V79 changed R50 around 5:45AM, and R50 was talking fine. I checked on R50 at 1 AM. R50 was talking in an angry voice, so I thought R50 was crying. I went to R50's room and R50 told me R50 was fine. I asked if R50 was congested and R50 said no R50 was fine. I didn't hear anything else from R50 that night. R50 sounded congested. When I went to check on R50 at the time (1AM), I could hear R50 congested when R50 talked. I didn't listen to R50 with my stethoscope. It was at the nurse's station so I couldn't listen to R50. I could hear R50 was congested in R50's throat. I elevated the head of R50's bed. I tried to suction R50, but R50 refused. I did not take any vital signs. That was my first time seeing him at 1 AM. It just sounded like R50 had stuff in R50's chest and in R50's throat. The nurse before me said R50 was congested and coughing a lot. R50 did not have any orders. We normally do rounds every two hours. The last time I checked on R50 was at 1 in the morning. I didn't check on R50 after that because I was busy. I think the CNA was checking on R50. When I talked to V79, V79 said V79 checked on R50 at 5:45am. I didn't see V79 go in the room. I didn't call the doctor about R50 sounding congested. R50 was new, so I wasn't really sure if that's how R50 normally was. It didn't seem that serious to me. I did hear R50 talking still during the night. I don't know who R50 was talking to, and I don't know what R50 was saying. You call the doctor anytime there's a major change in a resident. I don't know why I didn't call the doctor. I was just very busy.
On [DATE] at 12:06PM, V66 (Nurse) stated the nurse before me actually admitted R50. I did get R50's medication ordered, but that was the only thing. I didn't order dialysis at that time because that was the only important thing to order because of the time of night it was. I know R50 was getting dialysis. Those residents you have to watch for fluid overload. Fluid overload would be a resident having trouble breathing or needing oxygen when they didn't before. Dialysis isn't there on the weekend, so if any residents are having problems with breathing because their fluid overloaded then you just send them out to the hospital for an extra treatment. I didn't call the doctor for an order for dialysis. I was only able to put in the medication at that time.
On [DATE] at 2:16PM, V30 (Dialysis Administrator) stated when the facility is looking over the paperwork and see that they need dialysis, they will send over the referral information to our department. The facility give us an estimated date of arrival and they will let us know when the resident is actually admitted to the facility. The floor nurse will call us if we are here. Otherwise, we get an email from someone in the facility. For dialysis residents, you want to monitor for signs and symptoms of fluid overload, the vital signs, any infections to their access site. Signs of fluid overload would be trouble breathing, swelling anywhere, decreased oxygen saturations, and diminished lung sounds. If a resident is experiencing something like this, the only treatment really for them would be to get dialysis. A doctor should be immediately notified. The breathing treatment and suctioning is not something that would help a resident having respiratory distress if they are getting dialysis. The fluid needs to be removed from buildup in the blood. If they don't send them out 911 at the very least, the physician should be notified that the resident is having changes in the respiratory status. If they're having trouble breathing, then 911 should be called immediately. I have no notification that R50 actually arrived to the facility.
On [DATE] at 3:20PM, V69 (Nephrologist) stated I am notified of a new resident in the building by the company contracted for dialysis. I was never notified that R50 was in the facility or that R50 was coming. We never do an extra treatment for a new admission, if anything was off, he would need to be sent to the hospital. Dialysis patients can have very serious situations occur pretty quickly. The most prominent is fluid buildup in the lungs. Since I didn't get a notification that the resident was in the facility, I would expect the nurse to notify the Medical Director or primary physician. These residents can go into respiratory distress fairly quickly and need urgent dialysis. If a resident is unstable, you should default and just call 911. This resident has no IV and dialysis cannot be done in the facility. Oxygen would only be a temporary fix. Suctioning would not help a resident in fluid overload because it would never get the fluid off that needs to come off in certain areas. A physician should be notified immediately that this is going on. If R50's not at the level to be sent out to the hospital yet and then staff need to be keeping a closer eye R50 to make sure things don't become worse.
On [DATE] at 3:47PM, V46 (Nurse) stated R50 was admitted around 7 PM, but at that time we had no Internet. I couldn't complete the admission on the computer. I don't remember anything about dialysis or R50 needing extra dialysis. The admitting nurse will also check the paperwork from the hospital to make sure that all the orders are in place. When the system is working, we normally call the doctor and let them know that they are here and on dialysis. They will put in all the orders regarding dialysis. For those type of residents, you just want to make sure that you were doing assessments for fluid overload. I didn't tell the dialysis company that they were here. If someone is having a change in the respiratory status, you should listen to the lungs and see if they are congested. You should also do their vital signs and notify the doctor. For a dialysis resident any respiratory distress can mean that they have extra fluid in their body. Usually for cases like that they get sent out to the hospital for evaluation and extra dialysis. If you have extra fluid in your body, it usually backs up into your lungs causing you not to be able to breathe better.
On [DATE] at 1:40PM, V19 (ADON) stated the nurse will either do the admission or pass it onto the next shift depending on what time the patient comes. Also, the DON and ADON will make sure everything is completed the next time later in the facility. When we are not here, it is just the nurses responsibility to get the orders. If dialysis is in the building, then the nurse will call down to let dialysis know. The nurse will also review the paperwork from the hospital to make sure the orders are correct. If a resident is having any type of change in condition, then the nurse practitioner or physician must be notified. They should call as soon as it is noticed. They either need to get orders for some type of treatment or to be sent out if there's any type of change then they should always call to see what should be done. They should also do another assessment if there's a change. They should check the vital signs, check their mental status, check for pain, and check the area of the complaint. If it is specifically for respiratory distress or shortness of breath, then the head of the bed should be elevated, and the oxygen level should be checked. The doctor should immediately be called for a situation like this. If their doctor gave orders and there's no relief, the doctor should be called back or 911 should be called if they get worse. Rounds are done every two hours. This lets us check on the residents to see how they are doing and if they need anything. If a resident is having a change of condition, they need to round every two hours just to make sure it hasn't changed. Dialysis residents can have fluid overload because they cannot urinate. They cannot get the fluid out of their body. This can cause respiratory distress. If there is too much, then they cannot breathe and need a dialysis treatment or to be sent to the hospital.
This surveyor attempted to call V79 (Agency CNA) for an interview but a call was never returned during this survey.
The Hospital Records dated [DATE] document R50 was admitted on [DATE] for failure to thrive in an adult. R50 attends hemodialysis on Monday, Wednesday, and Friday. The plan is to continue dialysis 3 times a week with a 1.5 L fluid restriction upon discharge. R50 received a full hemodialysis on [DATE]. On [DATE], R50 received a half session of dialysis due to not being able to complete the entire session. R50 had a 0.8 L removed on this day.
The Admission/readmission Screen are dated [DATE] documents R50 admitted to the facility on [DATE] at 7 PM. R50 was admitted from the hospital. Vital signs were taken and within normal limits. R50 is alert and oriented to person and place. R50 has a regular respiratory rate with no cough. Breath sounds on the left side are clear and on the right side has a slight rhonchi. R50 is able to clear the rhombic. R50 has a dialysis schedule of Monday, Wednesday Friday with a dialysis port to the left upper chest.
The Death Certificate dated [DATE] documents the cause of death as end-stage renal disease.
Emails between the in-house dialysis and the facility were submitted for review. An email on [DATE] at 10:36AM from the in-house dialysis to the facility documents the in-house dialysis was asking for confirmation that R50 was being admitted to the facility that day. The facility replied to this email at 10:37AM confirming R50 is scheduled to arrive on [DATE]. There is no more email confirmation letting the in-house dialysis know what time R50 arrived. There is no email communication on [DATE]. An email on [DATE] at 3:44PM from the in-house dialysis to the facility documents the in-house dialysis asked if the facility was still expecting R50. This confirms the in-house dialysis had no knowledge R50 was admitted to the facility. The facility replied to this email at 10:41PM letting in-house dialysis know R50 expired.
The Physician Order Summary documents a renal diet order was placed on [DATE]. There are also orders for 11 medications placed on [DATE] and [DATE]. There is no documentation of a dialysis order or anything pertaining to dialysis.
The policy tilted, Dialysis Care, dated [DATE] documents, Purpose: To adequately assess residents needs and provide care goals which achieve the highest practicable level of care to residents with end stage renal disease receiving hemodialysis or peritoneal dialysis. Procedure: 1. Arrangements should be made prior to admission for acquisition and storage of supplies, location and type of dialysis and room accommodations.
The policy titled, Supervision and Safety, dated 03/2015 documents, . 10. Staff to make visual rounds on residents minimally every 2 hours and more often if necessary, based on resident's assessment needs.
The policy titled, Change in Resident's Condition, dated [DATE] documents, General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician/NP, and resident's responsible party of a change in condition. Responsible Party: RN, LPN, Social Services. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. b. There is a significant change in the resident's physical, mental, or emotional status . e. It is deemed necessary or appropriate in the best interest of the resident. 2. Appropriate assessment and documentation will be completed based on the resident's change in condition or indication . 4. The communication with the resident and their responsible party as well as the physician/NP will be documented in the resident's medical record or other appropriate documents.
On [DATE] and [DATE] the surveyor verified by interview and record review that the facility implemented the following to remove the immediacy:
- Education initiated on [DATE] by the Administrator, DON, Restorative Nurse, Social Service Director, Dietary Manager completed on [DATE].
- Prior to residents being admitted to the facility, the facility (Administrator/DON/ Social Service Director/RN/LPN) team must communicate/coordinate with in-house dialysis that the resident is admitting to the facility.
- During the referral process the facility team (Administrator/DON/Social Service Director) will communicate via email with the Dialyze Direct on resident ' s admission/readmission date to the facility.
- DON will notify Team (RN/LPN) via admission Notice of residents scheduled admission.
- The staff nurse (RN/LPN) will contact the Nephrologist upon resident admission to the facility that the resident has arrived and will obtain admission orders and place the orders into PCC.
- Facility staff (RN/LPN) must notify the nephrologist that a resident in need of dialysis has been admitted to the facility.
- The facility nurse (RN/LPN) must assess all residents who are having an acute condition change (shortness of breath).
- The facility nurse (RN/LPN) must notify the physician of any resident having an acute change in condition (having shortness of breath).
- Rounding: Facility staff will obtain their assigned schedule and conduct rounds. Facility staff (RN/C.N.A/Social service aids) will then round every two hours.
-All Staff (Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Agency C.N.A(Clipboard) Housekeeping Director, MDS Coordinators and
Maintenance Director, receptionist, dietary aide, Cooks, housekeepers, social service case manager, Social Service Aides, restorative aides, C.N.As, RNs, LPN, activity aides, Laundry aides), including those off duty (receptionist, Social Service Case Managers, social service assistants, housekeepers, Laundry aides, RNs, LPNs, dietary aides, and cooks) were educated via phone with the same training as the staff educated in person, however, the staff who received the in-service over the phone were notified that they will also be required to attend an in-person training prior to the beginning of the next shift worked. Upon completion of this in-person training staff will sign education sheets. In-service date of completion [DATE].
-There were no changes made to the rounding policy.
- Facility staff (RN/LPN/C.N.A/Social Service Aids) will check their assigned group upon arriving to duty.
- Nurse to Nurse rounds will be conducted at shift change then every two hours.
- C.N.A to C.N.A round will be conducted at shift change then every two hours.
- Social Service Assistant will conduct rounds every two hour while on duty.
- Ongoing education will be provided to all staff on notifying the in-house dialysis that the resident was admitted . The facility nurse (RN/LPN) to notify the nephrologist of the resident ' s requiring dialysis has been admitted to the facility, staff nurses (RN/LPN) to follow the facility policy and assess residents who have been identified of having an acute change of condition and to notify the physician immediately. Staff educated on the importance of conducting rounds every two hours all in services were completed on [DATE].
- A baseline audit was completed by the DON on [DATE] to identify if any newly admitted resident or potential admits has a dx of ESRD needing dialysis services. The audit will continue weekly for three months by the DON/Restorative Nurse. Audit tool attached.
- On [DATE] a meeting was held with the facility IDT members. Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director.
- Prior to admission the Administrator will coordinate a schedule with the in-house dialysis center for the newly admitted resident.
- The facility nurses will contact the nephrologist to make them aware of the resident ' s arrival.
- The facility nurse will assess the resident for any acute change in condition and notify the physician.
- RN, LPN, Social Workers, Social Service Assistance, and C.N.As will conduct rounds every two hours.
- No policy changes have been made to the change in condition policies.
- Medical Director was made aware of the IJ.
- Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director. This committee will determine if the audits continue after three months.
2. Based on interview and record review, the facility failed to follow their seizure policy by not adjusting seizure medication and having precautionary measures in place for one resident (R26) with a history of epilepsy and traumatic brain injury who was identify as having subtherapeutic Dilantin levels. This failure resulted in R26 sustaining a seizure and hospitalization with a diagnosis of epilepsy for one of three reviewed for improper nursing.
Findings include:
R26 was admitted to facility on [DATE] with a diagnosis of other psychological development, vitamin D, traumatic brain injury, epilepsy and bipolar disorder.
R26's physician orders dated [DATE] documents: Phenytoin Sodium Extended Capsule (Dilantin) 100 MG. Give 1 capsule by mouth two times a day for seizures.
R26's laboratory results dated [DATE] documents: Phenytoin level (Dilantin) 4.3 low. Reference ranges 10.0-20.0.
R26's laboratory results dated [DATE] documents: Phenytoin level (Dilantin) 4.3 low. Reference ranges 10.0-20.0.
R26's medical record or physician orders do not document any changes or notification of results for [DATE].
R26's progress note dated [DATE] documents: Nurse was notified that resident was noted on the floor in a lying down position with seizure. Resident alert and responsive. Body assessment done, no injuries or bleeding noted. Resident was assisted back to bed. Vital signs checked and stable. MD made aware and received an order to send her to hospital for evaluation.
R26's hospital record dated [DATE] documents: Patient presented from a nursing home due to breakthrough seizure. The patient Dilantin level was low. She was loaded with antiepileptics and admitted because she had another breakthrough seizure while in the emergency department. Patient was admitted for further management and evaluation of her breakthrough seizures which are likely due to inadequate dosing and missed medication doses. Dilantin level documented at 4.6.
On [DATE] at 1:11PM, R26's was observed in her bed. Observed unpadded bilateral side rails and no fall mats in place.
On [DATE] at 12:20PM, V67(MD) said he is unable to recall if he was notified of R26's Dilantin levels. V67 said he would expect to be notified of any abnormal laboratory results and would put in recommendations or changes based on results. V67 said if Dilantin levels are low, he would consult with neurology and/or adjust the dose of the medication. If Dilantin levels are low, it can increase the risk for seizures.
Facility policy titled Seizure Care dated 5/20 documents: to provide care and treatment to the resident having a seizure that protects the resident from harm when possible. Notifications should be made with each episode unless seizures are occurring in conjunction with a pattern of consistency known to physician. Consider laboratory testing and review of anticonvulsant drug therapy. Initiate precautionary measures to prevent injuries: padded side rails, pad next to the bed.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview, and record review, the facility failed to prevent potential fire hazard conditions in the ki...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview, and record review, the facility failed to prevent potential fire hazard conditions in the kitchen when the kitchen's flat top grill remained uncleaned resulting in buildup grease and had exposed wiring within the appliance. This has a potential to affect all residents residing within the facility.
This was identified as an Immediate Jeopardy which began on 7/6/23 when the surveyor observed an accumulation of grease on kitchen appliances and exposed wiring on the kitchen's flat top grill and oven.
V1 (Administrator) was notified on 7/11/23 at 1:28 PM of the Immediate Jeopardy and a template was presented. The facility presented an initial removal plan on 7/12/23. The plan was accepted on 7/13/23. On 7/14/23 the surveyor conducted an onsite observation, record reviews, and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on 7/12/23.
Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation.
Findings Include:
On 7/6/23 at 11:00AM, V86 (Firefighter) came to the library to notify the survey team of the condition of the appliances in the kitchen and that there was a smell of gas. V86 reported the flat top grill was covered in old, black, grease and paneling in the front of the grill was broken off with wires exposed and knobs missing on both the stove and flat top grill. V86 said having the grill and the stove in that condition is a fire hazard because the grease and wires exposed can catch fire and with the gas leak there could be an explosion. V86 stated something like that puts the whole building at risk.
On 7/6/23 at 11:53AM, the flat top grill was observed to have exposed wiring, exposed pilot igniter covered in a black grease like substance, broken knobs tin foiled used for a gas control knob, and a broken and cracked face plate. The double door oven was observed to be dirty with a black grease substance, exposed wire from the underneath next to the igniter and tin foil used on the oven door handles. The flat top grill was not being used but was on to have gas travel through the pipes to the other appliances.
On7/6/23 at 2:41PM, V16 (Dietary Manager) reported the wires (on the gas grilled top) were exposed and it was past the point of fixing so it just needed to be disposed. V16 said the flat top grill was also not clean. V16 stated staff has not been using the flat top grill but needs to turn it on for the gas to light on the other two stoves. V16 denied having a cleaning schedule for the appliances before this incident. V16 denied being aware of the last time the appliances were cleaned. V16 said this is just the way the appliances were being used when V16 got here so we just kept using it that way.
On 7/7/23 at 12:55PM, V15 (Maintenance) stated, V15 said the fire department was called out here back in April (2023) for that flat top and there was gas leaking where the knobs were at, and it caught fire. V15 stated the flat top grill has just been giving the facility too many problems lately. V15 stated it (the gas top grill) wouldn't light with the igniters on the grill, so they had to use one of them long lighters, and when staff uses a lighter, the grill went up in flames a little bit. V15 stated, It was like a big whoosh and then the fire went out. V15 said the facility still called the fire department to investigate, and they just told V15 to not turn it on and to get it fixed. V15 reported there was a lot of grease on the appliances. V15 said having the appliances in that condition is dangerous, because not only does it put everyone at risk in the kitchen who is working; it also puts the residents at risk if there was a big enough fire.
On 7/7/23 at 3:43pm, V1 (Administrator) stated V86 smelled gas so V86 called some more firefighters, and they found a gas leak. V1 reported the gas company then came out and said that we had a gas leak as well, and they shut down the gas line. V1 said the kitchen should have notified maintenance about the repairs that need to be done.
On 7/13/23 and 7/14/23 the surveyor verified by observation, interview, and record review that the facility implemented the following removal plan:
Education initiated on 7/11/2023 by the Administrator, DON (director of nurses), ADON (assistance director of nurses), Social Service Director completed on 7/11/2023.
a. Preventing a fire hazard in the kitchen by ensuring the flat top grill remains clean and in proper working condition.
b. Ensuring that all kitchen appliances that use natural gas are in good repair and good working condition to prevent a potential fire hazard.
All Staff (Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Agency C.N.A(Clipboard) Housekeeping Director, MDS Coordinators and Maintenance Director, receptionist, dietary aide, Cooks, housekeepers, social service case manager, Social Service Aides, restorative aides, C.N.As (certified nurse aides), RNs (registered nurses), LPN (licensed practical nurses), activity aides, Laundry aides), including those off duty ( receptionist, Social Service Case Managers, social service assistants, housekeepers, Laundry aides, RNs, LPNs, dietary aides, and cooks) was educated via phone with the same training as the staff educated in person, however, the staff who received the in-service over the phone were notified that they will also be required to attend an in-person training prior to the beginning of the next shift worked. Upon completion of this in-person training staff will sign education sheets. In-service date of completion 7/11/2023.
The flat top grill was removed from the facility on 07/06/2023. Maintenance Director disconnected the flat top from the gas line and redirected the gas line to the working oven.
The Maintenance Director was educated by the facility Administrator on 07/11/2023 on preventing hazards in the kitchen by ensuring the flat top grill remains clean and in proper working condition with an emphasis on ensuring that all kitchen appliances that are used are in good working repair.
A weekly audit was completed by the Maintenance Director to ensure all kitchen appliances are in good working repair, appliances using natural gas are in good working repair and in a condition that will prevent a fire hazard, the kitchen appliances are free from exposed wires, all kitchen appliances are free from dirt/grease/hazardous conditions, the ignitor unit is clean and free from grease and debris, and the appliances have received weekly deep clean. The initial audit was started and completed on 7/11/23 by the Maintenance Director and reviewed by the Administrator. These audits will continue to be completed weekly by the Maintenance Director and audited weekly by the Administrator.
On 07/11/2023 a meeting was held with the facility IDT members. Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director to discuss the nature of the IJ and the interventions that were put in place to ensure an effective plan is in place to prevent fire hazards.
A weekly routine equipment inspection will be conducted by the Maintenance Director or the Assistant Director of Nursing.
The Dietary Manager and the Cooks completed a deep clean of the kitchen on 7/11/23. The dietary staff will complete a deep clean of the kitchen weekly. The deep clean will address the cleanliness of the stove top/range/grill, steamer, microwave, oven, toaster, slicer, mixer, tilt skillet, knife storage rack, food scale, can opener, food processor/blender, worktable, mop buckets/mops, coffee machine, juice machine, steam table, tray delivery carts, serving line conveyor, and sanitizer buckets. The Maintenance Director will audit weekly to ensure the deep clean was completed as scheduled. The Administrator will review the Maintenance Director's audits weekly.
No policy changes have been changed.
Medical Director was made aware of the IJ.
Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director. This committee will determine if the audits continue after three months.
B. Based on interview and record review, the facility failed to develop fall interventions for one resident with the diagnosis of syncope. This affected 1 of 3 residents (R23) reviewed for fall prevention interventions. This failure resulted in R23 having a fall sustaining a subdural hematoma. The facility also failed to monitor/supervise residents in the dining room to prevent verbal/physical resident to resident altercations. This affected seven of seven residents (R1-R7) reviewed for supervision. This failure resulted in a verbal resident to resident altercation escalating to a physical altercation and R1 slipping during the altercation sustained a hip fracture.
Findings include:
1. R23 was admitted to the facility on [DATE] with a diagnosis of syncope and collapse.
R23's fall risk assessment dated [DATE] documents R23 as a high risk for falls.
R23's fall plan of care dated 4/6/23 documents: Be sure call light is within reach and encourage the resident to use the call light as needed; anticipate and meet individual needs of the resident; complete fall risk review per facility protocol.
Facility reportable dated 4/7/23 documents: R23 was standing in front of the nursing station waiting for the elevator when he suddenly fell back onto the floor and hit his head. The nurse immediately assessed R23 and no injuries were noted. Order obtained to transport
R23 to local hospital via 911. R23 returned to the facility with diagnosis of subdural hematoma.
R23's hospital record dated 4/7/23 documents under diagnosis: traumatic subdural hematoma with loss of consciousness. Under head CT: acute left parietal subdural hematoma measuring 7mm in maximal thickness. Heterogeneous subdural hematoma with areas of hyper density noted underlying the right frontoparietal convexity measuring 6mm in maximal thickness. Findings compatible subacute or acute on chronic subdural hematoma.
On 6/1/23 at 2:52PM, V5(Restorative Nurse) said R23 fell backwards when waiting by the elevator. V5 said the root cause of the fall was caused by a syncope episode and wheelchair a was provided. V5 said she was not aware of R23's diagnosis of syncope prior to the fall and if she would have known of the diagnosis, she would have had R23 utilize a wheelchair for safety prior to the fall.
On 6/8/23 11:05AM, V39(MDS) and V40 (MDS) said they did not generate a baseline care plan and that it is developed upon admission assessment from the nurse. V39 and V40 said they did not see any interventions related to R23's syncope until after the fall.
Fall prevention program dated 2/28/22: It is policy of this facility to have a fall prevention program to assure the safety of all residents in the facility. The program will include measures which determine the individual needs of each resident by assessing the risk for falls and implementation of appropriate interventions to provide necessary supervision and assistive device are utilized as necessary.
2. R1 is a [AGE] year old with the following diagnosis: heart failure, osteoporosis, cerebral vascular accident, presence of right artificial hip, and fracture of the right femur. R1 admitted to the facility on [DATE].
R2 is an [AGE] year old with the following diagnosis: dementia and bipolar disorder. R2 admitted to the facility on [DATE].
On 6/6/23 at 11:01AM V5 (Restorative Nurse) stated, in the fall report it says R1 slipped on water. R1 didn't see it and slipped on it. It says no witnesses in the fall report so I have to guess no one was in the dining room when it happened. R1 was unsteady but able to ambulate independently. R1 had a slight limp to one side. Locomotion off unit would be R1 walking to and from floors. We usually say supervision for everyone with that so we can keep an eye on them. R1 ended up with a fracture to the left hip. I educated staff on cleaning up spills even if you aren't housekeeping. Anything wet can be a fall hazard even for people who don't have issues walking. No one saw R1 fall besides other residents that I know. There should always be someone in the dining room supervising people.
On 6/6/23 at 12:29PM, V32 (Former Nurse) stated I was on break when a CNA came to tell me that R1 fell. I was told they got into an argument about something and R2 threw a cup of water at R1. I guess R1 went to go back after R2 and slipped and fell in the water that was all over the floor. I asked the CNA what happened and she said she didn't see it either. R1 was making faces like R1 was in pain so we sent R1 out to the hospital. When I called later to check on R1, they said R1 had a broken hip. R1 wasn't a fall risk. I think it was just because of the water on the floor and we weren't in there to redirect R1 from going through it. No one must have been in the dining room if they didn't see it happen. Yes, we should have people in there when they are eating but that didn't always happen.
On 6/7/23 at 1:57PM, V36 (CNA) stated there were no staff in the dining room. I was the first in there when I heard the screaming. There was maybe four or five other residents in there. We don't have any set designated person to watch them. We just keep an eye on them as we're walking by. We might get called down the hall to something. I need to go on break so there might not be enough people to watch at all times. We don't really have any system to monitor them when they are in the dining room. We don't really know who's responsibility is. Like I said, we just watch them when we can. I heard screaming. I was by the nurse's station. I came in and I saw R1 on the floor. R2 said R1 was trying to rearrange the seats and then somehow water ended up being thrown at each other and R1 was on the floor. I didn't see any staff in there to witness what happened. I was the first one down there again. We don't have any special plan that we use for before they have an outburst. We do not have any security. If someone was in there, watching them, they might have been able to step in before R1 slipped and fell.
On 6/16/23 at 2:03PM, V74 (Medical Director) stated there are a lot of psych patients there and their behaviors need to be managed. The facility needs to identify the patient with behaviors to help control them more. They should be working with a psych doctor to better manage the behaviors. I can't see how R1 fell or remember anything about the situation, but anyone can slip on the water. Even you and I, slipping on the water doesn't matter what your fall risk level is so being monitored could've potentially stop this fall.
On 6/20/23 at 12:49PM, V1 (Administrator) stated R2 was cleaning the tables and one of them was eating and wasn't done. They were both in the dining room. They some how ended up spilling water on each other. I think they were pulling on the tray and the water spilled. I guess R1 fell after slipping on the water. R1 was sent to the hospital and had a femur fracture. I don't remember this situation between R2 and R3. Saying the N-word to someone else would be derogatory and considered verbal abuse. This happened in the dining room again. R4 was talking loud to himself which can be disturbing for others around R4. I know R4 and R5 ended up getting in an argument then R5 hit R4. This also happened on the third floor in the dining room. I think R7 was talking to herself responding to stimuli and R6 went up and staring hitting R6. R7 started hitting R6 back and staff separated them. I had to have a meeting with staff saying that someone needs to be present in there at all times. If they have to pass a room tray or answer a call light, they need to change out with someone. We have a lot of psych behaviors in this facility so we need people monitoring the residents at all times in the common areas.
A General note dated 3/4/23 documents the nurse was made aware R1 fell in the dining room. The nurse reported to the scene of the fall and observed R1 sitting in the chair pointing to the left leg. The doctor was called in order to send R1 out to the hospital based off x-ray results.
A Behavior note dated 3/4/23 documents R2 had an altercation with R1. R2 reported telling R1 that if R1 moved the table again R2 would throw water on R1. R2 did end up throwing water on to R1. The residents were separated and educated on proper behavior.
An Event note dated 3/5/23 documents staff was notified that R2 displayed physical aggressive behavior towards R1. Both were separated immediately. R2 was counseled on behavior and educated on the policies of the facility.
The Hospital Records dated 3/4/23 documents R1 admitted to the emergency department for a fall with a left leg injury. The left leg is noted to be rotated and shorter. R1 is unable to answer in clear sentences, due to advanced dementia and history of a stroke. Left hip and left femur x-rays were ordered and show a comminuted fracture of the left hip. R1 was admitted to the floor due to the fracture and surgery was consulted.
The Facility Reported Incident dated 3/6/23 documents R1 was ambulating past R2. The liquids in R1's cup from the dinner tray spilled over onto R2. R2 threw the contents of R2's cup towards R1. R1 then turned to walk towards R2 and slipped and fell onto the floor. R1 was immediately assessed by the nurse. The x-ray results revealed R1 had a femur fracture. R1 was sent to the hospital for further evaluation. R1 was admitted to the hospital with a diagnosis of a femur fracture.
The Fall Report dated 3/7/23 documents the nurse was made aware that R1 fell in the dining room. The nurse reported to the scene of the fall and observed R1 sitting in a chair pointing to the left leg. R1 was unable to give a description. R1 was sent to the hospital. No injuries are observed. There were no staff witnesses of the fall.
The Care Plan dated 10/18/17 documents R1 is at risk for falls due to periods of confusion, history of falls, decreased strength, and possible side effects of medications taken. R1 has a diagnosis of dementia, CHF, arthritis, and seizures. An intervention documented for this care plan is to ensure the floor is free of glare, liquids, and foreign objects.
R6 is a [AGE] year old with the following diagnosis: traumatic brain injury and schizophrenia. R6 admitted to the facility on [DATE].
R7 is a [AGE] year old with the following diagnosis: paranoid schizophrenic, psychotic disorder with delusions, and cerebral infarction. R7 admitted to the facility on [DATE].
R32 is a [AGE] year old with the following diagnosis: type 2 diabetes and paranoid schizophrenia.
On 5/31/23 at 12:16PM, R7 reported sitting in the dining room on the day of the altercation when R6 rolled over to R7 in a wheelchair and began punching R7. R7 stated R6 hit R7 in the head twice then R7 started punching back. R7 endorsed knocking R6 out of the wheelchair and began wrestling on the ground. R7 reported they kept trying to punch each other and R6 was pulling R7's hair. R7 denied any staff members being in the dining room when the fight occurred. R7 endorsed they fought for 2-3 minutes before facility staff came to break them up. R7 denied staff ever staying in the dining room to monitor residents.
On 5/31/23 at 12:52PM, R6 admitted to getting in a physical altercation with R7. R6 also admitted to hitting R7 first because R6 thought R7 called R6 a racial slur. R6 stated that R6 hit R7 in the head with R6's fist and continued hitting R7 when R7 began hitting back. R6 denied remembering if any staff were in the dining room monitoring the residents. R6 was unable to state how long the fight went on for before staff intervened. R6
On 5/31/23 at 1:49PM, R32 was asked if R32 was witness to the altercation between R6 and R7 and R7 reported yes. R32 endorsed R7 has a habit of yelling out and R6 thought R7 was yelling at R6 so R6 hit R7 in the face with a closed fist. R32 stated that R7 then began to throw punches back at R6 hitting R6 all over the face and body. R32 endorsed the two residents then fell to the ground and began wrestling while continuing to punch each other. R32 reported calling out for staff to break up the fight. R32 stated that about 10 residents were in the dining room waiting for dinner when the fight happened. R32 denied any staff in the dining room with them when the fight occurred. R32 endorsed staff responded about 1-2 minutes after the fight started and immediately separated R6 and R7.
A General note dated 3/12/23 documents R6 was very agitated and had an altercation with another resident in the dining room. The doctor was notified and ordered to send R6 out to the hospital for a psych evaluation.
An Event note dated 3/12/23 documents staff made social services aware that R6 was presenting physical aggression by punching appear in the face with a close fist due to delusional ideation. R6 thought R7 was talking to him, but R7 was presenting with auditory hallucination.
The Hospital Records dated 3/13/23 document R6 presented to the hospital for a psych evaluation. Per the nursing home petition, R6 was aggressive and hit another resident. R6 was admitted for decompensated schizophrenia.
R3 is a [AGE] year old with the following diagnosis: bipolar disorder and paranoid schizophrenia. R3 admitted to the facility on [DATE] and discharged on 6/17/23.
On 6/1/23 at 12:08PM, R3 stated that R2 was throwing food out the window so R3 reminded R2 to keep food inside. R3 endorsed R2 became upset at R3 for telling R2 what to do. R3 reported R2 began to yell at R3 and called R3 the N-word. R3 stated everyone started yelling after that so R3 was not able to remember exactly what was said but knows R2 called R3 the N-word. R3 reported staff then came into the dining room and removed R2. R3 denied any staff being present in the dining room at the time R2 said the N-word.
On 6/1/23 at 12:28PM, R2 was not able to remember the incident with R3 but did remember they had a disagreement. R2 denied any staff being in the dining room and reported staff are never in there when we are. R2 admitted to saying the N-word but not where other people can hear it. When it was brought to R2's attention that R3 heard R2 call R3 the N-word. R2 did not want to speak any more on that incident.
An Event note dated 4/13/23 documents R3 received verbal aggression from a peer. Both residents were separated immediately. R3 was encouraged to utilize coping skills.
The Facility Reported Incident dated 4/19/23 documents R3 received verbal aggression from R2 in the first floor dining hall. R3 observed R2 sliding food out of the window. R3 verbalized to R2 to not do this. R2 stated to R3 to mind, your ni**er business. Both residents were separated immediately and counseled on appropriate behavior.
On 6/6/23 at 10:16AM, V3 (Asst Social Service Director) stated there should always be a staff member in the dining hall if residents are in there especially if they have behaviors. This just helps us better monitor them. We don't really have a system. We just take turn doing rounds in there.
R4 is a [AGE] year old with the following diagnosis: major depressive disorder. R4 admitted to the facility on [DATE].
R5 is a [AGE] year old with the following diagnosis: schizophrenia and dementia. R5 admitted to the facility on [DATE].
On 5/31/23 at 12:45PM, R5 denied remembering having a physical altercation with any other residents.
On 5/31/23 at 1:01PM, R4 reported R5 came up to R4 while they were in the dining room and began punching R4 with closed fists all over R4's body. R4 endorsed no staff was in the dining room and just waited for him to stop hitting me. R4 stated that R4 then went to tell staff what occurred.
On 6/6/23 at 11:20AM, V29 (PRSC) stated I believe they (R4 and R5) were in the dining room and whatever happened they were separated. That would be resident to resident physical abuse because R5 was hitting R4 with R5's hands. I don't remember that incident again. I know they were getting ready for dinner and some residents were in the dining room but I was told no staff. R32 had to call out for staff. There are supposed to be a staff in the dining room monitoring residents at meal times. Staff was on the floor but maybe bringing people to the dining room.
An Event note dated 4/12/23 documents it was reported to staff that R4 received physical aggression from another resident (R5).
An Event note dated 4/12/23 documents R5 presented with aggression towards another resident. R5 was counseled on presenting social and verbal appropriate behavior.
The Facility Reported Incident dated 4/12/23 documents R4 was in the dining room on this day waiting for breakfast to arrive. R4 started to respond to internal stimuli and yelled out due to auditory hallucinations. This upset R5. When R5 asked R4 to lower R4's tone, R4 then begin to yell at R5. R5 responded by hitting R4 with an open hand.
The policy titled, Fall Prevention Program, dated 2/28/22 documents, Policy: It is the policy of the facility to have a fall prevention program to ensure the safety of all residents in the facility when possible .3. Safety interventions will be implemented for each resident identified at risk using a standard protocol . STANDARD FALL/SAFETY PRECAUTIONS FOR ALL RESIDENTS: . 6. The resident's environment will be kept clear of clutter, which would affect ambulation and remove hazards.
The policy titled, Supervision and Safety, dated 03/2015 documents, Policy: Our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility wide priorities. 1. Our facility-oriented approach to safety addresses for groups of residents such as wanders, behaviors, aggressiveness, confusion, etc . 4. Resident supervision is a core component to resident safety.
C. Based on observation, interview and record review, the facility failed to monitor and supervise a a resident identified to be at high risk for elopement. This affected one of three residents (R56) reviewed supervision. This failure resulted in R56 being able to leave the resident care area unauthorized and leave the facility through the loading dock while a food shipment was being delivered.
R56 is a [AGE] year old with the following diagnosis: delusional disorder, violent behaviors, bipolar disorder and schizophrenia. R56 admitted to the facility on [DATE].
On 6/21/23 at 1:45PM, A code pink was called over the intercom system. This surveyor looked out the third-floor library windows and saw V3 (Assistant Social Service Director) exiting the facility parking lot on foot walking on the sidewalk adjacent to the facility. V3 then crossed the 4-lane highway and walked towards the gas station that is across the street from the facility (approximately 900 feet) until V3 was out of view. Multiple other staff from the facility were then noted walking across the parking lot down the sidewalk to where R56 was. R56 was not observed until staff walked R56 back to the facility parking lot. Police and ambulance arrived when R56 returned to the parking lot and took R56 to the hospital because R56 refused to return inside the facility. R56 was not able to be interviewed because of being taken to the hospital. The code pink was cleared over the intercom at 1:49PM.
V1 (Administrator) played the security camera footage from the smoking patio which shows the facility parking lot. According to V1, the security camera in the back of the facility where R56 eloped was not working at that time. The camera off the smoking patio shows R56 walking across the facility parking lot at 1:44PM, leave facility grounds, and walk down the sidewalk before R56 is not able to be seen anymore. V3 then comes into the frame at 1:45PM (about 1 minute and 30 seconds after R56 is noted on camera) crossing the parking lot and walking down the same side walk R56 walked down until V3 walk out of view of the camera.
On 6/21/23 at 2:05PM, V12 (Restorative Aide) stated I went outside to respond to the code pink. The resident went out the back door while we were getting a delivery. No alarms went off that I heard. For residents that are elopement risks just going to watch them to make sure that they're not standing by the doors or saying they want to leave because that usually means they're going to try.
On 6/21/23 at 2:15PM, V1 (Administrator) stated R56 was in the basement. There was also a vendor in the basement unloading a delivery. R56 walked out the door while he was unloading. It was a food vendor. V3 was in the basement in V3's office and V3 was right behind the resident when R56 ran out the door. V3 called the Social Service Director from V3's cell phone and we called a code pink. There were no alarms because the door was open. The door normally does alarm if it's pushed open but it has to be closed to alarm. R56 said R56 wanted to leave. R56 was sent to the hospital because R56 did not want to come back inside. R56 can kind of go wherever R56 wants but we normally don't want them in the basement around that area.
On 6/21/23 at 2:50PM, V15 (Maintenance Director) stated the delivery door keypad alarms when it opens. Staff opens the door for vendors. When the staff uses the keypad to open the door, the alarm won't sound. Residents are not allowed past the laundry area. Laundry room is closest to delivery door.
On 6/21/23 at 2:55PM, V3 stated I was in my office which is in the basement, and there was a delivery being unloaded at the dock. The delivery person told me that R56 left out the door. I immediately called the Social Service Director when I was outside in the parking lot to call the code pink. When I caught up to R56, R56 didn't want to come back at first. The residents aren't really supposed to be down in the basement. We try to refrain from having them down there as much as possible. We don't really like them going past the laundry area. After you go past the laundry area, that is where the loading dock is for deliveries. R56 is an elopement risk. R56 came from the hospital with paperwork saying that R56 needed a 1:1 because R56 was a high risk for elopement. We did have to have R56 be a 1:1 sitter a couple times for trying to elope. R56 does not have a access to the community unsupervised. R56 can go out if R56 is supervised but R56 cannot be out alone because R56's BIMS is not high enough. I believe R56 has a score of an 8. This means that she is really limited cognitively. R56 also has a developmental delay. R56 stayed on the sidewalk on our side of the street and then R56 did cross the street to go to the other side and was at the other gas station. When we're having a delivery, we normally have a staff member over there or the vendor responsible for monitoring who is coming in and out of the door. I didn't see anyone monitoring the door at that time. R56 does have the ability to go to other floors.
The Community Survival Skills assessment dated [DATE] documents R56 does not appear to be capable of an unsupervised outside pass privilege at this time due to mental diagnosis. R56 cannot navigate safely on community streets. The Nursing Observation Sheets from 04/2023 through 06/2023 document R56 was on 1:1 observations from 8:30 AM to 5 PM a total of 9 times for elopement and aggressive behavior.
The Elopement Risk Review dated 5/1/23 documents a score of a 10 indicating R56 is a high risk for elopement and should be placed on elopement risk protocol. In the comment section of this document, the guar[TRUNCATED]
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
Resident Rights
(Tag F0550)
A resident was harmed · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to develop and implement interventions to ensure direct care staff could effectively communicate with residents, whose primar...
Read full inspector narrative →
Based on observations, interviews, and record reviews, the facility failed to develop and implement interventions to ensure direct care staff could effectively communicate with residents, whose primary language is not English. This failure affected one resident (R16) out of three residents reviewed for resident rights. This failure resulted in one Spanish speaking resident (R16) experiencing psychosocial harm as evidenced by expression of feeling scared and isolated.
Findings include:
On 5/30/23 at 2:39pm, R16 was interviewed via a Spanish speaking surveyor. R16 who was assessed to be alert and oriented to person, place and time. R16 was observed lying in bed. R16 stated while crying, my left leg hurts. R16's right side of the bed was observed to be positioned against the wall and the head of bed positioned against an adjacent wall. R16 stated that staff only turn her on her right side by pushing her left leg causing pain to her left knee. R16 stated that R16 wants to be moved to the bed closest to the door so staff can turn her onto her right side.
On 5/30/23 at 2:45pm, the State surveyors informed V19 ADON (Assistant Director of Nursing) R16 wants to be moved to the bed closest to the door. R16 was thankful to the surveyors for listening to R16 and getting her bed moved.
On 5/31/23 at 1:30pm, R16 was interviewed via a Spanish speaking surveyor. R16 stated that R16 speaks little English and does not understand when spoken to in English. R16 stated that R16 has had one shower since admission to this facility on 5/4/23. R16 stated that her hair has not been washed x 2 weeks. R16 stated that her whole head is itchy due to hair not being washed. R16 stated that she has all of the supplies in her room to wash hair. R16 stated that she asks for her hair to be washed but staff have not done it. R16 stated that staff do not get her out of bed. R16 stated that it is easier for her to transfer on the right side of bed. R16 stated that she has pain in her left knee when staff turn her to the left. R16 stated that she had been requesting for one week to be moved to the bed closer to the door. R16 stated that there aren't any Spanish speaking clinical staff or residents she can talk to. R16 stays in the room all day every day isolated. R16 stated that R16 is scared to be at this facility because R16 does not know what medications/treatments she is receiving. R16 was thankful to the surveyor for communicating with her in Spanish so she could make her needs known.
On 5/31/23 at 2:36pm, V4 (Rehabilitation Director) stated that R16 speaks English fairly well. V4 stated that R16 was asking for a while, at least one week, about switching beds. V4 stated that the nursing staff had a Spanish speaking housekeeper speak with R16. When questioned reason it took State surveyors 5 minutes to understand what R16 wanted and it took staff with housekeeper translating one week to understand what R16 wanted, V4 responded R16 was not asking the question correctly so staff did not understand what she wanted.
On 6/1/23 at 3:35pm, V61 (R16's family member) stated that R16 understands a little English. V61 stated that the staff use a housekeeper to translate for R16, which is not appropriate. V61 stated that housekeeping staff do not have any health care training and would not be able to identify any changes in R16's medical condition. V61 stated that R16 does not know what medications she is receiving, because R16 does not understand what the staff are saying.
On 6/2/23 at 10:42am, V2 DON (Director of Nursing) stated that residents whose primary language is not English should have a communication board to utilize during their stay at this facility. V2 stated that this facility does not have a translator/interpreter service. V2 stated that prior to R16's admission to this facility there should have been a communication board in place in her room. V2 stated that this facility does not have an effective communication policy or provide communication training for its staff.
Review of R16's shower documentation, dated 5/4/23 - 5/31/23, notes R16 received a shower on 5/20/23. There is no further documentation that R16 received a shower during this time period.
Review of R16's hospital pre-admission transfer record, dated 5/4/23, notes on the first page R16's spoken language is Spanish.
Review of R16's BIMS (brief interview of mental status) score, dated 5/11/23, notes R16's score is 14 out of 15. R16 is alert and oriented x 3.
Review of this facility's residents' rights policy, revised 11/2018, notes your facility must provide services to keep your physical and mental health, at their highest practical levels. You have the right to complete information about your medical condition and treatment in a language that you can understand.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0557
(Tag F0557)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview and record review, the facility failed to follow their dignity policy by not ensuring residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview and record review, the facility failed to follow their dignity policy by not ensuring residents are appropriately dressed. This affected 2 of 3 (R41, R42) reviewed for dignity. This failure resulted in R41's penis being exposed during mealtime, and R42's briefs exposed during mealtime. Using the reasonable person concept R41 would have been humiliated and embarrassed.
B. Based on interview and record review, the facility failed to follow their dignity policy by putting a resident's deceased body in the beauty supply room with garbage cans and boxes for the family final viewing for one (R50) resident out of one reviewed for dignity during postmortem care.
Findings Include:
A. R41 has a diagnosis of Encephalopathy, Mental disorder and Bipolar disorder. Minimal data set dated [DATE] section C (cognitive pattern) documents a five which indicated severe impairment, section G (functional status) documents: R41 required extensive with one person physical assist with dressing.
On [DATE] at 12:54pm and 1:00pm, R41 was observed sitting in his wheelchair on a white towel, eating lunch in the dining room with his adult brief and jogging pants around his thighs with his penis exposed. R41 was asked why his clothing and adult brief was down, R41 replied, they did not pull them up.
On [DATE] at 2:09pm, V1 (Administrator) said, a resident should not be in the dining room with their penis exposed, it is a dignity issue.
R42 has a diagnosis of Dementia. Minimal data set dated [DATE] section C (cognitive patterns) documents a score of nine which indicates moderately impaired. Section G (functional status) dated [DATE] documents R42 required supervision with dressing with set up assist. R42 has self-care deficits Interventions: Performs dressing/grooming task without physical assist; cues and/or supervision as needed.
On [DATE] at 12:56pm, R42 was observed sitting with his pants and belt around his mid thighs exposing his adult brief. R42 said, he did not know why his pants were not pulled up.
On [DATE] at 2:09pm, V1 (Administrator) said, resident should not be in the dining room with their adult brief exposed, it is a dignity issue.
Dignity Policy dated 1/21 documents: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.
B. R50 is a [AGE] year old with the following diagnosis: end stage renal disease, dementia, and congestive heart failure. R50 was admitted on [DATE] and expired in the facility on [DATE].
A Nursing note dated [DATE] at 7AM documents R50 was changed by the CNA at 5:45 AM. R50 was verbally responsive. Around 6:45 AM, the morning nurse (V20) noted R50 unresponsive. R50's arms were cold and clammy. The second nurse (V56) went to assess R50. Vital signs were checked, but none were reported. CPR was not attempted since it was a presumptive death. The power of attorney was called. The administrator, DON, and nurse practitioner were also called to inform of the R50's demise. Postmortem care was completed.
Due to nursing staff, not following proper protocol, the police department was called. The Police Report dated [DATE] documents the police were called at 5:15 PM and arrived on scene at 5:51 PM. The day nurse began the shift at 6:30 AM and checked on R50 around 6:45 AM where R50 was found unresponsive. Life-saving measures were performed on R50 around 6:45 AM but R50 continued to be unresponsive and showed no vital signs. The staff then moved the deceased body to the beauty shop located in the basement of the nursing home. R50's body was laying on a gurney with a blanket covering R50 in the beauty shop.
On [DATE] at 1:42PM, V75 (Family Member) stated I got there around 4 PM because I was coming home from work. They had R50 downstairs wrapped in a sheet in the beauty room. There were a bunch of boxes in garbage cans next to R50's body. I couldn't believe they were having me view R50's body like that. I felt horrible. It was something that was happening out of a movie.
On [DATE] at 10:16AM, V22 (CNA) stated no family came to get the body right away so they took it downstairs. They held it there until the family came. Normally what we do is remove the roommate out of the room temporarily, so the body is still in the room when the family comes. We normally let them visit with the body where they passed away. I don't know why that didn't happen this time.
On [DATE] at 12:01PM, V47 (Detective) stated When I saw R50's body, R50 was in the basement in a room with some other supplies. There were some garbage cans in the room and some beauty chairs and R50 was wrapped in a sheet. The family member told me that this is how they first saw R50 as well.
On [DATE] at 12:49PM, V1 (Administrator) stated R50's family and the police viewed the body in the beauty room in the basement. I know there are some chairs in there like when you go to the salon. I'm not sure what else was in there at that time. Normally, family come pretty quick, so the resident's body is left in the room until the family gets there. The family wasn't answering so we moved R50 down there for the comfort of his roommate.
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**
4. On 6/2/23 at 12:09pm, during ADL care, R37 was observed with two opened wounds on the left lateral lower buttock with no dre...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
4. On 6/2/23 at 12:09pm, during ADL care, R37 was observed with two opened wounds on the left lateral lower buttock with no dressing. No dressing was observed on bed chuck or sheets. V65 (CNA) said, R37 did not have a dressing in place this morning.
On 6/2/23 at 12:14pm, V19 (ADON) said, R37 should have had a dressing in place.
On 6/2/23 at 12:24pm, V31 (Treatment Nurse) said, R37 did not have any treatments in place. R37's wounds measures 1.0 x 1.7 x 0 (length, width and depth).
Care plan initiated 10/28/2021 documents: R37 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to: DX of incomplete quadriplegia C5-C7, DM II, spinal stenosis, psychotropic med use per MD orders, G-Tube only source of dehydration and nutrition, and incontinence of B&B, non-compliance with wound care and turning/repositioning.
5. Physician order sheet dated 6/2/23 documents: site-left Ischium-clean with normal saline then pat dry, then apply skin prep, then apply xeroform, then cover with dry dressing three times weekly and as needed.
On 6/1/23 at 11:10am, V22 (CNA) said, R12 was left soiled with urine and feces for more than 3 hours. This happened to R12 five times when I reported to worked with R12.
On 6/1/23 at 11:20am, R12 who was assessed to be alert, oriented to person, place and time said, I was left soiled in urine and feces for over five hours. I was told by staff that, I had to wait until I ate breakfast to be changed. I was not changed/given incontinence care on the night shift for over five hours on multiple occasions while crying. I wasn't repositioned. No one should be treated that way.
On 6/13/23 at 5:08pm, V19 (ADON) said, I would expect R12's treatment to be changed when R12's sacrum wound increased in size.
Treatment administration record dated 3/31/23 -5/10/23 documents: Hydrocolloid three times a week.
Weekly Skin Assessment 5/2/23 documents: Sacrum pressure injury, stage II measured 2.5 x 1.5 x 0.1 Length x Width x Depth (LxWxD). Treatment: Hydrocolloid.
Wound doctor note dated 5/5/23 documents: Stage II pressure injury to sacrum reclassified to stage III. Measuring 4 x 1.5 x 0.1 cm. Deteriorated in surface area.
Weekly Skin assessment dated [DATE] documents: Sacrum pressure injury, stage III, measuring 4 x 1.5 x 0.1 (L x W x D). Treatment: Hydrocolloid.
3. R57 is a [AGE] year old with the following diagnosis: end stage renal disease, type 2 diabetes, human immunodeficiency disease, myocardial infarction, and hemiplegia of the right side. R57 admitted to the facility on [DATE] and discharged on 3/27/23.
A General progress note dated 2/16/23 documents R57 is a new admission from the hospital. R57's skin is intact but has mild redness to the coccyx.
A Skin note dated 3/2/23 documents R57 was readmitted to the facility and had an admission assessment. There is a skin alteration to right buttocks.
The Treatment Nurse Initial Skin Alteration Review of 3/1/23 documents there's a stage two pressure ulcer to the right buttocks that was found on 2/28/23. The size of the wound is 2.5 cm x 2 cm x 0.2 cm. There is a scant amount of serous drainage. The wound is 100% red smooth tissue. The preventative measures are to perform skin treatments done as physicians order, moisture barrier, and daily skin checks during routine rounds. It is documented that the family, physician, and register dietitian were notified of this wound.
There is no further documentation on the wound.
There are no physician wound notes documenting that R57 was ever seen by a physician for this wound.
The Physician Order Summary documents an order for the right buttocks to be cleansed with normal saline, patted dry, and covered with a hydrocolloid three times a week and as needed and was ordered on 3/1/23.
The Treatment Administration Record dated 03/2023 documents no treatments were given during this month. There's a treatment order to cleanse the right buttocks with normal saline, pat dry, and cover with hydrocolloid three times a week and as needed. A total of 12 treatments were missed before R57 was sent to the hospital and 3/27/23.
The Care Plan dated 3/1/23 documents R57 has a stage 2 pressure ulcer and/or potential for pressure ulcer development related to pressure ulcers present and epithelial scarring over the buttocks. Interventions include to assess/record/monitor wound healing by measuring the length, width, and depth where possible; report improvements and declines to the physician; monitor dressings to ensure it is intact and adhering; report loose dressings to the treatment nurse; and staff will follow facility policies for the prevention/treatment of skin breakdown.
On 7/7/23 at 10:40AM, V89 (Former Wound Care Nurse) stated R57 had a stage 2 pressure ulcer to the buttocks that was present after being readmitted from the hospital. V89 said that if dressing changes are not completed in the computer system; then it suggests the wound care is not completed. V89 reported wound care needs to be completed as the physician orders because it helps prevent the wound from getting worse. V89 was not able to say how many dressing changes were missed. V89 reported a physician normally sees residents with wounds on a weekly basis and that is when updated charting needs to be entered into the system.
On 7/7/23 at 11:11AM, V48 (Nurse) said she does not remember R57 having any wounds. V48 reported V89 was responsible for changing the dressings at that time. V48 endorsed staff need to chart the care that is given to the residents in the computer or there is no proof that care was done.
On 7/7/23 at 3:34PM, V1 (Administrator) said wound care treatment needs to be completed as ordered. V1 stated if the dressing changes are not charted as completed then it is to be assumed that they were not completed. V1 reported the wound care nurse or any nurse that completes the dressing change needs to chart it in the computer upon completion.
Based on interview and record review, the facility failed to follow their wound prevention policies and procedures to include not providing physician ordered wound treatments, not developing interventions to prevent the development and/or wounds worsening, and not conducting assessments to identify residents with new wounds and obtaining treatment. This affected five of 5 residents (R24, R25, R57, R37, and R12) reviewed for wound prevention protocols. These failures resulted in R24 developing a non-stageable wound, and stage 3 to the right elbow. R25 developed a sacral wound with 10% necrotic tissue, coccyx wound 6.5x6.0x0.8 with undermining, and a peri wound with macerated skin with scattered partial and full thickness wounds with purulent draining.
Findings include:
1. R24' s admission skin assessment dated [DATE] documents skin intact.
R24's Braden scale dated 3/31/23 documents: moderate risk for wounds.
R24's skin alteration dated 4/13/23 documents: nonstageable pressure sore measuring 5.0x2.7x0 CM(centimeter), scant drainage.
R24's skin alteration dated 4/23/23 documents: stage 3 pressure sore right elbow measuring 3.5x1.5x0.1CM, scant drainage.
On 6/14/23 at 10:03AM, V63 (Wound NP) said poor nutrition would aid in development of wounds. Wounds can develop within a day if there is poor nutrition or intake. This could have attributed to wound development for R24.
R24's nutritional risk review dated 4/3/23 documents: pureed diet and thick liquid diet, also bolus feeding if he eats less than 60% of tray.
R24's point of care charting for April for amount eaten documents: 97- not applicable on 4/2/23 and 4/3/23 at 0900 and 1300. On 4/5/23 document 3 which indicates 76-100% eaten at 0900 and 1300; on 4/11/23 documents a score of 1 which indicates 26-50% at 0900 and a score of 2 which indicates 51- 75% at 1300; on 4/12/23 at 1800 a score of 1 which indicates 26-50%; on 4/13/23 at 0900 and 1300 documents 98 which indicates refused. All other dates and times are not completed and blank.
R24's medical record does not document any bolus feedings were given to R24 until after 4/20/23.
2. R25 was admitted to the facility on [DATE] with a diagnosis of rheumatoid arthritis, abnormalities of gait, lack of coordination, pressure ulcer of sacral region unspecified stage, ankylosing spondylitis, scleritis with corneal involvement, severe protein caloric malnutrition.
R25's physician order dated 5/12/23 documents: sacrum cleanse with normal sterile saline. Pat dry and apply calcium alginate to wound bed and cover with a dry dressing daily. There were no documented treatment changes after 5/12/23.
R25's treatment record for May 2023 does not document any new treatment orders after 5/12/23. Dated 5/12/23 documents: cleanse with normal sterile saline and apply calcium alginate and cover with dry dressing.
R25's wound care note dated 5/15/23 documents: Sacrum measures 5.4x3.3x 0.6cm with 10 % necrotic tissue. Deteriorated in amount of necrotic tissue. No other active wounds. Under plan: change to honey and calcium alginate and dry dressing daily and as needed.
On 6/14/23 at 10:03AM, V63 (Wound NP) said R25's order was changed because the wound developed some necrotic tissue. Medihoney was added to help debride the wound. If Medihoney was not applied, the wound can get worse. V63 said she verbally sends a report of wound dressing recommendations and changes. V63 said she would expect her orders to be followed.
R25 hospital record dated 5/18/23 documents - coccyx 6.5x6x0.8cm with undermining noted from 6- 10 o'clock. Periwound noted with macerated skin with scattered partial and full thickness wounds. Purulent drainage noted.
R25's care plan dated 12/9/23 documents: administer wound treatments per MD orders.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow their weight management protocols by not followi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow their weight management protocols by not following physician ordered weekly weights, obtaining admission weights and preventing unplanned significant weight loss. This affected six of six (R24, R25, R16, R33, R34, and R35) all reviewed for weights. This failure resulted in R25 sustaining a severe unplanned weight loss of 17% in 6 months and R24 sustaining an unplanned weight loss of 3.8% in just 19 days.
Finding include:
1. R24 was admitted to the facility on [DATE] with a diagnosis of dysphagia, vitamin D, hypertension, constipation, and gastro-esophageal reflux disease.
R24's point of care charting for April for amount eaten documents: 97- not applicable on 4/2/23 and 4/3/23 at 0900 and 1300. On 4/5/23 document 3 which indicates 76-100% eaten at 0900 and 1300; on 4/11/23 documents a score of 1 which indicates 26-50% at 0900 and a score of 2 which indicates 51- 75% at 1300; on 4/12/23 at 1800 a score of 1 which indicates 26-50%; on 4/13/23 at 0900 and 1300 documents 98 which indicates refused. All other dates and times are not completed and blank.
R24's Minimum Data Set, dated [DATE] documents under nutrition proportion of total calories received through feeding documents 25% or less. Under eating documents one person assist.
R24's progress note dated 3/31/23 documents: puree diet and feeding through j-tube.
R24's diet order dated 4/4/23 documents: pureed texture. There were no prior diet orders.
R24's physician order under enteral feed dated 4/20/23 documents: enteral feed osmolyte 1.5 @70 CC/HR x 20 hours. There was no documentation of any prior feeding orders.
R24's physician order document dated 4/4/23 weekly weight times 4 then monthly.
R24's admitting weight dated 3/31/23 document 180 pounds.
R24 has only one documented weight for April dated 4/18/23 which documents weight of 173.6 pounds.
R24's nutritional risk review dated 4/3/23 documents: puree diet and thick liquid diet, also bolus feeding if he eats less than 60% of tray.
R24's skin alteration dated 4/13/23 documents: nonstageable pressure sore measuring 5.0x2.7x0CM, scant drainage.
R24's skin alteration dated 4/23/23 documents: stage 3 pressure sore measuring 3.5x1.5x0.1CM, scant drainage.
On 6/13/23 at 4:08PM, V19 (ADON) said R24 was admitted with pureed diet and if he didn't eat at least 60 % of meal staff would inform the nurse to give bolius feedings; but, he did not require bolus feedings because he was eating ok. R24 had a change on 4/20 and put in new order for continuous feeding. CNAs are responsible for informing the nurse if he didn't eat. V19 was shown point of care documentation and asked to provide any documentation that bolus feedings were provided; but, was unable to find that any bolus feedings were provided to R24.
On 6/1/23 at 1:00pm. V5(Restorative) said weights should be done on admission and then weekly x4.
On 6/9/23 at 11:58AM, V73 (dietician) said she was unaware of any prior feeding orders for R24 prior to an assessment on 4/20/23.
On 6/14/23 at 10:03AM, V63 (Wound NP) said poor nutrition would aid in development of wounds. Wounds can develop within a day if there are poor nutrition or intake. This could have attributed to the wound development of R24.
Nutritional monitoring policy dated 3/20 documents: it is the policy of the nursing department to monitor the residents nutritional intake at each meal and to record the average percent consumed. Under purpose to maintain a record of nutritional consumption to detect potential nutritional problems. Ensure staff awareness of resident diet order.
2. R25 was admitted to the facility on [DATE] with a diagnosis of rheumatoid arthritis, abnormalities of gait, lack of coordination, pressure ulcer of sacral region unspecified stage, ankylosing spondylitis, scleritis with corneal involvement, severe protein caloric malnutrition.
R25's admitting packet documents weight on 11/16/22 of 102.8 pounds.
R25 first documented weight on 1/4/23 documents 80.4 pounds
R25 weights dated 5/10/23- 85 pounds.
R25's Minimum Data Set, dated [DATE] documents under eating one person assist.
R25's nutritional risk dated 12/9/22 does not document any current weight. Documents fed by staff.
R25's point of care charting for amount eaten for May 2023 documents: no amount eaten for evening for all of May. No documented food eaten on 5/9/23, 5/12/23, 5/14/23 ad 5/16/23.
On 6/1/23 at 1:00pm. V5(Restorative) said weights should be done on admission and then weekly x4.
Nutritional monitoring policy dated 3/20 documents: it is the policy of then nursing department to monitor the residents nutritional intake at each meal and to record the average percent consumed. Under purpose to maintain a record of nutritional consumption to detect potential nutritional problems. Ensure staff awareness of resident diet order.
On 6/8/23 at 10:58am, V41 NP (Nurse Practitioner) stated that V41 is aware that staff are not obtaining weights daily. V41 stated that she has to ask staff to weigh residents with diagnosis of CHF (congestive heart failure) when she comes to facility.
On 6/8/23 at 12:15pm, V42 NP stated that obtaining weights is important for residents with CHF to monitor for increases in weight over a short period of time. V42 stated that these residents need to be monitored to prevent fluid overload.
On 6/8/23 at 3:00pm, V44 (Cardiology NP) stated that it is the standard of care for residents with CHF to monitor weights daily, to monitor for fluid overload. V44 stated that she would expect staff to follow her orders and weigh residents daily.
On 6/13/23 at 4:20pm, V19 ADON (Assistant Director of Nursing) stated that staff should monitor CHF residents' weight daily. V19 stated that residents are weighed on the morning shift. V19 stated that the restorative staff are expected to weigh the residents daily. V19 stated that any weight variations of +/- 3 pounds, the physician should be notified. V19 stated that the nurse is expected to document when the physician is notified and if any new orders are received.
On 6/15/23 at 12:30pm, V67 (Attending Physician) stated that he expects the nurse to carry out all orders given. V67 stated that it is very important to monitor weights daily for CHF residents. V67 stated that weight needs to be monitored closely for accumulation of fluid in the resident's body to prevent fluid overload, worsening CHF. V67 stated that it is also important for weight monitoring to be consistent by using the same scale and weighing resident at the same time of day due to weight fluctuating throughout the day and to ensure accuracy of weights obtained.
3. Review of R16's medical record notes R16 was admitted to this facility on 5/4/23 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, syncope and collapse, and chronic respiratory failure.
Review of R16's POS (physician order sheet), dated 5/24/23, notes an order for daily weights in the morning due to congestive heart failure (CHF) and recent hospitalization due to CHF exacerbation. Daily weights were re-ordered on 5/31/23.
Review of R16's medical record notes R16's first weight was not obtained until 5/19/23. There is no documented admission weight.
Review of R16's weight documentation notes:
On 5/19/23, R16's weight was 250.6 pounds, scale used, and time weight obtained are not documented.
On 5/22 at 1:44pm, weight 256.1 pounds using a mechanical lift device.
On 6/1 at 8:28pm, weight 262.6 pounds using a mechanical lift device.
On 6/3 at 10:07pm, weight 256.6 pounds using a mechanical lift device.
On 6/5 at 12:16pm, weight 256.2 pounds using a mechanical lift device.
On 6/6 at 851am, weight 255.3 pounds using a mechanical lift device.
6/7 at 10:04am, weight 256 pounds using a standing scale.
6/8 at 9:29am, weight 256 pounds using a mechanical lift device.
6/9 at 3:00pm, weight 258 pounds using a mechanical lift device.
6/12 at 5:17pm, weight 259 pounds using wheelchair scale.
4. Review of R33's medical record notes R33 with diagnoses including congestive heart failure, cardiomyopathy, cardiac pacemaker, and hypertensive heart disease with heart failure.
Review of R33's POS, dated 5/15/23, notes an order for weekly weights x 4 then monthly. On 6/1/23, there is an order for daily weights.
Review of R33's weight documentation notes:
On 5/12 at 4:50am, R33's weight was 109 pounds standing scale.
On 5/23 at 11:37am, R33's weight was 112.2 pounds standing scale.
On 6/1 at 2:05pm, R33's weight was 115.3 pounds standing scale.
There is no documentation found in R33's medical record, between 5/12/23 and 6/13/23, noting R33's weights were obtained per physician orders.
5. Review of R34's medical record notes R34 was admitted to this facility on 5/8/23 with primary diagnosis: congestive heart failure.
Review of R34's POS, dated 5/10/23, notes an admission order for weekly weights x 4 then monthly.
Review of R34's weight documentation notes:
On 5/11/23 at 2:04pm, R34's weight was 388 pounds mechanical lift.
On 6/1 at 2:05pm, R34's weight was 391 pounds on standing scale.
Review of R34's care plan does not note a CHF care plan was initiated.
6. Review of R35's medical record notes R35's primary diagnosis: congestive heart failure.
Review of R35's POS, dated 3/3/23, notes an order for daily weights. On 5/30/23, V44 (cardiology NP) ordered daily weights.
Review of R35's weight documentation notes:
On 2/9/23, R35's weight was 152 pounds using mechanical lift device.
On 3/8, R35's weight was 142.2 pounds using mechanical lift device.
On 3/9, R35's weight was 140.8 pounds using mechanical lift device.
On 4/18, R35's weight was 140.8 pounds using mechanical lift device.
On 5/10, R35's weight was 139.8 pounds using mechanical lift device.
On 6/1, R35's weight was 142.1 pounds using mechanical lift device.
There is no documentation found in R35's medical record noting daily weights were obtained.
Review of dietary's note dated 6/13/23, notes weight 142.1 pounds. +10.0% change. Significant weight gain x 6 months noted; question accuracy of weights previously of 117 pounds and 120 pounds.
Review of R35's care plan notes R35 is at risk for cardiac and respiratory distress related to CHF. An increased risk for lower extremity edema and shortness of breath related to fluid overload. Interventions identified: monitor R35 for edema of extremities, observe for shortness of breath, notify physician of any changes in condition, administer diuretic as ordered.
Review of this facility's weighing residents policy, dated 02/2020, notes each resident is weighed on admission and monthly thereafter, or in accordance with Physician orders. A licensed nurse evaluates weight changes and determines if there is a 3 pound or greater weight loss/gain in one week and notifies physician of unanticipated or undesired weight gain or loss. Weight gain may be due to CHF (congestive heart failure) with edema (swelling).
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to follow its pain management policy by not having tramadol 50 mg available for administration as prescribed. This affected o...
Read full inspector narrative →
Based on observations, interviews, and record reviews, the facility failed to follow its pain management policy by not having tramadol 50 mg available for administration as prescribed. This affected one resident (R16) out of three residents reviewed for pain management. This failure resulted in R16 being observed crying in pain on 5/30/23. R16 stated R16 has chronic left knee pain, and the pain was 10 out of 10.
Findings Include:
On 5/30/23 at 2:39pm, R16 who was assessed to be alert and oriented to person, place and time stated while crying, my left leg hurts. My pain level is a 10 out of 10. I didn't get my pain medication it was not ordered.
On 5/30/23 at 2:40pm, V13 (Nurse) stated that R16 was admitted to this facility on 5/4/23. V13 stated that R16's pain medication has not been ordered. V13 stated that V13 needed to call the doctor.
On 5/31/23 at 2:36pm, V4 (Rehabilitation Director) stated that R16 has arthritis in both knees and history of left knee surgery. V4 stated that R16 complains of pain throughout her therapy sessions and needs to keep being re-directed to stay on task with therapy. When questioned for the reason therapy was not stopped and the nurse notified so the nurse could assess R16's pain level and administer pain medication? V4 stated that the therapist assesses the resident's pain level before starting the session. V4 stated that staff are informed of therapy times so the resident can receive pain medication prior to therapy. This surveyor informed V4 that this facility did not order R16's pain medication until 5/30/23 and R16 was without pain medication since 5/4/23. V4 did not respond.
On 5/31/23 at 3:06pm, V18 (Doctor of Pharmacy) stated that R16's tramadol (pain medication) order was filled today. The facility did not print out and manually fax the order for controlled medication prior to today. Once the medication is entered into the computer system, the facility can take the medication out of the emergency kit or have it delivered urgently.
On 6/14/23 at 8:25am, V41 NP (Nurse Practitioner) stated that the nurse should be checking the resident's chart for any new orders placed. V41 stated that she expects the nurse to carry out all orders written. V41 was informed that R16 was admitted on 5/4 with an order for tramadol and this medication was not ordered until 5/31. V41 stated that staff know that they can ask her for medication orders, and she would have ordered the tramadol for R16.
R16's PT (Physical Therapy) daily progress notes, dated 5/12/23-5/30/23, were reviewed. There is no documentation found noting R16's pain was assessed prior to, during, or after each therapy session.
R16's OT (Occupational Therapy) daily progress notes, dated 5/15/23-5/30/23, were reviewed. On 5/15/23, R16's pain was assessed to be 4-7 out of 10. There is no documentation found noting R16's pain was assessed prior to, during, or after each subsequent therapy session.
Review of R16's POS (physician order sheet) dated 5/4/2023, notes an order for tramadol 50mg (milligrams), take one tablet by mouth every six hours as needed for mild pain.
Review of R16's MAR (medication administration record), dated May 2023, documents: tramadol was not signed out or administered to R16.
Review of R16's new prescription summary, dated 5/31/23, documents: R16 has an order for one hundred and twenty tablets, thirty day supply with five refills of tramadol 50mg tablets.
Review of this facility's pain management program, dated 11/2021, documents: to establish a program which can effectively manage pain in order to adverse physiologic and physiologic effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0773
(Tag F0773)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of abnormal lab levels. This affected 2 of 3 (...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of abnormal lab levels. This affected 2 of 3 (R26, R33) residents reviewed for laboratory results and notification of abnormal labs. This failure resulted in R26 having an incident of a seizure requiring hospitalization and treatment.
Findings include:
R26 was admitted to facility on 2/15/23 with a diagnosis of other psychological development, vitamin D, traumatic brain injury, epilepsy and bipolar disorder.
R26's physician orders dated 2/16/23 documents: Phenytoin Sodium Extended Capsule (Dilantin) 100 MG. Give 1 capsule by mouth two times a day for seizures.
R26's laboratory results dated [DATE] documents: Phenytoin level (Dilantin) 4.3 low. Reference ranges 10.0-20.0.
R26's medical record or physician orders do not document any changes or notification of results for 3/10/23.
On 6/15/23 at 12:20PM, V67(MD) said he is unable to recall if he was notified of R26's Dilantin levels. V67 said he would expect to be notified of any abnormal laboratory results and would put in recommendations or changes based on results. V67 said if Dilantin levels are low, he would consult with neurology and/or adjust the dose of the medication. If Dilantin levels are low, it can increase the risk for seizures.
R26's progress note dated 4/10/23 documents: Nurse was notified that resident was noted on the floor in a lying down position with seizure. Resident alert and responsive. Body assessment done, no injuries or bleeding noted. Resident was assisted back to bed. Vital signs checked and stable. MD made aware and received an order to send her to hospital for evaluation.
R26 hospital record dated 4/10/23 documents: Patient presented from a nursing home due to breakthrough seizure. The patient Dilantin level was low. She was loaded with antiepileptics and admitted because she had another breakthrough seizure while in the emergency department. Patient was admitted for further management and evaluation of her breakthrough seizures which are likely due to inadequate dosing and missed medication doses. Dilantin level documented at 4.6.
Facility policy reviewed 2/1/22 titled change in condition documents: It is the policy of the facility to alert the resident, physician/ nurse practitioner and resident party of a change in condition. Nursing will notify the residents physician when: there is a significant change in the resident's physical, mental or emotional well-being. The communication with the resident and their responsible party as well as the physician will be documented in the resident's medical record or other appropriate documents.
Facility policy dated 5/14 titled Laboratory test processing and reporting documents: To assure physician ordered diagnostic test is performed and to assure test results are promptly reported to the physician. A licensed nurse is responsible for monitoring the receipt of test results; test results are promptly reported to the physician or other practitioner who ordered them.
On 6/13/23 at 4:10pm, V60 (Psychiatrist) stated that V60 has not received lithium or Depakote level laboratory results since 10/14/22. V60 was informed that now (urgent) orders for lithium and Depakote levels on 4/4/23 and the now order for lithium level on 6/1/23 were not carried out for R33. V60 stated that he expects the nurses to carry out his orders.
On 6/13/23 at 4:20pm, V19 ADON (Assistant Director of Nursing) stated that the nurse enters the order into the facility's computer system, completes a laboratory requisition form, calls the lab for all now/urgent orders. V19 stated that a now order is to be ordered urgent. V19 stated that the nurse will receive a confirmation number from outside laboratory company, the nurse is expected to write the number on the lab requisition form. V19 stated that with urgent labs, the outside lab company will come in within 2-3 hours, sometimes it takes longer before lab tech comes to facility, but it is the same day. V19 stated that the nurse is expected to check for laboratory results online via the outside laboratory company's portal. V19 stated that the nurse is expected to check for any/all outstanding lab results. V19 stated that the nurse is expected to hand off to the on-coming nurse when there are any pending lab results.
On 6/14/23 at 8:25am, V41 NP (Nurse Practitioner) stated that the nurse should be checking the resident's chart for any new orders placed. V41 stated that V41 expects the nurse to carry out all orders written and follow-up on any outstanding laboratory test results. V41 stated that the nurse should be notifying the physician of laboratory results.
On 6/14/23 at 9:30am, V19 presented this surveyor with a lithium level from a blood sample collected on 4/5/23 at 11:17am and not reported until 6/13/23 at 4:49pm. The lithium level result was 0.33 (normal range is 0.60-1.20). V19 stated that she was unsure if the abnormal results had been reported to the physician. When questioned reason it took more than 60 days after blood sample collected and results known for V19 to obtain results, V19 was unable to explain.
Review of R33's medical record does not note the physician was notified of the low lithium level.
On 6/15/23 at 9:30am, V70 (Outside Laboratory Supervisor) stated that they absolutely would not process a blood sample, obtain results, and not enter those results in their portal for this facility to review. V70 stated that R33's lithium level was drawn on 4/5/23 and results known on 4/5/23. V70 stated that she is unsure of the reason this facility did not follow up with this outside lab company if they were not able to see R33's lithium results on 4/5/23. V70 stated that this facility did not contact this lab until 6/13/23 at 4:49pm requesting R33's lithium level from 4/5/23.
Review of R33's POS (physician order sheet), dated 4/4/23, notes orders for lithium level and Depakote level now. On 6/1/23, there is an order for lithium level now.
Review of this facility's laboratory tests processing and reporting policy, dated 05/2014, notes a licensed nurse is responsible for assuring the laboratory is notified of physician's orders for testing. Urgent (STAT) or same day orders will be called to the laboratory service by the nurse who transcribes the order. Laboratory test(s) will be written on either MAR (medication administration record)/TAR (treatment administration record). A nurse is responsible for monitoring the receipt of test results. Test results are promptly reported to the physician. The licensed nurse is responsible for documenting in the nurses notes physician notification.
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 F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide written notice to the resident and residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide written notice to the resident and resident's representative of a room change and the reason for this change prior to the resident's room change. This failure affected two residents (R17 and R18) out of three reviewed for resident right to be informed.
Findings include:
On 5/30/23 at 10:20am, V62 (family member) stated that on 3/16/23, R18 was admitted to this facility to room [ROOM NUMBER]. V62 stated that V62 visited on the evening of 3/17, approximately 6:00pm. V62 stated that V13 (nurse) confirmed R18 was in room [ROOM NUMBER] and she proceeded directly to R18's assigned room. V62 stated that when she turned on the light in the room, V62 did not see R18; the only resident in the room was sleeping. V62 stated that she went back to the nurses' station and informed V13 (nurse) that the resident in that room was not R18. V62 stated that V13 responded in an argumentative manner that it was R18 in that room. V62 stated that there was another nurse present who offered to help V62 find R18. V62 stated that R18 was located in a different room on the same nursing unit.
On 6/2/23 at 9:40am, V13 (nurse) stated that she does remember the incident involving R18. As V13 pointed with her left index finger to the skin coloring on her right forearm, V13 stated that the other resident looked like R18 so she thought it was R18.
Review of R18's medical record, dated 3/16/23 at an unknown time, notes R18 was moved in to room [ROOM NUMBER]. There is no documentation found in R18's medical record noting R18 and R18's family member were notified of the room change.
Review of R18's pre-admission hospital record, dated 3/16/23, notes R18 with diagnosis of dementia.
On 5/30/23 at 10:30am, R17 was observed in her room on the third floor nursing unit.
Review of R17's medical record, dated 6/1/23 at 3:04pm, V3 (Assistant Social Services Director) noted V3 will be moving R17's room to help provide a better living environment for R17. R17 was moved to room [ROOM NUMBER].
On 6/5/23 at 5:59pm, V29 PRSC (Psychiatric Rehabilitation Services Coordinator) noted R17's state guardian was called and voicemail message left in regards to R17's room change from 114 to 126.
There is no documentation found in R17's medical record noting R17's state guardian was notified prior to R17's room change on 6/1/23 or 6/5/23.
Review of R17's room change request form, dated 6/5/23 at 5:55pm, notes R17's room was changed from room [ROOM NUMBER] to room [ROOM NUMBER]. It also notes both the resident moving (and/or their responsible party) and the resident(s) (or their responsible party) receiving a new roommate must be notified prior to the room change.
There is no room change request form found in R17's medical record noting the room change from the third floor nursing unit on 6/1/23 to the first floor nursing unit.
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 F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow their physical restraints policy by not ens...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow their physical restraints policy by not ensuring residents were free from being physically restrained by facility staff. This failure affected two (R38 and R40) reviewed for physical restraints. R38 was physically prevented to ambulate in a wheelchair; facility staff were observed blocking R38's movements and holding R38 back with the wheelchair handles. R40 was observed sitting in bed with a reclining wheelchair and mattress propped against the bed; restricting R40's movement.
Findings include:
1. On 6/6/23 at 9:30am, State surveyors were in the library on the third floor of the facility. The State surveyors heard R38 repeatedly yelling let me go back to my room. When this surveyor looked out the window, V3 (Assistant Social Services Director) and V33 (Activity Aide) were observed standing on the patio near the entrance, not allowing R38 to exit the patio. R38 was observed attempting to turn his wheelchair toward the entranceway to leave. V3 was observed walking behind R38's wheelchair, grabbing the handles, and pulling the wheelchair backwards. V3 was observed with her back against the wall and R38's back of wheelchair pulled close to V3. Shortly thereafter, V1 (Administrator) was observed entering the patio.
On 6/6/23 at 9:37am, R38 again yelling let me go to my room. V33 was observed exiting the patio.
On 6/6/23 at 9:38am, this surveyor entered the patio and asked V3 what was going on with R38. V3 stated that they brought R38 to patio for fresh air. When questioned why R38 can't go back to his room, V3 stated that R38 removed his clothing while in R38's room. When questioned for what reason R38 cannot be without clothing in his room, V3 did not respond.
This surveyor asked R38 if R38 was okay and if he would like to go to his room now. R38 did not respond to any questions. R38 sat quietly in the wheelchair. R38 was observed to have a scratch on the bridge of his nose and redness to the nose.
When questioned what interventions have been put in place when R38 exhibits this behavior, V1 stated that this is the first time R38 has removed his clothing. V1 was informed that this surveyor observed R38 naked in the halls on 5/30/23 and staff looked away and did not attempt to re-direct R38 back to his room. When questioned what interventions should have been put in place after last week's inappropriate behavior. Again, V1 stated that this is the first time R38 has exhibited this inappropriate behavior. V1 stated that she called R38's psychiatrist and was instructed to send R38 to the hospital due to his behaviors. Throughout the conversation, V3 was holding the handles of R38's wheelchair and rocking the wheelchair back and forth. When questioned if they are restraining R38 and preventing R38 from returning to his room, V1 stated that R38 is not being restrained. When questioned again for the reason R38 is not allowed to go back to his room, V1 nor V3 responded. At that time, V3 was observed to let go of R38's wheelchair. As soon as V3 let go, R38 immediately turned his wheelchair and self-propelled into facility to go to his room.
At 12:00pm, R38 was observed lying in his bed naked listening to music and moving his right foot and left hand with the music. R38 appeared calm.
On 6/6/23 at 10:00am, V33 (Activity Aide) stated that V33 was passing the daily water/juice to residents on the third floor nursing unit. V33 stated that V1 (Administrator) came and instructed V33 to stand by R38's room. V33 stated that V1 went in to R38's room, asked R38 do you want to get fresh air? We are going to get you dressed. R38 responded with F***, no other verbalization by R38 was heard. V33 stated that R38 came out of his room with V1, V5 (Nurse), V11 (Restorative Aide), V3 (Assistant Social Services Director), and V33 and all got on the elevator. V33 stated that V33 left them to get her phone to play music for R38 outside. V33 stated that she also brought R38 a bottle of tea. V33 stated that when she came outside to the patio, R38 was rocking in wheelchair. V33 stated that V13 was rocking R38. V33 asked R38 what music did he like, R38 did not respond. V33 stated that V1 instructed her to put on Elvis. V33 stated that she offered R38 tea, he did not respond. V33 stated that R38 was not responding to the music playing. V33 stated that R38 began to forcefully rock self back and forth in wheelchair.
On 6/6/23 at 10:20am, V3 stated that the incident involving R38 started at 9:30am today. V3 stated that she observed R38 cursing in his room. V3 stated that she thought it would be therapeutic to take R38 outside for fresh air. V3 stated that she, V5, V11, and V1 were all in R38's room. V3 stated that she asked R38 if he wanted to go outside. V3 stated that V5 and V11 got R38 dressed. V3 stated that R38 was offered a wheelchair; wheelchair was placed next to R38's bed and R38 got self in wheelchair. V3 stated that R38 was brought down to the patio, still cursing. V3 stated that on the patio, R38 was shouting he wanted to go back to his room. When questioned why R38 was being blocked from exiting patio, V3 responded that R38 stays in his room and V1 thought fresh air would help him. V3 stated that she thought rocking R38 back and forth would calm him.
Review of R38's medical record notes R38 was admitted to this facility on 4/19/23 with diagnoses including Alzheimer's disease, dementia without behaviors, anxiety disorder, major depressive disorder, schizoaffective disorder, bipolar disorder, and history of falling.
2. R40 has the diagnosis of Dementia, Anoxia Brain Damage, Epilepsy Behavioral and emotional disorders. Minimal data set dated [DATE] section C (cognitive patterns) documents a score of four which indicates severely impaired.
On 5/30/23 at 3:02pm, R40 was observed sitting in middle of his bed with his upper body leaning towards the foot board, legs were off the bed, bent at knees with feet on the floor. R40's geri-chair was pushed laterally on/against R40's legs, restricting movement and a twin size mattress was pushed directly against the side of the geri-chair reinforcing the geri-chair against R40's legs.
On 5/30/23 at 3:07pm, V13 (Nurse) said, the geri-chair should not be placed against R40's legs. The mattress should be on the floor next to the bed.
On 6/7/23 at 10:59am, V1 (Administrator) said, objects in place that keep a resident from moving freely are physical restraints.
Physical Restraints Policy dated 12/21 documents: Physical restraints are any manual, physical or mechanical device or equipment attached to or adjacent to the resident's body that the resident cannot remove easily, and which restrict freedom of movement or normal access to one's body.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and report an allegation of a missing or stolen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and report an allegation of a missing or stolen phone charger to the regulatory agency. This failure affected 1 of 3 (R10) residents reviewed for theft and misappropriation of property.
Findings include:
R10 is a [AGE] year old with the following diagnosis: Parkinson's disease, bipolar disorder, and vascular dementia.
On 5/31/23 at 1:09PM, R10 showed this surveyor a phone but reported the phone was given to him by a family member a couple months ago. R10 endorsed the phone charger for the current phone has been missing about 4-6 weeks and it needed to be replaced by R10's family. R10 reported the new phone's missing charger to family and social services but nothing has been done to replace the phone charger. R10 denied being aware of any investigation the facility is doing to replace the phone charger.
On 6/1/23 at 7:01PM, V26 (Family member) stated that the Ombudsman needed to get involved. The Ombudsman (V25) was there a couple weeks ago and talked to V1 with me. We talked about the nursing care, medications, appointments, and the missing phone and the missing charger. This was the second charger that was missing. V1 acted like this was the first time V1 was hearing about it. V1 said V1 would write it down and start an investigation again but that was last week, and I still haven't heard anything. I did have to buy another charger for the new phone I bought. R10 said the charger was missing sometime in April. I did tell V1 again about that, but she stopped calling me until I called the Ombudsman for help.
On 6/2/23 at 11:02AM, V1 (Administrator) stated that the Ombudsman came in and had some complaints from R10's family. I went over the chart with the Ombudsman with the family on the phone. It has never been brought to my attention that R10 had a missing or stolen phone and charger. R10 or R10's family have never mentioned anything about a missing phone or charger. The Ombudsman never mentioned anything about the phone or a charger during any of our meetings.
On 6/2/23 at 12:56PM, V25 (Ombudsman) stated that I have been to the facility twice in the past 2 weeks for concerns R10's family has. Yes, R10's family told me there was missing a phone charger. The family said something like this is the second one that R10 had pulled from the wall. V1 was aware of the missing phone charger. I wrote it in my case manager notes. I told her myself about the phone changer and R10's family also mentioned it to V1 when we were on the phone.
On 6/13/23 at 10:32AM, V34 (PRSC) stated that when someone reports something missing, we usually do a grievance form and give it to the supervisor. We look forward to seeing if we can find it first. If we can't, then we pass it off to the Administrator and she takes it over.
An Administration note dated 5/22/23 documents the Ombudsman notified V1 (Administrator) of concerns regarding R10 not getting to medical appointment or getting assistance with discharge. V1 contacted a family member with the Ombudsman present and went over all the concerns.
An Administration note dated 6/1/23 documents V1 attempted to contact R10's family member regarding a concern, but the family did not answer.
The Facility Incident Report dated 6/8/23 documents a surveyor reported on 6/2/23 that R10's cell phone went missing in 02/2023. A review of R10's inventory showed R10 had a cell phone on admission. R10 and R10's family were educated to report all concerns to staff immediately to ensure they are addressed in a timely manner. R10 was provided a lock to keep belongings safe.
There is no mention in the facility report about the missing phone charger.
The policy titled, Abuse Prevention Program Facility Policy and Procedure, dated 1/4/18 documents, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator .Reports should be documented, and a record kept of the documentation.
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 F0740
(Tag F0740)
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 psychosocial services with interventions to reduce aggressi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide psychosocial services with interventions to reduce aggression and resident to resident physical altercations for residents with a history of aggressive behaviors. This affected 2(R5, R6) of 4 residents reviewed for behavioral services.
Findings Include:
R5 is a [AGE] year old with the following diagnosis: schizophrenia and dementia. R5 admitted to the facility on [DATE].
R6 is a [AGE] year old with the following diagnosis: traumatic brain injury and schizophrenia. R6 admitted to the facility on [DATE].
On 5/31/23 at 12:45PM, R5 denied going to any groups. R5 denied staff asking R5 to attend any groups. R5 denied any staff talking with R5 about being aggressive or how to manage aggressive behaviors.
On 5/31/23 at 12:52PM, R6 reported going to groups but was unable to say how often R6 goes or what the groups are about. R6 endorsed the groups usually just talk about living life or problems they have here. R6 denied having any groups or education on aggressive behaviors and how to manage them.
On 6/9/23 at 1:48PM, V48 (Nurse) stated Dr. [NAME] does groups here. I think he does them twice a week. They are on different topics. I think him and the residents pick what they want to talk about. If residents are having any type of behaviors, we normally tell social services so they can respond.
On 6/13/23 at 10:32AM, V34 (PRSC) stated we offer a behavior management group, men's group, anger management, journaling, and some other groups. All the residents can come to any group. We always encourage the resident with aggressive behaviors to come to the group but sometimes they don't. If they refuse, I just let my supervisor know who is the Social Service Director . We don't really have any plans for the residents if they refuse. We hold them once a week, so if they come, we just document it and if they don't, then they don't come. It should be documented in PCC. If it's not documented there or on an attendance sheet, then maybe the meeting didn't happen that day. Sometimes they get canceled if we have an emergency with other residents, we will try to push back the time and still have it that day, but it doesn't always happen if we are busy or there are other residents having lots of behaviors that we have to try to manage.
On 6/13/23 at 1:57PM, V57 (Social Service Director) stated a doctor comes on Tuesday and Thursday and holds group usually in the library. Dr. [NAME] will also do one to ones with certain residents. I think he picks the residents or sees what residents are struggling to do one on ones with him. Monday through Friday social services does the groups. We have behavior management, women's group, men's group, journaling, Bible study, constructive use of time, and weekend planning. It really depends on where the conversation goes in the groups to what we talk about. We listen to the resident needs and see how we can help them with what they are needing at that time through the group conversation. We can't force anyone to go, but we do encourage the residents to come especially the ones with behaviors. If they don't come to the groups; we will do well-being checks. Those happen once a week. It's normally just hey how are you doing, mostly general conversation. We listen to their needs and they kind of tell us what's going on. For the residents with behaviors, we just kind of monitor them through the well-being checks. Some people document in PCC and others documents on paper. Groups help residents because it teaches them things that they might not have known before about their diagnosis. It also helps them keep learning new or the same information to help kind of maintain their diagnoses.
On 6/13/23 at 3:20PM V29 (PRSC) stated, we have men's group, women's group, friendship group, bible group, and behavior management group. Each of these groups happen one time a week. They are open to everyone. For the symptom and behavior management group we really try to make sure that the residents having behaviors that week attend. We also invite them to go to Dr. [NAME]'s groups. He has those two times a week. If they don't want to go to the groups, then we will meet with them one on one to check on their well-being. We see how things are going and see what they need. In comparison to the groups, the groups are more of a focused topic. A one to one you just kind of let the resident lead the conversation, and you just ask some follow-up questions. The groups help with their skills and addressing any concerns they are having at the facility. We want them to have skills in managing their behaviors and just becoming more independent as much as possible. If there is no documentation of a group done that day, then I would have to say that it wasn't done.
The Care Plan dated 12/12/22 documents in spite of repeated counseling at times, R5 continues to refuse/resist the recommended psychosocial/psychiatric rehabilitation intervention, promoting enhanced mental health and physical well-being. It appears that R5 refuses this intervention secondary to impaired judgment and insight related to psychiatric illness, dementia, and inability to understand. Staff have attempted to motivate R5 to engage in appropriate re-habilitation mental health programming.
The PASAR dated 2/10/22 documents R5 needs special services for aggression/anger management and mental health rehabilitation activities.
The Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors dated 4/10/23 documents a total score of 7 indicating a substantial problem due to diagnoses of severe mental illness, history or recent episodes of aggressive/agitated behavior, history of substance abuse, and lack of general awareness/insight.
A Behavior note dated 4/10/23 documents R5 had verbal aggression. R5 was yelling in the hallway requesting certain foods. R5 was educated on scheduled mealtimes. R5 receptive to education. There is no education or counseling session documented addressing R5's aggressive behavior on this day.
An Event note dated 4/12/23 documents R5 presented with aggression towards another resident. R5 was counseled on presenting social and verbal appropriate behavior. R5 was encouraged to utilize coping skills. R5 was encouraged to seek out staff for assistance. The police were notified.
There is one documented attendance sheet on 2/28/23 where R5 attended the group held that day. The group note documents R5 presented angrily at the beginning of group and was uncooperative. There was no apparent trigger for R5's anger and R5 did not respond to inquiries. R5 does have well-being checks from social services that are documented about once a month. The documentation notes the well-being checks ask R5 how R5 is doing and there is no documentation on education for being aggressive or managing behaviors.
The Care Plan dated 7/15/22 documents in spite of repeated counseling attempts R6 continues to refuse/resist recommended psychosocial/psychiatric rehabilitation interventions promoting enhanced mental health and physical well-being. It appears that R6 refused this intervention secondary to: impaired judgment in insight related to psychiatric illness, inability to understand secondary to a thought disorder.
The Care Plan dated 3/12/23 documents R6 as a history of aggressive, inappropriate, attention seeking, and/or maladaptive behavior, but has demonstrated stability during the admission screening process, and is therefore considered appropriate for admission. The history includes: conflicts/altercations with others both verbal and physical aggression. An intervention documents to provide support intervention (X) (there is no specific time documented) times per week with a specific group or 1 to 1 and conduct a review of past behavior to evaluate the likelihood for aggressive/inappropriate behavior. This care plan also documents R6 presents with signs and symptoms of persistent anger towards self and others related to medical conditions, feeling abandoned by support system, persistent fears and anxiety, psychotic symptoms, and emotional insecurity. This problem is manifested by verbal hostility and physical abuse. An intervention documents to teach R6 anger management techniques, including talking about feelings and anger, and counting forwards, as well as backwards to regain composure.
A General note dated 3/12/23 documents R6 was very agitated and had an altercation with another resident in the dining room. The doctor was notified and ordered to send R6 out to the hospital for a psych evaluation.
An Event note dated 3/12/23 documents staff made social services aware that R6 was presenting physical aggression by punching a peer in the face with a closed fist due to delusional ideation. R6 thought R7 was talking to him, but R7 was presenting with auditory hallucination. The residents were separated. R6 was counseled on presenting social appropriate behavior. R6 was not receptive to counseling and presented with verbal aggression. R6 was placed on a 1:1 until hospitalized .
There is documentation of R6 attending groups on Tuesdays and Thursday, but the topics do not correlate with anger management or aggressive behavior. The last documented anger management group R6 attended was in 12/2022.
The PASAR screen was requested but was not given to this surveyor during this timeframe of this survey.
.
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 F0761
(Tag F0761)
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 have physician ordered medication available for admini...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have physician ordered medication available for administration to include Ativan and Norco. This affected 2 of 3 (R25, R27) residents reviewed for medication and medication storage.
Findings include:
1. R27 was admitted to facility on 12/27/22 with a diagnosis of depression, visual loss, suicide attempt, psychoactive substance abuse and multiple fractures of pelvis, fracture of lower end of left ulna and fracture of lower left humerus.
R27 brief interview for mental status dated 5/23/23 documents a score of 15/15 which indicates cognitively intact.
On 5/30/23 at 1:28PM, R27 who was alert and oriented at time of interview, said he did not have any Ativan today and the facility will runout of the medication sometimes.
On 5/30/23 at 1:54PM, V19 (ADON) said they did not have Ativan available for R27 on the medication cart and requested a refill today.
On 6/6/23 at - V71(Pharmacy) said R27's Ativan was requested by the facility on 5/30/23 with a total of 30 tablets sent with no delay in ordering.
R27 controlled drug sheet dated 5/11/23 for lorazepam 0.5 mg Take one tablet by mouth every 8 hours as needed documents last dose given on 5/28/23 at 500pm. R27's controlled drug sheet was dated 5/30/23 documents first dose given on 5/31/23 at 800AM.
R27 physician order sheet dated 1/24/23 documents lorazepam 0.5 mg Take one tablet by mouth every 8 hours as needed for anxiety.
2. R25 was admitted to the facility on [DATE] with a diagnosis of rheumatoid arthritis, abnormalities of gait, lack of coordination, pressure ulcer of sacral region unspecified stage, ankylosing spondylitis, scleritis with corneal involvement, severe protein caloric malnutrition.
R25's controlled drug receipt dated 4/27/23 documents for hydrocodone 10/325mg. Give one tablet every 8 hours for pain. Last dose was given on 5/8/23 at 3:00pm.
R25's controlled drug receipt dated 5/10/23 documents for Norco 5/325mg. Give one tablet every 6 hours for pain. First dose was given on 5/10/23 at 6:30am.
On 6/13/23 at 4:08PM, V19(ADON) said medications should be available for residents and nurses should follow the orders.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document an incident regarding a resident's death for on...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document an incident regarding a resident's death for one (R50) out of three residents reviewed for accurate documentation.
Findings Include:
R50 is a [AGE] year old with the following diagnosis: end stage renal disease, chronic heart failure, and type 2 diabetes. R50 admitted to the facility on [DATE] and expired in the facility on [DATE].
A Nursing note dated [DATE] at 1:21 AM that is struck out documents R50 sounded like R50 was crying. The nurse checked on R50 and found R50 awake. R50 denied crying. R50 sounded congested and this nurse offered suctioning but R50 refused. R50 claimed R50 was fine. The door was left open so the nurse could hear R50 if help was needed.
A Nursing note dated [DATE] at 1:21 AM documents R50 was talking but sounded upset. R50 would not tell the nurse what was wrong. R50 was sitting up in bed. R50 answered being fine. R50's breathing sounded congested but R50 refused to be suction. R50 was assisted to lie back with head part elevated and covered with a blanket to keep warm. The door was left open so the nurse (V56) could hear R50 if help was needed.
A Nursing note dated [DATE] at 7 AM that is struck out documents the night nurse (V56) was passing medication when the morning nurse (V20) came in to do initial rounds. R50 was found unresponsive at 6:45 AM. The morning nurse and the night nurse tried to revive R50 but was not successful. No vital signs were appreciated. the administrator, DON, and ADON were notified. The nurse practitioner was also notified of R50's demise. According to the CNA, the CNA last changed R50 around 5:45 AM.
A Nursing note dated [DATE] at 7AM documents R50 was changed by the CNA at 5:45 AM. R50 was verbally responsive. Around 6:45 AM, the morning nurse (V20) noted R50 unresponsive. R50's arms were cold and clammy. The second nurse (V56) went to assess R50. Vital signs were checked, but none were appreciated. CPR was not attempted since it was a presumptive death. The power of attorney was called. The administrator, DON, and nurse practitioner were also called to inform of the R50's demise. Postmortem care was completed.
Both notes that are struck out are documented as incorrect documentation. The notes that are struck out are the complete opposite of what occurred from what was documented at a later time.
On [DATE] at 11:08AM, V56 (Nurse) stated I talked to the DON and the DON told me to change my documentation from what I first put. When I charted that morning, I put that I did CPR. I didn't do any CPR. I felt guilty that I didn't do anything so that's why I charted I did CPR.
On [DATE] at 1:40PM, V19 (ADON) stated a nurse should only be charting what they did. If they didn't do something with a resident, then it shouldn't be charted. That would be considered incorrect charting. It should be corrected as soon as you realize it is done.
On [DATE] at 12:49PM, V1 (Administrator) stated when I first interviewed V56, V56 told me V56 didn't do CPR. I then went back and checked V56's charting and V56 documented V56 did CPR. I asked V56 why V56 documented that, and I guess V56 was nervous or something and thought V56 should have done it so V56 documented that. That would be considered wrongful documentation. You can't document doing something if you didn't do it.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0941
(Tag F0941)
Could have caused harm · This affected 1 resident
Based on observations, interviews and record reviews, the facility failed to develop an effective communication policy and implement staff training to ensure residents whose primary language is not En...
Read full inspector narrative →
Based on observations, interviews and record reviews, the facility failed to develop an effective communication policy and implement staff training to ensure residents whose primary language is not English could receive the necessary ADL (activities of daily living) care from all direct care staff in a language the residents could understand. This failure affected one resident (R16) out of one reviewed for communication.
Findings include:
On 5/30/23 at 2:39pm, R16 was interviewed via a Spanish speaking surveyor. R16 who was assessed to be alert and oriented to person, place and time. R16 was observed lying in bed. R16 stated while crying, my left leg hurts. My pain level is a 10 out of 10. I didn't get my pain medication it was not ordered. R16's right side of bed was observed to be positioned against the wall and the head of bed positioned against adjacent wall. R16 stated that staff only turn her on her right side by pushing her left leg causing pain to her left knee. R16 stated that R16 wants to be moved to the bed closest to the door so staff can turn her onto her right side.
On 5/30/23 at 2:40pm, V13 (Nurse) stated that R16 was admitted to this facility on 5/4/23. V13 stated that R16's pain medication has not been ordered. V13 stated that V13 needed to call the doctor.
On 5/31/23 at 1:30pm, R16 was interviewed via a Spanish speaking surveyor. R16 stated that R16 speaks little English and does not understand when spoken to in English. R16 stated that R16 has had one shower since admission to this facility on 5/4/23. R16 stated that her hair has not been washed x 2 weeks. R16 stated that her whole head is itchy due to hair not being washed. R16 stated that she has all of the supplies in her room to wash hair. R16 stated that she asks for hair to be washed but staff have not done it. R16 stated that staff do not get her out of bed. R16 stated that it is easier for her to transfer on the right side of bed. R16 stated that she has pain in left knee when staff push her left leg to turn her to the right. R16 stated that she had been requesting for one week to be moved to the bed closer to the door. R16 stated that there aren't any Spanish speaking clinical staff or residents she can talk to. R16 stays in room all day every day isolated. R16 stated that R16 is scared to be at this facility because R16 does not know what medications/treatments she is receiving. R16 was thankful to the surveyor for communicating with her in Spanish so she could make her needs known.
On 5/31/23 at 2:36pm, V4 (Rehabilitation Director) stated that R16 speaks English fairly well and is alert and oriented x 3. V4 stated that R16 was asking for a while, at least one week, about switching beds. V4 stated that the nursing staff had a Spanish speaking housekeeper speak with R16. When questioned reason it took State surveyors 5 minutes to understand what R16 wanted and it took staff with housekeeper translating one week to understand what R16 wanted, V4 responded R16 was not explaining what she wanted correctly so staff did not understand.
On 6/1/23 at 3:35pm, V61 (R16's Family Member) stated that R16 understands a little English. V61 stated that the staff use a housekeeper to translate for R16, which is not appropriate. V61 stated that housekeeping staff do not have any health care training and would not be able to identify any changes in R16's medical condition. V61 stated that R16 does not know what medications she is receiving, because R16 does not understand what the staff are saying.
On 6/2/23 at 10:42am, V2 DON (Director of Nursing) stated that residents whose primary language is not English should have a communication board to utilize during their stay at this facility. V2 stated that this facility does not have a translator/interpreter service available. V2 stated that prior to R16's admission to this facility there should have been a communication board in place in her room. V2 stated that this facility does not have an effective communication policy or provide communication training for its staff.
On 6/6/23 at 11:30am, V8 (Assistant Administrator/Human Resources Director) was questioned regarding staff communication training, responded do we have to do training on communication?
Review of R16's hospital pre-admission transfer record, dated 5/4/23, notes on the first page R16's spoken language is Spanish.
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 F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a plan to transition residents discharged f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a plan to transition residents discharged from the skilled therapy program to restorative nursing program. This affected four of four residents (R10, R25, R48 and R50), reviewed for plan of care post skilled therapy.
Findings Include:
R10 was admitted to the facility on [DATE] with diagnoses of but not limited to multiple fracture of ribs, vascular dementia, history of falling and lack of coordination.
R10's occupational Discharge summary dated [DATE]-[DATE] documents under discharge recommendations and status recommends restorative nursing program.
R10's PT (Physical Therapy) Discharge summary dated [DATE]-[DATE] documents under discharge recommendations: R10 to continue with Restorative Program.
V4 (Director of Rehab) provided therapy to nursing recommendations, stating R10 is NWB (no weight bearing) on BLE (Bilateral Lower Extremities) and LUE (Left Upper Extremity). Restorative recommendation Passive Range of Motion on BLE and LUE as tolerated. Active Range of Motion for RUE (Right Upper Extremity), 10x2 sets.
On 5/20/23 at 1:15pm, V4 stated that R10 met his therapy goal and is still NWB on BLE and LUE until cleared by R10's ortho doctor. Therapy services picked up again in May.
V4 provided OT Therapy progress notes that R10 started OT services on 5/5/23 and PT services started on 5/4/23.
On 5/30/23 at 1:40pm, V5 (Restorative Nurse) denied receiving the therapy to nursing recommendations form for R10. V5 stated, I do not have restorative aides to do the programs. We will start R10 in a restorative program today. There were no recommendations from PT department, and probably because this facility has not had a restorative program for about 6 months before I started here, so the therapy department did not communicate with me. And now that we have everything up and running and with 2 restorative aides on board, we can now do and start residents in restorative programs. I will now be communicating with the therapy department on who to put in the program once they are discharged in therapy services.
R25 was admitted to the facility on [DATE] with a diagnosis of rheumatoid arthritis's, lack of coordination, ankylosing spondylitis, pressure sore of sacral area, scleritis, hypertension, anemia, malnutrition, osteoporosis, abnormalities of gait and mobility.
R25's occupational Discharge summary dated [DATE]- 1/17/23, documents under discharge recommendations and status recommends restorative nursing program.
On 6/1/23 at 2:52PM, V5 (Restorative Nurse) said she did not have any documents related to restorative services provided to R25. V5 said he must have fallen through the cracks.
R48 was admitted to the facility on [DATE] with a diagnosis of gout, anxiety disorder, hypertension, type 2 diabetes and major depressive disorder.
R48's physical therapy Discharge summary dated [DATE]- 5/18/23 documents under discharge recommendations: patient to continue Restorative Nursing Program.
R50 was admitted to the facility on [DATE] with diagnosis of anxiety, schizophrenia, major depressive disorder, and orthopedic joint implant.
R50's physical therapy Discharge summary dated [DATE]- 5/9/23, documents under discharge recommendations: patient to continue Restorative Nursing Program.
On 5/30/23 at 1:15pm, V4 stated At the time we did not have an established restorative program, the form might have been handed to other Administrative/Management. The Restorative Nurse has computer access to our recommendations and evaluations also. The Restorative recommendation is given to maintain the level of function of any residents that was discharged in therapy services.
On 5/30/23 at 1:40pm, V5 (Restorative Nurse) I have not received any recommendation from the therapy department at all. We have a break in our system of communicating with the therapy department and my department. I will start these residents in restorative program today. I will do assessments and start them with appropriate restorative program.
V5 provided state surveyor the list of residents who are on restorative program in the facility.
On 6/1/23 at 2pm, reviewed and verified with V5 that R10 did not receive any restorative program while waiting for PT services. R48 and R50 are not on the list and not receiving restorative programs as well.
On 6/7/23 at 9am, V1 (Administrator) Traditionally, the therapy department will inform the restorative nurse about resident discharge to therapy services and their recommendation. We did not have a restorative program running for a while due to no restorative staff. But I had a sit down meeting with both departments (restorative and therapy) before May 1st, and we talked about starting May 1st that restorative will be accepting recommendations and have the program starting. We did not know that the recommendation is not getting to the restorative department. From now on, I have them communicating via email, and cc'ing me, so I have a paper trail that the recommendation by the therapy department is sent to our restorative team.
Therapy Policy and procedure with an issue date of 1/1/23 reads in part: To provide guidelines for therapeutic interventions to ensure residents maintain their highest level of functioning. When a decline or improvement is observed by nursing staff therapy will be notified. Based on the results of the screen the therapy department shall: Recommend restorative programming. Recommenced functional maintenance programming.
Restorative Nursing Policy and Procedure, not dated, reads in part: Program Description and Rationale: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. To promote each resident's highest practicable level of mental, physical and psychosocial functioning. To prevent further loss of independence. To promote wellness and prevent debilitation. Includes, but not limited to, programs in walking/mobility, dressing and grooming, eating and swallowing, transferring, bed mobility, communication, splint or brace assistance, amputation care and continence programs. Each resident will be screened for restorative nursing upon admission, annually, quarterly and with any significant change in function. Appropriateness of restorative program will be determined by the Restorative Nurse as needed and/or may be determined as continuation of care following a course of physical, occupational and/or speech therapy. A maintenance program is established based on the resident specific needs for the program. A care plan and appropriate form then initiated.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R36 has the diagnosis of Spina Bifida, Functional Quadriplegia, Muscle Wasting, Traumatic Brain Injury and Atrophy. Minimal data...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R36 has the diagnosis of Spina Bifida, Functional Quadriplegia, Muscle Wasting, Traumatic Brain Injury and Atrophy. Minimal data set section G (functional status) dated 5/1/23 documents: R36 was totally dependent with one person physical assist with eating. Upper extremity impairment on both sides. Care plan dated 5/1/23 documents: Resident (R36) has a self-care deficit (ADLs/Mobility) generalized weakness and diagnosis of quadriplegia r/t spina bifida. Assist at meals with hand over hand assistance.
On 6/2/23 at 12:31pm, R36 was observed in the dining room during lunch time, leaning to the left, feeding self, chopped meat, spilling food on the tray, table, wheelchair and floor.
On 6/2/23 at 12:41pm, V19 (ADON) asked R36 if he need help. R36 replied yes. V19 preceded to open milk carton. V19 said, sometimes R36 refuses feeding assistance.
Based on observation, interview and record review, the facility failed to follow their incontinence policy by failing to check the incontinent status of residents dependent on staff for toileting at least every two hours. This failure affected three of threes residents (R10, R27, R39) reviewed for incontinence in activities of daily living. The facility also failed to provide feeding assistance for a resident dependent on staff for feeding. This affected one of four residents (R36) reviewed for feeding assistance.
Findings include:
R27 was admitted to facility on 12/27/22 with a diagnosis of depression, visual loss, suicide attempt, psychoactive substance abuse and multiple fractures of pelvis, fracture of lower end of left ulna and fracture of lower left humerus.
R27's brief interview for mental status dated 5/23/23 documents a score of 15/15 which indicates cognitively intact.
R27's bladder and bowel dated 3/23/23 documents under urinary continence a score of 3 which indicates always incontinent. Under bowel continence a score of 2 which indicates frequently incontinent. Under section G toilet use score of 3 under self-performance which indicates extensive assistance and under support a score of 2 which indicates one person assistance.
On 5/30/23 at 1:28PM, R27's pulled the call light for care assistance. R27, who was alert and oriented, said he was uncomfortable and had not been changed since 8:30 this am. R27 had requested assistance at 11:30AM and staff said the CNA was on break and no one ever come back to provide care.
At 1:35PM, V9(CNA) observed providing care to R27. R27's incontinence brief was soiled with urine and feces. Feces was dry and stuck to his buttocks.
On 5/30/23 at 1:50PM, V9(CNA) said she changed R27 after breakfast and was not made aware that he needed to be changed while she was on break. V9 said staff were covering her side and should have assisted the resident with care as needed. Incontinence should be provided every two hours.
R10 was admitted to the facility on [DATE] with a diagnosis of hyperglyceridemia, history of falling, bipolar, tremor, vascular dementia, hyperlipidemia, hypertension, and prostatic hyperplasia without lower urinary tract symptoms. R10's brief interview for mental status dated 5/10/23 documents a score of 14/15 which indicates cognitively intact.
R10's bladder and bowel dated 5/12/23 documents under urinary continence a score of 1 which indicates occasionally incontinent. Under bowel continence a score of 2 which indicates frequently incontinent. Under section G toilet use score of 3 under self-performance which indicates extensive assistance and under support a score of 2 which indicates one person assistance.
On 5/30/23 at 2:04pm, R10 who was alert and oriented at time of interview, said he was changed this morning around 930am after breakfast. R10 was assisted with care by V10(CNA) who said she changed him after breakfast around 10:00am and was unable to provide care again until now. R10's incontinence brief was saturated with urine and dried feces with a strong odor of urine noted upon removal. Also observed a puddle of liquid under wheelchair, when asked what the liquid was V10 said it was from housekeeping cleaning the floor, but no other puddle of liquid noted in the room.
On 6/2/23 at 3:05pm, R10 was observed in common hallway with pants wet from his ankles up to his waist. R10 said it was urine and he needed to be changed. R10 reported he just came from a smoke break and was unable to say how long he had been wet for, but it was a while. V72 (CNA) observed R10 and assisted to room to change.
R39 was admitted to the facility on [DATE] with a diagnosis of hypertensive heart disease. Low back pain, acute kidney failure, hypothyroidism, bi-polar, anxiety and overactive bladder. R39's brief interview for mental status dated 4/14/23 documents a score of 15/15 which indicates cognitively intact.
R39's bladder and bowel dated 4/14/23 documents under urinary continence a score of 3 which indicates always incontinent. Under bowel continence a score of 3 which indicates always incontinent. Under section G toilet use score of 4 under self-total dependence which indicates full staff performance and under support a score of 2 which indicates one person assistance.
On 6/2/23 at 11:27AM, R39 bed was observed with brown rings on the sheets and bed wet. R39 incontinence brief was wet, and care provided. V65 (CNA) said care was provided in the am upon start of shift around 800AM.
Facility policy dated 9/20 titled incontinency policy documents: incontinent residents will be checked every two hours and provided perineal care after each episode.
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 F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews, the facility failed to ensure their in-house dialysis provider was available to provide scheduled dialysis services. This failure affects four residents (R28, R...
Read full inspector narrative →
Based on interviews and record reviews, the facility failed to ensure their in-house dialysis provider was available to provide scheduled dialysis services. This failure affects four residents (R28, R44, R45 and R46) of four residents reviewed for dialysis.
Findings Include:
Dialysis provider contracted by the facility to provide service on Mondays, Wednesdays and Fridays.
R28, R44, R45 and R46 receive dialysis treatment in the facility Mondays, Wednesdays and Fridays.
On 6/1/23 at 11am, R28 stated that R28 missed a couple of days of dialysis in May. R28 stated that the dialysis starts at 5am. R28 went down the 12th of May at 5am and there was no one in the dialysis unit at the basement and no one told her that there were no dialysis staff to provide the treatment. The staff on duty in R28's unit was not aware that the dialysis staff was not in the facility.
On 6/1/23 at 12pm, R46 reported he goes every Mondays, Wednesdays and Fridays, different shift (5am or 11am). At times R46 starts at 5am, and that R46 will go to the dialysis center in the basement but no one would be there. No staff in R46's unit informed him about not having a dialysis staff to give treatment for that day. R46 stated this happened multiple times. R46 reported that there is no communication between department, nursing and dialysis. R46 reported for example he would wait from 5am, would go back in the room until he receives the news that there is no dialysis staff coming to give treatment until about 9am. R46 would be waiting for the dialysis staff to come in the building from 6am to 9am and there would no staff coming at all for the day.
On 6/1/23 at 2pm, V30 (Dialysis Administrator) stated We missed May 1st, May 12th and May 15th, 2023. However, we came in the next day which were May 2nd, May 13th and May 16th. I remember on May 12th, there was a nurse that came in from an agency and the PCT (Patient Care Tech) called in that day, and the nurse was not able to provide the dialysis because of the lack of staff. That nurse left the faciity on that day (May 12th). We have two PCT who are regulars in that facility, but one is on medical leave and if one called in sick, we don't have the staff to provide the dialysis for the residents. We inform the facility that same day when the agency nurse left the facility. The other days, we informed the facility via email the day before.
On 6/2/23 at 11am V2 (DON) stated I have not been the DON here for long, but at least a couple of times the dialysis staff did not show up at all. There was no notification from the dialysis company. I remember even calling the dialysis corporate and letting them know that at least let us know ahead of time that there will be no one coming from dialysis. Residents will get up on their dialysis day and go down and no one is in there to do their dialysis treatment.
On 6/7/23 at 9am, V1 (Administrator) stated that the dialysis company informed them early the day off, that there is no dialysis staff coming in the facility. I would expect the dialysis company to email and communicate it to our (V2) DON either by phone or email that the dialysis will not come due to short staff, and V2 will then communicate this to the line staff. Most of the time, there is no nurse from the dialysis company. There is no regular dialysis nurse, the regular nurse got sick and not available to work, however now they have a regular dialysis nurse that comes in our facility. We had a meeting V1, V2, and V25 (Ombudsman) about the dialysis concern with staffing and communication to us in the facility.
On 6/7/23 at 12:30pm, V25 provided names of residents that spoke to her about missing multiple dialysis treatments. V25 mentioned R28, R44, R45 and R46.
V30 provided record of residents that received dialysis the day after missing their scheduled dialysis. R28, R44 and R45 missed their scheduled dialysis on 5/1/23. 5/12/23 and 5/15/23 and received dialysis treatment the day after, on 5/2/23, 5/13/23 and 5/16/23. R46 missed dialysis treatment 5/1/23, 5/12/23 and 5/15/23, however the resident list on dialysis only shows that R46 received dialysis treatment on 5/2/23 and 5/13/23, and nothing on 5/16/23.
Dialysis Care policy and procedure with an issue date of 1/1/21, reads in part: To adequately assess resident needs and provide care goals which achieve the highest practicable level of care to residents with end stage renal disease receiving hemodialysis or peritoneal dialysis. An individual care plan should be developed and followed in coordination with comprehensive assessment. Emergency protocols should be identified and incorporated into the individual care plan.
Mar 2023
11 deficiencies
3 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0557
(Tag F0557)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident was treated with dignity by not providing personal...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident was treated with dignity by not providing personal care prior to being transported to the hospital. This affected 1 of 3 residents (R11) reviewed for dignity. This failure resulted in R11 being transported to the hospital soiled with human excrement, R11 said he felt embarrassed and ashamed.
Findings include:
R11 census denotes was admitted to the facility on [DATE] and transferred to the hospital on 3/5/23.
R11's care plan denotes R11 has a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, essential hypertension, convulsion, abnormal enzymes levels, schizophrenia disorder, asthma, preexcitation syndrome, chronic venous hypertension with ulcer of bilateral extremity, other psychoactive substance abuse with unspecified psychoactive substance- induced disorder, opioid abuse. R11 MDS dated [DATE] denotes in-part R11 needs limited assist with toilet use. R11 care dated 3/7/23 denotes in-part 2 assist with toileting.
On 3/16/23 at 3:57p.m V47 (Nurse) said she was the nurse responsible for R11's care on 3/5/23 when R11 was sent to the hospital. V47 said she worked the 3-11:00pm shift. V47 said there was not any aide on duty for that shift. V47 said she did not provide R11 with incontinent care at all. V47 said she did the best that she could for the residents that evening. V47 said she got report from V42 (Nurse) that R11 was to be sent to the hospital for further evaluation for the surgical wound that opened. V47 said she did not assess R11's surgical wound, but she did see that it was open a little when the medics were at the bedside. V47 said she did not assess R11 before sending R11 to the hospital with the medics to ensure that R11 was clean, dry, and free of human excrements. V47 said R11 did not walk and R11 needed assistance with toileting.
On 3/16/23 at 2:23p.m V42 (Nurse) said R11 required assist with ADL (Activity of Daily Living) care, R11 needs one person assist with incontinent care. V42 said she was R11's nurse for the morning shift (7:00-3:00pm) and R1's wound was open and leaking yellow drainage. V42 said she did not put a dressing over the wound because it was supposed to be open to air. V42 was asked if she notified the physician of the open surgical wound that was leaking yellow drainage. V42 did not respond. V42 said stool could get in the wound if it is not covered, because of the location of the wound.
On 3/17/23 at 2:10pm V56 (physician) said R11's surgical wound should not be covered up, and R11 was being transported to hospital for further care for the surgical wound.
On 3/15/23 at 3:28p.m V7 (Captain of Fire Department) said he was the supervisor responding to a call to transport R11 to the hospital because R11's wound opening. V7 said R11 had on an ill-fitting adult brief, the brief was full of feces. V7 said the feces had dryed up. V7 said R11's surgical wound was covered in feces. V7 said R11 was awake and talking.
On 3/17/23 at 3:20pm V23 (Director of Nursing) said incontinent care should be provided every two hours or as needed to all residents as appropriate. V23 said the resident should be provided incontinent care prior to being escorted to the hospital, a resident should not be escorted to the hospital soiled with stool.
On 3/21/23 at 10:10am V9 (Administrator) said all residents should be treated in a dignified manner, the resident has a right to be treated in a dignified manner. V9 said the residents should be clean, dry and not be soiled in feces when escorted to the hospital.
On 3/21/23 at 1:07pm V62 (social services) said R11 is not on her case load, but she had an opportunity to work with R11 and make observations of R11. V62 said R11 showed signs and symptoms of poor self-esteem, R11 presents with isolative behavior, R11 wouldn't call for assistant, R11 was not vocal about the help he needed. V62 said she didn't document her observations of R11 as mentioned, and she has to do better with her documentation. V62 said R11 behaved in a manner, like he was not worthy of being helped and that is why R11 was care planned for poor self-esteem.
R11's fire department run report dated 3/5/23 denotes in-part 70 y/o male patient (R11) AOx3 (alert and orient) per norm found sitting on edge of bed naked and covered in feces. Nursing staff reported that PT needs to be transported to the ER (emergency room) for staples from a wound that have opened. Crew noted an open wound/scar, approx. 3-4 inches on patient (R11) upper inner right thigh. Crew also noticed that patient wound was not dressed at all, leaking puss, and covered in feces. Patient (R11) stated that his scar/staples were from a triple bypass. Crew assisted the patient to the stretcher where he was secured in position of comfort. While assisting the patient to the stretcher crew noticed that the patient's diaper was full of feces. The patient's diaper was not placed on the patient correctly. BLS (basic life support) care provided as noted and patient (R11) transported to local Hospital without incident.
R11's care plan dated 2/27/23 denotes in-part the resident (R11) presents with symptoms of poor self-esteem related to: Health & lifestyle changes imposed by medical symptoms & condition. Feeling abandoned by family, friends, physician, God & religion, etc. Feeling incompetent, incomplete because of a medical condition or not being able to contribute as he/she once did. Loss of important lifestyle, lifelong roles. This problem is manifested by minimal social interaction and self-imposed isolation. This problem is manifested by, not behaving assertively, not speaking up for oneself. I will discuss his/her feelings & the factors contributing to poor self-esteem during counseling sessions (#) time(s) per week. I will demonstrate increased self-esteem as evidenced by saying daily affirmations. Help resident build self-esteem through frequent/daily verbal positive affirmations. Help resident build self-esteem through writing out positive thoughts & affirmations. Help resident build self-esteem through: Focusing on abilities instead of disabilities. Help resident build self-esteem through helping the resident regain involvement in lifelong roles. Help resident build self-esteem through working with appropriate mental health professionals. Encourage the resident to become involved with an appropriate support group or individual counseling to work towards self-awareness & self-improvement goals.
R11 care plan dated 3/7/23 denotes in-part R11 has incontinence of bladder and/or bowel, R11 will be clean, dry & odor free through the next review. Administer appropriate cleansing & peri-care after each incontinent episode. Observe for signs of skin irritation &/or breakdown. Report irritation/breakdown to the physician. R11 has a self-care deficit (ADLs/Mobility), R11 will improve/maintain his highest level of function with participation in therapies and/or restorative programs through next review. One assist with dressing/ hygiene tasks; encourage as much self-performance as safely able. Assist with repositioning when in bed/chair. Encourage resident to participate as much as safely able with ADL hygiene tasks. PT/OT (physical therapy/ occupational therapy) to screen / eval as ordered. Toilet with 2 assists. Transfer with mechanical lift x 2.
Review of R11's documentation survey report for date of 3/5/23, there is not documentation noted for incontinent care provide, personal hygiene to R11.
Using the reasonable person concept R11 should expect to feel embarrassed, ashamed when not provided incontinent care prior to going to the hospital, R11 should expect to feel embarrassed and ashamed when not treated with dignity, R11 should expect to feel embarrassed and ashamed when escorted to the hospital and having to wear an adult brief full of feces and not cleaned and changed.
Facility policy titled Incontinency Care dated 9/14 denotes in-part incontinent residents will be checked periodically every two hours and provided perineal and genital care after each episode. Purpose: to prevent excoriation and skin breakdown, discomfort and maintain dignity.
The resident rights for people in the long-term care facilities denotes in-part your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source.
Review of R11's progress notes, there were no documentation noted that R11 refused incontinent care on 3/5/23.
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
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent incidents of resident-to-resident physical assault, and inci...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent incidents of resident-to-resident physical assault, and incidents of staff to resident verbal abuse. This affected 3 of 5 (R31, R32, and R3) residents reviewed for physical and mental abuse. This failure resulted in R31 being physically assaulted by R32 resulting in R31 sustaining a bump on her head, displaying fear and expressing being scared and unsafe.
Findings include:
1.R31 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, weakness, unsteadiness on her feet, major depressive disorder, and type II diabetes. R31's brief interview for mental status dated 1/18/23 documents a score of 15/15 which indicates cognitively intact.
On 3/16/23 at 11:06AM, R31 who was alert and oriented at time of interview, said R32 hit her in the head three times with her hand. Small bump noted on her forehead along with three superficial scratches. R31, who was crying during the interview, said she feels scared and does not feel safe at the facility. R31 said R32 is always going through her belongings and taking items.
On 3/17/23 at 3:38PM, V9 (Administrator) said R31 said R32 was going through her drawers and R32 hit R31. R31 had a bump on her head. Physical abuse would be hitting someone.
R31's progress note dated 3/16/23 documents: Nurse was informed that the resident was involved in physical aggression with her roommate in her room. Noted small bump on her forehead. Resident complaint of pain on her bump site. Resident stated her roommate was going through her stuff and she asked her to stop it. Roommate got aggressive and her hit her.
Facility abuse prevention program revised 1/4/18 documents: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse.
2.R3 is not available for interview or observation. R3's MDS dated [DATE] denotes R3's BIMS score is 15, cognitively intact.
On 3/15/23 at 1:18pm V32 (CNA- Certified Nursing Assistant) said she does remember the situation when the agency staff got into R3's face, and said that she would kick R3's a**. V32 said V33 (Agency CNA) pushed her out the way to try to get to R3. V32 said her and V35 (Nurse) had to pull V33 out of R3's face. V32 said V33 wanted to fight R3. V32 said she could tell that V33 wanted to fight by her V33's aggression and body language. V32 said she had to tell V33 that R3 was a resident and that she could not be getting in his face, and she asked V33 why she was acting like that. V32 said V33 was mad and walked out of the facility that night. V32 said the nurse was there and the nurse reported it to the Administrator and the Director of Nursing.
On 3/15/23 at 2:46pm V35 (Nurse) said she was one of the nurses working on the first floor when V33 (CNA) and R3 got into it. V35 said V33 was arguing with R3, and V33 was so aggressive that she was about to call the police. V35 said someone pulled V33 away from R3 and V33 left the facility. V35 said she doesn't remember the details, she just knows V33 was aggressive with R3. V35 said she reported this to V60 (Prior Administrator).
On 3/15/23 at 2:30pm V9 (Administrator) said she was the Administrator on 1/22/23, not V60. V9 said the staff should have reported the incident to her. V9 said she was not aware of the incident with V33 and R3. On 3/21/23 at 10:10am, V9 said R3 has the right to be free from abuse. V9 said V60 was not the Administrator on 1/22/23.
On 3/17/23 at 10:27am V33 said R3 was a resident on the third floor, and she was assigned to work with R3 on 1/22/23. V33 said she was scheduled to work a double shift. V33 said R3 was complaining about the nurse and banging on the nurse's station desk. V33 said R3 was aggressive, and she was afraid of R3. V33 said R3 had left the floor and R3 must have gone to the first floor. V33 said she decided that she was leaving and going home because R3 was so aggressive. V33 said she got her coat and got on the elevator. V33 said when she exited the elevator R3 was at the first-floor nurse's station. V33 said R3 must have gone there to tell them what happened. V33 said she stopped at the nurse's station and that's when her and R3 began arguing. V33 said one of the staff got in between her and R3, V33 said she doesn't know who it was. V33 said nothing happened. V33 was asked why she stopped at the nurse station if she was afraid of R3 and R3 was so aggressive, and why didn't she continue out the door as she had planned if R3 was aggressive and she was afraid? V33 said she had to tell the nurse she was leaving.
Facility abuse prevention program policy dated 1/4/18 denotes in-part this facility, Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental pr physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental anguish.
The facility abuse policy does not address the resident right to be free from verbal, physical, mental, emotional abuse.
The resident rights for people in the long-term care facilities denotes in-part you must not be abused, neglected, or exploited by anyone- financially, physically, verbally, mentally, sexually.
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 interview and record review, the facility failed to monitor, failed to follow physician orders and failed to notify the...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor, failed to follow physician orders and failed to notify the attending physician of a scrotum rupture. This affected 1 of 3 residents reviewed for pressure sore preventions. This failure resulted in R7 being observed in bed with his testicles outside of the scrotum, being sent to the local hospital and being diagnosed with a diagnosis of protrusion of scrotal content through the superficial ulceration area, scrotal swelling, necrosis to anterior right scrotum with purulent discharge and a stage II pressure ulceration to the posterior left scrotum.
Findings include:
R7 was admitted on [DATE] with the diagnosis of Diabetes Mellitus, Hypertension and Hydrocele. Skin integrity review dated 1/9/23 documents: swollen scrotum. admission summary dated [DATE] documents: Enlarged scrotum noted upon inspection. Care Plan dated 1/10/23 documents: R7 has incontinence of bladder and or bowel.
On 3/14/23 at 12:47pm, V10 (ADON) said, R7 had a wound. R7's treatment administration record is blank with no nurse initial; no documentation means the treatment wasn't completed as ordered. I expected the nurse to provide the treatment as ordered and sign the treatment out on the treatment administration record (TAR). R7 did not receive any treatments. R7 was not seen by the wound doctor.
On 3/15/23 at 2:19pm, V48 (Previous Treatment Nurse) said, R7 was admitted with enlarged testicles with a small amount of redness. R7 received barrier cream for the redness and was on a diuretic for the enlarge testicles. R7 did not require any treatment upon admission. One week after R7's admission, R7 had a small, opened area. R7 had a skin irritation similar to a diaper rash on R7's scrotum. R7 had a Foley catheter that was leaking. R7 had urine in his adult brief. R7 was given a wound paste that absorbed excessive moisture. On 1/17/23, I was informed, R7 needed to be seen. I went to assess R7. R7's testicle was out of the scrotum sack. R7's testicle was laying on the bed.
On 3/15/23 at 2:50pm, V45 (Nurse) said, R7 was getting a wound treatment every day. R7 had gauze wrapped around his scrotum daily. R7's scrotum was the size of a grapefruit. On 1/17/23 when R7 was discharged to the hospital, R7's scrotum was leaking green and yellow fluid. R7s scrotum was leakage due to the pressure of the swelling. R7's scrotum was similar to a boil coming to a head and bursting. There was so much pressure on R7's scrotum the fluid had to come out.
On 3/16/23 at 3:43pm, V23 (DON) said, full thick skin altercation is caused by pressure. R7's scrotum was elevated with a towel. The towel could have caused pressure to R7's scrotum.
On 3/16/23 at 4:38pm, V17 (Treatment Nurse) said, necrosis does not occur within twenty-four hours. Necrosis occurs over time. A wound must go through four other stages (stage 1 -4) before necrosis occurs.
On 3/17/23 at 2:14pm, V56 (Medical Doctor) said, I was not informed R7 had a ruptured scrotum. R7 was admitted with a hydrocele of testie. The facility has a wound care nurse and wound care doctor/specialist. I expect the physician orders to be followed for whatever treatment the wound doctor orders.
On 3/17/23 at 2:24pm, V49 (Nurse Practitioner) said, I was not aware R7 had an opened skin area on 1/12/23. I expect the nurses to follow the doctors' orders. R7 was not in the building long enough to see the wound doctor.
Physician order sheet (order date) 1/11/23 documents: Venelex external ointment ([NAME]-castor oil)-is an ointment that is used on skin to cover wounds, it can also help to get rid of smells and might relieve pain from the wound. Venelex Ointment is a wound dressing for topical use in the management of chronic and acute wounds and dermal ulcers including pressure ulcers (stage 1-4) (National Institutes of health) --- apply to scrotum topically as needed to wound every day and evening. -No TAR was provided for this order.
Medication Administration Record dated 1/11/23 documents: Venelex external ointment ([NAME]-castor oil) apply to scrotum topically every day and evening. R7's Medication Administration Record was blank with no nurse initial.
Skin/Wound note dated 1/12/23 documents: R7 has been noted to have scrotal edema, and skin impairment to the area.
Medication Administration Record dated 1/17/23 documents: Venelex external ointment ([NAME]-castor oil) apply to scrotum topically as needed for wounds. R7's Medication Administration Record was blank with no nurse initial.
Treatment Administration Record dated 1/1/23 - 1/31/23 documents: Site; Scrotum-Clean with Saline, pat dry, apply triamcinolone topical twice a day, as needed and evening shift start date 1/12/23 discontinue 1/20/23- was blank, no nurse initials.
Nurse Practitioner Note dated 1/17/23 documents: Called to see R7 because of a potential rupture of the scrotum. Upon assessment, Foley in place but skin has opened on R7's scrotum and there was foul smelling drainage coming from the open wound. R7 had edema of the scrotum and it had been elevated on a towel. General Progress note date 1/17/2023 documents: R7 was sent to the hospital, due to scrotum being enlarged, open and draining.
Hospital paperwork dated 1/17/23 documents: chief complaints: penis/scrotum problems worsening, skin breakdown and swelling to the scrotum. History of swelling with bilateral Hydroceles. On Monday, R7 developed some sores to the hemiscrotum-staff began to apply ointment. R7's family saw R7's wound on Tuesday. R7's family states, wounds looked very bad, the skin was falling off. GENITOURNARY: bilateral soft tissue swelling of hemiscrotum, right hemiscrotum full- thickness ulceration of the skin, with protrusion of scrotal content through the ulceration area. Superficial ulceration noted on the undersurface of scrotum bilaterally. Scrotal swelling and necrosis to anterior right scrotum with purulent discharge. Small area of stage II pressure ulceration to posterior left scrotum
Physician Order Policy dated 1/2020 documents: to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their abuse prevention policy and report an allegation of abu...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their abuse prevention policy and report an allegation of abuse to the state agency within 24 hours for 1 of 3 resident (R3) reviewed for abuse reporting.
Findings include:
R3 is not available for interview or observation. R3 MDS dated [DATE] denotes R3 BIMS score is 15, cognitively intact.
On 3/15/23 at 1:18pm V32 (CNA- Certified Nursing Assistant) said she does remember the situation when the agency staff got into R3 face, and said that she would kick R3's a**. V32 said V33 (Agency CNA) pushed her out the way to try to get to R3. V32 said her and V35 (Nurse) had to pull V33 out of R3's face. V32 said V33 wanted to fight R3. V32 said she could tell that V33 wanted to fight by her aggression and body language. V32 said she had to tell V33 that R3 was a resident and that she could not be getting in his face, and she asked V33 why she was acting like that. V32 said V33 was mad and walked out of the facility that night. V32 said the nurse was there and the nurse reported it to the Administrator and the Director of Nursing.
On 3/15/23 at 2:46pm V35 (Nurse) said she was one of the nurses working on the first floor when V33 and R3 got into it. V35 said V33 was arguing with R3, and V33 was so aggressive that she was about to call the police. V35 said someone pulled V33 away from R3 and V33 left the facility. V35 said she doesn't remember the details she just knows V33 was aggressive with R3. V35 said she reported this to V60 (Prior Administrator).
On 3/15/23 at 2:30pm V9 (Administrator) said she was the Administrator on 1/22/23, not V60. V9 said the staff should have reported the incident to her. V9 said she was not aware of the incident with V33 and R3. On 3/21/23 at 10:10am V9 said R3 has the right to be free from abuse. V9 said V60 was not the Administrator on 1/22/23.
On 3/17/23 at 10:27am V33(CNA) said R3 was a resident on the third floor, and she was assigned to work with R3 on 1/22/23. V33 said she was scheduled to work a double shift. V33 said R3 was complaining about the nurse and banging on the nurse's station desk. V33 said R3 was aggressive, and she was afraid of R3. V33 said R3 had left the floor and R3 must have gone to the first floor. V33 said she decided that she was leaving and going home because R3 was so aggressive. V33 said she got her coat and got on the elevator. V33 said when she exited the elevator R3 was at the first-floor nurse's station. V33 said R3 must have gone there to tell them what happened. V33 said she stopped at the nurse's station and that's when her and R3 began arguing. V33 said one of the staff got in between her and R3, V33 said she doesn't know who it was. V33 said nothing happened. V33 was asked why she stopped at the nurse station if she was afraid of R3 and R3 was so aggressive, and why didn't she continue out the door as she had planned if R3 was aggressive and she was afraid? V33 said she had to tell the nurse she was leaving.
The facility abuse prevention program policy dated 1/4/18 denotes in-part employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observed, hear about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as an administrator in the administrator absence. External reporting, initial reporting of allegations- when an allegation of abuse, exploitation, mistreatment, or misappropriation of resident property has occurred, the resident representative and the department of public health regional office shall be informed by telephone or fax. Department of public health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigated. This report shall be made immediately, but no later than two hours after the allegation is made, if the event that cause the allegation involve abuse or resulted in serious bodily injury; or not less than 24 hours if the event that cause the allegation do not involve abuse and did not result in serious bodily injury.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide incontinence care to a dependent resident prior being escort...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide incontinence care to a dependent resident prior being escorted to the local hospital. This affected 1 of 3 residents (R11) reviewed for incontinence care.
Findings include:
R11's census denotes R11 was admitted to the facility on [DATE] and transferred to the hospital on 3/5/23.
R11's care plan denotes R11 has diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, essential hypertension, convulsion, abnormal enzymes levels, schizophrenia disorder, asthma, preexcitation syndrome, chronic venous hypertension with ulcer of bilateral extremity, other psychoactive substance abuse with unspecified psychoactive substance- induced disorder, opioid abuse. R11's MDS dated [DATE] denotes in-part R11 needs limited assist with toilet use.
On 3/16/23 at 3:57p.m V47 (Nurse) said she was the nurse responsible for R11's care on 3/5/23 when R11 was sent to the hospital. V47 said she worked the 3-11:00pm shift. V47 said there was not any aide on duty for that shift. V47 said she did not provide R11 with incontinent care at all. V47 said she did the best that she could for the residents that evening. V47 said she got report from V42 (Nurse) that R11 was to be sent to the hospital for further evaluation for the surgical wound that opened. V47 said she did not assess R11's surgical wound, but she did see that it was open a little when the medics were at the bedside. V47 said she did not assess R11 before sending R11 to the hospital with the medics to ensure that R11 was clean, dry and free of human excrements. V47 said R11 did not walk and R11 needed assistance with toileting.
On 3/16/23 at 2:23p.m V42 (Nurse) said R11 required assist with ADL (Activity of Daily Living) care, R11 needs one person assist with incontinent care. V42 said she was R11's nurse for the morning shift (7:00-3:00pm) and R11's wound was open and leaking yellow drainage. V42 said she did not put a dressing over the wound because it was supposed to be open to air. V42 was asked if she notified the physician of the open surgical wound that was leaking yellow drainage. V42 did not respond. V42 said stool could get in the wound if it is not covered, because of the location of the wound.
On 3/17/23 at 2:10pm V56 (physician) said R11's surgical wound should not be covered up, and R11 was being transported to hospital for further care for the surgical wound.
On 3/15/23 at 3:28p.m V7 (Captain of Fire Department) said he was the supervisor responding to a call to transport R11 to the hospital because of R11's wound opening. V7 said R11 had on an ill-fitting adult brief, the brief was full of feces, V7 said the feces had dryed up. V7 said R11's surgical wound was covered in feces. V7 said R11 was awake and talking.
On 3/17/23 at 3:20pm V23 (Director of Nursing) said incontinent care should be provided every two hours or as needed to all residents as appropriate. V23 said the resident should be provided incontinent care prior to being escorted to the hospital, a resident should not be escorted to the hospital soiled with stool.
R11's fire department run report dated 3/5/23 denotes in-part 70 y/o male patient (R11) AOx3 (alert and orient) per norm found sitting on edge of bed naked and covered in feces. Nursing staff reported that PT needs to be transported to the ER (emergency room) for staples from a wound that have opened. Crew noted an open wound/scar, approx. 3-4 inches on patient (R11) upper inner right thigh. Crew also noticed that patient wound was not dressed at all, leaking puss, and covered in feces. Patient (R11) stated that his scar/staples were from a triple bypass. Crew assisted the patient to the stretcher where he was secured in position of comfort. While assisting the patient to the stretcher crew noticed that the patient's diaper was full of feces. The patient's diaper was not placed on the patient correctly. BLS (basic life support) care provided as noted and patient (R11) transported to local Hospital without incident.
R11's care plan dated 3/7/23 denotes in-part R11 has incontinence of bladder and/or bowel, R11 will be clean, dry & odor free through the next review. Administer appropriate cleansing & peri-care after each incontinent episode. Observe for signs of skin irritation &/or breakdown. Report irritation/breakdown to the physician. R11 has a self-care deficit (ADLs/Mobility), R11 will improve/maintain his highest level of function with participation in therapies and/or restorative programs through next review. One assist with dressing/ hygiene tasks; encourage as much self-performance as safely able. Assist with repositioning when in bed/chair. Encourage resident to participate as much as safely able with ADL hygiene tasks. PT/OT (physical therapy/ occupational therapy) to screen / eval as ordered. Toilet with 2 assists. Transfer with mechanical lift x 2.
Review of R11's documentation survey report for date of 3/5/23, there is not documentation noted for incontinent care provide to R11.
Facility policy titled Incontinency Care dated 9/14 denotes in-part incontinent residents will be checked periodically every two hours and provided perineal and genital care after each episode. Purpose: to prevent excoriation and skin breakdown, discomfort and maintain dignity.
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** R28 is a [AGE] year old with the following diagnosis: paranoid schizophrenia and heart disease. R28 admitted to the facility 12/...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R28 is a [AGE] year old with the following diagnosis: paranoid schizophrenia and heart disease. R28 admitted to the facility 12/24/20.
R29 is a [AGE] year old with the following diagnosis: osteomyelitis and type 2 diabetes. R29 admitted to the facility 3/2/23.
At approximately 3:10PM, the facility alarms began to ring. No staff on the third floor reacted to the alarms and continued with their scheduled tasks. When this surveyor stood up in the 3rd floor library, R28 was noted crossing a high traffic, 4 lane highway leaving the facility property. R28 was running. About 1 minute later, V54 (CNA) and V59 (Social Worker) were noted running across the same 4 lane highway and stopped R29 in the apartment parking lot directly across the street from the facility. V54 and V59 escorted R29 back to the facility inside. R29 was then put on a 1:1 observation. V43 was R28's assigned CNA at this time and was not aware R28 had eloped until R28 was brought back to the 3rd floor. At no time was a Code Pink called during the elopement of R28 or R29. R29 was not visualized outside by the surveyors but was reported by staff.
On 3/15/23 at 3:36PM, R28 was asked where R28 just was and R28 replied, I went outside. R28 stated walking a couple of blocks away then staff came to get R28. R28 reported walking down the stairwell across from R28's room down to the first floor and left the building through the door in that stairwell. R28 endorsed an alarm did sound once the door to the outside was pushed.
On 3/15/23 at 4:01PM, V9 (Administrator) stated, I don' t know who got out. I didn't hear a code pink be called. When I heard the alarm going off, I told them to do a headcount because the alarms were going off. I don't know who went outside to look if a resident was outside, I don't think anyone looked outside.
On 3/15/23 at 4:47PM, V9 replayed the camera footage from the camera that watches the smoking patio and parking lot. The replay showed at 3:10PM, R28 can be seen walking through the parking lot of the facility towards the 4 lane highway until R28 is no longer in camera view. At 3:11PM, V54 and V59 are seen running through the parking lot in the direction R28 was walking. At 3:12PM, V54 and V59 are seen walking back through the parking lot with R28 returning to the facility. Based on the camera angle, R28 and R29 were not able to be seen leaving out the door.
On 3/16/23 at 10:23AM, R29 stated taking the elevator to the first floor and left out the door on the side near the smoking patio. R29 reported walking through the fire exit door, going down a couple stairs and then walking through another door to the outside. R29 endorsed only standing on the sidewalk outside before staff came to get R29. R29 stated, I just wanted to get some fresh air for a second. R29 does not recall if any alarms were going off when R29 left the building.
On 3/16/23 at 12:49PM, V61 (Social Service Director) stated, no, code pink was not called on this day. I don't know why. As soon as we hear the alarm and confirm someone left, we will call the code pink so we can get as many people as possible to start looking for the person.
On 3/16/23 at 3:28PM, V43 (Nurse) stated, I didn't even know R28 left. There was no Code Pink called otherwise I would have been looking for someone.
On 3/17/23 at 12:28PM, V54 (CNA) stated, I heard the alarm coming from the fire exit door by the smoking patio. That alarm sounds louder from whichever door they leave from, so you know to go to that alarm. R28 wasn't on my floor, so I assume R28 went down the stairs from the third-floor and left out of the building. Once I opened the door and looked outside, I saw R28 crossing the street. The social worker (V59) was right behind me, so we ran out and cross the street and brought R28 right back. I went back on the first floor, and I saw R29 walking around with R29's stuff in R29's hands, saying R29 wanted to leave. R29 walked out the same door R28 left out of, and I was right behind R29. R29 just stood on the sidewalk, and I walked R29 back inside. If the alarm goes off, that means someone left the building. We all go and start looking on our floors and whoever is closest to the door that is alarming they will check that door and see if they could see anyone outside. The nurse is supposed to tell social services and then they tell the administrator what is going on. I yelled back to the nurse, but I don't know if she said anything. The alarm was never shut off. I know whoever can gets over the speaker system. The fastest person should announce the code pink. Just to let everyone know that we are all trying to find someone that is missing. I don't know who called the code pink on that day. I don't remember hearing it be called.
On 3/20/23 at 12:20PM, V59 (Social Worker) stated, I heard the alarm go off, so I went to the door where the alarm was going off and began to search for the resident. I didn't know who left at that time. I saw another CNA (V54) going out the door and V54 said that a resident had gotten out. I wasn't sure who it was at that time, but I found out that it was R28. R28 had ran across the street when we got him. Yes, R28 made it off facility property. Normally protocol is to call a code pink, but I was already heading towards the door and was outside, so I don't know if the code was called. No, I did not hear a code called before I left out the building.
A Social Service note dated 3/5/23 documents R28 went on the fire escape exit located by R28 room to purchase a bag of chips. R28 was found by the vending machine located on the first floor smoking lounge. When asked why R28 took the fire escape stairway instead of the elevator, R28 was not able to give a response. R28 was educated on not using this particular exit and was made sure that R28 understood. Social services will continue to monitor as well as give cues, reminders, and redirection as needed.
A Behavior note dated 3/5/23 documents R28 displayed an unauthorized exit today. Social service staff immediately redirected R28 back to the facility. R28 was reminded that the facility is currently R28's home.
A Nursing note dated 3/15/23 documents R28 attempted to exit the facility. R28 was redirected by the staff and provided 1:1 supervision.
An Administration note dated 3/16/23 documents the administrator overheard the alarm sounding in the facility. The administrator initiated a headcount and directed staff to begin to check the doors. R28 was observed exiting the door on the first floor near the patio. V54 saw R28 attempt to leave the premises and called for staff help to redirect R28 back into the building. The Elopement Assessment and care plan were updated.
The Elopement Risk Review dated 3/5/23 documents R28 scored an 8. This indicates R28 is a high risk for eloping and should be placed on the elopement risk protocol. R28 is at risk for elopement due to a diagnosis of dementia and/or severe mental illness. R28 hangs around facility exits and/or stairways, has the physical ability to leave the building, becomes agitated, and/or disoriented or displays consistently poor judgment, and verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan.
The Community Survival Skills assessment dated [DATE] documents R28 does not appear to be capable of unsupervised outside past privileges at this time due to auditory hallucinations.
The Care Plan dated 3/5/23 documents R28 exhibits behavior that may be interpreted as wandering, roaming or exit seeking. R28 attempts unauthorized exits of the unit and/or the facility. R28 currently is an elopement risk.
A Nursing note dated 3/15/23 documents R29 was attempting to exit seek. R29 was redirected by the staff back into the facility. Social services talked to R29 and R29 verbalized understanding.
An Administration note dated 3/16/23 documents the administrator overheard the alarm sounding in the facility. The administrator initiated a headcount and directed staff to begin to check the doors. R29 was observed exiting the door on the first floor near the patio. V54 saw R29 attempt to leave the premises and called for staff help to redirect R29 back into the building.
The Community Survival Skills assessment dated [DATE] documents R29 does not appear to be capable of unsupervised outside pass privileges at this time.
The Elopement and Search (Code Pink) Policy, dated 02/2021 documents Policy: To establish methods for protecting residents, were at risk for elopement, and for conducting an organized search for a resident who cannot be located. Policy Specifications: 1. All nursing personnel are responsible for: knowing the whereabouts of residence for which their assigned; department supervisors are responsible for conducting resident rounds; staff are responsible for keeping the nurse informed of a resident's whereabouts . 3. Residents are not permitted to leave the building alone unless the physician order is present . 5. All personnel are responsible for promptly going to the location in determining the cause of the activated audible door alarm . 7. In the event resident cannot be located. The following procedure is to be implemented: a. The charge nurse of the missing resident will announce CODE PINK (the Floor/unit of the missing resident) over the paging system. b. The administrator and the Director of nursing will be immediately notified. c. All available staff will immediately report to the Nursing Floor/unit of the code pink to be informed of the identity of the missing resident. The nurse should provide staff a description of what they look like, what they are wearing, etc. d. The charge nurse will assign available staff to search each of the following areas including: each floor/nursing unit/hallway. The resident room should be searched, including the bathrooms and closets; gathering areas, such as lounges, dining rooms, therapy, rooms, shower rooms; offices, equipment, rooms, utility rooms. Even rooms that are locked should be unlocked and searched; outside building grounds, including the parking lot, storage sheds, ponds, wooded areas, patios, etc.; some staff member should also be immediately assigned to start searching off facility, premises, such as streets, surrounding areas containing woods, ponds, railroad tracks within close proximity of the facility, etc. 8. When the resident is found a licensed nurse will; a. Announce CODE PINK ALL CLEAR over the paging system .
Based on observation, interview and record review, the facility failed to ensure a motorized scooter had a seat belt for safe operation for 1 of 3 (R4) residents reviewed for safety. The facility also failed to monitor and supervise a dementia resident and ensure all residents were accounted for after a smoke break. This affected 2 of 2 (R30 and R21) residents reviewed for supervision. These failures resulted in the facility using a gait belt instead of the safety belt for the motorized scooter, and R4 involved in a fall incident from the scooter and sustaining a right femur fracture, R30 wandering into another resident room getting into an altercation sustaining a fall after being pushed sustaining a broken collar bone, and R21 assessed as requiring supervision for smoking was locked out of the facility after a smoke break, R21 was observed receiving smoking material from a stranger, and smoking unattended and unsupervised.In addition, the facility failed to follow their policy by not announcing a Code Pink after 2 residents left the facility unauthorized. This affected 2 of 2 resident (R28, R29) reviewed for elopement protocols.
Findings include:
R4 has the diagnosis of Quadriplegia, Multiple Sclerosis, Abnormal Posture, lack of coordination and foot drop.
R4's Minimum data set section C brief interview for mental status dated 1/29/23 documents a score of fifteen which indicates cognitively intact. Section G (functional limitation in range of motion) documents: Impairment to both upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot).
On 3/14/23 at 3:23pm, R4 who was assessed to be alert and oriented to person, place and time said, I was attempting to get something off the floor. I was sitting in my motorized wheelchair. I had a gait belt around my waist and the chair. The gait belt was used due to my seat belt being broke. I leaned over and lost my balance falling to the floor fracturing my leg and my nose. R4 denied loosening or touching the gait belt.
On 3/15/23 at 9:34AM, V21 (Therapy Director) said R4 requires a seat belt due to poor trunk control. R4's seat belt was not secured properly. The Certified Nursing Assistant would apply the gait belt to R4. A gait belt is used for transferring a resident and it is advised that it is not appropriate to be used as a seat belt.
On 3/16/23 at 3:14PM, V23 (DON) said R4 was using a gait belt for a seat belt. Gait belt is used for transferring a resident and not for a seat belt. V23 said for the fall that occurred with R4, a Certified Nursing Assistant said she saw R4 with her gait belt on and when she came back to the room R4 was on the floor. V23 said R4 said she never loosened the gait belt.
R4's hospital record dated 1/22/23 documents: R4 was reaching forward while in wheelchair and slid out falling forward onto her right leg hitting her face on the ground. Xray of right femur documents: angulated distal femoral shaft fracture. Under maxillofacial CT: frontal processes and nasal bone and possible nasal septal fracture.
Progress note dated 1/22/23 documents: R4 fell out of her wheel chair trying to reach for something off her table. R4 states, that she is having pain. R4 was sent to the hospital. Incident note dated 1/22/23 documents: R4 was noted on the floor on lying down position in her room, on her face, electric chair next to her. Resident stated, she tried to grab something from floor then she fell. R4 complained of pain on right leg.
R30 was admitted to the facility on [DATE] with a diagnosis of anxiety, dementia without behavioral disturbances, mood disorder, major depressive disorder and acute cystitis. R30's brief interview for mental status score dated 3/9/23 documents a 9/15 which indicates moderately impaired. Minimum Data Set, dated [DATE] documents no impairments to upper or lower extremities. Under balance during transitions and walking documents: not steady but able to stabilize without staff assistance.
R30's progress note dated 3/1/23 at 17:42 documents: resident was noted on the floor in his room, he said he fell while trying to get tv remote control from the peer.
R30's incident report dated 3/1/23 at 16:27 documents: resident was noted on the floor in his room in sitting position next to the door, he said he fell on the floor while trying to get tv remote control from the peer. No witness found.
R30's hospital record dated 3/1/23 documents: patient was arguing with roommate over a TV remote and fell. Under right shoulder: fracture of the clavicle.
R30's hospital record dated 3/7/23 documents: R30 states he got in a shoving match with his enemy at his nursing home and he was pushed down. This all occurred about 4 days ago.
R30's room change request form dated 3/1/23 at 15:53 documents R30 moved to create/enhance a better living environment for this individual.
R35 was admitted to facility on 2/23/23 with a diagnosis of hemiplegia and hemiparesis affecting left side. Brief interview for mental status score dated 3/2/23 documents a score of 15/15 which indicates cognitively intact.
On 3/17/23 at 10:51AM, R35 who was alert and oriented at time of interview said he was R30's previous roommate. R35 said R30 was always changing the channel on his tv and thought the tv was R30's. R30 was moved to another room. That same day he entered back into our room looking for a remote control. R35 said he was lying on his bed and the remote for his TV was on his chest. R30 came in and tried to grab the remote from his chest and then took R35's pillow and was attempting to hit R35 with a pillow. R34 then stepped in to help and R30 was on the floor. R35 said R30 was always messing with his TV and remote and that is why he was being transferred to another room.
R34 admitted to the facility on [DATE] with a diagnosis of traumatic brain injury without loss of conscious, major depression, and epilepsy. Brief interview for mental status score dated 3/4/23 documents a score of 15/15 which indicates cognitively intact.
On 3/17/23 at 10:51AM, R34 who was alert and oriented at time of interview said he was R30's previous roommate. He said R30 entered the room and was not himself. He was trying to get the remote from R35 and hit R35 with a pillow. R34 said he went to intervene and pulled R30 off R35 causing him to fall.
On 3/17/23 at 2:47PM, V58 (Social Service) said R30 was not getting along with his roommates. R30 would change the channel on the TV without permission and a room change was initiated.
R30's fall root cause analysis undated documents: R30 is a fall risk, sometimes having an unsteady gait, narcolepsy, wandering, periods of confusion and aggression towards peers. On 3/1/23, R30 received a room change and went to his old room to obtain a remote control for his TV. R30's roommates informed him that it was not his remote and he started to walk out of the room backwards and fell.
R30's screening for indicators for aggressive behaviors dated 1/2/23 documents: minimal risk for aggression.
On 3/17/23 at 3:38PM, V9 (Administrator) said for R30's incident she interviewed resident's roommates and R34 was asked if he got into a fight with R30 and he denied it. R34 said R30 grabbed the remote. R35 said R30 took his remote and he grabbed it from him and R30 walking backwards and fell. Facility did not provide any documentation of these interviews with R34 and R35.
On 3/17/23 at 10:51AM, R34 and R35 said no staff has ever asked them about this incident before or at the time of incident. Both residents said surveyor was the first person to ask them what happened.
Facility policy titled supervision and safety dated 3/15 documents: Our facility- oriented approach to safety addresses risks for groups of residents such as wanders, behaviors, aggressiveness, confusion, etc. Resident supervision is a core component to resident safety.
R21 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder, hypertension, paranoid schizophrenia, and hyperlipidemia.
On 3/14/23 at 2:27PM, R21 observed on smoking patio sitting on bench. No staff were observed outside with R21. One door observed to enter and exit the smoking patio was locked. At 2:30PM, R21 was observed asking a person walking down the street for something. The person approached R21 and handed him a lit cigarette. At 2:34PM, R21 was attempting to enter back into the facility by pulling the door. R21 was unable to enter the building due to the door being locked. R21 was let back into the building at 2:37PM by staff.
On 3/14/23 at 3:00PM, observed video camera footage with V9 (Administrator). Observed camera on patio with visual to door but not the entire patio was able to be observed. At 2:14, R21 appeared out on the smoking patio. At 2:18, staff locked the door. At 2:34PM, R21 knocking on door. At 2:37PM, R21 entered back into the building.
On 3/15/23 at 3:24PM, R21 who was alert and oriented at time of interview, said he was out on the patio and asked a guy walking by for a cigarette because he did not have one and he gave him a cigarette and a light. R21 denies any harm from being outside.
On 3/14/23 at 2:37PM, V29 (Social Service) said staff are supposed to check the patio at the end of the smoke break. Residents should not be on the patio unattended.
On 3/14/23 at 3:12PM, V15 (Social Service assistant/smoking monitor) said he was assisting with the smoke break on 3/14/23. V15 said R21 came downstairs late, and the smoking cart was already put away. V15 said he thought R21 went back to his room and said he never saw R21 on the patio. We are supposed to check the patio before we lock but I just did not see him.
R21's progress note dated 3/14/23 documents: Resident was accidentally locked out after smoking break in the patio, was brought back in soon after staff was notified about him being locked out accidentally.
R21 smoking risk review dated 1/23/23 documents: Resident may not be capable of handling/carrying any smoking materials and requires supervision when smoking. Under begs, borrows trade items, panhandles for smoking materials documents a score of 2 which indicates moderate problem.
Facility smoker list undated identifies 85 current smokers within the facility.
Facility document titled Chicago Ridge Nursing PRSA- Job description undated documents: Supervision, ensuring a safe and hazard free environment.
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 F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to provide a renal diet as ordered, this affects 1 of...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to provide a renal diet as ordered, this affects 1 of 3 residents (R13's) reviewed for diet orders.
The findings include:
R13 is [AGE] years old with diagnosis including but not limited to End Stage Renal Disease, Epilepsy, Dependence on Renal Dialysis, and Diabetes. R13's is documented to be cognitively intact with a score of 15.
On 3/14/23 at 12:20PM V19, Cook, said we are serving lunch of tuna, black beans, pineapples and applesauce as dessert. V19 said the Certified Nursing Assistant calls the names out to make sure the resident gets the right diet.
On 3/14/23 at 12:25PM R13 said she has told the nurses and the CNAs many times that she is on a renal diet and there are several things she cannot have. R13 said she is not supposed to eat beans because she is on dialysis. R13 said she did not eat the beans because she is not supposed to get them. R13 said they did not offer her a substitute for the beans.
On 3/14/23 during interviews at 12:50PM and 2:04PM V12, Dietary Manager, said Renal diets had cauliflower on the menu today. V12 said Renal diets should not have starches served.
On 3/14/23 at 2:04PM V28, Dietary Manager, during an interview with V12 said Renal diets are supposed to have peas today.
Review of R13's nutritional risk review dated 1/30/23 documents R13 is able to communicate verbally her food preferences. Will honor food preferences. Additional documents provided state, will limit food items high in potassium, phosphor.
R13's Order Summary Report noted Renal Diet ordered on 4/19/22.
R13's care plan interventions revised on 11/2/22 includes prepare/serve the resident's nutritional diet as ordered. Prescribed diet is regular, renal, low concentrated sweets. Intervention revised on 8/12/22 documents food preferences through one to one interview.
The surveyor requested a Renal diet policy or list of served foods. The facility provided an undated list Foods that are Okay to Eat on a Renal Diet. Black beans are not on the list.
The facility provided an undated document titled Explanation of Diets Renal. The document notes the Renal diet follow components of the regular diet while encouraging the restriction of potassium, phosphorus, and sodium. The Renal diet is for residents who eat well and require some additional control of potassium, phosphorus, and sodium.
The facility Daily Spreadsheet for Tuesday (the date the surveyor made observations 3/14/23) documents Renal no salt added caulfwr (Cauliflower). General Diet includes Black Beans.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on interviews, observations and records reviewed the facility failed to have working lighting on the outdoor resident smoking patio and failed to ensure the common shower on the second floor nur...
Read full inspector narrative →
Based on interviews, observations and records reviewed the facility failed to have working lighting on the outdoor resident smoking patio and failed to ensure the common shower on the second floor nursing unit was clean and sanitary. This affected 2 of 3 resident (R18, R16) reviewed for safe clean environment. This failure has the potential to affect 85 of the smoking residents and 76 residents who use the second floor shower room.
The findings include:
On 3/14/23 at 11:36AM R18 said the last smoke break is at 5:30PM. R18 said we have no lights in the smoking patio, its dark sometimes in the evening. I don't like smoking in the dark. R18 said they (facility staff) know because they had a light out there before and they took it down and didn't replace it.
On 3/14/23 at 12:13PM V18, (Maintenance Director), said we have been waiting a couple of weeks for the parts to come in for the smoking patio light. V18 said there is no light until its fixed. The surveyor went outside with V18 and observed 2 outdoor lights on the wall over the smoking patio. V18 said the light does not work.
On 3/14/23 at 2:13PM V9 (Administrator) said the order for the light was placed on 12/15/22. V9 presented an invoice dated 12/15/22 for an outdoor light purchase. V9 said we found the light, V18 has it. V9 said the light is here but has not been put up.
On 3/15/23 at 10:49AM V18 said the smoking monitors had told me that the lights weren't working on the smoking patio. That is when we ordered the new light. V18 said he does not have service log or maintenance request forms to show when the non-working lights were reported. V18 presented a notebook without dates on it.
The facility presented a Final Details order report for 1 Touch & Glow Security Area Light with order placed on 12/15/22 (90 days ago). Report notes the light was shipped on 12/17/22.
On 3/14/23 at 11:26AM the surveyor walked into the shower room on the 2nd floor nearest to the dining room. The surveyor observed 3 empty milk cartons in the second stall, in the corner on the floor.
On 3/14/23 at 11:28AM the surveyor walked into the shower room with V17 (Nurse), and V17 said there are 3 milk cartons on the floor. V17 said I don't know why there are milk cartons on the floor. V17 left the shower room and the milk cartons on the floor.
On 3/14/23 at 11:29AM R16 said at night another resident goes into the shower room and drinks milk in there. R16 said then he leaves the empty cartons on the floor. R16 said I see the resident go in there. R16's room is across the hall from the shower room.
On 3/14/23 at 2:50PM the surveyor returned to the same shower room on the 2nd floor and observed a wet washcloth on the floor, a clear garbage bag with visible stool inside, and a bag with what appeared to be white linens in it. The linens appeared soiled thru the bag. The 3 milk cartons were still in the corner on the floor.
On 3/15/23 at 1:32PM V34, Certified Nursing Assistant (CNA), said shower rooms are cleaned by housekeeping, but the CNA using the shower room will remove any towels or garbage when they have completed giving a shower. Whatever you bring in you take out.
On 3/16/23 at 2:16pm V20 (housekeeping director) said the housekeeping staff should intermittently check the shower room and clean the shower rooms during their rounds.
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 F0725
(Tag F0725)
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 staff a nurse for the first floor night shift (11PM - 7AM) on 1/26/...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to staff a nurse for the first floor night shift (11PM - 7AM) on 1/26/23 in a timely manner leaving the first floor without a nurse for approximately 6 hours affecting 64 residents.
Findings Include:
R13 is a [AGE] year old with the following diagnosis: end stage renal disease with dependence on renal dialysis, ileostomy status, and heart disease. R13 admitted to the facility 4/19/22.
On 3/14/23 at 3:12PM, R13 reported there was no nurse the night of 1/26/23 to the morning on 1/27/23. R13 reported missing medication that is scheduled at 6AM on this day but was unable to state what medication it was. R13 stated the staffing at the facility is terrible and residents have to fend for themselves when a nurse decides not to show up. R13 reported feeling unsafe knowing there was no nurse to help that night and stated the CNA that was there is only able to do so much.
Staffing sheets for 1/26/23 and 1/27/23 were reviewed and document a nurse was working on the night shift on the first floor on 1/26/23 into 1/27/23. There is no documentation that a nurse on the first floor called off on this day. The Resident Daily Census Sheet for 1/26/23 and 1/27/23 document a total of 64 residents occupied the first floor. There was a total of 206 residents in the facility on 1/26/23. The Time Card Reports for all staff on 1/26/23 and 1/27/23 were reviewed. Per the time cards, V35 (Nurse) clocked in at 2:45 PM and clocked out at 10:17 PM. V35 then clocked in on 1/27/23 at 7:23 AM and clocked out at 2:59 PM. This nurse worked the first floor both shifts. V42 (Nurse) has no punches on 01/26/23. V42 clocked in on 1/27/23 at 4:29 AM and clock out at 9:16 PM. This nurse worked the first floor for the shift. V36 (Nurse) is documented as working on the staffing scheduling sheet, but does not have any recorded punches on the time card report. V44 (CNA) clocked in on 1/27/23 at 12:04 AM and clocked out at 8:46 AM. Per the time card reports, no staff was present on the first floor from 10:17 PM through 12:04 AM. V44 worked alone from 12:04 AM to 4:29 AM. V42 is the nurse that clocked in at 4:29 AM. There is no nurse that worked the first floor from 10:17 PM (1/26/23) through 4:29 AM(1/27/23) on this day.
On 3/15/23 at 2:26PM, V11 (Scheduler) stated, We have around 200 residents. Sometimes it is a little more or a little less. When we have our numbers around 200 we have 6 nurses during the day and evening shift and 4 nurses in the night. We use agency only for CNAs. We don't have enough CNAs to staff what we need. Currently we are hiring for CNAs but a lot of staff do doubles so we don't need that many positions. If we have a call off we get it covered by other staff, managers, or agency. Staff are supposed to call me and the DON when they call off. If there is a no call no show then staff should still call me so I can work on getting someone in and so the DON is aware.
On 3/16/23 at 10:39AM, V35 (Nurse) stated, Report does not happen nine out of 10 times. The nurses usually kind of know the residents so I might have cut out a little early that night thinking the nurse was going to be there in new her residents but I guess she never showed up. It's very hard to get staff to stay in the building. We don't get any bonuses or there's no incentive to pick up even. They keep excepting patients in new admissions when they know we are short for that shift, so it's just a lot to deal with. Management is aware, but nothing is being done. This has been something that's been happening for months and months. You have the DON in the ADON working the floor 10 or 11 days straight. That's not something that that position should be doing regularly. We mostly use agency CNA's because we don't pay our CNA's at a good rate so no one wants to apply. The residents complaint all the time about staffing. They tell us that they aren't being cared for well. They need to go to the bathroom and had an accident or they've gone in their brief and they've been sitting in it for a couple hours. Medications are also being passed late. We are keeping residents that are sick and should be sent out. If I work at night shift, I normally have the whole first floor to myself. Sometimes I have a CNA's with me and sometimes I don't. When you don't properly staff of a facility, the residents are the ones who suffer by getting care late or not at all.
On 3/16/23 at 12:14PM, V42 (Nurse) stated, I ended up coming in early that day around 4 that morning. I left the shift before around 11 PM. There was no nurse there when I left. I just assumed that another nurse would come in or they would send someone down from one of the other floors if no one showed up. I think someone had texted me that the night nurse didn't show up so I tried to come in a little early. 4:30AM was the earliest I could come in. I started going through everyone and trying to give them their meds but some people had 6 AM medications due that I just couldn't get to. Everyone ended up getting their scheduled 8 AM meds on time. When I work the first floor on night shift I will normally have 35 to 40 residents myself. When nurses don't come in, it affects the residents. They aren't being changed how they should or fed in a timely manner. On the first floor there's not too many residents that need to be changed, but we still aren't rounding on them as much as we should. Management knows about the issues with staffing but I don't know what they're doing for that.
On 3/16/23 at 3:18PM, V43 (Nurse) stated, I don't remember anybody calling and letting us know that they were working down there alone. The staffing is really bad. I do a lot of double shifts which are 16 hours and I have complained to the DON about the staffing. Sometimes when I go to leave the nurse that is replacing me is late and I will stay as late as I can, but I can't work 24 hours. All the facilities around this place pay more than here. A lot of these residents are more complex to care for especially on the second floor. There's been many times where I've had to beg for a CNA to come in. I can't pass medications and change the resident all night by myself.
On 3/16/23 at 3:32PM, V44 (CNA) stated, I came at midnight that night (1/27/23), and there was no nurse on the first floor. I was there by myself. There was no other CNA's. I worked alone that night. I think another nurse came in around 4:30AM, but from when I got in until around 4:30 that morning I was alone. I called up to the other floors to let them know what was going on, but no one ever came down to help out. I just monitored them the best I could that night. Normally we do rounds every one to two hours to check on them. I would finish up my rounds around two hours after seeing everyone then I would do a little bit of charting at the desk and then I would start my rounds again. I would say it was about three hours from the time I saw someone to the time I saw them again. I couldn't keep up with everyone by myself. We do have a problem with staffing. A lot of the agency CNA's won't show up when they are scheduled so the staff people end up working alone without any help. We might have one nurse that helps us out but even still that is a lot for the amount of patients we have. Residents aren't getting the proper care they need when we are short staffed. They aren't getting medication if they ask for them and I can't pass out any medications so they just have to wait until the next morning when the nurse comes in. The managers are aware of what is going on and when this happens. A lot of the people that are staffed here complain to management about what is going on but they aren't really doing anything about it to make any improvements.
On 3/17/23 at 3:00PM, V23 (DON) stated, I try to make sure that if someone lets me know there's a call off that we have coverage for all shifts. The protocol is to notify both the scheduler and me when someone is not here. We use agency for CNA's only. If we have call offs then the nurse managers pick up when needed and we also have staff that stay over. Staff should punch out at 11 PM because that is the time they are scheduled up until. Night Shift comes in around 10:30 PM to get report and get ready for their shift. The CNA's then come around 12 AM for the night shift. I think I remember that night. I told them one nurse should come down from one of the floors. I didn't know they didn't split up. That is usually what we do if we have a call off. One or two nurses for each floor. I should have been notified that the nurses did not split up that night. There should be at least one nurse on all floors. A nurse has to monitor the patients so a nurse needs to be on all floors. I am not aware about R13 missing any medication. If a resident is scheduled for blood sugar checks or any medications, they should not be missed. The doctor ordered them so they should not be missed and it is in the best interest of the resident to give the medications that are ordered. Our staffing is not good always.
On 3/17/23 at 3:38PM, V1 (Administrator) stated, I also was never notified that we didn't have a nurse come in for the night shift on the first floor. I have had a couple staff members come to me about the staffing concerns. We have people calling off because staffing is an issue which just creates a bigger problem. I just explain to them that our plans are to try to hire many of the agency CNAs once we are done speaking with them and see who we can get on board. There definitely should have been a nurse on the first floor that night even if someone called off. The staff should've notified us so we could've got someone in to be caring for those residents.
The Medication Administration Record (MAR) dated 01/2023 documents R13 did not have a blood sugar check on the morning of 1/27/23. This blood sugar check was scheduled at 6 AM. R13 last had blood sugar checked on 1/26/23 at 8 PM and received insulin as ordered for the sliding scale. The next time after that R13's insulin was checked again on 1/27/23 at 11 AM and R13 received sliding scale insulin as ordered. R13 has an order to take vital signs every eight hours. There is no documentation of vital signs taken at 6 AM on 1/27/23. R13 missed one dose of Calcitrol capsule 0.5mcg on 1/27/23 at 6AM. The blood sugars for R13 were reviewed and document the same information that the MAR documents regarding when the blood sugars were taken. R13 has a blood sugar range of 104 - 302 mg/dL.
The Care Plan dated 4/24/22 documents R13 has diabetes mellitus and the potential for complications related to elevated blood sugar. R13 is insulin dependent. An intervention documented is to take blood sugar checks as ordered and provide medication has ordered.
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
Based on interviews and observations the facility failed to cover food during meal delivery and maintain appetizing appearance of food. This failure has the potential to affect all 65 residents residi...
Read full inspector narrative →
Based on interviews and observations the facility failed to cover food during meal delivery and maintain appetizing appearance of food. This failure has the potential to affect all 65 residents residing on the first floor.
The findings include:
On 3/14/23 at 12:20PM, the surveyor observed 10 served plates that had not been delivered, the black beans look dry, some cracked open, and some with a white film over them. Plate is dry, beans served dry or absorbed the liquid. The plates remained on the table until the surveyor left the room at 12:31PM.
V19, Cook, said we are serving lunch of tuna, black beans, pineapples and applesauce as dessert. V19 said there are lids on the cart, V19 pointed to a silver cart across the room, next to the tray rack. V19 said I serve out the meals as the CNA calls them out. V19 said she calls the names out to make sure the resident gets the right diet. V19 said all these plates are regular diets and pointed at the food cart. The surveyor counted 10 plates with tuna sandwiches and black beans on them. There are no covers on the plates. 3 of the plates were stacked on top of other plates with food served on them. The surveyor observed the food cart's electrical cord that was not plugged in. V19 said he did not plug the cart in because the meal is cold. Surveyor looked at several plates on the resident tables in the dining room and the beans are uneaten.
On 3/14/23 at 12:59PM V12, Dietary Manager, said lunch meal served on 3/15/23 consisted of tuna salad and green peas. V12 said Black beans were served as an option. V12 said the black beans were being served as a substitute for the peas. V12 said the food cart keeps the food hot. V12 said after the food is served on the plate, the plates should not be stacked on the food cart. V12 said the plates should be covered with the lids to hold the food temperature. V12 said they should not be serving the food that way because it is not sanitary, and the black beans are not going to the room and the right temperature. V12 said I would not eat the cold beans.
The facility policy titled Holding and Service dated 2010 states dishes and utensils should be handled in a way, which does not contaminate the surface the food touches.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on interviews, observations, and record reviews, the facility failed to cover foods for transport to the resident rooms and to take food temperatures to ensure serving food temperatures remain a...
Read full inspector narrative →
Based on interviews, observations, and record reviews, the facility failed to cover foods for transport to the resident rooms and to take food temperatures to ensure serving food temperatures remain at safe serving temperatures during meal service. This failure has the potential to affect 65 residents residing on the first floor unit.
The findings include:
On 3/14/23 at 12:20PM V19, Cook, said we are serving lunch of tuna, black beans, pineapples and applesauce as dessert. V19 said there are lids on the cart, V19 pointed to a silver cart across the room, next to the open (skeleton) tray cart. V19 said I serve out the meals as the CNA calls them out. V19 said she calls the names out to make sure the resident gets the right diet. V19 said all these plates are regular diets and pointed at the food cart. The surveyor counted 10 uncovered plates with tuna sandwiches and black beans on them. 3 of the plates were stacked on top of other plates with food served on them. V19 said I didn't check for temperatures before I started serving or check between the meal service. The surveyor asked V19 if a temperature could be taken and V19 said he did not have a thermometer on the cart, no temperature was taken.
On 3/14/23 at 12:59PM V12, Dietary Manager, said lunch meal served on 3/15/23 consisted of tuna salad and green peas. V12 said Black beans were served as an option. V12 said the black beans were being served as a substitute for the peas. V12 said the food cart keeps the food hot. V12 said the food cart/table should be plugged in. V12 said no food temperatures are taken on the floors. V12 said the plates should be covered with the lids to hold the food temperature. V12 said the served plates should not be stacked on the table. V12 said they should not be serving the food that way because the black beans are not going to the room and the right temperature. V12 said I would not eat the cold beans. During another interview on 3/15/23 at 2:33PM V12 said the kitchen had 2 thermometers on 3/14/23 and more were supplied today. (The facility has 3 floors with residents.)
On 3/15/22 at 1:32PM V34, Certified Nursing Assistant, said meal trays are picked up from the dining room. V34 said we serve the people in the dining room first, then set up the carts to take to the rooms. V34 said we put the lids on skeleton carts because they are open. V34 said R6 used to complain the food was cold when she delivered R6's meal tray to her.
The surveyor requested a policy on food temperature frequency, and none was provided.
The facility policy for Holding and Service dated 2010 states hot food will be held at a minimum temperature of 135 degrees. Potentially hazardous cold foods will be held at 41 degrees or below.
Mar 2023
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to implement an effective pest control program to eliminate roaches within the facility. This has the potential to affect all 210...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to implement an effective pest control program to eliminate roaches within the facility. This has the potential to affect all 210 residents residing within the facility.
Findings include:
The facility's CMS (Centers for Medicare and Medicaid Services) Form 672 dated 3-3-23 and signed by V16 (Restorative Nurse) documents 210 residents currently reside within the facility.
The facility's Pest Control Policy dated 11/2014 documents, Purpose: To prevent or control insects and rodents from spreading disease. Responsibility: Administrator, Environmental Services Director. Standards: The Environmental Services Director will be responsible for coordinating the facility pest control program. Employees are instructed to promptly report all observations of pests to their department heads. Residents shall be allowed to keep a limited amount of open food at their bedside in sealed containers.
On 3-3-23 at 10:15 AM R6 stated, I have roaches crawling around my trash can in the corner and up the walls every day. I do not think my room has ever been sprayed for roaches. I have not been offered a plastic container to put my food in. R6's side table had an open package of cookies and R6's floor had crumbled cookies in three different areas. This surveyor picked up R6's trashcan and three live roaches were underneath the trashcan.
On 3-3-23 at 9:30 AM V6 (LPN/Licensed Practical Nurse) stated, I have recently seen live roaches in the elevators.
On 3-3-23 at 9:45 AM R5 stated, I see roaches go up my walls every other day. They are everywhere in this building.
On 3-3-23 at 3:00 PM R8 stated, I see roaches in my bathroom everyday. I am always afraid they are going to get in bed with me.
On 3-3-23 at 9:00 AM V3 (Agency CNA/Certified Nursing Assistant) stated, I worked at that facility for around two hours only. I lifted numerous lunch trays and would find roaches under the trays. That was so disgusting that I could not even continue to work there.
On 3-3-23 at 10:00 AM V7 (Housekeeper) stated, There are roaches on every floor, but mostly on the second floor. I try to bring my own spray in to kill them. We are not provided anything to spray for them, and I have not seen any traps.
On 3-3-23 at 10:40 AM V19 (Environmental Specialist) stated, No staff or housekeepers have reported seeing roaches to me. I do not have a communication or pest log that is kept for staff to communicate to me when they see pests. I know there have been reports of roaches in the kitchen. The pest control company is not getting the job done and eliminating roaches. I do not have anything at the facility to use to treat roaches.
On 3-3-23 at 2:00 PM V1 (Administrator) stated, Staff need to report to (V19) when they see roaches or hear of residents seeing roaches. All residents should have sealed containers to keep their food in.
Dec 2022
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure protected health information remained confidential for one resident (R66) reviewed for confidentiality of record in the...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure protected health information remained confidential for one resident (R66) reviewed for confidentiality of record in the sample of 69 residents. This failure has the potential to affect all 63 residents residing on the second floor.
Findings Include:
On 12/12/2022 V1 (Administrator) presented facility census report that documented the resident census on the second floor was 63.
On 12/12/22 at 10:47 am, Surveyor observed the facility's second floor Team B medication cart unattended with an empty medication dispensing card labeled visible with R66's, name, medication, dose, and frequency for (Levetiracetam 750 mg, give 2 tablets two times a daily) on top of Team B's medication cart. At 10:49 am, Surveyor observed V23's (Licensed Practical Nurse, LPN) walked to Team B's cart. When V23 was asked regarding the importance of not leaving the patients empty medication card visible on top of the medication cart, V23 stated, For HIPAA (Health Insurance Portability and Accountability Act). I (V23) was going to throw it away.
R66's Brief Interview for Mental Status (BIMS) dated 11/11/2022 documents R66 with a score of 13 which indicates that R66 is cognitively intact.
R66's Physician Order Sheet (POS) dated 09/07/22 documents that R66 receives Keppra Tablet 750 mg (Levetiracetam) give 2 tablets by mouth two time a day for convulsions.
Facility's undated document titled Residents Rights for people in Long-Term Care documents, in part: Your rights to privacy and confidentiality. You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care.
Facility's undated document titled Employee Handbook documents, in part: The company treats as confidential its (residents') medical records and other health information in accordance with the Federal Health Insurance Portability and Accountability Act of 1996 and it's implementing regulations, the Standards for Privacy of Individually Identifiable Health Information (Privacy Rule).
Facility's job description titled Charge Nurse documents, in part: . Main Duties . AB. Maintain the confidentiality of resident information and honor his/her personal and property rights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care and grooming receive n...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care and grooming receive nail care and skin care. This affects two residents (R81 and R165) in the total sample of 69 residents, reviewed for ADL care and grooming.
Findings include:
On 12/12/22 at 11:35am, R81 was observed awake in bed with dry peeling skin on the lower legs and long fingernails that had accumulated brownish black substances on the nail beds.
On 12/12/22 at 11:32am, R165 was observed awake in bed with dry peeling skin on the legs and feet. Resident's wife complained that resident was not getting assistance with foot care and nail care. R165's fingernails are long and dirty with the left-hand middle fingernail digging into resident's palm.
The care plans for both residents as dated below show that both R81 and R165 have self-care deficit, and they require assistance with ADL care and grooming:
R81's care plan dated 5/5/21
R165's care plan dated 5/12/22.
MDS (Minimal Data Status) Section G dated 10/19/22 for R81 shows that R81 is dependent on staff for ADL care.
MDS Section G dated 7/1/22 for R165 shows that R165 is dependent on staff for ADL care.
Facility's Policy and Procedure on ADL Care states in part under grooming: Maintaining personal hygiene, including planning the task and gathering supplies, combing hair, brushing teeth, and self-manicure. CNA (Certified Nursing Assistant) job description states under #C: Carry out assignments for resident care including but not limited to bathing, dressing, grooming, shaving, and feeding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide foot care to residents, to prevent complications from medical conditions. This failure affected three residents (R74,...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to provide foot care to residents, to prevent complications from medical conditions. This failure affected three residents (R74, R111, and R165) of five residents, reviewed for foot care and treatment, in a total sample of 69 residents.
Findings include:
On 12/12/22 between 11am and 1pm during observation of residents on the second floor, R74, R111, and R165 were observed awake in bed with dry peeling feet and discoloration on the long toenails.
R74 has no record that the foot doctor saw the resident. R74's right foot second toenail has brownish black dot mark underneath the toe. Other toenails are long and thickened, with blackish brownish color.
On 12/12/22 at 10:50am, R111 stated I need help with my toes. Toenails were long, thickened, and blackish brown. Left foot toes #3 and #4 have brownish black dot marks underneath the toes. V28 (RN/Registered Nurse) was notified.
On 12/12/22 at 12:02pm, R165 was observed awake in bed. R165 complained that staff was not helping with foot care and nail care.
Again, on 12/13/22 at 11:10 am, R74's and R111s' feet and toenails were still in the same condition.
V28 was notified and asked about how residents get to see the Podiatrist. V28 stated that the Social Services department will be notified of any resident that needs podiatry care, and they would be put on the list.
At this time, V10 (Assistant Social Services Director) was notified of the condition of the residents' feet. V10 stated that the podiatrist comes in once a month. V10 later presented the list of residents that were seen by the podiatrist and those yet to be seen. The names of R74, R111, and R165 were not on the list to be seen or had been seen.
R74's care plan dated 9/3/22 states that R74 has a self-care deficit and requires staff's assistance.
R111's care plan dated 11/9/22 states that resident has a self-care deficit and requires assistance.
R165's care plan dated 5/12/22 states that resident has a self-care deficit and requires assistance.
Facility's policy titled Foot Care dated 6/21 states under Purpose: To provide comfort and prevent infection of the feet. #5 states: Remove excess dried skin around heels, toes, and soles of feet by rubbing carefully with towel. Report ingrown toenails, inflammation, or foot problems to licensed nurse. Resident may require/request treatment by a podiatrist.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that a resident receives restorative care as indicated in the assessment and care plan, to prevent further contracture...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure that a resident receives restorative care as indicated in the assessment and care plan, to prevent further contractures of the left hand. This affects one resident (R165) of three residents, reviewed for restorative care, in a total sample of 69 residents.
Findings include:
On 12/12/22 at 11:45am during resident observation on the second floor of the facility, R165 was observed in bed with contracture of the left hand. R165 was asked if he (R165) was able to move his left-hand fingers that were contracted. R105 (R165's wife and roommate) stated that no one has come to help R165 with range of motion exercises for a long time.
On 12/13/22 at 1:45pm, the surveyor observed resident's left hand contracted with no device in place and resident's wife again complained that no staff came to help her husband with range of motion exercises.
On 12/12/23 at 2:50pm, V21(Restorative Aide) was interviewed regarding this. V21 stated that she (V21) is assigned to care for Rooms 101-117, and that the Restorative Nurse that was supposed to run the program does not work here any longer. V21 added that she (V21) did not do range of motion for R165 and there is no splint or device for R165. V21 later presented the list of residents on restorative care which was reviewed.
Upon interview, staff on the unit do not know who is supposed to do restorative care for residents on the floor.
On 12/13/22 at 2:15pm, V2 (Director of Nursing) stated that the Restorative Nurse quit a few weeks ago and they are in the process of hiring someone.
R165's care plan dated 6/24/22 states that R165 has left sided weakness. Goal states Resident will improve/maintain highest level of function with participation in therapies and/or restorative programs through next review.
R165's care plan dated 5/12/22 states that resident has a self-care deficit and requires assistance.
MDS Section G dated 7/1/22 for R165 shows that R165 is dependent on staff for ADL care.
Facility's document for Rehabilitation Assistant dated 9/2020 states under Contracture Preventions and Management Interventions states Perform during bathing, dressing, and grooming activities Upper Extremity Range of Motion.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement individualized fall prevention intervention...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement individualized fall prevention interventions for residents who were identified to be at risk for falls. This failure affected 2 residents (R113 and R129) out of 4 residents reviewed for fall injury prevention interventions, in a total sample of 69 residents.
Findings include:
On 12/12/22 at 11:00am, R129 was observed in bed, the bed was in a high position. Again at 12:05pm, R129 was still in bed, the bed was in a high position . R129 was not able to use the bed control to lower the bed due to cognitive status. R129's BIMS (Basic Interview for Mental Status) score was 4 out of 15 according to MDS (Minimum Data Status dated 12/6/22. V28 (RN/Registered Nurse) was notified of this.
On 12/12/22 between 11am and 12:22pm, R113 was observed in bed, the bed was in a high position. At 12:25pm, R113 was not able to use the bed control to lower the bed due to cognitive status. R113's BIMS score is 0 out of 15, according to MDS dated [DATE]. V28 (RN) was notified of this high bed.
On 12/14/22 at 11:10am, V2 (Director of Nursing) stated that the restorative nurse resigned a few weeks ago, and that she would answer questions regarding fall prevention. V2 stated, residents who don't have the cognitive ability to use the bed control to lower their beds should not be placed in the bed, with the bed in high position, because they could get injured if they fall.
R129's care plan dated 9/6/22 states that R129 is at risk for falls related to medical diagnoses.
R113's care plan dated 11/1/22 states that R113 is at risk for falls related to medical diagnoses including but not limited to Encephalopathy and Hemiplegia.
Facility's Fall Prevention Program dated 2/2018 states, under Standards #3: Safety interventions will be implemented for each resident identified to be at risk using standard protocol.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record review the facility failed to follow dietary orders and monitor for weight loss for one resident (R173) reviewed for nutrition in a total sample of 69 resi...
Read full inspector narrative →
Based on observation, interviews, and record review the facility failed to follow dietary orders and monitor for weight loss for one resident (R173) reviewed for nutrition in a total sample of 69 residents.
Findings include:
R173 is 68 yr. old male admitted to facility on 9/21/22 with diagnosis including but not limited to: Major depressive disorder, Type 2 diabetes mellitus and irritable bowel syndrome. R173 has a BIMS (Brief Interview for Mental Status) score of 10/15. R173's documented admission weight was 175.2 lbs. (pounds).
On 12/12/2022 at 12:25 PM, R173 was observed in dining room having a general regular single portion size lunch meal. After lunch, R173 was interviewed in his room and he (R173) stated in part, I eat fast because I have to catch the steam table before it leaves the dining room so that I can get seconds . I won't eat again until dinner, then I will starve from 5 PM to 8AM, because I don't get anything else to eat after dinner The food is not sufficient enough for me.
On 12/13/2022 at 12:20pm a second lunch observation for R173 was observed by surveyor. The meal tray ticket on R173's tray read, 'General regular. It did not indicate double-portion servings, as ordered by V38 (Nurse Practitioner) on 12/9/22.
At 12:22 PM, V19 (Dietary Aide) was interviewed and stated, I only serve what the meal ticket says. If a resident is supposed to get double portions, it would indicate it on the meal ticket. If someone asks for a second serving, they would have to wait until all the room trays are served to see if there is any (food) left.
At 12:25 PM, V20 (Dietary Manager) was also interviewed. He stated in part, The meal ticket would read 'double portions' if there was an order I'm not aware of the order. The Dietary Tech usually updates the meal tickets, but she is off. I will be sure to make the change.
On 12/14/22 at 10:00 AM, V2 (DON/ Director of Nursing) was interviewed and stated in part, I am not sure who carries out dietary orders If special orders are not carried out, the resident may be at risk for weight loss, nutritional compromise, skin compromise, and overall health issues.
On 12/14/22 at 12:30 PM, V38 (Nurse Practitioner) was interviewed and stated in part, I noticed the weight change but questioned it. He (R173) didn't look like he was declining Orders that I (V38) usually put in place for residents with weight loss are Dietician consult, labs, supplements, protein, and maybe weekly weights . When I put new orders in, I tell the nurse sometimes I'm not sure how they confirm orders I plan to order supplements.
On 12/14/22 at 12:40 PM, V37 (Dietician) was interviewed and stated, For residents with possible weight loss, I would recommend supplements, a sandwich at bedtime and monitoring at mealtimes I see high risk residents with nutritional concerns more frequently than quarterly. A nutritional assessment is complete on the month of the weight loss.
On 12/12/2022 at approximately 3:30pm surveyor requested all nutritional assessments completed for R173 from V4 (Assistant Director of Nursing) since admission.
During record review for R173, an initial Nutritional Risk Review (assessment) was documented on 9/22/2022 and no additional Nutritional assessments were noted. This initial nutritional assessment documented the resident's weight of 175 Lbs. and height of 70 inches.
A Nutrition note documented by V37 (dietician) dated 10/24/22 at 4:45 PM documents in part, 'WT: 143 Lbs., down 18.6% x 1 month. Concern for wt. (weight) accuracy No labs to report. Rec: (Recommendations) please re wt. (re-weight).
Weight recorded for R173 on 10/28/22 was 142.8 Lbs.
On 12/14/22 at 1:00 PM, surveyor requested for R173 to be weighed. V39 (Licensed Practical Nurse) weighed R173, and surveyor observed a weight of 139.5 lbs. on a standing scale.
During record review, the following weights were documented: 9/21/22- 175.2 Lbs., 10/12/22- 142.6 Lbs., 10/28/22- 142.8 Lbs., 11/07/22- 138.4 Lbs., 11/30/22-136.4 Lbs., also on 11/30/22- 138.4 Lbs., and 12/01/22- 136.4 Lbs.
A dietary order for R173 dated 12/09/22 entered by V38 reads in part, please provide double portions for patient for malnutrition.
R173's revised care plan on 10/3/2022 documents in part, Dietary consult for nutritional regimen and ongoing monitoring monitor/ document/ report to MD (Medical Doctor) PRN (as needed) for s/sx (signs/symptoms) of hyperglycemia: Increased thirst and appetite, frequent urination, weight loss .
The facility's policy titled, Policy & Procedure Special Diet' (dated 11/2022) documents in part, Ensure the residents receive special diets as needed and as ordered by the physician.
CONCERN
(D)
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 observation, interview and record review, the facility failed to ensure that residents' call light system is maintained...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents' call light system is maintained, functional and adequately equipped to allow residents to call for staff assistance. This failure affected three residents (R109, R105 and R165) of four residents, reviewed for functional resident call system, in a total sample of 69 residents.
Findings include:
On 12/12/22 between 10:55am and 12:20pm during resident observation on the second floor, the call lights for R109, R105 and R165 were observed to be non-functional, and the residents could not call staff for assistance.
On 12/12/22 at 11:59am, R105 complained that she (R105) and R165 (her roommate and husband) were not getting help. Surveyor asked R105 to pull the call light for help. Call light was not answered for about 15 minutes. Surveyor went to the nursing station and asked V28 (RN/Registered Nurse) about how residents' call lights function to show up at the nursing station to alert staff that residents need help. V28 found out that room [ROOM NUMBER]'s call light was not working right and did not show up at the residents' call system at the nursing station. V28 stated she would call Maintenance staff to fix it.
On 12/12/22 at 11:36am, R109 was observed in bed with call light not within reach. Resident was asked to pull call light for help but stated he could not find the call light. It was found that the call light's string was broken. V28 was notified.
On 12/12/22 at 12:25pm, V36 (Maintenance Assistant) was interviewed regarding this. V36 stated that he was notified about the call light issues and he would fix them.
Surveyor inquired from V28 (RN/Registered Nurse) about the maintenance log where staff record what needs to be fixed. V28 presented the log, and the call light issue was not listed on the log.
Facility's undated policy on Call Lights states under Standards: #1. All residents shall have the nurse call light system available and within easy accessibility to the resident at the bedside or other reasonable accessible location. #5: Handbells or other devices may be provided temporarily in case of total system failure.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure a homelike environment for six residents (R13, R19, R84, R88, R124 and R160) in the sample of 69 residents.
Findings i...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure a homelike environment for six residents (R13, R19, R84, R88, R124 and R160) in the sample of 69 residents.
Findings include:
On 12\12\2022 at 10:48am observed a blue trash can in R84's room with no trash can liner in the trash can.
On 12\12\2022 at 10:50am R84 stated housekeeping has been in my room this morning but did not put a bag in my trash can.
On 12\12\2022 at 1:02pm V11(Housekeeper) stated, there should be a trash bag in the trash can of R84. V11 stated, the floor care staff is responsible for putting the trash liner in the garbage can.
On 12\12\2022 at 1:07pm V12 (Housekeeper\Floor Care) stated, I changed the trash bags in the resident's rooms at about seven in the morning. V12 stated, I (V12) am responsible for putting a liner in the resident's garbage can.
On 12\13\2022 at 12:13pm V30 (Housekeeper\Floor Care) stated, the floor tech is responsible for placing the bag in the resident's trash can. V30 stated, the reason for placing the trash bag in the can is to make sure no trash damages the inside of the trash can.
On 12\14\2022 at 2:24pm V26 (Director of Housekeeping) stated, the floor tech staff are responsible for putting the trash liners into the resident's trash cans in the resident's room. V26 stated, the trash can liners in the resident's rooms should be changed out every day by the floorcare staff. V26 stated, it is important to change the trash can liner in the resident's room trash can to prevent the pile up of garbage, to prevent insects in the room and to prevent residents from going into the trash cans and getting things. V26 stated, the purpose of the liner is to keep the garbage cans clean.
On 12\14\2022 reviewed the (undated) job description for Housekeeping Assistant which documents, in part underneath job requirements: 4. Must perform regular inspections of resident's rooms for sanitation, order, safety, and proper performance of assigned duties. Underneath Main Duties documents in part, J. Discard waste\trash into proper containers in accordance with established sanitation procedures and reline trash receptacle with plastic liner.
On 12\14\2022 reviewed the (undated) housekeeping guidelines, which documents in part, 6. Housekeeping personnel shall adhere to daily cleaning assignments developed so to maintain the facility in a clean and orderly manner. 14. All trash collection containers are lined with plastic bags to prevent leakage into the primary container.
Findings include:
On 12/12/202 at 11:20am, R19, R88, and R124's window curtain hooks were detached from the track.
On 12/12/22 at 11:22 am, this surveyor pointed this observation to V7 (Certified Nursing Assistant). V7 looked at the curtain and stated, The curtain is falling. It is not okay for the curtain to be falling. This surveyor inquired if 'falling curtain' provided homelike environment to residents. V7 stated, It's not.
On 12/13/2022 at 12:09pm, inside R13 and R160's room, a privacy curtain was used as window curtain and R13 and R160's closet was missing doors. There were few clothes hanging inside the closet.
On 12/13/2022 at 12:27PM, these observations were pointed out to V13 (Maintenance Director). V13, in reference to the privacy curtain used as window curtain, stated We (facility) are using temporary curtain for these residents. We are using privacy curtains as window curtains. The whole thing came off about a month and half ago. V13, in reference to R13 and R160's missing closet doors, stated, We don't have doors for this closet. Some people put stuff in the closet and block the door. This surveyor inquired if there were stuff inside R13 and R160's closet that would block or would prevent the closet doors from closing. V13 stated, No stuff blocking the door. This surveyor inquired if facility was providing homelike environment to R13 and R160 if facility was using privacy curtain as window curtain and closet having no doors. V13 stated, No.
On 12/13/2022 at 12:32, inside R19, R88, and R124's room, this surveyor requested V13 to check the window curtain. V13 stated, It is falling apart but it is something that can be fixed right away. This surveyor inquired if facility was providing a home like environment to R19, R88, and R124 if window curtain was falling apart per his (V13) statement. V13 stated, No.
R13's (11/08/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating R13's mental status was moderately impaired.
R19's (10/18/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R19's mental status was cognitively intact.
R88's (10/13/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R88's mental status was cognitively intact.
R124's (11/09/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R124's mental status was cognitively intact.
R160's (11/24/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 07. Indicating R160's mental status was severely impaired.
The (undated) Residents' Rights for People in the Long-Term Care Facilities documented, in part As a long-term care resident . you are guaranteed certain rights, protections and privileges according to state and federal laws. Your rights to safety. Your facility must be safe, clean, comfortable and homelike.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Findings include:
On 12\13\2022 at 12:55PM surveyor with V15, Registered Nurse reviewed the 1-A (first floor) medication cart Controlled Substance Check Form for December 2022, this form is used by th...
Read full inspector narrative →
Findings include:
On 12\13\2022 at 12:55PM surveyor with V15, Registered Nurse reviewed the 1-A (first floor) medication cart Controlled Substance Check Form for December 2022, this form is used by the facility for shift change accountability for controlled substances. The Nurse On and Nurse Off signature\initial boxes were left blank for December 4, 2022, 11pm-7am shift, indicating controlled substance reconciliation at the end\beginning of shifts was not completed.
On 12\13\2022 at 12:55PM V15(RN\Registered Nurse) stated, Nurses are to sign the controlled substance shift count sheet, when the nurses are changing shifts. V15 stated, The nurses are to notify the Director of Nursing if the controlled substance shift to shift count sheet is not completed.
On 12\14\2022 at 10:10am V2(Director of Nursing) stated the nurses are responsible for completing the controlled substance shift to shift check form. V2 stated the controlled substance shift to shift check form is to be completed at the change of shift with the outgoing nurse counting the number of controlled substances with the nurse coming on the shift. V2 stated both the oncoming and outgoing nurses should be initialing the controlled substance shift to shift check form at the same time to indicate that the number of controlled substances is accurate. V2 stated the DON (Director of Nursing) should be notified if the controlled substance shift to shift check form is not initialed and completed for each shift.
Based on observation, interview and record review, the facility failed to ensure that two nurses document together on the shift-to-shift controlled substances count sheet and failed to sign out controlled substances on narcotics accountability sheet for two residents (R109 and R165). This has the potential to affect two (R109 and R165) residents on the second floor.
Findings include:
On 12/12/2022 V1 (Administrator) presented facility census report that documented the residents census on the second floor was 63.
On 12/12/22 at 3:15 pm, Surveyor and V24 (Registered Nurse, RN) performed a controlled substance audit of the second floor Team B medication cart. Surveyor observed the controlled substance binder containing the controlled drug receipt/record/disposition form that V24 did not sign for the following residents:
R109's Tramadol HCL tablet 50 mg, take 1 tablet by mouth every 6 hours as needed for pain. Surveyor observed R109's medication card with 7 pills and R109's-controlled drug receipt/record/disposition form observed with 8 pills indicated for dispense.
R165's Lacosamide tablet 150 mg, take 1 tablet by mouth once daily. Surveyor observed R165's medication card with 2 pills and R165's-controlled drug receipt/record/disposition form observed with 3 pills indicated for dispense.
On 12/12/22 at 3:20 pm, V24 was asked regarding the controlled drug receipt/record/disposition form in the narcotics accountability binder and V24 stated, I (V24) was signing them (referring to R109 and R165's-controlled drug receipt/record/disposition forms) when you (Surveyor) came. I (V24) did not get a chance to sign them (referring to R109 and R165's-controlled drug receipt/record/disposition forms) yet. When V24 was asked when the narcotics accountability sheets should be signed out, V24 stated, Medications should be signed out when they are given so that the narcotics count is not off.
On 12/14/22 at 9:38 am, V2 (Director of Nursing, DON) was interviewed regarding signing controlled drug receipt/record/disposition forms in the narcotic accountability binder and V2 stated, Narcotics should be signed out as you are giving them. The importance is to keep an accurate count of the narcotics. If the nurse fails to sign out a narcotic as she/he gives it the count could be off.
Facility's document dated 07/2020 and titled Narcotic-Controlled Medication Policy documents, in part: General: To provide guidelines for the handling, distributions and destruction of narcotics/controlled medications. Guideline: . 3. When a narcotic medication is administered it should be signed out Individual Narcotic Sign Out record and MAR (Medication Administration Record). 4. Individual Narcotic-controlled medication Sign Out record should include date, given, time given, dosage, signature of nurse administering medications and number remaining.
Facility's job description titled Charge Nurse documents, in part: Main Duties: .L. Administer all medications. Maintain a current and annual report of narcotics received and used.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 12\13\2022 at 12:16PM with V8, Licensed Practical Nurse, 3-B medication cart was inspected. The following was observed: V8 pu...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 12\13\2022 at 12:16PM with V8, Licensed Practical Nurse, 3-B medication cart was inspected. The following was observed: V8 pulled 62 loose tablets from the bottom of the second drawer of the 3-B medication cart. V8 stated, Every nurse is responsible for cleaning the medication cart, but the cleaning of the medication cart is usually done by the night shift nurses.
On 12\13\2022 at 12:55pm with V15, Registered Nurse, 1-A medication cart was inspected. The following was observed: V15 pulled three loose tablets from the bottom of the second drawer of the 1-A medication cart. V15 stated, Nursing staff is responsible for cleaning the medication cart at least once a week; the cleaning is usually done by the night shift nurses.
On 12\14\2022 reviewed the Facility's document, with an effective date of 10\25\2014 and a revision date of 05\01\2018 titled ID1: Storage of Medications which documents, in part: I. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperature and humidity.
Based on observation, interview and record review the facility failed to ensure two medication carts out of the three medication carts reviewed were free of loose tablets and failed to ensure Insulin vials were labeled with an open date after opening the vials. This failure has the potential to affect 68 residents on the third floor, 58 residents on the first floor who receive medications from the medication carts and four resident's (R85, R159, R171, and R332) who receive insulin on the first floor.
Findings include:
On [DATE] at 1:23 pm, Surveyor and V4 (Assistant Director of Nursing, ADON, Registered Nurse, RN) inspected the second-floor medication room and observed the following insulin medications inside of the second-floor medication room refrigerator, open in use without an open date:
R85's Levemir Solution 100 unit per ml vial open in use with no open date labeled.
R159's Novolog 70/30 suspension 100 unit per ml vial open in use with no open date labeled.
R171's Insulin Glargine Solution 100 unit per ml vial open in use with no open date labeled.
R332's Insulin Aspart Solution 100 unit per ml vial open in use with no open date labeled.
On [DATE] at 3:00 pm, V4 was interviewed regarding dating insulin vials with an open date and V4 stated, When insulin vials are open, they should be labeled with an open date. Whoever the nurse is that initially uses the insulin vial should put an open date because it is only good for about one month. When V4 was asked regarding the importance of dating the insulin vial when it's opened with an open date and V4 stated, So we (referring to the facility nurses) know when it (referring to the insulin vials) expires.
On [DATE] at 9:38 am, V2 (Director of Nursing, DON) was interviewed regarding dating insulin vials with an open date and stated, Once insulin vials are received and opened, it should be dated and stored in the medication cart. No insulin should be stored in the medication cart or refrigerator open and undated. When V2 was asked the importance of dating the insulin vial upon the insulin vial being open, V2 stated, To make sure the insulin is still active and able to be used. It can be expired and cause a wrong dose medication error.
R85's Brief Interview for Mental Status (BIMS) dated [DATE] documents R85 with a score of 15 which indicates that R85 is cognitively intact.
R159's BIMS dated [DATE] documents R159 with a score of 03 which indicates that R159 has some cognitive impairments.
R171's BIMS dated [DATE] documents R171 with a score of 15 which indicates that R171 is cognitively intact.
R332's Brief Interview for Mental Status (BIMS) dated [DATE] documents R332 with a score of 15 which indicates that R332 is cognitively intact.
Facility's undated document title Vials and Ampules of Injectable Medications documents, in part: Policy: Vials and Ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. Procedures: . B. The date opened and the initial of the first person to use the vial are recorded on multidose vials (on the vial label or an accessory label affixed for that purpose).
Facility's document dated [DATE] and title Storage of Medications documents in part: Policy: Medications and biologicals are stored safely, and properly, following manufacturer's recommendations or those of the supplier. Expiration Dating: . C. Certain medications or package types, such as IV solutions, multiple dose injectable . once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure oxygen tubing was changed per facility policy for one resident (R79); failed to ensure staff donned proper PPE (Persona...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure oxygen tubing was changed per facility policy for one resident (R79); failed to ensure staff donned proper PPE (Personal Protective Equipment) when entering an isolation room for two residents (R24 and R54) to prevent the spread of Covid 19; failed to ensure proper hand hygiene was performed during resident dining for four residents (R20, R50, R84, R166) with the potential to affect all 34 residents eating lunch in 3rd floor dining room; and failed to ensure that the indwelling catheter for one resident (R17) was not lying on the floor. These failures affected R17, R20, R24, R50, R54, R79, R84 and R166 in the total sample of 69 residents reviewed for infection control.
Findings include:
On 12/12/22 at 10:50 AM, the surveyor observed R79's oxygen concentrator with tubing dated 12/1/22. R79 stated, I wear it whenever I need it. The surveyor inquired how often the oxygen tubing is changed. R79 replied, It varies how often, and added that prior to the date of 12/1/22, the tubing hadn't been changed for a month.
On 12/12/22 10:59 AM, this observation was brought to the attention of V17 (LPN/Licensed Practical Nurse) who was asked to read the piece of paper tape wrapped around the tubing with the date on it. I think it's 12/1, stated V17. The surveyor inquired how often the oxygen tubing should be changed. V17 replied, Once a week on the weekend or when she (R79) needs it to be changed. The night shift and supervisors put the date on it.
On 12/15/22 at 12:39 PM, V2 (DON/Director of Nursing) stated that oxygen tubing is changed weekly or PRN (as needed) if it fell on the floor or if it is soiled. V2 added that it is usually done Sunday on the nocturnal shift. It (the tubing) should be labeled, dated and kept in a bag. The entire bag should be changed and start fresh from concentrator to the mask, per V2.
R79's admission Record documents diagnoses including but not limited to chronic obstructive pulmonary disease.
R79's 11/3/22 BIMS (Brief Interview for Mental Status) determined a score of 15, indicating that R79's cognition is intact.
R79's Order Summary Report documents physician orders dated 11/1/22 which state, Change oxygen tubing weekly every night shift every Tue, Sun and Oxygen 2LPM (liters per minute) via NC (nasal cannula) as needed.
The 5/14 Equipment Change Schedule documents, in part, Policy: Equipment will be changed following established schedules to prevent cross contamination.
On 12/12/22 at 1:35 PM, V18 (CNA/Certified Nursing Assistant) was observed walking into R54's room with no gown or face shield/goggles on to answer the call light. R54's room had a contact and droplet isolation sign outside the door.
On 12/12/22 at 1:50 PM, the surveyor inquired what type of PPE should be worn in addition to the gloves and N95 mask when entering a Covid isolation room. V18 replied, Should be wearing a gown.
12/14/2022 at 10:17 AM, V2 (DON) stated that when entering a Covid-19 isolation room, goggles, or face shield, not just glasses, a N95 mask, gloves, and a gown should be donned immediately outside the room. The surveyor inquired if staff still needs to apply full PPE (Personal Protective Equipment) if just coming in to turn off a call light. V2 replied, Absolutely.
R54's admission Record documents diagnoses including but not limited to personal history of Covid-19.
R54's 10/06/2022 BIMS determined a score of 12, indicating R54's cognition is moderately impaired.
R54's Clinical Summary documents a positive result for the SARS-CoV-2, NAAT test dated 12/07/22 at 11:20 PM at (Named) Health Lab.
R54's 12/08/22 care plan documents, in part, Resident is on isolation R/T (related to): COVID + diagnosis and PUI (Person Under Investigation) Admission. Interventions include but are not limited to, Set up isolation as per facility protocol.
The 11/8/2022 Policy and Procedure Care for Residents with Suspected or Confirmed SARS-Cov-2 Infection or a Close Contact with Someone with Confirmed Covid-19 Infection documents, in part, Residents with confirmed Covid-19: . 10. Staff must wear full PPE (N95 respirator, gown, gloves, eye protection) when providing care.
On 12\12\22 at 12:20PM observed lunch tray pass in the third-floor dining room, five staff were assisting with passing lunch trays to the residents.
On 12\12\2022 at 12:25PM observed V7(Certified Nursing Assistant) pass lunch trays to R20 and R84 without using alcohol-based hand sanitizer between passing each resident's tray.
On 12\12\2022 at 12:45PM V7(CNA\Certified Nursing Assistant) stated, I'm not for sure how often I(V7) should use hand sanitizer or wash my hands during the meal tray pass. V7 stated, Once I get the answer, I can get back to you. V7 stated, The purpose of using hand sanitizer or washing my hands during meal tray pass is because it reduces the risk of spreading germs or bacteria. V7 stated, No I did not use hand sanitizer during the meal tray pass.
On 12\14\2022 at 10:10am V2(Director of Nursing) stated the purpose of staff performing hand hygiene during dining or while passing meal trays is to prevent the spread of germs and to prevent contamination of the food. V2 stated staff using alcohol- based hand sanitizer while passing food trays promotes a safe and sanitary dining experience.
On 12\14\2022 reviewed Meal Service\Tray Delivery policy, dated 1\20 which documents in part, underneath procedure: 1. Wash hands. May use hand sanitizer between dirty and clean process.
On 12/12/22 at 12:55 pm, Surveyor observed a sign on the wall outside of R24's room that documented, in part: Contact Precautions Are you going in? Put gown on over your clothes. Droplet Precautions . Wash your hands.
On 12/12/22 at 12:55 pm, V25 (Certified Nursing Assistant, CNA) was observed on the second floor in the hallway entering into R24's contact/droplet isolation room without donning Personal Protective Equipment (PPE) (a gown) to serve R24, R24's lunch tray. When V25 was asked regarding the contact/droplet isolation sign on the wall outside of R24's room, V25 stated, I (V25) did not even look at that (referring to the Contact/Droplet precaution isolation sign on the wall outside of R24's room). When V25 was asked regarding the importance of donning PPE in a contact/droplet isolation room V25 stated, The importance of putting on PPE is to prevent droplets from getting on me (V25) and me (V25) from transferring it (referring to R24's contact/droplet isolation precaution) to other residents.
On 12/14/22 at 9:38 am, V2 (Director of Nursing, DON) was interviewed regarding donning PPE in a contact/droplet isolation room during dining and stated, If someone is going into an isolation room, PPE should be worn and anytime there is a potential for fluids to be splashed. PPE should be put on immediately outside of the room before entering. When V2 was asked regarding the importance of donning PPE prior to entering a contact isolation room V2 stated, The importance is to prevent the spread of infection. PPE should be worn even during dining to serve a lunch tray. The CNA can spread whatever the bug is that is in the residents room.
Facility's undated document titled Infection Control Policy documents, in part: Purpose: To establish methods and criteria, necessary within the facility and its operation, to prevent and control infections and communicable diseases . Standards: 1. The facility has established and Infection Control Program which addresses all phases of the organization's operation to reduce or prevent the risks of nosocomial infections in residents and health care workers . 15. All facility personnel shall adhere to the Infection Control Program in the performance of their daily assignments. 19. Contact precautions in addition to standard precautions will be initiated as specified in the specific isolate policy.
R24's Brief Interview for Mental Status (BIMS) dated 10/07/2022 documents R24 with a score of 15 which indicates that R24 is cognitively intact.
R24's Physician Order Sheet (POS) dated 12/07/22 documents in part that R24 is Contact/Droplet isolation for PUI (Person Under Investigation) for 10 days.
Facility's undated document titled Covid PUI Residents documents, in part: R24 is a COVID PUI resident in the facility.
Facility's document dated 01/01/2020 and titled Isolation Precautions documents, in part: Purpose: To establish transmission-based precautions for resident who are suspected or confirmed to have communicable diseases/infections that can be transmitted to other . Contact Precautions: . 3. Prior to entering the isolation room, the following steps are required: a. Perform hand-hygiene and apply gloves and gown prior to entering room.
On 12/12/22 at 11:15 am, Surveyor and V24 (Registered Nurse, RN) observed R17 lying in bed awake and alert with R17's indwelling catheter not in a privacy bag and on the floor near the foot of R17's bed. When V24 was asked regarding the facility's policy regarding indwelling catheters V24 stated, Catheters should be in a privacy bag, hanging from the side of the bed to prevent an infection control hazard and for the dignity of the patient. When V24 was asked regarding R17's indwelling catheter being on the floor V24 stated, R17's catheter should not be on the floor.
On 12/14/22 at 9:38 am, V2 (Director of Nursing, DON) was interviewed regarding indwelling catheter care and V2 stated, Indwelling catheters should not be on the floor. Indwelling catheters should be inside of a privacy bag. V2 explained that if an indwelling catheter is on the floor, it can be an infection prevention issue and that if an indwelling catheter is not in a privacy bag it can be a dignity issue.
R17's Brief Interview for Mental Status (BIMS) dated 10/07/2022 documents R17 with a score of 00 which indicates that R17 has some cognitive impairments.
R17's Physician Order Sheet dated 06/03/2020 documents that R17 has a catheter (Type/Size); fr#16 (French number 16) indication: Obstructive Uropathy, every shift catheter care.
Facility's undated document titled Urinary Catheter Care documents, in part: Purpose: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Standards . 5. Indwelling catheters will be secured to prevent trauma and tension . 7. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor.
The (undated) Dining Room Diners documented that there are 34 residents eating at the 3rd floor's dining room.
On 12/12/2022 at 12:25pm, during the dining observation in 3rd floor's dining room, V9 (PRSC Psychiatric Rehabilitation Services Coordinator) was helping a resident with putting on the resident's jacket. After assisting the resident, V9 proceeded with placing beverages on other residents' meal tray without performing hand hygiene.
On 12/12/2022 at 12:38pm, this surveyor inquired who did V9 assist with the jacket? V9 stated, (R50). V9 also identified the resident who first received the beverage from V9 after V9 assisted R50 as R166. This surveyor inquired if hand hygiene was performed by V9 after assisting R50 with R50's jacket. V9 stated, No.
On 12/12/2022 at 12:40pm, this surveyor inquired about staff expectation after assisting a resident and prior to passing beverages to residents. V9 stated, Making sure I (V9) wash my hands, after assisting (R50). We (facility) do not want to risk (R50) and any residents to the facility getting Covid.
R50's (11/16/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 09. Indicating R50's mental status was moderately impaired.
R166's (11/23/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. Indicating R166's mental status was moderately impaired.
The (undated) Policy and Procedure Meal Service/Tray Delivery policy documented, in part Policy: To provide adequate nutrition for residents. Procedure: 1. Wash hands. May use hand sanitizer between dirty and clean process.
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 interview and record review, the facility failed to track the vaccination status, failed to offer, and failed to educat...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to track the vaccination status, failed to offer, and failed to educate 4 eligible residents (R54, R178, R432 and R433) out of 5 residents reviewed for influenza and pneumococcal vaccinations in the total sample of 69 residents.
Findings include:
On 12/13/22 at 1:39 PM, the surveyor could not find any influenza or pneumococcal immunizations documented in the electronic medical record for R433. This was brought to the attention of V3 (Infection Preventionist/LPN, Licensed Practical Nurse) who stated, That's our new guy. I have not seen anything in his (R433) hospital records. I was researching. I was going to reach out to the liaison who sends us our admission to see if she has anything on him (R433). The surveyor inquired if there is a timeframe in which vaccination status has to be entered or vaccinations offered for new admissions. V3 replied, Not from my knowledge. They have not given me a time-frame. V3 added, New admissions are considered 30 days. After that, all assessments should be complete.
R433's admission Record documents and admission date of 12/08/22 and diagnoses including but not limited to autistic disorder and unspecified lack of expected normal physiological development in childhood.
R433's MDS (Minimum Data Set) Section C for Cognitive Patterns documents that R433 did not qualify for a Brief Interview for Mental Status and was coded as 3. Severely Impaired in the section titled, Cognitive Skills for Daily Decision Making.
R433's Orders Summary Report documents physician orders dated 12/9/22 for Flu vaccine yearly unless refused or contraindicated and May administer pneumococcal vaccine per CDC (Centers for Disease Control and Prevention) guidelines unless contraindicated or refused.
On 12/13/22 at 1:44 PM, the surveyor could not find any influenza or pneumococcal immunizations documented in the electronic medical record for R54. V3 stated, He (R54) may have been in the hospital when we reviewed it (vaccination audit). V3 started looking through a binder containing consents/declinations for influenza and pneumococcal vaccines and stated, I do not see a declination form. He (R54) doesn't have anything on file. The surveyor inquired how V3 keeps track of residents' vaccination status. V3 replied, I run reports in (electronic medical record) probably twice a month to see if anyone is missing a vaccination. (Electronic Medical Record) is the only resource I have to run reports. I enter everything into (electronic medical record). There is no other way to track the vaccinations.
R54's admission Record documents and admission date of 01/04/22 and diagnoses including but not limited to malignant neoplasm of base of tongue and malignant neoplasm of upper lobe, left bronchus or lung.
R54's 10/7/22 BIMS (Brief Interview for Mental Status) determined a score of 12, indicating R54's cognition is moderately impaired.
R54's Order Summary Report documents two physician orders dated 7/29/22 for Flu vaccine yearly unless refused or contraindicated and May administer pneumococcal vaccine per CDC (Centers for Disease Control and Prevention) guidelines unless contraindicated or refused.
On 12/13/22 at 1:50 PM, the surveyor could not find any influenza or pneumococcal immunizations documented in the electronic medical record for R178. V3 again searched the consents/declination binder and was unable to locate a declination for the influenza or pneumococcal vaccine. V3 stated, (R178) did not sign a consent, nor did he (R178) decline the flu or pneumonia vaccine. V3 added that any vaccinations either historical (given outside of the facility) or administered in the facility would be documented under the immunizations tab in the electronic medical record. V3 stated that she (V3) is the one that enters the vaccination status into the electronic medical record, but if I (V3) search and don't come up with anything then we treat them (residents) as unvaccinated. V3 added that then she (V3) offers and educates the resident about the vaccines. V3 stated, I let them know of the risks if they decline vaccination. When the surveyor inquired if this education is documented anywhere, V3 replied, I'll put a progress note in. V3 added that all vaccination consents/declinations are given to medical records to get scanned into the electronic medical record.
R178's admission Record documents an admission date of 11/10/22 and diagnoses including but not limited to chronic obstructive pulmonary disease, atrial fibrillation and unspecified dementia.
R178's 11/15/22 BIMS determined a score of 15, indicating R178's cognition is intact.
R178's Order Summary Report documents two physician orders dated 11/10/22 for Flu vaccine yearly unless refused or contraindicated and May administer pneumococcal vaccine per CDC (Centers for Disease Control and Prevention) guidelines unless contraindicated or refused.
R178's Order Summary Report documents a physician order dated 12/08/22 for Droplet Isolation for Influenza for 7 days for treatment and monitoring of influenza until 12/15/22.
On 12/13/22 at 2:00 PM, the surveyor could not find any influenza immunizations documented in the electronic medical record for R432. A Pneumovax (pneumococcal vaccine) dose 1 was documented as received on 8/29/14 for R432. R432 would have been 61 at the time of the first pneumococcal dose. The surveyor inquired if R432 should be offered another pneumococcal vaccine since the first dose was given before the age of 65. V3 replied, Most definitely. V3 could not present any influenza or pneumococcal consents or declinations for R432.
R432's admission Record documents an admission date of 12/05/22 and diagnoses including but not limited to cerebral infarction, atrial fibrillation, and type 2 diabetes mellitus.
R432's 12/13/22 BIMS determined a score of 15, indicating R432's cognition is intact.
R432's Order Summary Report documents two physician orders dated 12/06/22 for Flu vaccine yearly unless refused or contraindicated and May administer pneumococcal vaccine per CDC (Centers for Disease Control and Prevention) guidelines unless contraindicated or refused.
On 12/14/22 at 10:17 AM, V2 (DON/Director of Nursing) stated that the expectation regarding documentation of vaccination status would be that the infection preventionist looks through the resident's admission paperwork to make sure that any vaccinations already received get entered accurately into the electronic medical record. V3 added, If they (residents) don't have any vaccines historically, the IP (Infection Prevention) nurse may want to speak with the resident or representative and offer/provide education about receiving the flu, pneumo, covid, or even like the shingles vaccine.
On 12/14/22 at 1:48 PM, the surveyor inquired what is the importance of ensuring residents vaccinations are up to date. V33 (Corporate Nurse Consultant) replied, We know that if vaccinations are up to date, that can decrease the severity of infection, and it can prevent them (residents) from spreading the virus to family, staff, vendors. V33 added, We can educate and encourage them to get vaccinated if they don't believe in vaccinations. The residents have the right to decline, but then they have to sign the declination forms.
Review of R54, R178, R432, and R433's progress notes did not reveal any documentation regarding education provided on influenza or pneumococcal vaccinations.
The revised 8/20/20 Influenza Policy documents, in part, Residents are protected from the influenza virus by receiving the vaccine annually .Procedures: 1. The head nurse manager keeps a list of residents on each unit .c. As each resident is vaccinated, the date of vaccination and temperature are marked on this list so residents with delayed vaccinations are readily identified for subsequent vaccination .6. After all residents have been vaccinated and observed for 48 hours and the necessary information has been recorded, the sheet is to be returned to the infection control nurse.
The revised 8/20/20 Pneumococcal Policy documents, in part, All residents are provided with the opportunity and encouraged to receive pneumococcal vaccinations. Policy: The head nurse manager or designee is responsible to research the medical record and history to determine if the pneumococcal vaccinations have ever been given. The infection control practitioner maintains a file of current residents showing the status of vaccination.
The CDC (Centers for Disease Prevention) website's Vaccine Information Statements ([NAME]) for Inactivated Influenza documents, in part, Why get vaccinated? Flu is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous for some people. Infants and young children, people 65 years and older, pregnant people, and people with certain health conditions or a weakened immune system are at greatest risk of flu complications. Pneumonia, bronchitis, sinus infections, and ear infections are examples of flu-related complications. If you have a medical condition, such as heart disease, cancer, or diabetes, flu can make it worse. https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.html
The CDC (Centers for Disease Prevention) website's Vaccine Information Statements ([NAME]) for Pneumococcal Conjugate documents, in part, Pneumococcal conjugate vaccine can prevent pneumococcal disease. Pneumococcal disease refers to any illness caused by pneumococcal bacteria. These bacteria can cause many types of illnesses, including pneumonia, which is an infection of the lungs. Pneumococcal bacteria are one of the most common causes of pneumonia. Besides pneumonia, pneumococcal bacteria can also cause: Ear infections, sinus infections, meningitis (infection of the tissue covering the brain and spinal cord) and bacteremia (infection of the blood). Anyone can get pneumococcal disease, but children under 2 years old, people with certain medical conditions or other risk factors, and adults 65 years or older are at the highest risk . Adults 19 through [AGE] years old with certain medical conditions or other risk factors who have not already received a pneumococcal conjugate vaccine should receive either: a single dose of PCV15 followed by a dose of pneumococcal polysaccharide vaccine (PPSV23), or a single dose of PCV20. Adults 65 years or older who have not already received a pneumococcal conjugate vaccine should receive either: a single dose of PCV15 followed by a dose of PPSV23, or a single dose of PCV20. https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv.html
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 interview and record review, the facility failed to track the vaccination status, failed to offer, and failed to educate 4 eligible residents (R54, R178, R432, R433) out of 5 residents review...
Read full inspector narrative →
Based on interview and record review, the facility failed to track the vaccination status, failed to offer, and failed to educate 4 eligible residents (R54, R178, R432, R433) out of 5 residents reviewed for Covid-19 vaccinations in the total sample of 69 residents.
Findings include:
On 12/13/22 at 1:39 PM, the surveyor could not find any Covid-19 immunizations documented in the electronic medical record for R433. This was brought to the attention of V3 (Infection Preventionist/LPN, Licensed Practical Nurse) who stated, That's our new guy. I have not seen anything in his (R433) hospital records. I was researching. I was going to reach out to the liaison who sends us our admissions to see if she has anything on him (R433). The surveyor inquired if there is a timeframe in which vaccination status has to be entered or vaccinations offered for new admissions. V3 replied, Not from my knowledge. They have not given me a time-frame. V3 added, New admissions are considered 30 days. After that, all assessments should be complete.
R433's admission Record documents and admission date of 12/08/22 and diagnoses including but not limited to autistic disorder and unspecified lack of expected normal physiological development in childhood.
R433's MDS (Minimum Data Set) Section C for Cognitive Patterns documents that R433 did not qualify for a Brief Interview for Mental Status and was coded as 3. Severely Impaired in the section titled, Cognitive Skills for Daily Decision Making.
On 12/13/22 at 1:44 PM, the surveyor could not find any Covid-19 immunizations documented in the electronic medical record for R54. V3 stated, He (R54) may have been in the hospital when we reviewed it (vaccination audit). V3 started looking through a binder titled Resident Covid 19 Vax (Vaccination) Cards and Employee Covid-19 Vaccination Cards and Exempting and stated, He (R54) does not have a card. He (R54) doesn't have anything on file. The surveyor inquired how V3 keeps track of residents' vaccination status. V3 replied, I run reports in (electronic medical record) probably twice a month to see if anyone is missing a vaccination. (Electronic Medical Record) is the only resource I have to run reports. I enter everything into (electronic medical record). V3 added that she also (V3) uses the binder and has a Resident Covid Vaccination Tracker.
R54's admission Record documents and admission date of 01/04/22 and diagnoses including but not limited to malignant neoplasm of base of tongue and malignant neoplasm of upper lobe, left bronchus or lung.
R54's 10/7/22 BIMS (Brief Interview for Mental Status) determined a score of 12, indicating R54's cognition is moderately impaired.
R54's 1/05/22 care plan documents, in part, Risk for potential exposure to Covid-19 and/or potential risk to spread to others.
R54's Clinical Summary documents a positive result for the SARS-CoV-2, NAAT test dated 12/07/22 at 11:20 PM at (Named) Health Lab.
On 12/13/22 at 1:50 PM, the surveyor could not find any Covid-19 immunizations documented in the electronic medical record for R178. V3 again searched the Resident Vax Card Binder. V3 stated, No, he (R178) does not have a card. V3 added that any vaccinations either historical (given outside of the facility) or administered in the facility would be documented under the immunizations tab in the electronic medical record. V3 stated that she (V3) is the one that enters the vaccination status into the electronic medical record, but if I (V3) search and don't come up with anything then we treat them (residents) as unvaccinated. V3 added that then she (V3) offers and educates the resident about the vaccines. V3 stated, I let them know of the risks if they decline vaccination. When the surveyor inquired if this education is documented anywhere, V3 replied, I'll put a progress note in. V3 added that all vaccination consents/declinations are given to medical records to get scanned into the electronic medical record.
On 12/13/22 at 2:09 PM, V3 found a Covid CDC Vaccine Consent Form that was signed by R178, but the form was not filled out at all and there was no date on the form. Another Covid-19 Pfizer Booster-Resident Form Vaccine Consent Form was signed by R178 for the upcoming vaccination clinic. Section 2, Screening for Vaccine Eligibility which included a space to fill in the vaccine brand, dose 1 and dose 2 was not completed nor was the form dated. The surveyor inquired how can a booster be offered if the resident has not received the initial Covid-19 series yet. V3 replied, That's what I'm wondering too.
R178's admission Record documents an admission date of 11/10/22 and diagnoses including but not limited to chronic obstructive pulmonary disease, atrial fibrillation and unspecified dementia.
R178's 11/15/22 BIMS determined a score of 15, indicating R178's cognition is intact.
R178's 11/10/22 care plan documents, in part, Risk for potential exposure to Covid-19 and/or potential risk to spread to others.
On 12/13/22 at 2:00 PM, the surveyor could not find any Covid-19 immunizations documented in the electronic medical record for R432. V3 was unable to present a Covid-19 vaccination card, consent, or declination for R432.
R432's admission Record documents an admission date of 12/05/22 and diagnoses including but not limited to cerebral infarction, atrial fibrillation, and type 2 diabetes mellitus.
R432's 12/13/22 BIMS determined a score of 15, indicating R432's cognition is intact.
On 12/14/22 at 10:17 AM, V2 (DON/Director of Nursing) stated that the expectation regarding documentation of vaccination status would be that the infection preventionist looks through the resident's admission paperwork to make sure that any vaccinations already received get entered accurately into the electronic medical record. V3 added, If they (residents) don't have any vaccines historically, the IP (Infection Prevention) nurse may want to speak with the resident or representative and offer/provide education about receiving the flu, pneumo, Covid, or even like the shingles vaccine.
On 12/14/22 at 1:48 PM, the surveyor inquired what is the importance of ensuring residents vaccinations are up to date. V33 (Corporate Nurse Consultant) replied, We know that if vaccinations are up to date, that can decrease the severity of infection, and it can prevent them (residents) from spreading the virus to family, staff, vendors. V33 added, We can educate and encourage them to get vaccinated if they don't believe in vaccinations. The residents have the right to decline, but then they have to sign the declination forms.
Review of R54, R178, R432, and R433's progress notes did not reveal any documentation regarding education provided on Covid-19 vaccinations. Additionally, none of the residents reviewed (R54, R178, R432, R433) were listed on the Resident Covid Vaccination Tracker.
The facility Policy and Procedure Vaccinations dated 11/8/22 documents, in part, Purpose: Ensure all residents and staff are afforded the opportunity to receive vaccinations for preventable diseases. Procedure: 1. Educate residents, staff, and families on the importance of vaccination 2. Facilitate vaccination administration.
The CFR (Code of Federal Regulations) dated 05/21/21 documents, in part,
§483.80(d) (3) COVID-19 immunizations. The LTC facility must develop and implement policies and procedures to ensure all the following:
(i) When COVID-19 vaccine is available to the facility, each resident and staff member
is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized;
(ii) Before offering COVID-19 vaccine, all staff members are provided with education
regarding the benefits and risks and potential side effects associated with the vaccine;
(iii) Before offering COVID-19 vaccine, each resident or the resident representative
receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine;
(iv) In situations where COVID-19 vaccination requires multiple doses, the resident,
resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses;
(v) The resident, resident representative, or staff member has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision;
(vi) The resident's medical record includes documentation that indicates, at a minimum,
the following:
(A) That the resident or resident representative was provided education regarding the
benefits and potential risks associated with COVID-19 vaccine; and
(B) Each dose of COVID-19 vaccine administered to the resident; or
(C) If the resident did not receive the COVID-19 vaccine due to medical
contraindications or refusal .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure the Daily Nurse Schedule was posted in a prominent place readily accessible to residents and visitors; and failed to en...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure the Daily Nurse Schedule was posted in a prominent place readily accessible to residents and visitors; and failed to ensure the Daily Nurse Schedule was complete. This failure affected all 185 residents residing in the facility.
Findings include:
The (12/12/2022) facility census was 185.
On 12/12/2022 at 9:10am, by the receptionist area, there was no daily nursing staffing posted.
On 12/12/2022 at 10:58am, this surveyor inquired about the posting of daily nursing staffing. V4 ADON (Assistant Director of Nursing) stated, We (facility) keep it in the 2nd floor nurse's station. This surveyor inquired if the daily nursing staffing was visible to visitors who come into the facility. V4 stated, No. It should be visible. V4 and this surveyor went to the second floor. On the second floor, V4 pulled out the Facility Daily Nurse Schedule from the binder called Nursing Staffing Informational Binder and showed the daily nursing staffing to this surveyor. Upon review of the Daily Nurse Schedule, no resident census was written on the schedule. This surveyor pointed this out to V4 (Assistant Director of Nursing) V4 stated, We never put the resident's census on the schedule. We have a separate sheet for that.
On 12/12/2022 at 11:05am, surveyor inquired about posting of the daily nursing staffing. V5 (Scheduler) stated, We post it in the binder. This surveyor inquired if the nursing schedule was visible to visitors who come into the facility. V5 stated, No, because it is in the second floor.
On 12/12/2022 at 11:07am, surveyor inquired about the resident census on the daily nursing staffing. V5 stated, It is not posted in the Daily Nurse Staffing Schedule. This is how we've been posting it. This is how the ADON, and DON want it. This surveyor inquired if there were nursing hours written on the daily nursing staffing. V5 stated, No, Ma'am.
The (12/12/2022 - 12/16/2022) Facility Daily Nurse Schedule did not include resident's census and nursing staff hours.
The (12/15/2022) email correspondence with V1 (Administrator) documented, in part We do not have the policy for nursing daily schedules.
The (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) State Operations Manual documented, in part
§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.
§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.
GUIDANCE §483.35(g)
The facility ' s staffing data document may be a form or spreadsheet, as long as all the required information is displayed clearly and in a visible place
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 clean a kitchen fan; failed to ensure food items were discarded before the expiration date; and failed to practice safe use of...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to clean a kitchen fan; failed to ensure food items were discarded before the expiration date; and failed to practice safe use of glove practices to prevent food borne illness. These deficient food sanitation practices have the potential to affect all 183 residents receiving oral diets from the facility's kitchen.
Findings include:
On 12/12/22 during the facility entrance, V1 (Administrator) reported the facility census as 185. The NPO (Nothing by mouth) list provided by V1 indicated 2 residents are not receiving an oral diet from the kitchen.
On 12/12/22 at 10:20am during the initial inspection of the kitchen with V20 (Dietary Manager), the following observations were observed:
A metal fan was in use sitting near the dishwasher. The fan had visible accumulated dust on the front of the fan.
In the walk-in cooler, a box of 19 four-ounce containers of yogurt with the expiration date: 12/4/2022.
V20 stated, the yogurt was delivered to the facility on the previous Friday when he was not at the facility and that the case of yogurt was already expired when it was delivered.
V20 also stated, he is aware that expired foods could be harmful to the residents if consumed and fans are cleaned as needed with the other appliances in the kitchen.
On 12/13/22 at 10:00 am, V20 presented the cleaning schedule for the kitchen items cleaned on a daily basis by both am and pm staff.
The kitchen fans were not on the cleaning schedule.
Facility's policy titled Equipment and utensil cleanliness and sanitation (dated 5/2020), reads in part: Non-food contact surfaces of equipment used in the operation of a food service, including And fans, shall be cleaned as often as necessary to be free of accumulation of dust, dirt, food particles and other debris.
The facility did not follow these policies.Findings include:
On 12/12/22 at 12:28 PM, during the dining observation on the 1st floor, the surveyor observed V19 (Dietary Aide) using his (V19) right gloved hand to place a piece of meatloaf on a plate, then used the same gloved hand to touch perforated spoodle used to plate the broccoli. Using the same gloved hand, V19 grabbed a piece of cornbread and placed it on the plate. This was observed for multiple plates served with no changing of gloves in between.
On 12/12/22 at 12:50 PM, the surveyor inquired what the importance is of using the proper serving utensils when plating food. V19 replied, So we won't touch the food and have the correct portion size. The surveyor then asked why food items should not be touched with the same gloved hand. V19 replied, Because of cross-contamination.
On 12/12/22, 12/13/22 and 12/14/22 the surveyor requested a policy from both V1 (Administrator) and V20 (Dietary Manager) regarding general infection control practices in the kitchen or a tray line policy. None were provided except a one-page Meal Service/Tray Delivery policy which describes the process for passing out meal trays.
The State Food Safety website article titled Training Tip: Wearing Gloves for Food Safety documents, in part, Since gloves can become contaminated very easily, they must be changed often. They may only be used for one task and must be discarded if damaged or if the worker is interrupted during their task. Anytime the gloves become contaminated, they must be changed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to ensure that the outside dumpster lid was closed to prevent pest and rodents from entering into the garbage bin. This failure ha...
Read full inspector narrative →
Based on observation, interview and record review the facility failed to ensure that the outside dumpster lid was closed to prevent pest and rodents from entering into the garbage bin. This failure has the potential to affect all 185 residents residing in the facility.
Findings include:
The (12/12/22) facility census was 185 as reported by V1 (administrator).
On 12/12/22 at 1:55 pm, four outside dumpsters were observed without lids. Each dumpster had a black lid attached which were all flipped to the back of the dumpster.
On 12/13/22 at 1:30 pm, three outside dumpsters were observed without lids. Each dumpster had a black lid attached which were all flipped to the back of the dumpster.
On 12/13/22 at 1:30 pm, V26 (Director of Housekeeping) observed the open dumpster's and stated, the lids are often left open after the garbage is picked up by disposal service.
V26 further stated, the wind often prevents the lids from staying down and they do not have locks or latches on the lids.
Facility policy received by V26 on 12/13/22 titled, Waste Management (dated 5/2014), reads in part: Maintenance and Housekeeping personnel shall assure the dumpster area is kept clean and all trash bags are inside the dumpster, and dumpster lids closed.
The facility did not follow this policy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to develop policies and procedures that include the processes for ensuring documentation for religious exemptions for Covid-19 vaccination; pr...
Read full inspector narrative →
Based on interview and record review, the facility failed to develop policies and procedures that include the processes for ensuring documentation for religious exemptions for Covid-19 vaccination; process for tracking and securely documenting staff Covid-19 vaccination status; a process for contingency plans for staff who are not fully vaccinated with Covid-19 vaccine; and failed to track and ensure 100% of staff were vaccinated as required by CDC (Centers for Disease Control and Prevention). These failures have the potential to affect all 185 residents in the facility.
Findings include:
On 12/12/22 at 10:11 AM, V1 (Administrator) stated that the official facility census is 185 residents.
On 12/13/22 at 12:00 PM, the surveyor requested a policy on staff vaccinations for Covid-19. V3 (Infection Preventionist) provided the surveyor with a policy dated 11/8/2022 titled Policy and Procedure Vaccinations with the procedure comprised of only 3 steps: 1. Educate residents, staff, and families on the importance of vaccination. 2. Facilitate vaccination administration. 3. Report SARS-CoV-2 infection data including vaccination and testing data to the National Healthcare Safety Network (NHSN) Long-Term Care Facility (LTCF) Covid-19 Module. The surveyor inquired if there was another policy which includes tracking of vaccination, exemptions and a contingency plan for staff who are not fully vaccinated. V3 stated that she (V3) would check with corporate.
On 12/14/22 at 12:04 PM, the surveyor requested V3 for an interview, and V32 (Assistant Administrator) stated that V3 had called off today.
On 12/14/22 at 12:39 PM, the surveyor asked V2 (DON/Director of Nursing) for a Covid-19 staff vaccination policy as an appropriate one had not been provided yet by V3. V2 provided the surveyor with the same Policy and Procedure Vaccinations that was already provided by V3. The surveyor inquired if the policy contains any information about how the facility tracks vaccination for staff or addresses exemptions. V2 replied, It does not say anything like that.
On 12/14/22 at 11:44 AM, V1 emailed the surveyor a screenshot of the percentage of staff vaccinated which was taken from the Covid Vaccination Tracker Staff provided by V3. It listed the total staff as 114 with 4 religious exemptions and 16 unknown resulting in a complete vaccination of 81.6% of staff. The surveyor asked V1 to complete the Covid-19 Staff Vaccination Matrix created by the Department of Health and Human Services Centers for Medicare and Medicaid Services since it was unclear what the unknown meant.
On 12/14/22 at 12:58 PM, V1 emailed the surveyor a screenshot of Section 1 of the Covid-19 Staff Vaccination Matrix which now listed the total staff as 120 with 20 granted exemptions and 6 not vaccinated without exemption/delay.
On 12/14/2022 at 1:48pm, surveyor inquired about who was responsible for tracking staff vaccination status. V1 stated, It is the Infection Preventionist's job to track all staff vaccination status, or who have religious or medical exemptions.
On 12/14/22 at 2:49 PM, the surveyor inquired about the discrepancy in number of staff on the two screenshots provided. V1 stated, We have HR (Human Resources) looking into that because we had a couple people that came last week and left last week.
On 12/14/22 at 2:51 PM, V33 (Corporate Nurse Consultant) brought the surveyor a new Covid-19 Staff Vaccination Matrix which had the total number of staff listed as 115, 1 partially vaccinated staff, and 94 completely vaccinated staff and 20 granted exemptions. V33 stated, I had to tally up to see what who was on the tracker and who was missing on the list of staff on the payroll lines, and it came up that the wound treatment nurse was not on there. She just started Monday. V33 stated that the Covid-19 vaccination trackers for both staff and residents should be updated weekly.
Upon review of the staff vaccination binder which contained copies of staff vaccination cards and exemptions, the surveyor counted 16 religious exemptions. Three staff members [V40 (former LPN/Licensed Practical Nurse), V41 (Receptionist) and V42 (Laundry Aide)] were not listed on the Covid Vaccination Tracker Staff.
On 12/14/22 at 3:27 PM, V2 stated, (V40) is not here anymore. V2 then confirmed with V1 that V41 and V42 are currently employed at the facility. The surveyor asked V2 to look at the Covid Vaccination Tracker which was provided by V3 to see if those two current staff members are listed. V2 replied, I do not see either on the staff tracker. V2 also verified that not including V40 who no longer works at the facility, there were only 15 staff exemptions while the Covid-19 Staff Vaccination Matrix provided by V33 listed 20 exemptions. The surveyor inquired what is the expectation regarding staff vaccinations, V2 replied, That they would be vaccinated and boosted according to CDC (Centers for Disease Control and Prevention) and IDPH (Illinois Department of Public Health) guidelines unless they have a religious exemption.
The Centers for Medicaid and Medicare Services Revised Guidance for Staff Vaccination Requirements dated 10/26/2022 (Ref: QSO-23-02-ALL) documents, in part,
§483.80 Infection control
§483.80(i) COVID-19 Vaccination of facility staff. The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine.
(1) Regardless of clinical responsibility or resident contact, the policies and procedures must apply to the following facility staff, who provide any care, treatment, or other services for the facility and/or its residents: (i) Facility employees;
(ii) Licensed practitioners;
(iii) Students, trainees, and volunteers; and
(iv) Individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement.
(2) The policies and procedures of this section do not apply to the following facility staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section; and
(ii) Staff who provide support services for the facility that are performed exclusively outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section.
(3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (i)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents;
(ii) A process for ensuring that all staff specified in paragraph (i)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom
COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19;
(iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (i)(1) of this section;
(v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC;
(vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law;
(vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the facility has granted, an exemption from the staff COVID-19 vaccination requirements;
(viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains: (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and
(B) A statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications;
(ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and
(x) Contingency plans for staff who are not fully vaccinated for COVID-19.
Nov 2022
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 respond to a resident's request for assistance in a ti...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to respond to a resident's request for assistance in a timely manner for 2 of 3 residents (R8 and R18) reviewed for call lights in a sample of 27.
Findings include:
1. R18's admission Record documents that R18 was admitted to the facility on [DATE] with diagnoses including acute on chronic diastolic (congestive) heart failure, personal history of transient ischemic attack, cerebral infarction without residual deficits, and lymphedema.
R18's Minimum Data Set (MDS) assessment dated [DATE] documents in section C (Cognitive Patterns) that R18 has a Brief Interview for Mental Status (BIMS) score of 15 indicating that R18 is cognitively intact. Section G (Functional Status) documents that R18 requires total dependence on staff to perform bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Section H (Bladder and Bowel) documents that R18 is always incontinent of urine and bowel.
R18's Care Plan (last reviewed 9/21/22) documents under the section titled Focus that R18 is at risk for falls related to (R/T) diagnosis (DX) of Congestive Heart Failure (CHF), obesity, bilateral lower extremity (BLE) lymphedema, incontinence of bowel and bladder (B&B) and impaired mobility. The CarePlan document's interventions of Be sure the call light is within reach and encourage the resident to use it for assistance as needed. Staff to respond promptly to all requests for assistance.
On 11/18/22 at 3:05 PM, R18 said that it takes the staff over an hour to check on R18 when the call light is turned on. R18 said that she needed someone to change her and said that her undergarment was a little wet. At 3:10 PM, R18 turned the call light on. At 3:39 PM, V7 (Registered Nurse) entered R18's room and R18 requested to be changed. V7 said that she would get an aide to assist R18. At 4:15 PM, V9 (Certified Nurse's Aide) entered R18's room and changed R18's disposable undergarment.
2. R8's admission Record documents that R8 was admitted to the facility on [DATE] with diagnoses including personal history of other malignant neoplasm of bronchus and lung, rheumatoid arthritis, history of falling, difficulty in walking, Chronic Obstructive Pulmonary Disease (COPD) with exacerbation, glaucoma, lack of coordination, and abnormalities of gait and mobility.
R8's MDS assessment dated [DATE] documents in section C (Cognitive patterns) that R8 has a BIMS score of 14 indicating that R8 is cognitively intact. Section G (Functional Status) documents that R8 requires total dependence on staff to perform transfers and extensive assistance for bed mobility, dressing, and personal hygiene. Section H (Bladder and Bowel) documents that R8 is always incontinent of urine and bowel.
R8's Care Plan (last care plan review dated 10/25/22) documents under the section titled Focus that R8 is at risk for falls related to diagnosis of Rheumatoid Arthritis (RA), incontinence of bowel and bladder, and generalized weakness. The CarePlan documents an intervention of Be sure call light is within reach and encourage the resident to use it for assistance as needed. Staff to respond promptly to all requests for assistance.
On 11/18/22 at 3:55 PM, R8 said that it takes an hour or more for the staff to answer R8's call light. V25 (family member) said that they have been at the facility visiting R8 and it has taken the staff over an hour before anyone will come in and answer R8's call light. V25 said that R8 had an appointment, and it took the staff over an hour to transfer R8 from the wheelchair to the bed after R8 returned to the facility from the appointment. V25 said that R8 is very weak and is not used to sitting up for that long.
The facility policy titled Call Light (undated) documents under the section titled Policy that all call lights will be answered by staff within a reasonable amount of time, depending on the task required. Staff will carry out the required task according to staff scope of practice.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect a resident from physical abuse from occurring for 1 of 6 (R4...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect a resident from physical abuse from occurring for 1 of 6 (R4) residents reviewed for abuse in the sample of 26.
Findings included:
On 10/14/2022, V2 (Assistant Administrator) notified the Illinois Department of Public Health of a reportable incident of a physical altercation that occurred on 10/10/2022 between R3 and R4. The report documented on 10/10/2022 at 5:30am, R3 had a physical altercation with R4 after R3 discovered R4 had removed R3's property from R3's dresser and placed them into R4's dresser. R3 asked for his belongings back, but R4 denied having R3's property. R3 became angry and struck R4 over the head with a wooden chair. R4 was injured, received treatment from the local emergency room and received 5 staples to his scalp as a result. The report showed V6 (Certified Nursing Assistant/CNA/Scheduler) had entered the room and witnessed R3 was striking R4 with the chair. The report documented V6 separated R3 and R4 and both received medical treatment at the local emergency room. R4 received medical treatment and R3 received psychiatric treatment.
According to R3's MDS (Minimum Data Set) dated 9/22/2022, R3 was assessed by the facility using a BIMS (Brief Interview for Mental Status) score in which R3 scored a 14 out of a possible 15. BIMS score of 14 out of 15 indicates R3 as cognitively intact. According to R4's MDS dated [DATE], R4 was assessed by the facility using the BIMS and scored a 9 out of 15, which indicates R4 has moderately impaired cognition.
On 11/18/2022 at 4:00pm, V2 (Assistant Administrator) said she and/or V1 (Administrator) investigate all incidents of abuse and together determine if abuse occurred. V2 said on 10/10/2022 at 5:30am, R3 became angry at R4 and physically assaulted R4 by hitting R4 over the head with a wooden chair and caused severe physical injury to R4, but the assault was not considered physical abuse of R4 and thus abuse was not substantiated at the conclusion of their investigation. V2 said R3 and R4 had a misunderstanding and were able to work things out and since have not had any further altercations. V2 said both R3 and R4 should have been arrested for their actions on 10/10/2022, but neither R3 nor R4 wanted the police to get involved and so the physical assault on R4 was not reported to the local police. V2 said the local police were not notified because both R3 and R4 said they feared being arrested and sent to jail and specifically requested the incident not be reported. V2 verified V6 (CNA/Certified Nursing Assistant/Scheduler) and V8 (Registered Nurse) were the staff on duty at the time R4 assaulted R3.
A written statement from V6 was documented by V2 during the facility's investigation of the alleged physical abuse. This written statement, dated 10/10/2022 at 5:30am, documented the following: (V6) stated he heard two residents (R3 and R4) yelling. He ran down the hall to the room and stated he immediately separated the residents and conducted a room change. (V6) spoke with the nurse (V8/Registered Nurse) to assist with the residents.
A Progress note entered into R4's medical record on 10/10/2022 at 5:20am by V8 (Registered Nurse), documented the following: Patient had altercation with roommate, he (R4) took his roommate's phone and refused to give it back, roommate asked for his phone back, then there is a physical (altercation), called sister but unable to leave a voice message, refused vitals, continue to monitor.
A Progress note entered into R4's medical record on 10/10/2022 at 9:20am by V2(Assistant Administrator) documented the following in part, Resident (R4) alert and oriented x (times) 2. Resident (R4) is a [AGE] year old Caucasian male with a dx (Diagnosis) of Major Depressive Disorder, Schizoaffective Disorder. Resident (R3) has a BIMS of 9 out of 15 Staff notified administration, DON (Director of Nursing), and family. Resident (R4) denied police involvement.
A progress note entered into R4's medical record on 10/10/2022 at 12:00pm by V28 (Licensed Practical Nurse/LPN) documented the following, Pt (Patient/R4) returned from (Local Hospital name) in wheelchair with 1 attendant. Pt (Patient) stable, no c/o (complaints of) pain. A/O (Alert and Oriented) x (times) 3. Able to make all needs known. Pt (Patient) has 5 staples to right top of head. No bleeding noted, open to air. Has instructions to follow up with primary MD (Medical Doctor) or the referred MD (emergency room doctor) within 10-12 days for staple removal.
A Progress noted entered into R3's medical record on 10/10/2022 at 11:10am by V28 (LPN) documented the following, Pt (Patient/R3) got into a physical altercation with another resident this morning where a chair was used to caused bodily injury to the other pt. (patient). MD (Medical Doctor) was notified and orders to send pt. (patient) to (local hospital name). Petition and all paper is sent with pt. (patient). All department heads notified, and sister and emergency contact notified and made aware. (Local Ambulance Service name) called with ETA (estimated time of arrival) of 60 minutes. Pt (Patient) made aware of transfer.
On 11/18/2022 at 6:00pm, R3 said he was angry when R4 stole his stuff. R3 said he intended to hurt R4 when he hit him with the wooden chair. R3 said he did not want the police involved and he did not want to go back to jail.
On 11/18/2022 at 5:30pm, R4 said he was hit over the head with a chair by R3 and had to get his head fixed up at the hospital with 5 staples. R3 said his head wound was all healed up, long ago. R4 said he did not want the police called because he was afraid of being arrested for stealing R3's phone.
A facility policy titled Abuse Prevention Program, Facility Policy and Procedure with the most recent revision date of 1/4/2019, documented the following, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately. This facility policy also documents the following, Informing Local Law Enforcement. The facility shall also contact local law enforcement authorities in the following situations: Suspected physical abuse involving physical injury inflicted on a resident by another resident except in situation where the behavior is associated with dementia or developmental disability.
On 11/18/2022 at 3:00pm, V3 (Director of Nursing) verified neither R3 nor R4 have been diagnosed with Dementia or Developmental Disabilities and did not know why the local police where not notified of R3 being physically assaulted on 10/10/2022.
R4's medical records under the diagnosis section lists the following diagnosis for R3: Chronic Obstructive Pulmonary Disease, Hypertension, Diabetes type 2, Cellulitis of Right Lower limb, Hypokalemia, Gastro-Esophageal Reflux, Major Depressive Disorder, Unspecified Convulsions, Schizoaffective Disorder, Insomnia, Muscle weakness, Unsteadiness on feet, Hypoxemia, Abdominal Hernia.
R3's medical records under the diagnosis section lists the following diagnosis for R4: Seizures, Personal History of Traumatic Brain Injury, Schizophrenia, Depressive Episodes, Unsteadiness on feet, Weakness, Abnormalities of Gait and Mobility, Muscle Weakness, Anemia, Fracture of Right Mandible with routine healing.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow its Abuse Policy by not notify local authorities of an occurr...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow its Abuse Policy by not notify local authorities of an occurrence of physical abuse for 1 of 6 residents (R3) reviewed for abuse in the sample of 26.
On 10/14/2022, V2 (Assistant Administrator) notified the Illinois Department of Public Health of a reportable incident of a physical altercation that occurred on 10/10/2022 between R3 and R4. The report documented on 10/10/2022 at 5:30am, R4 had a physical altercation with R3 after R4 discovered R3 had removed R4's property from R4's dresser and placed them into R3's dresser. R4 asked for his belongings back, but R3 denied having R4's property. R4 became angered and struck R3 over the head with a wooden chair. R3 was injured, received treatment from the local emergency room and received 5 staples to his scalp as a result. The report showed V6 (Certified Nursing Assistant/CNA/Scheduler) had entered the room and witnessed R4 was striking R3 with the chair. The report documented V6 separated R3 and R4 and both received medical treatment at the local emergency room. R3 received medical treatment and R4 received psychiatric treatment. According to R4's MDS (Minimum Data Set) dated 9/22/2022, R4 was assessed by the facility using a BIMS (Brief Interview for Mental Status) score in which R4 scored a 14 out of a possible 15. A BIMS score of 14 out of 15 indicates R4 as cognitively intact. According to R3's MDS dated [DATE], R3 was assessed by the facility using the BIMS and scored a 9 out of 15, which indicates R3 has moderately impaired cognition.
On 11/18/2022 at 4:00pm, V2 (Assistant Administrator) said she and/or V1 (Administrator) investigate all incidents of abuse and together determine if abuse occurred. V2 said on 10/10/2022 at 5:30am, R4 became angry at R3 and physically assaulted R3 by hitting R3 over the head with a wooden chair and caused severe physical injury to R3. V2 said both R3 and R4 should have been arrested for their actions on 10/10/2022, but neither R3 nor R4 wanted the police to get involved and so the physical assault on R3 was not reported to the local police.
A facility policy titled Abuse Prevention Program, Facility Policy and Procedure with the most recent revision date of 1/4/2019, documented the following, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately. This facility policy also documents the following, Informing Local Law Enforcement. The facility shall also contact local law enforcement authorities in the following situations: Suspected physical abuse involving physical injury inflicted on a resident by another resident except in situation where the behavior is associated with dementia or developmental disability.
On 10/18/2022 at 3:00pm, V3 (Director of Nursing) verified neither R3 nor R4 have been diagnosed with Dementia or Developmental Disabilities and did not know why the local police where not notified of R3 being physically assaulted on 10/10/2022.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an instance of physical abuse of a resident to the local poli...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an instance of physical abuse of a resident to the local police for 1 of 6 residents (R4) reviewed for abuse in the sample of 26.
Findings included:
On 10/14/2022, V2 (Assistant Administrator) notified the Illinois Department of Public Health of a reportable incident of a physical altercation that occurred on 10/10/2022 between R3 and R4. The report documented on 10/10/2022 at 5:30am, R3 had a physical altercation with R4 after R3 discovered R4 had removed R3's property from R3's dresser and placed them into R4's dresser. R3 asked for his belongings back, but R4 denied having R3's property. R3 became angry and struck R4 over the head with a wooden chair. R4 was injured, received treatment from the local emergency room and received 5 staples to his scalp as a result. The report showed V6 (Certified Nursing Assistant/CNA/Scheduler) had entered the room and witnessed R3 was striking R4 with the chair. The report documented V6 separated R3 and R4 and both received treatment at the local emergency room. R4 received medical treatment and R3 received psychiatric treatment.
According to R3's MDS (Minimum Data Set) dated 9/22/2022, R3 was assessed by the facility using a BIMS (Brief Interview for Mental Status) score in which R3 scored a 14 out of a possible 15. A BIMS score of 14 out of 15 indicates R3 as cognitively intact.
According to R4's MDS dated [DATE], R4 was assessed by the facility using the BIMS and scored a 9 out of 15, which indicates R4 has moderately impaired cognition.
On 10/18/2022 at 6:00pm, R3 said he was angry when R4 stole his stuff and would not return the missing items. R3 said R4 was messing around in his dresser and was stealing his things, including his phone. R3 said he intended to hurt R4 when he hit him with the wooden chair. R3 said he did not want the police involved because he did not want to go to jail.
On 10/18/2022 at 5:30pm, R4 said he was hit over the head with a chair by R3 and had to get his head fixed up at the hospital with 5 staples. R4 said he did not want the police called because he was afraid of being arrested for stealing R3's phone.
On 11/18/2022 at 4:00pm, V2 (Assistant Administrator) said she and/or V1 (Administrator) investigate all incidents of abuse at this facility. V2 said on 10/10/2022 at 5:30am, R3 became angry at R4 and physically assaulted R4 by hitting R4 over the head with a wooden chair and caused severe physical injury to R4 which required emergency medical treatment at the local hospital. V2 said both R3 and R4 should have been arrested for their actions on 10/10/2022, but neither R3 nor R4 wanted the police to get involved and so the physical assault on R4 was not reported to the local police by the facility's administrative staff.
A facility policy titled Abuse Prevention Program, Facility Policy and Procedure with the most recent revision date of 1/4/2019, documented the following, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately. This facility policy also documents the following, Informing Local Law Enforcement. The facility shall also contact local law enforcement authorities in the following situations: Suspected physical abuse involving physical injury inflicted on a resident by another resident except in situation where the behavior is associated with dementia or developmental disability.
On 10/18/2022 at 3:00pm, V3 (Director of Nursing) verified neither R3 nor R4 have been diagnosed with Dementia or Developmental Disabilities and did not know why the local police where not notified of R3 being physically assaulted on 10/10/2022 at 5:30am by R4.
R4's medical records under the diagnosis section lists the following diagnosis for R3: Chronic Obstructive Pulmonary Disease, Hypertension, Diabetes type 2, Cellulitis of Right Lower limb, Hypokalemia, Gastro-Esophageal Reflux, Major Depressive Disorder, Unspecified Convulsions, Schizoaffective Disorder, Insomnia, Muscle weakness, Unsteadiness on feet, Hypoxemia, Abdominal Hernia.
R3's medical records under the diagnosis section lists the following diagnosis for R4: Seizures, Personal History of Traumatic Brain Injury, Schizophrenia, Depressive Episodes, Unsteadiness on feet, Weakness, Abnormalities of Gait and Mobility, Muscle Weakness, Anemia, Fracture of Right Mandible with routine healing.
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 observation, interview and record review, the facility failed to respond to a resident's request for assistance in a ti...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to respond to a resident's request for assistance in a timely manner for 1 of 3 residents (R10) reviewed for call lights in a sample of 27.
Findings include:
R10 is a [AGE] year old year old female with diagnosis including: bipolar disorder, drug induced subacute Dyskinesia, Anxiety Disorder, personal history of Covid-19.
On 11/18/22 at 4:05 PM R10 was heard yelling from the end of the hall. When surveyor went to the room to ask if she was ok, R10 stated she wanted food, it was initially thought that she stated she wanted moved. After V7 (Certified Nurse Aide) and V14 (Certified Nurse Aide) walked by her room and did not stop in, this surveyor went to the nurse's station to tell them R10 would like moved. At 4:15 PM V14 (Certified Nurse Aide) stated, R10 did not want repositioned, he just checked on her. At 4:17 PM R10 stated, she wanted food. At 4:18 PM this surveyor went back to the nurse's station and told V10 (Registered Nurse (RN)) that she misunderstood and R10 wanted food. V10 (RN) said, OK, she does yell a lot.
On 11/18/22 between 4:05 PM and 5:27 PM R10 could be heard yelling that she wanted dinner down the hall and at the nurse's station.
On 11/18/22 at 5:00 PM V7 (RN) stated to R10, you don't get your tray now. You know you do not eat until later.
On 11/18/22 at 5:02 PM V7 (RN) stated, she (R10) knows she does not eat until last; the feeders do not get their tray until everyone else has been given theirs, she (R10) knows that.
On 11/18/22 at 5:05 PM R27 stated, R10 has been yelling louder since she received her food because she knows that she has food and R10 doesn't, it makes her feel bad that she is eating and R10 is hungry and yelling for food. R27 asked if surveyor could help R10 and get her dinner.
On 11/18/22 at 5:15 PM R10 stated, she was hungry, she wanted dinner. At 5:15 PM R10's dinner still had not arrived.
On 11/18/22 at 5:35 PM V9 (Certified Nurse Aide) arrived with R10's food and assisted her to eat.
On 11/18/22 at 6:05 PM R10 was laying in her bed, no signs or symptoms of distress noted. R10 was not yelling out for anything.
On 11/18/22 at 6:55 PM R10 was laying in her bed, no signs or symptoms of distress noted. R10 was not yelling out for anything.
On 11/19/22 at 7:25 AM R10 was laying in her bed, no signs or symptoms of distress noted. R10 was not yelling out for anything.
On 11/19/22 at 8:44 AM R10 can be heard yelling down the hall that she wants breakfast. R10 was asked (by surveyor) if she could turn on her call light. R10 pulled the string for the call light and was unable to activate the call light. The call light switch was observed and noted that the switch is a toggle switch that activates in a vertical motion, R10's bed is horizontal with the wall the call light toggle switch is located, the toggle switch is approximately 5 feet from where R10 pulls the string to activate the call light, which pulls horizontally on a vertical switch, thus not activating the call light.
On 11/19/22 at 8:50 AM R10 is still yelling for breakfast.
On 11/19/22 at 8:55 AM V27 (Activities Director) stated, she is currently the manager on duty. V27 (Activities Director) stated, she does not know why if R10 is supposed to be encouraged to eat more, why they do not assist her at a different time since she is yelling for breakfast and has been for a bit. They (the staff) are doing the best they can.
R10's Progress note on 11/10/2022 documents: Note Text: WT: 115 pounds, down 8.3% x 3 months. weight continues to decline each month, down 2 pounds since last month. Diet order: pureed, with double portions of meat/eggs with meal. Supplement: house supplement bid and protein powder 1 scoop bid (twice a day). Po (oral) intake is poor per staff reports. She continues on Hospice care.
R10's Progress note on 11/4/2022 at 1:44 PM documents -10.0% change (Comparison Weight 9/24/2022, 134.0 ponds, -13.9%, -18.6 pounds).
R10's Care Plan on 10/10/2022 documents: Significant Change 10-17-22: R10 is at risk for compromised nutritional status related to: Major depressive resulting in loss of appetite or refuse to eat at times. Weight loss 12% x 1 month, significant weight change x 1 month BMI (Body Mass Index) is 18.4 denoting underweight. R10 has impaired skin with a supplement in place. R10 has a mechanical altered diet (puree) due to swallowing difficulty. With an intervention listed as: Provide cueing, encouragement, one-to-one staff intervention and attention as indicated to promote consumption of the meal, with a date Initiated of 10/20/2022.
R10's Minimum Data Set (MDS) dated [DATE] documents: R10's Brief Interview of Mental Status (BIMS) as 06 indicating cognition is severely impaired. Section E documents: Behaviors as No to overall presence of behaviors. Section G documents under eating: total dependence as resident's ability to feed herself with a physical assist of one individual.
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 F0923
(Tag F0923)
Could have caused harm · This affected most or all residents
Based on interview, observation and record review the facility failed to maintain functioning ventilation equipment for the shower rooms. This has the potential to affect all 188 residents residing in...
Read full inspector narrative →
Based on interview, observation and record review the facility failed to maintain functioning ventilation equipment for the shower rooms. This has the potential to affect all 188 residents residing in the facility.
On 11/19/22 at 7:45 AM V12 (Social Services/PRSC) stated, she does not know why the exhaust fan in the shower rooms does not work or when they are supposed to get it fixed. Different residents have told her about it before and she passed the information on.
On 11/18/22 at 3:15 PM R5 stated, the exhaust fans in the shower rooms do not work. It will get so steamy in there that you cannot even dry off.
On 11/18/22 at 12:10 PM R16 stated the exhaust fans in the shower room do not work, it does get steamy in there.
On 11/18/22 at 4:55 PM the exhaust fans in the shower room on the 3rd floor were observed, the fans did not come on.
On 11/19/22 at 7:30 AM the exhaust fans in the shower room on the 2nd floor were checked to see if they turned on and they did not.
On 11/19/22 at 7:25 AM the exhaust fans in the shower room on the 1st floor were checked to see if they worked and they did not work.
On 10/04/22 the resident council minutes document: Residents express to maintain upkeep of shower rooms.
The facility policy dated 01/22 titled, Preventative Maintenance documents: Protocol: to conduct environmental tours/safety audits of the facility .
The Resident List Report dated 11/18/22 documents 188 residents residing at the facility.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "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: Federal abuse finding, 10 life-threatening violation(s), Special Focus Facility, 18 harm violation(s), $597,937 in fines, Payment denial on record. Review inspection reports carefully.
- • 131 deficiencies on record, including 10 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $597,937 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
✓ Report will be sent to your email
About This Facility
What is Chicago Ridge Snf's CMS Rating?
CMS assigns CHICAGO RIDGE SNF 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 Chicago Ridge Snf Staffed?
CMS rates CHICAGO RIDGE SNF's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 52%, compared to the Illinois average of 46%.
What Have Inspectors Found at Chicago Ridge Snf?
State health inspectors documented 131 deficiencies at CHICAGO RIDGE SNF during 2022 to 2025. These included: 10 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 18 that caused actual resident harm, 102 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Chicago Ridge Snf?
CHICAGO RIDGE SNF 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 SABA HEALTHCARE, a chain that manages multiple nursing homes. With 231 certified beds and approximately 205 residents (about 89% occupancy), it is a large facility located in CHICAGO RIDGE, Illinois.
How Does Chicago Ridge Snf Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, CHICAGO RIDGE SNF's overall rating (1 stars) is below the state average of 2.5, staff turnover (52%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Chicago Ridge Snf?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Chicago Ridge Snf Safe?
Based on CMS inspection data, CHICAGO RIDGE SNF has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 10 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Chicago Ridge Snf Stick Around?
CHICAGO RIDGE SNF has a staff turnover rate of 52%, which is 6 percentage points above the Illinois average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Chicago Ridge Snf Ever Fined?
CHICAGO RIDGE SNF has been fined $597,937 across 4 penalty actions. This is 15.3x the Illinois average of $39,058. 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 Chicago Ridge Snf on Any Federal Watch List?
CHICAGO RIDGE SNF is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.