ALIYA ON 87TH
For profit - Limited Liability company
210 Beds
ALIYA HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#314 of 665 in IL
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Aliya on 87th has received a Trust Grade of F, indicating poor performance with significant concerns about care quality. It ranks #314 out of 665 facilities in Illinois, placing it in the top half, but this is still a concerning position. The facility is showing an improving trend, with issues decreasing from 29 in 2024 to 17 in 2025, but it still has serious problems. Staffing is a weakness, rated at just 1 out of 5 stars with a turnover rate of 57%, which is higher than the state average. Additionally, there were alarming incidents, including a critical failure to provide necessary feeding assistance to a resident, leading to that resident's death, and serious lapses in medication administration that resulted in dangerously high blood glucose levels for another resident. Overall, while there are some signs of improvement, the facility has serious deficiencies that families should consider carefully.
- Trust Score
- F
- In Illinois
- #314/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 57% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $231,981 in fines. Higher than 71% of Illinois facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 75 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Top 47%
Review needed
29 → 17 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 29 issues
2025: 17 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Illinois average (2.5)
Below average - review inspection findings carefully
Staff Turnover: 57%
11pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $231,981
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: ALIYA HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (57%)
9 points above Illinois average of 48%
The Ugly 75 deficiencies on record
1 life-threatening 6 actual harm
May 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
Based on record review and interview the facility failed to follow their abuse policy for two residents (R1,R2,) out of four residents reviewed for abuse. This failure resulted in staff members not im...
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Based on record review and interview the facility failed to follow their abuse policy for two residents (R1,R2,) out of four residents reviewed for abuse. This failure resulted in staff members not immediately intervening in a situation where residents became abusive to each other. Staff did not intervene in time resulting in R1 and R2 engaging in a physical altercation that lead to them both putting scratches/abrasions on each other's faces.
Finding Include:
R1's wound assessment sheet dated 4/25/25 reads upon assessment writer noted skin alteration to face. Classification abrasion. Doctor made aware , staff to continue to monitor.
R1s Nursing Note 4/25/2025 08:35 reads: was notified of the situation that occurred and will notify the rest of her family. MD has also been notified.MD wants wound care to evaluate and treat. Resident does not need to go out to the hospital at this time. Resident was separated and in stable condition. No c/o(complaints of) pain or discomfort at this time. First aid applied.
R2's wound assessment sheet dated 4/25/25 reads upon assessment writer noted skin alteration to face. Classification abrasion. Doctor made aware , staff to continue to monitor.
R2'S Nursing Note4/25/2025 15:42 reads: MD wants wound care to evaluate and treat. Resident does not need to go out to the hospital at this time. Resident was separated and in stable condition. No c/o pain or discomfort noted. First aid applied.
On 5/6/25 at 10:45 am V3 (Certified Nurse Aide) stated she was sitting at the nurses station and saw R1 wandering down the hall and redirected her to sit down in the hallway by the nurses station. V3 stated R2 rolled to where R1 was sitting and heard them talking and heard R1 tell R2 to move her hand away. V3 stated as she was getting up from the nurses station when R1 stood up over R2 then they started wailing their hands at each other. V3 stated she separated them both and the nurse (V6) came and assessed them. V3 stated after they were separatedshe noticed scratches on both of their faces.
On 5/7/25 at 10:10 amV6 (Licensed Practical Nurse) stated she was getting off the elevator and saw R1 and R2 wailing their arms at each other while V3 was separating them. V6 stated they separated them and took them to their rooms. V3 stated she noted after assessing R1 and R2 they both had small scratches on their face. V3 stated she gave them first aide by cleaning the scratches with normal saline. V3 stated she has worked on the Dementia unit for five years. V3 stated R1 had been on that unit for about a year and a half, while R2 had lived up there for about three years. V3 stated she has never witnessed them getting into an altercation before like the one she had witnessed.
V2 (Wound Nurse) stated on 5/6/25 at 11:15 am stated she was told by V6 to look at R1 and R2 faces because they had gotten into a little scuffle. V2 stated noticed R1 had two small superficial scratches/abrasions under her right eye and that R2 had a small scratches/abrasions on her top lip . V2 stated neither needed extensive treatment only they were cleaned and monitored for any signs of an infection. V2 stated since the incident both resident scratches/abrasions have healed.
Facility's abuse policy reads the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse; corporal punishment; and involuntary seclusion. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.
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 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 notify a resident's responsible party about a room ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to notify a resident's responsible party about a room change prior to being moved to a new room on a different unit within the facility. This affected one (R1) of one resident reviewed for resident rights.
Findings include:
R1 was initially admitted to 1st floor nursing unit on 12/03/24 and has diagnosis which includes but not limited to Neurocognitive Disorder with Lewy Bodies, Type 2 Diabetes Mellitus, Cerebral Infarction, Personal History of Transient Ischemic Attack, Unspecified Dementia With Other Behavioral Disturbance, Age-Related Osteoporosis, Unspecified Severe Protein Calorie Malnutrition, Difficulty Walking, Lack of Coordination, Dysphasia, Generalized Anxiety, Unspecified Psychosis.
R1's MDS (Minimum Data Set) assessment dated [DATE] documents in part, resident is rarely/never understood. BIMS (Brief Interview for Mental Status) was not able to be conducted.
R1's electronic health record (EHR) lists R1's daughter, V16 as R1's Power of Attorney.
Per R1's EHR's Census List indicates R1's room was change from the 1st floor to the 2nd floor on 04/07/25. A nursing note on 04/07/25 time stamped 14:48 documented in part, received resident at 2:30 PM from the first floor . Upon initial review of R1's EHR on 04/15/25 there was no documentation in R1's record indicating R1's POA was notified about the room change and/or the reason for the room change. Upon later review of R1's EHR V13 (Social Service Coordinator) entered a late entry progress note time stamped 04/15/25, 14:45:38 backdated to 04/07/25, 19:20:00 which documented in part, this worker informed daughter (V16) due to dementia dx (diagnosis) and by (R1) being considered a long-term resident, is the reason why (R1) was moved to the 2nd floor .
On 04/16/25 at 11:46 AM, via phone interview V16 (R1's Power of Attorney) stated she did not receive any notification either verbally or in writing about R1 being moved from the 1st floor to the 2nd floor. V16 stated she found out about the move when another family member came to visit R1 on 04/07/25 around 4:30 PM and the family member could not find R1 on the 1st floor. V16 stated the residents in the 1st floor day room are the ones who informed the family member that R1 had been transferred to a different unit, not the staff. V16 stated on that same day (04/07/25) she had called the facility around 3:15 PM to get an update on her mom (R1) and the nurse did not mention anything about R1 being moved to a different unit. V16 stated they transferred my mother (R1) to a new floor, and V16 received no notification about the change which is why V16 knew nothing about it. V16 stated the 2nd floor is a dementia unit and if the facility had notified her about their decision to change R1 to the dementia unit before it happened, she (V16) would have had the opportunity to express her concerns so the facility could understand her reasoning for why she preferred R1 to stay on the 1st floor. V16 stated they could have a discussion about it, but the facility made the move without even notifying her (V16) before they moved R1.
On 04/15/25 at 3:20 PM, V13 (Social Service Coordinator) stated the resident's family/POA/guardian are notified when a resident will be transferred to a different room or unit and this notification is documented in the resident's EHR in a progress note section by a social service staff member. V13 stated the facility can let the family know about the transfer the day before and/or the day of but the family/POA must be notified prior to when the transfer occurs. V13 stated the only time they do not notify the family is if the resident is responsible for themselves, and/or they do not have a Power of Attorney or guardian. V13 stated it is important to notify the POA/guardian about the room change so the family/POA/guardian is aware of the change. V13 stated on 04/07/25 in the afternoon, R1's family member came in to visit R1 and by that time R1 had already been transferred to the 2nd floor. V13 stated R1's family member who was visiting then called V16 (R1's POA) and then V16 called V13. V13 stated V16 was upset that R1 was transferred to the 2nd floor but V13 stated she had educated them when R1 was initially admitted that the 1st floor was not for long-term placement so V13 felt the family knew this transfer was coming eventually even if they did not know the specific day/time it was going to happen. V13 stated notification of the transfer was not addressed prior to the change happening.
On 04/16/25 at 10:00 AM, V14 (Social Service Director) stated we normally figure out the room/unit the resident will be transferred to and then we notify the POA/guardian/next of kin verbally by telephone before the transfer occurs and we also notify them in writing by giving them a form called Notification of Room Change form. V14 stated the Notification of Room Change form specifies the date the notification was given and the reason for the room change. V14 stated it is important that the facility notify the POA/guardian ahead of the move when a change is going to be made so that they are aware that their loved one is going to be moved.
On 04/17/25 at 9:10 AM, V2 (Director of Nursing) stated a resident's POA/guardian or responsive party should be notified verbally prior to the transfer and written documentation can be provided later when the POA/guardian is in the building. V2 stated it is important that they are notified ahead of time so they know where their loved one will be located before they come to visit the resident, so they know where to find them. V2 stated this is a resident's right and they should be provided with an explanation of why the transfer will be happening. V2 stated notification should be documented somewhere in the EHR about the verbal notification to the resident's responsible party about the pending transfer. V2 stated all documentation should be done in the EHR, the facility does not keep paper records and therefore, if it is not in the EHR there is no proof that it was done.
On 04/17/25 at 12:59 PM, V1 (Administrator) stated for any resident getting transferred to a different room the POA/guardian should be notified before the transfer/change happens. V1 stated that is part of resident rights. V1 stated the notification can be done verbally in which case the conversation should be documented in the progress note section to prove that it happened. V1 stated if it is not documented in the resident's EHR there is no proof that it happened. V1 stated it was an oversight that R1's POA was not called ahead of time and V13 should not be backdating information in the progress notes. V1 stated it is his expectation that she (V13) enters the information in EHR when it occurs.
R1's Notification of Room/Roommate Change form dated 04/07/25, 12:44 is blank for the section on notification for the name of the resident/resident's representative notified, date written notification provided and reason for change.
Facility provided policy titled, Room Change/Transfer within Facility dated 01/2025 documents in part, to assure the resident and/or their representatives are appropriately notified of room transfers, when a resident is being moved to a new room at the request of the facility, the residents, family or resident representative shall receive an explanation in writing of why the move is required.
Facility provided document titled, Illinois Long-Term Care Residents' Rights for People in Long-Term Care Facilities documents in part, you have the right to be told in advance and in writing if your room is being changed and you have the right to receive notice, including the reason for the change before your room or roommate in the facility is changed.
Jan 2025
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record interview, the facility failed to follow their own policy of getting a physician' or...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record interview, the facility failed to follow their own policy of getting a physician' order and completing a care plan when initiating resident self-administration of medication. This failure affected 1 (R53) resident reviewed for self-administration of medication and has the potential to affect all residents on the 3rd floor.
Findings include:
The (01/05/2024) facility census documented that there were 72 residents on the 3rd floor.
On 01/05/25 at 10:52 AM with V10 (Restorative Director), there was a container of Nystatin Powder on top of R53's nightstand. R53 stated I have a rash at the back of my thigh. Nobody taught me how to apply the medication. Somebody is doing it for me. This surveyor requested V10 to read the label on the container and stated this is Nystatin Powder. It has to be applied every morning and at bedtime. V10 shook the container and stated there is still some powder inside the container.
On 01/05/25 at 10:55 AM outside of R53's room, V10 stated there should be no medication on his bedside because no medication should be left at bedside. He (R53) is not supposed to self-administer, it can be a hazard to him and to other residents who may come into his room.
On 01/06/2025 at 10:18am, V2 (Director of Nursing) stated we cannot let the resident self-administer a medication without a doctor's order. It is a hazard to the resident and to anyone who are capable to go inside the room of the resident.
On 01/07/2025 at 2:00pm, this surveyor handed to V2 R53's 1/6/2025 8-page Order Summary Report and requested to check if an order to may self-administer Nystatin was obtained. V2 stated no, I did not see the order to may self-administer Nystatin.
On 01/07/2025 at 2:02pm, this surveyor handed R53's Self Administration of Medication assessment dated [DATE] and R53's 1/06/2025 self-administration of medication care plan to V2 and inquired the expectation for care planning R53's self-administration of medication. V2 reviewed the documents and stated care plan was not completed in a timely manner. I am sure if the resident is assessed on 11/20/2024, the care plan should be in place in 14-days, on the 4th of December 2024.
R53's (10/01/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating R53's mental status as cognitively intact. Section M. Skin conditions. M1200 Skin Treatment. H. Application of ointments/medications.
R53's (Active Order as Of: 01/06/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) essential hypertension, type 2 diabetes mellitus, and contact dermatitis. Order summary: Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to affected area on Back topically every morning and at bedtime for MAD (Moisture Associated Dermatitis) Fungal Rash Apply Zinc oxide to area then sprinkle powder over area after cleanse with NSS or mild soap/water. Order Date: 08/04/2024. Of note, there was no order to may self-administer this medication. The 8-page 01/06/2025 Order Summary Report was reviewed with no order to may self-administer medication/s.
R53's (Active Order as Of: 01/07/2025) Order Summary Report documented, in part Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to affected area on Back topically every morning and at bedtime for MAD Fungal Rash unsupervised self-administration Apply Zinc oxide to area then sprinkle powder over area after cleanse with NSS or mild soap/water. Order Date: 08/04/2024.
R53's (11/20/2024) Self-Administration of Medication documented, in part 1. Based on the answers, is it appropriate for the resident to self-administer any medications? B. Yes. 1a.
R53's (01/06/2025) care plan documented, in part Focus: able to self-administer medication (Nystatin Powder. Goal: will administer medication appropriately. Interventions: MD ordered (sic) obtained for resident to self-administer. Of note, there was no doctor's order to may self administer this treatment as of 01/06/2025.
The (1/2024) Self administration of medications and treatments Documented, in part General: Self administration of medications and treatments are done to prepare a resident for discharge and to help the resident maintain their independence. The decision for self administration is done by the interdisciplinary team. Guideline: 1. Self administration of medications and treatments is determined by an order after determining that the resident is able to self administer. Procedure: 1 if it is determined by a member of the interdisciplinary team, or if the resident requests to self administer, it is documented in the chart and the healthcare provider is called for an order to self administer medications, and keep the medications at bedside. 7. A care plan is for resident who self administer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow their abuse prevention policy and failed to report abuse to the state survey agency within required time parameters. This failure af...
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Based on interview and record review, the facility failed to follow their abuse prevention policy and failed to report abuse to the state survey agency within required time parameters. This failure affects 1 resident (R45) in a sample of 74 residents.
Findings include:
R45's admission record documents in part the following diagnosis: right-sided hemiplegia, type 2 diabetes mellitus, unspecified dementia without behavioral disturbance, cerebral infarction.
R45's minimum data set (11/18/2024) documents in part a brief interview of mental status score of 13, indicating that resident is cognitively intact.
On 1/5/2025 at 10:40 AM, R45 was observed lying in bed. Observed bruises to R45's left wrist and inner forearm. R45 stated that the bruises were from the staff handling me (R45) too rough and began to cry. R45 could not name a staff member or a time when this occurred. Additionally, R45 stated that R45's nurse (V40, Registered Nurse) had yelled at him this morning and had threatened him saying if you don't take your fucking medication, I will not help you!.
On 1/5/2025 at 10:50 AM, V1 (Administrator) was notified about the allegation of physical abuse (handling roughly) and mental abuse (yelling/threatening).
On 1/5/2025 at 11:35 PM, V1 stated that V1 had talked to the resident, and that the bruises were from lab draws. V1 stated that V40 (Registered Nurse) was being suspended pending investigation. Surveyor confirmed with V1 that V1's investigation into the allegation of physical abuse determined that the bruising was from lab draws (uncommon places for blood draws).
Record review of the facility's initial report to the state survey agency for the incidence of alleged abuse reported to V1 on 1/5/2024 documents that an allegation of verbal abuse was reported to V1. The allegation of physical abuse (handling roughly) was not included in the initial report.
On 1/7/2025 at 12:21 PM, V1 reviewed the initial report that was sent to the facility regarding R45's allegations. V1 affirmed that the physical abuse was not on the report and stated, remember, I told you that the bruises were from blood draws or from the hospital. V1 affirmed that V1 did complete an investigation into the incident and surveyor inquired to why the allegation of physical abuse was not reported to the state survey agency if an investigation was completed. V1 stated, Oh, I thought by telling you (surveyor) that would be enough. V1 affirmed that V1 would document the details of the investigation and submit the investigation to the state survey agency.
Facility policy titled, ABUSE POLICY AND PREVENTION PROGRAM (dated 10/2022) documents in part, .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish to a resident . 1. Initial reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee shall notify Department of Public Health's regional office immediately by telephone or fax. Public health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRR) was completed prior to resident's admission for one resident R137. This failure...
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Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRR) was completed prior to resident's admission for one resident R137. This failure affects 1 (R137) resident in a sample of 74.
Findings include:
R137 has a diagnosis of but not limited to Hemiplegia and Hemiparesis, Aphasia, Vascular Dementia, Bipolar Disorder, Major Depressive Disorder and Weakness.
R137 has a Brief Interview of Mental Status score of 08.
R137's admission date is 12/07/2021.
On 1/05/2025 surveyor could not find in the facility's electronic records a PASRR for R137.
On 1/6/2025 at 12:20pm V41 (admission Coordinator) stated that R137 was admitted prior to the start of the Maximus program and his information was not submitted to the program. V41 also stated that staff will be coming out soon to complete the Level ll determination than the care plan will be updated with their recommendations.
On 01/06/25 at 1:49 pm V41 stated that they did not have a PASRR for R137 and that they (facility) initiated a new PASRR after the start of the survey on 1/5/2025.
PAS screening with a review date of 1/2024 documents, in part, in accordance with Illinois regulatory standards and recommended practices, this organization requests Level 1 (one) and Level 2 (two, where applicable) Pre-admission Screening documents prior to the individual's arrival at the facility and the screening material should be reviewed as a component of the assessment process and treatment suggestions/recommendations should be identified and appropriately addressed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
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 review the baseline care plan with the resident/resident's represen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review the baseline care plan with the resident/resident's representative and failed to provide a copy of the baseline care plan to the resident/resident's representative. This failure affects 1 resident (R398) in a sample of 74.
Findings include:
Record review of R398's face sheet documents in part the following diagnosis: gout, type 2 diabetes mellitus, end stage renal disease, chronic obstructive pulmonary disease, Alzheimer's disease, heart failure.
Record review of R398's minimum data set (dated 1/7/2024) documents in part a brief interview of mental status (BIMS) summary score of 11, indicating resident is cognitively impaired.
On 1/5/2025 at 11:42 AM, V39 (R398's family member) stated that V39 was upset because we don't really know what's going on. V39 clarified, stating that V39 and R398 were confused about R398's plan of care. R398 and V39 affirmed that R398 has not been provided a copy of R398's baseline care plan or invited to participate in the development of R398's plan of care. V39 stated that R398 was admitted on [DATE].
Record review of R398's progress notes does not indicate that R398's care plan had been reviewed with R398 or V39. Additionally, no documentation was noted of the care plan being given to R398 or V39.
On 1/6/2025 at 11:45 AM, V2 (Director of Nursing) stated that baseline care plan meetings are conducted with the family when it is convenient for them and should be offered within the first 5 days of being admitted . V2 reviewed progress notes and progress notes document that a care plan meeting was offered on 1/6/2025 and scheduled for 1/7/2025. V2 stated that the facility does not document giving a copy of the baseline care plan to residents so they do not have any documentation that R398 got R398's plan of care.
Facility policy titled, Baseline Care Plan dated 1/2023, documents in part, .The baseline care plan will be developed within 48 hours of the residents admission into the facility . The facility will provide the resident AND their representative with a summary of the baseline care plan . [NAME] facilities will provide a copy of the following as a summary of the baseline care plan to the resident and the resident's representative within 5 days of admission to a [NAME] facility .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide a person center care plan focus PASRR (Pre-admission Screening and Resident Reviews) for one resident (R137).
Findings include:
R13...
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Based on interview and record review the facility failed to provide a person center care plan focus PASRR (Pre-admission Screening and Resident Reviews) for one resident (R137).
Findings include:
R137 has a diagnosis of but not limited to Hemiplegia and Hemiparesis, Aphasia, Vascular Dementia, Bipolar Disorder, Major Depressive Disorder and Weakness.
R137 has a Brief Interview of Mental Status score of 08.
R137's admission date is 12/07/2021.
R137's Order Summary Report with active orders as of 1/6/2025 documents, in part, Escitalopram Oxalate oral tablet 5mg daily (Major Depressive Disorder) and Quetiapine Fumarate oral tablet 3 times a day for Bipolar Disorder.
R137's Level I PASRR (Pre-admission Screening and Resident Review) dated 1/5/2025, documents, in part, diagnosis of Major Depression and Bipolar disorder and PASRR Level 1 Determination: Refer for Level ll onsite.
R137's care plan focus-PASRR Level 2 dated 1/5/2025 documents, in part, R137 has been screened by an agency and determined to have persistent mental illness and require LT (long Term Care) placement. Level 2 screening recommendation.
On 1/6/2025 at 12:20pm V41 (admission Coordinator) stated that R137 was admitted prior to the start of the Maximus program and his information was not submitted to the program. V41 also stated that staff will be coming out soon to complete the Level 2 determination than the care plan will be updated with their recommendations. V41 stated care plan was not implemented prior to the start of the survey because R137 was admitted prior to the start of the Maximus program and his information was never submitted.
On 1/08/2025 at 3:47pm via email V4 (Social Service Director) stated yes, PASRR should be completed prior to admission and the care plan is updated once the Level 2 screening is completed.
On 1/8/2025 at 3:54pm via email V2 (Director of Nursing) stated do not have a policy specific for updating the care plan for PASRR.
Comprehensive care plan policy dated 1/2023 documents, in part, the care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental, and psychological needs.
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 ADL care (Activities of Daily Living) to two dependent residents (R137, R176) to maintain grooming and personal hygiene...
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Based on observation, interview and record review the facility failed to provide ADL care (Activities of Daily Living) to two dependent residents (R137, R176) to maintain grooming and personal hygiene. This failure affected two residents (R137, R176) in a sample of 74 residents.
Findings include:
R137 has a diagnosis of but not limited to Hemiplegia and Hemiparesis, Aphasia, Vascular Dementia, and Weakness.
R137 has a Brief Interview of Mental Status score of 08.
R176 has a diagnosis of but not limited to Myopathies, Dysphagia, Hypo-Osmolality and Hyponatremia, Glaucoma, Hypertension, Lack of Coordination and Megaloblastic Anemia.
R176 has a Brief Interview of Mental Status score of 15.
R176's admission date 7/15/2024.
R176 census documents that she has been in her current room (307-1) since 11/06/2024.
On 1/05/2025 at 11:02am surveyor observed R176 with facial hair, and long fingernails on both hands.
On 1/05/2025 at 11:05am R176 stated that she had not had a shower since she's been on this floor, and they (facility staff) offered to shave the hair off her face once, but they never came back to cut it. R176 stated that staff will give her a bed bath, but she has never been in the shower since arriving to this floor. R176 said she would like for it to be cut and her nails to be trimmed. R176 stated that it makes her feel hairy and that this is the most hair she has ever had on her face.
On 1/5/2025 at 11:32am surveyor observed R137's first three fingers on his right hand to be cut but his 4th and 5th fingers the fingernails were long and digging into his hand.
On 1/5/2025 at 11:33am R137 showed me his 4th and 5th fingernails and nodded yes when asked if he would like for them to be cut and if the long nails hurt.
On 1/5/2025 at 12:19pm V16 (Certified Nursing Assistant) stated that resident receives a shower twice a week and nails are cut and trimmed, and shaves (men and women) are offered as needed.
On 1/06/2025 at 9:10am surveyor observed R137's fingernails on his 4th and 5th fingers not to be cut.
On 1/6/2025 at 9:12am surveyor observed R176's fingernails to be long and not trimmed.
On 1/06/2025 at 9:14am R176 stated that she did receive a shower yesterday and her face shaved but they did not cut her fingernails.
On 1/7/2025 at 10:21am surveyor observed R176's fingernails to be long and not trimmed.
On 1/7/2025 at 10:24am V10 (Restorative Director/Licensed Practical Nurse) stated that R176 did receive her shower and her facial hair shaved, but she did not get a chance to cut her nails. V10 stated that the nurses and CNAs can cut the residents fingernails, but she wanted to do it.
On 1/7/2024 at about noon V10 stated that R176's shower days are on Tuesday and Friday and provided shower sheets for R176 that documents showers were given twice a week for December of 2024.
On 1/7/2025 at 12:55pm V2 (Director of Nursing) stated showers are offered twice a week and as needed and nail care should be offered and completed when showers are given. Male and female residents should be offered to be shaved as needed, and they should be shaven if they agree to be shaved.
Point of Care showers/bathing documentation for 12/07/2024 to 1/072025 does not document any showers were given for R176.
R176's care plan focuses for ADL's dated 12/29/2024 documents, in part, R176 requires assist with daily care needs related to generalized weakness and mobility and assist R176 with ADL's.
R137's care plan focuses for ADL's dated 12/26/2024 documents, in part, R137 requires assist with daily care needs related to right side hemiplegia and hemiparesis and assist resident with ADL's and maintain clean and trimmed nails.
Activities of Daily Living policy with a revision date of 5/2024 documents, in part, a program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning and Hygiene: a. resident self-image is maintained, f. showers or baths are scheduled, and assistance is provided when required and Grooming: c. resident's facial hair should be shaved if necessary and appropriate per personal preference.
Nail care policy with a revision date of 1/10/2024 documents, in part, to provide care and maintain hygiene for the resident's nails and nail care is offered and performed on the resident's shower day and as needed.
Undated Certified Nursing Assistant job description documents, in part, to provide assigned residents with routine daily nursing care in accordance with established nursing care procedures, give or assist resident with bathing, shave female residents as needed and keep resident's fingernails clean and trimmed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure the Low Air Loss Mattress were set based on the resident's weight. This failure affected 1 resident (R100) reviewed for...
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Based on observation, interview, and record review the facility failed to ensure the Low Air Loss Mattress were set based on the resident's weight. This failure affected 1 resident (R100) reviewed for pressure ulcer/injury prevention and treatment in a sample of 74 residents.
Findings include:
R100's diagnoses include but not limited to Alzheimer's, Atherosclerotic Heart Disease, hypertension, and chronic kidney disease.
R100's (10/31/24) MDS (Minimal Data Set) documents in part, Section C: Brief Interview of Mental Status (BIMS) score is blank. Section M: Skin Condition 1. Number of Stage 4 pressure ulcer - 1 checked in box.
On 1/5/25 at 10:25 am, R100 was lying on a low air loss mattress with a setting at 300.
R100's monthly weight report documents in part, November 2024 weight 132.4, December 2024 weight 133.6 and January 2025 weight 132.8.
R100's (11/18/24) care plan documented in part, Focus: R100 has a pressure injury R/T (Related/To) self-care deficits impaired mobility and comorbidities DX (Diagnosis)of Alzheimer's, CKD (Chronic Kidney Disease), Covid-19, HTN (Hypertension), Hypoxia, Insomnia, Depression, Psychosis, and weakness. Interventions: Apply pressure redistribution or low air loss therapy pressure redistribution mattress when in bed.
The (undated) Protekt Aire 3000/3500/3600 Operation Manual documented, in part, Instructions: Step 6 Determine the patient's weight and set the control knob to that weight setting on the control unit.
On 1/7/25 at 12:40 pm, V2 DON (Director of Nursing) stated that the low air loss mattress settings should be based on the resident's weights.
On 1/8/25 at 11:25 am, V30 Wound Care Coordinator (WCC) stated that the low air loss mattress settings should be based on the resident's weight. At no time should a low air loss mattress should be set over 300 for R100. It could cause the wound to worsen.
Facility job description titled Register Nurse/License Practical Nurse documents in part, Essential Duties: 12. Adhere to all facility and department safety policies and procedures.
Facility's job description titled Wound Care Nurse documents in part, 5. Monitor the resident overall condition and provide care as required while maintaining compliance with the facility and procedures.
CONCERN
(D)
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 observation, interview, and record review the facility failed to provide foot care for one resident (R64) who is depend...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide foot care for one resident (R64) who is dependent on staff for Activities of Daily Living (ADL) care (foot care). This failure affected one resident reviewed for foot care in the total sample of 74 residents.
Findings include:
R64's Face sheet shows that R64 has diagnosis which include but not limited to pain in right knee, rheumatoid arthritis, generalized osteoarthritis, and essential hypertension.
R64's Brief Interview for Mental Status (BIMS) dated 11/25/24 shows that R64 has a BIMS score of 12 which indicates that R64 has moderate cognitive impairment.
On 01/06/25 at 11:18 am, Surveyor observed R64 in bed awake and alert. Surveyor observed R64's right and left foot toenails, long, thick, and ridged (ungroomed, in need of foot care). Surveyor also observed R64's right great toe and second toenails with a white dry substance, and white tissue paper adhered to R64's right great toe and 2nd toe. R64 stated, They hurt (referring to R64's right great toe and right second toenails). R64 then stated, I (R64) put baking soda on it a while ago and wrapped it with tissue to make it feel better.
On 01/06/24 at 12:26 pm, V22 (Social Service) was asked regarding residents being seen by the podiatrist at the facility and V22 stated that the podiatrist visits the facility weekly, monthly and as needed (depending on the schedule) and that the nurses and Certified Nursing Assistants (CNAs) are responsible for letting the social service department know the residents who need to be seen by the podiatrist. V22 also stated that the podiatrist last visited the facility in November and that V22 will check to see when the next time the podiatrist will visit the facility.
On 01/07/25 at 9:02 am, Surveyor observed R64 remain in bed awake, alert with R64's right and left foot toenails, long, thick, and ridged (ungroomed, in need of foot care). R64's right great toe and second toenails long, thick, with a white dry substance, and white tissue paper remained adhered to R64's right great toe and 2nd toenails. R64 stated, They hurt (referring to R64's right great toe and right second toenail bed) but I put toothpaste on them today and wrapped them with tissue to sooth them. When R64 was asked if staff provides foot care to R64, R64 stated I can do some things for myself, but I need some help. Since I got here they (referring to R64's right and left feet toenails) have gotten worse. They grew so long they hurt. No one has provided me (R64) foot care. When R64 was asked if R64 would like foot care to R64's bilateral feet, R64 stated, Yes.
On 01/07/25 at 9:04 am, Surveyor brought this observation to V23 (Registered Nurse, RN) and V23 stated, I assume that is some sort of paste on R64's feet. I am unaware of her (R64) in need of any foot treatments. V23 explained that Certified Nursing Assistants, CNAs are responsible for providing foot care during Activities of daily living (ADL) care daily and as needed as well as reporting any foot issues to the nurse. V23 also explained that if V23 observes any issues with a residents foot, V23 will notify the residents physician for treatment orders and recommend the resident to be seen by the podiatrist. V23 stated that V23 is not aware of how often the podiatrist visits the facility and if a resident requires foot care nursing will treat the resident until the resident is able to be seen by the podiatrist. V23 also stated that V23 would call R64's physician for orders to treat R64's feet until R64 is seen by the podiatrist at the facility. When V23 was asked regarding what could happen if a resident goes without foot care, V23 stated that the resident could possibly develop a foot infection.
On 01/07/25 at 9:40 am, V2 (Director of Nursing, DON) was asked regarding providing residents foot care at the facility and V2 stated that CNAs are responsible for providing foot care to the residents and reporting any abnormalities to the nurse. When V2 was asked what could happen if a resident who depends on staff for foot care does not receive foot care, V2 stated, The resident can develop a odor, wound, sores, and a possible infection.
R64's Minimum Data Set (MDS) dated [DATE] shows that R64 requires partial/moderate assistance with personal hygiene.
R64's Physician Order Sheet (POS) dated January 2025 does not indicate that R64 has orders for R64's foot care.
The facility's undated document titled Podiatrist List presented by V22 (Social Service) shows a list of resident to be seen by the Podiatrist next visit at the facility and does not show R64 scheduled to be seen by the podiatrist.
The facility's email document dated 12/01/24 presented by V22 shows a list of residents seen by the podiatrist last visit at the facility and does not show R64 was seen by the podiatrist at the facility.
The facility document dated 01/2024 and titled Foot Care documents, in part: General: Foot care is given to promote cleanliness, prevent infection, control odor, provide comfort, monitor for skin breakdown, and promote healing. Guidelines: Foot care is provided routinely with the bath and prn (as needed). 2. During the bath examine the feet for any open areas, redness, bruises, odor, or color change. 3. Make sure to clean feet in and around toenails and between toes. 9. If resident needs further foot care, notify the nurse so an assessment of the foot can be completed and documented. Notify the physician or nurse practitioner for any further orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Findings include:
On 01/05/25 at 11:26 AM, R132 was lying on her bed. R132 was receiving oxygen through a concentrator via a nasal canula (oxygen tubing). The oxygen tubing was dated 12/23/24.
On 01/...
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Findings include:
On 01/05/25 at 11:26 AM, R132 was lying on her bed. R132 was receiving oxygen through a concentrator via a nasal canula (oxygen tubing). The oxygen tubing was dated 12/23/24.
On 01/05/25 at 11:30 AM, V12 (Licensed Practice Nurse) was requested to check the date on R132's oxygen tubing. V12 stated the date on the oxygen tubing is 12/23/2024. Oxygen tubing should be changed weekly. Her (R132) tubing was not changed weekly. The purpose of changing the oxygen tubing weekly is to prevent infection.
On 01/06/2025 at 10:16am, V2 (Director of Nursing) stated it is expected of the nursing staff to change the oxygen tubing weekly to prevent any bacteria into the tubing. It also should be labeled with the date it was changed to know when the tubing was changed.
R32's (Active Order as Of: 01/06/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) Chronic Obstructive Pulmonary Disease (COPD) and asthma. Order Summary: Oxygen (O2) @ 2Liters prn (as needed) maintain SpO2 greater than 92%. Order date: 06/20/2024. Change O2 tubing weekly every night shift every Sun(day) for infection control. Order Date: 01/05/2025.
R132's (10/02/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 8. Indicating R132's mental status as moderately impaired. Section O. Special Treatments. Respiratory Treatments. C1. Oxygen therapy: b. while a resident.
R132's (04/12/2024) care plan documented, in part has oxygen therapy r/t (related to) diagnosis of COPD. Will have no sign and symptoms of poor oxygenation absorption. Administer oxygen per physician's order.
The (1/ 2024) Oxygen Safety/Use documented, in part Oxygen sources will be provided that ensures ready access and safe distribution of oxygen to patients/residents. General. 9. Oxygen tubing will be changed weekly.
Based on observation, interview and record review, the facility failed to label and date oxygen equipment (nebulizer mask); failed to change oxygen tubing (nasal cannula tubing) per facility policy; and failed to properly contain oxygen equipment (nebulizer mask). These failures affected two residents (R132 and R349) reviewed for oxygen equipment, in a total sample of 74 residents.
Findings include:
R349's face sheet shows that R349 has a diagnosis which includes but not limited hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, acute congestive heart failure, and hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease.
R349's Brief Interview for Mental Status (BIMS) dated 01/02/25 (in progress) shows that R349 has a BIMS score of 15 which indicates that R15 is cognitively intact.
On 01/05/25 at 11:05 am, R349 was observed in bed awake, alert, and oriented. Surveyor observed R349 with a nebulizer mask undated and uncontained on R349's nightstand. When R349 was asked when the last time R349 used R349's nebulizer machine and mask, R349 stated that R349 used R349's nebulizer mask yesterday. When R349 was asked regarding how R349 nebulizer mask is stored when not in use, R349 stated, I (R349) just through it on the dresser.
On 01/05/25 at 12:48 pm, this observation was brought to the attention of V23 (Registered Nurse, RN) and V23 stated, I (V23) imagine that mask was given to him (R349) yesterday. I don't see a date. It should be dated with a date. When V23 was asked how R349's nebulizer mask is stored when not in use, V23 stated, Not on the table (referring to R349's nightstand). It should be in a bag. When V23 was asked regarding the importance of the nebulizer mask being labeled with a date and stored in a bag when not in use, V23 stated, For infection control.
On 01/07/25 at 9:41 am, V2 (Director of Nursing, DON) was asked regarding labeling, dating, and storing oxygen equipment (nebulizer mask) when not in use, V2 stated that the nebulizer mask should be labeled with a date and with the residents room number. V2 also stated that the nebulizer mask should be in a bag when not in use. When V2 was asked regarding the importance of labeling the nebulizer mask and storing the nebulizer mask in a bag when not in use, V2 stated, To decrease infection.
R349's Physicians Order Sheet (POS) dated 12/29/2024 shows that R349 has orders for: Albuterol Sulfate Inhalation Nebulization Solution
(2.5 mg (milligram)/3 ML (milliliter) 0.083% (Albuterol Sulfate), 1 vial inhale orally three times a day for Shortness of breath.
The facility policy dated 01/2024 and titled Oxygen Safety/Use documents, in part: Policy: Oxygen sources will be provided that ensures ready access and safe distribution of oxygen to patients/residents. General: 9 . Oxygen tubing will be changed weekly and appropriately stored to prevent contamination when not in use.
The facility policy dated 01/2024 and titled Equipment Change Schedule documents, in part: Equipment will be changed following established scheduled to prevent cross contamination.
The facility policy dated 01/2024 and titled Oxygen Safety Use documents, in part: 9. Oxygen tubing will be changed weekly and appropriately stored to prevent contamination when not in use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to follow policy of reconciling controlled substances at the end of the shift. This failure has a potential to affect all 3 resid...
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Based on observation, interview, and record review the facility failed to follow policy of reconciling controlled substances at the end of the shift. This failure has a potential to affect all 3 residents (R116, R144, and R172) receiving controlled substances on the 2nd floor.
Findings include:
Facility presented Shift Change Accountability Record for Controlled Substances dated January 2025 on the 2nd floor medication cart containing medications and controlled substances for rooms 201 to 218 which was missing a signature to verify a controlled substance count was conducted during the 3rd shift to shift change on 1/5/2025.
Facility presented a list of residents recorded on the Shift Change Accountability Record For Controlled Substances on the 2nd floor receiving controlled substance medication which includes R172, R116 and R144.
On 1/6/2025 at 10:45 am, observed 2nd floor medication cart missing narcotic count on 3rd shift dated 1/5/2025. V29, Licensed Practical Nurse (LPN), stated that the narcotic count is done shift to shift by the oncoming and outgoing nurse.
On 1/7/25 at 11:00 AM, V35, Licensed Practical Nurse (LPN), stated that they are stored in a narcotic box under a double lock. V35 stated that on her shift she counts with the 3pm-11pm shift, when she comes to work, and when she leaves, she counts with the 11p-7a shift. V35 stated that the narcotic count is recorded in the book on the blue page and if she is counting medication narcotics with the nurse that results in a discrepancy, it is reported to the Director of Nursing (V2).
On 1/7/2025 at 12:30 pm, V2, (Director of Nursing) stated that the controlled substances are stored in a locked medication cart that contains an affixed lock box designated to securely store narcotics and that the nurses are responsible for making sure all narcotic reconciliation or count is accurate and all narcotic medication is accounted for shift to shift. V2 stated that each care has a binder stored on every medication cart that contains the Shift Change Accountability Record For Controlled Substances for which is used for recording the accuracy of shift to shift narcotic count.
The facilities Controlled Substances Policy documents in part, All schedule II substances (and other schedules if facility policy so dictates) will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses and Both nurses will sign the Shift/Shift Controlled Substance Count Sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure that the environment was free from hazards. This failure has the potential to affect all 46 residents on the first-floo...
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Based on observation, interview, and record review the facility failed to ensure that the environment was free from hazards. This failure has the potential to affect all 46 residents on the first-floor unit.
Findings include:
On 01/05/25 V2 (Director of Nursing, DON) presented a facility census of 46 residents on the first-floor unit.
On 01/05/25 at 11:00 am, Surveyor toured the first-floor unit and observed three oxygen cylinder tanks across from the first-floor nursing station, free standing and not in a holder.
On 01/05/25 at 11:04 am, Surveyor brought this observation to V20 (Registered Nurse, RN, Weekend Supervisor) and V20 stated that when oxygen is not in use it should be stored downstairs in the oxygen room. Surveyor and V23 observed one of the three oxygen tanks, full, with 2000 psi (pounds per square inch) and two oxygen tanks with 1000 psi. When V20 was asked regarding what can happen if an oxygen cylinder tank is free standing and not in a holder, V20 stated that oxygen tanks should be in a holder because they can tip over and explode.
On 01/07/25 at 9:41 am, V2 (Director of Nursing, DON) was asked regarding storage of oxygen cylinder tanks and V2 stated, Oxygen cylinders should be stored in a holder at all times so that the oxygen cylinder will not fall, cause friction, and set on fire.
The facility policy dated 01/2024 and titled Oxygen Safety/Use documents, in part: Policy: Oxygen sources will be provided that ensures ready access and safe distribution of oxygen to patients/residents.
The facility policy dated 01/2023 and titled Oxygen Cylinder documents, in part: General: standards for safe handling of cylinder gases are set by the National Fire protection Association (NFPA) and regulated by the Compressed Gas Association (CGA). Administrative authorities shall ensure that these standards and others that apply are met . Storage of Oxygen Cylinders: Store in designated area. Oxygen cylinders must be protected from mechanical shock, falling objects, etcetera (etc.).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to properly label, date and store prepared food items and store unthawed meats, to complete daily temperature logs to prevent the ...
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Based on observation, interview and record review the facility failed to properly label, date and store prepared food items and store unthawed meats, to complete daily temperature logs to prevent the spread of foodborne illnesses. This failure has the potential to affect all residents receiving oral nutrition.
Findings include:
On 1/5/2025 surveyor observed the temperature logs for the refrigerator, freezer and cooler missing temperatures (morning and afternoon) for 1/1/2025-1/03/2025 and the afternoon temperatures for 1/05/2025.
On 1/5/2025 at 9:18am surveyor observed 5 long steel pans of flavored gelatin (2 raspberry, 2 orange and 1 green) that was not dated and uncovered.
On 1/5/2025 at 9:18am V5 (Cook)stated the flavored gelatin was made last night and it should have a date and that it should not have a covering because it would not set right.
On 1/5/2025 at 9:22am surveyor observed 2 uncovered black tubs of pork chops, out of the original packaging, sitting on the bottom shelf in the refrigerator. The first tub was sitting on top of the second tub of pork chops uncovered.
On 1/05/2025 at 9:32am V6 (Dietary Manager) stated all temperature logs (freezer, refrigerator, cooler) should be dated twice a day.
On 1/7/2025 at 11:17am V6 (Dietary Manager) stated meat should be thawed in the refrigerator in a large tub with a lid or plastic on it. Jello is allowed to sit overnight in the refrigerator uncovered and, in the morning, we cover it up and everything that is put in the refrigerator or cooler should be dated.
Job description for dietary manager documents, in part, to manage and oversee the daily operations of the dietary department, ensuring that meals are prepared, served, and stored in compliance with dietary guidelines, safety, and sanitation standards, and maintains and enforces food safety regulations and practices for storing, preparing, and serving food.
Job description for dietary aide documents, in part, stores food properly.
Storage of Refrigerated Foods, with a date of May 20, 2014 documents, in part, Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality, air temperature inside the refrigerator is checked twice daily and food in the refrigerator is covered, labeled and dated with a use by date.
Undated policy titled Labeling and Dating documents, in part, foods will be labeled upon delivery to the facility and staff will follow the expiration date guidelines as posted or use by date on the product itself, all foods that are opened are to be wrapped or put in a sealed container for storage to prevent contamination.
Undated policy titled Fridge/Freezer (Walker) Temperature Policy documents, in part, to assure food is kept and stored appropriately to prevent foodborne illness and staff will complete temperatures twice daily to assure the walk-in, fridge, and freezers are maintained and in good working condition to maintain food safety temperatures.
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 observations, interviews, and record reviews, the facility failed to ensure staff don appropriate PPE (personal protective equipment) prior to performing ADL (activities of daily living) care...
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Based on observations, interviews, and record reviews, the facility failed to ensure staff don appropriate PPE (personal protective equipment) prior to performing ADL (activities of daily living) care to 3 (R100, R139, and R189) residents; and failed to ensure an EBP (enhanced barrier precaution) sign was posted for 2 (R53 and R189) residents on EBP. These failures affected 4 residents (R53, R100, R139, and R189) reviewed for infection control and has the potential to affect all the residents on 2nd floor and 3rd floor.
Findings include:
The (01/05/2024) facility census documented that there were 71 residents on the 2nd floor and 72 residents on the 3rd floor.
On 01/05/25 at 10:35 AM, surveyor inquired about the acuity of the floor, V10 (Restorative Director) stated (R53) and (R189) have an indwelling catheter.
On 01/05/25 10:37 AM, there was no EBP sign posted by R189's door.
On 01/05/25 at 10:40 AM, this observation was pointed out to V10. V10 stated there is no EBP sign posted by his (R189) room. Anyone who has a gtube, foley, and wound should have an EBP sign posted. Informed V10 that this surveyor needed to speak with the infection preventionist nurse.
On 01/05/25 at 10:41am, V13 (Certified Nursing Assistant) and another CNA who was later identified as V14 went inside R189's room with a mechanical lift. Both did not don appropriate PPE.
On 01/05/25 at 10:57 AM, R189 was outside of his room well dressed and seated on a geriatric chair.
On 01/05/25 at 11:03 AM, inquiring if R189 is on EBP. V13 stated he is not on isolation. He has an (indwelling) catheter that is attached to a leg bag. I (V13) went to his room without donning a gown. I (V13) and another CNA (V14- CNA) transferred him (R189) to the chair with a (mechanical) lift with 2-person assist. She (V14) did not wear a gown, too. This surveyor informed V13 that anyone who has an indwelling catheter is on EBP. V13 stated it would help me a lot to know that I have to wear PPE if there was an EBP sign posted by his (R189) door.
On 01/05/25 at 10:42 AM, by R53's room, no EBP sign was posted. V10 stated he (R53) has foley catheter. He should be on EBP, too.
On 01/05/25 at 10:48 AM, V10 stated he (R53) has suprapubic catheter. The importance of posting an EBP sign by the resident's door is to let anyone, entering the room, know that he is on EBP and to know what PPE to don because staff or visitor may be dealing with body fluid. We try to prevent infection and protect him (R53). The start of infection could be coming from him and other residents could be infected.
On 01/05/25 at 11:05 AM, V11 (LPN/Infection Preventionist) stated residents placed on EBP are residents who have wounds, central line, foley catheter, and colonized from MDROs (multi drug resistant organisms). Basically, residents who have artificial opening on the skin and with wounds. The purpose of placing residents on EBP is to prevent transmission of infection. V11 handed this surveyor the list of residents on EBP. Upon review, R53 and R189 were not included in the list. This was pointed out to V11. V11 stated they should be on EBP list because they (R53 and R189) have a indwelling catheter. I will update the list.
On 01/05/25 at 11:08 AM outside of R189's room, V11 stated there should be an EBP sign posted by the resident's door. The purpose of the sign is to let the staff know what PPE to wear. Staff are expected to wear gown and gloves if they are transferring a resident, staff are expected to wear gown and gloves during transfer of a resident because it is considered a direct care to the resident to prevent any transmission of infection to their clothing and to prevent transmission of infection to the residents and other staff.
On 01/05/25 11:11 AM, outside of R53's room, V11 stated he (R53) should have an EBP sign posted as well.
On 01/07/2025 at 1:59pm, V2 (Director of Nursing) stated EBP signage should be posted by the resident ' s door on eye level so staff and visitor can see it.
R53's (10/01/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating R53's mental status as cognitively intact. Section H. Bladder and Bowel: H0100. Appliances: A- Indwelling catheter.
R53's (Active Order as Of: 01/06/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) essential hypertension, obstructive and reflux uropathy (when urine can't flow (either partially or completely) through your ureter, bladder, or urethra due to some type of obstruction. Instead of flowing from your kidneys to your bladder, urine flows backward, or refluxes, into your kidneys) type 2 diabetes mellitus and contact dermatitis. Order summary: Suprapubic catheter 16Fr Dx: BPH/Obstructive and Reflux Uropathy. Order Date: 01/17/2024.
R53's (08/09/2023) care plan documented, in part requires suprapubic catheter r/t (related to) obstructive uropathy. Will be/remain free from catheter-related trauma. Catheter care q (every) shift/PRN (as needed).
R53's (12/18/2024) care plan documented, in part Enhanced Barrier Precautions for use of (indwelling) catheter. Goal: will not acquire no MDROs. Interventions: wear gown and gloves as outlined by CDC for patients placed on EBP.
R189's (Active Order as Of: 01/06/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) cerebral infarction, obstructive and reflux uropathy, and muscle weakness. Order summary. Indwelling Catheter 16 Fr(ench) for a dx (diagnosis) of obstructive uropathy. Change urinary bag as needed. Order Date: 12/02/2024. Change urinary catheter as needed. Order Date: 12/02/2024. Provide catheter care every shift and as needed. Order Date: 12/02/2024.
R189's (12/23/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C1000. Cognitive Skills for daily decision making: 2 = moderately impaired. Section GG. Functional Abilities. Admission. GG0170. Mobility. E. Chair/Bed-to-chair transfer: 01 - Dependent. Section H. Bladder and Bowel. H0100. Appliances. A. indwelling catheter Section O. Special Treatment, Procedures, and Programs. M1. Isolation or quarantine for active infectious disease: b. while a resident.
R189's (11/22/2024) care plan documented, in part requires use of an indwelling catheter r/t (related to) obstructive uropathy. Will remain free of complication and infection of foley catheter placement. Empty catheter bag every shift and as needed.
R189's (12/15/2024) care plan documented, in part Enhanced Barrier Precautions for use of (indwelling) catheter. Will acquire no MDRO's within the facility. Wear gown and gloves as outlined by CDC for patients placed on EBP.
The (undated) Catheter List indicated that R53 and R189 were on the list.
The (01/02/2025) updated EBP list indicated that R53 and R189 were on the list.
The (01/07/2025) email correspondence with V2 (Director of Nursing) documented, in part Should there be an EBP sign posted for residents on EBP? If so, where should it be posted?
V2 responded It should be posted at eye level by the door.
The (undated) Enhanced Barrier Precautions Sign documented, in part Providers and Staff Must also: wear gloves and a gown for the following High-Contact Resident Care Activities. Transferring.
The (3/20/2024) Enhanced Barrier Precautions (EBP) documented, in part EBP expand the use of PPE (personal protective equipment) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi drug resistant organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high contact resident care activities is indicated for nursing home residents with indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Policy: EBP requires the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. High contact resident care activities requiring gown and gloves those among residents that trigger EBP use include: transferring.
Findings include:
R100's diagnoses include but not limited to Alzheimer's, Atherosclerotic heart disease, hypertension, and chronic kidney disease.
On 1/5/25 at 10:35 am, observed an Enhance Barrier Precaution (EBP) sign outside of R100's door with no EBP bin outside of R100's room or near the room. V17 LPN (License Practical Nurse) and V18 CNA (Certified Nursing Assistant) observed in R100's room. V18 was rubbing soap on R100's body giving a bed bath to R100 with only gloves and mask on without donning a gown.
R139's diagnoses include but not limited to cerebral infarction, chronic obstructive pulmonary disease, malignant neoplasm of prostate, and obstructive and reflux uropathy.
R139's Active orders as of 1/6/2025 documents in part, Indwelling Catheter 16 Fr (French) 10 cc (Cubic Centimeter) balloon size for a diagnosis of Obstructive and Reflux Uropathy. Change urinary bag as needed when clinically appropriate.
R139's MDS (Minimal Data Set) section H-Bladder and Bowel documents in part, Appliances: A. Indwelling Catheter.
On 1/6/25 at 9:25 am, observed an EBP sign outside of R139's door with an empty EBP bin outside of R139's room. Observed V26 LPN (License Practical Nurse) in R139's room changing a urine leg bag without donning a gown. Surveyor inquired to V26 (LPN) about the posted EBP sign outside of R139's room, if a gown should have been worn when changing the urine bag? V26 stated, No then looked at the sign and read it then stated, Yes, I should have had a gown on.
On 1/7/25 at 11:40 am, V11 (Infection Preventionist, IP, Licensed Practical Nurse, LPN) stated that residents who are on EBP, its to protect the residents who are susceptible to MDRO (Multidrug-Resistant Organism) and infection with residents with Gastrostomy tubes, catheters, indwelling catheters, lines, and wounds are to be placed on precautions. EBP residents should have signage on the resident's door with a PPE (Personal Protective Equipment) bin at the door or hallway for accessibility. When V11 was asked if regarding PPE supplies not being accessible, V11 stated that there is a chance staff will run out of PPE supplies and IP, central supply or a nurse manager should be notified to bring more supplies. V11 stated that it is important for staff to wear proper PPE and have accessible PPE for residents who requires EBP to prevent the potential spread of infection between the staff and the residents.
On 1/7/25 at 12:40 pm, V2 DON (Director of Nursing) stated that an EBP sign is a quick sheet for staff to know what to put on before going into the room when providing care to the resident. V2 stated, Staff should have had on PPE when giving a bed bath and changing a urine bag. The reason for EBP signs is provide protection for staff with contamination from resident to resident.
Facility's Enhanced Barrier Precautions sign documents in part, Providers and Staff Must: Wear gloves and a gown for the following High-Contact Resident Care Activities; dressing bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting. Device care or use: .urinary catheter .
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 posted nursing staffing information was accurate and failed to ensure the posted staffing information included all ...
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Based on observation, interview and record review, the facility failed to ensure the posted nursing staffing information was accurate and failed to ensure the posted staffing information included all required data. This failure affects all 190 residents residing within the facility.
Findings include:
Record review of facility census documentation indicates that 189 residents reside within the facility.
On 1/5/2025 at 9:50 AM, observed posted nursing staffing information near the front door of the facility. The posted nursing staffing information was dated for 1/3/2025 (incorrect date) and did not have the facility's name, or current census numbers. No other staffing information (other sheets) were noted to be dated 1/5/25 behind the 1/3/2025 staffing posting.
On 1/6/2025 at 1:31 PM, V38 (Staffing Coordinator) affirmed that V38 is responsible for updating the staffing information and that the receptionist is responsible for updating it on the weekend. V38 stated that the staffing information for the weekend is located behind the staffing posting and the receptionist just pulls it from the top to reflect current staffing. V38 could not give a reason why the staffing information was not posted. V38 provided a copy of the staffing information that should have been posted for 1/5/2025. V38 reviewed the staffing posting with this surveyor and affirmed that the census information was left blank and the name of the facility was not located on the staffing posting.
On 1/6/2025 at 2:41 PM, V1 (Administrator) stated, We do not have a policy for the daily staffing form because it is a regulatory requirement that the facility has to adhere to to ensure quality of care in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide snacks to the facility's residents when the duration between meals (dinner and breakfast) exceeded 14 hours. This failure affects a...
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Based on interview and record review, the facility failed to provide snacks to the facility's residents when the duration between meals (dinner and breakfast) exceeded 14 hours. This failure affects all 190 residents that reside within the facility.
Findings include:
Record review of facility census documentation indicates that 189 residents reside within the facility.
Record review of facility mealtimes documents in part, first floor meal times (7:30 AM, 11:30 AM, and 4:45 PM), second floor meal times (7:45 AM, 11:30 AM, and 5:00 PM), and third floor meal times (7:45 AM, 11:30 AM, and 5:00 PM). This indicates that the mealtimes are greater than 14 hours.
On 1/6/2025 at 10:42 AM, during the resident council meeting, all residents present unanimously affirmed that the facility does not serve snacks and that they would want snacks if they were available. R114 stated that if the facility does have snacks, there is never enough for all the residents.
On 1/7/2025 at 10:40 AM, V1 (Administrator) stated that snacks are served nightly to all the floors. Surveyor requested documentation from V1 that snacks were being administered to the residents. V1 replied that V6 (Dietary Manager) would have the documentation regarding snacks.
On 1/7/2025 at 1:20 PM, V6 provided a document titled SNACKS that had 11 resident names listed on it (facility census is 190). V6 stated, those are the residents that get snacks at night. They get a peanut butter and jelly sandwich, a juice and a cookie. Surveyor reviewed mealtimes with V6 and confirmed there is 14 hours and 45 minutes between dinner and breakfast for the facility. Surveyor inquired how long can the duration of meals be in a facility before snacks needed to be administered to all residents, and V6 replied 14 and a half hours. V6 stated, we used to give snacks to all the residents every night, but a lot of times they didn't eat them and it was a waste, so we stopped. V6 explained that it's the dietary departments job to make the snacks and nursing has to pass them out.
On 1/7/2025 at 1:39 PM, V2 (Director of Nursing) stated that the expectation is that the nursing department distributes snacks to any residents that want them or request them. Surveyor reviewed the document titled SNACKS with V2 and was unfamiliar with the document. V2 stated, all resident should be offered snacks if they want them.
On 1/7/2025 at 2:39 PM, surveyor requested a policy for snack administration. V1 (Administrator) replied, .we are in compliance and not required to offer a snack based on our mealtimes offered. We have 14 hours between meals and we are in the regulation. Breakfast is at 7:30am started and dinner is at 4:30pm . This statement indicates there is 15 hours in-between meals. No policy for snack administration was received.
Oct 2024
5 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
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to follow policy procedures, failed monitor blood gluco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to follow policy procedures, failed monitor blood glucose levels, failed to ensure that medication administration records include actual times for administration, failed to follow physician orders, and/or failed to ensure that medications/supplements were administered and documented within regulatory requirements for nine of thirteen residents (R1, R3, R5, R6, R7, R8, R9, R10) in the sample. The facility also failed to ensure that (R2's) Humalog was ordered and administered before meals, this failure resulted in R2's frequent blood glucose levels above 200. On 9/2/24, R2's blood glucose level was 399 (critical high).
Findings include:
On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that medications are not administered at the facility as ordered and there's no set schedule for when medications are given. In addition, blood glucose and blood pressure are not being monitored at the facility.
R2's diagnoses include type II diabetes mellitus and metabolic encephalopathy.
R2's POS (Physician Order Sheets) include (4/2/24) blood glucose check before meals. (4/7/24) Humalog (Insulin) per sliding scale one time a day.
R2's (September 2024) MAR (Medication Administration Record) affirms blood glucose level was above 200 on 9/1, 9/2, 9/3, 9/6, 9/8, 9/9, 9/11, 9/12, 9/13, 9/14, 9/16, 9/17, 9/18, 9/19, 9/22, 9/23, 9/25, 9/26, 9/27, and 9/29 [20 days]. R2's (9/2/24) 11:00am blood sugar was 399.
On 10/8/24 at 12:12 pm, surveyor inquired if blood glucose checks are ordered before meals and a resident is prescribed Humalog how often should the Humalog be administered V11 (Medical Director) stated Usually whenever they check the blood sugar, it depends on how the physicians order it. Usually, we check the blood sugar before meals and try to cover that. Surveyor inquired if prescribing Humalog only once a day is appropriate for a resident with blood glucose levels frequently above 200 V11 responded It can be that way depending on the patient. We might need to adjust the dose or the frequency, it depends on the patient. Surveyor inquired about Humalog insulin V11 replied It's not a long acting one, it doesn't last a long time. Surveyor inquired about potential harm to a resident with a blood sugar of 399 that's not treated, V11 stated If it's a one time reading probably nothing but if it's a persistent reading over a couple weeks, it can start causing dehydration or frequent urination. Long term non-controlled diabetes can affect the kidneys.
R1's diagnoses include type II diabetes mellitus.
R1's (9/27/24) BIMS (Brief Interview Mental Status) determined a score of 9 (moderate impairment).
On 10/2/24 at 9:49am, surveyor inquired if medications are received (at the facility) as ordered R1 stated I don't know.
On 10/2/24 at 2:50pm, surveyor inquired about medication administration concerns at the facility V6 (Family) stated When my mother (R1) got there, they (facility) didn't have her medication. The Nurse said the medication wasn't there.
R1 was admitted to the facility on [DATE].
R1's POS (Physician Order Sheets) include the following medications with (9/20/24) start date: Atorvastatin Calcium 80mg (milligrams) at bedtime, Gabapentin300mg three times daily, Metformin (Hypoglycemic) 500mg twice daily, Metoprolol Succinate ER (Extended Release) 25mg at bedtime, Pantoprazole Sodium 40mg twice daily, and Sacubitril Valsartan 24-26mg twice daily. [Blood Glucose orders are excluded however hypoglycemic medication is prescribed].
R1's MAR (Medication Administration Record) affirms the following medications (scheduled for 9/20/24 administration) were marked 9 (see Nurse notes): Atorvastatin Calcium, Gabapentin Metformin, Metoprolol Succinate ER, Pantoprazole Sodium, and and Sacubitril Valsartan. In addition, several of R1's medications were noted to be scheduled for morning, afternoon, or evening therefore not specified times - as warranted.
R1's (9/20/24) Nursing Progress Notes affirm at 4:23pm resident was received for admission. (11:41-11:43pm) EMAR (Electronic Medication Administration Record): pharmacy to deliver Metformin, Pantoprazole Sodium, Atorvastatin Calcium, Gabapentin, and Metoprolol Succinate ER [R1 was admitted roughly 7 hours prior].
On 10/7/24 at 12:49pm, surveyor inquired about the requirements for receiving medication orders V2 (Director of Nursing) stated In that order you have to have the name of the medication, the milligrams or the dosage, how often it's to be given, it needs to be verified with the doctor and have a diagnosis. The schedule depends on what the doctor orders, if it's ordered daily, usually daily is scheduled for 9am. Surveyor requested the actual times for R1's medication administration V2 reviewed R1's (September 2024) MAR and responded It says for Atorvastatin bedtime, I don't actually see a time on there, it just says bedtime. Metoprolol just says given at bedtime. Metformin it says give by mouth 2 times a day, it says morning and evening. Pantoprazole it says morning and evening, it's not giving a specific time. Surveyor inquired about the regulatory requirement for medication administration, V2 replied It should be given a time, so if its 9:00 we have a hour before and a hour after to administer the medication. Surveyor inquired if staff should be monitoring blood sugars if residents are receiving hypoglycemic medication, V2 stated If they (residents) are on anything for diabetes, we (staff) should call and get orders for checking blood sugars once or twice a day.
On 10/8/24 at 12:19pm, surveyor inquired about potential harm to a resident receiving oral hypoglycemics if blood sugars are not monitored, V11 (Medical Director) replied Potential harm is they can get all sorts of high or low blood sugars, this can cause coma.
On 10/2/24 at 10:29am, surveyor stated that medication administration will be monitored this morning V4 (Registered Nurse) responded Actually, I'm done for now unless you want to see the 12:00. V4 accessed the EMAR (Electronic Medication Administration Record) as requested however R3's name was highlighted red (indicating late administration). Surveyor inquired why R3's name was highlighted red V4 replied Right now I (V4) need to see about getting the medicine from the c (convenience) box. The Metoprolol (ER) 25 milligrams, its scheduled for 9:00 but we got 1 hour after and 1 hour before to give it. Surveyor inquired why R3's Metoprolol (scheduled for 9am administration) was not administered V4 stated I believe that was a new order. [R3's POS affirms Metoprolol ER 25 milligrams was prescribed 7/26/24 therefore not a new order]. Surveyor inquired what time it is V4 responded It's after 10:00.
On 10/2/24 at 11:34am, V5 (Licensed Practical Nurse) was observed passing R4's AM medications per EMAR [actual time of administration was excluded}. Surveyor inquired if all V5's assigned residents received their AM medications today V5 stated Yes. Surveyor inquired what residents highlighted red on the EMAR indicates V5 responded The red? this means late. Surveyor inquired why R5, R6, R7, R8, R9 and R10 were highlighted red on the EMAR V5 responded These are done I just haven't signed em out yet. V5 reviewed the EMAR with surveyor and affirmed that R5's supplement (scheduled for 10am administration) was not documented. Surveyor inquired if R6's scheduled Haldol, Morphine, and Lorazepam were administered this morning V5 replied The 9am Morphine is the only one I gave. Surveyor inquired when prescribed medications are not given (as scheduled) what's the requirement V5 stated When I (V5) don't give em, I just put the reason why I didn't give it however nothing was documented for R6's Haldol and Lorazepam (scheduled for 10am administration). R7's (10/2/24) 7:30am blood sugar and Humalog administration were not documented. Surveyor inquired why R7 did not receive Humalog this morning V5 responded When we checked his blood sugar it was like 110 however appeared unsure. Surveyor inquired if R7's (10/2/24) 7:30am blood sugar was documented in the EMAR V5 affirmed it was not. Surveyor inquired if R7's blood sugar was documented on paper V5 stated No. R7's MAR (received after interview) affirms 10/2/24 7:30am blood sugar result states N/A (not applicable). Surveyor inquired if R8 received 9am medications this morning V5 stated Yes, I haven't signed em out yet. Surveyor requested to inspect R8's medications V5 removed R8's medications from the cart (which are labeled individually - including date and time) however the 10/2/24 medications (scheduled for 9am administration) remained in the packages. V5 stated Oh no, his (R8's) I (V5) didn't get to yet. I thought I did his, this is the 2nd (October 2nd). Surveyor inquired if R9 received Nifedipine ER (Antihypertensive) scheduled for AM administration, V5 responded I didn't give it yet. Surveyor inquired if R10 received Sacubitril Valsartan (Antihypertensive) scheduled for AM administration, V5 replied I didn't give that one yet because I didn't check his blood pressure for today.
The medication administration policy (reviewed 1/2024) states verify that the medication is being administered at the proper time. If the medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. Vital signs are taken as required prior to medications and documented on MAR.
The diabetes management policy (reviewed 1/2024) states residents with a diagnosis of diabetes will be managed per physician orders. Physician's orders for diabetic management may include but are not limited to specialized diet, oral medications, insulin injections, and blood glucose monitoring.
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 upon record review and interview the facility failed to ensure that a baseline care plan includes required ADL (Activities of Daily Living) care assistance for one of three residents (R1) review...
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Based upon record review and interview the facility failed to ensure that a baseline care plan includes required ADL (Activities of Daily Living) care assistance for one of three residents (R1) reviewed for quality of care.
Findings include:
On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that a resident residing in the facility has no plan of care.
R1 was admitted (9/20/24) with diagnoses which include but not limited to morbid obesity, cerebral infarction, and history of falling.
On 10/2/24 at 9:49am, surveyor inquired why R1 was admitted to the facility, R1 stated I had a stroke. R1 affirmed she now has left sided weakness and requires physical therapy.
R1's (9/25/24) Care Conference states resident is receiving physical therapy. Physical Therapy focus: bed mobility and transfers.
R1's (9/27/24) functional assessment affirms resident is dependent on staff for sit to stand, chair/bed to chair transfer, and toilet transfer. Dressing requires substantial/maximal assistance.
R1's care plan (initiated September 2024) includes self-care deficit, impaired mobility, and high risk for falls [Interventions exclude required transfer and/or dressing assistance].
On 10/3/24 at 11:46am, surveyor inquired about the requirements for resident baseline care plans, V8 (MDS/Minimum Data Set Coordinator) proceeded to read the facility policy and stated Based on the policy it says here that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will be developed within 48 hours of the resident admission into the facility. Surveyor inquired if R1's care plan includes required dressing assistance, V8 responded So under restorative it says she (R1) has a self-care deficit and bed mobility related to decreased ability to position or reposition self in bed. The intervention is position and reposition resident in bed for comfort, joint support, and skin integrity [provide dressing assistance was excluded]. Surveyor inquired if R1's care plan includes transfer instructions, V8 replied That would be under the task, if its anything specific it would be here, so I don't see anything specific for her (R1). Surveyor inquired how R1 transfers from the bed to the chair, V8 stated You would have to ask restorative that's beyond MDS's scope, I provide medical data. MDS is responsible to oversee the care plan and oversee the accuracy of the assessment. Each department has a section they are responsible for. Surveyor inquired if V8 is responsible for checking the care plan after each department completes their section, V8 responded Yes.
The (1/2023) baseline care plan policy states the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will be developed within 48 hours of the resident admission into the facility. The baseline care plan will include at a minimum the following necessary information to properly care for a resident. Activities of Daily Living needs. Supervision needs. The baseline care plan must reflect the resident's stated goals and objectives and include interventions that address his or her current needs.
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
Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that care requirements are documented in the plan of care, failed to implement ca...
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Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that care requirements are documented in the plan of care, failed to implement care plan interventions, and failed to provide timely ADL (Activities of Daily Living Care) to one of three dependent residents (R1) reviewed for quality of care.
Findings include:
On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that a facility resident is often found soaked due to not being changed overnight.
R1's (9/27/24) functional assessment affirms resident is dependent on staff for sit to stand, chair/bed to chair transfer, and toilet transfer. Dressing requires substantial/maximal assistance.
R1's (9/23/24) care plan includes self-care deficit/impaired mobility, Intervention: provide peri-care after each incontinent episode. Elimination: assistance and instruction are given as required. [dressing assistance is excluded].
R1's (9/27/24) BIMS (Brief Interview Mental Status) determined a score of 9 (moderate impairment).
On 10/2/24 at 9:49am, R1 was observed lying in bed and wearing a gown. Surveyor inquired why R1 was admitted to the facility, R1 stated I couldn't walk, and my blood pressure was low. I went to the hospital, and they told me I had a stroke. R1 affirmed that she now has left sided weakness and requires physical therapy. Surveyor inquired if R1 uses the toilet R1 responded I have a diaper on, I haven't been changed this morning at all. When I call them (staff) they take their time. Surveyor inquired when R1 was last checked or changed R1 responded It was probably after dinner and affirmed that she was not changed during the night.
On 10/2/24 at 10:18am, surveyor inquired if R1's incontinence brief was changed this morning, V3 (Certified Nursing Assistant) stated I'm gonna get to her however failed to answer the question therefore surveyor requested to inspect R1's brief. V3 subsequently removed R1's brief and it was saturated with urine. Surveyor inquired about concerns with the appearance of R1's brief, V3 responded That she wet, that she's soiled? She's a heavy wetter. Surveyor inquired again if R1's brief was changed this morning, V3 replied This the first round, I'm still getting people up for dialysis and all kinda stuff. Surveyor inquired when V3's shift started, V3 stated 6:00 [over 4 hours prior]. Surveyor inquired about the required frequency for checking and/or changing incontinent residents, V3 responded I think it's every two hours. Surveyor inquired why R1 was lying in bed (after 10am), R1 responded They'll (staff) get me up when I go to therapy.
The ADL policy (reviewed 5/2024) includes responsible party: all Nursing Personnel. Dressing: residents are given instructions and assistance as required. Elimination: assistance and instruction are given as required.
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 upon observation, interview, and record review the facility failed to ensure that five of thirteen residents (R1, R3, R8, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to ensure that five of thirteen residents (R1, R3, R8, R9, R10) in the sample remained free of significant medication errors.
Findings include:
On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that medications (including antihypertensive and hypoglycemic) are not administered at the facility as ordered.
R1's (9/27/24) BIMS (Brief Interview Mental Status) determined a score of 9 (moderate impairment).
On 10/2/24 at 9:49am, surveyor inquired if prescribed medications are received as ordered R1 stated I don't know.
On 10/2/24 at 2:50pm, surveyor inquired about facility concerns V6 (Family) stated When my mother (R1) got there (facility) they (staff) didn't have her medication. The Nurse said the medication wasn't there.
R1 was admitted [DATE] with hypertensive heart disease and type II diabetes mellitus.
R1's POS (Physician Order Sheets) include but not limited to the following significant medications with (9/20/24) start date: Metformin 500mg/milligrams (Hypoglycemic), Metoprolol Succinate ER 25mg (Antihypertensive) 25mg, and Sacubitril Valsartan 24-26mg (treats heart failure).
R1's (9/20/24) MAR (Medication Administration Record) affirms Metformin, Metoprolol Succinate ER, and Sacubitril Valsartan were marked 9 (see Nurse notes).
R1's (9/20/24) Nursing Progress Notes state pharmacy to deliver the following medications: Metformin, Metoprolol Succinate ER, and Sacubitril Valsartan.
On 10/3/24 at 3:15pm, surveyor inquired about the facility protocol for acquiring medications for new admissions, V2 (Director of Nursing) stated After you get the medications verified, we (Nurses) usually get the medications from the (brand name convenience box).
The facility convenience box log includes Metformin 500mg and Metoprolol Succinate ER 25mg however on 9/20/24 neither of which were administered to R1 [Sacubitril Valsartan was excluded from the list therefore unavailable].
R3's diagnoses include heart failure and hypertension.
R3's (7/26/24) POS includes Metoprolol Succinate ER daily for hypertension.
On 10/2/24 at 10:29am, surveyor inquired if R3 received Metoprolol Succinate ER today as ordered V4 (Registered Nurse) stated Right now I (V4) need to see about getting the medicine from the c (convenience) box. The Metoprolol (ER) 25 milligrams, its scheduled for 9:00 but we got 1 hour after and 1 hour before to give it. Surveyor inquired what time it is V4 responded It's after 10:00 therefore not administered within regulatory requirements.
On 10/2/24 at 10:42am, V4 accessed the convenience box, searched for Metoprolol Succinate ER (to no avail) and affirmed It's not in there.
R3's (8/1/24) BIMS determined a score of 14 (cognition intact).
On 10/2/24 at 10:48am, surveyor inquired if R3 received her blood pressure medication this morning R3 stated He (Nurse) didn't bring it in yet, he said he had to get it out of the cabinet.
On 10/2/24 at 11:34am, surveyor inquired what residents highlighted red on the EMAR (Electronic Medication Administration Record) indicates V5 (Licensed Practical Nurse) stated The red? this means late. Surveyor inquired why R8, R9 and R10 were highlighted red on the EMAR V5 responded These are done I just haven't signed them out yet. V5 reviewed the EMAR with surveyor at this time. Surveyor inquired if R8 received medications today (scheduled for 9am administration) V5 stated Yes, I haven't signed them out yet. Surveyor requested to inspect R8's medications at this time. V5 removed R8's medications from the cart (which are labeled individually - including date and time) however the 10/2/24 (9am) medications including Clopidogrel Bisulfate (Antiplatelet) and Levetiracatam (Anticonvulsant) remained in the packages. V5 stated Oh no, his (R8's) I (V5) didn't get to yet. I thought I did his, this is the 2nd (October 2nd). Surveyor inquired if R9 received Nifedipine ER (Antihypertensive) scheduled for AM administration, V5 responded I didn't give it yet. Surveyor inquired if R10 received Sacubitril Valsartan scheduled for AM administration, V5 replied I didn't give that one yet.
On 10/7/24 at 12:49pm, surveyor inquired about the regulatory requirement for administering medications, V2 (Director of Nursing) stated It should be given in time, so if its 9:00 we have a hour before and a hour after to administer the medication.
The medication administration policy (reviewed 1/2024) states all medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Check the medication administration record prior to administering medication for the right medication, dose, route, patient/resident, and time. Verify that the medication is being administered at the proper time.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that pres...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that prescribed medications are available for two of three residents (R1, R3) reviewed for pharmacy services, failed to ensure that the location of medication in the convenience box is accurate, and failed to ensure that staff utilize the convenience box when medications are unavailable in the medication cart or not received from pharmacy. These failures have the potential to affect 191 residents.
Findings include:
On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that a resident has not been receiving prescribed medications and the facility blames the pharmacy for medication issues.
The (10/2/24) facility census includes 191 residents.
On 10/2/24 at 2:50pm, surveyor inquired about medication administration concerns at the facility V6 (Family) stated When my mother (R1) got there, they (facility) didn't have her medication. The Nurse said the medication wasn't there.
R1 was admitted to the facility on [DATE].
R1's POS (Physician Order Sheets) include the following medications with (9/20/24) start date: Atorvastatin Calcium 80mg (milligrams), Gabapentin300mg, Metformin 500mg, Metoprolol Succinate ER (Extended Release) 25mg, Pantoprazole Sodium 40mg, and Sacubitril Valsartan 24-26mg.
R1's (9/20/24) MAR (Medication Administration Record) affirms the following medications were marked 9 (see Nurse notes): Atorvastatin Calcium, Gabapentin, Metformin, Metoprolol Succinate ER, Pantoprazole Sodium, and and Sacubitril Valsartan [therefore none of which were documented administered].
R1's (9/20/24) Nursing Progress Notes state pharmacy to deliver the following medications: Atorvastatin Calcium, Gabapentin, Metformin, Metoprolol Succinate ER, Pantoprazole Sodium, and Sacubitril Valsartan.
On 10/3/24 at 3:15pm, surveyor inquired about the facility protocol for acquiring medications for new admissions V2 (Director of Nursing) stated After you get the medications verified, we (Nurses) usually get the medications from the (brand name convenience box).
The facility convenience box log includes the following medications which were prescribed for R1: Gabapentin 300mg, Metformin 500mg, Metoprolol Succinate ER 25mg, Pantoprazole 40mg however none of which were administered [Sacubitril Valsartan was excluded from the list therefore unavailable].
R3's (7/26/24) POS includes Metoprolol Succinate ER daily.
On 10/2/24 at 10:29am, surveyor inquired why R3's name was highlighted red on the Electronic Medication Administration Record (indicating late administration) V4 (Registered Nurse) responded Right now, I need to see about getting the medicine from the c (convenience) box. The Metoprolol (ER) 25 milligrams, its scheduled for 9:00 am.
On 10/2/24 at 10:42am, V4 accessed the (brand name convenience box) which states Metoprolol 25mg ER is in box #7 - in the cabinet. V4 subsequently removed box #7 from the cabinet, searched for Metoprolol Succinate ER (to no avail) and affirmed It's not in there.
R3's (8/1/24) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact).
On 10/2/24 at 10:48am, surveyor inquired if R3 received her Metoprolol Succinate ER this morning R3 stated He (Nurse) didn't bring it in yet, he said he had to get it out of the cabinet.
The (undated) ordering medications policy states medications and related products are ordered from (pharmacy name) on a timely basis. New medication order requests can be faxed to the pharmacy's main fax number, sent via electronic health records, EHR (Electronic Health Records) system, electronically prescribed by the prescriber, and/or called in by the appropriate personnel according to State laws and regulations. Refill requests should be sent in 72 hours prior to the last dose.
The medication administration policy (reviewed 1/2024) states if medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain it from the contingency or convenience box.
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 observations, interviews, and record reviews, the facility failed to ensure that residents who are dependent on staff a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents who are dependent on staff assistance for toileting receive the care needed. This failure applies to 1 (R2) of 3 residents reviewed for improper nursing care.
The findings include:
On 07/09/24 at 11:26 AM, observed R2 sitting in a wheelchair in the unit dining room with other residents. R2 stated R2 was admitted to the facility this past Friday, 07/05/24. R2 stated R2 cannot use the bathroom because R2 cannot bear weight on R2's leg so R2 uses incontinence briefs. R2 stated R2 knows when R2 is wet or soiled. R2 stated, I'm wet right now and I've been wet for a couple of hours now R2 stated the last time R2 was changed was around 6:45-7:00 AM this morning and that no one had asked R2 since then if R2 was wet or needed to be changed.
On 07/09/24 at 11:43 AM, V6 (Certified Nursing Assistant) stated V6 has been a CNA for four years and has been working at the facility since November 2023. V6 stated V6 checks on V6's residents every 20 minutes and that V6 is taking care of R2 today. V6 stated V6 gave R2 a bed bath and changed R2 around 7:00 AM this morning. V6 stated since then V6 has not checked with R2 to see if R2 required a change because R2 was in the unit dining room and V6 was busy taking care of V6's other residents. V6 stated V6 has not seen R2 since around 7:00 AM to see if R2 needed to be changed.
On 07/09/24 at 11:49 AM, surveyor told V6 that R2 is self-reporting that R2 is wet and needs to be changed.
On 07/09/24 at 11:50 AM, observed V6 take R2 to R2's room to change R2's incontinence brief. Surveyor heard V6 ask R2 did any staff check on you when you were in the dining room to see if you needed to be changed? and R2 replied, no, no one asked me. V6 stated someone should have asked R2 if R2 needed to be changed and R2 is alert and orientated so R2 knows when R2 is wet or not.
On 07/09/24 at 11:59 AM, after V6 provided incontinent care was provided V6 showed surveyor R2's soiled incontinent brief and stated, that's a good amount of urine. Surveyor observed R2's soiled incontinent brief to be saturated with dark yellow colored urine covering a large area of the brief. V6 stated we don't want her (R2) sitting in her (R2) urine because this could cause a skin breakdown especially if she (R2) is sitting up in a wheelchair for long periods because of all that pressure in that one area.
On 07/10/24 at 3:15 PM, V2 (Director of Nursing/Registered Nurse) stated that between the nurse and the CNA rounding on the residents is done every hour and incontinence care should be provided when the staff is doing their hourly rounds. V2 stated it is important to provide incontinence care when the resident needs it because it could help to prevent a fall, and/or wound development. V2 stated if a resident is wet, they may try to make a move to go to the bathroom which could potentially lead to a fall and if a resident is wet for an extended period of time, it could cause skin irritation which could develop into a skin breakdown. V2 stated if a resident was last changed at 7 AM then the CNA should recheck on that resident at least by 9AM and then again at 11AM. V2 stated even if a CNA's resident is sitting in the dining room all morning for activity functions it is still that CNA assigned to that resident responsibility to round on their residents and check to see if they need to be provided with incontinence care.
R2's diagnosis includes but not limited to Polyneuropathy, Monoplegia Of Lower Limb, Fracture Of Upper End Of Left Radius, Subsequent Encounter For Closed Fracture, Unspecified Fall, Need For Assistance With Personal Care, Limitation Of Activities, Unsteadiness On Feet, Reduced Mobility, Cognitive Communication Deficit, Limitation of Activities Due To Disability, Type 2 Diabetes Mellitus.
R2's Minimum Data Set (MDS) dated [DATE] documented that R2 is dependent for toileting and substantial/maximal assistance with toilet transfer.
R2's Brief Interview for Mental Status (BIMS) not completed yet. R2 was admitted to the facility on [DATE].
R2's Braden Score is 16 (At Risk) dated 07/06/24 listing additional risk factors to include R32 has a scar over bony prominence.
R2's Daily Skilled Nursing Noted dated 07/06/24 documented in part, R2 has urinary and bowel incontinence, and needs assistance with toileting.
R2's care plan documents in part, R2 is at risk for injury from falls (related to) weakness. Goals include that the facility will reduce the likelihood of the resident experiencing a fall through next review and interventions include but not limited to toilet resident in a timely manner dated 07/07/24.
Facility provided policy titled, Incontinence Care dated 1/2024 which documents in part incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown.
Facility provide policy titled, Activities of Daily Living dated 05/2024 which documents in part, a program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis.
Jun 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to properly log refrigerator temperatures; failed to label food items with a date; and failed to discard food items placed in the...
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Based on observation, interview, and record review the facility failed to properly log refrigerator temperatures; failed to label food items with a date; and failed to discard food items placed in the dining room refrigerator for residents personal use. This failure has the potential to affect all 49 residents on the first-floor unit.
Findings include:
On 06/17/24 at 10:15 am, Surveyor, V8 (Registered Nurse, RN) and V9 (Housekeeper) inspected the facility's first floor dining room refrigerator for residents personal use and observed residents personal food items stored without being labeled with a residents name, or date the item was placed in the refrigerator used for residents personal food items. Surveyor and V8 observed five bags of food with not labeled with a date or a residents name, five small containers that V8 stated was applesauce labeled with a date of 06/10/24, a small black container with brown gravy and mashed potatoes adhere to the back of the refrigerator bottom shelf without a residents name or date, and another container of an unknown food item without a residents name or date. V8 stated, This refrigerator is not cleaned every day, only on Mondays. Surveyor also observed the first-floor refrigerator temperature log used to store residents personal food items incomplete, with no temperature recorded on June 13, 2024, June 14, 2024, June 15, 2024, and June 16, 2024. V9 (Housekeeper) stated, I (V9) have not completed the temperature log for today yet.
On 06/17/24 at 10:16 am,V8 (RN) stated that when staff place residents food items in the residents personal refrigerator in the dining room, staff should place the residents name, room number and the date on the food item. When V8 was asked regarding the items in the first-floor resident personal refrigerator being discarded, labeled with a residents name or date V8 stated, I (V8) don't know why they (referring to staff) didn't do it.
On 06/17/24 at 10:17 am, V9 (Housekeeper) stated that V9 cleans and discard items in the first-floor dining room residents personal refrigerator once a week on Mondays. V9 stated that V9 discards food items without a residents name, date, or that is more than 2 days old from the dining room refrigerator for the residents personal food items. V9 explained that staff frequently place items into the residents personal refrigerators without placing the residents name or date on the food item. V9 then stated that if items are dated pass three days old in the dining room residents personal refrigerator, the item is not tossed until V9 checks the refrigerator on Monday.
V9 then explained that V9 checks the first-floor dining room residents personal refrigerator log every day when V9 is working. When V9 asked regarding the incomplete temperature log for the first-floor dining room refrigerator for residents personal food items V9 stated, I (V9) am the only one that completes the temperature log when I (V9) is here (referring to at the facility). When V9 was asked regarding the importance of checking the dining room refrigerator for residents personal use per the facility policy, V9 stated for the safety of the residents.
On 06/17/24 at 12:50 pm, V10 (Dietary Manager) stated that V10 usually monitors the dining room refrigerator for residents personal food items daily for labeling and dating. V10 stated that items that are past three days old or without a date are discarded. V10 stated that on the weekends V16 (Kitchen Manager) is responsible for checking the dining room refrigerator for residents personal food items. When V10 was asked regarding the food observed in the dining room refrigerator for residents personal food items, that were dated past 7 days old and without a labeled with a residents name, V10 stated, Housekeeping is also responsible for checking the refrigerator. I (V10) don't know housekeeping schedule for checking the refrigerator. I (V10) only know my schedule. V16 was off since Friday. When V10 was asked regarding the facility's policy for cleaning the dining room refrigerator for residents personal use. V10 stated, I (V10) don't know the policy. The policy is downstairs on my desk.
On 06/17/24 at 1:15 pm, Surveyor requested to speak with V11 (Housekeeping Director) and V9 stated that V11 was out sick and that V12 (Housekeeping Assistant) was overseeing the housekeeping department in V11's absence.
On 06/17/24 at 1:19 am, V12 (Housekeeping Assistant) stated that V12's responsibilities is to watch over the building and make sure the daily routines are being completed. When V12 was asked regarding the facility's policy for dining room refrigerator for residents personal food items V12 stated that V12 was not sure of what V12's job duties were as it pertained to the dining room refrigerator for residents personal food items. V12 stated, I (V12) am not 100% sure but I (V12) can find out. V12 denied any knowledge of R1 having concerns with R1's food items stored in the dining room refrigerator for residents personal use being thrown away by staff.
On 06/17/24 at 1:28 pm, V2 (Director of Nursing, DON) stated that V2 has been the DON at the facility since April 2024. V2 stated that residents, residents family members, and staff can store residents personal food items in the residents personal refrigerator in the unit dining room area as long as the item is labeled with a date and the residents name and room number is placed on the food item. V2 stated that both the kitchen and the housekeeping department are responsible for cleaning the residents personal refrigerators in the dining rooms once a week. V2 further explained that residents home cooked food items and restaurant food items are able to be stored in the dining room refrigerator for the residents personal food items use for up to three days before kitchen and housekeeping staff are responsible for discarding the items. V2 stated that store brought food items with the product expiration date are discarded according to the product expiration date. When V2 was asked what happens to items that should be discarded within three days that are left in the dining room refrigerator for residents personal food items before the kitchen and housekeeping scheduled weekly check and V2 stated, Items can potentially be in the refrigerator several days after they should have been tossed because the refrigerator is only checked once a week. V2 was asked regarding the importance of the dining room refrigerator for residents personal food items are being monitored and checked per the facility's policy and V2 stated, To ensure no expired foods are stored in the residents personal refrigerator, so the residents don't get sick and for the residents safety.
The facility's policy dated 04/29/24 and Titled Menu and Nutritional Adequacy documents, in part: Policy: Residents, family members and visitors are permitted to bring food in for the residents to enjoy. Due to the potential for foodborne illness or interference with nutritional treatment, residents, family members, and other visitors who bring in food/drink in from the outside will be educated on safe food handling practices as well as the importance of diet order compliance. Foods or beverages brought in from the outside will be monitored by staff for spoilage, contamination, and safety. Procedure: 3. Foods or beverages brought in from the outside will be assessed for diet compliance and labeled and dated with the residents name, room number and the date the item was brought into the facility for consumption/storage . 11. Cooked or prepared foods brought in for a resident will be stored in the resident's personal refrigerator or in the facility's appropriate pantry or refrigerator. a. They will be appropriately labeled and dated when accepted for storage and the discard dated in 48 hours . 15. All refrigerators in use in the facility have an internal thermometer to monitor temperature. A. All refrigerators have their internal temps (temperatures) recorded daily.
The facility's document dated January 2024, February 2024, March 2024, April 2024, May 2024, and June 2024 and titled Refrigerator Temperature Log shows incomplete temperatures recorded for June 13, 2024, June 14, 2024, June 15, 2024, and June 16, 2024.
The facility's job description document dated 08/2020 and titled Food Services Director documents in part: As the food Services Director, you are responsible for management, supervision and direction of the food service staff and program within the facility . Essential Job Functions: Ensures that established sanitation and safety standards are maintained.
The facility's undated job description document and titled Housekeeping Director/Assistant documents, in part: Summary: The primary purpose of the Housekeeping Director is ensuring the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standard, guidelines ad regulations governing our facility, and as may be directed by the Administrator, and/or the Director of Environment Services, to assure that our facility is maintained in a clean, safe, and comfortable manner. Responsibilities: Ensure that work/cleaning schedules are followed as closely as practical.
Apr 2024
4 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
Quality of Care
(Tag F0684)
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 (A) failed keep one resident [R1] head of the bed elevated, and failed to pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility (A) failed keep one resident [R1] head of the bed elevated, and failed to provide one to one feeding assistance, (B) failed to follow their code blue policy to call 911, R1 was unresponsive and having difficulty breathing, (C) failed to notify the physician in a timely manner of an acute change in condition, and failed provide an accurate report to the physician, (D) failed to relay STAT (immediate) laboratory and diagnostic test results to the physician. These failures resulted in R1 higher level of care being delayed, R1 experiencing an acute change in condition and subsequently expiring on 3/3/24 in the facility.
This was identified as an Immediate Jeopardy which began on 3/2/24. On 4/11/24 at 9:14 AM, the administrator was notified of the immediate jeopardy.
The immediate jeopardy was removed on 04/16/2024 at 12:24 PM. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan.
Findings Include:
R1's clinical record indicated in part; R1 was admitted to the facility on [DATE] with medical diagnosis of pneumonitis due to inhalation of food and vomit, dysphagia, cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, visuospatial deficit and spatial neglect, memory deficit, , protein-calorie malnutrition, muscle weakness, cognitive communication deficit, dysphagia, essential (primary) hypertension, attention-deficit hyperactivity disorder, weakness, gastrostomy, and generalized anxiety disorder.
R1's care plan dated 2/27/24:
-R1 needs the head of bed elevated 45 degrees during and thirty minutes after tube feeding.
-Monitor R1 and report to physician if noted aspiration, shortness of breath, abnormal lung sounds, abnormal lab values, nausea or vomiting.
R1's physician orders:
-2/27/24 - Aspiration Precautions:
Keep HOB elevated during and 30min after G/T Feedings and 1:1 Feed with Pureed Diet and HTL [Honey think liquid] every shift.
-2/27/24- four times a day flush enteral tube QID with 150 mL [milters] of water after feeding.
-2/27/24 - four times a day enteral feeding: Jevity 1.5 360ml bolus QID [four times per day].
-2/27/24- general diet, pureed texture, honey thick consistency with one-to-one feeding assistance.
-3/2/24 -Oxygen at 2-3L/nasal cannula as needed to maintain O2 Sat at 93% or greater every shift.
-3/2/24 (14:42)- - Oral Suction at bedside. Suction PRN [as needed].
-3/2/24 (14:40) - Robinul Oral Tablet 1 MG, give 1 mg via G-Tube every 12 hours for drooling /excessive secretions.
-3/2/24- CBC, BMP, Magnesium level STAT
- 3/2/24 Chest Xray STAT
- 2/28/24- Monitor vital signs every shift for 30 days then daily
R1's laboratory reported dated 3/2/24 indicated the lab results were faxed to the facility on:
-Complete Blood Count [CBC] at 11:16 PM.
-Basic Metabolic Panel [BMP] at 11:47 PM.
[Lab Results was never Relayed to a Physcian]
R1's progress notes documented in part:
V8 [Speech Pathologist/Therapist] Note documented in part:
On 2/29/24- Recommendations for R1, to continue puree diet, with 1:1 assistance and to follow R1's swallowing precautions: only feed when alert, up right at 90 degrees for all meals, reposition as needed, aspiration precautions, monitor or pocketing, small bites, small sips, alternate liquids, and solids, monitor for signs and symptoms of aspiration related illness.
V3 [Nurse Practitioner] Note: 3/2/2024 at 3:51 pm CHIEF COMPLAINT: R1 is a [AGE] year-old male seen today for a follow-up skilled SAR visit to manage multiple medical conditions. R1 had a PEG placed on 1-04 2024. R1 stabilized transferred here from inpatient rehab to subacute rehab. Pt seen today alert, nonverbal, not following commands. Pt in NAD [No Apparent Distress]. Scattered Rhonchi and cough noted during my exam. Pt appeared to have difficulty clearing his airway. I [V3] ordered bedside suction and Robinul for excessive secretions.
V5 nursing progress note: 3/2/24 7:19 pm
Note: R1 is breathing easy. V/S [Vital Signs] 98.7,89,18,124/80,02 R.A @ 92%. V31 instructed to maintain R1 in an upright position to prevent reflux.MD order CXR & magnesium level stat with CBC/differential. Orders carried out.
V5 [Registered Nurse] nursing progress note 3/2/2024 9:19 pm Note: V31[Certified Nurse Assistant] found R1 shaking and called nurse-observed pt having secretions coming out of nose and mouth. R1 regurgitated. Having difficulty breathing. Congestion noted on listening to lung sounds. V3 [Nurse Practitioner] was in house earlier on today and ordered oral suction at bedside PRN [as needed]. R1 was suctioned and stabilized. Respiration even non labored.
[Nurse failed to document code blue was initiated]
V30 [Telehealth Physician] Note:
3/2/2024 at 9:03 pm
telehealth evaluation (other)
Date of Service: 03/02/2024 8:09 PM CT
Details: Nurse Name: V24 [ Nurse Supervisor/Licensed Practical Nurse]
Patient Name: R1
Primary Chief Complaint: General: Chills
History Present Illness: [AGE] year-old male with past medical history of dysphagia status post G-tube, hypertension. Earlier today got his bolus feed. Nurse performed bedside suctioning but has lot of secretions, mucus coming out of nose and mouth had chills per CNA [Certified Nurse Assistant-V31], no AMS [altered mental status]
Vital Signs: T [temperature]: 98.7 (°F), HR [heart rate]: 89 (bpm), BP [blood pressure]: 124/80 (mm/Hg),
RR [respirations rate]: 18 (rpm), SpO2: 92 (%), Pain Level: 0)
Physical Exam: Exam findings per nurse Physical Exam - Notes: GEN NAD [ No apparent distress]
Respiratory: congested on room air, Diagnosis, Assessment/Plan: Chills (without fever) (Primary)
The patient's condition is stable. This is an acute new problem. Nurse performed patient concern is aspiration pneumonia although he is not having any respiratory stress at time of this evaluation. Will order labs and chest x-ray. Technology Used: Audio and video with patient and nurse present.
Statement of Medical Necessity.
[V24 failed to tell the Physician: Code Blue was initiate, R1 was found laying flat, R1 was self-feeding, R1 has an emesis with food particles projecting out of his nose and mouth, and started on supplemental oxygen to sustain oxygen levels of 92%.]
V29 [Agency Registered Nurse] Nurse Progress note: 3/3/2024 07:50 AM
Note: Received R1 in bed awake and alert lying upright in bed verbally responsive. Notified by CNA [V31-Certified Nurse Assistant] that R1 was unresponsive patient found lying upright in the bed pulselessness code blue called, CPR initiated and 911 called, blood sugar 171 BP 111/54 CPR continued until fire department arrived.
There was no documentation on (3/2/24) 7AM-11PM from V4 [Licensed Practical Nurse] no progress note, no vital signs.
There was no documentation on (3/2/24) 11PM-7AM V36 [Agency Registered Nurse], no progress note, no vital signs.
Interviews:
On 3/26/24 at 4:21 PM, at V6 [R1's Family Member] stated, On 3/2/24 I went to the facility approximately 5:30 PM. Upon arrival to the facility R1's door was closed; I thought the staff was changing his under brief at the time. Then I saw nursing staff going in and out of his room running pass me and no one said a word to me. A few seconds later, I heard over the intercom speaker code blue for R1's room number. I asked V5 [Registered Nurse] coming out of R1's room what was going on. V5 told me that R1 was lying flat down in bed eating and aspirated. When V5 went back into the room I went in the room with him. I saw R1 foaming at the mouth and nose, not responding with his eyes closed and V4 [Licensed Practical Nurse] was suctioning R1. Another young lady brought in oxygen and V4 started oxygen on R1. A few minutes later R1 opened his eyes and was looking around. V4 and V5 left out the room, and I asked R1 was he okay, he turned his head side to side meaning no. R1 can usually say simple words like yes or no, but R1 could not talk. After staying with R1 for a few hours, he continued coughing, drooling, and I can hear his chest rattle when he breaths in and out. I asked V5 at the nursing station was my father going to be alright, V5 said yes, he will be okay, for me to go home and rest. On 3/3/24 at 8:42 AM, a nurse called me from the facility and said she was sorry R1 passed away 45minutes ago.
On 3/26/24 at 12:44 PM, V8 [Speech Pathologist/Therapist] stated, I completed R1 speech evaluation and worked with him. R1 had a medical diagnosis of dysphagia with moderate oral phase. R1 would have oral phase trace residue 4 out of 4 exercises. R1 would have a little food left on his tongue. With drinking honey thick liquid, R1 would have some liquid come out of his mouth that he did not swallow. My recommendations for R1 were to continue puree diet, honey thick liquid, one-to-one feeding assistance and follow aspiration precautions. On 2/29/24, I placed R1's aspiration precautions at the head of his bed under a privacy cover. The top cover read 'Please see attached swallowing precautions', underneath I listed the following: [only feed when R1 is alert, feed him in an upright 90-degree position, and reposition as needed, due to R1's past stroke he would lean to the side, small bites, and small sips of liquid]. During mealtime if R1 was noted coughing, chest congestion, rattle, or difficult breathing staff was notified to stop oral intake and notify R1's provider for further instructions.
On 3/26/24 at 6:26 PM, V5 [Registered Nurse] stated, On 3/2/24 around 5PM, V4 [Licensed Practical Nurse] yelled out for my help and said code blue in R1's room. V4 was the assigned nurse for R1. When I went into the R1's room I saw R1 lying flat down in the bed throwing up food, out of his nose and mouth, with his dinner tray in front of him, not responsive and having a hard time breathing, R1 was weak and limp. V4 sat R1 up in bed, and I ran and got the crash cart while V4 was suctioning R1. I sent V31 [R1's Certified Nurse Assistant] to get the oxygen tank. R1's oxygen level was reading in the 70's percentile. After suctioning and started oxygen R1 started to come back around. R1 started breathing and looking around. R1 continued to cough, and I could hear chest congestion, but he was back breathing and stopped vomiting. I did not call 911 when R1 was unresponsive because R1 was left lying down in bed and aspirated, that situation could be managed by nursing interventions. When I left out the room, V6 [R1's Family Member] asked me what was going on with R1. I explained R1 was left flat and aspirated, but he was okay now. I spoke to V31 and gave her education that no one with a gastric feeding tube should ever be laid flat in bed, and R1 was a one-to-one feed assist, R1 was not to receive a dinner tray to eat alone. V31 said she understood, and that she did not see the sign above R1's head. I documented a brief note in R1's chart to help out V4, because she [V4] was having a rough night with her set of residents. I documented vital signs after R1 was stable in my progress note, not on the electronic medication sheet. I did not document the vital signs during his code blue. I thought V4 would chart a complete progress note and assessment to what happened with R1, V4 was his assigned nurse. I worked 3/2/24 night shift, but I did not have R1 on my assignment.
On 3/26/24 at 1:01 PM, V9 [Certified nurse Assistant] stated, I worked with R1 on 3/2/23 morning shift. R1 was alert but nonverbal, he understood what I would say by following commands and nodding his head yes or no. R1 had a gastric feeding tube, and he received a food tray. I did not remember if I fed R1 on 3/2/23. R1 had a post at the head of his bed with his feeding instructions. R1 needed to be sitting up, fed slowly one to one, with small bites of food. I do remember R1 being congested, I could hear a rattle in his chest, and I notified the nurse [V4-Licensed Practical Nurse]. The next day, I worked with R1 on 3/3/24 day shift. During rounds, I notice R1's breathing was off, with his lips curled back in his mouth and his mouth was open. I reported my findings to the nurse [V29- Agency Registered Nurse]. V29 told me R1 was lying down in bed and aspirated on his food yesterday evening (3/2/24), and he was awake all night needed suctioning throughout the night, and R1 was okay he was just tired. After I passes the breakfast trays, I went to collect the trays around 9AM. I went to collect R1 breakfast tray and noticed he was not breathing. I ran and got the nurse. V29 [Agency Registered Nurse] started CPR, I called the code, and other nurse called 911. Then I went out in the hallway assisting other residents. I did not attempt to feed R1 any breakfast, because he was sleeping.
On 3/26/24 at 12:10 PM, V7 [Physician] stated, I am R1's physician, V3 [Nurse Practitioner] and I manages R1's care. The rule from the facility and Third Eye, told me if I receive a phone call from the facility staff not to answer the phone after 7PM during the weekdays and not to answer after 7PM on Friday until Monday morning. I only seen R1 one time, he was alert and non-verbal on a pureed diet. R1 also received nutrition via gastric tube due to poor oral intake. I was notified on 3/2/23, there was mild episode of R1 coughing earlier that day, but R1 lung sounds were clear, and R1's oxygen level did not drop, he was not receiving supplemental oxygen. The second episode later that evening (3/2/24) when there was a code blue for R1 due to him vomiting, coughing and need suctioning. R1 became stable with 3-4 liters of oxygen and suctioning, R1 was okay to remain in the facility, with the chest x-ray ordered. A chest x-ray would have ruled out aspiration pneumonia or any mechanical issues. I was not made aware of R1's blood work results or chest Xray that was ordered from V30 [Third Eye Physician]. However, If R1 continued to cough, could hear chest rattle congestion sounds, and need frequent suctioning that lasted at least four hours, then V30 should have been notified and R1 should have been sent out the hospital emergency room for further evaluation.
On 3/27/24 at 2:50 PM, V31 [Certified Nurse Assistant] stated, I took care of R1 on 3/2/24 during second shift. I made rounds and R1 was resting in bed. Dinner trays came up and I passed out the food trays, and I gave R1 a dinner tray as well. I did not reposition R1 or raise the head of bed up. Approximately around 5:30 PM, I was walking down the hallway picking up the dinner trays. I went into his room and saw half of his food missing from the food tray and he was making gurgling gasping sounds with vomiting coming from his nose and mouth. The vomit looked like it was his dinner, with food particles. R1 was lying down in bed and leaning on his side, shaking like he was having a seizure, and his eyes was rolled back into his head. I ran out and got the nurse V4 [Licensed Practical Nurse]. V4 went into R1's room and yelled out for help. V4 said R1's is aspirating and get the crash cart. V5 [Registered Nurse] came running into the room to help with the crash cart. V5 called over the speaker system code blue to R1's room, and other nurses came to help. I passed R1 his dinner tray, I did not know R1 needed one to one feeding assistance. I thought he could feed his self. After the code, V5 asked me if I gave R1 a food tray and did R1 feed himself alone. I told V5 I did give R1 his food tray, but I did not know R1 was a one -to-one feed assist. V5 told me that R1 was lying down too far and aspirated on his dinner while eating alone. V5 told me that R1 should have sitting up 90 degrees due to his aspiration precautions, and I needed to feed R1.
[Survey showed V31 the sign that read 'Please See Attached Swallowing Precautions']
V31 stated, I saw the sign that was on the wall, above R1's head of bed after R1 coded, I did not pay attention to the sign before he aspirated. I did not read the swallow precautions.
On 3/27/24 at 3:50 PM, V24 [Nurse Supervisor-Licensed Practical Nurse] stated, I was working on the second floor and heard code blue to R1's room around 5PM. When I peeped my head into R1's room V4 and V5 was working on R1. I did not go into R1's room. I went back to my floor. A few minutes later there was another code blue called for another room on the first floor. I went to that code and assisted with CPR. I do not remember video calling Telehealth physician for R1. I do not remember what happened to R1.
[Surveyor showed V24 her progress nursing note dated 3/2/24 at 8:09 PM with the Telehealth physician.]
V24 stated, I see the documented progress noted dated 3/2/24 at 8:09 with my name, but I cannot remember. To access a call with a Telehealth physician, each nurses have their own individual log in and passwords to access the video call. No one could document or call the Telehealth Physician under my name; I must have called the Telehealth Physician. I am so confused, and I do not recall the code for R1 on 3/2/24. I do not know why I called the physician three hours after the code blue, and V4 did not call, she was R1's nurse not me. I am not trying to give you [surveyor] a hard time, I just cannot remember. It does not make any sense that I would call the physician and did not know what happened to R1, I had no information. I don't know what to say, because I was not in the room with R1's code. I have no more information to give you.
On 3/27/24 at 4:48 PM, V30 [Telehealth Physician] stated, I received a request for telehealth visit at 8:09 PM for R1. V24 explained that R1 had some mucus, chills, with stable vital signs, no fever, and no respiratory distress. V24 told me she had concern of aspiration pneumonia, but R1 was stable without any respiratory distress noted, I ordered blood work and a chest x-ray to be completed as soon as possible, meaning STAT. I knew the test would be completed by an outside agency to perform the test, so STAT would mean to complete soon as possible. I was not made aware that code blue was called in the facility for R1 at 5PM, three hours prior to calling me. I was not made aware that R1 was found lying flat in bed, unresponsive, oxygen level in the 70's percentile, threw up food particles out of his nose and mouth, having difficulty breathing, needed to be suction, started oxygen, and needed continuous oxygen to sustain a blood oxygen of 92%. If V24 gave me a complete accurate report of R1's condition, I would have given an order to send R1 to the hospital. I did not know R1 labs came back, and his white blood count was 15, and chest Xray showed early infiltrates in the right lung base. No one from the facility notified me or my staff at the Telehealth of the test results. Those results indicated R1 aspirated, and now developing pneumonia. If I would have received the test results, I would have sent R1 to the emergency room.
On 3/27/24 at 1:22 PM, V29 [Agency Registered Nurse] stated, I worked on 3/3/24, with R1 and received in report from V36, that R1 had aspirated the day before [3/2/24]. During making rounds at the start of my shift, R1 was awake, and alert sitting upright in bed. A little while later, V9 [certified nurse assistant] came and told me R1 was not looking right. I went immediately and noted R1 was sitting up in bed, nothing coming from his mouth or nose. R1 was not breathing and did not have a pulse. I started CPR, called code blue, and 911. I notified the physician, and family. 911 was unable to resuscitate R1. 911 did not remove the body, R1's family had the funeral home pick up R1.
On 3/27/24 at 3:20 PM, V3 [Nurse Practitioner] stated, R1 has a gastric feeding tube and oral pureed diet with honey thick liquids. I assessed R1 earlier in the afternoon on 3/2/24, I was in the facility, he had some rhonchi and coughing. I did not order a chest Xray because R1 had the same symptoms in the hospital, it was his baseline. I ordered a medication called Robinul for excessive secretions, and a suction machine at the bed side. I felt the medication would assist with drying up the secretions. The evening of 3/2/24, was on a Saturday, the facility policy is during the week after 7PM, and on weekends the nursing staff is to call Telehealth Physicians on call service for assistance and change of conditions with residents. I was not notified on 3/2/24, that code blue was initiated for R1. If the facility staff called code blue, and R1 oxygen decreased in the 70's percentile, 911 should have been called. I did not receive any test results from R1's labs or chest x-ray from 3/2/24.
On 3/27/24 at 1:45PM V2 [Assistant Director of Nursing] stated, Residents with a gastric feeding tube should never be lay down flat, the head of bed should be elevated at all times at least 45 degrees. R1 had a gastric feeding tube and received oral diet with specific swallow aspiration precautions. R1's physician order dated 2/27/24, aspiration precautions, to keep head of bed elevated during and 30-minutes after gastric tube feedings and 1:1 feed assistance with all meals. The speech therapist places an instruction sheet on the wall above resident's bed that is on swallowing precautions as a reminder for staff. 1:1 feed assistance means R1 needed to receive assistance with all meals, R1 needs to be fed by a nursing staff member and to follow the swallow aspiration precautions. If a resident with a gastric feeding tube lays flat in bed, the resident could potentially aspirate. If a resident with 1:1 feed assists with meals, self-feed the resident could potentially aspirate. Whenever the nursing staff calls a code blue, 911 should have been phoned. Any change of condition, once the nurse cares for the resident, the nurse should call the physician right away. If a change of condition occurs around 5PM, it is unacceptable for the nurse to notify the physician 3-hours later at 8PM. STAT Labs (blood work), and chest Xray abnormal results, should be relayed to the physician right away. Not relaying results, is delaying potential treatment. The agency nurses and our staff nurses all have access to look up the lab results. If the results were not available, the nurse could call the lab for the results. Each nurse has their own Telehealth log in username and password. No one should share their passwords, log in information with anyone it is against HIPPA.
On 3/28/24 at 4:48 PM, V4 [Licensed Practical Nurse] stated, I worked with R1 on 3/2/24, I worked first shift 7AM to 3PM and second shift 3PM-11PM. Around 5:30 PM, V31 [Certified Nurse Assistant] came to me in the hallway and said R1 was not breathing and was throwing up food out of his nose and mouth. I entered the room and R1 had difficulty breathing, not responsive, eyes were half open his eyeballs were rolling up and he was vomiting lying down in bed. V5 [Registered Nurse] came in to help me and called code blue. I pulled R1 up in bed and started to suction him and V5 applied oxygen. I did not remember R1's blood oxygen level, or his vital signs during the code I did not write them down or input the vitals in R1 electronic chart, I was busy. After suctioning and giving him oxygen, R1 came back around, alert, and looking around, R1 became stable and was okay. I did not chart on R1, V5 and V24 [Nurse Supervisor] help me chart that day because there were a couple of code blues on the same day and same time. I did not call the Telehealth Physician, V24 called telehealth and spoke with the physician. I do not know what time V24 called the physician. V24 called in labs and chest x ray to be completed STAT. No, I did not receive any test results, maybe the results came in on 11PM-7AM shift. [Surveyor asked V4 why she did not call 911.] V4 stated, I did not call 911, because R1 was stable after I suctioned him and started him on oxygen. I was able to handle the situation.
On 4/9/24 at 1:05 PM, V2 stated, her investigation showed V24 did call the Telehealth Physician and gave report to V30.
On 4/9/24 at 12:11 PM, V38 [Certified Nurse Assistant] stated, I been working at the facility for five months. I worked on 3/2/24 from 10PM to 6AM. R1 was cleaned and changed twice that shift. During ADL incontinent care, I left R1 head elevated, he was never laid down flat. R1 was woke through the night, coughing, and I could hear chest congestion like a rattle, and V36 [Agency Registered Nurse] kept suctioning him. R1 looked normal but was sweating and clammy. Other than R1 sweating, he looked okay, and R1 was non-verbal as usual. I did not take R1's vital signs, the night shift aides don't take the vital signs the day shift aides take the vitals.
On 4/9/24 at 11:50 AM, V36 [Agency Registered Nurse] stated, I worked at the facility twice. I've been a registered nurse for ten years. On 3/2/24 I worked 11PM to 7AM, and that was my last time working at the facility. I got report from V4. She [V4] told me, on second shift, R1 aspirated while lying flat in bed feeding himself, and she suctioned R1 very well, the physician was notified, order blood work and chest x-ray. I received R1 sitting up in bed, awake, alert, non-verbal and he was sweating. I kept a cold face towel on his forehead to keep him cool and removed the cover off his feet. I made sure R1 was sitting straight up in bed, because he was coughing, I could hear chest congestion, and secretions coming out of his mouth. R1 needed frequent suctioning, at least a couple times per hour. I did not call the physician because V4 said she already called the physician. I did not receive R1's blood work or chest x-ray report. I am an agency nurse and do not have access to check the results. It did not occur to me to ask another staff nurse to print of R1's results, I was so busy with the other residents and suctioning R1 that I did not have time to ask another nurse. I did not chart on R1 because I was too busy taking care of the other residents. I took one set of vital signs, but I did not place the vital signs in R1's electronic chart, I just ran out of time and forgot to put them into the system. I do not remember the vital signs; I am sure they were normal. On 3/2/24, was my last time working at that facility. V2 placed me on the DNR [Do Not Return] list. V2 did not give me any reason why I could not return to the facility. I did not go back into the system and place in any vital signs later after I left the faciity on 3/2/24, I did not have access to the facility's system.
On 4/9/24 at 10:26 AM, V9 stated, I started work on 3/3/24 at 6AM. I started making rounds around 6:15-6:30 AM. When the food trays came to the floor, all staff assist with passing out food trays. I did not pass R1 his breakfast tray, but someone gave him a breakfast tray. When I was walking on the unit to collect the breakfast trays around 9:30 AM, R1 was sitting up in bed, leaning to the side and was not breathing. R1 was not throwing up, nothing was coming up from his mouth or nose. I called for the nurse, and she started CPR, called code blue, and called 911. R1's food tray was untouched. R1 was in deep sleep and did not wake up to eat anything.
On 4/9/24 at 11:01 AM, V3 stated, During the weekdays from 7PM to 7AM, and from Friday 7PM to Monday 7AM the Telehealth Physicians are on call. If a nurse reaches out to the Telehealth Physician on call service, that physician is responsible for the resident's care. Any resident that is lying flat down that has a gastric tube feeding, has the potential to aspirate. If any resident that has high risk for aspiration, swallowing precautions, and must have one to one feeding assistance, is given a meal tray and the resident self-feed alone, has a potential to aspirate.
On 4/9/24 at 10:48 AM, V7 stated, Telehealth Physicians are responsible for that resident's care and making health decisions during that on call time. If R1 was feeding himself alone, and he was on swallowing precautions one to one feed it could potentially cause R1 to aspiration. If R1 was lying flat, he has a potential to aspirate.
On 4/9/24 at 12:26 PM, V37 [Director of Nursing] stated, I been working here since 4/1/24. I been a registered nurse since 2007, and six years of director of nursing experience. If nurse calls out code blue, the nursing staff should check advance directives, start CPR, and to call 911. If a resident that has a gastric feeding tube lays flat, they could potentially aspirate. The staff should never give or place a food tray to a resident that is 1:1 feed assist, due to aspiration swallow precautions, the resident could potentially aspirate. The laboratory can call or fax the lab results. The nursing staff can also call the lab for results as well. Our nursing staff and agency nurses all have access to the computer system to look up lab results as well. When there is a change in condition, the assigned nurse should notify the physician to give a accurate report of the resident's condition and document the change, orders, and vital signs.
R1's care plan dated (2/27/24) documents in part:
-R1 needs the head of bed elevated 45 degrees during and thirty minutes after tube feeding.
-Monitor R1 and report to physician if noted aspiration, shortness of breath, abnormal lung sounds, abnormal lab values, nausea or vomiting.
Facility's Policy Code Blue dated (1/10/24) Documented in part:
-A code is initiated for all residents requiring emergency medical attention
-If a resident requires emergency medical attention, then a code blue should be announced
-As staff arrive staff should, call 911, notify the physician and family
Facility's Policy Change in Resident Condition: dated (1/10/24) documents in part:
-It is the policy of the facility, except in a medical emergency, to alert the resident's physician and resident's responsible party of a change in condition.
-Nursing will notify the resident's physician or nurse practitioner when there is a significant change in the resident's status; when there is s significant change in the resident's status, when it is deemed necessary or appropriate in the best interest of the resident.
-Communication with the physician will be documented in the resident's medical record
Facility's Policy Documentation dated (1/24)documents in part:
-Documentation should include any change of condition of the resident
-Any communication with the physician, or nurse practitioner should also be documented.
Facility Assessment Tool dated (1/24) documents in part:
Licensed Staff: Identification of resident changes in condition - identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life.
Facility policy Critical Lab Results Reported dated (1/10/24) documents in part:
The facility will communicate the results of test considered critical to the patient care to the responsible licensed caregiver in a timely and reliable manner.
The surveyor confirmed through observation on 04/16/2024, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: the facility completed all measures on the abatement plan. Therefore, the abatement plan could be approved on 04/16//2024.
Abatement Plan:
1A. The Director of Nursing [V37], Assistant Director of Nursing [V2] and Administrator [V1] educated all nursing staff on 4/11/24 that all residents that need 1:1 feeding assistance must be provided 1:1 assistance and that the head of the bed will be elevated, and residents properly position during and after feeding. Staff were educated that they can find the plan of care for any resident in the Kardex for the resident or the CNA [Certified [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
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 staff failed to provide necessary treatment and services to promote healing an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility staff failed to provide necessary treatment and services to promote healing and prevent infection of an existing pressure ulcer for 1 (R2) of 4 (R4, R7, R8) residents. R2 was admitted to the facility on [DATE] with a pre-existing pressure ulcer, however the facility was unable to provide consistent documentation that the physician ordered treatments for R2's sacral pressure ulcer was documented on from 03/06/24 through 03/11/24 and 03/12/24 through 03/17/24. The deficient practice resulted in R2 sacral wound becoming infected.
Findings Include:
During record review R2's sacral wound initial assessment documentation dated 03/05/24 with the second assessment dated [DATE] during which time R2 sacral wound evolved with no further wound documentation. R2 was admitted to the hospital on [DATE] with a diagnosis of Infected Decubitus Ulcer and received IV (Intravenous) antibiotics.
R2 was admitted to the facility on [DATE] with diagnosis not limited to Paroxysmal Atrial Fibrillation, Essential (Primary) Hypertension, Hyperlipidemia, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Dysarthria Following Cerebral Infarction, Fall, Ataxia, Cerebral Infarction, Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Chronic Atrial Fibrillation, Acute Kidney Failure, Repeated Falls, Encounter for Other Orthopedic Aftercare, Muscle Weakness, Dysphagia, Difficulty in Walking, Cognitive Communication Deficit, Weakness, Urinary Tract Infection, Pressure Ulcer of Sacral Region, Unstageable, Pressure-Induced Deep Tissue Damage of Left Heel, Disruption of External Operation (Surgical) Wound, Pressure induced Deep Tissue Damage of Right Ankle and discharged to the hospital on [DATE]. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 13 indicating intact cognitive response.
Order Summary Report document in part: Complete weekly skin checks to ensure no new skin alterations are present. Sacrum/Xeroform one time a day every Tue, Thu, Sat cleanse with ns (normal saline) pat dry apply treatment cover with dry dressing order date 03/05/24. Sacrum/Medihoney & Silver Ag (Alginate) one time a day every Mon, Wed, Fri cleanse with ns pat dry apply treatment cover with dry dressing order date 03/13/24. Cefdinir Oral Capsule 300 mg (milligram) give 1 capsule by mouth every 12 hours for 7 days order date 03/11/24. Collagenase Ointment 250 Unit/GM (gram) Apply to sacrum topically as needed for itching order date 03/12/24. Collagenase Ointment 250 Unit/GM (gram) Apply to sacrum topically everyday shift for itching cleanse with ns (normal saline) pat dry apply treatment cover with dry dressing order date 03/12/24.
Treatment Administration Record: document in part: Sacrum/Xeroform one time a day every Tue, Thu, Sat cleanse with ns pat dry apply treatment cover with dry dressing -D/C (discontinue) Date- 03/17/24 with missing initials on 03/09/24 and 03/16/24. Sacrum/Medihoney & Silver Ag one time a day every Mon, Wed, Fri cleanse with ns pat dry apply treatment cover with dry dressing -D/C Date- 03/17/24.
Care Plan document in part: Focus: Nutritional Status: Focus: Skin: At risk for skin complications. Focus: R2 is at Risk for alteration in skin integrity R/T (related/to) self-care deficits, Impaired mobility, and comorbidities. Interventions: Remind/Assist resident to reposition frequently. Provide peri-care after each incontinent episode and apply barrier cream. Focus: R2 has a pressure injury R/T self-care deficits, Impaired mobility, and comorbidities. Site: Sacrum Site: Left heel Site: Right medial knee Date Initiated: 03/06/2024. Focus: R2 has an alteration in skin integrity R/T self-care deficits, Impaired mobility, and comorbidities Date Initiated: 03/06/24.
Patient Risk Profile dated 03/05/24 document in part: Braden score 14 (Moderate Risk).
Most Recent Risk Assessment: Braden Score: 14 (Moderate Risk) dated 03/11/24.
Wound Assessment Details Report assessment date 03/05/24 document in part: Wound: Sacrum, Status: Active, Type: Pressure, Classification: Ulceration, Source: Present-on-admission, Date identified: 03/05/24, Clinical Stage: Deep Tissue Pressure Injury. Tissue Types: Deep Maroon = 65%, Bright Pink or Red = 25%, Slough loosely Adherent 10%. Size: 8.50 x 15.00 x unknown. Resident is incontinent of b/b (Bowel/Bladder) and able to verbalize needs.
Wound Assessment Details Report assessment date 03/12/24 document in part: Wound: Sacrum, Status: Active, Type: Pressure, Classification: Ulceration, Source: Present-on-admission, Date identified: 03/05/24, Clinical Stage: Unstageable. Tissue Types: Bright Pink or Red = 20%, Slough loosely Adherent = 80%. Size: 8.00 x 14.00 x unknown. DTI (Deep Tissue Injury) evolved, wound site 70% slough and 30% non-granulation.
Progress note dated 03/04/24 18:21 document in part: Nursing Note: Uses Condom foley. Incontinent of bowel.
Progress note dated 03/04/24 19:48 document in part: Medical Practitioner Note HPI: Pt (patient) seen today to manage multiple medical conditions. Sacrum 03/05/24 Pressure Ulceration Active Unstageable Sacral wounds - Consult wound care.
Progress note dated 03/11/24 14:37 document in part: Skin/Wound Note Text: Received call from (R2 family member) gave a wound update, advised (R2 family member) that writer would know more on tomorrow after assessment is complete.
Progress note dated 03/13/24 16:38 document in part: Social Service Note: IDT (interdisciplinary team) met with (R2 family member) via phone. Wound nursing and MD (Medical doctor) reviewed wounds, treatments, stage (unstageable).
Progress note dated 03/17/24 17:51 document in part: Nursing Note: Brought to writer's attention by residents' (family members) that they want their father sent out of the facility because R2 wound is not healing to them and that they feel like R2 got an
infection in the wound.
Progress note dated 03/17/24 19:35 document in part: telehealth evaluation (other) Date of Service: 03/17/24 6:34 PM CT Primary Chief Complaint: Skin: Pressure Wound History Present Illness: Family believes that patient is not getting good care and think the wound has worsened. They want R2 transferred back to the hospital. They believe it is infected and do not want to wait to talk to primary or wound care. Physical Exam: Exam findings per nurse and video observation. SKIN: Patient with large sacral wound Diagnosis, Assessment/Plan: - Pressure ulcer of sacral region, unstageable (Primary) The patient's condition is worsening. Transfer patient to hospital per requests of family.
Hospital record dated 03/17/24 document in part: Specimen Information Culture: wound collected 03/18/24: Moderate Corynebacterium species. Moderate Escherichia coli. ESBL (Extended Spectrum Beta-Lactamase) positive status. Skin: Comments: Stage 2 ulcer across his (R2) sacrum, warm tender, erythematous margins with purulent discharge. History of Present Illness: Patient's ulcer does appear infected. Clinical Impression 1. Infected decubitus ulcer. The patient was started on antibiotics in the ED (Emergency Department). Assessment: Sacral Decubitus/gluteal ulcer wounds, present on admission, with concern for skin and soft tissue infection/cellulitis. Principle Problem: Soft tissue infection. Assessment: Infected sacral decubitus ulcer.
On 03/26/24 at 10:43 AM V11 (R2's Family Member) stated R2 was admitted to the facility on [DATE]. On Tuesday 03/05/24 we spoke to two certified nurse assistants and when they flipped R2 over he had an area on his buttocks. R2 wound traveled and on the last day 03/17/24 last day the wound ended up with an infection, was sore, spreading, and full of pus. R2 is now on IV (intravenous) antibiotics.
On 03/26/24 at 12:19 PM V7 (Physician) stated R2 had a wound, but I am not sure where it was or if there was drainage.
On 03/27/24 at 08:55 AM V16 (Wound Care Doctor) stated I saw R2 one time. R2 had a pressure relate wound from the sacral extending to the buttock. When R2 was admitted he had a DTI (Deep Tissue Injury) and it had evolved and progressed. It was unstageable. On 03/13/24 the sacral wound was unstageable pressure with a combination of tissue types; a quarter granulation tissue, a quarter to a third slough tissue, and half of the area was still epithelial. R2 sacral tissue was damaged on admission and evolving over the next week or two. Some DTI's resolve and some become stage 4. There were no signs of infection when I saw the wound. Physiologically when you get a DTI the tissue has been damaged and it can take a while to break down because the tissue has to necrose. The thing is if someone is wet and there is pressure that has the potential for causing further damage to the wound. If those things happen that will make the wound worst. The protocol is there to prevent those factors from convening. When showing V16 the hospital records V15 responded, Cultures show that there are bacteria present. E. coli is part of the flora of our gut because it is in proximity of the anus. The erythema will indicate an infection if the hospital says the sacral wound was infected it was infected. If the hospital had R2 there and there was a change in the wound, warm tender, and purulent drainage it evolved and became infected. If R2 was incontinent of stool and urine it is possible for the sacral wound to become infected.
On 03/27/24 at 09:23 AM V17 (Certified Nurse Assistant) stated When we would come in the morning R2 would tell us the night shift did not come in the room. I did witness R2 being wet or soiled.
On 03/27/24 at 09:30 AM V18 (Licensed Practical Nurse) stated I was here the day that R2's family members came and said R2 has a wound that is not getting better. I called the third eye zoom call and the doctor offered to do a culture, but the family refused. I did not remove R2's sacral wound dressing. I never physically saw or smelt R2's sacral wound. At times I had to reinforce R2's dressing because it was draining through with a light pink in color drainage. R2 had a bowel movement, and I changed the dressing one time.
On 03/27/24 at 11:33 AM V13 (Wound Care Coordinator) stated R2 was admitted to the facility on [DATE]. I did R2 initial skin assessment on 03/05/24. When R2 first got here R2 had a DTI (Deep tissue injury) to the sacrum. A DTI and ulceration are under the same category. R2 had 25% granulation which is more healthier pinkish reddish tissue. 65% deep maroon where the epidermis is not open but there is something going on underneath and 10% slough, bad tissue until you clear away the slough you don't know what is going on underneath. The slough tissue was within the open area. The treatment R2 started with on 03/05/24 was Xeroform. The Xeroform is like a Vaseline gauze 3 times a week. The only time documentation that is done is every 7 days when the wound assessment I done. I saw R2 a couple of times between the assessments and there was nothing major going on. I can't remember the other days that I saw R2. The Xeroform order was discontinued on 03/12/24. With the Xeroform we wanted to remove the deep maroon tissue and remove all the tissue on top of the wound. The 20% granulation was the good tissue and the 80% slough was the bad tissue. The sacral wound was not close to R2's rectum. The meaning of the wound evolving is until the maroon tissue breaks away the wound is changing. It is an expectation of the wound evolving/changing. We expected for the wound to look like it did on 03/12/24 compared to 03/05/24. Unfortunately, we are to document every 7 days on the assessment. There is no further documentation after 03/12/24. The last time that I saw R2 wound was on 03/13/24 with the wound care doctor. While showing V13 the hospital records V15 responded, E. coli is related to stool. Purulent discharge would be signs of infection.
On 03/27/24 at 02:23 PM V32 (Certified Nurse Assistant) stated R2 was incontinent of both bowel and bladder and was a total assist. R2 had a dressing on his bottom, it was brown/tan like a band aid. The last time I saw R2 his (R2) daughter peeled off the sacral wound dressing. I held R2 so that the daughter could go get the nurse. V5 (Registered Nurse) came in the room and helped me change R2. I had not seen R2's wound before. The dressing had a little red drainage on it with no odor. V5 cleaned the wound and put another dressing on.
On 03/27/24 at 03:06 PM V5 (Registered Nurse) stated I don't remember what R2's wound look like or if there was any drainage. On 03/17/24 I do recall putting the dressing back on R2 sacral wound.
On 03/27/24 at 03:30 PM per telephone interview V3 (Nurse Practitioner) stated I did not see R2's wound aside from seeing pictures from the wounds nurse. The picture with slough, redness around sacral area, the buttocks with an open area where it was kind of pink and slough. The family was concerned that R2 did not have any wounds. The goal is to remove eschar and slough, keep the pressure relieved, and turn every 2 hours. There is a high probability that E. coli could have been in R2 sacral wound. Given the position of the wound the E. coli lives near the butt. The purulent discharge is indicative of an infection. If the hospital found R2's sacral wound was infected upon being admitted the sacral wound became infected at the facility.
On 03/27/24 at 04:06 PM V35 (Certified Nurse Assistant) stated I change R2 and sometimes I did the wound dressing. The gauze dressing was dirty with stool and wet. I changed R2 sacral wound dressing 2 or 3 times. I did not see the nurse, so I changed the dressing.' When asked by the surveyor was, she (V35) trained to do wound dressing changes V35 responded the nurse went for her break, and I was changing R2. I looked for nurse and just managed to do the best I can to protect R2's wound. I work the night shift and R2 was always urinating. R2 would urinate 2 - 3 times while I was changing him.
On 03/27/24 at 04:33 PM V2 (Assistant Director of Nursing) stated my expectations for wound care and prevention are upon noticing any skin breakdown to notify the family and physician. My expectation for documentation is for the nurse to document correctly and what treatment that they are providing.
On 03/28/24 03:03 PM V25 (Wound Care Nurse) stated R2 came to us admitted with a DTI to the sacrum. It evolved if I am not mistaking to an unstageable covered in mostly yellow to white slough. I don't recall what R2 wound looked like. I don't know what the wound care order was. R2 wound did not have any signs and symptoms of infection or drainage that I can recall. We don't document as we do a bandage change and do not do daily documentation. The facility protocol is to turn and reposition the residents as needed, and it depends on the patient. R2 is incontinent of both bowel and bladder.
Policy:
Titled Skin Care Prevention reviewed 01/24 document in part: All residents will receive appropriate care to decrease the risk of skin breakdown. Guideline: 2. Dependent residents will be assessed during care for any changes in skin condition including redness, (non-blanching erythema), and this will be reported to the nurse. The nurse is responsible for alerting the Health Care Provider. 3. All residents will be evaluated for changes in their skin condition. 5. All residents unable to reposition themselves will be repositioned as needed, (minimum of every 2 hours). 9. Clean skin at time of soiling and at routine intervals.
Titled Skin Management: Monitoring of Wounds and Documentation reviewed 01/24 document in part: It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. General Guidelines: An evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking); The status of the area surrounding the PU/PI (Pressure Ulcer/Pressure Injury) (that was observed without removing the dressing); General Monitoring Guidelines: With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), and evaluation of the PU/PI should be documented. At a minimum, documentation should include the date observed and: location and staging:
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 F0741
(Tag F0741)
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 staff [A] failed to have the necessary skills and competencies to meet one [...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility staff [A] failed to have the necessary skills and competencies to meet one [R1] resident health care needs [B] failed to keep the head of bed elevated, and [C] failed to provide 1:1 feeding assistance. These failures resulted in R1 experiencing an acute change of condition and subsequently expiring on 3/3/24 in the facility.
Findings Include:
R1's clinical record indicated in part; R1 was admitted to the facility on [DATE] with medical diagnosis of pneumonitis due to inhalation of food and vomit, dysphagia, cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, visuospatial deficit and spatial neglect, memory deficit, , protein-calorie malnutrition, muscle weakness, cognitive communication deficit, dysphagia, essential (primary) hypertension, attention-deficit hyperactivity disorder, weakness, gastrostomy, and generalized anxiety disorder.
R1's care plan dated 2/27/24:
-R1 needs the head of bed elevated 45 degrees during and thirty minutes after tube feeding.
-Monitor R1 and report to physician if noted aspiration, shortness of breath, abnormal lung sounds, abnormal lab values, nausea or vomiting.
R1's physician orders:
-2/27/24 - Aspiration Precautions:
Keep HOB elevated during and 30min after G/T Feedings and 1:1 Feed with Pureed Diet and HTL [Honey think liquid] every shift.
-2/27/24- four times a day flush enteral tube QID with 150 mL [milters] of water after feeding.
-2/27/24 - four times a day enteral feeding: Jevity 1.5 360ml bolus QID [four times per day].
-2/27/24- general diet, pureed texture, honey thick consistency with one-to-one feeding assistance.
R1's progress notes documented in part:
V8 [Speech Pathologist/Therapist] Note documented in part:
On 2/29/24- Recommendations for R1, to continue puree diet, with 1:1 assistance and to follow R1's swallowing precautions: only feed when alert, up right at 90 degrees for all meals, reposition as needed, aspiration precautions, monitor or pocketing, small bites, small sips, alternate liquids, and solids, monitor for signs and symptoms of aspiration related illness.
V5 [Registered Nurse] nursing progress note 3/2/2024 21:19:40
Note: V31[Certified Nurse Assistant] found R1 shaking and called nurse-observed pt having secretions coming out of nose and mouth. R1 regurgitated. Having difficulty breathing. Congestion noted on listening to lung sounds. V3 [Nurse Practitioner] was in house earlier on today and ordered oral suction at bedside PRN [as needed]. R1 was suctioned and stabilized. Respiration even non labored.
[Nurse failed to document code blue was initiated]
On 3/26/24 at 4:21 PM, at V6 [R1's Family Member] stated, On 3/2/24 I went to the facility approximately 5:30 PM. Upon arrival to the facility R1's door was closed; I thought the staff was changing his under brief at the time. Then I saw nursing staff going in and out of his room running pass me and no one said a word to me. A few seconds later, I heard over the intercom speaker code blue for R1's room number. I asked V5 [Registered Nurse] coming out of R1's room what was going on. V5 told me that R1 was lying flat down in bed eating and aspirated. When V5 went back into the room I went in the room with him. I saw R1 foaming at the mouth and nose, not responding with his eyes closed and V4 [Licensed Practical Nurse] was suctioning R1. Another young lady brought in oxygen and V4 started oxygen on R1. A few minutes later R1 opened his eyes and was looking around. V4 and V5 left out the room, and I asked R1 was he okay, he turned his head side to side meaning no. R1 can usually say simple words like yes or no, but R1 could not talk. After staying with R1 for a few hours, he continued coughing, drooling, and I can hear his chest rattle when I breath in and out. I asked V5 at the nursing station was my father going to be alright, V5 said yes, he will be okay, for me to go home and rest. On 3/3/24 at 8:42 AM, a nurse called me from the facility and said she was sorry R1 passed away 45minutes ago.
On 3/26/24 at 12:44 PM, V8 [Speech Pathologist/Therapist] stated, I completed R1 speech evaluation and worked with him. R1 had a medical diagnosis of dysphagia with moderate oral phase. R1 would have oral phase trace residue 4 out of 4 exercises. R1 would have a little food left on his tongue. With drinking honey thick liquid, R1 would have some liquid come out of his mouth that he did not swallow. My recommendations for R1 were to continue puree diet, honey thick liquid, one-to-one feeding assistance and follow aspiration precautions. On 2/29/24, I placed R1's aspiration precautions at the head of his bed under a privacy cover. The top cover read 'Please see attached swallowing precautions', underneath I listed the following: [only feed when R1 is alert, feed him in an upright 90-degree position, and reposition as needed, due to R1's past stroke he would lean to the side, small bites, and small sips of liquid]. During mealtime if R1 was noted coughing, chest congestion, rattle, or difficult breathing staff was notified to stop oral intake and notify R1's provider for further instructions.
On 3/27/24 at 2:50 PM, V31 [Certified Nurse Assistant] I took care of R1 on 3/2/24 during second shift. I made rounds and R1 was resting in bed. Dinner trays came up and I passed out the food trays, and I gave R1 a dinner tray as well. I did not reposition R1 or raise the head of bed up. Approximately around 5:30 PM, I was walking down the hallway picking up the dinner trays. I went into his room and saw half of his food missing from the food tray and he was making gurgling gasping sounds with vomiting coming from his nose and mouth. The vomit looked like it was his dinner, with food particles. R1 was lying down in bed and leaning on his side, shaking like he was having a seizure, and his eyes was rolled back into his head. I ran out and got the nurse V4 [Licensed Practical Nurse]. V4 went into R1's room and yelled out for help. V4 said R1's is aspirating and get the crash cart. V5 [Registered Nurse] came running into the room to help with the crash cart. V5 called over the speaker system code blue to R1's room, and other nurses came to help. I passed R1 his dinner tray, I did not know R1 needed one to one feeding assistance. I thought he could feed his self. After the code, V5 asked me if I gave R1 a food tray and did R1 feed himself alone. I told V5 I did give R1 his food tray, but I did not know R1 was a one -to-one feed assist. V5 told me that R1 was lying down too far and aspirated on his dinner while eating alone. V5 told me that R1 should have sitting up 90 degrees due to his aspiration precautions, and I needed to feed R1.
[Survey showed V31 the sign that read 'Please See Attached Swallowing Precautions']
V31 stated, I saw the sign that was on the wall, above R1's head of bed after R1 coded, I did not pay attention to the sign before he aspirated. I did not read the swallow precautions.
On 3/28/24 at 4:48 PM, V4 [Licensed Practical Nurse] stated, I worked with R1 on 3/2/24, I worked first shift 7AM to 3PM and second shift 3PM-11PM. Around 5:30 PM, V31 [Certified Nurse Assistant] came to me in the hallway and said R1 was not breathing and was throwing up food out of his nose and mouth. I entered the room and R1 had difficulty breathing, not responsive, eyes were half open his eyeballs were rolling up and he was vomiting lying down in bed. V5 [Registered Nurse] came in to help me and called code blue. I pulled R1 up in bed and started to suction him and V5 applied oxygen. I did not remember R1's blood oxygen level, or his vital signs during the code I did not write them down or input the vitals in R1 electronic chart, I was busy. After suctioning and giving him oxygen, R1 came back around, alert, and looking around, R1 became stable and was okay. I did not chart on R1, V5 and V24 [Nurse Supervisor] help me chart that day because there were a couple of code blues on the same day and same time. I did not call R1's physician; we must use Telehealth Physician on call service on the weekends. I did not call the Telehealth Physician, V24 called third eye and spoke with the physician. I do not know what time V24 called the physician. V24 called in labs and chest x ray to be completed STAT. No, I did not receive any test results, maybe the results came in on 11PM-7AM shift. [Surveyor asked V4 why she did not call 911.] V4 stated, I did not call 911, because R1 was stable after I suctioned him and started him on oxygen. I was able to handle the situation.
On 3/26/24 at 6:26 PM, V5 [Registered Nurse] stated, On 3/2/24 around 5PM, V4 [Licensed Practical Nurse] yelled out for my help and said code blue in R1's room. V4 was the assigned nurse for R1. When I went into the R1's room I saw R1 lying flat down in the bed throwing up food, out of his nose and mouth, with his dinner tray in front of him, not responsive and having a hard time breathing, R1 was weak and limp. V4 sat R1 up in bed, and I ran and got the crash cart while V4 was suctioning R1. I sent V31 [R1's Certified Nurse Assistant] to get the oxygen tank. R1's oxygen level was reading in the 70's percentile. After suctioning and started oxygen R1 started to come back around. R1 started breathing and looking around. R1 continued to cough, and I could hear chest congestion, but he was back breathing and stopped vomiting. I did not call 911 when R1 was unresponsive because R1 was left lying down in bed and aspirated, that situation could be managed by nursing interventions. When I left out the room, V6 [R1's Family Member] asked me what was going on with R1. I explained R1 was left flat and aspirated, but he was okay now. I spoke to V31 and gave her education that no one with a gastric feeding tube should ever be laid flat in bed, and R1 was a one-to-one feed assist, R1 was not to receive a dinner tray to eat alone. V31 said she understood, and that she did not see the sign above R1's head. I documented a brief note in R1's chart to help out V4, because she [V4] was having a rough night with her set of residents. I documented vital signs after R1 was stable in my progress note, not on the electronic medication sheet. I did not document the vital signs during his code blue. I thought V4 would chart a complete progress note and assessment to what happened with R1, V4 was his assigned nurse. I worked 3/2/24 night shift, but I did not have R1 on my assignment.
On 4/9/24 at 11:01 AM, V3 [Nurse Practitioner] stated, Any resident that is lying flat down that has a gastric tube feeding, has the potential to aspirate. If any resident that has high risk for aspiration, swallowing precautions, and must have one to one feeding assistance, is given a meal tray and the resident self-feed alone, has a potential to aspirate.
On 4/9/24 at 10:48 AM, V7 [Physician] stated, If R1 was feeding himself alone, and he was on swallowing precautions one to one feed it could potentially cause R1 to aspiration. If R1 was lying flat, he has a potential to aspirate.
On 3/27/24 at 1:45PM V2 [Assistant Director of Nursing] stated, Residents with a gastric feeding tube should never be lay down flat, the head of bed should be elevated at all times at least 45 degrees. R1 had a gastric feeding tube and received oral diet with specific swallow aspiration precautions. R1's physician order dated 2/27/24, aspiration precautions, to keep head of bed elevated during and 30-minutes after gastric tube feedings and 1:1 feed assistance with all meals. The speech therapist places an instruction sheet on the wall above resident's bed that is on swallowing precautions as a reminder for staff. 1:1 feed assistance means R1 needed to receive assistance with all meals, R1 needs to be fed by a nursing staff member and to follow the swallow aspiration precautions. If a resident with a gastric feeding tube lays flat in bed, the resident could potentially aspirate. If a resident with 1:1 feed assists with meals, self-feed the resident could potentially aspirate.
On 4/9/24 at 12:26 PM, V37 [Director of Nursing] stated, I been working here since 4/1/24. I been a registered nurse since 2007, and six years of director of nursing experience. If a resident that has a gastric feeding tube lays flat, they could potentially aspirate. The staff should never give or place a food tray to a resident that is 1:1 feed assist, due to aspiration swallow precautions, the resident could potentially aspirate.
Record review:
R1's care plan dated (2/27/24):
-R1 needs the head of bed elevated 45 degrees during and thirty minutes after tube feeding.
-Monitor R1 and report to physician if noted aspiration, shortness of breath, abnormal lung sounds, abnormal lab values, nausea or vomiting
Certified Nurse Assistant Job Description:
-To provide assigned residents with routine daily nursing care in accordance with established nursing care procedures, state, and federal guidelines.
-Position residents maintaining good body alignment.
-Prepare resident for meals, assist serving food trays or feed as necessary and record or report residents' intake or acceptance of food.
-Follow established safety precautions in performance of all duties.
-Review care plans daily to ensure provision of appropriate care.
-Adhere to all facility and department policies and procedures.
-Ability to read, write, and spell and to understand and follow both written and oral directions.
Registered Nurse/Licensed Practical Nurse Job Description
-Responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, resident nursing care, staff performance and adherence by staff members to facility policies and procedures.
-Recognize significant changes in the condition of residents and take necessary action
-Document nursing care rendered, resident response, and all other pertinent and necessary data as outlined in facility's policies and procedures.
-Function as a charge nurse by problem solving and making decisions relevant to resident care.
-Participate in the development and implementation of an individualized patient care plans for the resident with allied health team members
Facility Assessment Tool dated (1/24) documents in part:
Licensed Staff: Identification of resident changes in condition - identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of pertinent facility documentation on 3/26/24 and 3/27/24, it was determined the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of pertinent facility documentation on 3/26/24 and 3/27/24, it was determined the facility failed to provide an accurate record of the actual experience for one [R1] of 6 sampled resident's vital signs.
Findings Include:
R1's clinical record indicated in part; R1 was admitted to the facility on [DATE] with medical diagnosis of pneumonitis due to inhalation of food and vomit, dysphagia, cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, visuospatial deficit and spatial neglect, memory deficit, , protein-calorie malnutrition, muscle weakness, cognitive communication deficit, dysphagia, essential (primary) hypertension, attention-deficit hyperactivity disorder, weakness, gastrostomy, and generalized anxiety disorder.
R1's physician order: 2/28/24- Monitor vital signs every shift for 30 days then daily.
R1's Medication administration sheet was printed on 3/26/24 without any vital signs documented for 3/1/24, 3/2/24, 3/3/24. Received R1's medication administration record printed on 3/27/24 with vital signs in place on 3/1/24, and 3/2/24. [Vital signs were placed in R1's chart 24 days after R1 expired.]
On 3/27/24 at 1:45PM V2 [Assistant Director of Nursing] stated, I see on 3/26/27 R1's medication administration sheets dated 3/1/24 thru 1/31/24 there were no vital signs recorded. Today's [3/27/24] copy of R1's medication administration sheet there are vital signs present. I did make R1's copies of his March 2024 medication administration sheets, but I do not know how the vital signs appeared the next day. All nursing should document vital signs on the medication administration sheet right after they obtain the vital signs. No nurse should be documenting in a resident chart 24-days after the resident expired.
On 3/27/24 V1 [Administrator] stated, I observed R1 medication sheet that we provided to you on the 3/26/24, with no vital signs documented and today [3/27/24] there were vital signs, I am not sure how that happened with the same document showing different information.
Facility's Policy Documentation dated 1/24 Documented in part:
-Residents with specific financial requirements for documentation will be documented
Mar 2024
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to refer one resident (R21), out of thirty six residents in a total sample reviewed, for a Level II Preadmission Screening and Resident Review...
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Based on interview and record review, the facility failed to refer one resident (R21), out of thirty six residents in a total sample reviewed, for a Level II Preadmission Screening and Resident Review (PASARR) in alignment with facility policy.
Findings include:
On 03/06/24 at 12:19 pm V11 (Director Social Services) confirmed that OMBRA I - Part IV was not completed for R21.
R21's Record review noted that state-designated authority initial screen was completed 11/4/2022. Answer to Part III (Reasonable Basis to Suspect a Mental Illness), Question 4 (There are other indicators of mental illness) is answered Yes. Indicators were noted to be schizophrenia and major depressive disorder. The form states that if any part of Part III is marked yes, Part IV is to be completed. Part IV is not completed.
R21's state-designated authority document dated 11/2/2022 states that No Level II required - No SMI/ID/RC. Page 2 states diagnosis of schizophrenia (current), acute psychosis, serious difficult interacting with others, serious difficulty thinking through or completing tasks, excessive irritability, bizarre thought process and not goal directed.
Facility policy PAS Screening dated 1/2023 and updated 1/2024 documents in part: In accordance with Illinois regulatory standards and recommended practices, this organization requests Level 1 (one) and Level 2 (two where applicable) Pre-admission Screening documents prior to the individual's arrival at the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to include a resident's (R286) high-risk medications on the baseline care plan for one out of a total sample of 36 residents.
Findings inclu...
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Based on interviews and record reviews, the facility failed to include a resident's (R286) high-risk medications on the baseline care plan for one out of a total sample of 36 residents.
Findings include:
R286's physician orders contain medication orders for Hydroxyzine (antianxiety), Trazodone (antidepressant), Mirtazapine (antidepressant), and Duloxetine (antidepressant).
R286's baseline care plan does not include these medications.
On 03/07/24 at 9:17 AM, V4 (Assistant Director of Nursing) stated the facility is to care plan for psychotropic medications including antianxiety and antidepressants upon admission and after any change in the physician's orders for high-risk medications.
Facility's Baseline Care Plan dated 1/2023 documents in part: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will include necessary information to properly care for a resident including physician orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interview the facility failed to provide a individualized care plan related to code status of 1 o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interview the facility failed to provide a individualized care plan related to code status of 1 out of 36 resident (R57) reviewed for care plan. This failure has the potential to affect 1 resident (R57) right to choose code status.
Findings include:
R57 is [AGE] years old, with medical diagnosis of cerebral infraction, traumatic ischemia of muscles, metabolic encephalopathy. R57's physician order dated [DATE] for code status documents, do not attempt resuscitation or DNR. Practitioner Order for Life-Sustaining Treatment (POLST) Form dated [DATE] also documents No CPR (Cardiopulmonary Resuscitation): Do Not Attempt Resuscitation (DNAR).
Care Plan of R57 dated [DATE] on advance directive documents that R57 has no advance directive at this time and that R57 is a Full Code. If becomes unresponsive, call help immediately and begin Basic Life Support.
On [DATE] at 12:25 PM, V11 (Social Service Director) stated that care plan should reflect R57 status as DNR and not full code. Care plan should be individualized and person-centered to reflect resident choice.
Title 42 of Code of Federal Regulation (CFR) under §483.21(b), reads:
The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident 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
Finding include:
R21's Record review notes that MDS Section GG eating signed 12/13/2023 includes partial to moderate eating assistance.
Record review notes that R21's Dietary Care Plan updated 2/27/...
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Finding include:
R21's Record review notes that MDS Section GG eating signed 12/13/2023 includes partial to moderate eating assistance.
Record review notes that R21's Dietary Care Plan updated 2/27/2024 includes interventions to assist with feeding resident as needed and monitor food and beverage intake.
During observation of R21 on 03/05/24 at 12:16 PM, facility staff provided residnt's lunch tray in R21's room with resident sitting in bed. R 21 poured water on his hands and rubbed them together, lifted the lid of his lunch tray, removed the bread and balanced it on the water cup and returned the lid to the tray. During constant observation from 12:16 PM to 1:06 PM, staff did not provide assistance or encouragement. At 1:06 PM, V 19 (Certified Nurses Aide) entered the room and removed the covered lunch tray from the room. Once on the lunch cart and as V 19 (Certified Nurses Aide) began to proceed to the next room, surveyor asked to look at the tray. V 19 (Certified Nurses Aide) removed the lid and stated he only ate the bread. When surveyor asked if the bread was on R 21's overbed table, V19 (Certified Nurses Aide) stated It's actually balancing on the cup. He didn't eat anything. No eating encouragement or support was provided.
During observation on 03/06/24 at 12:15 PM, lunch tray was observed to be on R21's bedside table and covered. R21 was not eating. During constant observation of R 21 from 12:15 PM to 12:45 PM, staff provided no encouragement or assistance with eating. At 12:45 PM V 24 (Certified Nurses Aide) picked up the meal tray and placed it on a cart. As V 24 (Certified Nurses Aide) proceeded to the next room, surveyor asked V24 (Certified Nurses Aide) what R 21 ate. V24 (Certified Nurses Aide) lifted the plate cover and replied that he ate some of the meat out of the entrée and a few pieces of pear.
Review of policy entitled Activities of Daily Living dated 2/2023 states that a program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis.
Based on observations, interviews and record reviews, the facility [A] failed to provide incontinence care timely, [B] failed to provide scheduled showers for 1 resident [R36] who requires assistance with activities of daily living and [C] failed to provide eating assistance per MDS [Minimum Data Set] assessment for one resident (R21) out of thirty-six residents in the total sample reviewed.
Findings Include:
On 3/5/24 at 10:45 AM, during the initial tour, surveyor entered R36's room and smelled a strong odor of urine. Surveyor and V29 [Certified Nurse Assistant] with the permission of R36, allowed surveyor to observed ADL care. Surveyor and V29 observed R36 with an under brief in place, and she was laying on a bed pad. The bed pad was wet with dark color rings extending off the bed on to the bed linen. Inside R36's under brief the under brief lining was soaked with urine and the cotton was coming out the under brief.
On 3/5/24 at 11:00 AM, V29 stated, I started work at 6AM, I made rounds then started getting residents up for therapy, appointments, and need to be up for breakfast. Then 9AM got here fast, and I needed to pass out the breakfast trays on time so the resident's food would not be cold. I had to help feed residents and pick up the breakfast trays. Now, I am just getting to R36. This is my first time cleaning R36 up.
On 3/5/24 at 10:26 AM, R36 was observed resting in bed, and noted a strong odor of urine.
R36 stated, I am wet, and have not been changed since yesterday at 9 PM. The night [11PM-7 PM] certified nurse assistant/CNA [V31] answered my call light twice. Both times I told V31 I was wet, V31 told me that she had two other residents to change and then will come back to me. Around 6AM I told the nurse [V30 Registered Nurse] I was wet and have not been changed all night, V30 said that he would get someone to clean me up. I guess the night CNA must have gone home. I seen that V31 had cleaned up my roommate but forgot about me, but V30 did not send anyone in my room to clean me up, the nurse must have forgot about me as well, I been wet for over twelve hours.
On 3/5/24 at 3:10 PM, V30 [Registered nurse] stated, I been working here for thirteen years. I worked with R36 last night. R36 is alert and oriented x3, able to make her needs known. R36 need maximum, extensive assist the ADL care, due to her having multiple sclerosis, and muscle weakness. I gave R36 her 6AM medication, and she told me that she was wet and has not been changed through the night shift. If she would have told me, I would have cleaned her up myself.
On 3/5/24 at 5:10 PM, V31 [Certified Nurse Assistant] stated, I worked with R36 last night shift. R36 legs are contracted and needs extensive assistance with ADL incontinence care. R36 placed on the call light twice last night I did tell her I would be back to take care of her, but I just forgot. I was so busy getting up the residents on the get up list. I am to make rounds every two hours and provide incontinence care.
On 3/7/24 at 9:44 AM, V4 [Assistant Director of Nursing] stated, Nursing staff should make rounds at least every two hours and as needed. During rounds residents are check and clean up from incontinence, and repositioned. If resident is not provided incontinence care at least every two hours it could potentially cause infection or skin breakdown.
Policy document in part
Incontinence Care dated 1/24
-Incontinence care is provided to keep residents as dry, comfortable and odor free as possible
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to follow their policy and a physician's order for weights for one (R74) out of a total sample of 36 residents.
Findings include:
R74's face...
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Based on interviews and record reviews, the facility failed to follow their policy and a physician's order for weights for one (R74) out of a total sample of 36 residents.
Findings include:
R74's face sheet documents in part an admission date of 1/23/2024.
R74's dietary evaluation dated 2/21/2024 documents in part: significant weight loss over one month related to pneumonia, flu, and poor oral intake.
R74's weights are as follows: 135 lbs (pounds) on 1/24/2024, 135 lbs on 2/05/2024, and 127.2 lbs on 2/19/2024. No other recent weights listed.
R74's physician orders document in part: Weekly Weight Times 4 Then Monthly every day shift every [Wednesday] for 30 Days ordered 2/19/2024.
On 03/07/2024 at 9:17 AM, V4 (Assistant Director of Nursing) stated the Restorative Department is supposed to do the residents' weights and chart them on their electronic medical records. V4 stated the ones provided to the survey team are the entirety of R74's weights.
On 03/07/24 at 11:44 AM, R74 stated facility does not weigh [R74] weekly.
Facility's Weight Management policy, last revised 1/2024, documents in part: To establish a policy for the consistent, timely monitoring and reporting of resident weights. All residents will be weighed on admission, readmission, weekly for the first 4 weeks and then at least monthly. Weekly weights will also be done with a significant change of condition, food intake decline that has persisted for more than one week, or with a physician order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 2 residents with limited range of motion r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that 2 residents with limited range of motion receives appropriate treatment and services to prevent further decrease in range of motion by not applying / maintaining left hand splint and right-hand roll. The facility also failed to obtain orders for splint / device use. These failures could potentially affect 2 (R48 and R87) of 6 residents reviewed for limited range of motion in a sample of 36.
The findings include:
R48's health record documented admission date on 5/21/2021 with diagnoses not limited to Cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Ulcerative colitis, Unspecified asthma, Type 2 diabetes mellitus with hyperglycemia, Flaccid hemiplegia affecting right dominant side, Hypertensive heart disease without heart failure, Hypertensive urgency, Hyperlipidemia.
R87's health record documented admission date on 5/21/2021 with diagnoses not limited to Cerebral infarction, Rhabdomyolysis, Other seizures, Essential (primary) hypertension, Chronic kidney disease, Type 2 diabetes mellitus, Obstructive and reflux uropathy, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Atherosclerotic heart disease of native coronary artery.
On 3/05/24 at 10:23am R87 observed lying in bed, head slightly elevated, bed on lowest position, with floor pads. Observed left upper arm contracted or not able to move. He stated he is not able to move his left arm. Observed splint at bedside table.
At 11:06am R48 observed sitting up on wheelchair in the dining room, alert and verbally responsive. Observed right arm contracted and stated she is not able to move her right arm. No device or hand roll observed on right arm or hand.
At 2:31pm Rounded R87 again and was observed lying in bed, left arm splint not in place and was seen at bedside table.
On 3/7/24 at 9:35am V15 (Restorative Director, LPN/Licensed Practical Nurse) said she has been working in the facility for almost 6years. She said residents with contractures / limited range of motion are assessed and provided with orthotic / devices like hand splint, hand rolls, etc. as ordered by physician to prevent further contractures or to maintain mobility of the affected area. Reviewed R87's electronic health record (EHR) with V15 and said he has a diagnosis of CVA with contractures to the left arm and using resting hand splint and should have an order. V15 said not able to find order for resting hand splint in R87's EHR. She said the purpose / goal of left-hand splint is to open left hand a little bit, to prevent further contractures and maintain mobility. V15 said R48 has right arm contracture. She said R48 uses a hand roll and should have an order but there is no order found in EHR. V15 said the goal or purpose of right hand roll is to maintain mobility so it will not to close completely.
R48's EHR under TASK tab: NURSING REHAB: Assistance with Splint or brace: Apply right hand roll on at all times except during ADL (activities of daily living) care and PROM (Passive Range of Motion).
Care plan dated 2/1/23 documented in part: Restorative Program: Splints: R48 has contracture to right hand related to CVA (Cerebrovascular Accident) (R) hand roll referred by therapy.
R87's EHR under TASK tab: NURSING REHAB: Assistance with Splint or brace: R87 is to wear Left resting hand (splint)at all times except during G/H (grooming / hygiene), selfcare and PROM tasks with one person staff assist.
Care plan dated 4/5/23 documented in part: Restorative Program: Splints: R87 has contracture to (L) hand r/t CVA Right hand resting hand splint referred by therapy.
MDS dated [DATE] showed cognition was moderately impaired. R87 needed set up/clean up assistance with eating and oral hygiene; Dependent with toileting hygiene and lower body dressing; Substantial/maximal assistance with shower/bathe self, upper body dressing, personal hygiene, chair/bed, and toilet transfer. MDS showed R87 was frequently incontinent of bladder and always incontinent of bowel. MDS showed restorative programs for splint or brace assistance was performed for R87.
MDS dated [DATE] showed cognition was severely impaired. R48 needed supervision/touching assistance with eating; Partial/moderate assistance with oral hygiene, Dependent with toileting hygiene and lower body dressing; Substantial/maximal assistance with shower/bathe self, upper body dressing, personal hygiene, chair/bed, and toilet transfer. MDS showed R48 was always incontinent of bladder and bowel.
Facility's splints policy dated 1/2023 documented in part:
-
Adaptive devices will be used as ordered by the physician to prevent deformities or further contractures.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain order, comprehensively assess, and develop care...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain order, comprehensively assess, and develop care plan for indwelling urinary catheter use. These failures could potentially affect 1 (R87) resident reviewed for urinary catheter in a sample of 36.
The findings include:
R87's health record documented admission date on 5/21/2021 with diagnoses not limited to Cerebral infarction, Rhabdomyolysis, Other seizures, Essential (primary) hypertension, Chronic kidney disease, Gastro-esophageal reflux disease without esophagitis, Type 2 diabetes mellitus, Obstructive and reflux uropathy, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Hyperlipidemia, Benign prostatic hyperplasia with lower urinary tract symptoms, Atherosclerotic heart disease of native coronary artery without angina pectoris.
On 3/5/24 at 10:23am R87 observed lying in bed, alert and verbally responsive, with indwelling urinary catheter draining to yellow colored urine, no privacy bag.
On 3/7/24 at 9:35am V15 (Restorative Director) said indwelling urinary catheter should have a physician order to communicate with staff that resident has it and to obtain diagnosis for use. She said that indwelling urinary catheter assessment is completed upon admission if applicable, quarterly or as needed when it was inserted and should be care planned to communicate with staff on how to care for resident. V15 said indwelling urinary catheter should have a reason or diagnosis for use like obstructive uropathy and neurogenic bladder and should be removed if not necessary as resident could get an infection easily. Reviewed R87's electronic health record (EHR) with V15 and said there was order for indwelling urinary catheter dated 3/5/24 at 4:54pm. V15 was not able to determine when it was inserted. She stated no assessment and no care plan for indwelling urinary catheter use found in R87's EHR.
On 3/7/24 at 10:16am V4 (Assistant Director of Nursing/ADON) said indwelling urinary catheter should have an order in resident's EHR, should have a privacy bag, and need to have an assessment to indicate the reason for use. V4 said physician order for indwelling urinary catheter is important so the nurse is aware regarding the use and will be able to follow up, maintain and monitor.
R87's progress notes documented in part:
-
Nursing notes dated 3/3/2024: Bladder scan completed current residual is 294ml, 18fr foley catheter insert draining to gravity.
-
Nursing notes dated 3/4/2024: Resident alert and oriented, able to voice needs, foley catheter intact/patent, draining to gravity with yellow urine.
R87's order summary report provided by facility on 3/5/24 at 3:22pm showed no order for indwelling urinary catheter. Facility did not provide care plan and assessment for indwelling urinary catheter use.
MDS dated [DATE] showed cognition was moderately impaired. R87 needed set up/clean up assistance with eating and oral hygiene; Dependent with toileting hygiene and lower body dressing; Substantial/maximal assistance with shower/bathe self, upper body dressing, personal hygiene, chair/bed, and toilet transfer. MDS showed R87 was frequently incontinent of bladder and always incontinent of bowel.
Facility's catheterization of the urinary bladder dated 1/10/24 documented in part:
-
Catheterization is done with a physician or nurse practitioner order.
-
Make sure the physician order sheet contains the specific reason, size of catheter and balloon, and to change the catheter prn.
-
Care plan the catheter and reason.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow a resident's (R286) food preferences for on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow a resident's (R286) food preferences for one out of a total sample of 36 residents.
Findings include:
R286's Mini Nutritional assessment dated [DATE] documents in part that R286 is malnourished. V9's (Registered Dietician) Dietary Evaluation dated 2/27/2024 documents in part: moderate muscle and fat loss in arms, clavicle, and temporal region. R286's body mass index is low for [R286's] age. R286 would like to gain some weight, requested sandwich with lunch and double protein at meals.
R286's physician's orders did not include the double protein.
R286's care plan documents in part that R286 is at nutrition risk. Interventions include but are not limited to Modify diet as appropriate according to resident's food tolerances and preferences (2/27/2024) and 'Provide additional snacks/D portions as ordered.'
On 03/05/2024 at 11:30 AM, R286 stated losing a lot of weight since hospitalization. R286 spoke to V9 last week regarding the weight loss. R286 stated V9 was supposed to have the kitchen staff provide an extra sandwich at lunch and double protein during meals. R286 stated facility has not provided it.
At 12:15 PM, R286 had lunch tray on the bed. Did not receive a sandwich or double protein. Reviewed R286's meal ticket on the tray. It did not document in part double protein or sandwich with lunch. During a follow-up interview at 1:15 PM, R286 stated facility did not provide the sandwich.
On 03/06/2024 at 10:31 AM, V10 (Dietary Manager) stated V9 puts the resident's assessment into the electronic medical records and then V10 will put the food preferences on the ticket. The nurses will also put the orders in the electronic medical records. Asked about R286's 2/27/2024 assessment and food preferences. V10 stated R286 should have had it yesterday.
On 03/07/2024 at 9:17 AM, V4 (Assistant Director of Nursing) stated V9 will place the dietary recommendations in the resident's electronic medical records. V9 will also speak with the management team and dietary team.
Facility's Quick Resource Tool: Food Preference and Portions policy issued 09/01/2021 documents in part: Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system. The Registered Dietician/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents that do not consume certain foods or food groups. The Dining Services Director, RDN or other clinically qualified nutrition professional, or designee, will enter information pertinent to the individual meal plan into the plan of care. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies & intolerances, and preferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure accurate documentation and reconciliation of narcotic medications for 2 (R179, R286) of 2 residents reviewed in 1 of 3 m...
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Based on observation, interview and record review the facility failed to ensure accurate documentation and reconciliation of narcotic medications for 2 (R179, R286) of 2 residents reviewed in 1 of 3 medication carts.
Findings Include:
On 03/05/24 at 02:28 PM the first-floor medication cart 1 narcotic count was reviewed with V16 (Agency Registered Nurse). Review of document titled Shift Change Accountability Record Sheet for Controlled Substances dated March 2024 was reviewed with missed nurse's initials for the date of 03/04/24 11-7 and 7-3. Surveyor asked V16 was the change of shift narcotic count done by the oncoming and off going nurse, V16 responded yes. R179 Controlled Drug Receipt/Record/Disposition Form document in part: Hydrocodone/APAP (Acetaminophen) tab 5-325 mg (milligrams) take 1 tablet by mouth every 6 hours as needed. Quantity received 24, amount remaining 15. Fourteen Hydrocodone/APAP 5-325 mg tabs were observed in R179 medication punch card. R286 Controlled Drug Receipt/Record/Disposition Form document in part: Oxycodone HCl (hydrochloric acid) Tablet 10 MG Tabs take 1 tablet by mouth every 6 hours as needed for pain. Quantity received 28, amount remaining 17. Sixteen Oxycodone HCl 10 MG Tabs were observed in R286 medication punch card.
Document titled Narcotic Count dated 03/05/24 document in part: Two nurses must count narcotics at the beginning of and end of each shift, initialing the narcotic record. The two nurses counting should be incoming and outgoing nurses. If there is a discrepancy in the narcotic count, notify supervisor and DON (Director of Nursing) immediately. All nurses are responsible for ensuring they are safely administering and documenting usage of medications. Do not scratch out on the forms.
On 03/06/23 at 12:25 PM V4 (Assistant Director of Nursing) stated the narcotic count policy is for each nurse to do a shift-to-shift report and count the narcotics with the oncoming nurse to ensure that the narcotic count is correct. The narcotic count sheet should be initial by each nurse to verify the count was completed.
Policy:
Titled Controlled Substance reviewed 01/10/24 document in part: Medications classified by the FDA (Federal Drug Administration) as controlled substances have high abuse potential and may be subject to special handling, storage and record keeping. 7. While a controlled substance is in use the nursing staff will maintain the following medication records: 8. Record each dose at the time of administration on the following. 9. MAR (Medication Administration Record) a. Date, b. Time, c. Initial of nurse administering dose. 10. Controlled Substance Count Sheet. a. Date, b. Time, c. Signature of nurse who administered dose, d. Number of doses remaining. 11. All schedule II-controlled substances will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses. The two nurses will: a. Inspect both the drug package and the corresponding count sheet to verify the accuracy of the amount remaining. b. Both nurses will count the number of packages of controlled substances that are being reconciled during the shift/shift count and document on the Shift Controlled Substance Count Sheet. d. both nurses will sign the Shift/Shift Controlled Substance Count Sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented. Discrepancies: a. Any discrepancy in the count of controlled substances shall be reported in writing to the responsible supervisor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on review of records and interview the facility failed to follow antibiotic stewardship policy in monitoring and maintaining record for 2 out of 5 residents (R88 and R21) on antibiotic therapy p...
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Based on review of records and interview the facility failed to follow antibiotic stewardship policy in monitoring and maintaining record for 2 out of 5 residents (R88 and R21) on antibiotic therapy per physician orders. These failures have the potential to affect 2 residents (R88 and R21) proper use of antibiotic therapy.
Findings include:
On 03/05/2024 at 02:02 PM, V40 (Infection Control Preventionist) was informed to bring antibiotic stewardship binder for October to present on all residents taking antibiotic therapy. V40 agreed and affirmed the request.
On 03/06/2024 at 01:13 PM, V40 (Infection Control Preventionist) stated, I do not have December 2023 files of residents on antibiotic and for March 2024 it is not complete.
During infection control review under antibiotic stewardship topic. IP does not have any documentation for the month of December 2023 and March 2024. IP out to print out documentation from EHR in the middle of the review and took more than an hour to finish printing. After printing no documentation were presented for R88 and R21 who has order for antibiotics.
Per physician orders:
-
R21 has an order for Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) with order date of 3/2/2024.
-
R88 Vancomycin HCl Intravenous Solution (Vancomycin HCl) and Cefepime HCl Injection Solution Reconstituted (Cefepime HCl) with order date for both antibiotics 12/24/2023.
Per Antibiotic Stewardship policy dated 2/2023:
It is the policy of facility to maintain an Antibiotic Stewardship Program with the mission on promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. Part of the seven core elements of the facility Antibiotic Stewardship program is tracking. Facility will monitor antibiotic use and outcome. Reporting, facility will provide feedback on antibiotic use and resistance to prescribing clinicians, nursing staff, and other relevant staff. Under prescribing and record keeping, dose, duration, route, and indication of every antibiotic prescription must be documented in the medical record for every resident. Record will be reviewed monthly to assess compliance with this requirement, as well as prescription appropriateness for the individual resident, site and type of infection.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings Include:
R52's Minimum Data Set (MDS) dated [DATE], Brief Interview Score (15) indicates R52 is cognitively intact. R5...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings Include:
R52's Minimum Data Set (MDS) dated [DATE], Brief Interview Score (15) indicates R52 is cognitively intact. R52 Physician Order Sheet (POS) dated 3/6/24 shows an active diagnosis of Respiratory Failure with Hypoxia and Simple Chronic Bronchitis, and an active order for Oxygen at 4 Liters/Minute, for Shortness of Breath (SOB).
On 02/05/24 at 11:15 AM, surveyor and V14 (License Practical Nurse/Unit Manager) entered R52's room, V14 and surveyor observed R52 lying in bed, R52's Oxygen Nasal Cannula was not in a bag when not in use. V14 picked the nasal cannula on the oxygen concentrator, V14 stated, the oxygen nasal cannula should have been in a bag when not in use. Having the oxygen nasal cannula outside the bag when not in use has the potential to contaminate the nasal cannula and makes R52 at risk for breathing in germs like bacteria.
On 3/7/24 at 11:14 AM, V4 Assistant Director of Nursing (ADON) stated, it is V4's expectation that nurses will keep oxygen nasal cannula tubing in a bag when not in use to maintain good hygiene and prevent bacterial infection.
Facility Policy titled, Oxygen Use, Storage and Labeling dated 1/2024 documents in part: If the nasal cannula/mask/tubing is not in use, it must be stored in a clean bag.
Based on observation, interview and record review, the facility:
1.
Failed to maintain proper storage and handling of oxygen tubing for 1 (R52) resident.
2.
Failed to date / label oxygen tubing and humidifier bottle and failed to develop care plan for 2 (R77 and R87) residents.
3.
Failed to follow oxygen liter flow as ordered and failed to change oxygen tubing, nasal cannula weekly for 1 (R90) resident.
4.
Failed to monitor / check oxygen device was functioning properly for 1 (R131) resident.
These failures could potentially affect 5 (R52, R77, R87, R90, R131) of 6 residents reviewed for respiratory care in a sample of 36.
The findings include:
R87's health record documented admission date on 5/21/2021 with diagnoses not limited to Cerebral infarction, Rhabdomyolysis, Other seizures, Essential (primary) hypertension, Chronic kidney disease, Type 2 diabetes mellitus, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Atherosclerotic heart disease of native coronary artery without angina pectoris.
R90's health record documented admission date on 11/7/2019 with diagnoses not limited to Chronic obstructive pulmonary disease (COPD), Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Acute respiratory failure, Encounter for palliative care, Dependence on supplemental oxygen, Atherosclerotic heart disease of native coronary artery, Unspecified systolic (congestive) heart failure, Essential (primary) hypertension.
R131's health record documented admission date on 4/21/2023 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Dysphagia oropharyngeal phase, Pneumonia, Presence of coronary angioplasty implant and graft, Peripheral vascular disease, Hemothorax, Essential (primary) hypertension, Atherosclerotic heart disease of native coronary artery, Anemia, Acute respiratory failure with hypoxia, Type 2 diabetes mellitus, Chronic obstructive pulmonary disease, Cerebral infarction, Unspecified asthma.
On 3/5/24 at 10:23am R87 observed lying in bed on moderate high back rest, alert and verbally responsive with oxygen at 3L/min, O2 tubing, and humidifier bottle no date. Requested V7 (Agency Registered Nurse) to R87's room and she stated oxygen tubing and humidifier bottle should be dated but were not dated / labeled.
At 10:50am R131 observed sitting up on wheelchair by the nurse's station, oxygen tubing nasal cannula was in place in nostrils, but oxygen concentrator was not working. Observed oxygen liter flow showed 0L/min. Requested V8 (Wound Care Coordinator), checked oxygen concentrator and was off. R131 stated she has been sitting around 8:00am and oxygen was off. V8 said oxygen machine was not working and she changed the oxygen concentrator.
At 11:25am R90 observed sitting up on wheelchair in the dining room, alert and verbally responsive, with oxygen via nasal cannula at 3L/min. Oxygen tubing dated 2/23/24, humidifier bottle was not dated.
On 3/7/24 at 10:16am V4 (Assistant Director of Nursing/ADON) said nurses are expected to administer oxygen as ordered to deliver the correct oxygen liter flow. She said oxygen tubing and humidifier bottle should be dated and changed weekly as needed. V4 said that nurses are expected to monitor or to make sure oxygen concentrator is functioning properly to make sure that oxygen is provided to resident. She said dating and labeling is important to know when to discard the oxygen tubing and humidifier bottle.
MDS (Minimum Data Set) dated 11/29/2023 showed R87's cognition was moderately impaired. R87 needed set up/clean up assistance with eating and oral hygiene; Dependent with toileting hygiene and lower body dressing; Substantial/maximal assistance with shower/bathe self, upper body dressing, personal hygiene, chair/bed, and toilet transfer.
R87 POS (Physician Order Sheet) showed order but not limited to: Apply oxygen for 02 level of 92% or less titrate between 2-4 liters as needed.
No care plan found for oxygen use in R87's electronic health record. Facility was not able to provide care plan for oxygen use.
MDS dated [DATE] showed R90's cognition was moderately impaired. R90 needed set up/clean up assistance with eating and oral hygiene; Substantial/maximal assistance with toileting and personal hygiene, shower/bathe self, lower body dressing, chair/bed, and toilet transfer; Partial/moderate assistance with upper body dressing. MDS showed R90 used Oxygen therapy.
R90 POS showed orders but not limited to:
-
Oxygen (02) @ 2 Liters/Minute per shift, Maintain 02 Saturation @ 92% or greater every shift.
Care plan dated 1/3/24 documented in part: R90 has Oxygen Therapy related to COPD. Administer oxygen per physician's orders.
MDS dated [DATE] showed cognition was severely impaired. R131 substantial/maximal assistance with oral and personal hygiene and upper body dressing; Dependent with toileting hygiene, shower/bathe self, lower body dressing, and chair/bed transfer. MDS showed R131 used oxygen therapy.
R131 POS: Change O2 tubing and humidifier weekly every night shift every Sunday. Oxygen (02) @ 2-3 Liters/Minute per nasal cannula, Maintain 02 Saturation @ 92% or greater as needed.
Care plan dated 5/1/23 documented in part: R131 has Asthma/COPD, and SOB (shortness of breath) when lying flat. Give oxygen therapy as ordered by the physician.
Facility's policy for oxygen therapy, use, storage and labeling dated 1/2024 documented in part:
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Residents who require oxygen therapy will have a physician order in their medical record which includes amount of oxygen to be administered, route of administration, and indication of use.
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Oxygen tubing, nasal cannula and masks are changed weekly and PRN (as needed). Tubing and Humidifier bottle should be dated.
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Nasal cannula tubing is not in use, it must be stored in a clean bag.
Findings include:
R77 has medical diagnoses of chronic obstructive pulmonary disease, emphysema, acute and chronic respiratory failure, and asthma.
R77's physician orders document in part orders for continuous oxygen (ordered 1/5/2024) and to change the oxygen tubing weekly (ordered 11/13/2023).
R77's comprehensive care plan does not contain a focus for R77's oxygen use/needs.
On 03/05/2024 at 11:08 AM, R77 was lying in bed receiving oxygen via nasal cannula. The nasal cannula and humidifier bottle were not dated.
Facility's Oxygen Use, Storage and Labeling policy last revised on 1/2024 documents in part: Oxygen tubing, nasal cannula and masks are changed weekly and PRN [as needed]. Tubing and Humidifier bottle should be dated.
Facility's Comprehensive CarePlan policy dated 1/2023 documents in part: The facility must develop a comprehensive person-centered care plan for each resident. The care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental, and psychosocial needs. The comprehensive care plan should drive the care and services provided for the resident and allow for the highest level of physical, mental, and psychosocial function based on the comprehensive MDS assessment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure a.) medications were labeled when opened, b.) ensure medications were stored to present cross contamination and c.) ensu...
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Based on observation, interview and record review the facility failed to ensure a.) medications were labeled when opened, b.) ensure medications were stored to present cross contamination and c.) ensure medications for discharged residents were removed from the medication cart in 3 of 3 medication carts reviewed for medication storage and labeling.
Findings Include:
On 03/05/24 at 01:04 PM the second-floor medication cart 1 was reviewed with V6 (Licensed Practical Nurse). R53 (Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (microgram/activated clotting time) 1 puff daily and Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligram/milliliter) 1 vial inhale orally Twice a day was observed opened in the medication cart and undated. V6 stated I think they are good for 30 days after opening. R99 Combigan Solution 0.2-0.5 % (Brimonidine Tartrate-Timolol) Instill 1 drop in both eyes twice a day was observed open in the medication cart and undated. V6 (Licensed Practical Nurse) stated it is good for 45 days from the date that it was opened. The eye drops and inhalers should be dated once opened.
On 03/05/24 at 02:28 PM the first-floor medication cart 1 was reviewed with V16 (Agency Registered Nurse). R20 Humalog Kwik Pen 100 UNIT/ML Solution pen-injector Inject 7 unit subcutaneously three times a day was observed stored in the medication cart drawer in a plastic tray opened and undated. R20 (Two) Humalog Kwik Pen 100 UNIT/ML Solution pen-injector Inject 7 unit subcutaneously three times a day was observed stored in the medication cart drawer in a plastic tray opened, undated with no storage bag. R20 Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 17 unit subcutaneously at bedtime was observed stored in the medication cart drawer in a plastic tray opened and undated. R43 Lantus Solostar 100 UNIT/ML Solution pen-injector Inject 8 unit subcutaneously at bedtime was observed stored in the medication cart drawer in a plastic tray opened and undated. R77 Fluticasone Propionate Nasal Suspension 50 MCG/ACT 1 spray in each nostril in the morning was observed opened in the medication cart and undated. R84 Basaglar Kwik Pen Solution Pen injector 100 UNIT/ML (Insulin Glargine) Inject 25 at bedtime was observed stored in the medication cart drawer in a plastic tray opened, undated with no storage bag. R84 Basaglar Kwik Pen Solution Pen injector 100 UNIT/ML (Insulin Glargine) Inject 25 at bedtime was observed stored in the medication cart drawer in a plastic tray opened, undated with no storage bag. R84 Humalog Solution 100 UNIT/ML Inject as per sliding scale: if 0 - 70 call MD and initiate hypoglycemia protocol; 71 - 200 = 0 units; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 8 units; 351+ = 10 units 351 and > give 10 units and call MD, subcutaneously before meals was observed stored in the medication cart drawer in a plastic tray opened and undated. R181 Insulin Glargine Solution 100 UNIT/ML Inject 20 unit subcutaneously at bedtime was observed stored in the medication cart drawer in a plastic tray opened and undated. R181 Humalog Mix 75/25 Kwik Pen Suspension Pen-injector (75-25) 100 UNIT/ML Inject 30 unit subcutaneously three times a day was observed stored in the medication cart drawer in a plastic tray opened, undated with no storage bag. R182 Insulin Lispro Injection Solution 100 UNIT/ML Inject as per sliding scale: if 201 - 250 = 1 unit; 251 - 300 = 2 units; 301 - 350 = 3 units >350 Notify MD, subcutaneously with meals was observed stored in the medication cart drawer in a plastic tray opened and undated. R186 was discharged from the facility on 03/03/24. R186 Fluticasone Propionate HFA Inhalation Aerosol 110 MCG/ACT (Fluticasone Propionate HFA) 2 spray in nostril Daily and Moxifloxacin HCl Ophthalmic Solution 0.5 % Instill 1 drop in left eye four times a day was observed open in the medication cart and undated. R187 Azelastine HCl Nasal Solution 0.1 % (Azelastine HCl) 1 spray in both nostrils twice a day was observed in the medication cart opened with no open date. R188 was discharged from the facility on 01/19/24. Insulin Glargine Subcutaneous Solution 100 UNIT/ML Inject 15 unit subcutaneously at bedtime was observed stored in the medication cart drawer in a plastic tray opened and undated. R286 Insulin Glargine Subcutaneous Solution 100 UNIT/ML Inject 20 unit subcutaneously at bedtime was observed stored in the medication cart drawer in a plastic tray opened, undated with no storage bag.
03/06/24 at 12:12 PM the third-floor medication cart 2 was reviewed with V7 (Agency Registered Nurse). R98 Admelog Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 6 unit subcutaneously before meals was observed stored in the medication cart drawer in a plastic cup opened, undated with no storage bag. R122 Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 20 unit subcutaneously at bedtime and Humalog Solution (Insulin Lispro) Inject 13 unit subcutaneously with meals.
On 03/06/23 at 12:25 PM V4 (Assistant Director of Nursing) stated the inhalers, eye drops, and insulin pens should be
dated as soon as they are opened so that way we will know if it's a new insulin pen. Any insulin pens that are not opened should be stored in the refrigerator. The insulin pens are good for 28 days. If the insulin pens are used beyond the 28 days, the nurse should notify the physician and monitor the resident. The purpose for dating the insulin pens when opened is so that they will not be used beyond the 28 days. The insulin pens are stored in bags for proper labeling and to prevent cross contamination.
On 03/07/24 at 09:15 AM V4 (Assistant Director of Nursing) stated when a resident is discharged their medications are sent back to the pharmacy and if they are discharged home, we discharge the medications with the resident. Upon discharge of a resident, their medications should be taken out of the medication cart.
Policy:
Titled Medication Storage in the Facility reviewed 01/24 document in part: Medications and biologicals are store safely, securely, and properly following the manufacture or supplier recommendations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on review of records and interview the facility failed to follow immunization policies for both influenza and pneumococcal vaccination in determining and documenting influenza and pneumococcal s...
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Based on review of records and interview the facility failed to follow immunization policies for both influenza and pneumococcal vaccination in determining and documenting influenza and pneumococcal status to record under immunization tab on electronic heath record (EHR) of 4 out of 5 residents (R57, R60, R336, R338) for a total sample of 5 residents reviewed for vaccination / immunization services. These failures have the potential to affect 4 residents (R57, R60, R336, R338) in receiving information of the benefits and risks of the vaccines.
Findings include:
Five (5) residents for influenza and pneumococcal were sampled for pneumococcal and influenza vaccination determination and documentation under immunization tab of the electronic health record (EHR):
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R57 no immunization on record.
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R60 influenza 10/18/2023 (Historical) no other immunization on record.
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R336 no immunization on record.
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R337 influenza and pneumococcal vaccinations documents consent required.
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R338 no immunization on record.
On 03/06/2024 at 01:13 PM, V40 (Infection Control Preventionist) All vaccination (Pneumococcal, Influenza and Covid-19) must be under immunization tab, we are not 100% some people are waiting, some people refuse. I know that I need to check their (residents) immunization status and determine if they (residents) needed vaccines.
Pneumococcal Vaccinations policy dated 1/2024, reads:
To provide information on the process for giving the pneumococcal vaccinations. All current residents or the responsible party will be screened and offered the pneumonia vaccine within 1st week of admission and annually if eligible per CDC guidelines. Pneumococcal vaccines previously received, vaccines given and refused will be documented in the immunization tab of the electronic heath record (EHR).
Influenza (Flu) Vaccine policy dated 1/2024, reads:
To provide information on the process for administering the flu vaccine in order to prevent and control influenza outbreaks. Annually all residents or resident responsible parties will be asked if they want to receive the influenza vaccine. Influenza vaccine received, and all refusal for the influenza vaccine will be documented in the immunization tab of the electronic heath record (EHR).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient Certified Nursing Assistant (CNA) on weekends to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient Certified Nursing Assistant (CNA) on weekends to care for residents' needs based on the staffing scheduling and PBJ (Payroll Based Journal) staffing data report. This failure could potentially affect 189 residents residing in the facility as of census 3/5/24.
The findings include:
On 3/5/24 at 10:13am R116 observed sitting on the side of the bed, alert, and oriented x 4, verbally responsive. She said she has concern with short staff on weekend, staff/help is not enough. R116 said care or assistance is not being done in a timely manner. She said that usually there are 4-5 CNA's working on 3rd floor but on weekends there were times that there were only 3 CNAs working so care / assistance was not done promptly.
R116's health record documented admission date on 6/20/23 with diagnoses not limited to Chronic obstructive pulmonary disease, Essential hypertension, Chronic kidney disease, Obesity, Hyperlipidemia. Minimum Data Set (MDS) dated [DATE] showed R116's cognition was intact.
On 3/6/24 at 10:18am V4 (Assisted Director of Nursing/ADON) said she has been working in the facility since 2016 and currently doing staffing due to staffing coordinator resigned about 3 weeks. V34 (Corporate staffing and retention) said she oversight staffing in the facility.
V4 and V34 said for day (6am-2pm) and pm (2-10pm) shifts, 12-14 CNAs are needed and 10-12 CNAs for night shift. V4 and V34 said at times due to call off, numbers are not met but staff in the building helped.
Reviewed facility's daily schedule with V4 and V34 and showed the following:
- On 12/10/23 (Sunday) only 11 CNAs (Certified Nursing Assistant) worked for 2-10pm shift.
- On 1/13/24 (Saturday) only 11 CNAs worked for 2-10pm and 7 CNAs worked for 10pm-6am shift.
- On 1/14/24 (Sunday) only 11 CNAs worked for 7am-3pm and 7 CNAs worked for 10pm-6am shift.
- On 1/27/24 (Saturday) only 8 CNAs worked for 10pm-6am shift.
- On 2/3/24 (Saturday) only 10 CNAs worked for 2-10pm shift.
- On 2/10/24 (Saturday) only 9 CNAs worked for 10pm-6am shift.
- On 2/11/24 (Sunday) only 9 CNAs worked for 10pm-6am shift.
- On 2/25/24 (Sunday) only 11 CNAS worked for 2-10pm and 9 CNAs worked for 10pm-6am shift.
V4 said number of staff should be maintained to provide adequate care, not delaying treatment or care, meet the needs of the resident. She said the number of staff is important every day and every shift and should have the same number of staff on weekdays and weekends.
At 12:25pm V35 (Certified Nursing Assistant/CNA) said she has been working in the facility since June 2023. She said, small issues with staffing on weekends, low staff or not enough staff working on weekends.
At 12:31pm R68 observed lying in bed in moderate high back rest, alert and oriented x 3, verbally responsive. She said she has concerns with staffing. R68 said CNA is taking forever to come and attend to her needs especially on weekends. She said, I guess they are low in staffing and worst on weekends.
R68's health record documented admission date on 11/29/22 with diagnoses not limited to Systemic lupus erythematosus, Type 2 diabetes mellitus, Essential hypertension, Peripheral Vascular Disease, Rheumatoid arthritis.
PBJ (Payroll Based Journal) report showed the following information:
- on 10/1/23 CNAs total number of hours was 205.73.
- on 10/8/23 CNAs total number of hours was 231.26.
- on 10/14/23 CNAs total number of hours was 232.95.
- on 10/15/23 CNAs total number of hours was 198.
- on 10/21/23 CNAs total number of hours was 248.87.
- on 10/22/23 CNAs total number of hours was 220.36.
- on 10/28/23 CNAs total number of hours was 233.48.
- on 10/29/23 CNAs total number of hours was 199.73.
- on 11/5/23 CNAs total number of hours was 223.1.
- on 11/11/23 CNAs total number of hours was 223.36.
- on 11/12/23 CNAs total number of hours was 172.31.
- on 11/26/23 CNAs total number of hours was 205.54.
On 3/7/24 at 10:16am V34 said total number of CNAs should be 34-40 residents every day. CNAs are working 7.5 hours per shift and should be at least 255hours - 280Hours every day.
V4 said if the staffing number is not met, or not enough staff could potentially affect resident's care.
CMS (Centers for medicare and medicaid services) casper report dated 2/22/24 documented in part: Triggered for excessively low weekend staffing.
Facility's staffing policy dated 1/2024 documented in part:
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To have appropriate numbers of staff available to meet the needs of the residents.
On 03/05/24 at 02:34 PM V25 (R104 Family Member) stated there is a shortage of staff on the weekends and sometimes there is only one nurse on the floor and it is difficult getting what you need. If staffing is short R104 feedings (Gastric feedings) aren't appropriate because they end up getting hung late. I come to the facility everyday and sometime twice a day.
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 observations, interviews, and record reviews, the facility failed to follow sanitary standard and hand hygiene before handling clean side of the dishwashing machine to unload the sanitized di...
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Based on observations, interviews, and record reviews, the facility failed to follow sanitary standard and hand hygiene before handling clean side of the dishwashing machine to unload the sanitized dishes and utensils. This deficient practice has the potential to affect all 183 residents receiving food prepared in the facility kitchen.
Findings Include:
Facility diet type report provided by facility dated 3/7/24 documents that a total of six residents residing in the facility are NPO/nothing by mouth.
On 03/05/24 at 10:11 AM, surveyor observed V17 (Food Handler) walked to the clean side of dish washing area. V17 did not perform hand washing before handling clean dishes. V17 stated V17 should wash hands and wear a pair of gloves before handling clean dishes. V17 stated handling clean dishes without hand washing could cause cross contamination.
On 03/5/24 at 10:16 AM, V9 (Registered Dietitian) stated that the staff on the clean side of the dishwashing machine should perform hand washing before handling clean dishes to prevent cross contamination, and infection.
On 03/05/24 at 10:20 AM, V10 (Dietary Manager) stated it is V10's expectation that the kitchen staff handling the clean side of the dishwashing machine will perform hand washing and don a pair of gloves before handling clean dishes to prevent cross contamination, infection, and foodborne illness.
Facility policy dated 5/2/14, titled Dish Room Safe Food Handling documents in part: wash their hands and put on fresh gloves whenever they cross over to the clean side of the dishwashing machine to unload the sanitized dishes and utensils.
Facility policy undated, titled Hand Washing documents in part: Food and Nutrition Services employees will thoroughly wash their hands and exposed areas of their arms with soap and water in the designated hand-washing sink.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of records the facility have the following failures related to infection control, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of records the facility have the following failures related to infection control, procedures, practices, and prevention: Failed to follow policy on putting signage on a COVID-19 positive resident (R168). Failed to follow hand hygiene and Enhanced-Based Precaution policies by not performing hand hygiene during care and not using Personal Protective Equipment (gown and gloves) for a resident on Enhanced-Based Precaution (R336). Failed to ensure Enhanced Barrier Precaution signage was posted on the door of one resident (R152). Failed to dispose Personal Protective Equipment (gown) in a designated disposal equipment (large red bin with lid closure) for one resident (R21) Failed to ensure reusable medical equipment was cleaned and disinfected between four (4) residents (R19, R110, R111, R128) used to prevent cross contamination. Failed to follow policy on proper handling of linens (linens overflowing in the linen cart and not covered exposing to environment) and maintaining clean laundry room equipment (large standing fans). Fan was not clean and was used during folding of clean linens. These failures have the potential to affect all 189 residents in the facility.
Findings include:
On 03/05/2024 at 09:46 AM, V4 (Assistant Director of Nursing) stated that facility does not have any COVID-19 residents.
On 03/05/2024 at 10:33 AM, V16 (Registered Nurse/Agency) stated that R168 is positive of Covid-19 infection. Room of R168 was seen without any signage on the door or the wall that will alert any person going inside the room that COVID-19 precaution should be observed. At the Nurse's Station V4 stated, I know that we told you we do not have Covid-19 but R168 was admitted last night, and she is positive with Covid-19. Per V4, hospital record confirm that R168 is positive with COVID-19. V4 said, I will put a sign on her door.
On 03/06/2024 at 01:13 PM, V40 (Infection Control Preventionist) stated that there must be signage on the door due to high risk of any person family, visitor, or staff, to get COVID-19 being exposed without using PPE when entering R168's room. V40 said that there was a failure to communicate when R168 was admitted to staff for proper precaution to put in place.
On 03/05/2024 at 10:58 AM, V43 (Certified Nursing Assistant) was seen changing linens on R336 bed without using gown and gloves. V43 stated that R336 has skin issues and is on enhance-based precautions. V43 was not seen performing hand hygiene before and after entering the R336's room. After few minutes V44 (Certified Occupational Therapist Assistant) was pushing R336 on a wheelchair. V44 did not perform hand hygiene, wear gown and gloves while in contact with R336.
On 03/06/2024 at 01:13 PM, V40 (Infection Control Preventionist) stated that R336 is in enhanced-based precaution because of her wounds. Staff needs to perform hand hygiene and use proper PPE while in contact with R336 and while changing linens.
On 03/05/2024 at 01:17 PM V18 (Licensed Practical Nurse) stated that R21 was on contact precaution for urine. There are two large red bins inside the room, but gown was seen discarded not on those bins but on a small open trash can that was overflowing.
On 03/06/2024 at 01:13 PM, V40 (Infection Control Preventionist) stated that PPE (personal protective equipment) gowns must be discarded in the red bin. There are two bins, one for linen and one for garbage that includes PPE/gowns. PPE/gowns must not overflow on a regular trash can. And red bins has cover or lid to contain contaminated things like PPE/gowns.
On 03/06/2024 at 10:48 AM, At laundry room, V42 (Laundry Aide) was seen folding linens that was placed in the linen bin. There was another linen bin few feet away from V42 that was overflowing with linen touching surfaces in the surroundings or cover of linen cart. Linens are dangling 6 to 10 inches to the floor. V42 stated that linen needs to be in an amount that the bin can contain. While V42 was folding the linen, a large fan was used in front of V42 blowing air directly to clean linens. V41 (Laundry Aide) came near the fan and turn off the fan. The fan was visibly full of lint and dirt, greyish in color at the blade and grills. V41 stated that the fan need to be clean and is supposed to be clean on a daily basis. Air coming from the fan is not good for clean linens. Another fan was seen a few feet away with the same condition. V40 (Environmental Service Director) came and stated that bins should not be overflowing and will make sure fans are cleaned today. V40 stated that air coming from the fan and circulating cause contamination because it was not clean.
Applicable facility policies and procedures related to infection control:
Infection Control - Enhanced Barrier Precautions (EBP) policy dated 1/2024, reads:
EBP requires the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.
High-contact resident care activities requiring gown and gloves use among residents that trigger EBP use includes:
Transferring, changing of linens.
Enhanced-Barrier Precautions posted on the wall reads: Everyone must: Clean their hands, including before entering and when leaving the room.
Hand Hygiene policy dated 1/2024, reads:
Hand hygiene is done before and after resident contact, before and after any procedure.
Transmission Based Precaution policy dated 1/1/2023, reads:
Transmission Based Precaution are a second tier of basic infection control and are to be used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Resident confirmed to have COVID-19 needs contact and droplet precaution that needs sign on the door.
Linen Handling policy dated 1/2024, reads:
The facility promotes the control of infections through the use of Standard Precautions while handling linen. Clean linen is stored in a covered or closed area.
Per agency contract with facility titled job description dated 11/2019 that outlines housekeeping duties and responsibilities. Under essential job functions, it includes clean and sanitizes the work area including machines, worktable and sorting area. Fold and bundles clean linen according to standard.
On 03/06/24 at 08:14 AM V12 (Licensed Practical Nurse) entered R128 room to obtain R128 vital signs using a blood pressure cuff to the right arm with a reading of 107/65 pulse 66. V12 removed a tympanic thermometer from her (V12) right pocket, obtained a reading of 98.4 then placed the thermometer back in her (V12) right pocket. Placed the pulse oximeter on R128 right index finger with a reading of 98% then placed the pulse oximeter in her (V12) left pocket. V12 then exited R128 room, placed the blood pressure cuff without cleaning it on top of the medication cart. R128 is on Enhanced Barrier Precautions.
On 03/06/24 at 08:24 AM V12 (Licensed Practical Nurse) opened the medication cart retrieved a glucometer strip, retrieved the glucometer and blood pressure cuff from the top of the medication cart, entered R19 room obtained a blood glucose reading of 78, removed the pulse oximeter from her (V12) left pocket and placed it on R19 left middle finger with a reading of 95%, placed the blood pressure cuff on R19 left arm without cleaning it and obtained a reading of 176/89 pulse 63.
On 03/06/24 at 08:26 AM V12 (Licensed Practical Nurse) exited R19 room, placed the blood pressure cuff on top of the medication cart without cleaning it and began preparing R19 medications.
On 03/06/24 at 08:32 AM V12 (Licensed Practical Nurse) retrieved the blood pressure cuff from the top of the medication cart, entered R111 room, removed the pulse oximeter from her (V12) left pocket and placed it on R111 finger with a reading of 98%, placed the blood pressure cuff on R111 arm without cleaning it and obtained a reading of 135/82 pulse 76. V12 returned to the medication cart placed the blood pressure cuff on top of the medication cart without cleaning it and prepare R111 medication.
On 03/06/24 at 08:41 AM V12 (Licensed Practical Nurse) retrieved the blood pressure cuff then entered R110 room placed the blood pressure cuff on R110 arm without cleaning it and obtained a reading of 140/84 pulse 71, removed the pulse oximeter from her (V12) left pocket, placed it on R110 finger and obtained a reading of 96%. V12 returned to the medication cart placed the blood pressure cuff on top of the medication cart without cleaning it and prepare R110 medication.
On 03/06/24 at 08:46 AM V12 (Licensed Practical Nurse) returned to the medication cart. Surveyor asked V12 the policy for cleaning the reusable equipment (blood pressure cuff, pulse oximeter and tympanic thermometer), V12 responded it should be cleaned between every two residents with the Bleach/Lysol wipes. The cleaning should be done directly after using it on a resident that is on Enhanced Barrier Precautions. The cleaning should be done to prevent the spread of infections.
On 03/06/23 at 12:25 PM V4 (Assistant Director of Nursing) stated the reusable blood pressure cuff, pulse oximeter and tympanic thermometer cleaning should be done with bleach wipes and should be cleaned after each use between residents to prevent cross contamination.
On 03/07/24 at 09:04 AM V38 (Infection Control Preventionist) stated Enhanced Barrier Precautions are used for residents with g-tubes, tracheostomy, urinary catheters, Intravenous lines, or a wound. When the residents are admitted or readmitted , they are assessed to see if they need to be on Enhanced Barrier Precautions. When R152 was readmitted , he should have been placed on Enhanced Barrier Precautions. R152 roommate R149 does not have any reason to be on Enhanced Barrier Precautions. A Gown and gloves should be worn when caring for a resident on Enhanced Barrier Precautions. The nurse should be educating the Certified Nurse Assistants. If an Isolation sign is seen on a resident door, stop and get educated before entering the room. The risk is that R152 is at high risk for infection. Enhanced Barrier Precautions is to protect the resident. R149 could have gotten an infection as well. When using reusable medical equipment use bleach wipes between each resident to stop the spread of infection.
Policy:
Titled IC (Infection Control) - Enhanced Barrier precautions (EBP) reviewed 01/24 document in part: General: EBP expand the use of PPE (Personal Protective Equipment) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multidrug Resistant Organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Policy: EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. High-contact resident care activities requiring gown and glove use among residents that trigger EBP use include Dressing, Bathing/showering, transferring, providing hygiene, Changing Linen, changing briefs, Device care or use: central line, urinary catheter, feeding tube, Wound care.
Titled Equipment Change Schedule revised 01/24 document in part: Equipment will be changed following established scheduled to prevent cross contamination. 10 Miscellaneous: c) Pulse oximeter finger clip should be wiped with approved disinfectant wipes between resident uses. d) Any reusable medical equipment should be wiped with approved disinfectant wipes between resident uses.
R152 was readmitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Dementia, with Agitation, History of Falling, Obstructive and Reflux Uropathy, Frontotemporal Neurocognitive Disorder, Dementia in other Diseases Classified elsewhere, Mild, with other Behavioral Disturbance, Retention of Urine, Anxiety Disorder, Adult Failure to Thrive, Weakness), Difficulty in Walking, Rhabdomyolysis, Chronic Kidney Disease, Stage 2, Heart Failure, Sepsis, Gastrostomy Status, Dysphagia, Oropharyngeal Phase and Muscle Weakness(Generalized).
Hospital records dated 01/01/24 document in part: Current Visit Summary: Procedure: EGD (Esophagogastroduodenoscopy) with PEG. Assessment: R152 multiple medical problems found to have significant dysphagia and feeding difficulties. R152 is status post EGD with PEG tube placement.
Progress note dated 12/31/23 16:00 document in part: Nursing Note: At 16:00 p.m. family member made a report to the nurse that resident (R152) is in great pains. Writer assessed resident by verbally asking where exactly he feels pain. Resident was combative and would not allow writer to touch him. Family member reported that resident has been feeling pains for the past three days and not eating or drinking any fluids. Informed NP (Nurse Practitioner) of recent change of condition. NP spoke with family member who insisted that Resident should be sent out to the ER (Emergency Room). Resident was taken from the facility at 17:18 pm to ER.
Progress note dated 01/01/24 05:39 document in part: Nursing Note: Resident (R152) admitted to hospital with dx (diagnosis) of Sepsis, abdominal pain, and Flu.
Progress note dated 01/09/24 19:17 document in part: Activities/Recreation Note: Resident (R152) arrived to facility via stretcher. Resident has a g (gastric)-tube.
Progress note dated 01/10/24 15:00 document in part: Nursing Note: Resident (R152) NPO (nothing by mouth) with new g tube intact. Nutrition Feeding infusing.
Progress note dated 01/11/24 14:47 document in part: Nursing Note: Resident (R152) g tube intact. Nutrition Feeding infusing as indicated.
Progress note dated 01/14/24 03:22 document in part: Nursing Note: G tube feeding of Jevity 1.2 at 75ml(milliliter)/hr (hour) infusing as ordered.
Progress note dated 01/15/24 23:00 document in part: Nursing Note: G-tube patent and intact. Feeding running with flushing's at prescribed rate.
On 03/05/24 at 10:52 AM V6 (Licensed Practical Nurse) stated there are no residents on isolation in my assigned rooms. (V6 assigned rooms included R152).
On 03/05/24 at 12:26 PM R152 was observed sitting in a recliner chair near the nurse station. R152 was taken to his room by staff and was observed in the recliner chair with the gastric tube feeding infusing at 75 ml (milliliters)/hour. There was no isolation bin near R152 door and there was no Enhanced Barrier Precaution signage posted on R152 door.
On 03/05/24 at 02:34 PM surveyor accompanied V6 (Licensed Practical Nurse) to R152 room. While standing in front of R152 door the surveyor asked V6 are residents that have urinary catheter, gastric tubes, and wounds on Enhanced Barrier Precautions. V6 responded, R152 should be on Enhanced Barrier Precautions. R152 roommate R149 has no invasive devices or wounds. R104 is on Enhanced Barrier Precautions. During the second-floor observation Enhanced Barrier Precaution Signage was observed on the entry doors of R29, R45, R104, R106 and R129.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected most or all residents
Based on review of records and interview the facility failed to follow COVID-19 vaccination policy for resident in determining and documenting COVID-19 immunization status. And failed to follow COVID-...
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Based on review of records and interview the facility failed to follow COVID-19 vaccination policy for resident in determining and documenting COVID-19 immunization status. And failed to follow COVID-19 vaccination for staff in tracking COVID-19 immunization status of staff. These failures have the potential to affect all 189 residents.
Findings include:
Five (5) residents were sampled for COVID-19 vaccination determination and documentation offering:
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R57 no immunization on record.
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R60 influenza 10/18/2023 (Historical) no other immunization on record.
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R336 no immunization on record.
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R337 influenza and pneumococcal vaccinations documents consent required.
-
R338 no immunization on record.
On 03/05/2024 at 11:25 AM, V6 (Licensed Practical Nurse) stated that she only got flu/influenza vaccine. That her most recent COVID-19 vaccination was a long time ago. And that facility does not offer COVID-19 vaccination and got her flu vaccine in the hospital.
On 03/06/2024 at 01:13 PM, V40 (Infection Control Preventionist) All vaccination (Pneumococcal, Influenza and Covid-19) must be under immunization tab, we are not 100% some people are waiting, some people refuse. I know that I need to check their (residents) immunization status and determine if they (residents) needed vaccines. Facility does not offer COVID-19 vaccination to staff, and the last clinic for residents was December 2023. I do not have details as to staff COVID-19 because HR (human resources) has the record. V40 stated, I needs to get hold and review staff COVID-19 vaccination status especially those that are in direct contact with residents. V40 further stated that since facility has a COVID-19 positive resident, it is important to know the COVID-19 vaccination status of staff that takes care of the resident.
COVID-19 Vaccination for resident policy dated 5/31/2023, reads:
COVID-19 vaccination is one of the Core Principles of COVID-19 Infection Prevention. Facility is dedicated to ensuring that vaccination is available for all residents. All residents will be offered the COVID-19 vaccine. Vaccine clinics will be held within the facility on a regular basis. Unvaccinated residents will be offered the COVID-19 vaccine prior to each clinic date.
COVID-19 Vaccination for Staff policy dated 9/2023, reads:
The policy defines the procedure for the COVID-19 vaccination program for facility healthcare. In accordance with patient safety standards, facility strongly encourages that all employees participate in the COVID-19 vaccination program or complete a statement of declination if the vaccine is medically contraindicated or because of religious beliefs if appropriate. All staff will be strongly encouraged to receive the primary COVID-19 vaccination series. In addition, staff are equally encouraged to remain up to date with all eligible COVID-19 booster vaccinations. Facility will track all Staff Members COVID-19 Vaccine status.
Feb 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
Dec 2023
4 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
1. Based on observation, interview, and record review, the facility failed to supervise ten residents (R2, R9, R10, R11, R12, R13, R14, R15, R16, R17) in the sample. This failure also affected R2 who ...
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1. Based on observation, interview, and record review, the facility failed to supervise ten residents (R2, R9, R10, R11, R12, R13, R14, R15, R16, R17) in the sample. This failure also affected R2 who had an unwitnessed fall which resulted in R2 sustaining a fractured nose. This failure has the potential to affect all residents on the first and second floor of the facility.
The facility failed to ensure that the emergency cart on the 3rd floor was safely locked when not in use and failed to ensure that a full oxygen tank for the emergency cart was stored securely in the oxygen rack. These failures have the potential to affect all the resident on the 3rd floor.
Findings include:
R2's admission records documented admission date as 10/30/23 with diagnosis that includes but not limited to End Stage Renal Disease, Fracture of nasal bone, Fluid overload, Anxiety Disorder, Unspecified Dementia, Dependence on Renal Dialysis and Other specified Diabetes Mellitus.
R2's MDS (Minimum Data Set) dated 11/09/23 scored R2's BIMS as 07 indicating that R2 is cognitively impaired.
R2's plan of care initiated 05/03/23 showed R2 has a wanderer behavior with goal R2's safety will be maintained.
According to facility investigation report incident date 10/28/2023 and time of incident 8:44pm. R2 was observed lying on the floor in the dining area none of the staff knows what happened to R2 on 10/28/23. Upon assessment R2 was noted with a skin alteration on the nose and complained of pain to right shoulder.
R2's medical record progress note dated 10/28/2023 22:02 (10:02pm) V8 LPN (licensed Practical Nurse) identified as the nurse assigned to R2 documented in part Writer (V8) sitting at nursing station charting and heard resident in dining room yelling help. Writer went into dining room and noted resident laying on the floor with bloody nose stating someone pushed him out his w/c (wheelchair), no staff present in the dining room when writer arrived at the dining room. Resident stated someone pushed him out his w/c. Writer assessed resident for injuries, no visible injuries noted, small laceration on the bridge of nose, area cleansed with NS, V/S obtained, myself and another nurse on the unit assisted resident into w/c. Pt c/o pain 7/10, Writer called third eye and spoke with (V28) and informed her of incident that occurred and that fall was unwitnessed, and neuro checks are in place also requested orders for pain medication, orders rec'd for Tylenol 650mg p q6 hours prn for pain, (family)made aware, Writer called Elite ambulance for p/u dispatch stated they have no availability, writer then called ATI ambulance eta 4 hours. Pt sitting at nursing station being monitored closely, pt shows no s/s of respiratory distress, bleeding subsided, no discharge or drainage noted from nose or ears, neuro checks in progress will cont. to monitor. 167/91-20-75-98%-97.8.
R2's hospital record documents R2 was transferred to another hospital for trauma evaluation and management.
R2's hospital records presented dated 10/28/23 timed 23:59 (11:59pm) and electronically signed by V29 (Medical Doctor) showed CT head without contrast, CT cervical Spine without contrast and Maxillofacial CT without contrast was done and the impression under Cervical documented in part that there may be a nondisplaced avulsion, fracture at the medial aspect of the left occipital condyles. Additionally, there may be nondisplaced avulsion fractures arising from the lateral masses of C1. These are age indeterminant. MRI may be helpful in determining acuity. Head impression showed there is no intracranial hemorrhage, midline shift, or calvaria fracture. Parenchymal volume loss and chronic microvascular ischemic changes of cerebral hemispheres are present. Mild chronic Crooner infarctions are seen within the right basal ganglia.Maxillofacial impression showed there is a mildly displaced right nasal bone fracture.
On 12/04/23 at 1:25pm, V2 DON (Director of Nurse's) stated, V7 CNA (Certified Nurse's Aide) worked directly with R2 on the day of the incident and is no longer working at the facility.
On 12/04/23 at 12:35pm, V13 LPN (Licensed Practical Nurse) and 2nd floor unit manager stated, R2 needs staff supervision constantly. V13 stated, Staff are supposed to monitor the areas where residents are gathered like the dining room, but whose to say R2 did not go back there after everyone had left. I'm just saying.
On 12/04/23 at 12:56pm, V16 (Activity Director) identified as the 2nd floor activity director stated, all the staff are responsible for monitoring the resident but the schedule for monitoring is activities staff monitors from 7:30am to 1:00pm and after that nursing staff monitors from 1:00pm to 2:00pm and this is worked into the nursing staff schedule daily.
On 12/04/23 at 1:01pm, surveyor observed nine residents sitting in the first-floor dining room area without any staff monitoring or supervision. Surveyor observed R13 crying and appeared confused. Surveyor asked V11 (Unit Manager) and V20 (Case Manager) to come to dining room to identify the residents in the dining room. V11 and V20 identified the resident as: R9, R10, R11, R12, R13, R14, R15, R16, and R17. V20 stated, There should be staff with the residents supervising/monitoring. V11 further stated there was a call off from a nurse today so she (V11) had to work the cart (referring to passing medication). V11 identified V9 as the CNA (Certified Nurse's Aide) who should have been supervising and monitoring the residents according to the daily dining room monitoring assignment sheet.
On 12/04/23 at 1:06pm V17 (Activity Director) for the first floor stated, there should be staff monitoring the dining room when the residents are present. V17 stated, the CNA's (Certified Nurse aides) monitors every thirty minutes whether there is an activity or not. V17 stated, the residents are to be supervised and not to be left alone. V17 stated, the daily schedule is for activity to monitor from 10am to 11am and from 2:00pm to 3:30pm.
On 12/04/23 at 1:08pm, V9 (CNA) stated, she was busy assisting another resident. V9 stated, it has being chaotic changing the residents and assisting in changing bandages. V9 stated, the previous staff supervising should not have left the residents without her (V9).
On 12/04/23 at 1:25pm, V2 DON (Director of Nurse's) stated, V7 CNA (Certified Nurse's Aide) worked directly with R2 on the day of the incident and no longer is working at the facility. V2 stated, rounds are to be made frequently at least every hour.
On 12/18/23 at 3:09pm, V26 NP (Nurse Practitioner) stated, she is aware of R2's fall. V26 stated, R3 was found on the floor and was sent to the hospital and after R2 came back she saw (referring to assessment of R2) R2. V26 stated, she cannot say R2's nasal fracture was due to the fall of 10/26/23 because R2 is very impulsive, and it can be due to another incident. V26 stated, the hospital record she reviewed showed that R2 had a nose fracture.
As of 12/18/23 at 3:45pm, the facility was unable to provide the policy for hazard and supervision after several request.
During the course of the survey, V7 was unable to be contacted.
2. On 12/04/23 at10:04am, on the 3rd floor in the hallway surveyor observed emergency red and white cart unlocked and unattended and a green oxygen tank unsecured and being stored on the bare floor. V12 LPN (Licensed Practical Nurse) identified as the unit manager stated, they (referring to oxygen tank) should be hooked up to the emergency cart and the cart should be locked with the breakaway plastic tag lock. V12 stated the cart lock is broken and cannot be locked with the breakaway tag lock. V12 stated storing the oxygen tank on the floor unsecured is a fire hazard. V12 opened the cart with the surveyor and stated, there were needles (referring to IV needles), scissors, lancets, IV solutions that were stored in the cart. V12 tried to fix the black belt attached to the cart for holding the cart and the belt was broken.
On 10/04/23 at 10:40am, V2 DON (Director of Nurse's) stated, the crash cart on each floor should be locked after use with the oxygen tank attached.
On 12/05/23 at 2:01pm, V2 stated, the emergency cart should be locked with the plastic tag (referring to the breakaway tag lock) and oxygen tank attached to the emergency cart.
Facility policy on Crash Cart and AED dated 1/2023 presented documented in part that in general the policy is to provide the staff with guidance on the crash cart contents and monitoring. Responsible party listed includes the DON (Director of Nurse's, RN (Registered Nurses), LPN (Licensed Practical Nurses), and maintenance. Listed items in the crash cart includes but not limited to sharp IV (Intravenous) needles, suture removal kit, lancet, and scissors. Facility protocol includes but not limited to making sure that the drawer to the crash cart is always locked to ensure contents remain intact. Securing that the cart is locked using breakaway tag lock.
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 report to IDPH (Illinois Department of Public Health) within the required regulation time, an allegation of abuse for two residents (R3 and ...
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Based on interview and record review the facility failed to report to IDPH (Illinois Department of Public Health) within the required regulation time, an allegation of abuse for two residents (R3 and R4) reviewed for abuse.
Findings include:
R4's admission record diagnosis listed information documentation includes but not limited to Acute Embolism and Thrombosis of right femoral vein, muscle weakness (Generalized), abnormal weight loss, hemiplegia, unspecified lack of coordination, adult failure to thrive, and Epilepsy.
On 12/04/23 at 3:45pm, V18 (Family) complained to the surveyor that R4's wallet was stolen from R4's room and. R4's wallet has not been found. Surveyor asked whether this had been reported to the facility staff, V1 (administrator) or V2 DON (Director of Nurse's). V18 stated, yes and there has been activity noted on R4's credit card and bank account. V18 stated, V21 (Social Services) was notified on 11/29/23.
On 12/04/3 at 3:52pm, V21 acknowledged V18 informed her (V21) on 11/29/23 about the missing purse and V19 (Customer Services) was made aware. V21 stated, they (Staff) searched everywhere for the missing purse, but it was not found. V21 stated, she was not sure whether this was reported to IDPH.
On 12/04/3 at 4:24pm V19 stated in part that she was made aware, and a concern form was filled out on 11/29/23. V19 stated, we (referring to V21 and self) searched for the purse in R4's room, laundry, lost and found area and there was no purse or bag. When the surveyor asked whether this was reported to IDPH (Illinois Department of Public Health), V19 stated, my job is to file the concerns forms, it will be the manager's job to follow up. V19 stated, V11 (Unit Manager) was made aware of the concern.
On 12/04/23 at 4:40pm, the surveyor informed V1 (Administrator) about V18's allegation. V1 stated, she (V1) was not aware the purse was still missing until today. V1 further stated, she had just asked V18 about it and V18 stated, activity on the card started on 12/01/23. Surveyor asked V1 if prior to today (12/04/23) if V1 initiate an investigation. V1 stated, no report or investigation has been initiated. V1 presented a copy of the concerns form dated 11/29/23 and stated I (V1) did not report it or start any investigation.
On 12/05/23 at 10:00am, R3 complained staff are treating (R3) like R3 is not a human being because they come into the room and will not let (R3) know what they are trying to do. R3 stated, they will yank the cover off me (R3), and hit me. R3 stated, (R3) would rather not be changed (referring to Care) stay dirty than for them (staff) to constantly mistreat (R3).
On 12/05/3 at 10:24am, V25 CNA (Certified Nurse's Aide) assigned to R3, stated when she got to R3 for ADL's, R3 was soiled from top to bottom (soiled with urine and feces, dressing to the leg and butt wounds were soiled. V25 stated, R3 said (R3) was waiting for V25.
On 12/05/23 at 11:34am, V22 (R3's Family Member) identified V23 as a family friend who was very concerned about R3's complaints of being hit by staff during care. V22 stated in part, on Sunday 12/3/23 she (V22) made a verbal complaint to V1 (Administration) who was present at the facility about R3's treatment by the facility staff, the hitting, roughness during care not paying attention to details and speaking to R3 in a demeaning way. R3 wanted to be moved from this place (facility) because of this.
On 12/05/23 at 11:44am, V21 (Social Services) stated, I was the MOD (Manager on Duty) Sunday 12/03/23. I received a call from V23 (R3's family friend) from out of state. She had concerns about R3's treatment at the (facility), and R3 being abused. V23 stated, the staff were hitting R3. I (V21) told her (V23) R3's sister is in the room, and I will go and talk to both R3 and V22 who was in the room. R3 did not know anyone by name who the abuser was but stated this hitting of hands and handling in a rough manner happens during care. The sister (V22) also complained of R3's vital signs not been done, and it should be done frequently. V21 stated, she forwarded the complaint to V20 (Case Manager).
On 12/05/23 at 11:52am, V20 (Case Manager) stated, he is familiar with R3. V20 stated., R3 has complained about staff not knocking on the door before entering and not explaining what care the staff was about to assist R3 in doing and being rough on R3, but R3 did not say they were being aggressive or being abusive. Surveyor asked V20 if hitting or being rough during care a form of abuse and should it be reported. V20 stated, hitting is a form of abuse and it should be reported. V20 stated I will meet with (V22) R3's family member today during family partners in care meeting today.
On 12/05/23 at 12:32pm, V1 stated, V22 (Family) complained to her about the treatment from staff to R3 but both R3 and V22 did not say it was an abuse. V1 stated, the communication must be better between the staff and the resident. Surveyor asked whether hitting and being rough during care by facility staff is a form of abuse. V1 stated, because R3 and V22 did not say it is an abuse, no investigation or report was made to IDPH.
On 12/05/23 at 12:50pm, V11 (Unit Manager) stated in part on Wednesday last week (referring to 11/29/23), V18 (family) complained that R4's purse was missing with R4's cards and bank account information. A concern form was filled out because that is the protocol. V11 stated in part, she (V11) and other staff searched in R3's room, everywhere on the floor, and also went down stair to laundry but it was not found. V11 stated, V1 (administrator) was notified and aware of the purse missing. V11 presented a copy of concerns form filled out on 11/29/23 regarding this issue.
The facility Abuse policy and Prevention Program 2022 presented and dated 10/2022 documented in part that the facility affirms the right of the facility residents to be free from listed form of abuse that includes but not limited to misappropriation of property and mistreatment. Internal reporting requirements and Identification of Allegations documented in part that employees are required to report any incident, allegation or suspicion of potential abuse that includes mistreatment or misappropriation of resident property either observed or hear about or suspected to the administrator immediately. In the absence of administrator reporting can be made to an individual who has been designated to act in the administrator's absence. Under external reporting the policy indicated that when an allegation of abuse has been made the administrator, or designee, shall notify department of Public Health's Regional Office immediately by telephone or fax. The policy documented in part that physical abuse includes hitting and slapping. Misappropriation of resident property means the deliberate misplacement, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.
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 immediately initiate an investigation into alleged physical abuse and misappropriation of resident property for two residents (R3 and R4) re...
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Based on interview and record review the facility failed to immediately initiate an investigation into alleged physical abuse and misappropriation of resident property for two residents (R3 and R4) reviewed for abuse. This failure affected R3 who alleged staff mistreatment and being physically aggressive during care and R4 who alleged theft and misappropriation of property. This failure has the potential to affect all 190 resident residing in the facility.
Findings include:
R4's admission record diagnosis listed information documentation includes but not limited to Acute Embolism and Thrombosis of right femoral vein, muscle weakness (Generalized), abnormal weight loss, hemiplegia, unspecified lack of coordination, adult failure to thrive, and Epilepsy.
On 12/04/23 at 3:45pm, V18 (Family) complained to the surveyor that R4's wallet was stolen from R4's room and R4's card and wallet cannot be found. Surveyor asked whether this has been reported to the facility staff, V1 (administrator) or V2 DON (Director of Nurse's). V18 stated, yes and there was activity noted on R4's credit card and bank account. V18 stated, V21 (Social Services) was notified on 11/29/23.
On 12/04/23 at 3:52pm, V21 acknowledged V18 informed her (V21) on 11/29/23 about the missing purse and V19 (Customer Services) was made aware. V21 stated, they (Staff) searched everywhere for the missing purse, but it was not found. V21 stated, she was not sure whether this was reported to IDPH.
On 12/04/23 at 4:24pm V19 stated in part, she was made aware, and a concern form was filled out on 11/29/23. V19 stated, we (referring to V21 and self) searched for the purse in R4's room, laundry, lost and found area and there was no purse or bag. When the surveyor asked whether this was reported to IDPH (Illinois Department of Public Health), V19 stated my job is to file the concerns forms, it will be the manager's job to follow up. V19 stated, V11 (Unit Manager) was made aware of the concern.
On 12/04/23 at 4:40pm, the surveyor informed V1 (Administrator) about V18's allegation and V1 stated she (V1) was not aware the purse was still missing until today and she just asked V18 about it and V18 stated activity on the card started on 12/01/23. Surveyor asked V1 if allegations were throughly investigated V1 stated, no report or investigation has been initiated. V1 presented a copy of the concerns form dated 11/29/23 and stated I (V1) did not start any investigation.
On 12/05/23 at 12:50pm, V11 (Unit Manager) stated in part, on Wednesday last week (referring to 11/29/23), V18 (family) complained that R4's purse was missing with R4's cards and bank account information's, a concern form was filled out because that is the protocol. V11 stated in part that she (V11) and other staff searched in the room everywhere on the floor, also went down stair to laundry but it was not found. V11 stated the V1 (administrator) was notified and aware of the purse missing presenting a copy of concerns form filled out on 11/29/23 regarding this issue.
The facility Abuse policy and Prevention Program 2022 presented and dated 10/2022 documented in part that the facility affirms the right of the facility residents to be free from listed form of abuse that includes but not limited to misappropriation of property and mistreatment. Internal reporting requirements and Identification of Allegations documented in part that employees are required to report any incident, allegation or suspicion of potential abuse that includes mistreatment or misappropriation of resident property either observed or hear about or suspected to the administrator immediately. In the absence of administrator reporting can be made to an individual who has been designated to act in the administrator's absence. Under external reporting the policy indicated that when an allegation of abuse has been made the administrator, or designee, shall notify department of Public Health's Regional Office immediately by telephone or fax. The policy documented in part that physical abuse includes hitting and slapping. Misappropriation of resident property means the deliberate misplacement, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.
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 F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure residents call light was within reach for 5 residents (R1, R5, R6, R7, and R8) reviewed for call light.
Findings include...
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Based on observation, interview and record review the facility failed to ensure residents call light was within reach for 5 residents (R1, R5, R6, R7, and R8) reviewed for call light.
Findings include:
On 12/04/23 at 9:36am, R1 and R5 were observed in bed in their room with call light observed under their beds and not within their reach.
On 12/04/2023 at 9:40am, V11 LPN (Licensed Practical nurse) identified as the 1st floor manager stated, call light should be attached to the pillow or bed sheet and within the resident reach.
On 12/04/2023 at 9:42am R6 observed in bed with call light observed under the bed.
On 12/04/2023 at 9:43am, R7 was observed in bed and call light was not within reach.
On 12/04/2023 at 9:50am, V5 CNA (Certified Nurse's Aide) stated, call light should be placed where the resident can reach it and clipped to the bed linen.
R1's MDS (Minimum Data Set) dated 10/09/2023 scored R1's BIMS (Brief Interview for Mental Status) as 15.
R1's fall plan initiated 08/23/23 documented listed interventions that includes but not limited to promoting placement of call light within reach.
R5's MDS (Minimum Data Set) dated 01/01/2023 scored R5's BIMS (Brief Interview for Mental Status) as 15.
R6's MDS (Minimum Data Set) dated 10/24/2023 scored R6's BIMS (Brief Interview for Mental Status) as 03.
R7's MDS (Minimum Data Set) dated 10/09/2023 scored R7's BIMS (Brief Interview for Mental Status) as 15.
The facility Call Light Response policy dated 1/2023 presented documented general the policy is to provide the staff with guidance on responding to residents' request and needs. Protocol listed includes but not limited ensuring that the call light is always within the resident's reach, when the patient or resident is in bed or confined to a bed or chair, provide the call light within easy reach of the patient or resident.
Oct 2023
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
ADL Care
(Tag F0677)
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 ADL (Activities of Daily Living) care was provi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of two residents (R6) reviewed for ADL care.
Findings include:
R6's medical record (Face Sheet) documents R6 is an [AGE] year-old admitted to the facility on 11.16.2022 with diagnoses including but not limited to: Anemia, Hyperlipidemia, Essential (Primary) Hypertension, Chronic Kidney Disease, Muscle Weakness, and Difficulty in Walking. R6's MDS (Minimum Data Set, dated 8.23.2023) documents the following:
-BIMS (Brief Interview for Mental Status):14 of 15 (cognitively intact)
-Functional Status: Bed Mobility: 3/2 (Extensive assistance/One-person physical assist) and Toilet use: 3/3 (Extensive assistance/Two persons physical assist)
-Bladder and Bowel: 3/3 (Always incontinent of urine/Always incontinent of stool)
On 10.26.2023 at 1:20 PM, R6 was observed awake and alert, sitting up in bed. A fecal odor was noted. R6 said she is wet and needs to be changed, was last changed on the 11-7 shift. R6 said she put the call light on several times to let staff know that she is wet but still hasn't been changed.
On 10.26.2023 at 1:36 PM V11 (CNA-Certified Nursing Assistant) came to R6's room to change resident. V11 said that she last changed R6 at 6:00 AM. The front of R6's brief was saturated with urine; large amount of brown feces was noted to the back of brief.
On 10.26.2023 at 1:50 PM, V12 (ADON-Assistant Director of Nursing) said, it actually should be every two hours and as needed (that residents are checked/changed for incontinence). We try to identify our heavy wetters. We don't have a set time frame to check on heavy wetters, but they should be checked on more frequently then every two hours. The 3rd Floor is our heaviest floor, but we could always have more staff.
On 10.26.2023 at 2:51 PM via telephone, V1 (DON-Director of Nursing) said,
Staff should be checking at least every two hours (for incontinence) or more frequently if needed. Heavy wetters should be checked on more frequently.
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 safely transfer a resident to prevent a fall for one of three reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to safely transfer a resident to prevent a fall for one of three residents (R1) reviewed for falls. Staff failed to utilize a gait belt during transfer from toilet to wheelchair. This failure resulted in R1 sustaining a subarachnoid hemorrhage (bleeding in the space that surrounds the brain) and a left zygomaticomaxillary complex fracture (fracture involving the cheekbone and the surrounding bones).
Findings include:
R1's medical record (Face Sheet) documents R6 is a [AGE] year-old admitted to the facility on 8.2.2023 with diagnoses including but not limited to: Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), Difficulty in Walking, Acute Kidney Failure, Repeated Falls, Weakness and Chronic Kidney Disease.
R1's MDS (Minimum Data Set, dated 8.9.2023) documents the following:
-BIMS (Brief Interview for Mental Status):3 of 15 (severely cognitively impaired)
-Functional Status: Toilet use: 3/2 (Extensive assistance/ One-person physical assist), Moving on and off toilet-2 (not steady, only able stabilize with staff assistance
Facility's Final Incident Report (8.29.2023) documents in part: On 8.22.2023 at 6:40 AM the nurse entered the room on the request of staff and observed the patient lying supine on the floor next to the toilet. When questioned, the patient was unable to explain how the fall occurred. The patient was noted with a skin tear to her left eyebrow. 911 was contacted and the MD and family were made aware of the fall and subsequent transfer to the hospital. While in the hospital the patient was diagnosed with a subarachnoid hemorrhage and a left zygomaticomaxillary complex fracture. Interview with the assigned nursing assistant revealed that while helping the resident to the bathroom the resident fell while completing the toileting task. During the IDT (Interdisciplinary Team) meeting it was determined that the fall was caused by the patient's ongoing delirium and impulsiveness.
Hospital Progress Note (electronically signed on 8.23.2023 at 7:25 AM) documents in part: This is a [AGE] year-old female with past medical history of CKD, dementia, hypertension, hyperlipidemia who presents for fall. Clinical impression: 1. Fall, 2. Subarachnoid hemorrhage, 3. Closed fracture of left zygomaticomaxillary complex.
CT Brain Final Result (8.22.2023 at 9:09 AM) documents in part: Indication: Head trauma. Fell at nursing home. Impression: 1. Tiny subarachnoid hemorrhage noted in the right sylvian fissure, likely posttraumatic in nature. 2. Left zygomaticomaxillary complex fracture.
On 10.24.2023 at 1:35 PM, V2 (LPN/Nurse Case Manager/Fall Nurse) said, V4 (CNA-Certified Nursing Assistant) was interviewed but never said how R1 fell during transfer. V2 said a resident should never fall during a transfer.
On 10.26.2023 at 10:07 AM, V2 (LPN/Nurse Case Manager/Fall Nurse) said, V4 said while transferring the patient, the resident fell. The IDT completed the investigation (V1, V2-Director of Nursing, and V6-Administrator). We determined that there was some error in the transfer that resulted in the resident falling.
On 10.26.2023 at 2:51 PM via telephone, V1 (DON-Director of Nursing) said, we (IDT) discussed R1's fall. To our knowledge and after speaking with the CAN (V4), the resident lost her footing when the CNA was getting the resident off the toilet. They (CNAs) should use gait belts when completing transfers. We did ask her (V4) if she used a gait belt (during the transfer) and she said no.
V4 (CNA-Certified Nursing Assistant) was not available for interview.
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
Based on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bow...
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Based on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of two residents (R6) reviewed for ADL care.
Findings include:
On 10.26.2023 at 12:59 PM the 3rd Floor Census was 70 (residents). There were two nurses and four CNAs (Certified Nursing Assistants) on the unit to take care of residents.
10.26.2023 at 1:20 PM, R6 was observed awake and alert, sitting up in bed. A slight odor of feces noted. R6 said there isn't enough staff. R6 said she is wet and needs to be changed, she was last changed on the 11-7 shift. R6 said she put the call light on several times to let staff know that she is wet but still hasn't been changed.
10.26.2023 at 1:36 PM V11 (CNA-Certified Nursing Assistant) came into R6's room to change resident. V11 said that she last changed R6 at 6:00 AM. V11 said there aren't enough CNAs to take care of the residents. V11 said she, today, she is responsible for the care of about 17 residents; of those residents, only one, is not dependent upon staff for assistance with ADLs (Activities of Daily Living).
10.26.2023 at 1:50 PM, V12 (ADON-Assistant Director of Nursing) said, the 3rd Floor is our heaviest floor, but we could always have more staff.
7.26.2023 Resident Council Meeting Minutes document: Residents requested to have additional staff (CNAs-Certified Nursing Assistants) 2nd and 3rd shifts due to it's been difficult to find somebody to answer the call light.
Aug 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Findings include:
On 8/23/2023 at 10:00am surveyor reviewed R12's July MAR (Medication Administration Record) dated 7/1/2023 to 7/31/2023. Surveyor noted R12's scheduled ad prescribed medication order...
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Findings include:
On 8/23/2023 at 10:00am surveyor reviewed R12's July MAR (Medication Administration Record) dated 7/1/2023 to 7/31/2023. Surveyor noted R12's scheduled ad prescribed medication order for Nystatin Mouth/Throat Suspension-Give 400000 unit by mouth every 6 hours related to Candidiasis Unspecified until 7/31/2023, Swish in mouth several minutes then swallow times 10 days. R12 did not receive scheduled medications on the following date and times: 7/22/2023 at 0000(per MAR) and 7/22/2023 at 0600.
On 8/23/2023 at 12:25pm V31(LPN/Licensed Practical Nurse) stated the nurses are responsible for signing the MAR (medication administration record). V31 stated a blank space on the MAR indicates the medication was not given to the resident. V31 stated there should not be any blank spaces on the MAR. V31 stated there are codes nurses can use on the MAR when a resident does not receive the medication due to some reason. V31 stated with best practice standards in mind, missing initials, or a missing code on the MAR (medication administration record) indicates the medication was not administered to the resident.
On 8/23/2023 at 12:46pm V2(DON/Director of Nursing) stated the nurses are responsible for signing out on the medication administration record after a medication is administered to a resident. V2 stated a blank space on the medication administration record would indicate that a medication was not given to a resident. V2 stated there are codes located on the medication administration record that can be used by the nurses when a medication is not administered to the resident. V2 stated with best practice standards in mind missing nurses' initials or a missing code on the medication administration record would indicate that the nurse did not administer the medication to the resident.
On 8/23/2023 at 1:29pm V14(LPN/Licensed Practical Nurse) stated R12 had thrush and was receiving a medication to treat the thrush. V14 stated if there are no nurses' initials on the medication administration record indicating the medication to treat R12's thrush was administered, then the medication was not administered to R12.
Based on interview and record review the facility failed to follow doctor's orders for two residents (R5, R6) for medication administration. This failure affected two residents R5 and R12 out of a sample of 2.
Findings:
R5 has a diagnosis of but not limited to Dysarthria and Anarthria, Hypertension, Hyperlipidemia, Gastro-Esophageal Reflux Disease and Vitamin D Deficiency.
On 8/22/2023 at 4:00pm surveyor reviewed R5 MAR (Medication Administration Records) for June 2023 that indicated medications were not given on many days.
On 8/24/2023 at 9:00am surveyor reviewed R5's June 2023 MAR that documents prescribed and scheduled AM 1 (8:00am-10:00am) were not given on 6/06/2023, 6/07/2023 and 6/22/2023. R5's scheduled and prescribed medications were Aspirin, Atorvastatin, Multivitamin Women 50+, Norvasc and Vitamin D3.
On 8/24/2023 at 9:00am surveyor reviewed R5's June 2023 MAR that documents prescribed and scheduled Bedtime (8:00pm-10:00pm) were not given on 6/06/2023, and 6/20/2023. The scheduled and prescribed medication was Famotidine.
On 8/23/2023 at 12:20pm V31 (LPN) stated an empty box on the MAR would indicate that the medicine was not given and missing initials or codes means that the medication was not administered to the resident for that time slot.
On 8/23/2023 at 1:07pm V1 (DON) stated it expected that the nurse document on each medication pass and an empty box would mean that the medication was not given.
Medication Administration Policy dated 1/2023 states, in part, all medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help diagnosis, document as each medication is prepared on the MAR and if medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required.
Undated Job description for Floor RN/LPN documents, in part, administer or supervise the preparation and giving of prescribed medication to residents.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
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 adequately supervise two high fall risk residents (R1 and R5) to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to adequately supervise two high fall risk residents (R1 and R5) to prevent further falls, and facility failed to ensure that a fall care plan was updated after each fall for (R1).
Findings include:
R1 is [AGE] year old with diagnosis including but not limited to: Disorder of brain, Unsteadiness on feet, Muscle weakness, Need for assistance with personal care, Dementia, Lack of coordination, Hemiplegia and Hemiparesis.
R1 has a BIMS (Brief Interview for Mental Status) score of 5, which indicates severe cognitive impairment.
On 8/21/23 at 9:45 AM during investigation, R1 was observed in bed.
Surveyor inquired about R1 ' s fall on 6/11/23.
At that time, R1 said, I don ' t remember how I fell. I think I was trying to get in bed.
On 8/22/23 at 9:51 AM, V31 (LPN/ Licensed Practical Nurse) said, R1 is mostly bed bound. She gets up sometimes but with a mechanical lift. R1 is total assist resident and does not ambulate. R1 props her feet to the wall and pushes herself off of the bed. She (R1) has had a few falls that I am aware of.
On 8/22/23 at 10:19 AM V6 (Advocate Nurse Liaison/ Falls Nurse) said, On 6/11/23 a Nurse observed R1 laying on the floor near the bed with a raised area on her head. She (R1) is considered a high fall risk.
On 8/23/23 at 1:08 V2, DON said, We expect for nursing staff to make frequent rounds to ensure that residents who are High risk for falls are safe. I was not aware of her (R1) scooting out of bed prior to the incident. The care plan should indicate the she (R1) has a history of sliding out of bed. The care plan should also be updated after each fall.
On 8/23/23 at 2:00 PM V6 said, I believe R1 has had three falls since she has been admitted here in April (2023). Sometimes she (R1) pushes herself outside of the bed. Post fall, we review with IDT (Interdisciplinary) to see how the fall occurred and ways to prevent falls in the future. We also update the care plan after each fall to implement new fall prevention measures. R1 ' s care plan was not updated after each fall in August (2023) but, there were Fall Evaluations complete after each fall. The care plan should be updated post fall to indicate any new fall precaution measures.
Facility document titled State Report of Patient Incident documents, on 6/11/23 at 4:18 AM the nurse entered the room and observed the patient (R1) lying face down on the floor mat next to her bed.
R1 ' s Fall Care Plan updated 6/11/23 documents, Interventions: Perform frequent safety checks and monitor for impulsive behaviors.
Facility document titled Fall Risk Evaluation dated 8/7/2023 documents, fall risk score of 22 (High Risk for falls), Reason for assessment: Post Fall.
Facility document titled Fall Risk Evaluation dated 8/9/2023 documents, fall risk score of 24 (High Risk for falls), Reason for assessment: Post Fall.
R1 ' s Fall Care Plan documents, updated 8/15/2023, Interventions: Evaluate for bolster mattress.
Facility Fall Policy dated 1/2023 documents, Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.
Findings:
R4 has a diagnosis of but not limited to Traumatic Ischemia of Muscle, Cerebral Infarction, Hyperlipidemia, Hypertension, Syncope and Collapse, Pressure Ulcer of Right Buttock. Brief Interview of Mental Status score is 11 that indicates moderately impaired.
On 8/21/2023 at 10:00am surveyor reviewed the fall list for June 2023, July 2023 and August 2023 that documents R4 had falls on or about 7/15/2023, 7/19/2023, 7/26/2023, and on 8/08/2023.
On 8/22/2023 at 10:37am V6 (Nurse Liaison/Fall Coordinator) stated R4 had 4-5 falls, but he don't quite remember the actual number and R4 is considered a high fall risk.
On 8/23/2023 at 1:07pm V2 (DON) stated they (residents) would be required to be moved closer to the nurse's station, supervision and bolsters.
On 8/23/2023 at about 3:05pm V38 (Unit Manager/LPN) stated resident who are fall risk we should get them up and bring into common area for observation.
Fall Prevention and Management dated 1/2023 documents, in part, those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible.
Undated chart of 1st Floor Fall Risk Residents documents, in part, frequent safety checks are conducted.
R5's Care plan focus with a date of 7/02/2023 documents, in part, high risk for falls and frequent safety checks to ensure the resident doesn't have any care needs.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient Certified Nursing Assistant staff were scheduled ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient Certified Nursing Assistant staff were scheduled on the overnight shift. This has the potential to affect all residents that reside in facility.
Findings include:
R15 is [AGE] years old with diagnosis including: Multiple Sclerosis, Impacted cerumen, Joint pain and Muscle weakness.
R15 ' s BIMS (Brief Interview for Mental Status) Score is 15, which indicates cognitively intact.
R16 is [AGE] years old with diagnosis including but not limited to: Weakness, Difficulty Walking, Peripheral Vascular Disease, Pressure Ulcer of Sacral Region, Hypertension and Heart Failure.
R16 ' s BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact.
On 8/22/23 at 11:15 AM during investigation, R15 and R16 were observed in their bedroom in bed.
At this time, R15 said, There are not enough CNAs (Certified Nurse Assistants) on the overnight shift. Sometimes I have to wait a long time to get help.
On 8/22/23 at 11:17 AM R16 said, I know they have been short-staffed here. On the night shift when I call to be changed, I have to wait a long time.
On 8/22/23 at 11:27 V17 (CNA) said, I sometimes work the overnight shift and it is difficult because it is usually myself (V17) and one other CNA on a unit. So When I work the day shift, I automatically get started cleaning residents when I get in because I know that it is hard for the 2 CNAs to clean 68- 70 residents in the before the change of shift in the morning.
On 8/22/23 at 11:38 AM, V18 (Unit Manger) said, There are usually 65-70 residents on this unit. (3rd floor). Today, there are 70 residents on the unit.
On 8/22/23 at 11:42 AM, V19 (CNA) said, I work overnight here sometimes. There are usually only 2 CNAs on one unit on the overnight shift. Two CNAs on the overnight shift are not enough to properly care for all of the residents.
Surveyor inquired about the CNA Staffing.
On 8/23/23 at 1:38 PM, V4 (Staffing Coordinator) said, For the second floor ideally, there are six CNAs on the day shift, 4-5 CNAs on the evening shift and 2-3 CNAs on the night shift. Depending on the circumstances, the nurse is able to assist with care. CITs (CNAs In Training) are not allowed to assist with ADL (Activities of Daily Living) care with residents. We have been challenged on the night shift at times, but we are getting better. We just hired a lot of CNAs.
Surveyor inquired about the C/O on some of the schedules.
On 8/23/23 at 1:38 PM, V4 said, C/O means call off. If there is a c/o next to an employee ' s name, they did not work that shift.
On 8/23/23 at 1:02 PM, V2 (Director of Nursing) said, We have been working towards getting more overnight CNAs (Certified Nurse Assistants). For overnight shift CNAs, the expectations is to have at least 3-4 CNAs per floor (9-12 CNAs total in facility), to ensure that the needs are met for the residents. It is a challenge on the night shift with CNA staffing. With not enough staff on the overnight shift, there could be increased falls, increased bed sores from not being changed, and just a whole safety factor altogether.
The facility staff schedules for 7/1/23 through 8/20/23 documents the following TOTAL number
of CNAs working in facility (all three units combined):
7/1/23- 11 CNAs worked on the day shift and 4 CNAs worked on the overnight shift.
7/7/23- 11 CNAs worked on the day shift and 2 CNAs worked on the overnight shift.
7/15/23- 10 CNAs worked on the day shift and 3 CNAs worked on the overnight shift.
7/16/23- 8 CNAs worked on the day shift and 4 CNAs worked on the overnight shift.
7/22/23- 8 CNAs worked on the day shift and 4 CNAs worked on the overnight shift.
7/23/23- 8 CNAs worked on the day shift and 5 CNAs worked on the overnight shift.
7/28/23 -12 CNAs worked on the day shift and 3 CNAs worked on the overnight shift.
8/12/23- 12 CNAs worked on the day shift and 6 CNAs worked on the overnight shift.
8/20/23- 9 CNAs worked on the day shift and 4 CNAs worked on the overnight shift.
Residents ' Concerns and Issues documents, Date: July, 27, 2020, Residents name/ Room number: 3rd Floor, Concern & Issue: Requesting to have additional CNA (staff) for the 2nd and 3rd shift due to difficulty finding staff to answer call lights and take residents to the bathroom when requested.
Compliment/ Concern Form documents, Resident ' s name: Resident Council, Concern: Patients concern overnight staffing.
Resident Rights- Accommodation of Needs and Preferences and Homelike Environment Policy documents, It is the policy of the facility to identify and provide reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a homelike environment for the residents. This ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a homelike environment for the residents. This failure applies to all 181 residents in the facility.
Findings include:
On 8/21/2023 at 11:00am surveyor observed broken areas on the railings along the stairwell leading into and out of the facility.
On 8/22/2023 at 9:34am surveyor observed R6's room bathroom, R6's bathroom did have a missing ceiling panel located above the toilet and white spackle was located on two places on the bathroom walls, no paint was applied over the spackled area.
On 8/22/2023 at 9:45am observed missing ceiling tiles above the toilet in room [ROOM NUMBER].
On 08/22/2023 at 10:00am surveyor observed peeling paint located on a left side panel of the second-floor south elevator.
On 8/23/2023 at 11:20am V21(Maintenance Assistant) stated the ceiling tiles were ordered three months ago, but the ceiling tiles never came to the facility. V21 stated the ceiling tiles have been missing from the bathroom in room [ROOM NUMBER] for one month now. V21 stated there is flooding from the second floor and the water comes down from the second floor damaging the ceiling tiles on the first floor. V21 stated the missing ceiling tiles in the bathroom in room [ROOM NUMBER] have been like that for one month. V21 stated the missing ceiling tiles in the bathroom in room [ROOM NUMBER] is due to flooding water from the second floor. V21 stated the second-floor south elevator located to the left side when exiting the second-floor south elevator has a panel with chipping paint. V21 stated the panel needs to be replaced. V21 stated maintenance staff is responsible for removing and replacing the panel with the chipping paint. V21 stated with this new company it is hard to get things.
On 8/23/2023 at 10:59am V21(Maintenance Assistant) stated I reported to the new company who took ownership of this facility that the handrail leading up the facility door was broken. V21 stated I reported to the new company about one month ago. V21 stated the handrails have been broken for four months now. V21 stated maintenance staff closed access off to the steps and handrails by placing the yellow caution tape at the beginning of the handrails near the public sidewalk and at a middle point of the handrails, through the handrails. V21 stated the visitors coming into the facility tore down the yellow caution tape and the yellow caution tape was not replaced. V21 stated the right-side handrail when entering the facility from the public sidewalk is broken, rusted, and not connected to the concrete. V21 stated the left side handrail to the facility is broken, rusting, and not connected to the concrete at the bottom of the handrail located near the third step, when exiting the facility. V21 stated yes, the broken handrails do pose a safety risk for visitors and staff who use the handrails. V21 stated a vendor is coming to the facility to fix the handrails, I will get you a copy of the work order.
On 8/24/2023 surveyor reviewed the invoice dated 06/22/2023 which documents, in part, Service: Railing Repair. Notes: Thank you for having me come out to your facility and inspect your front iron railings. The current railings are in extremely dangerous conditions and collapse with the right amount of weight. All 16 base footings are rotted and or separated completely due to rotting. To completely remove the old iron railings and install new ones bust up the concrete sidewalk to install new footings would cost 7 to $8000 dollars. I'm proposing to save the railings and cut out all the rusty material and weld fresh steel tubing. The cost of the material is $2000, and the cost of my labor is $2000. I would need $2000 plus my $1000 deposit to do the job and the $1000 balance paid once job is completed. So, $3000 down. This is a 3-day job. Guaranteed to last the next ten plus years. Total amount paid: $0.00.
On 8/24//2023 reviewed the facility's undated Director of Maintenance job description which documents in part, the primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner.
On 8/24/2023 reviewed the facility's Resident Rights-Accommodation of Needs and Preferences and Homelike Environment Policy dated 1/2023 documents in part, the facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. 7. The resident's environment will be maintained in a homelike manner.
Apr 2023
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to ensure residents (R17, R115) were treated with dignity and serve meals at the same time for 2 out of a total sample of 32 ...
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Based on observations, interviews, and record reviews, the facility failed to ensure residents (R17, R115) were treated with dignity and serve meals at the same time for 2 out of a total sample of 32 residents.
Findings include:
On 04/25/2023 at 11:24 AM, R10 and R115 were sitting at a table in the dining room. R115 stated staff pick and choose who they wait first in the dining room. R115 stated it gets frustrating because I can be waiting for a while before they serve me my tray.
At 12:00 PM, R17 joined R10 and R115 at the table. Staff were starting to pass lunch trays in the dining room.
At 12:07 PM, V5 (CNA, Certified Nurse Aide) dropped off R10 and R115's lunch tray. Both residents started eating. R17 did not get a lunch tray.
At 12:18 PM, R17 remained without a lunch tray. R17 yelled Can I get a tray please!
At 12:19 PM, V6 (CNA) provided R17 with a lunch tray.
On 04/26/23 at 01:34 PM, V17 (CNA) stated all residents sitting at the same table should have a meal tray and eat at the same time.
Facility's Resident Rights policy, created 05/2022, documents in part: Employees shall treat all residents with kindness, respect, and dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to follow their policy and ensure a resident (R76) had a pre-admission screening and resident review (PASARR) prior to admission to a nursin...
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Based on interviews and record reviews, the facility failed to follow their policy and ensure a resident (R76) had a pre-admission screening and resident review (PASARR) prior to admission to a nursing facility for 1 out of a total sample of 32 residents.
Findings include:
R76's face sheet documents in part an admission date of 10/23/2021. Medical diagnoses include but are not limited to schizophrenia with an onset date of 08/14/2021 and major depressive disorder with an onset date of 08/14/2021.
On 04/25/2023 at 3:00 PM, survey team leader requested for R76's PASSAR.
On 04/26/2023 at 10:05 AM, surveyor reviewed the provided documents for R76. R76's PASARR Level I review date was 04/25/2023. The determination documents in part that R76 needs a Level II onsite evaluation.
On 04/26/2023 at 3:03 PM, V4 (Social Services Director) stated the Admissions Department does all the PASARRs for all new admissions. V4 stated everyone who comes in as a new admit should have a PASARR Level I. V4 stated when the facility checked the system, R76 did not have a PASARR Level I completed.
Facility's Pre-admission Screening and Resident Review (PASARR) policy dated 02/2020 documents in part: The facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. This initially pre-screening is referred to as PASARR Level I and is completed prior to admission to a nursing facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure an air mattress used for pressure reduction was on the correct settings, for 2 (R112, R119) of 2 residents reviewed for...
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Based on observation, interview, and record review the facility failed to ensure an air mattress used for pressure reduction was on the correct settings, for 2 (R112, R119) of 2 residents reviewed for pressure ulcers, in a sample of 32.
Findings include:
R119 has diagnosis not limited to Osteoarthritis, Seizures, Pressure Ulcer of Contiguous Site of Back, Buttocks and Hip, Unstageable, Sever Sepsis with Septic Shock, Cutaneous Abscess and Urinary Tract Infection. R119 BIMS (Brief Interview Mental Status) Section C Cognitive Pattern BIMS (Brief Interview Mental Status) score of 15 indicating
cognitively intact.
R119 Treatment Administration Record dated 04/01/23 - 04/30/21 document in part: Left Ischial / Silver Alginate everyday shift, Cleanse with normal saline. Pat dry. Apply treatment and cover with dry dressing. Right Lateral Leg /Hydrogel & Alginate everyday shift Cleanse with normal saline. Pat dry. Apply treatment and cover with dry dressing. Right Thigh Back / Santyl & Dakin's every shift Cleanse with normal saline. Pat dry. Apply treatment and cover with dry dressing. Sacrum ext. (extension) to right ischium / Dakin's every shift Cleanse with normal saline. Pat dry. Apply treatment and cover with dry dressing.
R119 Document titled Weights and Vitals Summary dated 04/26/23 document in part: 04/05/23 as 170 pounds.
Care Plan document in part: R119 has pressure injury's R/T (related to) self-care deficits, Impaired mobility, and comorbidities. has pressure injury's R/T self-care deficits, Impaired mobility, and comorbidities. Site: Left ischial, Site: Left distal leg, Site: Right lateral leg, Site: Left proximal leg, Site: Right thigh back and Site: Sacrum ext. to Right ischial. Interventions: Pressure redistribution mattress. Date Initiated: 02/23/23.
R112 has diagnosis not limited to Type 2 Diabetes Mellitus, Major Depressive Disorder, Chronic Kidney Disease, Resistance to Multiple Antibiotics and Altered Mental Status. R112 BIMS (Brief Interview Mental Status) Section C Cognitive Pattern BIMS (Brief Interview Mental Status) score of 06 indicating severe impairment.
R112 Treatment Administration Record dated 04/01/23 - 04/30/21 document in part: Right lower leg: cleanse with nss (normal saline), apply bacitracin oint (ointment), apply dry dressing as needed.
R112 Document titled Weights and Vitals Summary dated 04/27/23 document in part: 04/05/23 230.6 pounds.
Care Plan document in part: R112 has a Pressure injury R/T self-care deficits, Incontinence, Impaired mobility, and comorbidities. Site: Sacrum. Interventions: Pressure redistribution mattress.
On 04/25/23 at 10:35 AM V23 (Registered Nurse) indicated R119 had a pressure ulcer.
On 04/25/23 at 10:58 AM R119 was observed lying in bed, on a partially deflated low air loss mattress. The low air loss mattress had settings which indicated, Weight, and was set on 90 pounds. Surveyor asked R119 what her current weight was. R119 responded, around 170 pounds. R119 asked the surveyor the reason for asking her weight. Surveyor responded the settings for the low air loss mattress is set at 90 pounds. R119 was asked by the surveyor if she (R119) had any wounds. R119 responded, yes, I have wounds on my back side.
On 04/25/23 at 11:49 AM V23 (Registered Nurse) entered R119 room with the surveyor. V23 was asked by the surveyor the setting R119 low air loss mattress, while the V34 (Certified Nurse Assistant) was providing care for R119. V23 looked behind the privacy curtain and stated the low air loss mattress setting is at 150. I do not know who changed the settings on the low air loss mattress. If the setting is incorrect, the natural thing is to reweigh the resident. The purpose of the low air loss mattress is to support the pressure of the resident weight.
On 04/25/23 at 11:52 AM V24 (3rd Floor Unit Manager) stated wound care would change the settings on the low air loss mattress.
On 04/25/23 at 02:34 PM V25 (Wound Care Nurse) stated I started working here 10/03/22. R119 wounds were changed early this morning. When we come in, we do rounds in the morning to make sure the low air loss mattress is on the right setting. There is a sheet in the office that we go by to see how much the resident weighs. The low air loss mattress settings go from 90 - 120, 120 - 150 then 180. R119 setting is at 150. We can not set the low air loss mattress to a setting that under weighs the resident lower than what their weight is. The night nurse change R119 dressings because R119 wounds are bad and R119 be in a lot of pain. I change R119 leg dressings every day and make sure R119 receive Norco before the dressings are changed. R119 wounds are getting better. The appearance of R119 wounds were like leather with necrosis measuring about 30 x 20 centimeters and is now measuring about 12 x 12 centimeters. The low air loss mattress settings are based on the resident's weight. If the setting is incorrect there is a potential that R119 would be laying on a deflated mattress and whatever part of the body is a pressure point can potentially get a wound. If the low air loss mattress settings are too high the resident can slide out of the bed. If the low air loss mattress settings are too low, there is a potential that it can make the pressure ulcers worst. R119 had the wounds when R119 arrived at the facility.
On 04/25/23 at 02:52 PM V24 (3rd Floor Unit Manager) stated we can change the low air loss mattress settings, but it had to be the wound tech person that changed R119 low air loss mattress settings.
On 04/26/23 at 08:32 AM V26 (Wound Care Tech) stated I have worked here for 1 month. I come up to the floors a couple of time to check the low air loss mattress settings. On 04/25/23 when I went in R119 room the low air loss mattress was set at 90 and I changed it to 150.
On 04/27/23 at 08:37 AM V2 (Director of Nursing) stated The low air loss mattress is use for residents with wounds to relieve pressure and for comfort. If the low air loss mattress is not on the correct setting the resident wound could deteriorate. It is ultimately the wound care staff responsibility to check the low air loss mattress settings and all the clinical staff understand the settings.
On 04/27/23 at 09:06 AM V34 (Certified Nurse Assistant) stated I was the CNA (Certified Nurse Assistant) that was providing care for R119 when the nurse asked the setting on R119 bed. The bed was set at 150. I do not know who went in and changed the setting.
On 04/27/23 at 09:10 AM V25 (Wound Care Nurse) entered R112 room with the surveyor. Surveyor asked V25 the setting on R112 low air loss mattress. V25 responded it is between 300 and 400. I don't really know how to tell. V25 began pushing buttons on the low air loss mattress controls and stated I don't really know how to do this one because the weight won't go up or down. V25 asked R112 how long have you been on this mattress? R112 responded ever since I have been here.
On 04/27/23 at 09:12 AM V35 (Traveling Wound Nurse) entered R112 room and stated R112 low air loss mattress is set on approximately 370 - 380. V35 began pushing buttons on the low air loss mattress control and stated, it was locked. V35 asked V25 (Wound Care Nurse) R112 weight. V25 responded 230 pounds. V35 adjusted the low air loss mattress settings then pressed the lock button.
On 04/27/23 at 09:14 AM V35 (Traveling Wound Nurse) and V25 (Wound Care Nurse) entered R119 room with the surveyor. R119 low air loss mattress was observed to be set at 150. V35 stated when setting the low air loss mattress, we go down with the weight not above the resident weight. The low air loss mattress is set according to the resident's weight. R112 bed was set incorrectly.
Document titled True Low Air Loss Mattress Replacement System document in part: Patient comfort control panel features an adjustable Soft/Firm key to provide variable pressure to accommodate the patient's weight and comfort. Operating Instructions: 4. Using the comfort control keys set the required patient weight position.
Policy:
Titled Skin Care Prevention revised 12/19 document in part: All residents will receive appropriate care to decrease the risk of skin breakdown. Guideline: 2. The Wound Coordinator will review all new admissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. 13. For residents who are bed or chair bound consider using a pressure reducing device.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews the facility failed to follow their policy and Facility Assessment Tool and identify hazards and risks by allowing a resident (R156) to enter the ...
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Based on observations, interviews, and record reviews the facility failed to follow their policy and Facility Assessment Tool and identify hazards and risks by allowing a resident (R156) to enter the shower room and take a shower unsupervised while using an electric oxygen concentrator (a potential for electrocution) and failing to address a resident (R27) who was leaning forward, asleep in an unlocked wheelchair for 2 out of a total sample of 32 residents.
Findings include:
R27's face sheet documents in part medical diagnoses of weakness, difficulty in walking, limitation of activities due to disability, need for assistance with personal care, and dementia.
R27's comprehensive care plan contains a focus created on 07/18/2015 that documents in part that R27 has a potential risk for fall due to history of fall. R27 is at risk for injury from a fall related to impaired balance.
On 04/25/2023 at 11:22 AM, V7 (CIT, Certified Nurse Aide-in-Training) and V8 (CIT) were passing water in the dining room. V9 (Activity Aide) was sitting near the television.
At 11:27 AM, surveyor observed R27 in a wheelchair sitting near a dining table. R27 was asleep with face resting on the right armrest on the wheelchair. R27's right arm was resting on the wheelchair's right wheel and R27's right hand was resting on the brake. R27's wheelchair was not locked, and it was not up close to the table.
At 11:35 AM, V9 stood at the entrance to the dining room. R27 within view of V9.
At 11:37 AM, R27 was asleep leaning forward in the wheelchair. R27's right arm was now grasping the right wheel.
At 11:42 AM, V9 was sitting at the same table as R27. V9 was directly to R27's right. V8 woke up R27 and told [R27] it was almost time to eat. Wheelchair remained unlocked.
At 11:57 AM, R27 fell back asleep and leaned on the wheelchair's right armrest. Multiple staff were in the dining room including V7, V8, and V9.
At 11:59 AM, V10 (Certified Nurse Aide) woke R27 and told [R27] it was time for lunch. V10 moved R27 up to the table and locked the wheelchair.
On 04/26/2023 at 11:45 AM, V3 (Assistant Director of Nursing) stated if residents are sitting up in a wheelchair, the staff should lock their wheelchairs if the residents are stationary. Staff should move the residents close to the table. Surveyor informed V3 of observations of R27 from the day prior. V3 stated staff should have assessed R27 to see what was going on. Staff should have asked if R27 was too tired or wanted to lay down. If it was a safety risk, the staff should have tried to reposition R27 better or tried to engage with [R27] to keep [R27] awake.
Facility Assessment Tool dated 03/02/2022 documents in part that the facility provides person-centered/directed care. This includes identifying hazards and risks for residents.
R156 has diagnosis not limited to Dependence on Supplemental Oxygen, Shortness of Breath, Heart Failure, Dependence on Renal Dialysis, Paroxysmal Atrial Fibrillation, Essential (Primary) Hypertension, End Stage Renal Disease and Chronic Obstructive pulmonary Disease. R156 BIMS (Brief Interview Mental Status) Section C Cognitive Pattern BIMS (Brief Interview Mental Status) score of 10 indicating moderately impaired.
R156 Order Summary Report document in part: Oxygen (02) @ 4 Liters/Minute per nasal cannula, Maintain 02 Saturation @ 92% or greater every shift for SOB (Shortness of Breath).
R156 Care Plan document in part: R156 uses Oxygen PRN (as needed). Date Initiated: 04/25/23. Administer oxygen per physician's orders: (O2 (oxygen) @4L (liters)/min (minute)) O2 sats (saturations) @ 92% or greater. Date Initiated: 04/25/23.
On 04/25/23 at 10:50 AM upon entering R156 room surveyor observed R156 standing near the foot of the bed holding toothpaste in his hand with oxygen tubing wrapped around his (R156) neck, undated, not in use and not connected to the oxygen concentrator. R156 stated I am about to go take my shower down the hall. Surveyor asked R156 if there was a portable oxygen tank that he would be using. R156 responded, I do not have a portable oxygen tank, I take this (referring to the oxygen concentrator that operates by electricity) in the shower room with me. R156 then exited the room and proceeded to the shower room to take a shower.
On 04/25/23 at 11:45 AM V23 (Registered Nurse) entered R156 room with the surveyor. R156 stated I finished taking my shower.
On 04/25/23 at 11:52 AM V24 (3rd Floor Unit Manager) stated R156 take the oxygen concentrator into the bathroom when taking a shower. The surveyor asked V24 do they have portable oxygen tanks and V24 responded, yes, we have portable oxygen tanks. There is a potential that R156 can get electrocuted.
On 04/26/23 at 09:00 AM R156 was observed standing in the doorway with 2 gowns on. R156 stated I took a shower this morning in the second shower room. I took the oxygen machine in the shower room with me and plugged it in. They told me that the portable oxygen tank on the wall near the nurse station is for the nurses to use in an emergency.
On 04/27/23 at 08:37 AM V2 (Director of Nursing) stated The portable oxygen tanks are used for transport. The staff has access to get the portable oxygen tanks. R156 is alert and oriented x 2-3 and ambulatory. The oxygen concentrator is operated by electricity. If we know R156 go to the shower room R156 should have a portable oxygen tank to make sure he (R156) is being oxygenated correctly. If R156 is taking the oxygen concentrator in the shower room with him, it can cause a lot of risk factors including electrocution.
On 04/27/23 at 09:24 AM R156 asked the surveyor if it were possible to get a portable oxygen tank so that he would not have to drag the heavy oxygen concentrator into the shower room to take a shower. V35 (Traveling Wound Nurse) heard R156 request and stated, I will check for you.
Policy:
Titled Safety and Supervision of Residents dated 10/21 document in part: General: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting processes. 4. Employees shall be trained and in serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents. Systems Approach to safety: 2. Resident supervision is a core component of the system approach to safety.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure the physician orders for insulin administration were folllowed as prescribed for 1 (R112) resident reviewed for signifi...
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Based on observation, interview, and record review the facility failed to ensure the physician orders for insulin administration were folllowed as prescribed for 1 (R112) resident reviewed for significant medication errors during the medication administration observation. This failure resulted in an elevation of R112 blood glucose reading.
Findings Include:
R112 has diagnosis not limited to Type 2 Diabetes Mellitus, Major Depressive Disorder, Chronic Kidney Disease, Resistance to Multiple Antibiotics and Altered Mental Status. R112 BIMS (Brief Interview Mental Status) Section C Cognitive Pattern BIMS (Brief Interview Mental Status) score of 06 indicating severe impairment.
Order Summary Report date 04/26/23 document in part: Blood glucose monitoring AC (Before meals) and HS (Hour of sleep). Insulin Lispro (1 Unit Dial) 100 UNIT/ML (Milliliter) Solution pen-injector Inject 6 unit subcutaneously with meals.
Care Plan document in part: Focus: R112 has Diabetes Mellitus. Intervention: Diabetes Medication as ordered by doctor. Monitor/document side effects and effectiveness.
Medication Administration Record dated 04/01/23 - 04/30/23 document in part: Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution pen injector Inject 6 unit subcutaneously with meals. Entry dated 04/26/23 at 08:00 AM with no documented insulin administration for a blood glucose reading of 133 and an incorrect blood glucose reading entry for 11:00 AM.
Weights and Vitals Summary dated 04/26/23 document in part: Blood Sugar Summary; 04/26/23 at 08:22 AM with a reading of 133 and 04/26/23 documented at 15:23 with a reading of 302.
On 04/26/23 at 08:16 AM V28 (Licensed Practical Nurse) stated R112 is an accu check. V28 entered R112 room with the blood pressure machine and glucometer then checked R112 blood glucose with a reading of 133. V28 exited R112 room and began preparing R112 medications. V28 stated to R112 you are scheduled for insulin, but the blood sugar is too low, and I do not want to give it to you.
Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution pen injector Inject 6 unit subcutaneously with meals was observed to be omitted by V28 (Licensed Practical Nurse).
On 04/26/23 at 01:01 PM V28 (Licensed Practical Nurse) stated R112 did not want the insulin and I did not notify the doctor.
On 04/26/23 at 01:14 PM V28 (Licensed Practical Nurse) was asked by the surveyor the next scheduled blood glucose check for R112. V28 stated I will go check it now. V28 returned to the nurse station and stated R112 blood sugar is 302.
On 04/27/23 at 08:37 AM V2 (Director of Nursing) stated if a medication is ordered by the physician my expectation is for the nurse to follow the right medication, right dose, right route, right patient, right time, and document in the EMAR (Electronic Medical Record). If giving insulin to make sure there are no parameters and if there are no parameters to give the insulin as ordered. If the insulin is not given, notify the doctor to get further orders. If the insulin is not given there is a potential for hyperglycemia.
Policy:
Titled Medication Administration reviewed 11/20/21 document in part: General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline: 18. If medication is not given as ordered, document the reason on the MAR (Medication Administration Record) and notify the Health Care Provider and the resident representative if applicable. 20 Medications are held as specified by the Health Care Provider.
Titled Physician's Orders dated 08/01/21 document in part: General: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the resident.
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 ensure medications were not left on top of the medication cart unattended during medication administration for R132 in a sampl...
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Based on observation, interview, and record review the facility failed to ensure medications were not left on top of the medication cart unattended during medication administration for R132 in a sample of 32 residents.
Findings Include:
On 04/26/23 at 09:29 AM V29 (Licensed Practical Nurse) prepared R132 medications then entered R132 room and administered R132 medications leaving 5 medication cards and the bottle of Multivitamins on top of the medication cart unattended.
On 04/26/23 at 09:31 AM V29 (Licensed Practical Nurse) returned to the medication cart then put the medication cards inside of the medication cart. V29 then told R67 I am going to take your blood pressure. V29 entered R67 room with the blood pressure machine, applied the blood pressure cuff to R67 right arm obtaining a blood pressure reading of 144/69 pulse 62.
On 04/26/23 at 09:33 V29 (Licensed Practical Nurse) returned to the medication cart with the blood pressure machine and began preparing R67 medications. V29 entered R67 room and administered R67 medications leaving the bottle of Multivitamins, Acetaminophen and Aspirin on top of the medication cart unattended.
On 04/26/23 at 09:41 V29 (Licensed Practical Nurse) stated I should have put the medications back in the medication cart and not left them on top of the medication cart because a resident can walk pass and grab them.
On 04/27/23 at 08:37 AM V2 (Director of Nursing) stated When passing medication, the nurse should not leave medication on top of the medication cart unattended. The medications should have been put back in the medication cart drawer for safety because someone could have come by and grabbed the medication. There is also an issue of privacy because the resident information is on the medication cards.
Policy:
Titled Medication Storage in the Facility dated 11/21 document in part: Medication and biologicals are store safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. E. Except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated areas.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
On 04/25/23 at 11:31 AM, observed R57 lying in bed. Call light was not visible. R57 stated, I press the button when I need help. When surveyor asked for R57 to trigger R57's call light, R57 looked aro...
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On 04/25/23 at 11:31 AM, observed R57 lying in bed. Call light was not visible. R57 stated, I press the button when I need help. When surveyor asked for R57 to trigger R57's call light, R57 looked around, and used R57's hands to feel around the bed and then replied, I don't know where it is right now and it's at the bottom of the bed.
On 04/25/23 at 11:43 AM, V12 (Certified Nursing Assistant) entered R57's room and saw that call light was not within reach of R57 and stated, he (R57) cannot reach it and it is a problem because he (R57) wouldn't be able to call for help. Observed V12 look around R57's bed to locate R57's call light. V12 eventually had to pull on the call light cord from the wall to locate the end of the call light cord with the button on it because the call light cord was twisted over the foot end of the bed, under the mattress and dangling toward the floor.
R57 has diagnosis which includes Unspecified Dementia, Type 2 Diabetes Mellitus, Weakness, Unspecified Fall Limitations of Activities Due to Disability, Dizziness and Giddiness, Anemia, Major Depressive Disorder, Hypertension.
R57's MDS (Minimum Data Set) dated 03/15/23 BIMS (Brief Interview for Mental Status) score is 08 indicating moderately intact cognition and section G (Functional Status) documents in part that R57 requires extensive assistance with transfer, dressing, toilet use and personal hygiene.
R57's care plan for ADL Self Care dated 03/21/23 documents in part R57 has self care performance deficit related to mobility and cognitive impairment and intervention includes to encourage resident to use bell to call for assistance.
R57's care plan for fall risk dated 02/04/22 documents in part R57 is at risk for falls and to place call light within resident's reach when in room.
R57's Call Light Ability Screen dated 03/14/23 documents in part resident is able to follow instruction to use call light, and resident is able to use the call light.
Based on observation, interview, and record review, the facility failed to follow their call light protocol to ensure dependent residents have accessibility to the call light at all times for 4 [R47, R57, R103, R109] residents reviewed for call lights in a sample of 32.
Finding include,
On 4/22/23 at 11:09 AM, observed R47's call light lying across the overhead light cover. R47 stated, I use the call light, whenever I can find it.
On 4/22 23 at 11:10 AM V16 [Registered Nurse] stated, I been working here for several months and is familiar with R47. I'm not sure who left R47's call light on top of the overhead night light. R47 always use her call light for assistance. I will place the call light in reach. V16 and surveyor observed R47 press the call light button for assistance.
R47's medical record document in part; Minimum Data Set Section C [Brief Interview Mental Status] indicates R109 is mildly impairment. Section G [Functional Status] R109 require physical assistance. Medical diagnosis-morbid obesity, repeated falls, history of fractures.
On 4/25/23 at 11:12 AM, observed R109 call light on the floor, underneath the bed. R109 stated, I have not seen my call light in a while, I know how to press the circle for help.
On 4/25/23 at 11:14 AM, V16 stated, Oh wow, I'm not sure how R109's call light got under the bed. I am familiar with R109, and he is able to use the call light for assistance. I will place the soft touch call circle in reach now. Surveyor and V16 observed R109 tap the soft touch call light for assistance.
R109's medical record document in part; Minimum Data Set Section C [Brief Interview Mental Status] indicates R109 is moderate impairment. Section G [Functional Status] R109 require total dependence. Medical diagnosis-cerebral infarction, and abnormalities of gait and mobility.
04/25/22 at 12:05 PM observed R103 resting in bed with the call light attached the to the top of privacy curtains at the foot of the bed, out of R103's reach. R103 stated, I don't see my call light, I know how to use it for help.
4/25/22 at 12:07 PM, V15 [Licensed Practical Nurse] stated, I been working here at this facility for three years, I am familiar with R103. He {R013] is able to use the call light. R103's call light is attached to the privacy curtains; I'll place the call light in reach.
R103's medical record document in part; Minimum Data Set Section C [Brief Interview Mental Status] indicates R103 is moderate impairment. Section G
[Functional Status] R103 require total dependence. Medical diagnosis hemiparesis following cerebral infarction affecting left side.
4/27/23 at 9:06 AM, V2 [Director of Nursing] stated, The call light should always be in place for residents that are able to use the call light. If the call light is not in reach the residents are not able to call for assistance.
Policy: Document in part:
Call Light Answering
-Assess for call light ability
-When the patient or resident is in bed or confined to bed or chair, provide the call light
within easy reach of the patient or resident
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
R40's face sheet and comprehensive care plan documents in part that R40 has oxygen therapy related to chronic obstructive pulmonary disease with pulmonary fibrosis, chronic heart failure, and paroxysm...
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R40's face sheet and comprehensive care plan documents in part that R40 has oxygen therapy related to chronic obstructive pulmonary disease with pulmonary fibrosis, chronic heart failure, and paroxysmal atrial fibrillation.
On 04/25/2023 at 10:53 AM, surveyor entered R40's room for interview. R40 was lying in bed with oxygen via nasal cannula. Nasal cannula did not have a label or date on it.
On 04/26/2023 at 11:45 AM, V3 (Assistant Director of Nursing) stated staff should label and date residents' oxygen tubing.
Based on observation, interview, and record review the facility failed to a.) ensure that oxygen tubing was labeled and stored properly to prevent the potential for contamination for 4 (R3, R40, R83, R156) out of 4 residents and b.) ensure the correct oxygen settings were set per physician orders for 2 (R83, R156) of 4 (R3, R40) residents reviewed for oxygen therapy in a sample of 32.
Findings include:
R156 has diagnosis not limited to Dependence on Supplemental Oxygen, Shortness of Breath, Heart Failure, Dependence on Renal Dialysis, Paroxysmal Atrial Fibrillation, Essential (Primary) Hypertension, End Stage Renal Disease and Chronic Obstructive pulmonary Disease. R156 BIMS (Brief Interview Mental Status) Section C Cognitive Pattern BIMS (Brief Interview Mental Status) score of 10 indicating moderately impaired.
R156 Order Summary Report document in part: Oxygen (02) @ 4 Liters/Minute per nasal cannula, Maintain 02 Saturation @ 92% or greater every shift for SOB (Shortness of Breath). Change 02 (oxygen) tubing weekly every night shift, every Sunday.
R156 Care Plan document in part: R156 uses Oxygen PRN (as needed). Date Initiated: 04/25/23. Administer oxygen per physician's orders: (O2 (oxygen) @4L (liters)/min (minute)) O2 sats (saturations) @ 92% or greater. Date Initiated: 04/25/23.
On 04/25/23 at 10:50 AM upon entering R156 room surveyor observed R156 standing near the foot of the bed holding toothpaste in his hand with oxygen tubing wrapped around his (R156) neck undated, not in use, with the nasal cannula end in the pocket of his gown and the oxygen tubing was not connected to the oxygen concentrator. R156 oxygen tubing with the extension tubing was observed undated, lying on a box next to the wall with the nasal cannula lying on the floor. R156 stated I am about to go take my shower down the hall. R156 then exited the room and proceeded to the shower room to take a shower.
On 04/25/23 at 11:45 AM V23 (Registered Nurse) entered R156 room with the surveyor. Surveyor asked V23 should the oxygen tubing be labeled and dated? V23 responded, usually they supposed to change the oxygen tubing on the night shift and label the tubing. R156 is on continuous oxygen at 5 liters per nasal cannula. The oxygen concentrator is set at 5 liters. R156 stated dialysis gave me the oxygen tubing that was around my neck. This (referring to the oxygen tubing that was in use) is the oxygen tubing that was on the box. The tubing is long so that I can go to the bathroom. V23 stated I will educate R156 not to wrap the oxygen tubing around his neck. I did not see the oxygen tubing on the floor. I can change the oxygen tubing.
On 04/25/23 at 11:52 AM V24 (3rd Floor Unit Manager) If R156 oxygen tubing was on the floor it should have been tossed. The oxygen tubing should be stored in a bag to prevent contamination.
On 04/25/23 at 12:23 PM R83 was observed sitting in a wheelchair in the dining room with oxygen at 3 liters per nasal cannula connected to an oxygen concentration in use. The oxygen tubing was observed undated.
R83 has diagnosis not limited to Essential (Primary) Hypertension, Congestive Heart failure, Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure. R83 BIMS (Brief Interview Mental Status) Section C Cognitive Pattern BIMS (Brief Interview Mental Status) score of 06 indicating severe impairment.
R83 Order Summary Report document in part: Oxygen (02) @ 2 Liters/Minute per shift, Maintain 02 Saturation @ 92% or greater every shift. Change 02 (oxygen) tubing weekly every night shift, every Sunday.
Care Plan document in part: Focus: R83 has Oxygen Therapy r/t (related to) COPD (Chronic Obstructive Pulmonary Disease). Interventions: Administer oxygen per physician's orders.
On 04/26/23 at 09:14 AM V28 (Licensed Practical Nurse) entered R156 room with the surveyor. When asked by the surveyor the oxygen setting V28 responded 4.5 liters, I do not see a label on the oxygen tubing.
R3 has diagnosis not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Alzheimer's Disease, Shortness of Breath, and Atrial Fibrillation.
On 04/26/23 at 09:18 AM V29 (Licensed Practical Nurse) entered R3 room with the surveyor to check the setting on R3 oxygen concentrator. V29 stated R3 oxygen is set at 3 liters per nasal cannula. The oxygen bottle is dated but the oxygen tubing does not have a date. Both the oxygen bottle and tubing should be dated.
On 04/26/23 at 01:06 PM V28 (Licensed Practical Nurse) entered R156 room with the surveyor to observed R156 oxygen settings. Surveyor and V28 exited R156 room. When asked the order for R156 oxygen V18 stated R156 oxygen order is for 4 liters, and it was at 4.5 liters. V28 was asked by the surveyor to check V83 oxygen orders. V28 checked the computer and stated R83 oxygen order is for 2 liters of oxygen.
On 04/26/23 at 01:09 PM V28 (Licensed Practical Nurse) entered R83 room with the surveyor to observed R83 oxygen settings. V28 lean over to check R83 oxygen settings then V28 stated R83 oxygen is set at 3 liters, I placed it to 2 liters.
On 04/27/23 at 08:37 AM V2 (Director of Nursing) stated The oxygen tubing should be on the resident appropriately and the if the oxygen is not in use the tubing should be stored in a bag and not on the floor or in R156 pocket. That is an issue of infection control. When the oxygen tubing is changed a piece of tape should be put on the tubing and the humidity bottle. Labeling the oxygen tubing is done so that you will know when the tubing was last changed and for infection control. The oxygen tubing is changed weekly and as needed. When the nurse starts their shift, it is part of the resident assessment to make sure the oxygen is on the correct setting. If the oxygen is not on the correct setting it is a potential for over oxygenation depending on the resident need.
Policy:
Titled Oxygen Administration dated 07/22 document in part: General: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Procedure: 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Infection Control Issues: 2. The oxygen delivery device (e.g., nasal cannula, mask) will be changed once a week or as needed, the tubing will be dated to assist with tracking of when the tubing should be changed. 4. If the nasal cannula/mask/tubing is not in use, it must be stored in a clean bag.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to give adequate portion sizes of pureed food to 7 residents (R9, R14, R34, R71, R81, R104, and R110) out of 7 residents reviewed...
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Based on observation, interview, and record review the facility failed to give adequate portion sizes of pureed food to 7 residents (R9, R14, R34, R71, R81, R104, and R110) out of 7 residents reviewed for menus and nutritional adequacy in a sample of 32.
Findings Include:
On 04/25/23 at 12:08 PM, during lunch round observations on the 2nd floor unit, observed V13 (Diet Aide) placing pureed food on resident trays. V13 stated the following items were given to the pureed diets for lunch using the serving utensil: pureed hot dog using green scoop, mashed potatoes using blue scoop and pureed bread using blue scoop. V13 stated V13 did not know what sizes the blue and green scoops were. V13 stated V13 usually asks the chef what size utensils V13 needs to bring up to the unit for serving but V13 got the utensils to use on his own and did not ask the chef today.
On 04/25/23 at 12:10 PM, observed facility staff placing bananas on the trays of residents receiving regular consistency diets. Residents on pureed diets did not receive any dessert on their tray. Surveyor did not observe any ice cream or pudding or yogurt or fortified gelatin supplements in the steam table area or on the food carts from the kitchen.
On 04/25/23 at 12:24 PM, during meal round observations observed that the residents on pureed diets had not been given any dessert.
On 04/25/23 at 12:25 PM, V13 stated that the dessert for the regular diet consistencies was a fresh banana, and the dessert for residents on a pureed diet was ice cream. V13 stated that the desserts are organized by the cold prep position and sent up in bulk to the unit. V13 said ice cream should have been given to the residents on pureed diets and that ice cream was sent up to the unit.
On 04/25/23 at 12:30 PM, V18 (Activity Director) assisting with meal delivery on the 2nd unit stated, ice cream was not sent up and there was no ice cream for us to give out today.
On 04/26/23 at 2:25 PM, V11 (Food Service Director) stated the residents received a special meal of the month at lunch (04/25/23) and residents on regular diets received fresh bananas and the residents on pureed diets received pureed bananas for their dessert at lunch on (04/25/23). V11 stated residents on pureed diets receive the same items as regular consistency diets except in pureed form. V11 was not aware the pureed diets did not receive any dessert at lunch (04/25/23).
On 04/26/23 at 2:29 PM, V11 reviewed the recipes for the pureed items served at lunch on (04/25/23) and used the scoop size chart posted in the kitchen to answer surveyor questions about the portion sizes. V11 stated the ivory scoop (#10) should have been used to serve the pureed hot dog and that the #10 scoop provides 3.25 ounces. V11 stated if the diet aide used the green scoop (#12) that was not the correct scoop size and would have only provide approximately 2 2/3 ounces instead of 3.25 ounces of protein. V11 stated, they didn't get the right amount of protein. V11 stated the gray scoop (#8) should have been used to serve the mashed potatoes and pureed bread and that the #8 scoop provides 4 ounces. V11 stated if the diet aide used the blue scoop (#16) that was not the correct scoop to use because the blue scoop would have only provided 2 ounces instead of 4 ounces.
On 04/26/23 at 2:36 PM, V11 stated using the correct serving utensils is important to make sure the residents are getting the right amount of calories and protein. V11 stated the residents on the pureed diet did not receive the calories they needed for the day and there is a potential for them to lose weight.
On 04/27/23 at 8:49 AM, V32 (Registered Dietitian) stated that an outside vendor provides menus to the facility which have been approved by Registered Dietitian to make sure the menus are meeting minimum standards for calories, and protein. V32 stated the kitchen staff should be following the menus and the recipes so that the nutrition provided to the residents is correct, so they know they are receiving 100% RDAs and protein for the day. V32 stated the recipes indicate the portion size to be served and there are also education material posted in the kitchen which lists the color and ounces of each scoop size. V32 stated the kitchen staff need to gather the appropriate serving utensils to bring to the unit for meal service and that if the portions sizes are not followed there is a risk of weight loss for the residents. V32 stated on Tuesday, 04/25/23 a special meal of the month was served at lunch time and with the special meal of the month most residents have a physician order that they can participate in the special meal of the month. V32 read out loud that the physician order states, may be exempt from dietary restrictions for special occasions. V32 stated exemption from dietary restrictions such as low salt or no added sugar diets for diabetics would be relaxed but that total calories and protein menu requirements would still need to be met. Surveyor reviewed portion sizes served on 04/25/23 at lunch meal to residents receiving a pureed diet on the 2nd floor. V32 stated the portions did not provide an adequate amount of calories for the day and this could cause weight loss, placing residents at nutritional risk. V32 stated the 2nd floor is the dementia unit and those residents with dementia may not be able to ask for more food due to limited cognition.
V11 provided surveyor with recipe titled, Pureed Hot Dog printed 04/26/23 at 2:03 PM from contracted food company menus system which documents in part, serving size: #10 scoop.
V11 provided surveyor with recipe titled, Mashed Potatoes printed 04/26/23 at 3:40 PM from contracted food company menu systems which documents in part, serving size: #8 scoop = ½ cup.
V11 provided surveyor with recipe titled, Pureed Bread printed 04/26/23 at 1:49 PM from contracted food company menu systems which documents in part, serving size: #8 scoop = ½ cup.
R9 has diagnosis not limited to Unspecified Dementia. R9's Physician Order Report documents in part pureed texture diet ordered 3/24/23.
R14 has diagnosis not limited to Unspecified Dementia. R14's Physician Order Report documents in part pureed texture diet ordered 2/9/23.
R34 has diagnosis not limited to Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Weakness, Respiratory Failure with Hypoxia, Dysphagia. R34's Physician Order Report documents in part, pureed texture diet ordered 5/12/22.
R71 has diagnosis not limited to Unspecified Dementia, Protein Calorie Malnutrition, Dysphagia, Weakness. R71's Physician Order Report documents in part, pureed texture diet order 11/23/22.
R81 has diagnosis not limited to Alzheimer's Disease, Dysphagia. R81's Physician Order Report documents in part, pureed texture diet order 10/9/22.
R104 has diagnosis not limited to Unspecified Dementia, Severe Protein Calorie Malnutrition, Weakness. R104's Physician Order Report documents in part, pureed texture diet order 3/16/22.
R110 has diagnosis not limited to Senile Degeneration of Brain, Dysphagia, Weakness. R110's Physician Order Report documents in part, pureed texture diet order 9/29/22.
Kitchen document titled, Client List Report printed 04/26/23 at 12:15 PM documents in part R9, R14, R34, R71, R81, R104, and R110 receive a pureed diet consistency.
Facility policy titled, Serving Portions dated 2016 documents in part, food will be served in portions indicated on the standardized recipes and prior to the meal the director of food and nutrition services or person in charge will check the serving utensils to ensure that the correct ones will be used.
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 the glucometer and reusable medical equipment was cleaned and disinfected between resident use. This failure has the po...
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Based on observation, interview, and record review the facility failed to ensure the glucometer and reusable medical equipment was cleaned and disinfected between resident use. This failure has the potential to affect 6 (R3, R61, R112, R119, R126, R67) out of 7 (R132) residents reviewed during medication administration.
Findings Include:
On 04/26/23 at 08:16 AM V28 (Licensed Practical Nurse) entered R112 room with the blood pressure machine and glucometer, applied the blood pressure cuff to R112 right arm obtaining a Blood Pressure reading of 144/58 pulse 79. V28 then checked R112 blood glucose with a reading of 133. V28 exited R112 room with the blood pressure machine, wiped off the glucometer with a sanitizing wipe then placed the glucometer in the bottom drawer of the medication cart. V28 did not sanitize the blood pressure machine.
On 04/26/23 at 08:36 AM V28 (Licensed Practical Nurse) removed the glucometer from bottom drawer of the medication cart. V28 entered R61 room with the blood pressure machine and the glucometer, applied the blood pressure cuff to R61 right arm obtaining a blood pressure reading of 131/68 pulse 91. V28 then checked R61 blood glucose with a reading of 165. V28 placed the glucometer in the basket that is attached to the blood pressure machine the returned to the medication cart leaving the blood pressure machine near R61 door. V28 did not sanitize the blood pressure machine.
On 04/26/23 at 08:54 AM V28 (Licensed Practical Nurse) entered R119 room with the blood pressure machine, applied the blood pressure cuff to R119 right arm obtaining a blood pressure reading of 116/68 pulse 81. V28 returned to the medication cart to prepare R119 medications leaving the blood pressure machine near R119 door. V28 did not sanitize the blood pressure machine.
R61, R112 and R119 were observed to be on Enhanced Barrier Precautions.
On 04/26/23 at 09:14 AM V28 (Licensed Practical Nurse) was asked by the surveyor the policy for cleaning the glucometer. V28 responded I use a bleach wipe and wiped it off. I know usually we are supposed to have 2 glucometers and let one dry while using the other one. The blood pressure machine should be cleaned between each resident.
On 04/26/23 at 09:18 AM V29 (Licensed Practical Nurse) was observed standing by the medication cart with the blood pressure machine displaying a blood pressure reading of 102/67 pulse 98. V29 stated that is R3 vital signs. V29 did not sanitize the blood pressure machine.
On 04/26/23 at 09:31 AM V29 (Licensed Practical Nurse) returned to the medication cart then put the medication cards inside of the medication cart. V29 then told R67 I am going to take your blood pressure. V29 entered R67 room with the blood pressure machine, applied the blood pressure cuff to R67 right arm obtaining a blood pressure reading of 144/69 pulse 62.
On 04/26/23 at 09:33 V29 (Licensed Practical Nurse) returned to the medication cart with the blood pressure machine and began preparing R67 medications. V29 did not sanitize the blood pressure machine.
On 04/26/23 at 09:38 V29 (Licensed Practical Nurse) stated I am going to switch over to R126. V29 entered R126 room with the blood pressure machine, applied the blood pressure cuff to R126 left arm obtaining a blood pressure reading of 115/64 pulse 82.
On 04/26/23 at 09:41 V29 (Licensed Practical Nurse) stated The blood pressure machine should be cleaned between each resident with the bleach wipes. I should have some bleach wipes on the medication cart. V29 opened the medication cart drawers to search for the bleach wipes. V29 stated I don't have any bleach wipes on the medication cart.
On 04/28/23 at 08:37 AM V2 (Director of Nursing) stated The nurse should make sure the blood pressure cuff is wiped down with bleach wipes in between each use to prevent the spread of infection.
On 04/27/23 at 10:24 AM V2 (Director of Nursing) stated when the nurse is checking a resident blood glucose it is my expectation that clean the glucometer before using it on another resident. It is cleaned with the bleach wipes. Gather bleach wipes, clean thoroughly wiping the entire glucometer. We clean the glucometer according to the bleach wipe recommendations as far as the contact time to prevent the spread of infection.
Document titled Micro-kill Bleach Wipes document in part: 5. Gross soil must be removed prior to disinfecting. A 30 second contact time is required to kill the bacteria and viruses on the label except 1 minute contact time is required to kill Candida Albicans and Trichophyton interdigital, a 2-minute contact time is required to kill Candida Auris.
Policy:
Titled Cleaning and Disinfection of Resident-Care Items and Equipment reviewed 08/22 document in part: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to CDC (Centers for Disease Control and Prevention) recommendations and the OSHA (The Occupational Safety and Health Administration) Bloodborne Pathogens Standard. Cleaning and disinfection Supplies: Cleaning and disinfectant products should be readily available for use at the point-of-care. Policy: c. non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident care items include bedpans, blood pressure cuffs, crutches, and computers. D. Reusable items are cleaned and disinfected between residents. 2. Durable medical equipment (DME) must be cleaned and disinfected with EPA (Environmental Protection Agency) approve cleaning solution before reused by another resident. 2. Check the product label of the disinfectant wipes for the appropriate length of contact time prior to cleansing. 3. Take a pre-moistened disinfecting wipe and squeeze out any excess liquid in order to prevent damage to the meter, wipe down the body of the meter, being careful not to allow any liquid to get inside the battery compartment, strip port, or screen for appropriate length of contact time. 4. Cleanse and disinfect meter between each use.
Titled Blood Glucose Monitoring Machine Cleaning reviewed 05/21 document in part: To provide guidance on how to clean the blood glucose monitoring machine between residents. 2
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected multiple residents
Based on interview and record reviews, the facility failed to follow their policy and procedure for determining COVID-19 vaccination status for healthcare personnel (HCP) providing care of services to...
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Based on interview and record reviews, the facility failed to follow their policy and procedure for determining COVID-19 vaccination status for healthcare personnel (HCP) providing care of services to residents under contract by the facility. This failure has the potential to affect all 28 resident receiving hospice services in the facility.
Findings Include:
On 4/25/23 at 10:14 AM, interviewed V3 (Assistant Director of Nursing/Infection Control Preventionist) and stated that V3 is responsible for infection control program related to COVID-19. V3 stated that V3 is tracking vaccination status for facility employees and non-facility employees under contract. However, V3 stated that hospice workers under contract by the facility are not included in the staff matrix vaccination status. V3 stated V3 has no information about the hospice workers' vaccination statuses because We don't know which staff comes in the building.
At around 11:55 AM, surveyor observed V33 (Contracted Hospice Social Worker) in the facility visiting R314.
At 12:14 PM, interviewed V33 and stated that V33 visits her hospice residents couple of times a month. V33 stated V33 has been coming in the facility for probably three to four years. V33 stated V33 is fully vaccinated and does not remember if facility requested for V33's COVID-19 vaccination information.
At 2:29 PM, the facility's COVID-19 staff vaccination status list was received from V3. Contracted hospice workers' vaccination statuses were not included in the list.
On 4/26/23 at 1056 AM, V3 stated that V3 does not have the staff's actual vaccination cards but the information regarding the staff's vaccination statuses are all entered electronically in the facility's COVID-19 staff's vaccination list.
A review of the facility's hospice residents roster shows that there is a total of 28 residents receiving hospice services contracted by the facility. The facility's list of contracted companies shows a total of 12 hospice companies.
The facility's untitled policy with revised date of 2/16/22 reads in part:
II. SCOPE
This policy applies to all individuals working or volunteering at [Facility Name] including all team members, employed physicians, credentialed staff, volunteers, and students. It also applies to contracted personnel who have direct contact with patients or the patient environment.
IV. POLICY
A.
[Facility Name] requires the COVID-19 vaccination for all team members listed in IV.B. The required vaccination will be offered through [Facility Name].
B.
B. Required immunization mandatory for:
1.
all team members on payroll
2.
all volunteers
3.
students of [Facility Name]
4.
contracted services which may direct contact with the patient or the patient environment
VI.
C.
Contracted Services will require, through their agreements, mandatory vaccination for individuals who have direct contact with the patient or the patient environment.
1.
Contractors may present to any [Facility Name] to receive vaccination.
2.
Compliance tracking will be the responsibility of the employer.
3.
The employer must be able to furnish proof of vaccination upon request.
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 a.) ensure food items were properly labeled with dates having the potential to affect all 158 residents receiving food prepare...
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Based on observation, interview and record review, the facility failed to a.) ensure food items were properly labeled with dates having the potential to affect all 158 residents receiving food prepared in the facility's kitchen; b.) follow facility policy regarding use of gloves during food handling on the 2nd floor unit having the potential to affect 56 residents receiving regular and mechanical soft diets.
Findings include:
On 04/25/23 at 09:26 AM, observed in walk-in refrigerator the following items:
1.) Opened 1-gallon container of Golden Italian Dressing labeled with a delivery date of 02/28/23. There was no open or use by date labeled on the container.
2.) Opened 1-gallon container of Sweet Relish with no dates on the container. No delivery date, no open date or use by date.
3.) Two opened 1-gallon containers Concord Grape Jelly labeled with a delivery date of 04/20/23. There was no open or use by date labeled on either container.
4.) Two unopened 5-pound [NAME] American Sliced Cheese out of box not labeled with a delivery date.
5.) Small amount of orange American sliced cheese wrapped in plastic not labeled with any dates.
On 04/25/23 at 09:33 AM, V11 (Food Service Director) stated all items in the refrigerator should have dates on them including a delivery date, an open date and use by date. V11 stated this is the policy so that the kitchen staff knows when the item came in, when it was opened, and we they need to throw the item out because we don't want to get the resident's sick.
On 04/25/23 at 09:48 AM, observed in reach-in refrigerator two opened containers of apple juice dated with 04/13/23 as the delivery date. There was no open or use by date on the containers. V11 stated, the items should have an open and use by date on them. V11 said, I cannot tell you when they were opened, so to keep everyone safe I'm going to throw them out.
On 04/25/23 at 11:48 AM, observed V13 (Dietary Aide) distributing food from portable steam table on the 2nd unit. For the regular consistency diets observed V13 handle an empty plate with V13's gloved hand and then pick up a hamburger bun using the same gloved hand and place the hamburger bun on the plate. V13 then used tongs to pick up a hamburger patty and place the hamburger patty on top of the bottom hamburger bun. V13 then used the same gloved hand to pick up a slice of cheese and put the cheese on top of the hamburger patty. V13 then used the same gloved hand to pick up a piece of fresh lettuce and put the lettuce on top of the slice of cheese. Using the same gloved hand V13 then picked up a slice of raw tomato and put the tomato on top of the lettuce. Finally, using V13's same gloved hand V13 picked up the top of the hamburger bun and placed it on top of the sliced tomato to assemble the burger. For the mechanical soft diets observed V13 take an empty plate with V13's gloved hand and then pick up a hamburger bun using the same gloved hand to place the bun on the plate. V13 then picked up a serving utensil to put ground hamburger on top of the bottom hamburger bun on the plate using the same gloved hand. V13 then picked up the top of the hamburger bun using V13's same gloved hand and placed it on top of the ground hamburger to assemble the burger. No hand hygiene was noted in between these steps, V13 wore the same gloves throughout the process, and only tongs were used for the hamburger patty.
On 04/26/23 at 2:45 PM, V11 stated any food that goes directly into the resident's mouth should not be touched with a gloved hand unless hand washing is done before and after due to concerns over cross contamination which could make a resident sick.
On 04/27/23 at 9:00 AM, V32 (Registered Dietitian) stated if a kitchen staff member is working on one single task, then they can touch read-to-serve food using a gloved hand however if there is any other step in that process they need to use tongs and hand washing needs to be done when changing gloves and/or when moving from one task to another. V32 stated it is important for the kitchen staff to use utensils such as tongs instead of their hands when touching multiple ready-to-serve items such as bread, lettuce, tomatoes, sliced cheese because of food safety concerns related to cross contamination and food illness.
Facility document titled, Client List Report printed 04/26/23 at 12:15 PM list number of residents receiving regular and mechanical soft consistency diets on the 2nd floor unit.
Kitchen policy titled, Labeling and Dating Food dated 2016, documents in part to decrease the risk of food borne illness and to provide the highest quality, food is labeled with the date received, the date opened, and the date by which the item should be discarded.
Kitchen policy titled, Use of Gloves dated 2016 documents in part the Food and Nutrition Services employees will practice safe food handling to prevent food borne illness and disposable gloves worn to handle ready-to-eat food shall be single-use gloves used only for one task.
Mar 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure nursing staff properly documented on the medication administration record. This failure affected four residents (R1, R2, R3 and R4) ...
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Based on interview and record review, the facility failed to ensure nursing staff properly documented on the medication administration record. This failure affected four residents (R1, R2, R3 and R4) of the four residents reviewed for quality of care.
Findings include:
On 3/28/2023 at 2:00pm R1's, R2's, R3's and R4's February 2023 and March 2023 MARs (Medication Administration Records) were reviewed. There were missing entries for nurses' signatures on the MARs for February 2023 and March 2023 for the following medications:
R1's February (2/1/2023-2/28/2023) 2023 MAR
2/5/2023 AM Amlodipine Besylate Oral Tablet 5mg(milligrams) give 5mg by mouth in the morning.
2/11/2023 AM Amlodipine Besylate Oral Tablet 5mg(milligrams) give 5mg by mouth in the morning.
2/5/2023 AM Aspirin Tablet 81mg give 81mg by mouth in the morning.
2/11/2023 AM Aspirin Tablet 81mg give 81mg by mouth in the morning.
2/11/2023 Bedtime Atorvastatin Calcium Tablet 20mg give 1 tablet by mouth at bedtime.
2/3/2023 5a-6a Famotidine Oral Tablet 20mg give 20mg by mouth in the morning.
2/8/2023 5a-6a Famotidine Oral Tablet 20mg give 20mg by mouth in the morning.
2/13/2023 5a-6a Famotidine Oral Tablet 20mg give 20mg by mouth in the morning.
2/15/2023 5a-6a Famotidine Oral Tablet 20mg give 20mg by mouth in the morning.
2/17/2023 5a-6a Famotidine Oral Tablet 20mg give 20mg by mouth in the morning.
2/27/2023 5a-6a Famotidine Oral Tablet 20mg give 20mg by mouth in the morning.
2/11/2023 PM Ferrous Sulfate Tablet 325(65 Fe) mg give 1 tablet by mouth in the evening.
2/5/2023 AM Ferrous Sulfate Tablet 325(65 Fe) mg give 1 tablet by mouth in the morning.
2/11/2023 AM Ferrous Sulfate Tablet 325(65 Fe) mg give 1 tablet by mouth in the morning.
2/5/2023 AM Glipizide tablet 10mg give 10mg by mouth in the morning.
2/11/2023 AM Glipizide tablet 10mg give 10mg by mouth in the morning.
2/5/2023 AM Januvia oral tablet 50mg give 50mg by mouth in the morning.
2/11/2023 AM Januvia oral tablet 50mg give 50mg by mouth in the morning.
2/7/2023 2100 Levemir FlexTouch Solution Pen-Injector 100unit/ml(milliliters) Inject 33 unit subcutaneously at bedtime.
2/8/2023 2100 Levemir FlexTouch Solution Pen-Injector 100unit/ml(milliliters) Inject 33 unit subcutaneously at bedtime.
2/11/2023 2100 Levemir FlexTouch Solution Pen-Injector 100unit/ml(milliliters) Inject 33 unit subcutaneously at bedtime.
2/12/2023 2100 Levemir FlexTouch Solution Pen-Injector 100unit/ml(milliliters) Inject 33 unit subcutaneously at bedtime.
2/14/2023 2100 Levemir FlexTouch Solution Pen-Injector 100unit/ml(milliliters) Inject 35 unit subcutaneously at bedtime.
2/16/2023 2100 Levemir FlexTouch Solution Pen-Injector 100unit/ml(milliliters) Inject 35 unit subcutaneously at bedtime.
2/20/2023 2100 Levemir FlexTouch Solution Pen-Injector 100unit/ml(milliliters) Inject 35 unit subcutaneously at bedtime.
2/11/2023 Bedtime Melatonin tablet 3mg give 2 tablets by mouth at bedtime.
2/11/2023 Evening Metoprolol Tartrate tablet 100mg give 100mg by mouth in the evening.
2/3/2023 5a-6a Metoprolol Tartrate tablet 100mg give 100mg by mouth in the morning.
2/8/2023 5a-6a Metoprolol Tartrate tablet 100mg give 100mg by mouth in the morning.
2/13/2023 5a-6a Metoprolol Tartrate tablet 100mg give 100mg by mouth in the morning.
2/15/2023 5a-6a Metoprolol Tartrate tablet 100mg give 100mg by mouth in the morning.
2/17/2023 5a-6a Metoprolol Tartrate tablet 100mg give 100mg by mouth in the morning.
2/27/2023 5a-6a Metoprolol Tartrate tablet 100mg give 100mg by mouth in the morning.
2/5/2023 AM Multivitamin Women Tablet give 1 tablet by mouth in the morning.
2/11/2023 AM Multivitamin Women Tablet give 1 tablet by mouth in the morning.
2/4/2023 1700 Humalog Solution 100 unit/ml Inject per sliding scale: If 0-149=0 units Blood glucose results below 70 and above 401 notify MD (medical doctor). 150-200=2 201-250=4 251-300=6 301-350=8 351-400=10 subcutaneously two times a day.
2/5/2023 1700 Humalog Solution 100 unit/ml Inject per sliding scale: If 0-149=0 units Blood glucose results below 70 and above 401 notify MD (medical doctor). 150-200=2 201-250=4 251-300=6 301-350=8 351-400=10 subcutaneously two times a day.
2/11/2023 1700 Humalog Solution 100 unit/ml Inject per sliding scale: If 0-149=0 units Blood glucose results below 70 and above 401 notify MD (medical doctor). 150-200=2 201-250=4 251-300=6 301-350=8 351-400=10 subcutaneously two times a day.
2/18/2023 1700 Humalog Solution 100 unit/ml Inject per sliding scale: If 0-149=0 units Blood glucose results below 70 and above 401 notify MD (medical doctor). 150-200=2 201-250=4 251-300=6 301-350=8 351-400=10 subcutaneously two times a day.
2/19/2023 1700 Humalog Solution 100 unit/ml Inject per sliding scale: If 0-149=0 units Blood glucose results below 70 and above 401 notify MD (medical doctor). 150-200=2 201-250=4 251-300=6 301-350=8 351-400=10 subcutaneously two times a day.
2/27/2023 1700 Humalog Solution 100 unit/ml Inject per sliding scale: If 0-149=0 units Blood glucose results below 70 and above 401 notify MD (medical doctor). 150-200=2 201-250=4 251-300=6 301-350=8 351-400=10 subcutaneously two times a day.
2/5/2023 0900 Magnesium Oxide Oral Tablet 400mg give 2 tablets by mouth every morning and at bedtime.
2/11/2023 0900 Magnesium Oxide Oral Tablet 400mg give 2 tablets by mouth every morning and at bedtime.
2/7/2023 2100 Magnesium Oxide Oral Tablet 400mg give 2 tablets by mouth every morning and at bedtime.
2/8/2023 2100 Magnesium Oxide Oral Tablet 400mg give 2 tablets by mouth every morning and at bedtime.
2/11/2023 2100 Magnesium Oxide Oral Tablet 400mg give 2 tablets by mouth every morning and at bedtime.
2/12/2023 2100 Magnesium Oxide Oral Tablet 400mg give 2 tablets by mouth every morning and at bedtime.
2/16/2023 2100 Magnesium Oxide Oral Tablet 400mg give 2 tablets by mouth every morning and at bedtime.
2/3/2023 0600 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/8/2023 0600 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/13/2023 0600 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/15/2023 0600 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/17/20230 0600 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/27/2023 0600 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/5/2023 1400 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/11/2023 1400 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/18/2023 1400 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/7/2023 2200 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/8/2023 2200 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/11/2023 2200 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/12/2023 2200 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/16/2023 2200 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
2/20/2023 2200 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
R1's March (3/1/2023- 3/31/2023) 2023 MAR
3/27/2023 AM Amlodipine Besylate Oral Tablet 5mg(milligrams) give 5mg by mouth in the morning.
3/27/2023 AM Aspirin Tablet 81mg give 81mg by mouth in the morning.
3/27/2023 5a-6a Famotidine Oral Tablet 20mg give 20mg by mouth in the morning.
3/27/2023 AM Ferrous Sulfate Tablet 325(65 Fe) mg give 1 tablet by mouth in the morning.
3/27/2023 AM Glipizide tablet 10mg give 10mg by mouth in the morning.
3/27/2023 AM Januvia oral tablet 50mg give 50mg by mouth in the morning.
3/27/2023 5a-6a Metoprolol Tartrate tablet 100mg give 100mg by mouth in the morning.
3/27/2023 AM Multivitamin Women Tablet give 1 tablet by mouth in the morning.
3/27/2023 0900 Spironolactone oral tablet 25mg give 0.5mg tablet by mouth one time a day.
3/27/2023 0900 Fluticasone propionate inhalation aerosol powder breath activated 2500mcg 1 blister inhale orally every 12 hours.
3/27/2023 0730 Humalog Solution 100 unit/ml Inject per sliding scale: If 0-149=0 units Blood glucose results below 70 and above 401 notify MD (medical doctor). 150-200=2 201-250=4 251-300=6 301-350=8 351-400=10 subcutaneously two times a day.
3/5/2023 1700 Humalog Solution 100 unit/ml Inject per sliding scale: If 0-149=0 units Blood glucose results below 70 and above 401 notify MD (medical doctor). 150-200=2 201-250=4 251-300=6 301-350=8 351-400=10 subcutaneously two times a day.
3/27/2023 0900 Magnesium Oxide Oral Tablet 400mg give 2 tablets by mouth every morning and at bedtime.
3/27/2023 0900 Torsemide tablet 20mg give 20mg by mouth two times a day.
3/27/2023 0600 Hydralazine HCL tablet 25mg give 1 tablet by mouth every eight hours.
R2's February (2/1/2023-2/28/2023) 2023 MAR
2/5/2023 AM Amlodipine Besylate tablet 5mg give 1 tablet by mouth in the morning.
2/11/2023 AM Amlodipine Besylate tablet 5mg give 1 tablet by mouth in the morning.
2/11/2023 Evening Remeron tablet 15 mg give 7.5mg by mouth in the evening.
R3's February (2/1/2023-2/28/2023) 2023 MAR
2/11/2023 Evening Apixaban oral tablet 5mg give 1 tablet by mouth in the evening.
2/5/2023 AM Apixaban oral tablet 5mg give 1 tablet by mouth in the morning.
2/11/2023 AM Apixaban oral tablet 5mg give 1 tablet by mouth in the morning.
2/11/2023 2000 Aricept tablet 5mg give 1 tablet by mouth at bedtime.
2/11/2023 bedtime Atorvastatin Calcium oral tablet 40mg give 1 tablet by mouth at bedtime.
2/11/2023 evening Carvedilol oral tablet 25mg give 1 tablet by mouth in the evening.
2/5/2023 AM Carvedilol oral tablet 25mg give 1 tablet by mouth in the morning.
2/5/2023 AM Docusate sodium oral capsule 100mg give 1 capsule by mouth in the morning.
2/11/2023 AM Docusate sodium oral capsule 100mg give 1 capsule by mouth in the morning.
2/11/2023 evening Gabapentin capsule 100mg give 1 capsule by mouth in the evening.
2/5/2023 AM Gabapentin capsule 100mg give 1 capsule by mouth in the morning.
2/11/2023 AM Gabapentin capsule 100mg give 1 capsule by mouth in the morning.
2/11/2023 Bedtime Hydralazine HCL oral tablet 50mg give 1 tablet by mouth at bedtime.
2/5/2023 Afternoon Hydralazine HCL oral tablet 50mg give 1 tablet by mouth in the afternoon.
2/11/2023 Afternoon Hydralazine HCL oral tablet 50mg give 1 tablet by mouth in the afternoon.
2/3/2023 5a-6a Hydralazine HCL oral tablet 50mg give 1 tablet by mouth in the morning.
2/8/2023 5a-6a Hydralazine HCL oral tablet 50mg give 1 tablet by mouth in the morning.
2/13/2023 5a-6a Hydralazine HCL oral tablet 50mg give 1 tablet by mouth in the morning.
2/15/2023 5a-6a Hydralazine HCL oral tablet 50mg give 1 tablet by mouth in the morning.
2/17/2023 5a-6a Hydralazine HCL oral tablet 50mg give 1 tablet by mouth in the morning.
2/3/2023 0600 Lidocaine Pain Relief 4% patch apply to both knees topically in the morning for pain.
2/8/2023 0600 Lidocaine Pain Relief 4% patch apply to both knees topically in the morning for pain.
2/13/2023 0600 Lidocaine Pain Relief 4% patch apply to both knees topically in the morning for pain.
2/15/2023 0600 Lidocaine Pain Relief 4% patch apply to both knees topically in the morning for pain.
2/17/2023 0600 Lidocaine Pain Relief 4% patch apply to both knees topically in the morning for pain.
2/5/2023 AM Losartan Potassium oral tablet 100mg give 1 tablet by mouth in the morning.
2/11/2023 AM Losartan Potassium oral tablet 100mg give 1 tablet by mouth in the morning.
2/5/2023 AM MiraLAX Powder give 17 grams by mouth in the morning.
2/11/2023 AM MiraLAX Powder give 17 grams by mouth in the morning.
2/5/2023 2200 Hydralazine HCL oral tablet 50 mg give 1 tablet by mouth at bedtime.
R4's February (2/1/2023- 2/28/2023) MAR
2/5/2023 AM Lasix tablet 20mg give 1 tablet by mouth in the morning.
2/11/2023 AM Lasix tablet 20mg give 1 tablet by mouth in the morning.
2/3/2023 5a-6a Levothyroxine sodium tablet 50mcg (micrograms) give 50mcg by mouth in the morning.
2/8/2023 5a-6a Levothyroxine sodium tablet 50mcg (micrograms) give 50mcg by mouth in the morning.
2/13/2023 5a-6a Levothyroxine sodium tablet 50mcg (micrograms) give 50mcg by mouth in the morning.
2/15/2023 5a-6a Levothyroxine sodium tablet 50mcg (micrograms) give 50mcg by mouth in the morning.
2/17/2023 5a-6a Levothyroxine sodium tablet 50mcg (micrograms) give 50mcg by mouth in the morning.
2/5/2023 Am Tab-A-Vite tablet (Multiple Vitamin) give 1 tablet by mouth in the morning.
2/11/2023 Am Tab-A-Vite tablet (Multiple Vitamin) give 1 tablet by mouth in the morning.
R4's March (3/1/2023-3/31/2023) MAR
3/27/2023 5a-6a Levothyroxine sodium tablet 50mcg (micrograms) give 50mcg by mouth in the morning.
On 3/28/2023 at 1:45pm V7(LPN/Licensed Practical Nurse) stated if a resident does not get their medication administered, I would click the absent from home tab on the electronic medication administration record, this will leave a number in the box for the date the medication was not administered to the resident, this would indicate why the resident did not receive their medication.
On 3/28/2023 at 4:29am V2(ADON/Assistant Director of Nursing) stated the nurses are responsible for administering medications to the residents. V2 stated if there is a blank space on the medication administration record that indicates the nurse assigned did not sign the medication out, or that the medication was missed. V2 stated best practice standards, if there is missing initials on the medication administration record the medication was not administered to the resident. V2 stated if a nurse finds missing documentation on the medication administration record, it is expected the nurse who observed the missing documentation would inform the supervisor or the unit manager so that management can address the issue.
Reviewed facility's Medication Administration Policy dated 10/03 which documents, in part, underneath Guidelines: 14. Document as each medication is prepared on the MAR (medication administration record). 18. If medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider and resident representative if applicable.
Reviewed facility's undated Job Description for Floor RN/LPN (Registered Nurse/Licensed Practical Nurse) which documents, in part, underneath Duties and Responsibilities: 14. Give initial dose of all medications and immediately record them in the chart.
Dec 2022
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based upon record review and interview the facility failed to implement the abuse prevention policy for one of four residents (R2) reviewed for abuse.
Findings include:
R2's (9/19/22) progress note st...
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Based upon record review and interview the facility failed to implement the abuse prevention policy for one of four residents (R2) reviewed for abuse.
Findings include:
R2's (9/19/22) progress note states resident daughter in facility visiting resident when daughter states that it look like her mom has a black eye and she wants her to be sent out 911. Writer examined resident and informed daughter that it looks as if the resident scratched herself with her fingernails. Daughter disagrees with writer and insist on having resident sent out 911.
R2's (9/19/22) hospital history & physical states patient arrived from nursing home with large skin tear on left shoulder.
On 12/13/22 at 3:07pm, V3 (Wound Care Coordinator) affirmed that she was R2's assigned Nurse on 9/19/22 (prior to transfer). Surveyor inquired about R2's (9/19/22) alleged injury V3 stated The daughter came up to the nurse's station and said that it looked like her mom (R2) has a black eye and wanted her (R2) sent to the hospital. When I assessed her (R2), I said to the daughter that she (R2) does not have a black eye. It looked like she (R2) had a stye but the daughter said I don't care, I want her sent to the hospital [V3 documented that R2's eye looked as if it was scratched therefore incongruent with the documentation]. Surveyor inquired if R2's alleged black eye was reported to Administration V3 responded No because her (R2) eye wasn't black. Surveyor inquired who IOUO's (Injuries of Unknown Origin) are reported to V3 replied In general, IOUO is reported to the Administrator.
The abuse prevention policy (reviewed 1/2019) states resident and family concerns will be recorded, reviewed, addressed and responded to using the facility's concern identification procedures. The Nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered.
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 upon record review and interview the facility failed to ensure that staff report resident IOUO (Injury of Unknown Origin) to the Administrator and failed to report an alleged and/or actual IOUO ...
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Based upon record review and interview the facility failed to ensure that staff report resident IOUO (Injury of Unknown Origin) to the Administrator and failed to report an alleged and/or actual IOUO to IDPH (Illinois Department of Public Health) within regulatory requirements for one of four residents (R2) reviewed for abuse.
Findings include:
The (12/8//22) facility census includes 160 residents.
R2's (9/19/22) progress note states resident daughter in facility visiting resident when daughter states that it look like her mom has a black eye and she wants her to be sent out 911. Writer examined resident and informed daughter that it looks as if the resident scratched herself with her fingernails. Daughter disagrees with writer and insist on having resident sent out 911.
R2's initial FRI (Facility Reported Incident) submitted to IPDH (9/22/22) includes date of occurrence 9/22/22 [R2's black eye was reported 3 days prior]. During complaint survey by IDPH it was brought to our attention that (R2's) daughter reported a skin tear to left shoulder. We were not aware of an alteration of skin integrity upon discharge. Resident was taken to hospital on 9/19/22 and admitted with UTI (Urinary Tract Infection).
R2's (9/22/22) final FRI (submitted to IDPH 9/29/22) states the IDPH surveyor originally inquired about an alleged bruising to her eye which was determined inaccurate after following up from the hospital staff [R2's 9/19/22 facility progress notes include black eye allegation]. Hospital staff concurred there was no bruising but did indicate there was a skin alteration to her left shoulder. After review of the incident, allegation was unsubstantiated.
R2's (9/19/22) hospital history & physical (received from the facility) states patient arrived from nursing home with large skin tear on left shoulder [excluded from R2's Final FRI].
On 12/13/22 at 2:46pm, surveyor inquired about the (9/22/22) date of on R2's FRI's [which were incorrect] V2 (Director of Nursing) stated That's the day that it occurred, we didn't find out about it until we had a complaint survey. I guess the patient was supposed to have bruising to her shoulder, it was supposed to have been a skin tear to her shoulder. Surveyor inquired how the injury occurred on 9/22/22 if R2 was transferred to the hospital on 9/19/22 [3 days prior] and did not return to the facility V2 responded I don't know why I put the 22nd on there, that's the day the State came in and the surveyor mentioned it to me. Surveyor inquired about the regulatory requirements for IOUO V2 replied Once we are notified of it then we report it to IDPH immediately. We start the investigation and notify the family and physician. Put interventions in place if we can come up with a conclusion with what occurred and notify IDPH of the findings. Surveyor inquired why R2 was transferred to the hospital on 9/19/22 V2 responded I think she had altered mental status and I think she may be hyperglycemic, her daughter requested she go to the hospital [9/19/22 progress notes affirm transfer was requested due to R2's black eye]. Surveyor inquired if V2 conducted an investigation for R2's reported IOUO on 9/19/22 V2 stated No I didn't.
On 12/13/22 at 3:07pm, V3 (Wound Care Coordinator) affirmed that she was R2's assigned Nurse on 9/19/22 (prior to transfer). Surveyor inquired about R2's (9/19/22) alleged injury V3 stated The daughter came up to the nurse's station and said that it looked like her mom (R2) has a black eye and wanted her (R2) sent to the hospital. Surveyor inquired if R2's alleged black eye was reported to Administration V3 responded No. Surveyor inquired who IOUO's are reported to V3 replied In general, IOUO is reported to the Administrator.
The abuse prevention policy (reviewed 1/2019) states 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. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee shall notify Department of Public Health's regional office immediately by telephone or fax. Within 5 working days after the report of occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to Department of Public Health. The final investigation report shall contain the following: a summary of facts determined during the process of the investigation, review of medical record and interview of witnesses. Conclusion of the investigation based on known facts.
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 upon observation, interview and record review the facility failed to provide ADL (Activities of Daily Living) care to two ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview and record review the facility failed to provide ADL (Activities of Daily Living) care to two of four dependent residents (R4, R6) reviewed.
Findings include:
On 12/7/22, IDPH (Illinois Department of Public Health) received concerns regarding lack of ADL care provided by the facility.
R4 is [AGE] years old with diagnoses which include dementia, cognitive communication deficit and generalized muscle weakness.
R4's (11/2/22) BIMS (Brief Interview Mental Status) determined a score of 4 (severely impaired).
R4's (11/2/22) functional assessment affirms (1 person) physical assist is required for dressing and toilet use.
R4's care plan includes the following: (2/16/22) Resident has an ADL self-care performance deficit related to dementia and mobility impairment. Intervention: make sure shoes are comfortable and not slippery. (12/12/22) Resident is incontinent of bowel and bladder. Intervention: assist as needed with toileting at regular intervals.
On 12/12/22 at 12:39pm, R4 was sitting on the bed while eating lunch. A dried tan ring was observed on the fitted sheet (encircling R4's buttocks). Surveyor inquired if R4 uses the toilet R4 stated I haven't used it in a long time. Surveyor inquired about the incontinence brief R4 responded I'm dry.
On 12/12/22 at 12:49pm, surveyor inquired if R4 uses the toilet V6 (LPN/Licensed Practical Nurse) replied He can walk with assistance to go to the bathroom and he knows when he needs to go. Surveyor inquired about R4's (mismatched) shoes which appeared too big. V6 stated, He has on two different shoes these are the roommates' shoes. You have on your roommates' shoes. Surveyor inquired about the appearance of R4's fitted sheet. V6 responded, It looks like a brown stain there I can't say if its urine or what. Surveyor requested to inspect R4's incontinence brief R4 stood up and the sheet beneath him was saturated. V6 removed R4's saturated brief and stated It's pretty soiled. It's pretty dirty.
__
R6 is [AGE] years old with diagnoses which include malignant neoplasm of the bladder and generalized weakness.
R6's (11/16/22) BIMS determined a score of 11 (moderately impaired).
R6's (11/16/22) functional assessment affirms (1 person) physical assist is required for toilet use.
R6's (10/31/22) care plan states resident has a self-care deficit related to impaired mobility and generalized weakness. Assist patient with transfers promptly as needed to bedside commode or toilet to ensure continence.
On 12/12/22 at 1:10pm, surveyor inquired when R6's incontinence brief was last checked and/or changed R6 stated This morning at breakfast time, 8am [over 5 hours ago]. Surveyor inquired if the brief is currently wet R6 responded It feels wet. Surveyor requested to inspect R6's brief. V7 (LPN) removed R6's incontinence brief which was moderately saturated with diarrhea. R6's buttocks were noted to be deep red. Surveyor inquired about the appearance of R6's buttocks V7 stated Her skins a little reddened. Surveyor inquired about the required frequency for checking and/or changing incontinent residents V7 stated They're supposed to check them and change them every two hours.
The incontinence care policy (revised 1/22) states incontinence care is provided to keep residents as dry, comfortable and odor free as possible [The required frequency is excluded].
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview and record review the facility failed to provide timely incontinence care to (R6) to prevent s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview and record review the facility failed to provide timely incontinence care to (R6) to prevent skin breakdown and failed to ensure that treatments were administered (as ordered) for one of four residents (R5) reviewed for pressure ulcers.
Findings include:
The (October-December 2022) wound report includes R5's (left buttock) pressure ulcer.
R5 is [AGE] years old with diagnoses which include type 2 diabetes mellitus, peripheral vascular disease, gout, rheumatoid arthritis and weakness.
R5's (12/6/22) BIMS (Brief Interview Mental Status) determined a score of 9 (moderately impaired).
R5's (12/6/22) functional assessment affirms (2 person) physical assist is required for toileting and (1 person) physical assist is required for personal hygiene.
R5's (12/9/22) care plan states resident has pressure injury (left buttock) treat as ordered.
R5's (11/30/22) Physician Orders include left buttock foam every Monday, Wednesday, Friday and as needed. Cleanse with normal saline. Pat dry and apply treatment.
On 12/12/22 at 12:57, surveyor inquired if R5 has any wounds R5 responded On my butt they said I do but it's not bothering me. It's a dressing on it every day.
On 12/12/22 at 1:05pm, surveyor requested to inspect R5's wound V7 (LPN/Licensed Practical Nurse) removed R5's incontinence brief and a small pink wound was observed on R5's left buttock (without a dressing). Surveyor inquired if a dressing was on R5's wound. V7 stated, No. Surveyor inquired if staff let V7 know that R5's dressing was removed. V7 responded, No. Surveyor inquired what staff are required to do if a dressing comes off while providing care. V7 replied, They (Certified Nursing Assistants) come and get us (Nursing Staff) and we place a dressing on em (Residents), that's what usually happens.
12/12/22 at 2:55pm, surveyor inquired about R5's left buttock wound V3 (Wound Care Coordinator) stated she (R5) gets the foam every Monday, Wednesday and Friday. Her butt is the same as when she came in, it hasn't changed at all. Surveyor inquired what staff are required to do if R5's dressing comes off. V3 responded, We have a PRN (as needed) treatment placement order so if it comes off, they (Nursing Staff) should put it back on.
__
R6's (11/10/22) wound assessment includes (sacrum) DTPI (Deep Tissue Pressure Injury).
R6 is [AGE] years old with diagnoses which include protein calorie malnutrition, malignant neoplasm of bladder and generalized weakness.
R6's (11/16/22) BIMS determined a score of 11 (moderately impaired).
R6's (11/16/22) functional assessment affirms (1 person) physical assist is required for toilet use.
R6's care plan includes (10/31/22) Resident has a self-care deficit related to impaired mobility and generalized weakness. Assist patient with transfers promptly as needed to bedside commode or toilet to ensure continence. (10/22/22) Resident has potential risk for alteration in skin integrity related to self-care deficits. Provide peri-care after incontinent episode.
On 12/12/22 at 1:10pm, surveyor inquired when R6's incontinence brief was last checked and/or changed R6 stated This morning at breakfast time, 8am [over 5 hours ago]. Surveyor inquired if the brief is currently wet R6 responded It feels wet. Surveyor requested to inspect R6's brief. V7 (LPN) removed R6's incontinence brief which was moderately saturated with diarrhea. R6's buttocks were noted to be deep red. Surveyor inquired about the appearance of R6's buttocks. V7 stated, Her skins a little reddened. Surveyor inquired about the required frequency for checking and/or changing incontinent residents. V7 stated, They're supposed to check them and change them every two hours.
On 12/12/22 at 3:01pm, surveyor inquired about R6's sacrum wound. V3 (Wound Care Coordinator) responded, All her wounds are healed. Surveyor inquired what happens to skin integrity if sitting in diarrhea for extensive periods of time. V3 stated, If they're sitting in diarrhea, then they're more likely to have a skin breakdown.
The incontinence care policy (revised 1/22) states incontinence care is provided to keep residents as dry, comfortable and odor free as possible [The required frequency is excluded].
The wound care policy was requested during this survey however only skin care prevention and wound evaluation/documentation policies were provided.
The skin care prevention policy (revised 1/22) states clean skin at time of soiling and at routine intervals. [Following physician wound care orders and/or reporting treatment concerns to the Nurse are excluded].
Nov 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 ensure that a pressure reducing wheelchair cushion was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a pressure reducing wheelchair cushion was used which affected one (R8) of three residents (R5, R8, R10) reviewed for pressure ulcers.
Findings include:
R8's admission Record documents, in part, that R8's diagnoses include dementia, altered mental status, weakness, unsteadiness on feet and need for assistance with personal care.
R8's Minimum Data Set (MDS), dated [DATE], documents, in part, that R8's Brief Interview for Mental Status (BIMS) score is a 6 which indicates that R8 has severe cognitive impairment. R8's Functional Status for Activities of Daily Living (ADL) Assistance for Locomotion on unit - how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair is documented, in part, for Self-Performance coded as 3 for Extensive assistance and for Support coded as 2 for One person physical assist. R8's Mobility Devices is documented, in part, as Wheelchair. R8's Skin Conditions are documented, in part, for Risk of Pressure Ulcers/Injuries as 1. Yes; for Unhealed Pressure Ulcers/Injuries as 1. Yes; for Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage as number of 1 for Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling; and Skin and Ulcer/Injury Treatments as Pressure reducing device for chair.
On 11/21/22 at 11:32 am, R8 was observed sitting in R8's wheelchair without a wheelchair pressure reducing cushion at a table in the east dining room. V9 (R8's Family Member) was observed sitting next to R8 at the table. V9 stated to this surveyor that R8 was not sitting on a wheelchair pressure reducing cushion in the wheelchair.
On 11/22/22 at 9:35 am, R8 was observed in bed with R8's wheelchair in R8's room with no pressure reducing wheelchair cushion noted.
On 11/22/22 at 12:02 pm, R8 was observed sitting in R8's wheelchair in the east dining room at the table with no wheelchair pressure reducing cushion.
On 11/22/22 at 12:04 pm, V27 (Certified Nursing Assistant, CNA) stated that after R8's pressure ulcer wound care treatment this morning, V27 dressed R8 and transferred R8 from the bed to R8's wheelchair with no pressure reducing wheelchair cushion for R8. This surveyor asked V27 to come to R8's room with this surveyor, and V27 verified to this surveyor that there was no wheelchair pressure reducing cushion in R8's room.
In R8's Wound Progress Note, dated 11/16/22, V35 (Wound Care Physician) documents, in part, for R8's sacrum pressure ulcer wound is currently classified as a Category/Stage III (3) with the plan of Wheelchair Pressure Redistribution Cushion per Facility Policy/Protocol.
In R8's Wound Assessment, dated 11/2/22, V11 (Wound Care Coordinator) documents, in part, the active pressure ulceration to R8's sacrum is a Stage 3 with . All preventative measures in place. This is contradictory to this surveyor's observations of R8 with no wheelchair pressure reducing cushion on 11/21/22 and 11/22/22.
On 11/22/22 at 12:24 pm, V11 (Wound Care Coordinator) stated that R8's pressure ulcer interventions include a wheelchair pressure reducing cushion that works like an air mattress to prevent direct pressure from hard wheelchair so (there's) no pressure to the wound which allows for (R8's) wound to heal. V11 stated, (R8) is to be sitting on it (pressure reducing cushion) whenever (R8) is in the wheelchair.
On 11/23/22 at 12:58 pm, V2 (Director of Nursing, DON) stated that for pressure ulcer prevention interventions, nursing staff will perform Braden scores on admission to identity a resident's risk or actual skin conditions which will determine what interventions are to be used specific to each resident. When asked what is the expectation of a resident with Stage 3 sacral pressure ulcer wound, should a resident have a pressure reducing cushion when in the wheelchair, and V2 stated, Yes. Absolutely. V2 stated that the purpose of a wheelchair pressure reducing cushion is to alleviate pressure to the wound and add comfort.
R8's Care Plan, dated 9/15/22, documents, in part, a focus of (R8) has a pressure injury R/T (related/to) self-care deficit, impaired mobility and comorbitities DX (diagnosis) of . AMS (Altered Mental Status) . Dementia . Site: Sacrum with an intervention of Apply pressure redistribution cushion when up in a chair/wheelchair.
R8's admission Clinical Evaluation with Braden Scale, dated 9/9/22, documents, in part, that R8's Braden Scale for Predicting Pressure Sore Risk score is a 13 indicating R8 is moderate risk.
Facility policy dated January 2022 and titled Skin Risk Evaluation (Braden), documents, in part, Skin Risk Assessment. General: To identify residents with potential risk for impairment of skin integrity and ensure that the proper measures are instituted based on the resident's condition. Responsible Party: Wound Team, RN (Registered Nurse), LPN (Licensed Practical Nurse). Guideline: . 6. The Risk Level will be determined using the Braden Scale. 7. A Care Plan is then developed based on the resident's identified risk factors.
Facility policy dated January 2022 and titled Skin Care Prevention, documents, in part, General: All residents will receive appropriate care to decrease the risk of skin breakdown. Responsible Party: All nursing staff. Guideline: . 13. For residents who are bed or chair bound consider using a pressure-reducing device.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 6 harm violation(s), $231,981 in fines, Payment denial on record. Review inspection reports carefully.
- • 75 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $231,981 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Aliya On 87Th's CMS Rating?
CMS assigns ALIYA ON 87TH an overall rating of 2 out of 5 stars, which is considered 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 Aliya On 87Th Staffed?
CMS rates ALIYA ON 87TH's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 57%, which is 11 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Aliya On 87Th?
State health inspectors documented 75 deficiencies at ALIYA ON 87TH during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 6 that caused actual resident harm, and 68 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Aliya On 87Th?
ALIYA ON 87TH 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 ALIYA HEALTHCARE, a chain that manages multiple nursing homes. With 210 certified beds and approximately 188 residents (about 90% occupancy), it is a large facility located in CHICAGO, Illinois.
How Does Aliya On 87Th Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, ALIYA ON 87TH's overall rating (2 stars) is below the state average of 2.5, staff turnover (57%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Aliya On 87Th?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Aliya On 87Th Safe?
Based on CMS inspection data, ALIYA ON 87TH has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-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 Aliya On 87Th Stick Around?
Staff turnover at ALIYA ON 87TH is high. At 57%, the facility is 11 percentage points above the Illinois average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Aliya On 87Th Ever Fined?
ALIYA ON 87TH has been fined $231,981 across 2 penalty actions. This is 6.6x the Illinois average of $35,399. 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 Aliya On 87Th on Any Federal Watch List?
ALIYA ON 87TH is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.