What is AUSTIN OASIS, THE's CMS rating?

AUSTIN OASIS, THE has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does AUSTIN OASIS, THE have?

AUSTIN OASIS, THE has 74 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at AUSTIN OASIS, THE?

AUSTIN OASIS, THE has a three-star staffing rating from CMS with 0.91 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is AUSTIN OASIS, THE located?

AUSTIN OASIS, THE is located in CHICAGO, IL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does AUSTIN OASIS, THE have?

AUSTIN OASIS, THE has 216 certified beds.

Who owns AUSTIN OASIS, THE?

AUSTIN OASIS, THE is a for profit - limited liability company facility and is part of the ICARE CONSULTING SERVICES chain.

Is AUSTIN OASIS, THE safe?

AUSTIN OASIS, THE has documented safety concerns including a substantiated abuse finding on record. Families should ask about corrective actions taken.

Do nurses at AUSTIN OASIS, THE stick around?

AUSTIN OASIS, THE has average staff turnover at 39%, which is typical for the nursing home industry.

Was AUSTIN OASIS, THE ever fined?

Yes, AUSTIN OASIS, THE has been fined $532,728 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is AUSTIN OASIS, THE on any federal watch list?

No, AUSTIN OASIS, THE is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at AUSTIN OASIS, THE?

Medicare inspectors have found 74 deficiencies at AUSTIN OASIS, THE: 8 serious, 66 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting AUSTIN OASIS, THE?

Families visiting AUSTIN OASIS, THE should ask about what corrective actions were taken after fines. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does AUSTIN OASIS, THE compare to other nursing homes?

AUSTIN OASIS, THE has a 1-star overall rating, which is below average compared to other nursing homes in IL. Families should carefully review inspection findings and consider alternatives.

AUSTIN OASIS, THE | 0/100 (Grade F)

Mar 2025 16 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect one (R40) resident's right to be free from physical abuse...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect one (R40) resident's right to be free from physical abuse out of one sampled resident. R132 slapped R40 on the face that resulted in R40's falling on her back and sustained left elbow, back, and neck pain. R40 felt scared and shaken. Findings Include: The facility's incident investigation report dated 3/3/25 documents in part: On 3/3/25 [V1 Administrator] was notified by [R40] that [R132] pushed [R40] down. Both residents' representatives and the police were notified. R40's Minimum Data Set (MDS) dated [DATE] shows R40 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15 and requires supervision with walking. R40's functional assessment dated [DATE] shows R40 had no limitation with range of motion to upper extremities. R40's progress notes dated 3/3/25 at 4:39 PM documented by V10 (Psychiatric Rehabilitation Services Coordinator) reads in part: Resident had an altercation with another resident this morning. Resident was redirected and was checked by nurse. The writer will continue to assist resident's needs. R132's MDS dated [DATE] shows R132 is cognitively intact with BIMS of 15 and independent with walking. R132's progress notes dated 3/3/25 at 10:30 AM documented by V13 (Registered Nurse/RN) reads in part: Patient came to the medication cart where other patients was standing in line for their medication and stated I want my medication now, I am not waiting. [R132] started yelling and became aggressive with another resident slapped her [R40] in her face and pushed her to the floor. On 3/4/25 at 10:55 AM, R40 stated on 3/3/25 at around 10:00 AM, R40 was in line to get medications from V13 (Registered Nurse). R40 stated, [R132] came up real fast next to [V13] and said [R132] needs her medication. [R132] was loud and angry. [V13] tried to tell [R132] that [V13] will finish giving my meds. [R132] was so angry and demanding her meds. I said please have some respect the nurse was telling you something. Then [R132] took her hand, slapped me on my face, and pushed me real hard and knocked me out on my butt. I fell on the ground. I fell on my butt and back and left shoulder. I had a replacement surgery there it's very very painful. Now the pain level is 8. I landed on my left side. Now my left side of my neck, my left side of my mid to lower back and my left elbow is hurting. I was so scared, and I was shaken. [R132] was twice as big as me. [R132] was double the frame of me. I'm only 124.8 pounds. I screamed for pain. [V13] the nurse and another staff helped me up. I stood for a while. I slowly walked to my room and laid down. I didn't want to go to the hospital. I told [V13] I was having pain. [V13] gave me Hydrocodone. I already have chronic pain on my left arm but it got worse because of the incident. My elbow, my neck, my back are hurting more. R40 stated the pain medications help control the pain. R40 stated [V13] sent [R132] to the hospital. Surveyor asked R40 to lift R40's left arm and noted R40 with limitation on range of motion. On 3/5/25 at 9:34 AM, interviewed V10 (Psychiatric Rehabilitation Services Coordinator/PRSC) about the incident that happened on 3/3/25 between R40 and R132. V10 stated, It was around 10:15 to 10:30 in the morning it happened at the nurses' station on the 5th floor. Front desk paged social service to go to the fifth floor. When I came up there they had the residents [R40, R132] separated already. [V13] and the [Certified Nursing Assistant] CNA (does not know her name) were there they witnessed the incident. [R40] was a little shaky she told me that [R132] pushed [R40]. [R132] was being disrespectful to [V13] and [R40] told [R132] to be more respectful and then [R132] got angry at [R40] and proceeded to pushing [R40] on the face. [R40] told me she fell and hurt her left shoulder and left elbow. [R132] was already in the room and [R40] was in the hallway sitting on the chair with [V13]. The nurse was assessing [R40]. [R40] said that she was okay but [R40] said she was hurting on her left shoulder and left elbow. [R40] did not want to go to the hospital. We kept them separated. After that I started the petition for [R132]. We removed [R132's] roommate from the room because [R132] was still agitated. V10 stated that physical abuse is when someone put their hands on somebody attempting to hurt them in a malicious way. V10 stated that what [R132] did to [R40] is a type of physical abuse. A follow up interview was conducted with V10 on 3/6/25 at 9:55 AM and stated that R132 had history of aggressive behavior prior to the incident with [R40]. On 3/6/25 at 9:29 AM, a phone interview was conducted with V13 (RN) about R40 and R132's incident on 3/3/25. V13 stated, It happened in the morning time. I was passing medication when it happened. [R132] came up to me and wanted me to stop to give her medications. I told [R132] that there is a line and people are in line waiting. [R132] started saying she will punch me on my face. [R40] tried to stop [R132] and told [R132], Oh no you can't talk to the nurse like that. Then [R132] slapped [R40] on the face and pushed her. [R40] fell on her back, I think on her left side. V13 stated she assessed [R40] with no injuries and did not complain of pain. V13 stated R40's doctor was notified but R40 did not want to go to the hospital. V13 stated R132 was sent to the hospital for psychotic behaviors. The facility's Abuse Prevention Program Facility Policy (no date) documents in part: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental mends and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure the residents were treated with respect and dignity by not passing out meals to all residents sitting at a table at the...

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to ensure the residents were treated with respect and dignity by not passing out meals to all residents sitting at a table at the same time. These failures affected 3 residents (R27, R43, R125) reviewed during dining in a total sample of 35 residents. Findings include: On 03/04/25 at 12:20 PM, observed R43 and R332 sitting at the same table in the main dining room with R332 eating lunch from his tray. Observed R43 watching R332 eat. R43 did not have a lunch tray in front of her. R43 stated, I'm hungry. Sometimes I have to wait to get my meal. On 03/04/25 at 12:24 PM, observed R27, R35, R125 and R174 sitting at a table in the main dining room. Observed R35 and R174 eating from their lunch trays. Observed R27 and R125 watching R35 and R174 eating their lunch and the staff passing out other resident trays. R35 and R174 did not have a lunch tray in front of them. R27 stated, I wish we were served all at the same time. I'm hungry. R125 stated, I'm hungry. I want my lunch. On 03/04/25 at 12:34 PM, as R35 was eating R35 stated, we always sit together but our trays come out at different times and we don't get our trays served to us all at the same time. On 03/04/25 at 12:37 PM, R35 finished eating her lunch meal. Observed R27 and R125 still waiting to receive their food and looking at the staff distributing the lunch trays to the other residents sitting in the main dining room. On 03/04/25 at 12:38 PM, as R43 was delivered her meal, her tablemate (R332) who had already finished eating his lunch tray, stood up and walked away from the table. R43 began to eat her lunch independently right away. On 03/04/25 at 12:41 PM, R27 and R125's lunch trays arrived at their table. R27 and R125 began to eat independently immediately. On 03/05/25 at 12:10 PM, V23 (Registered Dietitian) stated during meal service residents sitting at the same table should receive meal at the same time. V23 stated one resident should not be sitting watching the other residents eating; that would be a dignity issue. R27's diagnosis which includes but not limited to Chronic Obstructive Pulmonary Disease, Cerebral Infarction, Anemia, Violent Behavior, Psychosis, Bipolar Disorder, Schizoaffective Disorder, Panic Disorder, Dementia, Major Depressive Disorder. R27's Physician Orders dated 03/04/25 documents in part General diet regular texture, thin liquids consistency ordered 02/17/25. R27's MDS (Minimum Data Set) from 12/10/24 BIMS (Brief Interview for Mental Status) was 12 out of 15 indicating moderately impaired cognition. R43's diagnosis which includes but not limited to Type 2 Diabetes Mellitus, Chronic Kidney Disease, Hypertension, Anemia, Schizoaffective Disorder. R43's Physician Orders dated 03/05/25 documents in part No Added Salt, regular texture, thin liquids consistency, NCS (No Concentrated Sweets). R43's MDS (Minimum Data Set) from 12/11/24 BIMS (Brief Interview for Mental Status) was 15 out of 15 indicating intact cognition. R125's diagnosis which includes but not limited to Chronic Obstructive Pulmonary Disease, Heart Failure, Protein Calorie Malnutrition, Hypotension, Hypothyroidism. R125's Physician Orders dated 03/05/25 documents in part No Added Salt, mechanical soft, chopped meat texture, thin liquids consistency. R125's MDS (Minimum Data Set) from 03/12/24 BIMS (Brief Interview for Mental Status) was 14 out of 15 indicating intact cognition. Facility provided policy titled The Dining Experience dated 2017 which documents in part, meals served will respect the client's dignity as an individual and meals are served at approximately the same time to all the clients sitting at a table. Facility provided policy titled, Resident Rights undated which documents in part, employees shall treat all residents with respect, kindness, and dignity.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure (A) The five administration rights were followe...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure (A) The five administration rights were followed for one [R151] of three [R108, R139] residents reviewed for medication administration in a sample of 35 residents. Findings Include, R151's Physician orders: 6/25/24 Insulin Glargine 100unit/ml, inject 30units daily. On 3/4/25 at 9:40 AM, observed V5 [Licensed Practical Nurse] prepare R151's insulin: V5 administered R151's insulin in the upper left arm. Surveyor observed the open half-filled insulin Glargine vail was labeled with R59's name, no open or expiration date on the vail. On 3/4/25 at 9:46AM, V5 stated, I was aware that I obtained R151's insulin dose from R59's multi use insulin vial, R151 did not have any more insulin. I re-ordered R151's insulin and should be delivered sometime tonight. The facility has an emergency Insulin Box. I am under the weather, and I did not feel like going to the other nursing floor to get the insulin from the emergency Insulin Box. I did not notice there was no open or expiration date on the insulin vial, prior to administering the medication. The insulin vials should be dated with an open and expiration date at the time of opening the vail, so the nurse will know the insulin is effective. On 3/5/25 at 1:22 PM, V2 [Director of Nursing] stated, All insulins vail, and pens are to be labeled at the time they are open. The label should include the date opened and discontinue date. If the insulins are not labeled, it can potentially cause adverse reactions, and ineffectiveness of the medication that can harm a resident. The nurse should never borrow medication from another resident. The facility has an emergency Insulin box to retrieved needed insulin. Policy documents in part: Medication Administration Policy Medications supply to one resident may not be administered to another resident. Multi-use [NAME] must be dated when opened. Medications must be administered in accordance with the physician's order act their discretion the right resident right medication right dosage right route and right time. All medications must be properly labeled with resident's name, medication name, dosage, and frequency. Medications labeled Refrigerate must be kept in refrigerator.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to a.) ensure oxygen tubing and nebulizer mask were labeled and dated, b.) ensure nebulizer supplies were properly stored when no...

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to a.) ensure oxygen tubing and nebulizer mask were labeled and dated, b.) ensure nebulizer supplies were properly stored when not in use to prevent contamination for and c.) ensure oxygen signage was posted for residents receiving oxygen therapy. This failure has the potential to affect 3 (R10, R63, R104) residents reviewed for oxygen therapy in a sample of 35. R10 has diagnosis not limited to Generalized Anxiety Disorder, Heart Failure and Chronic Obstructive Pulmonary Disease. R10's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R10's Physician Orders document in part: Oxygen via NC (Nasal Cannula) at 3L (Liters) continuous every shift. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter) inhale orally two times a day. R10's Care Plan document in part: Focus: R10 has head of bed elevated while in bed or lays on extra pillows to facilitate easier breathing related to diagnosis of COPD (Chronic Obstructive Pulmonary Disease), Acute Respiratory Failure with Hypoxia and receives bronchodilator, MED (Medication)/NEB (Nebulizer) treatments routinely and PRN (as needed). Interventions: Give aerosol or bronchodilators as ordered. Give oxygen therapy as ordered by the physician. On 03/04/25 at 11:24 AM R10 was observed sitting in the bed with oxygen per nasal cannula in use. The oxygen tubing was not labeled or dated. The nebulizer set up was laying on the table next to the bed with no bag. On 03/04/25 at 12:54 PM The surveyor asked V5 (Licensed Practical Nurse) to enter R10's room. Upon arriving at R10's room entrance the surveyor made V5 aware that there was no oxygen sign posted at R10's room entrance. V5 then entered R10's room. R10 was sitting on the bed with oxygen per nasal cannula in use. V5 picked up R10's nebulizer set up dated 02/10/25. V10 stated the nebulizer is supposed to be changed every night shift if I am not mistaken. The oxygen tubing is not dated. Oxygen signage lets everyone know there is oxygen in use just in case we have a fire. The oxygen tubing and nebulizer is stored in a bag to prevent contamination. R63 has diagnosis not limited to Dementia, Heart Failure and Obstructive Pulmonary Disease. R63's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 13 indicating intact cognitive response. R63's Physician Orders document in part: Oxygen at (2) L/Min per Nasal Cannula as needed. R63's Care Plan document in part: Focus: R63 has her HOB elevated while in bed and/or uses additional pillows to prevent SOB when lying flat related to diagnosis of COPD. Interventions: Give oxygen therapy as ordered by the physician. On 03/04/25 at 12:32 PM R63 was observed lying in bed with oxygen per nasal cannula in use. Oxygen tubing was observed with no label. On 03/04/25 at 12:42 PM the surveyor asked V5 (Licensed Practical Nurse) to enter R63 room then asked the flow rate of R63's oxygen and if there was a label on R63's oxygen tubing. V5 exited R63's room and responded, R63's oxygen is at 3 liters and the tubing was not labeled. The oxygen tubing is supposed to be labeled. The tubing is to be changed out on night shift and labeled when it is changed out. R104 has diagnosis not limited to Seasonal Allergic Rhinitis, Acute Cough, Cardiomyopathy, Pneumonia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Hypoxemia and Acute Respiratory Failure with Hypoxia. R104's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 14 indicating intact cognitive response. R104's Physician Orders document in part: Albuterol Sulfate Inhalation Nebulization Solution 2 puff inhale orally every 4 hours as needed. Oxygen every 4 hours as needed 4 liters. R104's Care Plan document in part: Focus: R104 is receiving Oxygen Therapy PRN related to Ineffective gas exchange. Interventions: Give oxygen as ordered by physician. Focus: R104 has her HOB elevated while in bed and/or uses additional pillows to prevent SOB while lying flat related to diagnosis of Acute Respiratory Failure with Hypoxia, Pneumonia, COPD with Acute Exacerbation, Allergic Rhinitis, Nicotine Dependence. Interventions: Give aerosol or bronchodilators as ordered. Give oxygen therapy as ordered by the physician. On 03/04/25 at 11:16 AM R104 was observed sitting in the bed with the oxygen nasal cannula on the floor. R104 stated I took off the oxygen. R104 picked up the nasal cannula and placed it on. R104 nebulizer setup was observed on the bedside table not in a bag. On 03/04/25 at 12:52 PM The surveyor asked V5 (Licensed Practical Nurse) to enter R104's room. Upon arriving at R104's room entrance the surveyor made V5 aware that there was no oxygen sign posted at R104's room entrance. V5 then entered R104's room. R104 was sitting on the bed with oxygen per nasal cannula in use. V5 stated, I need a baggy, something to put the nebulizer in. R104 should have an oxygen sign at the door. On 03/06/25 at 09:12 AM V2 (Director of Nursing) stated my expectations of the nursing staff when a resident has oxygen are they should check the oxygen saturation and make sure oxygen tubing and nebulizer is dated. When the oxygen and nebulizer face mask are not in use they should be stored in a bag in the residents' drawer. The oxygen tubing and nebulizer should be changed weekly. If oxygen is being used there should be an oxygen sign. Policy: Titled Oxygen Therapy dated 09/19 document in part: To administer oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. Procedure: 2. Place Oxygen in Use sign outside the room when in use. Smoking is Prohibited. 6. Discard disposable mask, cannulas, and tubing after use minimal weekly and prn (as needed). Titled Oxygen Equipment dated 09/19 document in part: To administer oxygen in conditions in which infection control is maintained. 2. Facility will use disposable nasal cannula and facemasks. Equipment will be changed weekly and prn on date of facility's choice and dated. 3. Humidifier Bottles: prefilled bottles will be changed and dated when empty. Other bottles will be changed and dated weekly and prn. 4. Oxygen tubing/nebulizer masks will be changed and dated weekly and prn. 5. Oxygen tubing/nebulizer mask will be covered when not in use.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to document the information on the resident's (R332) COVID-19 vaccine...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to document the information on the resident's (R332) COVID-19 vaccine and failed to document if education was provided regarding the benefits and potential risks associated with the COVID-19 vaccine to 3 (R61, R156, R332) out of 5 residents reviewed for COVID-19 immunizations in a final sample of 35. Findings include: On 3/5/25 at 9:24 AM, R61, R156, and R332's electronic health records (EHR) were reviewed for immunizations. R61 and R156 revealed both refused the COVID-19 vaccine. R332 had no documentation regarding each dose of COVID-19 vaccine administered to R332 or if he did not receive the COVID-19 vaccine due to medical contraindications or refusal. R61, R156, and R332's EHR also do not have documentation if education was provided to them or their representatives regarding the benefits and potential risks associated with the COVID-19 vaccine. There were no COVID-19 consents found in R61, R156, and R332's EHR. On 3/6/25 at 10:35 AM, Surveyor requested from V2 (Director of Nursing/Infection Preventionist) documentation showing education was provided to R61, R156, and R332 regarding the COVID-19 vaccine, but did not provide. V2 stated there are no documentation that education was provided about the COVID-19 vaccine to the residents because there were done verbally. R61's EHR revealed R61 was admitted to the facility on [DATE] with diagnoses that included, but not limited to diabetes mellitus, alcohol abuse, cerebral infarction, and hyperlipidemia. R61's minimum data set (MDS) dated [DATE] shows R61 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15. R156's EHR revealed R156 was admitted to the facility on [DATE] with diagnoses that included, but not limited to psychoactive substance abuse and psychosis. R156's MDS dated [DATE] shows R156 is cognitively intact with BIMS of 15. R332's EHR revealed R332 was admitted to the facility on [DATE] with diagnoses that included, but not limited to type 2 diabetes mellitus, hyperlipidemia, and essential hypertension. R332's MDS dated [DATE] shows R332 is cognitively intact with BIMS of 15. The Department of Health & Human Services Centers for Medicare & Medicaid Services QSO-21-19-NH documents in part: The resident's medical record must include documentation that indicates, at a minimum, that the resident or resident representative was provided education regarding the benefits and potential side effects of the COVID-19 vaccine, and that the resident (or representative) either accepted and received the COVID-19 vaccine or did not receive the vaccine due to medical contraindications, prior vaccination, or refusal. If there is a contraindication to the resident having the vaccination, the appropriate documentation must be made in the resident's medical record. Documentation should include the date the education and offering took place, and the name of the representative that received the education and accepted or refused the vaccine, if the resident has a representative that makes decisions for them. Facilities should also provide samples of the educational materials that were used to educate residents.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0575 (Tag F0575)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to display, in a public and accessible location, post...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to display, in a public and accessible location, posters informing residents of their rights to explore or decline community transition under the [NAME] Consent Decree, and their right to be free from retaliation, regardless of their decision on transition. This has the potential to affect all [NAME] Class Members. Findings include: On 03/04/2025 at 10:56 AM, conducted first floor observations at the main entrance and main dining room. No [NAME] Consent Decree postings or signs related to residents' rights to explore community transition with the program. On 3/04/2025 at 11:01 AM, there was no sign at the second-floor nurses' station, in front of the elevator or at the dining room pertaining to the [NAME] Consent Decree. V5 (second floor Nurse) and V7 (second floor Nurse) stated they do not know who the facility works with to help residents transition into the community. V5 and V7 could not locate a sign related to the [NAME] Consent Decree or facility's partnered agencies that help residents' transition to the community on the second floor. On 3/04/2025 at 11:06 AM, there was no sign at the third floor pertaining to the [NAME] Consent Decree. V8 (third floor nurse) stated [V8] doesn't know which transition agency the facility works with for their [NAME] Class Members. On 3/04/2025 at 11:09 AM, no sign at the 4th floor. At 11:12 AM, V9 (fourth floor Nurse) named the transition agency but could not locate the agency's contact info, poster, or information. On 3/04/2025 at 11:13 AM, V10 (Psychiatric Rehabilitation Services Coordinator) named the transition and reporting agency. V10 stated [V10] has not seen the posters for [NAME] Consent Decree around the facility. On 3/04/2025 at 11:18 AM, no posters/signs observed on the fifth floor related to the [NAME] Consent Decree. At 11:22 AM, V11 (Quality Assurance and Psychotropic Nurse) stated [V11] doesn't know who the facility works with for residents' transition into the community. V11 did not know if there were posters or signs for it. On 3/04/2025 at 11:52 AM, V4 (Social Service Director) stated the facility should have flyers pertaining to the [NAME] Consent Decree and transition agency on every floor. When surveyor asked staff where they were located and asked to be shown the posters, staff could not locate them. V4 stated the facility used to have them but will order more. Facility's Pre-admission Screening and Resident Review (PASRR) policy (last revised 12/2023) documents in part facility's role in submitting census data to IDPH appointed company to be compliant with [NAME] Consent Decree. However, it does not document in part how the facility provides education to all [NAME] Class Members regarding their rights. Facility did not provide any other policy pertaining to [NAME] Consent Decree. Illinois Administrative Code, Title 77: Public Health, Chapter I: Department of Public Health, Subchapter d: Long-Term Care Facilities, Part 300 Skilled Nursing and Intermediate Care Facilities Code, Section 300.3210 General, Subsection (u): Cook County facilities with [NAME] Class Members shall provide residents access to the supports and services they need in the most integrated settings appropriate to their needs, including community-based settings, to promote and maximize their independence, choice, and opportunities to develop and use independent living skills. For the purposes of this subsection (u), community-based setting means the most integrated setting appropriate to promote the resident's independence in daily living and ability to interact with persons without disabilities to the fullest extent possible. State Operations Manual Appendix PP - Long Term Care Facilities (Rev. 225; Issued: 08-08-24): The facility must post, in a form and manner accessible and understandable to residents or resident representatives a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R63 has diagnosis not limited to Constipation, Schizophrenia, Cerebrovascular Disease, Essential Hypertension, Vitamin Deficienc...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R63 has diagnosis not limited to Constipation, Schizophrenia, Cerebrovascular Disease, Essential Hypertension, Vitamin Deficiency, Hyperlipidemia, Dementia, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Gastro-Esophageal Reflux Disease, Atherosclerosis of Native Arteries of Extremities with Gangrene, Left Leg), Heart Failure, Acquired Absence of Left Leg Below Knee, Peripheral Vascular Disease and Chronic Obstructive Pulmonary Disease. During review of R63 Physician Orders, Care Plan and Electronic Medical Record there were no documented Advance Directives. Based on interviews and record reviews, the facility failed to follow their policy and procedure by not obtaining a physician's order for 4 residents' (R44, R63, R129, R332) code status and failed to develop a comprehensive person-centered care plan for 2 (R44, R63) out of 2 residents' code status in a final sample of 35 reviewed for advance directives. Findings Include: R44's face sheet shows an admission date of [DATE] and the advance directive section was blank. R44's minimum data set (MDS) dated [DATE] shows R44 is cognitively intact with BIMS (Brief Interview for Mental Status) of 14. R44's order summary report with active orders as of [DATE] shows no physician order for R44's code status. R44's comprehensive care plan does not address R44's advance directive/code status. R332's face sheet shows an admission date of [DATE] and the advance directive section was blank. R332's MDS dated [DATE] shows R332 is cognitively intact with of 15. R332's order summary report with active orders as of [DATE] shows no physician order for R332's code status. On [DATE] at 9:25 AM, interviewed V4 (Social Service Director) and stated, When residents come in we talk about advance directives and ask them if they want to be full code or DNR [Do Not Resuscitate] or if they have active advanced directive. V4 stated that residents with BIMS of 12 and above can make their own decisions regarding their code status. V4 stated that it is the facility's policy that residents' code status should be ordered by the physician, should show on the residents' face sheets and should be in their care plans. The facility's ADVANCE DIRECTIVES policy and procedure dated 4/14 documents in part: A written physician's order is required in response to the resident's Advanced Directive(s). Physician's orders shall be specified and address each Advanced Directive(s). Advanced Directive(s) shall be addressed on the resident's plan of care, physician progress notes, and physician's orders and in Social Service Progress Notes. R129 has a diagnosis included but not limited to Rhabdomyolysis, Epilepsy, Unspecified, Not Intractable, Without Status Epilepticus, Hypothermia, Sequela, Acquired Absence Of Left Foot, Other Psychoactive Substance Abuse, Other Disorders Of Electrolyte And Fluid Balance, Other Iron Deficiency Anemias, Homelessness, Conversion Disorder With Seizures Or Convulsions, Pain In Unspecified Foot, Hyperglycemia, Major Depressive Disorder, Personal History Of Covid-19, Unspecified Dislocation Of Left Ulnohumeral Joint. R129's MDS (Minimum Data Set) dated [DATE] BIMS (Brief Interview for Mental Status) score is 12/15 indicating moderate cognition. R129's signed form titled IDPH Uniform Practitioner for Life-Sustaining Treatment (POLST) Form dated [DATE] which indicates R129's wish for full treatment and yes to CPR (cardiopulmonary resuscitation). R129's care plan dated [DATE] documents in part, (R129) wishes for full code status as specified in his/her advance directive documents will be honored and clearly delineated in the medical record in compliance with status law. R129's Order Summary Report dated [DATE] does not include any order for Advanced Directives.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer 9 (R1, R22, R35, R55, R59 R70, R83, R99, R136) residents to t...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer 9 (R1, R22, R35, R55, R59 R70, R83, R99, R136) residents to the appropriate state designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation out of 9 residents reviewed for PASARR in a total sample of 35. Findings Include: 1. R22 was admitted to the facility on [DATE] with diagnosis not limited to Multiple Sclerosis, Muscle Spasm, Personal History of Suicidal Behavior, Bipolar Disorder, Schizoaffective Disorder, Bipolar Type and Major Depressive Disorder, Recurrent. R22's Document titled Notice of PASRR Level II Outcome dated 09/26/24 document in part: PASRR Determination: Approved without Specialized Services. This Level II evaluation is good within 90 calendar days of the Notice date listed on the Notice of PASRR Level II Outcome that came with this letter. You fall into the category of having a diagnosis that the PASRR program was designed to assess. Your condition is likely to require expert treatment in the future. You are diagnosed with major depressive disorder, schizophrenia, bipolar disorder, and generalized anxiety disorder. The admitting Nursing Facility should contact their local Care Coordination Services Agency to have a post-admission screening conducted. There is no documented follow up screening for R22. 2. R59 was admitted to the facility on [DATE] with diagnosis not limited to Auditory Hallucinations, Newborn Affected by Maternal use of Alcohol, Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, Single Episode, Severe with Psychotic Features, Bipolar Disorder, Current Episode Depressed, Severe, Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, Anxiety Disorder and Schizophrenia, Suicidal Ideations. R59's Document titled Notice of PASRR Level II Outcome dated 06/25/24 document in part: PASRR Determination: Approved without Specialized Services. This Level II evaluation is good within 90 calendar days of the Notice date listed on the Notice of PASRR Level II Outcome that came with this letter. You fall into the category of having a diagnosis that the PASRR program was designed to assess. You have a level II PASRR condition of bipolar this order, current episode depressed, severe, without psychotic features, schizoaffective disorder bipolar type, major depressive disorder, recurrent, severe with psychotic symptoms, and generalized anxiety disorder, which needs routine follow up with a mental health professional and a medication regimen of Depakote, Seroquel, Melatonin, Ativan, Zyprexa, and Gabapentin. There is no documented follow up screening for R59. 3. R70 was admitted to the facility on [DATE] with diagnosis not limited to Schizophrenia, Personal History of Suicidal Behavior, Schizoaffective Disorder, Depressive Type, Psychotic Disorder, Bipolar Disorder, Paranoid Schizophrenia, Obesity, Anxiety Disorder, Psychosis, Auditory Hallucinations and Schizoaffective Disorders. R70's Document titled Notice of PASRR Level II Outcome dated 06/22/24 document in part: PASRR Determination: Approved without Specialized Services. This Level II evaluation is good within 90 calendar days of the Notice date listed on the Notice of PASRR Level II Outcome that came with this letter. You fall into the category of having a diagnosis that the PASRR program was designed to assess. You are diagnosed with paranoid schizophrenia which significantly impacts your daily life. You may benefit from medication management and psychiatric support. There is no documented follow up screening for R70. 4. R1's admission Record documents in part an initial admission date of 11/12/2024. R1 with diagnoses of bipolar disorder, schizoaffective disorder-bipolar type, and hallucinations. R1's 11/09/2024 Notice of PASRR (Preadmission Screening and Resident Review) Level II Outcome documents in part a short-term approval without specialized services. The date the short-term approval ended was on 2/07/2025. On 3/05/2025 at 11:56 AM, V12 (Director of Admissions) provided a copy of R1's 11/09/2024 PASRR. V12 stated the facility does not have a more recent PASRR. On 3/05/2025 at 1:02 PM, V12 stated R1 is due for another evaluation. V12 stated facility did not schedule the re-evaluation until the time of the survey. 5. R136's admission Record documents in part an initial admission date of 8/29/2024. R136's 6/27/2023 Notice of PASRR Level I Screen Outcome documents in part that R136 did not require a level II due to no diagnosis of severe mental illness, intellectual disabilities, and/or related condition. R136's admission Record, however, documents a diagnosis of bipolar disorder with an onset date of 8/29/2024. R136's Order Summary Report documents in part that R136 is on Olanzapine (antipsychotic), Prozac (antidepressant), and Trazadone (antidepressant). On 3/05/2025 at 2:26 PM, V12 stated R136 did not have a more recent PASRR than the one from 6/27/2023. V12 stated facility did not request for a PASRR re-evaluation for R136 after the new diagnosis of bipolar disorder. Facility's Pre-admission Screening and Resident Review (PASRR) policy (last revised 12/2023) documents in part: It is the policy of this facility to comply with Federal, State and the appointed screening agency, [contracted company], in standards addressing the PASRR assessment/screening process. It is the policy of this facility to: review the PASRR documents to help assess/ascertain what type of problems, needs and issues need to be addressed to help the resident function at his/her maximum level of well-being. 6. R83 admitted to the facility 04/21/22 with admitting diagnosis which included Type 2 Diabetes Mellitus with Foot Ulcer, Acquired Absence of Left Leg Below Knee, Acute Osteomyelitis, Left Ankle & Foot, Cellulitis of Left Lower Limb, Asthma, Syphilis, Chronic Viral Hepatitis C, Dyspnea, Seizures. R83's Notice of PASRR Level I Screen Outcome dated 04/15/22 documents in part, no level II required - no SMI/ID/RC and suspected or confirmed PASRR condition(s): not applicable. During R83's stay the following diagnoses were added on these dates: Anxiety Disorder (05/05/22), Depression (05/05/22), Major Depressive Disorder (07/04/22), Schizophrenia (12/17/22). R83 does not have a Level II PASRR evaluation after newly added mental illness diagnoses. 7. R35 admitted to the facility 10/07/24 with admitting diagnosis including but not limited to Schizoaffective Disorder, Schizophrenia. R35's Notice of PASRR Level II Outcome dated 10/05/24 documents in part, short term approval without specialized services and date short term approval ends as 01/03/25. 8. R55 admitted to the facility 03/12/10, diagnosis with date of onset as follows: Major Depressive Disorder (10/05/21), Paranoid Schizophrenia (04/10/17), and Generalized Anxiety (04/10/17). R55's Notice of PASRR Level II Outcome dated 09/26/24 documents in part, short term approval without specialized services and date short term approval ends as 12/25/24. 9. R99 admitted to the facility 04/30/24 with admitting diagnosis including but not limited to Schizophrenia, and Psychosis. R99's Notice of PASRR Level II Outcome dated 09/02/24 documents in part, short term approval without specialized services and date short term approval ends as 12/01/24. On 03/05/25 at 1:50 PM, V12 (Director of Admissions) V12 stated if a resident has a completed PASRR level I which says that a PASRR level II screen is not required but the resident is later diagnosed with a mental illness or intellectual disability then a request for a clinical review for PASRR level II must be submitted to Maximus so the resident can be re-evaluated. V12 stated the facility has never had this scenario before where a new diagnosis is added after the initial PASRR level I was completed. V12 stated if a resident receives a PASRR level I screen with a short-term approval it will specify the approval end date, which means if the resident remains in the facility past this end date, then the facility is supposed to request re-screening for PASRR level I/II via Maximus. V12 stated on the Maximus dashboard it will flag the resident as Update Needed for PASRR II, which lets the facility know the resident(s) who are getting ready to expire beyond the approval end date. V12 stated she could see the residents flagged as needing PASRR level II, but she was not able to request a re-screening via Maximus because she did not have access to do so. V12 stated she called Maximus today to find out why she does not have access to request a PASRR level II screening and Maximum was able to give her access as of today. V12 stated prior to today the residents with PASRR level I with short term approval were not being rescreened by Maximus for PASRR level II. V12 stated she submitted screenings for R1, R35, R55, and R99 as of today, 03/05/25. V12 stated she was not aware of R83 or R136 needing to be screened for PASRR level II due to mental illness diagnosis added. V12 stated PASRR evaluations are important, so the facility understands the resident's diagnosis, can provide the level care and services required for the resident and to make sure the resident is appropriate for a nursing home placement. R35, R55, R99's Maximus PASRR Outcome Explanation - Notice of Short Term Nursing Facility Approval documents in part, this determination allows you a limited number of days in a Medicaid-certified nursing facility. The short term approval will end on the Date Short Term Approval Ends listed on the Notice of PASRR Level II Outcome and if you or your care provider thinks you need to stay after that date, a nursing facility staff member must submit a new Level I screen to Maximus. The new Level I screen must be submitted no later than 10 days before the Date Short Term Approval Ends.

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 interviews and record reviews, the facility failed to complete a quarterly smoking assessment for one resident (R1) and have individualized smoking care plans for independent smokers. This ha...

Read full inspector narrative →

Based on interviews and record reviews, the facility failed to complete a quarterly smoking assessment for one resident (R1) and have individualized smoking care plans for independent smokers. This has the potential to affect R1 and all the independent smokers in the facility. Findings include: R1's admission Record documents in part a diagnosis of nicotine dependence. R1's 12/18/2024 Minimum Data Set (MDS) Assessment documents in part that R1 is cognitively intact. On 3/04/2025 at 10:40 AM, R1 was in the smoking patio. R1 was holding a lighter and igniting other residents' cigarettes. At 10:43 AM, V29 (Psychosocial Aide) stated R1 is a smoker and smokes in the smoking patio. V29 stated R1 also volunteers to help other residents during smoke break by assisting residents into the patio and igniting their cigarettes. V29 stated R1 does this in front of staff and does not keep the lighter. At 10:48 AM, R1 stated [R1] typically smokes five to six cigarettes a day. R1 stated [R1] has been helping out during the smoke breaks for the past month by lighting other residents' cigarettes. R1's 11/13/2024 Smoking Risk Review Assessment documents in part that R1 is a smoker and has had no smoking behaviors since admission. R1 may independently handle smoking materials at the time of the assessment. Facility did not provide a more recent Smoking Risk Review Assessment for R1. No recent assessment related to handling smoking materials or R1's ability to safely ignite other residents' cigarettes. R1's comprehensive care plan did not contain a focus on R1's nicotine dependence or smoking habit. On 3/05/2025 at 2:18 PM, V2 (Director of Nursing) stated that staff should conduct Smoking Risk Review Assessments on the residents at least quarterly. V2 also stated the facility does not care plan residents for smoking if the residents are compliant with the smoking policy and do not require supervision. On 3/06/2025, facility provided a list of independent smokers consisting of 53 residents. The Independent list included R1, R8, R44, R85, R129, and R168. These residents did not have smoking care plans. R61's 1/22/2025 Smoking Risk Review Assessment documents in part that R61 is a smoker and can independently handle smoking material. R61 also did not have a smoking care plan. Facility Smoking Safety Policy (undated) documents in part: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. Smokers will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. Policy does not include how often staff should conduct these assessments. Facility's Care Plan policy (rev 2/15/2024) documents in part: All residents will have comprehensive assessments and an individualized plan of care developed to assist them in achieving and maintaining their optimal status. The Interdisciplinary Team develops a comprehensive, individualized care plan based on interdisciplinary team assessments and comprehensive assessment of the resident prior to the care conference. Concerns, problems, needs, and/or strengths are listed based on resident's individual needs. All concerns, problems, needs and/or strengths have a corresponding goal. The format for a goal is who, what, how, and when. Goals are resident oriented, specific problem-oriented goals relative to medical and nursing diagnosis, realistic, measurable, and directed towards increased functional levels. All interdisciplinary Team departments are responsible for charting that reflects the care plan concerns, problems, needs and/or strengths, approaches, progress or lack of progress with possible reasons for and any new problems.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to label open insulins for 4 [R36, R282, R283, R284] re...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to label open insulins for 4 [R36, R282, R283, R284] residents on 2 of 8 medication carts reviewed for medication storage in a sample of 35. Findings Include, On 3/4/25 at 9:12 AM, V7 [Licensed Practical Nurse] and surveyor conducted inventory of the second-floor south medication cart observed the following: A plastic open cup with [28] dark green pills. R36's open vail of Basaglar Kwik Pen, inject 12 units at bedtime. R283's Lantus (Glargine Insulin) Pen, inject 20 units one time per day. A label on the pen Refrigerate. [Pen was in top drawer of med cart] R284 's Humalog, inject per sliding scale, before meals and at bedtime. R282's Insulin NPH Isophane and Regular Subcutaneous 70/30, inject 12 units in the morning. On 3/4/25 at 9:20 AM, V7 stated, This morning I did not have any iron supplement pills on my medication cart available. I borrowed from the north cart. The facility has house stock, but I was trying to pass out my morning medications. On 3/4/25 at 9:30 AM, V6 [Assistant Director of Nursing] stated, All medication should be in its original bottle with the appropriate label and dated with the open date. All insulins should be dated when opened. On 3/4/25 at 9:38 AM, V5 [Licensed Practical Nurse] and surveyor conducted inventory of the second-floor north medication cart observed the following: R155's Lantus (Insulin Glargine) inject 30untis, one time per day. R285's Humalog [Insulin Lispro] inject 14 units, three times per day. On 3/5/25 at 1:22 PM, V2 [Director of Nursing] stated, All insulins vail, and pens are to be labeled at the time they are open. The label should include the date opened and discontinue date. If the insulins are not labeled, it can potentially cause adverse reactions, and ineffectiveness of the medication that can harm a resident. The nurse should never borrow medication from another resident. The facility has an emergency Insulin box to retrieved needed insulin. Policy documents in part: Medication Administration Policy Medications supply to one resident may not be administered to another resident. Multi-use [NAME] must be dated when opened. Medications must be administered in accordance with the physician's order act their discretion the right resident right medication right dosage right route and right time.

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 prepare food items listed on menu for pureed diets and prepare adequate food portions as documented on the recipe. This failur...

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to prepare food items listed on menu for pureed diets and prepare adequate food portions as documented on the recipe. This failure has the potential to affect 165 residents receiving pureed and regular diets prepared in the facility's kitchen based on the diet order list dated 03/04/25. Findings Include: On 03/04/25 at 12:00 PM, observed lunch tray line. Regular diets were receiving Sweet and Sour Chicken, Steamed Rice, and Oriental Vegetables. Pureed diets were receiving Pureed Sweet and Sour Chicken, Mashed Potatoes, and Pureed Spinach. V19 (Cook) stated she did not make pureed rice and the pureed diets were receiving mashed potatoes in place of pureed rice. On 03/04/25 at 12:54 PM, surveyor tasted pureed vegetable which was spinach. There was no spinach in the Oriental vegetables. On 03/04/25 at 12:59 PM, V17 (Dietary Manager) stated the pureed diets should have received pureed rice, not mashed potatoes based on the spreadsheets/menus. V17 stated the pureed diets should have received pureed oriental vegetables, not pureed spinach. V17 stated the pureed diets should be getting the same food as the regular diets except in pureed form. V17 stated this is important for menu variety and dignity. On 03/05/25 at 11:58 AM, V23 (Registered Dietitian) stated the cook should be following the spreadsheets and serving the items listed. V23 stated residents on pureed diets should all be receiving the same food as the regular diets but in pureed consistency. V23 stated just because the residents are on pureed diets they should not be receiving anything different than the regulars. V23 stated this is important to provide menu variety and all residents should be receiving a variety of foods. V23 stated if the pureed diets are given mashed potatoes every day, they could get sick of them, and this could affect their intake. V23 stated the kitchen should not be using left over vegetables for the purees, and the purees should have received pureed Oriental vegetables like everyone else. On 03/05/25 at 11:30 AM, V19 stated each resident will receive one slice of ham which is equivalent to 3-ounces for lunch. V19 stated the kitchen does not have a slicer, so she had to hand cut all the ham into 3-ounce slices and the slices did not come out uniform because the knives they have in the kitchen are not the best, so it was difficult to get a clean cut of the ham. Surveyor could see that none of the slices of ham were uniform in thickness and some of the slices of ham were very thin. On 03/05/25 at 11:32 AM, surveyor asked V19 to weigh a randomly selected slice of ham from the prepared sheet pan. Using an industrial scale that had been tared to zero the 1st slice of ham weighed 2.5 ounces. Surveyor asked V19 to weigh a 2nd slice of ham and this slice of ham weighed 1-ounce. Surveyor asked for a 3rd slice of ham to be weighed and this slice of ham was 2-ounces. On 03/05/25 at 12:25 PM, as surveyor was leaving the kitchen observed lunch tray line in progress. Observed V19 serving single slices of ham on each resident plate. On 03/05/25 at 11:56 AM, V23 (Registered Dietitian) stated the menus and recipes should be followed so the residents get the right amount of protein and if the kitchen is not following them the residents may not be getting the correct nutrition for the day. V23 stated this has the potential to make their diet nutritional inadequate. V23 stated if that continues to happen over time there is the potential for weight loss. Facility provided diet order list dated 03/04/25. Facility provide Diet Spreadsheet Day 3-Tuesday which listed in part for pureed diets to receive Pureed Sweet and Sour Chicken, Pureed Steamed [NAME] and Pureed Oriental Vegetables. Facility provided recipes titled, Pureed Buttered [NAME] and Pureed Cooked Vegetables using stir fry vegetables. Facility provided recipe titled Baked Ham which documented in part, portion size 3-ounces. Facility provided policy titled Standardized Recipes dated 2018 which documents in part, food will be prepared according to standardized recipes provided by the menu source. Facility provided [NAME] Job Description which documents in part, duties to prepared all food as planned on the cycle menu for the clients and follow standardized recipes in food preparation to ensure quality of foods prepared.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review, the facility failed to prepare ground/mechanical soft and pureed food in appropriate diet consistency form. This failure has the potential to affect ...

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to prepare ground/mechanical soft and pureed food in appropriate diet consistency form. This failure has the potential to affect 10 residents on mechanical soft/ground diets (R15, R19, R26, R36, R39, R60, R79, R81, R82, R95) and 8 residents on pureed diets (R68, R71, R84, R94, R106, R114, R115, R116) prepared in the facility kitchen based on list of residents receiving mechanical soft with ground meat and pureed diets dated 03/04/25. Findings Include: Facility had 10 residents on mechanical soft/ground diets and 8 residents on pureed diets. On 03/04/25 at 12:16 PM, observed V19 (Cook) portioning out food on the tray line. Observed large pan of Sweet and Sour Chicken and smaller container of pureed Sweet and Sour Chicken. V19 stated the regular diets and mechanical soft/ground diets are receiving the same entrée in the same form for lunch. V19 stated a separate ground Sweet and Sour Chicken was not prepared. V19 stated the chicken already comes in diced up. Observed multiple large chunks of chicken mixed in with smaller diced up pieces of chicken. On 03/04/25 at 12:54 PM, tasted Sweet and Sour Chicken and noted multiple large pieces of chicken which had to be broken up with a fork for surveyor to fit into mouth to taste. On 03/04/25 at 1:06 PM, V17 (Dietary Manager) observed the Sweet & Sour Chicken and stated the diced chicken does not have uniform sized pieces of chicken and there are some large pieces mixed in with smaller pieces. V17 stated the chicken in the Sweet & Sour Chicken should be ground for the mechanical soft diets. V17 stated the larger chicken pieces could be a potential choking hazard and that is why the chicken should be ground. On 03/05/25 at 10:50 AM, during pureed lunch food preparation observed the pureeing process for ham and V19 stated she uses a blender to puree the food and the consistency of the puree should be pudding like with no chunks or particles in it. V19 stated the overall consistency should be smooth like baby food and require no chewing. On 03/05/25 at 11:43 AM, observed V19 pureeing ham and adding broth and noticed the solids and liquids were separating instead of becoming emulsified into a cohesive product. V19 was using an older blender which did not seem to be working effectively. When V19 finished pureed preparation and the final product was portioned into a serving pan surveyor tasted the pureed ham. The final product was not pureed. The ham had large particles of ham that the surveyor had to chew before swallowing. On 03/05/25 at 11:45 AM, V17 tasted the pureed ham and stated the ham was not pureed enough and could not be served like that. On 03/05/25 at 12:00 PM, V23 (Registered Dietitian) stated reasons residents may be on a mechanical soft or ground diet is that they could have chewing problems. V23 stated ground/mechanical soft consistency should be like taco meat texture, not large chunks of regular meat. V23 stated the potential problem if a resident on a ground diet was to receive large chunks of chicken that was not ground is the residents may not be able to eat the food and it could potentially cause a resident to choke. V23 stated the chicken should be ground up not cut up or diced. V23 stated the reason a resident may be on a pureed diet could be swallowing or chewing issues. V23 stated the pureed consistency should be mashed potatoes, no chunks and cohesive meaning the liquids should not be separating from the solids. V23 stated the problem with serving a resident on a pureed diet food that is not pureed is that they could potentially choke. Facility provided [NAME] Job Description dated 2017 which documents in part, duties to prepare all food as planned on the cycle menu for the clients and prepare all foods for the clients on special diets as planned on the extended menus. Facility provided document titled Diet Spreadsheet Day 3-Tuesday which documents in part, for Mechanical Soft diets to serve ground Sweet and Sour Chicken with sauce. Facility provided recipe titled, Ground Sweet & Sour Chicken dated 2025 which documents in part, ingredients to use as diced ground chicken. Facility provided recipe titled Pureed Baked Ham dated 2025 which documents in part, blend until smooth and to achieve smooth, pudding or soft mashed potato consistency. Facility provided policy titled Mechanical Soft Diet dated 2017 which documents in part, food will be provided in a form designed to meet individual needs and unless otherwise indicated, meat and meat substitutes will be mechanically ground. Facility provided policy titled, Pureed/Dysphagia Diet undated which documents in part, food will be provided in a form designed to meet individual needs and whole food will be pureed in a blender or a food processor to a semi-solid consistency (i.e. the consistency of pudding-like) and standardized recipes for pureed food will be followed.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected multiple residents

Based on observations, interviews, and record reviews, the facility failed to provide double portions as part of the therapeutic diet as prescribed by the physician for 19 (R9, R17, R18, R23, R47, R78...

Read full inspector narrative →

Based on observations, interviews, and record reviews, the facility failed to provide double portions as part of the therapeutic diet as prescribed by the physician for 19 (R9, R17, R18, R23, R47, R78, R97, R98, R100, R107, R134, R136, R155, R164, R165, R174, R176, R232, R433) residents reviewed for dining services in a total sample of 35. Finding include: On 03/04/25 at 12:16 PM, during tray line observation observed V19 (Cook) portioning out food onto resident's trays for lunch. V19 stated the serving size for regular diets was 6-ounce ladle Sweet & Sour Chicken, #8 scoop (4-ounces) [NAME] Rice, and 4-ounce ladle Stir Fry Oriental Vegetables. V19 stated the residents with orders for double portions receive a double portion of the white rice (8-ounces total), and a standard portion of the Sweet and Sour Chicken (6-ounces) and Stir Fry Oriental Vegetables (4-ounces). V19 stated only the rice/starch is doubled, not the protein/main entrée or vegetables. On 03/04/25 at 12:17 PM, observed V19 portion out food for double portion diets based on their meal tickets for R47, R97, R134, R174 which consisted of 6-ounces Sweet and Sour Chicken, 8-ounces white rice and 4-ounces Stir Fry Oriental vegetables. On 03/05/25 at 12:06 PM, V23 (Registered Dietitian) stated a double portion order is a therapeutic diet if it is ordered by the physician. V23 stated residents may have orders for double portions to give them more calories to promote weight gain and there are some residents who have that order because it is a food preference for more food. V23 stated double portions for the meal means everything on the plate should be doubled. V23 stated yesterday the residents on double portions should have received double the standard portion for the protein, starch and vegetable. V23 stated if this is not what the residents received that means the diet order is not being followed. V23 stated maybe that is why the residents are still hungry and asking for more food after meals. Facility provided list of residents with diet orders dated 03/04/25 including those with orders for double portions. Facility provided policy titled, Transmitting Diet Orders to Food and Nutrition Services dated 2017 documents in part, clients are served their diets as ordered. Facility provided policy titled, Double/Large Portion dated 2017 which documents in part, double portions are served as double serving of food on the plate.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: (1) provide eligible residents and/or resident representatives edu...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: (1) provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations; (2) assess eligibility and offer pneumococcal vaccinations to five (R61, R85, R156, R44, R332) of five residents reviewed for pneumococcal vaccinations; (3) update the facility's Pneumococcal Screening and Immunization policy to reflect the recent Centers for Disease Control and Prevention (CDC) Adult Vaccination Schedule and guidance. This had the potential to affect any residents eligible to receive the Pneumococcal vaccinations. Findings include: 1. Review of R61's electronic health record (EHR) revealed R61 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included, but not limited to diabetes mellitus, alcohol abuse, cerebral infarction, and hyperlipidemia. R61's minimum data set (MDS) dated [DATE] shows R61 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15. R61's smoking risk review dated 1/22/25 shows R61 is a smoker. R61's EHR revealed no documentation indicating the facility assessed R61's eligibility to receive the pneumococcal vaccination and/or that R61 was provided education related to the pneumococcal vaccination. 2. Review of R85's EHR revealed R85 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included, but not limited to chronic obstructive pulmonary disease, essential hypertension, and hyperlipidemia. R85's MDS dated [DATE] shows R85 is cognitively intact with BIMS of 15. R85's smoking risk review dated 2/17/25 shows R85 is a smoker. R85's EHR revealed no documentation indicating the facility assessed R85's eligibility to receive the pneumococcal vaccination and/or that R85 was provided education related to the pneumococcal vaccination. 3. Review of R156's EHR revealed R156 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included, but not limited to psychoactive substance abuse and psychosis. R156's MDS dated [DATE] shows R156 is cognitively intact with BIMS of 15. R156's smoking risk review dated 1/1/25 shows R156 is a smoker. R156's EHR revealed no documentation indicating the facility assessed R156's eligibility to receive the pneumococcal vaccination and/or that R156 was provided education related to the pneumococcal vaccination. 4. Review of R44's EHR revealed R44 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included, but not limited to chronic diastolic heart failure, cirrhosis of liver, hyperlipidemia, alcohol dependence, and chronic obstructive pulmonary disease. R44's MDS dated [DATE] shows R44 is cognitively intact with BIMS of 14. R44's smoking risk review dated 12/9/24 shows R44 is a smoker. R44's EHR revealed no documentation indicating the facility assessed R44's eligibility to receive the pneumococcal vaccination and/or that R44 was provided education related to the pneumococcal vaccination. 5. Review of R332's EHR revealed R332 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included, but not limited to type 2 diabetes mellitus, hyperlipidemia, and essential hypertension. R332's MDS dated [DATE] shows R332 is cognitively intact with BIMS of 15. R332's EHR revealed no documentation indicating the facility assessed R332's eligibility to receive the pneumococcal vaccination and/or that R332 was provided education related to the pneumococcal vaccination. During an interview with V2 (Director of Nursing/Infection Preventionist) on 3/5/25 at 11:36 AM, V2 stated that the corporate nurse was responsible for updating the facilities policies and procedures related to infection control including immunization policies. V2 stated pneumococcal consents and education are only provided to certain residents if they are above [AGE] years old and immunocompromised. V2 stated if a resident is under [AGE] years of age, pneumococcal consent and education will not be provided because they are not eligible to receive the vaccine. Review of Facility Policy: Immunizations dated 9/14 documents in part: Usually only one dose of pneumococcal vaccine is administered however, a second dose is recommended for those people aged 65 or older who got their first dose when they were under 65, if 5 or more years have passed since that dose. This second dose should only be given based on an assessment and practitioner recommendation. Each resident or the resident's representative will receive education regarding the benefits and potential side effects of pneumococcal immunization. Each resident over the age of 65 is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized. The facility's policy did not reflect the CDC's Pneumococcal Vaccination guidance and did not include information on recommended doses of PCV15, PCV20 or PCV21.

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 ensure a.) kitchen staff wearing appropriate hair covering, b.) hand washing was being done in between handling dirty and ...

Read full inspector narrative →

Based on observations, interviews, and record reviews, the facility failed to ensure a.) kitchen staff wearing appropriate hair covering, b.) hand washing was being done in between handling dirty and clean dishes/equipment, c.) food items were properly labeled and dated. These failures have the potential to affect all 175 residents receiving food prepared in the facility's kitchen. Findings include: On 03/04/25 at 9:10 AM, upon entering the kitchen to conduct initial kitchen tour observed V18 (Dietary Aide) working in the dish machine area by himself. A hairnet was covering his head however V18 had a full mustache that was not covered. V18's mustache was extending over his top lip. On 03/04/25 at 9:15 AM, V17 (Dietary Director) stated everyone who enters the kitchen must wear a hairnet to cover their hair on their head. V17 stated beard/mustache coverings do not need to be worn in the kitchen and that facial hair does not need to be covered, only the hair on someone's head needs to be covered. V17 stated the purpose of wearing a hairnet is to prevent hair from falling into the prepared food and served to the residents. On 03/04/25 at 12:00 PM, observed V18 working on the lunch tray line. V18 was still not wearing any hair protector to cover V18's mustache. On 03/04/25 at 12:10 PM, observed V21 (Dietary Aide) walking around the kitchen filling up water pitcher with ice from the ice machine only wearing a hairnet on his head. V21 had a mustache and beard which were not covered with a hair restraint. V21 stated he was never told or asked to cover his beard or mustache before. On 03/04/25 at 12:45 PM, observed V18 and V21 walking around the kitchen wearing face masks. On 03/04/25 at 01:10 PM, V17 stated when she pulled the policy on hair restraints it said that facial hair should be covered so she told the male staff to cover their beards/mustaches with a face mask until she can order beard protectors for them to wear. On 03/04/25 at 9:10 AM, observed V18 feeding dirty trays into the dish machine and then pulling the cleaned trays out of the dish machine without performing any hand hygiene in between handling the dirty and cleaned items. On 03/04/25 at 9:17 AM, observed V18 putting dirty plates into the dish machine and then removing the cleaned plates from the dish machine and stacking the plates in a pile. No hand hygiene was performed in between handling the dirty and cleaned items. On 03/04/25 at 9:20 AM, V17 stated the dish machine area typically has two people working in there with one staff scraping and feeding the dirty items into the dish machine and the other staff pulling out the cleaned items from the machine once they are cleaned. V17 observed V18 working in the dish room putting soiled items into the dish machine and pulling the cleaned items out of the dish machine without performing any hand hygiene. V17 stated after V18 feeds the dirty items into the dish machine he should be changing his gloves, washing his hands, and putting on new gloves before pulling the cleaned items out of the dish machine. V17 stated this is important because she does not want V18 transferring bacteria and other pathogens from his dirty gloves or hands to the cleaned items. V17 stated this could potentially make the residents sick and proper hand hygiene is important for infection control to minimize potential illness which could spread throughout the facility. On 03/04/25 at 9:25 AM, V17 stated any prepared or opened food should be wrapped in plastic and a sticker should be added which has the prepared/opened date and use by date/expiration date of the product and stored in the refrigerator. V17 stated prepared items should be used within three days; all other items used within seven days except for condiment items which are good for 30 days. V17 stated it is important to label and date the items with open and use by dates so that the staff knows if an item(s) is safe to use. V17 stated if the item is opened but not labeled with an open/use by date then the staff would not be able to know who long the item has been in the refrigerator. On 03/04/25 at 9:27 AM, in Prep Refrigerator observed the following: 1.) Opened one-gallon Italian Dressing delivered 02/01/25. There was no open or use by date on the product. 2.) Opened 46-ounce container of Thickened Apple Juice from Concentrated Moderately Thick with no opened or use by date on it. On 03/04/25 at 9:32 AM, in Walk-In Refrigerator observed the following: 1.) Opened plastic bag of Shredded Cheddar and Monterey [NAME] Cheese wrapped in plastic. Not labeled with an open or use by date. 2.) Opened five-pound Sliced American Yellow Cheese wrapped in plastic. Not labeled with an open or use by date. 3.) Container of prepared chili like material covered in tin foil. Not labeled with an open or use by date. 4.) Container of diced tomatoes with a label documenting a preparation date 02/03/25 and a use by date 02/10/25. On 03/04/25, facility provided list of diet orders for all residents in the facility. The diet order list indicates there are not any residents nothing by mouth (NPO). Facility provide policy titled, Hair Restraints/Jewelry/Nail Polish/False Eyelashes dated 2017 documents in part, food and nutrition service employees shall wear hair restraints and beard guards and hairnets will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated. Facility provided policy titled, Dish Room Safe Food Handling dated 2017 documents in part, potential for cross-contamination is prevented in the Dish Room and the task of loading the dirty dishes and utensils into the dishwashing machine is handled by one person. The task of removing the clean dishes and utensils from the dishwashing machine is handled by a different person. If there is only one person working in the dish room, the person will remove their gloves, 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 provide policy titled Labeling and Dating Food documents in part, foods prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality of product for the residents and minimize waste and foods prepared on the premises to be held cold will be labeled with the date of preparation and this food will also be labeled with the date to discard or use by date. The discard/use by date will be a maximum of 6 days after preparation.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review, the facility failed to follow their linen handling policy and procedure to ensure soiled linens are properly placed inside closed plastic bags with n...

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to follow their linen handling policy and procedure to ensure soiled linens are properly placed inside closed plastic bags with no loose items. This failure has the potential to affect all 175 residents residing in the facility reviewed for infection control. Findings Include: On 3/5/25 at 1:46 PM, Surveyor inspected the facility's laundry chute with V30 (Laundry Aide). When V30 opened the laundry chute, loose soiled and dirty incontinence pads, towels, and bed sheets were found that were not inside a plastic bag. V30 stated that staff should be bagging dirty soiled linens and clothing before dropping them in the laundry chute. V30 stated it's not sanitary to drop them in the chute without properly bagging them. On 3/5/25 at 1:54 PM, V2 (Director of Nursing/Infection Preventionist) stated that staff should properly place dirty and soiled linens inside a plastic bag and make sure the bag is securely closed before dropping them in the laundry chute to keep from spreading bacteria. V2 stated that if soiled dirty linens are not properly bagged, biohazard materials could get on things that it should not get on. It could contaminate other things that would negatively affect the staff and residents. The facility's LINEN AND LAUNDRY HANDLING FOR LAUNDRY DEPT policy dated 10/14 documents in part: To ensure proper handling of soiled and clean linen and personal laundry to prevent the spread of microorganisms. Every effort will be made to ensure that soiled articles do not come into contact with the floor, uniforms, furniture, or other areas deemed clean. Soiled linens shall be placed in plastic bags by nursing personnel. The facility's residents' roster printed on 3/4/25 shows a total of 175 residents residing in the facility.

Feb 2025 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to protect a resident from physical abuse. This failure affec...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R1) of 4 residents reviewed for physical abuse. This failure resulted in R2 physically attacking R1, resulting in R1 bleeding from an abrasion R1 sustained under the left eye and R1 being transferred to the hospital for evaluation and treatment. Findings include: Facility's Final Investigation Report (dated 02/03/2025) documents in part: On 01/27/2025, the facility administrator was notified by a facility nurse that resident R2 was physically aggressive towards resident R1. R1 was noted to have an abrasion under her left eye for which care was provided by her assigned nurse. Both residents' representatives were notified of the reported incident along with the resident's physician and the police. R2 refused to be interviewed and left the facility against medical advice. R1 was interviewed and stated that R2 has become verbally and physically aggressive towards her for no reason. R1 stated that R2 struck and grabbed her prior to pushing her out of their shared room. R1 was sent to the hospital for safety precautions. Abuse Prevention Program Facility Policy (dated 2011) documents in part. The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property corporal punishment and involuntary seclusion. This will be done by identifying occurrences and patterns of potential mistreatment, immediately protecting residents involved in identifying reports of possible abuse. R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Chronic obstructive pulmonary disease with (acute) exacerbation, heart failure, hypotension, insomnia, shortness of breath, abdominal distension (gaseous). Minimum Data Set Section (MDS) section C (dated Jan. 1, 2025) documents that R1 has a Interview for Mental Status (BIMS) score of 14, indicating that R1's cognition is intact. Care plan (dated 12/18/2024) documents that R1 is at risk for alteration in comfort related to advanced disease process, chronic physical disability. R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: schizoaffective disorder, bipolar type, unspecified psychosis not due to a substance or known physiological condition, anemia, bipolar disorder, altered mental status. Minimum Data Set Section C (dated Dec. 12, 2024) documents that R2's Brief Interview for Mental Status (BIMS) score is 14, indicating that R2's cognition is intact. Care plan (dated 01/14/2025) documents that R2 displays behavioral symptoms related to: Severe mental illness, poor and/or ineffective coping skills. These behavioral symptoms are manifested by verbal abuse/aggression, and disturbed sense of entitlement. On 02/06/2025, at 10:13 AM, V1 (administrator) stated, On 01/27/2025, it was reported to me that there was a loud commotion coming from R1 and R2's room. R1 and R2 were roommates at the time. V3 (registered nurse) went down the hallway to see what was going on. He explained to me that he saw R2 throw/push R1 from their bedroom into the hallway. V3 immediately intervened and escorted R1 to the nurse's station. V3 called the nursing supervisor and the nursing supervisor called me. We called the family; the physician and we called the police. The nursing supervisor went to speak to R2. R2 was informed that the police were called. R2 was notified that she would be petitioned and sent out to the hospital. R2 said that she refused to be sent to the hospital. R2 signed herself out against medical advice and left the facility. R1 said that R2 attacked R1 for no reason. V3 said that it appeared like R2 was going through some psychosis issues because R2 was acting bizarre and making weird statements that did not make sense. This could be the possible reason why she attacked R1. R1 had an abrasion under her eye. R1 said that R2 hit her, grabbed her and pushed her out of the room. R1 was kept safe away from R2. R1 was sent out to the hospital because she had an abrasion under her eye, and we were not sure if R2 hit R1 on the head. R1 is frail and R2 was of bigger frame, so that was an advantage over R1. On 02/06/2025, at 11:31 AM, during an interview with R1, surveyor observed an abrasion under R1's left eye, which appeared to be healing. R1 stated, On 01/27/2025, R2 was my roommate at the time. I was sitting on my bed, watching tv and doing puzzles. R2 said to me, B**** it's my room get out. Then R2 started attacking me. R2 started hitting me on my face and on my head and pulled my hair. R2 was beating me, and I fell to the floor. Then R2 grabbed me by my hair and called me names. R2 pulled me into the hallway by my hair. R2 went back into the room and slammed the door. The nurse came and asked me what happened. The nurse went into the room to talk to R2. The nurse gave me gauze to wipe my face and the nurse took me to the nursing station and called the social worker. My family, the physician and the police were notified. I was sent to the hospital because I was bleeding. I had a cut under my eye. I was examined in the hospital, and I received a tetanus shot just in case due to the scratches. R2 attacked me for absolutely no reason. I never provoked R2 in any way. R2 and I never had any issues in the past prior to the physical attack. I want to press charges against R2 but she left before the police came and now they cannot find her. On 02/06/2025, at 2:39 PM, V3 (registered nurse) stated, On 01/27/2025, R2 came and told me that she wanted to change rooms because she did not like her roommate. When I asked R2 what her issue was with her roommate, R2 said that she did not have to explain herself to me. I told her that social services handled room changes and since it was still relatively early, she can still talk to social services. R2 did not want to do that and said to me, What if I go in there and beat the woman up. I told her that she should not do that because then I would have to call the police. She left to go to her room, and she came back a short while later and called her mom. R2 started to complain to her mom that she was mad at her roommate and that she was going to do something to her roommate. R2 slammed the phone and went to her room and started knocking things down to the floor on her way to her room. I figured that she was going to do something to her roommate because R2 was upset. I got on the phone with social services to let them know that there is an incident possibly brewing and that the social worker needed to come up. In the middle of that phone call, I heard yelling and commotion in R1 and R2's room. I went to the room, and I saw R2 tossing R1 out of the room. R2 tossed R1 into the hallway with a lot of force, holding R1 by her pants. I separated R1 and R2 by getting in between them. Social services came up also and I took R1 by the nursing station. I tended to R1's laceration under her left eye because it was bleeding. R2 left against medical advice from the facility before the police got there. R1 was sent to the hospital for evaluation for the laceration under her eye. R1's Progress Note (dated 01/27/2025) documents, While on the phone with social services at start of this incident. Writer heard yelling coming from the residents' room. Writer went to the room and saw R1's roommate holding her by her hair and back of her pants tossing her out into the hallway. Writer stood between the two residents to prevent further assault until social services arrived. Residents separated; vitals taken. R1 stated she did not hit her head. A small 1 centimeter laceration was noted under the left eye. Writer dressed the wound with gauze. There was minor bleeding. R1 was medicated with Tylenol for pain. R1's Progress Note (dated 01/28/2025) documents, Received report from nurse at community hospital. CT scan done, no fracture. Laceration treated. Awaiting to transport resident back to facility. R1's Progress Note (dated 01/28/2025) documents, Resident has a laceration to left eyebrow, resident will receive wound care. Physician notified; new orders carried out. R2's Progress Note (dated 01/27/2025) documents, R2 came to nursing station complaining that she wanted a new room because she did not like her roommate. Writer informed her that social services handled all room changes and she could consult with them as they had not left for the day. She got increasingly upset and wanted something done now. Writer asked the resident what the issue was. R2 stated I don't have to explain anything to you. Writer informed her again that social services can help her. She then stated; What if I just go beat her a**. Writer informed the resident that would be a bad idea because of the possibility of police involvement and expulsion from the facility. R2 came back to nursing station and called her mother telling her that she was going to attack her roommate. She began pushing items off the counter and knocking CNA's (Certiified Nursing Assistant) belongings on the floor on her way back to her room. Writer called social services to inform them of the situation and impending issue. While on the phone with social services, writer heard yelling and items falling coming from residents' room. Writer went to room and saw R2 holding her roommate by her hair and back of her pants tossing her out into the hallway. Writer stood between the two residents to prevent further assault until social services arrived. The residents were then separated. R2 was in the care of social services. R2 chose to sign out AMA (Against Medical Advice). Family stated to call her when R2 returns. Received police report number. Resident gone when Chicago Police Department & EMS Arrived. R1's emergency room Patient Discharge Summary (dated 01/28/2025) documents in part: Chief complaint/diagnosis: Assault. Discharge diagnoses: Acute head trauma/ Acute knee pain.

Dec 2024 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one resident (R1) out of 9 from physical abuse. This failur...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one resident (R1) out of 9 from physical abuse. This failure affected R1 who was pushed in the elevator by R8. As a result, R1 had an unwitnessed fall, R1 was sent to a local hospital. R1 sustained a left lateral tibial plateau fracture approximately 1mm (One millimeter) depression and small joint effusion. Findings include: R1's medical record admission record showed documentation that R1 was originally admitted to the facility on [DATE] with latest recorded admission date of 12/02/17. Listed diagnosis includes but not limited to Displaced fracture of lateral condyle of the left tibia, subsequent encounter to closed fracture with routine healing, type 2 diabetes mellitus without complications, muscle weakness (Generalized), paranoid schizophrenia, depression, unspecified fracture of shaft of left fibula initial encounter for closed fracture. R8's medical record admission Record showed that R8 original admission date as 08/22/2023 and latest admission date 11/02/2023 with diagnosis list that includes but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. Aphasia, weakness, unspecified abnormal of gait and mobility, furuncle of neck, restlessness, and agitation. On 12/16/24 at 11:45am R1 noted on the 1st floor of the facility ambulating around with a sit to stand roller walker. R1 was able to communicate in English as a second language. R1 was able to remember about what happened on 09/30/24 stating that one man pushed R1. R1 stated that I was next to the wall in the elevator (indicating that there was no other space to move in the elevator). R1 stated the man pushed R1 to the floor (Fall to the floor) and broke R1 leg. According to the facility Preliminary Incident Investigation Report dated 09/30/24. V1 (Administrator) documented that he (V1) was notified by a facility nurse that (R8) was physically aggressive towards (R1) in the elevator on the 4th floor. Both residents were checked for injuries. R1 was noted to have pain in the left knee. R1 was sent to the (hospital) for evaluation. V1 documented that R8 forcefully rolled into the elevator hitting R1 in the legs causing R1 to fall. R8 was interviewed and R8 stated that R1 would not let (R8) into the elevator and hit (R8). R8 stated R1 fell on (R1)'s own. V1 documented that (V10 Nurse) was interviewed and stated she did not see the altercation but heard yelling. V10 walked to the elevator and saw R1 on the ground complaining of knee pain. V1 documented that both resident (R1 and R8) files (medical Record) were reviewed. R1 was noted to have history of verbal aggression and R8 was noted to have history of verbal and physical aggressiveness. The report documentation showed that the local law enforcement (police) and both residents' physician was notified. Recording the incident as a simple battery. R1's hospital record dated 09/30/24 documented that R1's reason for visit patient (R1) here for L (left) knee pain s/p (status post) fall from wheelchair in the elevator 2 hrs PTA (Prior to Arrival) per patient (R1). R1's hospital record presented showed documentation that CT (Computer Tomography) left knee without contrast showed that R1 had lateral tibial plateau fracture approximately 1mm (One millimeter) depression and small joint effusion. On 12/17/24 at 10:00 am, when the surveyor asked about the conclusion of the incident of the incident of 09/30/24 and if this incident can be a form of abuse. V1 (Administrator) stated that yes, it is an abuse, I will consider that to be abuse. V1 stated that due to R8's history of being verbally and physically aggressive towards peers R8 was sent to the hospital for psych-eval and has not returned to the facility. On 12/17/24 at 10:08 am V2 DON (Director of Nurse's) who was present at this time stated it is a form of abuse because R8 pushed R1. On 12/17/24 at 12:38 pm, V10 (Licensed Practical Nurse) who identified self as the nurse in charge on the 4th floor at the time of incident on 09/30/24. V10 stated that Yes, I was passing meds (Medicines) on the 4th floor when I heard some noise between residents on the 4th floor elevator. I (V10) went to see what was happening. I (V10) saw (R1) on the floor in the elevator lying down on the floor inside the elevator. (R8) was in-between the entrance of the elevator, the elevator could not close. I (V10) asked what happened and R1 said R8 pushed her. So, I called the front desk (receptionist) to call social services and V1 (Administrator). After that I (V10) assessed R1 who was having lots of pain to the legs. I (V10) could not remember which leg, but I think is the left leg, I called 911 (emergency number). I (V10) called the guardian and R1 was sent to the hospital, R8 was also sent to the (local hospital) for psych-evaluation. The surveyor asked V10 in your professional opinion can this incident on 09/30/24 be considered a form of abuse, V10 stated Yes. On 12/18/24 at 12:07pm, V3 NP (Nurse Practitioner) stated that R1 had a fracture of the tibia. V3 stated in part that after the unwitnessed fall (R1) was complaining of left knee pain, so V3 sent R1 out (to the hospital). When asked whether in V3 medical professional opinion if R1's fracture occur due to the fall. V3 stated I do believe so. R1's falls/accident care plan initiated on 10/13/2028 and revision date 07/12/2022 showed that R1 is at high risk for fall. Goal documented that R1 will not sustain injury throughout the review date. Initiated date 10/13/2018, revision date 11/21/2024 and target date 02/05/2025. R1's MDS (Minimum Data Set) dated 11/07/2024 showed that R1 has a BIMS (Brief Interview for Mental Status) Score of 04. R8's plan of care initiated 03/26/2024 with revision date 04/01/2024 showed a focus documentation that R8 has history of being physically aggressive toward others when angry and due to poor impulse control. Goal is that R8 will not harm self or others through the review date initiated 04/01/2024, revised date 06/20/2024 and target date 12/29/24. The interventions listed includes but not limited to assisting verbalization of source of agitation and seeking out of staff member when agitated. R8's MDS (Minimum Data Set) dated 09/23/2024 showed that R8 has a BIMS (Brief Interview for Mental Status) Score of 11. The facility Abuse Prevention Program policy presented documented in part that the facility affirms the right of our residents to be free from abuse. this facility therefore prohibits mistreatment, neglect, or abuse of its residents. The facility is committed to protecting our residents from abuse by anyone including, but not limited to another resident. The policy documented in part that abuse means/ includes any physical injury or mental injury. Abuse is willful infliction of injury. Physical abuse is infliction of injury on a resident that occurs other than by accidental means.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer right dosage of a prescribed medication as ...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer right dosage of a prescribed medication as per physician order for one resident (R3,) out of three residents reviewed. This failure affected R3 who has a physician order to receive Ibuprofen oral tablet 800mg (milligrams) as needed every eight (8) hours for pain but was administered 600 mg instead with potential that R3's pain may not be controlled. Findings include: R3's medical record admission Record showed that R3 was admitted to the facility on [DATE]. Listed diagnosis includes but not limited to chronic obstructive pulmonary disease, bipolar disorder, Anemia, progressive vascular leukoencephalopathy and anogenital herpes viral infection. On 12/16/24 at 1:05pm, R3 was observed on the 4th floor at the nurse's station requesting for pain medication Ibuprofen from V13 LPN (Licensed Practical Nurse). V13 checked the order and proceeded to prepare the medication. V13 looked for the medicine it was unavailable. V13 found ibuprofen 200mg/tablet bottle from the facility house stock. V3 prepared three tablets and administered it to R3 when the surveyor brought this to V13, asking V13 to clarify the order with surveyor watching the R2's electronic medication order. V13 confirmed that that R3 is supposed to get 800 mg. V13 stated I don't know whether to give R3 all the 800 mg because it usually comes as one tablet and giving (R3) equivalent of 800 mg will be four tablets that is why I gave three tablets (600mg). On 12/16/24 at 1:08pm, The surveyor asked what the facility policy/protocol of medication administration is. V13 stated that the medication should be given to resident as ordered in ordered dose. V13 stated that the 800 mg has not been refilled since November 30th by the pharmacy. V13 stated we have been given R3 acetaminophen because R3 has orders for it too. The surveyor asked what the facility policy/protocol of medication administration is. V13 stated that the medication should be given to resident as ordered in ordered dose. V13 stated, that the 800 mg has not been refilled since November 30th, 2024, by the pharmacy. On 12/16/24 at 1:15 pm, V13 signed out R3's medication has been given 800 mg. R3 medical record Order Summary Report showed that R3 has order for Ibuprofen oral tablet 800mg give one tablet by mouth every 8 hours as needed (PRN) for pain with ordered date 11/30/23 and no end date. On 12/16/24 at 1:30pm, when this was brought to V2 DON (Director of Nurse's) attention and was asked about facility policy /protocol on medication administration. V2 stated in part the medications are to be administered according to physician order and the right dose should be administered. V2 stated that it is not acceptable for any nurse to take upon themselves to change the medication dosage without physician order. V1 (administrator) who was present at the time of interview and V2 then stated that V13 will be asked to add the remaining 200 mg to make 800 mg to control R3's pain. V2 stated that the pharmacy will also be notified to refill for 800 mg because it comes in one big pill because of the strength. On 12/18/24 at 12:00 pm, the surveyor asked V3 NP (Nurse Practitioner) if in her own professional opinion is it appropriate for a nurse to change medication dosage for the resident. V3 stated Not without an order from the physician. Facility policy on Ordering and receiving Non-Controlled Medications from the Dispensing Pharmacy presented with effective date 10/25/2014 documented that the policy is for medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. The facility policy on Medication Administration dated 8/15 presented documented that medications must be administered in accordance with physician's order at his /her discretion that includes but not limited to right dosage. The facility policy on Physician Orders dated 6/17 documented listed guidelines to ensure that the physician order includes but not limited any orders given by physician are carried out.

Oct 2024 3 deficiencies

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to follow proper sanitation in the kitchen to prevent food-borne illnesses; and failed to ensure that staff store their food and ...

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to follow proper sanitation in the kitchen to prevent food-borne illnesses; and failed to ensure that staff store their food and personal items out of the facility kitchen used for residents. These failures have the potential to affect all 177 residents receiving an oral diet in the facility. Findings include: On 10/15/24 at 12:40 pm, Surveyor and V3 (Dietary Manager) toured the facility's kitchen and observed poor cleaning all over the entire kitchen area (food on kitchen floor, trash on kitchen floor, soiled floors, soiled stagnant draining water, and dirty walls). V3 explained that is the entire kitchen staff responsibility to maintain cleanliness in the kitchen. Surveyor and V3 observed a staff coat hanging on the food rack in the dry storage area. When Surveyor asked V3 regarding the coat hanging in the clean utility area V3 stated, That is an employee coat. It (referring to the employee coat) should be in the locker room. That doesn't should not be in here. When V3 was asked regarding what could happen if sanitation is not kept in the kitchen and staff store their personal items where residents food are kept and V3 stated, Infection control. On 10/16/24 at 2:12 pm, Surveyor and V4 toured the facility kitchen and observed V24 (Dietary Aide) personal food items (fried chicken) in a brown bag and wrapped in aluminum foil stored on a cart near the pots and pan sink. V24 stated, I (V24) didn't have time to put it up (referring to V24's food in the brown bag in the kitchen). When V24 was asked what could happen if staff store personal food items in the kitchen and V24 stated, Bugs can come into the kitchen. On 10/17/24 1:27 pm, V22 (Housekeeping Director) stated that the housekeeping department does not clean in the facility kitchen. V22 stated that it is the responsibility of the kitchen staff to clean in the kitchen. The facility's undated policy and titled Sanitation and Safety Operations documents, in part: policy non refrigerated foods disposable dishware and other dry goods will be stored in a clean dry area which is free from contaminants. The facility's document dated 10/16/24 and titled Service Inspection Report documents, in part: Area Comments: Healthcare Combined: Kitchen Main Kitchen Area: poor cleaning all over kitchen and dish room area especially under dishwasher machine, behind washing racks, all corners under/behind equipment, stagnant water, broken tiles under sink/dishwasher, missing grout between towers, floor drains, dust pan and dirty mops and needs to be cleaned and fixed to eliminate breeding areas for fruit flies. The facility's undated policy and titled Infection Control For Food Service Covid 19 Prevention documents, in part: Policy: The facility stores, prepares, distributes and serves food in a sanitary manner to prevent foodborne illness, cross contamination and to assure infection control. The facility's job description document titled Food Service Director documents, in part: 2. Adheres to all sanitary and food safety regulations governing handling and serving of food . 14. maintains the department and regulatory compliance . 15. concerns his/herself with the safety of all center customers in order to minimize the potential for fire and accidents. Also ensures that the center adheres to legal, safety, health care health, fire, and sanitation codes by being familiar with his or her role.

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to ensure that the dumpster was closed and fee from overflowing trash. These failures have the potential to affect all 178 resid...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure that the dumpster was closed and fee from overflowing trash. These failures have the potential to affect all 178 residents residing at the facility. Findings include: On 10/15/24, V2 (Director of Nursing , DON) stated that the facility census was 178 residents at the facility. On 10/16/24 at 2:15 pm, Surveyor and V24 (Dietary Aide) toured the facility dumpster area and observed the dumpster area open with two broken lids and overflowing with trash. V24 stated, Someone broke this (referring to the broken dumpster lids). They (referring to garbage pickup) come and get the trash every other day. They (referring to garbage pickup) should be here today. When V24 was asked regarding who is responsible for the dumpster lids to be repaired V24 stated, V21 (Maintenance Director). When V24 was asked regarding the importance of the dumpster lids to remain close V24 stated, So that it (referring to the dumpster) does attract rodents to the facility. On 10/17/24 at 1:04 pm, V21 (Maintenance Director) stated that the dumpster is managed by V22 (Housekeeping). V21 stated that if the lids on the dumpster are missing or broken V21 is responsible for ensuring the dumpster lids are repaired or replaced. V21 stated that V21 don't dump garbage and garbage is left in front of the maintenance room so unless an issue is reported to V21 regarding the dumpster V21 don't see the dumpster area. On 10/17/24 1:27 pm, V22 (Housekeeping Director) stated that the dumpster area is maintained by the housekeeping staff. V22 stated that V22's department is responsible for ensuring the dumpster area is clean and free from trash/garbage around the dumpster. V22 stated that V22 was aware the dumpster lids have been missing from the dumpster area for about 2 weeks. When V22 was asked regarding what could happen if the dumpster lids are broken, missing, or remain open and V22 stated, If the dumpster is open it can increase rodents in the facility. V22 stated that V22 will call the number on the dumpster to repair the dumpster as soon as possible. The facility's policy dated 11/14 and titled Pest Control Policy documents, in part: Purpose: To prevent or control insects and rodents from spreading disease. Responsibility: Administrator, Environmental Service Director. Standards: . 16. Outside dumpster's shall be of sufficient size that the lid can be tightly closed. The container shall be stored on a smooth surface of nonabsorbent material. #17 the dumpster shall be kept clean and maintain in good repair. The facility's job description titled Environmental Services/Housekeeping Director documents, in part: Responsibilities/Accountabilities: 12. Concerns his/herself with the safety of all customers in order to minimize the potential for fire and accidents. Also, ensures that the center adheres to the legal, safety, health, fire, and sanitation codes by being familiar with his/her role in carrying out the centers fire, safety and disaster plans and by being familiar with current MSDS (Material Safety Data Sheet). The facility's job description titled Maintenance Director documents, in part: Job Summary: The maintenance director is responsible for the day-to-day activities of the maintenance department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility and maintained in a clean, safe, and comfortable manner. As the maintenance director you are delegated the administrative authority responsibility and accountability necessary to carry out your assigned duties. Essential duties and responsibilities: 2. Maintains the building and good repair and free of hazards such as those caused by electrical plumbing heating and cooling systems life safety etc. (etcetera) . 12. Maintains the building and grounds and compliance with federal, state, local, and Joint Commission laws and standards.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure that the facility's kitchen is free of insects. This failure has the pot...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure that the facility's kitchen is free of insects. This failure has the potential to affect all 178 residents in the facility. Findings include: On 10/15/24 at 12:40 pm, Surveyor and V3 (Dietary Manager) toured the facility's kitchen and observed poor cleaning all over the entire kitchen area (food on kitchen floor, trash on kitchen floor, soiled floors, dirty stagnant draining water, and soiled walls). Surveyor and V3 also observed an infestation of flies (fruit flies, gnats) throughout the kitchen in the food prep area where V18 (Dietary Aide) was preparing sandwiches for residents to eat and in the pots and pans area where V24 (Dietary Aide) placed pots and pans dishes that were cleaned. V3 stated that V3 sees flies infest the kitchen daily and that V3 has seen roaches in the kitchen near the pots and pans area. V3 stated that pest control last visited the kitchen about 2 weeks ago however the flies and roaches are still an issue in the kitchen. Surveyor also observed broken tiles under sink/dishwasher area, holes in the wall behind and underneath the food prep area and food cart storage area in the kitchen. V3 stated that V21 (Maintenance Director) was aware of the holes in the wall in the kitchen in need of repair. When V3 was asked regarding who is responsible for cleaning the facility's kitchen area V3 stated that all kitchen staff are responsible for cleaning the kitchen. When V3 was asked regarding what could happen if the kitchen is not kept clean and sanitation is not kept in the kitchen, V3 stated that the kitchen can become infested with rodents and insects. On 10/15/24 at 12:45 pm, Surveyor toured the kitchen and spoke with V13 (Dietary Aide), V14 (Dietary Aide), V15 (Cook), V16 (Dishwasher), V17 (Dietary Aide), V18 (Cook), and V19 (Dietary Aide) who all stated seeing roaches, fruit flies and gnats and the facility kitchen daily. On 10/16//24 11:38 am, V21(Maintenance Director) stated that V21 coordinates the pest control company visiting the facility with V1 (Administrator). V21 stated that pest control company should be checking and treating the kitchen for pest and rodents every time pest control visits the facility. V21 explained that staff from the kitchen should be reporting pest control concerns in the kitchen in the front desk pest control log. V21 also stated that V21 rounds with pest control sometimes if V21 is not tied up with another project in the facility. V21 stated that V21 has recently seen gnats and fruit flies in the kitchen and is unsure if pest control treated the issue and if the issue of flies in the kitchen is resolved in the kitchen. When V21 was asked regarding the holes in the wall in the kitchen in need of repair and V21 stated that V21 is aware and will repair the issue. When V21 asked regarding what could happen if a kitchen has holes in the walls and V21 stated that it can create and entry way for pest, insects, and rodents to entire the kitchen. On 10/16/24 at 2:10 pm, Surveyor and V3 toured the facility kitchen and observed a large dead insect on the floor in the dry storage room. V3 also stated that pest control treated the kitchen on 10/15/24 but did not treat all areas of the kitchen including the dry storage area during the pest control visit. V3 stated, I (V3) don't think they come in here when they (referring to pest control) visits the kitchen. On 10/17/24 1:27 pm, V22 (Housekeeping Director) stated that the housekeeping department does not clean in the facility kitchen. V22 stated that it is the responsibility of the kitchen staff to clean in the kitchen. The facility's document dated 09/24/24 and titled Service Inspection Report documents, in part: Area Comments: Healthcare Combined: Kitchen dish room: Poor cleaning all over dish room area especially under dishwasher machine, behind washing racks and all corners, stagnant water, broke titles and leaks need to be cleaned and fix to eliminate breeding areas for German roaches. The facility's document dated 10/16/24 and titled Service Inspection Report documents, in part: Area Comments: Healthcare Combined: Kitchen Main Kitchen Area: poor cleaning all over kitchen and dish room area especially under dishwasher machine, behind washing racks, all corners under/behind equipment, stagnant water, broken tiles under sink/dishwasher, missing grout between towers, floor drains, dust pan and dirty mops and needs to be cleaned and fixed to eliminate breeding areas for fruit flies. The facility's undated policy and titled Infection Control For Food Service Covid 19 Prevention documents, in part: Policy: The facility stores, prepares, distributes and serves food in a sanitary manner to prevent foodborne illness, cross contamination and to assure infection control. The facility's job description document titled Food Service Director documents, in part: 2. Adheres to all sanitary and food safety regulations governing handling and serving of food . 14. maintains the department and regulatory compliance . 15. concerns his/herself with the safety of all center customers in order to minimize the potential for fire and accidents. Also ensures that the center adheres to legal, safety, health care health, fire, and sanitation codes by being familiar with his or her role. The facility's job description document titled Dietary Aide documents, in part: Position Summary: the dietary aid performs a variety of food service functions and maintaining clean and sanitary conditions of food service areas, facilities, and equipment. Responsibilities accountabilities . 12. Maintains cleanliness and sanitation through entire work areas . 13. performs daily or scheduled cleaning duties, in accordance with established policies and procedures, scrubs and mops doors, cleans and sanitizes equipment . 14. empties trash contains regularly. The facility's policy dated 11/14 and titled Pest Control Policy documents, in part: Purpose: To prevent or control insects and rodents from spreading disease. Responsibility: Administrator, Environmental Service Director. Standards: 1. The Environmental Services Director will be responsible for coordinating the facility pest control program. 3. The pest control program will be conducted on a regular and as needed basis. 5. Employees are instructed to promptly report all observations of pest to their department heads. 9. All building openings shall be tight -fitting and free of breaks. 10. The facility shall be kept in such conditions and cleaning procedures used to prevent the harborage or feeding of insects and rodents. 11. Floors, and wall finishes in the food preparation, storage and utensil washing areas, walk-in refrigerator units, dressing rooms, lockers, toilet which may be washed and cleaned.

Jul 2024 2 deficiencies

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

Based on observation, interview and document review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents and staff on 4 of 5 resident floors (2nd, 3rd,...

Read full inspector narrative →

Based on observation, interview and document review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents and staff on 4 of 5 resident floors (2nd, 3rd, 4th, and 5th floors) of the facility. Findings include: The following was observed during tour of facility on 7/5/24 with V3 (Housekeeping staff). R6's room was observed with extensive wall damage at the wall/floor junction on all 4 walls. R7's toilet room was observed with heavy ceiling plaster damage on entire ceiling. The plaster was wet and had black mold. The plaster/drywall was sagging . On 7/5/24 at 10:22AM R7 stated it has been in that condition for a long time. R8's room was observed with plaster wall damage at the floor/wall junction next to the window. R10's room was observed with extensive plaster wall damage at the floor/wall junction on all 4 walls. R1's room was observed with wet and collapsing plaster damage above the room window at the ceiling wall junction. The plaster had black mold like growth on the surface. Walls of room had drywall damage on all 4 walls. R20's room was observed with falling plaster damage at the wall / ceiling junction above the window. R21's room was observed with extensive wall damage at the floor wall junction on all 4 walls, the wall behind bed was plaster damaged. The wall ceiling above room window was plaster damaged. On 7/6/24 at 10AM V1 (Administrator) stated I am aware of the wall damage in the facility. The wall damage was caused by leaking air conditioner units, leaking showers and leaking toilets. I have a maintenance crew of 3 staff that are presently working on repairs. Air conditioning units are being replaced. Showers are being recaulked. These repairs are ongoing. On 7/7/24 V1 (Administrator) was requested to provide a maintenance policy that includes maintaining walls/ceilings of residents rooms. V1 provided the following. Facility policy titled Preventative Maintenance & Inspections states including: 1. Policy Guidelines In order to provide a safe environment for residents , employees , and visitors , a preventative maintenance program has been implemented to promote the maintenance of equipment in a state of good repair and condition. C. Inspections 1 A schedule is developed to delineate all inspections that are to be completed on a regular basis. Inspections verify that all equipment and furnishings are in working order and free from safety hazards. 4 Building inspections included the following : Heating and air conditioning systems Mechanical equipment & ventilation ducts. Doors-electronic, patient rooms, stairwells. Interior hallways and common areas Resident/patient rooms.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility fails to maintain an effective pest control program so that the...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility fails to maintain an effective pest control program so that the facility is free of insects and rodents on 5 of 6 floors of the facility. Findings include: The following was observed during tour of facility on 7/5/24 with V3 ( Housekeeping staff). R9's room was observed with a live adult roach on the floor in the toilet room. R12's room was observed with a rodent glue board on floor of outside wall, the glue board had 3 dead adult roaches attached. Mouse droppings were observed in the corner of floor next to the window. On 7/5/24 at 10:37AM R12 stated there are roaches and mice in our room all the time. R13's room mouse droppings in the toilet room on the floor. R15's room mouse droppings on the floor in room. Two dead roaches on the floor in the toilet room. On 7/5/24 at 10:55AM R15 stated there are mice and roaches in my room at night. I don't like them in here. R18's room was observed with 4 adult roaches on the floor behind the bedside cabinet next to bed. On 7/5/24 at 11:25AM R18 stated there are a lot of roaches in my room. They came in here and tried to cover the holes. But there are still roaches. R22's room was observed with 1 live adult roach on the floor near the bed. On 7/5/24 at 11:05AM R16 stated there are little roaches in my room at night all the time. On 7/5/24 at 11:15AM R17 stated there are roaches and mice in our room mostly at night. On 7/5/24 at 1:15PM R3 stated there were roaches in our toilet room two days ago. My room mates and I see roaches all the time. On 7/5/24 at 11:50AM V5 (Cook) stated we have a roach problem in the dietary area. In the dietary food prep area in basement 5 adult roaches were observed under the dishwasher countertop on the wall behind 2 inch copper water pipes. 3 adult roaches were observed under the 3 compartment sink countertop. In the dietary dry food storage room in basement 1 adult roach was observed on the floor under storage shelf. Mouse droppings were observed under the storage shelf in corner of room. In the laundry service soiled linen storage room [ROOM NUMBER] adult live roach was observed on the floor. On 7/6/24 at 9:47AM V1 (Administrator) stated I do not know why the pest control service reports have not been showing any sightings of roaches and mice. I keep a binder on each floor for residents and staff to report sightings of rodents and insects. I myself have been seeing roaches on the floors and have made reports to the pest control service. I train my staff in monitoring for pests in the facility. On 7/6/24 at 11:29AM R23 (Resident Council President) stated the residents have been complaining of roaches and mice in the building . The residents are sick and tired of the roaches and mice. Some say they see big rats in the building on the 2nd floor. This information was brought up at the last resident council meeting. The residents have also been complaining about all the wall damage and leaks in the residents rooms. They stated sometimes facility staff come in room and just throw some plaster over the wall and leave it that way. They never finish and paint the walls. Facility policy titled Pest Control Policy states Purpose : To prevent or control insects and rodents from spreading disease. Responsibility : Administrator, Environmental Services

May 2024 8 deficiencies

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that 5 residents (R2, R5, R77, R114 and R137) h...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that 5 residents (R2, R5, R77, R114 and R137) have clean and sanitary bathrooms, failed to ensure that an incontinent brief was properly disposed for 1 resident (R18) and failed to ensure that 1 resident (R76) has a screen in the bedroom window. This failure affected a total of 7 residents reviewed for resident's rights to enjoy a safe and clean homelike environment, in a total sample of 65 residents. Findings include: On 5/13/24 at 10:24am, this surveyor observed human feces on the wall in R2's, R5's and R114's bathroom. On 5/13/24 at 10:25am, R5 said, Oh honey, the bathroom is always messy. Sometimes there is poo on the toilet seat too. It's just terrible. R5's Face Sheet documents, in part, diagnoses of unspecified dementia, heart failure, hyperlipidemia, schizoaffective disorder and bipolar disorder. R5's Minimum Data Set, dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 09 which indicates that R5 is moderately cognitively impaired. On 5/13/24 at 10:25am, R2 said, Tell me about it. There's poop all over the bathroom. It's not mine. It's gross. R2's Face Sheet documents, in part, diagnoses of heart failure, hypertension, hyperlipidemia, schizophrenia and bipolar disorder. R2's Minimum Data Set, dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 11 which indicates that R2 is moderately cognitively impaired. R114 was not able to be interviewed. R114's Face Sheet documents, in part, diagnoses of hyperlipidemia, schizoaffective disorder, unspecified dementia and hypertension. R114's Minimum Data Set, dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 00 which indicates that R114 was unable to complete the interview. On 5/13/24 at 10:37am, This surveyor observed human feces on R77's and R137's bathroom wall. On 5/13/24 at 10:38am, R137 said, That's probably my only issue with this place. Is they (facility staff) need to clean better. At least clean the shit up in my bathroom. It's disgusting. R137's Face Sheet documents, in part, diagnoses of type 2 diabetes, hemiparesis and hemiplegia, hyperlipidemia and anemia. R137's Minimum Data Set, dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 13 which indicates that R137 is cognitively intact. R77 was not able to be interviewed. R77's Face Sheet documents, in part, diagnoses of type 2 diabetes, hyperlipidemia, schizoaffective disorder, anxiety disorder and anemia. R77's Minimum Data Set, dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R77 is cognitively intact. On 5/13/24 at 10:48am, this surveyor inquired about the brown substance on the wall in R2's, R5's and R114's bathroom. V6 (Licensed Practical Nurse/LPN) replied, That's stool! I'll get someone to clean that up right away! On 5/13/24 at 10:51am, this surveyor inquired about the brown substance on the wall in R77's and R137's bathroom. V6 replied, Oh Lord! You know what that is! More stool again! That's a housekeeping issue. I'll get someone to clean that up right away! I'm sure the residents are not happy with this. On 5/15/24 at 11:09am, V11 (Housekeeping Supervisor) stated, Housekeeping is responsible for cleaning the resident's bathrooms. If there is poo on the walls of the resident's bathroom or on the resident's toilet seat, it is also housekeeping's responsibility to clean that. Facility policy title, Housekeeping Guidelines, dated 2/14, documents, in part, Purpose: To provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors . Housekeeping personnel shall adhere to daily cleaning assignments developed so to maintain the facility in a clean and orderly manner .All horizontal surfaces will be cleaned daily and as needed with an approved disinfectant. Facility Policy title Resident Rights, dated, 11/18, documents, in part, To provide an environment of care that supports a positive self image . The right to an environment that preserves dignity and contributes to a positive self image. Facility job description title, Job Description Position Title: Environmental Services/Housekeeping Director, undated, documents, in part, The Director supervises a variety of activities in housekeeping and laundry in maintaining the center in an orderly, clean, and sanitary condition. Facility job description title, Job Description Position Title: Housekeeper, undated, documents, in part, The Housekeeper ensures that the center is maintained in a clean and sanitary condition at all times to provide for care and welfare of the customers in a healthful environment. In addition, he/she ensures that good housekeeping services are performed in every department of the center and are planned in cooperation with the department head. Facility job description title, LPN Job Description, undated, documents, in part, Ensure assigned work areas and resident rooms are maintained in a clean manner. Findings include: R18's admission diagnoses includes but not limited to bipolar, schizoaffective disorder, depression, and multiple sclerosis. R18's (4/17/24) BIMS (Brief Interview of Mental Status) score is 15. Functional Status for toileting hygiene and personal hygiene requires substantial/maximal assistance. Mobility: wheelchair. Walk coded a 9 (Not applicable- Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury). On 5/13/24 at 10:30 am, surveyor entered R18's room and a foul smell was noticed. Surveyor observed a soiled incontinent brief with a brown substance inside the brief on a flat linen sheet lying on the floor. R18 stated that the CNA (Certified Nursing Assistant) came in to change me and took the brief off and put it on the floor. She said she was coming back but didn't come back. Surveyor inquired to R18, how does that make you feel, the CNA leaving the room and not coming back? R18 stated, Well, it does not make me feel good about it. I don't like smelling feces. I do not want to smell it. If I could walk, I would put it in the garbage myself. On 5/13/24 at 10:38 am, Surveyor requested for V19 LPN (License Practical Nurse) to come into R18's room. V19 saw the soiled incontinent brief on R18's floor. V18 stated, This is not acceptable. Where is the aide? Surveyor inquired to V19 if this is the practice here at the facility to throw a soiled incontinent brief on the floor instead of disposing it properly? V19 stated, This is not the practice here and is not acceptable. On 5/13/24 at 10:45 am, V21 CNA (Certified Nursing Assistant) stated, I left the diaper on the floor. I was supposed to get a bag and I got sidetracked and started doing something else. Surveyor inquired to V21 if leaving an incontinent brief on the floor is acceptable? V21 stated, No it is not acceptable to leave it on the floor, On 5/15/24 at 11:47 am, V2 DON (Director of Nursing) stated, Staff should have all their supplies with them when they are giving incontinent care on the residents. Surveyor inquired to V2 if it is the facilities practice throwing a soiled incontinent brief on the floor? V2 stated, It is not the facilities practice throwing a soiled incontinent brief on the floor. It is not acceptable. Facility policy (11/18) titled Resident Rights documents in part, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: ee. The right to an environment that preserves dignity and contributes to a positive self-image. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Facility policy (9/14) titled Incontinency Care documents in part, Procedure: 9. Place soiled cloths in linen hamper bag . Potentially infectious or biohazardous waste will be handled and disposed of in accordance with all appropriate regulations. Facility's undated job description titled Certified Nursing Assistant documents in part, Infection Control: ., no soiled linen or bags on floors. Provide privacy and dignity with care. Facility undated job description titled LPN (License Practical Nurse) documents in part, Essential Duties and Responsibilities: 1. Directs the day-to-day functions of the Nursing Assistants. 22. Make multiple daily rounds on your shift to ensure acceptable standards are met. 38. Ensure assigned work areas and resident rooms are maintained in a clean manner. Findings include: R76's Brief Interview for Mental Status (BIMS) dated shows that R76 has a BIMS score of 15 which indicates that R76 is cognitively intact. R76 has a diagnosis which includes but not limited to: Obesity, major depressive disorder, generalized anxiety, paranoid schizophrenia and essential hypertension. On 05/13/24 at 11:05 am, Surveyor observed R76's room with the window open about six inches and without a window screen. Surveyor observed five flies flying in R76's room. R76 stated that R76 did not know how long R76's window has been without a window screen. On 05/14/24 at 1:27 pm, Surveyor observed R76's room remain with the window open about six inches and without a window screen. Surveyor observed five flies still flying in R76's room. On 05/15/24 at 9:35 am, V17 (Maintenance Director) stated that all residents windows should have a window screen. V17 explained that windows screens are in place to prohibit flies and other insects from entering the resident's window. V17 then explained that the residents should have the luxury of opening the window in the resident's room without concerns of insects such as flies getting into the residents' room. V17 stated that V17 is responsible for ensuring that every resident's window has a window screen and that V17 would place a window screen in R76's room window. The facility's job description titled Maintenance Director documents in part: Job Summary: The Maintenance Director is responsible for the day-to-day activities of the Maintenance Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility and maintained in a clean, safe and comfortable manner. As the Maintenance Director you are delegated the administrative authority, responsibility, and accountability necessary to carry out your assigned duties. Essential Duties and Responsibilities: Including the following, other duties may be assigned. 1. Performs overall supervision of the Maintenance Department including hands-on performance of maintenance and repair work. 2. Maintains the building in good repair and free of hazards such as those caused by electrical, plumbing, heating and cooling systems, life safety etc. The facility's job description titled Maintenance Assistant documents, in part: Position Summary: The Maintenance Assistant provides a variety of standard and unskilled tasks in the maintenance and repair of center grounds and facilities. Responsibilities/Accountabilities: 2. Maintains the building grounds in a clean, safe, and orderly condition . 5 Makes minor repairs on handrails, windows, flooring walls, ceiling, beds, wheelchairs, Geri-chairs (geriatric chairs), electrical equipment, sprinkling systems, generators, emergency lighting, fire alarms and extinguishers, changes filters on HVAC (heating, ventilation, and air conditioning) equipment, carriers, lifts and stocks supplies.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

Findings include: Census on the second floor is 40 residents. On 5/13/24 at 11:40 am, Surveyor observed laundry/linen chute on the 2nd floor unlocked. Surveyor inquired to V23 CNA (Certified Nursing A...

Read full inspector narrative →

Findings include: Census on the second floor is 40 residents. On 5/13/24 at 11:40 am, Surveyor observed laundry/linen chute on the 2nd floor unlocked. Surveyor inquired to V23 CNA (Certified Nursing Assistant) if the linen chute should be locked? V23 CNA tested the linen chute and saw it was not locked and could not lock the chute. V23 CNA stated, It normally is locked. I don't know what's wrong with it. It should be locked. Based on observation, interview, and record review, the facility failed to ensure that the laundry chute in the hallway of the second floor and the fourth floor, are locked to prevent residents from falling through the chute to the ground floor. This failure has the potential to affect all 40 residents on the second floor, and all 44 residents on the fourth floor, reviewed for safety from environmental hazards. Findings include: On 5/13/24 at 11:15am after the entrance conference, V1 (Administrator) presented the facility census as 163 residents as follows: Second Floor - 40, Third Floor - 37, Fourth Floor - 44, Fifth Floor - 42. On 5/13/24 at 10:59am on the fourth-floor hallway, the laundry/linen chute was observed to be unlocked. V15(CNA/Certified Nurse Assistant) was called to see the linen chute. V15 stated It's supposed to be locked for the protection of the residents, so no one will fall and hurt themselves. I used it this morning and it's always likes this. I don't have a key and cannot lock it. I will call maintenance. On 5/13/24 at 11:05am, V17(Maintenance Director) came to the fourth floor and stated It cannot lock. I have to replace the latch that comes through here and replace the cylinder. Yes, the cylinder comes with a key. On 5/14/24 at 12:55pm, V17 stated I put a lock on it. I did the same thing for the second floor also. So, all the floors now have locks for the chutes. I did in-service for the staff to always lock the chute. On 5/13/24 at 1:10pm, V1(Administrator) was notified of this and stated that he(V1) would ask Maintenance to fix it because We don't want any resident to fall through. Facility's policy on supervision and Safety dated 3/15. This policy states: Our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility-wide priorities. #2 states: Safety risks and environmental hazards are identified on an ongoing basis through employee training conducted upon hire, annually and as needed.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0741 (Tag F0741)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to have sufficient Psychiatric Rehabilitation Services Coordinators/PRSC to meet the individualized psychosocial and mental heal...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to have sufficient Psychiatric Rehabilitation Services Coordinators/PRSC to meet the individualized psychosocial and mental health needs of residents. This failure has the potential to affect all 49 residents with diagnoses of Severe Mental Illness and other residents in the facility who require psychosocial support. Findings include: On 5/13/24 at 11:15am after the entrance conference, V1 (Administrator) presented the facility census as 163 residents as follows: Second Floor - 40, Third Floor - 37, Fourth Floor - 44, Fifth Floor - 42. V1 later presented the list of 49 residents with diagnoses of Severe Mental Illness (SMI). On 5/13/24 between 10:30am and 12pm, residents including R47, R58, and R83 were observed just sitting in the room with flat affect. R47, R58, and R83 all stated that they have not spoken with any Counselor or PRSC in a while. Nursing staff, including V9(Licensed Practical Nurse, LPN) and V15(CNA/Certified Nurse Assistant) were observed and interviewed on the fourth floor regarding the availability of social services staff to speak with residents individually. V9 stated that the social worker/PRSC was not there on the floor. On 5/14/24 at 8:55am, V18(PRSC) was asked how many PRSCs work in the facility and how many residents were on the case load for each PRSC. V18 stated that's he is the only PRSC for the morning shift and another PRSC is supposed to come for the afternoon shift. Inquired from V18 if V5 (Social Services Director/PRSD - Psychiatric Rehabilitation Services Director), was available in the building. V18 stated that V5 will not be here today but would be here tomorrow. Inquired from V18 how only one PRSC in the building right now will be able to meet the psychosocial needs of the residents. V18 stated that he (V18) is responsible for all residents on the 2nd floor and 4th floor (approximately 84 residents) while the other PRSC that comes for the afternoon shift is responsible for the third floor and 5th floor (approximately 79 residents). On 5/14/24 at 10am, V1(Administrator) expressed the concerns that only one PRSC was available in the building and the other PRSC would only come in the afternoon shift. Inquired from V1 if the afternoon shift PRSC would come at 12 noon, V1 stated that this PRSC turned in a resignation letter and 5/15/24 was supposed to be her last day at the facility. The surveyor asked V1 how the PRSD and one PRSC can provide psychosocial services to 163 residents. V1 stated that they had advertised the positions and made efforts to hire more PRSCs to meet the needs of the residents. On 5/15/24 at 11:45am, V5 (Social Services Director/PRSD - Psychiatric Rehabilitation Services Director), was interviewed regarding the individualized mental health services the facility provides for residents. V5 stated that they encourage residents to attend groups and that they are trying to hire psychiatric rehabilitation services coordinators/PRSCs, and someone was interviewed already. The surveyor inquired from V5 how many PRSCs the facility is trying to hire. V5 stated that the facility is trying to hire 2 or 3 PRSCs. At this time, V5 presented a list of 49 residents with diagnoses of Severe Mental Illness (SMI). Facility's undated document titled Psychiatric Rehabilitation Service Coordinator (PRSC) under Responsibilities states in part: #A: To provide the resident with a stable therapeutic relationship. This includes welcoming the new resident, providing support, establishing a trusting relationship, and initiating the assessment process. #E: To provide and /or coordinate the delivery of the psychiatric rehabilitation services programs; #F: To monitor the resident in the areas of self-directed care and for overall compliance with the treatment plan. #6 states to provide active listening with individuals on the assigned case load. The PRSC needs to establish a good rapport with residents and be available to provide behavioral intervention/counseling. Facility's document titled Administrative Code Section 300.4090, #C) 5) states in part: There shall be a PRSC for each 30 participants.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to label an opened multi dose vial and discard an expired...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to label an opened multi dose vial and discard an expired opened multi dose vial. These failures have the potential to affect all 44 residents on the 4th floor and all 42 residents on the 5th floor, potentially affecting a total of 86 residents at the facility reviewed for labeling and storage of drugs and biologicals. Findings include: On [DATE] at 9:56am, with V9 (Licensed Practical Nurse/LPN), during observation of medication storage on the 4th floor, a house stock vial of Tuberculin PPD (purified protein derivative) was observed opened with no label of when it was opened. The tuberculin label states that once opened discard after 30 days. When asked the purpose of labeling the Tuberculin PPD once opened, V9 (LPN) replied, Because it expires 30 days after opening so the test may not be accurate. On [DATE] at 10:07am, with V10, (LPN), during observation of medication storage on the 5th floor, a house stock vial of Tuberculin PPD was opened with an open date of [DATE]. The house stock vial of Tuberculin PPD is more than 30 days passed the open date. The tuberculin label states once opened discard after 30 days. When asked about the opened date on the house stock vial of Tuberculin PPD, V10 replied, The open date on the vial says [DATE]. It's definitely over 30 days since the vial has been opened. I am going to report it to the DON (Director of Nursing) and throw it out because it isn't good anymore. On [DATE] at 1:47pm, V2 (Director of Nursing/DON) stated Tuberculin PPD vials should be dated once opened. Once it hits 30 days toss it. It's expired after opening after 30 days and you can't use it. V1, Facility Administrator, presented document title, (Facility) Midnight Census report [DATE], stating that there are 44 residents on the 4th floor and 42 residents on the 5th floor. Facility policy title, Medication Administration Policy, dated 8/15, documents, in part, Multi-use vials and house stock liquids must be dated when opened. Facility policy title, MEDICATION PASS: PROCESS AND PROCEDURE, dated 2/14, documents, in part, NOTE: Date when opened if house stock. Facility Policy title Resident Rights, dated, 11/18, documents, in part, To provide an environment of care that supports a positive self image . The right to an environment that preserves dignity and contributes to a positive self image. Facility job description title, LPN Job Description, undated, documents, in part, Ensure an adequate supply of house stock medications, equipment and supplies Make multiple daily rounds on your shift to ensure acceptable standards are met. Facility job description title, Director/Assistant Director of Nursing Job Description, undated, documents, in part, Ensure that adequate supplies are readily available .Ensure that stock level of medications, medical supplies, equipment, etc. is maintained on premises at all times to adequately meet the needs of the resident.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include: On 5/13/24 at 10:18am, this surveyor observed a droplet precautions sign on R8's bedroom door with PPE (Person...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include: On 5/13/24 at 10:18am, this surveyor observed a droplet precautions sign on R8's bedroom door with PPE (Personal Protective Equipment) available hanging on R8's bedroom door. R8's Face Sheet documents, in part, diagnoses of unspecified dementia, anemia, schizophrenia and Alzheimer's Disease. R8's Minimum Data Set, dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 00 which indicates that R8 was unable to complete the interview. R8's Care plan, review date of 5/13/24, documents, in part, (R8) is at higher risk for infection secondary to presence of needed wound care for chronic wound. Resident will receive enhanced barrier precautions during care. On 5/13/24 at 10:48am, this surveyor inquired about the droplet sign on R8's bedroom door. V6 (Licensed Practical Nurse/LPN) said, That's for R8 and her (R8) wound but she (R8) is not on droplet, she (R8) is on enhanced barrier. The wrong sign is up. I'll (V6) get that fixed right away. On 5/13/24 at 10:41am, this surveyor observed an enhanced barrier sign on R22's bedroom door with no PPE (Personal Protective Equipment) observed readily available for the staff. R22's Face Sheet documents, in part, diagnoses of metabolic encephalopathy, pressure ulcer of sacral region, chronic obstructive pulmonary disease with (acute) exacerbation and schizophrenia. R22's Minimum Data Set, dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 13 which indicates that R22 is cognitively intact. R22's Care plan, date initiated 4/22/24, documents, in part, (R22) is at higher risk for infection secondary to presence of needed wound care for chronic wound. Resident will receive enhanced barrier precautions during care through next review. Wear PPE during high contact resident care activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs/toileting etc On 5/13/24 at 10:48am, this surveyor inquired about the PPE for R22's room. V6 (LPN) said, There should be PPE available for enhanced precautions. I'm not sure why it's not there. It needs to be there to prevent infections from spreading. I'll ensure we get the PPE supplies that hang on the door. Facility Policy title Resident Rights, dated, 11/18, documents, in part, To provide an environment of care that supports a positive self image . The right to an environment that preserves dignity and contributes to a positive self image. Facility job description title, LPN Job Description, undated, documents, in part, Make multiple daily rounds on your shift to ensure acceptable standards are met. Based on observation, interview and record review the facility failed to you provide appropriate Personal Protective Equipment (PPE) supplies for two residents (R22 and R86) with Enhance Barrier Precautions; and failed to display Enhance Barrier Precaution sign for one resident (R8). This failure affected all 37 residents on the third floor and all 42 residents on the fifth floor reviewed for infection control. Findings include: On 05/13/24 V1 (Administrator) presented a facility census of 37 residents on the third floor and 42 residents on the fifth floor at the facility. On 05/13/24 at 10:26 am, R26, R33 and R86's room was observed with a sign displayed Enhanced Barrier Precautions . Providers and Staff must also wear gloves and 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: central lines, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing Surveyor observed R86 with a urinary catheter leg bag adhered to R86's left leg. Surveyor did not observe Personal Protective Equipment (PPE) supplies available for R26, R33 and R86 room that was available for staff use. On 05/13/24 at 11:44 am, Surveyor brought this observation to V2 (Director of Nursing, DON) and V2 stated, Every Enhanced Barrier Precaution room should have PPE supplies for staff to use. They (referring to staff) must have taken it down. It was one up there (referring to the PPE door supplies). R86 requires Enhanced Barrier Precautions because R86 has a catheter (referring to R86's urinary catheter). On 05/14/24 at 1:25 pm, Surveyor observed an Enhanced Barrier Precaution sign on R26, R33 and R86's room door and R26, R33, and R86's room door without PPE supplies available for staff to use. On 05/14/24 at 2:23 pm, V2 stated that V22 (Central Supply) is responsible for ordering and stocking Personal Protective Equipment (PPE) for residents' rooms. V2 explained that V2 provides V22 with a list of residents on Enhanced Barrier Precautions every day and that V22 restocks PPE supplies every morning at the facility for residents who require Enhanced Barrier Precautions. When V2 was asked regarding the importance of residents with Enhanced Barrier Precautions to have PPE supplies for staff to use, V2 stated, Its mainly for the staff to protect the resident with enhanced barrier precautions. On 05/15/24 2:30 pm, V22 (Central Supply) stated that V22 receives a list from V2 every other day with the list of residents who require supplies for Enhanced Barrier Precautions. V22 stated that V22 does not provide the isolation sleeve on the front of the resident's doors. V22 stated that V22 only provide the PPE supplies to be placed inside of the isolation sleeve on the residents' doors that require Enhanced Barrier Precautions. When V22 was asked regarding R86's missing PPE supplies for staff use on 05/13/23 and 05/14/24, V22 stated, I (V22) did not get the updated list showing R86 has Enhanced Barrier Precaution until today. The facility's undated document titled Enhanced Barrier Precautions shows that R86 has Enhanced Barrier Precautions at the facility. R86's Brief Interview for Mental Status (BIMS) dated 02/07/24 shows that R86 has a BIMS score of 10 which indicates that R86 has some cognitive impairments. R86 has a diagnosis which includes but not limited to: Hematuria, unspecified vision loss, and acute kidney failure. R33's Brief Interview for Mental Status (BIMS) dated 05/113/24 shows that R33 has a BIMS score of 0 which indicates that R33 is cognitively impaired. R33 has a diagnosis which includes but not limited to acute kidney failure, dementia, encounter for fitting and adjustment of urinary device. R26's Brief Interview for Mental Status (BIMS) dated 02/14/24 shows that R26 has a BIMS score of 09 which indicates that R26 has some cognitive impairments. R26 has a diagnosis which includes but not limited to dementia, asthma, chronic kidney disease and centrilobular emphysema. The facility's undated document titled Infection Control Policy/Procedures documents, in part: General Infection Control: Purpose: To establish methods and criteria, necessary within the facility and its operation, to prevent and control infections and communicable diseases. Responsibility: All employees and Quality Assurance Committee. Policy: It is the policy of this facility to maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to prevent or eliminate, when possible, the development and transmission of disease and infection . Selection /Use of Personal Protective Equipment (PPE) Purpose: Personal protective equipment (PPE) is an essential element in preventing the transmission of disease-causing microorganism. If used correctly PPE will fail to prevent transmission and may facilitate the spread of disease. Appropriate PPE will also protect staff from exposure . Enhanced Barrier Precautions: Purpose: Recommendation from CDC (Center for Disease Control) to protect residents from multidrug resistant organisms (MDROs). Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precaution. Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of acquiring MDRO. R86's Care plan dated 04/22/24 documents in part: Focus: R86 is at high risk for infection secondary to presence of needed catheter care related to (r/t) indwelling catheter. Goal: R86 will receive enhanced barrier precautions during care through next review. PPD (PPE) to be worn during high contact activities: gown and gloves, and shield when risk of splash is present (i.e., emptying a catheter, working with feeding tubes, etc.) . Wear PPE during high contact resident care activities: dressing, bathing, transferring, changing linens, providing hygiene, changing brief s/toileting etc. R86's Physician Order Sheet (POS) dated 04/17/24 Change Indwelling (Catheter (18) FR French with (10) CC (cubic centimeter) balloon every 3 months, every 3 months (s) starting on the last day of month for 84 day (s) related to Obstructive and reflux uropathy, unspecified.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

Findings include: On 5/13/2024 at 10:25am arrived on the fourth floor, observed the fourth-floor dayroom with chipped areas of paint on the walls in the dayroom. On 5/13/2024 at 10:59am observed the...

Read full inspector narrative →

Findings include: On 5/13/2024 at 10:25am arrived on the fourth floor, observed the fourth-floor dayroom with chipped areas of paint on the walls in the dayroom. On 5/13/2024 at 10:59am observed the vents in the ceiling of the fourth floor coated with a black substance. On 5/14/2024 at 2:44pm V17(Maintenance Director) stated there is patching on the walls on each floor of the building. V17 stated the entire building needs painting. V17 stated that is dust on the vents in the ceiling. V17 stated housekeeping should be wiping the vents clean. V17 stated painting the facility may make the residents feel better about living here. Findings include: R9's Brief Interview for Mental Status (BIMS) dated 03/27/24 shows that R9 has a BIMS score of 15 which indicates that R9 is cognitively intact. R9 has a diagnosis which includes but not limited to chronic obstructive pulmonary disease, acute kidney failure, anxiety, and immunodeficiency. R43's Brief Interview for Mental Status (BIMS) dated 03/20/24 shows that R43 has a BIMS score of 14 which indicates that R43 is cognitively intact. R43 has a diagnosis which includes but not limited to bipolar disorder, anxiety, contusion of unspecified part of head sequela and insomnia. On 05/13/24 at 10:34 am, R9 and R43's bathroom was observed with the bathroom light not functional and unable to provide light for R9 and R43's bathroom. R9 stated that the bathroom light bulb has been broken a long time. On 05/14/24 at 11:340 am, R9 and R43's bathroom was observed with the bathroom light still not functional and unable to provide light for R9 and R43's bathroom. On 05/15/24 at 9:43 am, V17 (Maintenance Director) stated that V17 is responsible for checking the lighting in the residents' rooms and bathrooms. V17 stated that it is important for the residents to have functioning lighting in the residents' bathrooms so that the residents won't fall and can see a clear pathway while using the bathroom area. V17 stated that V17 rounds every day to inspect the building for lighting fixtures that require replacing. The facility's job description titled Maintenance Director documents in part: Job Summary: The Maintenance Director is responsible for the day-to-day activities of the Maintenance Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility and maintained in a clean, safe and comfortable manner. As the Maintenance Director you are delegated the administrative authority, responsibility, and accountability necessary to carry out your assigned duties. Essential Duties and Responsibilities: Including the following, other duties may be assigned. 1. Performs overall supervision of the Maintenance Department including hands-on performance of maintenance and repair work. 2. Maintains the building in good repair and free of hazards such as those caused by electrical, plumbing, heating and cooling systems, life safety etc. Based on observation, interview, and record review, the facility failed to ensure that the community shower room on the fourth-floor is maintained in a sanitary manner and in good repair, and failed to ensure that the fifth-floor bathroom and day room are kept in good repair. These failures have the potential to affect all 44 residents on the fourth floor and all 42 residents on the fifth floor. Findings include: On 5/13/24 at 11:00am after the entrance conference, V1 (Administrator) presented the facility census which shows that there are 44 residents on the fourth floor and 42 residents on the fifth floor. On 5/13/24 at 10:50am during observation of residents on the fourth floor, the community shower room was observed to be locked. V16 (Housekeeper) was asked to open the shower room. Together with V16, the surveyor observed the following: The toilet water tank was partially covered with a smaller cover that has brown stains that left about one-third of the tank open; The only shower stall in the shower room has blackish brown substance on the wall tiles closer to the front left corner; The bath-tub faucet is non-functional and no water came out of it when inspected; The closet in the shower room has filthy clothes on the floor which V16 stated belong to the residents; There was a chrome color large rod on the floor of the shower room. The clean utility room has a bag of clothes on the floor which V16 states belong to some residents. The fourth floor Maintenance Log Sheet dated 5/1/24 to 5/13/24 does not show that staff reported these issues for Maintenance Staff to see on the Log Sheet. On 5/13/24 at 11:05am, V17(Maintenance Director) was called to the fourth floor and shown the above issues. V17 stated The only thing we can do is to power-wash the mold on the wall and use grout. On 5/15/24 at 11:09am, V11 (Housekeeping Supervisor) was interviewed regarding the housekeeping issues on the fourth floor. V11 stated there was one housekeeper scheduled for 7am-3pm shift for the fourth floor, and he(V11) works on the second floor. V11 added that the housekeepers are supposed to clean the shower rooms. Facility's Housekeeper job description states in part, under Position Summary: The housekeeper ensures that center is maintained in a clean and sanitary condition at all times to provide for care and welfare of the customers in a healthful environment. Facility's Job Description for Maintenance Director states in #6: Coordinates daily maintenance services with nursing services when performing maintenance assignments in residents' living and recreation areas. #8: Assures that maintenance work schedules are followed as closely as practical. The facility did not follow these guidelines.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review the facility failed to ensure food in the refrigerator and freezer was labeled with a date indicating when the item was placed into the refrigerator/f...

Read full inspector narrative →

Based on observation, interview and record review the facility failed to ensure food in the refrigerator and freezer was labeled with a date indicating when the item was placed into the refrigerator/freezer, a thermometer was inside of the freezer, and expired food was discarded on or before the expiration date. These failures have the potential to affect 163 residents in the facility who are receiving an oral diet. The findings include: On 5/13/2024 at 9:17am while in the walk-in refrigerator, observed 1 box of chicken base cups- the date on the box was unreadable. On 5/13/2024 at 9:20am surveyor checked the thermometer on the outside of freezer; temperature reading of minus 3 degrees. Surveyor asked V8 (Dietary Manager) to locate the thermometer inside of the freezer. V8 stated there is no thermometer in the inside of the freezer. V8 stated, yes there should be a thermometer in the inside of the freezer. V8 stated a thermometer is needed inside of the freezer to have an accurate temperature inside of the freezer just in case the thermometer on the outside of the freezer goes out or breaks. On 5/13/2024 at 9:36am while inside the freezer surveyor observed a box labeled 5/2/23 Emergency Only Do Not Touch. The box contained 1 bag of frozen seasoned mashed potatoes with no expiration date on the bag. V8 (Dietary Manager) stated I have not checked the date of this (referring to the box and bag of mashed potatoes inside the box), I have glanced over this box. On 5/13/2024 at 9:39am while inside the freezer surveyor observed the following items not labeled with a date the items were stored in the freezer: a box of 48 pizza puffs, 1 two-pound box of chicken breast patties and 6 full turkeys in a plastic bin. On 5/13/2024 at 9:40am while inside the freezer observed a box of Thick and Easy Shaped Pureed frozen foods, the box was labeled 5/24/2023 and the use by date on the product containers inside the box was 1/4/2024. Also observed a box of egg pasta sheets with a date of 1/6/2023 written on the box. V8 (Dietary Manager) stated those things are outdated. On 5/13/2024 observed the dry storage room with V8 (Dietary Manager). Observed one plastic bag containing breadcrumbs on the top shelf of a chrome rack. The bag of breadcrumbs documented on a label a prep date of 2/6/2024 and a use by date of 2/9/2024. On 5/15/2024 at 12:27pm V8 (Dietary Manager) stated the purpose of labeling the food containers in the freezer, cooler and dry storage room so that staff can monitor what and when food are put into these areas and know when those food items should be removed from those areas. V8 stated the dietary aide is responsible for labeling food items when the food items are placed in the freezer, refrigerator, and dry food storage areas and checking for expired food items. V8 stated it is my expectation that all kitchen staff label food items who the food items come into the kitchen. V8 stated if a food item is not labeled with a date or checked for an expiration date the resident can get sick. V8 stated the purpose for having a thermometer in the inside of the refrigerator and freezer is to keep an accurate temperature in the inside of the refrigerator and the freezer. V8 stated the thermometer should be inside the freezer and refrigerator just in case the thermometer on the outside of the refrigerator and the freezer goes out. V8 stated I placed a thermometer in the freezer the other day. V8 stated me and the cooks should be checking the thermometers in the freezer and refrigerator in the morning, at twelve noon, and at night before leaving the facility for the day. Upon inquiry from the surveyor, V8 stated that there were 163 residents who are receiving an oral diet. On 05/15/2024 at 1:50pm observed a thermometer inside of the freezer, the temperature reading on the thermometer was in acceptable range. Reviewed the Facility's Policy dated 6/14 Food Storage which documents in part, 5. All stored food products will be covered, identified, and dated. Dating of potentially hazardous foods shall indicate the last day the item can be consumed. Reviewed the Facility's undated Policy titled Older Adults and Food Safety Guidelines for Safe Food Handling which documents in part, use a refrigerator/freezer thermometer to check the temperatures. Reviewed the Facility's policy dated 6/14 and titled Food Preparation which documents in part, 17. Expiration dates on food products will be monitored daily and if outdated, shall be discarded. 18. Food items not stored in the original container will be stored in clean labeled and dated containers. Reviewed the facility's undated Food Service Director Job Description which documents in part, 2. Adheres to all sanitary and food safety regulations governing handling and serving of food.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review the facility failed to ensure the outside dumpster lid was closed and garbage bags were placed into the dumpster to prevent pests and rodents from ent...

Read full inspector narrative →

Based on observation, interview and record review the facility failed to ensure the outside dumpster lid was closed and garbage bags were placed into the dumpster to prevent pests and rodents from entry into the garbage bin. This failure has the potential to affect all 163 residents residing in the facility. Findings include: The (05/13/2024) facility census was 163. On 05/13/2024 at 9:55am escorted to the outside dumpsters by V8 (Dietary Manager), observed four dumpsters for the facility. Observed the red dumpster overfilled with trash bags which caused the lid of this dumpster to be opened. Observed a dumpster with three lids, the middle lid was opened. Observed a plastic trash bag sitting on the side of the dumpster. On 5/13/2024 at 9:56am V8 (Dietary Manager) stated the plastic trash bag sitting on the ground next to the dumpster contains charcoals. On 5/13/2024 at 10:00am V8 (Dietary Manager) stated I don't know what was going on this weekend, the staff was just overfilling the trash dumpsters. The garbage disposal company comes to the facility every day to empty the dumpsters. V8 stated the dumpster lids should be closed, this can cause rodents to be around the facility. On 05/14/2024 at 9:45am observed two white trash bags overfilling the dumpster which caused the dumpster lid to be open. On 5/15/2024 at 12:27pm V8 (Dietary Manager) stated it is all the staff job to check the lid of the dumpsters to make sure the lids are closed. V8 stated the manager of housekeeping, and the administrator is responsible for maintaining the outside dumpsters. On 5/15/2024 at 2:44pm V17(Maintenance Director) stated the staff does rounds to check to see if the outside dumpsters are not overfilled with trash and to make sure the lids are closed. V17 stated the dumpster lids should be closed, open dumpster lids will attract rodents. Reviewed the facility's policy dated 5/14 and titled Waste Management which documents in part, 4. Plastic liners shall be tied and placed in outside dumpster, and dumpster lid kept closed. 5. Maintenance and Housekeeping personnel shall assure the dumpster area is kept clean and all trash bags are inside the dumpster, and dumpster lids closed.

May 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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

Based on Observation, interview and record review the facility failed to administer scheduled medications in the schedule time frame. This failure affected 4 residents (R1, R2, R3, and R4) reviewed fo...

Read full inspector narrative →

Based on Observation, interview and record review the facility failed to administer scheduled medications in the schedule time frame. This failure affected 4 residents (R1, R2, R3, and R4) reviewed for medication administration. This failure has the potential to cause negative outcome to a resident's physical, mental, psychosocial health, or well-being. Findings Include: On 4/30/24 at 12:00 pm, surveyor observed V3 LPN (License Practical Nurse) passing medications to residents. Surveyor inquired to V3 if afternoon medications were being passed. V3 stated, No I'm passing 9:00 morning meds. I was call in to work and didn't get here until 9:00 this morning. I normally work second shift 3 to 11p. Surveyor inquired to V3 how many residents V3 is taking care of. V3 stated, I have 23 residents. V3's timecard preview report for 4/30/24 clock in time is 9:02 am. R1's admission diagnoses include, but not limited to cerebral infarction, diabetes, hypertension, rhabdomyolysis, and depression. On 4/30/24 at 12:20 pm, surveyor observed V3 administer R1's morning medications of Aspirin, Losartan, Metformin, Sertraline, and Empagliflozin. R1's medications were scheduled to be given at 9:00 am on R1's Medication Administration Record (MAR). R1's Order Summary Report document in part, Aspirin (one time a day) related to cerebral infarction, Losartan (one time a day) for hypertension, Metformin (two times a day) for diabetes type 2, Sertraline (one time a day) for MDD (Major Depression Disorder), and Empagliflozin (Two times a day) related to diabetes. R1's care plan documents in part, Focus: R1 is receiving psychotropic medications to help manage/alleviate symptoms. Interventions: Give antidepressant medications as ordered by physician. R3's admission diagnoses include but not limited to type 2 diabetes, peripheral vascular disease (PVD), peripheral vascular angioplasty, atherosclerosis arteries of extremities, and hypertension. On 4/30/24 at 12:44 pm. Surveyor observed V3 administer R3's morning medications of Losartan, Metformin, Aspirin and Glipizide. R3's medications were scheduled to be given at 9:00 am on R3's MAR. R3's Order Summary Report documents in part, Losartan (once daily) for hypertension, Metformin (two times a day) for diabetes mellitus, Aspirin (one time a day) for prophylactic, and Glipizide (once daily) for diabetes mellitus. R3's care plan documents in part, Focus: R3 has potential risk for altered cardiac function related to diagnosis of hyperlipidemia, atherosclerosis of arteries, PVD, and hypertension. Interventions: give medications for hypertension, Focus: R3 is at risk for discomfort complications related to diagnosis of Peripheral Vascular Disease and Peripheral Vascular Angioplasty status. Interventions: give medications for improved blood flow or anticoagulants as ordered. Focus: R3 is a risk for signs/symptoms including hypoglycemia, hyperglycemia or uncontrolled diabetes related to diagnosis of diabetes mellitus. Interventions: diabetes medications as ordered by doctor . R2's admission diagnoses include but not limited to cerebral infarction, epilepsy, hemiplegia, and hemiparesis. On 4/30/24 at 1:00 pm, surveyor observed V3 administer R2's morning medications of Aspirin. Omega 3, and Levetiracetam. R2's medications were scheduled to be given at 9:00 am on R2's MAR. R2's Order Summary Report documents in part, Aspirin (One time a day) for pain and swelling. Omega 3 (two times a day) for high triglycerides, and Levetiracetam (two times a day) for seizures. R2's care plan documents in part, Focus: R2 has potential for altered cardiac function related to diagnosis of hyperlipidemia . Interventions: Give meds to control cholesterol level as ordered by the physician. Focus: R2 has potential risk for injury during seizure activity related to diagnosis of Seizure Disorder . Interventions: Give seizure medications as ordered by doctor. R4's admission diagnoses include but not limited to congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, coronary angioplasty, cerebral infarction, and hypertension. On 4/30/24 at 1:08 pm, surveyor observed V3 administer R4's morning medications of Aspirin, Breo Ellipte inhalation, Clopidogrel Bisulfate, Lidocaine Patch, Lisinopril, Metoprolol Succinate ER (Extended Release), Pantoprazole, Apixaban, Furosemide, and Gabapentin. R4's medications were scheduled to be given at 9:00 am on R4's MAR. R4's Order Summary Report documents in part, Aspirin (one time a day) for prophylaxis, Breo Ellipte inhalation (one time a day) for SOB (Short of Breath), Clopidogrel Bisulfate (one time a day) for prophylaxis, Lidocaine Patch (one time day) for pain, Lisinopril (one time a day) for hypertension, Metoprolol Succinate ER (Extended Release) for hypertension, Pantoprazole (one time a day) for GERD (Gastroesophageal reflux disease), Apixaban (Two times a day) for prophylaxis, Furosemide (two times a day) for fluid retention, Gabapentin (three times a day) for pain. Progress notes reviewed for R1, R2, R3, and R4, there were no documentation that V3 call the doctor to notify of late administration of medications to R1, R2, R3 and R4. On 5/2/24 at 12:39 pm, V2 DON (Director of Nursing) stated that medication is to be passed within the 2-hour window, (1 hour before and 1 hour after). It is not acceptable for resident to get their medication after the 2-hour window. Staff should notify the doctor if medications are not given at the scheduled time. On 5/1/24 at 2:45 pm, V1(Administrator) stated that medications should be given in the 2-hour time frame. V1 stated that medications that are schedule at 9:00, should be given within the 2-hour time frame. Resident council meeting minutes reviewed from January to April 2024. In January and February 2024 concerns for medications not being passed in a timely manner noted. Medication Pass: Process and Procedure: documents in part, Procedure: 9. Administration of medication: a. Administer mediation in accordance with frequency prescribed by physician, within 60 minutes before or after prescribed dose time. Documentation: Document of medication administration is recorded on the Medication Administration Record (MAR) and include the date, time, and initials of the licensed nurses who administered the medication. Facilities job description titled LPN (License Practical Nurse) documents in part, Essential Duties and Responsibilities 16. Prepare an administer medications and treatments as ordered by Physician.

Apr 2024 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident was free from physical abuse. This failure a...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident was free from physical abuse. This failure affected R3 who was physically punched and pushed by R8, causing R3 to fall and sustained a left hip fracture and right finger fracture that required emergency transfer to the trauma hospital with surgical repair of the left hip fracture and right finger fracture when reviewed for physical abuse in the sample of 4 residents (R3, R6, R7 and R9). Findings include: On 4/16/24 at 11:22 am, R3 stated that a while back, R3 broke R3's hip and that it was hurt real bad. When asked about the hip fracture, R3 stated that R3 was hit by R8 when R8 knocked the h*** out of R3. R3 confirmed with this surveyor that this occurred on 4/10/2020. R3 stated that it was on R3 and R8's floor, down the hallway by the entryway to the stairs, and that R3 was not bothering anyone. R3 stated that R8 punched R3 first and that R3 then tried to stop R8 from hitting R3 again when R3 fell to the floor, saying down I (R3) went. R3 stated that staff came to break it up and that R3 had immediate pain on R3's left hip and right hand. R3 stated that R3 went to the hospital and had surgery on R3's left hip. R3's admission Record, documents, in part, diagnoses of seizures, mild protein-calorie malnutrition, schizoaffective disorder, major depressive disorder, dysphagia, pain in right hip, hypokalemia, fracture of part of left femur neck, displaced fracture of base of 5th metacarpal bone of R hand and paranoid schizophrenia. R3's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 11 which indicates that R3 has moderate cognitive impairment. R3's MDS, dated [DATE], documents, in part, a BIMS score of 12 which indicates that R3 has moderate cognitive impairment. On 4/17/24 at 2:42 pm, V20 (Former Employee, Licensed Practical Nurse, LPN) stated that V20 worked in facility through 2021 and does remember R3 and R8's physical altercation on 4/10/2020. V20 stated that V20 was at the nurse's station which was at the other end of the hallway, and V20 responded immediately to R3 and R8's altercation and observed R3 on the floor. V20 stated that R3 was trying to get up from the floor but could not move due to the pain. V20 stated that other staff, including V19 (Certified Nursing Assistant, CNA) were present separating R8 from R3. V20 stated that R3 was complaining of pain to R3' left hip and right hand. V20 performed assessment, vital signs and that V20 called 911 for R3's emergent transfer to the hospital. V20 stated that V20 assessed R8 too, and R8 informed V20 that there was another resident, R13, who R3 was talking to in the hallway, and that R8 punched (R3) and knocked (R3) down to the ground. V20 stated that both R3 and R8 were both liking (R13). In R3's Progress Note, dated 4/10/2020 at 2:44 pm, V20 (LPN) documents, in part, that R3 and R8 were involved in a physical altercation in the hallway, and that V20 assessed (R3), laying on the floor, complaining of right hand and left hip pain with physician orders to send R3 via 911 to the hospital. In R3's Progress Note, dated 4/10/2020 at 3:09 pm, V20 (LPN) documents, in part, that V20 was informed by hospital staff that R3 was being transferred to a trauma hospital due to R3's left hip fracture and right pinky fracture. R3's trauma hospital records, document, in part, that on 4/14/2020, R3 has surgical repair of R3's left hip fracture (hemiarthroplasty pinning surgery) and R3's right 5th metacarpal fracture (closed reduction and external fixation pinning surgery). Hospital records document, in part, that R3's fractures are result of a physical altercation with R3 being assaulted in the facility by another resident (R8), and that R3 stated that R8 started the physical altercation. R8's admission Record, documents, in part, diagnoses paranoid schizophrenia, hyperlipidemia, dysarthria, hypertension, benign prostatic hyperplasia with lower urinary tract symptoms, osteoarthritis, insomnia, bipolar disorder, abnormal posture, obstructive and reflux uropathy, chronic obstructive pulmonary disease, acute sinusitis, drug induced subacute dyskinesia, and flaccid neuropathic bladder. R8's MDS, dated [DATE], documents, in part, a BIMS score of 15 which indicates that R8 is cognitively intact. R8's Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors, dated 3/9/2020, documents, in part that R8 has a history of presence of dysfunctional behavior (e.g. {for example} provoking, aggressive, manipulative, derogatory, disrespectful, obnoxious, abhorrent, insensitive, attention-seeking, and/or otherwise abrasive/inappropriate behavior) including roaming/wandering into peer's room/personal space. R8's Census documents, in part, that R8 was discharged from the facility on 11/7/2022 and was not able to be interviewed. In R8's Progress Note, dated 4/10/2020 at 2:35 pm, V20 (LPN) documented, in part, that (R8) was in a physical altercation with peer (R3) in the hallways, (R8) stated 'peer (R3) was talking to R8's lady (R13) friend'. On 4/17/24 at 11:04 am, V19 (CNA) stated that V19 was routinely working on R3 and R8's floor in 2020 and does remember a physical altercation between R3 and R8 with V20 being the nurse on 4/10/2020. V19 stated that R8 used to walk around the floor, was difficult to redirect and didn't want to take no for an answer. V19 stated that on 4/10/2020, V19 responded to R3 and R8's physical altercation at the end of the hallway (by the stairwell) with R3 on the floor. V19 stated that V19 was unsure if R3 lost R3's balance, and that V19 broke it up between R3 and R8. V19 stated that R8 did have a friend (R13) that R8 was always around and R13's room location was in the hallway area where R3 and R8 had a physical altercation. Facility roster, dated 4/10/2020, and R3 and R8's Census reports document that R3, R8 and R13 were all residing on the same floor on 4/10/2020. R13's admission Record documents, in part, that R13 was discharged from the facility on 10/22/2020. On 4/17/24 at 2:42 pm, V20 (Former Employee, LPN) stated that V20 worked in facility through 2021, and that V20 does recall R3 and R8's physical altercation on 4/10/2020. V20 stated that V20 was at the nurse's station at the other end of the hallway. V20 stated that V20 responded immediately and observed R3 on the floor and was trying to get up from the floor but could not due to pain. V20 stated that other staff were present separating R8 from R3. V20 stated that R3 was complaining of pain to left hip and right hand. V20 performed assessment, vital signs and that V20 called 911 for R3's transfer to the hospital. V20 stated that R8 informed V20 that there was another resident, R13 (whose room was the first room down that hallway, next to R8's room), who R3 was talking to in the hallway, and that R8 punched (R3) and knocked (R3) down to the ground. V20 stated that both R3 and R8 were both liking (R13). On 4/18/24 at 11:07 am, when asked if a resident has the right to be free from physical abuse, V2 (Director of Nursing, DON) stated, Absolutely. V2 stated that facility staff prevent physical abuse from happening by monitoring residents and intervening and separating when residents before it escalates into a physical altercation. On 4/18/24 at 1:14 pm, V1 (Administrator) stated that V1 is the abuse coordinator for the facility. When asked about residents admitted to and residing in the facility, how are staff ensuring that residents are not being abused, and V1 stated, It's harm and safety. We make sure that residents are safe. That their rights are not violated. That they are not harmed. That they are getting care. And not getting beat up. In R3/R8's physical abuse report to the state agency, dated 4/10/2020, V16 (Former Administrator) documents, in part, that V20 reported that (R8) allegedly punched and pushed (R3) down to the floor while passing in the hallway with resident injuries or complaints of injury as (R3) complains of right hand pain and left hip pain. Facility policy, date 2011 and titled Abuse Prevention Program Facility Policy, documents, in part, Policy: This facility affirms the right of our residents to be free from abuse . This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment . The facility is committed to protecting our residents from abuse by anyone including, but not limited to, . other residents . Definitions: . Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention . Physical abuse includes hitting, slapping, pinching, kicking.

Feb 2024 8 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that adequate supervision was provided for five...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that adequate supervision was provided for five of five residents (R15, R16, R17, R18, and R19) reviewed for supervision in the sample. This failure affected R15 who had a fall with injury laceration to the right side of the head and was sent to hospital emergency room where R15 received seven staples for laceration closure. This also affected R16 who was noted in the shower room without any supervision and R17, R18 and R19 who were observed in the dining room during lunch time without supervision. This has potential to affect all the resident on the 2nd and 4th floor of the facility. Findings include: On 02/15/24 at 10:05am, R15 was observed in bed with 7 (Seven) staples noted on the right side of the head. When the surveyor asked R15 what happen to R15's head. R15 stated that I (R15) fell in the shower, and I went to the hospital. R15 stated I was in pain, and it hurts bad. R15 stated on a scale of one to ten the pain was at 10. R15 stated they give me (R15) something for pain. R15 stated it still hurts now. R15 stated that there was no one (Referring to staff) to help me, R15 stated I was shouting for help, but no one came. R15's medical record admission Record showed that R15 was admitted to the facility on [DATE] with listed diagnosis that includes Schizophrenia, Unspecified, Acute Kidney Failure, Adjustment disorder with mixed anxiety and depressed mood, Bradycardia, and Vitamin D deficiency. On 02/09/24 had unwitnessed fall and was sent to the medical center. R15's MDS (Minimum Data Set) facility assessment tool used in assessing facility resident showed R15 a score of 09 indicating that R15 is moderately cognitively impaired. According to facility investigation report, V24 CNA (Certified Nurse's Aide) statement dated 02/09/24 documented that I (V24) took (R15) in the shower room and told him to wait until I come back. I told the other CNA identified by V2 DON (Director of Nurses) as V26 that R15 was in the shower room. V24 stated that when she came back R15 told her that R15 had a fall. On 02/15/24 at 10:15am, V7 (MDS / Care plan coordinator) who identified self as the 4th floor supervisor stated that there are call light in the rooms and she will have to refer to V1 (Administrator) to share whether the shower room call light should be functional (In working condition). V5 LPN (Licensed Practical Nurse) stated that call light should be always placed within resident reach when in the room. V7 also stated that a staff member should be present when resident is in the shower room to monitor and supervise for safety reasons. On 02/15/24 at 1:00pm, R17, R18 and R19 were observed in on the 2nd floor dining room eating with no staff supervision. R18 was observed trying to move the food plate so R18 can reach it. When this observation was brought to V18 CNA's attention and was asked about the facility protocol /policy on dining supervision. V18 who came into the dining area stated there should be a CNA assigned to monitor the dining room. V18 stated that R17 and R18 looking on their tray are on puree diet and should be monitored because they (referring to R17 and R18) can shock, they have problem in swallowing. At 1:12pm, V27 RN (Registered Nurse) stated that the dining room should be monitored by the staff they are not supposed to be left by them self while eating, R17 and R18 are on puree diet and should be monitored by the (CNAs) because they are at high risk for aspiration. At 1:41pm, V2 DON (Director of Nurses) stated whenever the resident is still eating in the dining room they should be monitored by staff and any staff can monitored. When asked specifically about monitoring or supervising for resident on mechanical diet puree diet. V2 stated the nursing staff should monitor. R17's medical record admission record listed diagnosis includes but not limited to Anemia unspecified, Dysphagia, oropharyngeal phase, abnormal posture, weakness, and Extrapyramidal movement disorder. R18's medical record admission record listed diagnosis that includes but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, moderate protein-calorie malnutrition, chronic obstruction pulmonary disease unspecified, Type 2 diabetes mellitus without complications, acute respiratory failure with hypoxia, dysphagia following cerebral infarction, gastrostomy status and bell's palsy. R19 medical record admission record listed diagnosis that includes but not limited to Epilepsy, abnormal reflex, obesity, major depressive disorder, schizophrenia, hypothyroidism, unspecified psychosis not due to substance or known physiological condition and other intervertebral disc displacement lumbar region. On 02/15/24 at 10:10am, V8 (Housekeeping) staff who was cleaning the opposite room to the shower room was asked to observe with the surveyor the functionality of the call light system in the shower room. R16 was noted in the shower room without any staff monitoring or supervising the shower area or the room. V8 stated the CNAs are the staff who monitors during shower. At 10:14am, V22 (CNA) who identified self as CNA who was supposed to monitor the residents during shower was made aware of the observation and was asked about the facility policy on supervision during shower stated that the residents are to be monitored closely so the no one (referring to staff or other resident) can go in the shower room for safety of the resident because we don't know what can happen (referring to fall incident or abuse). V22 stated in part that she is the only one on the floor and was checking on other resident's needs. R15's fall care plan focus initiated 05/02/23 with revision date of 05/11/2023 documented that R15 is at risk for fall / accidents related to medical complexities, psychotropic medications. Goal indicated that (R15) will not sustain serious injury throughout the review date. Interventions listed includes but not limited to be sure that the resident (R15) call light is within reach. R15's actual fall plan of care with revision date 02/08/24, listed interventions include resident (R15) instructed to use call light when feeling dizzy. Added intervention dated 02/09/24 documented that R15 instructed on importance of not trying to shower without assistance. On 02/20/24 at 12:25pm, V26 confirmed that V24 made her aware that R15 was in the shower room but was sitting in the middle of the hallway documenting and was not aware that R15 fell. V26 stated she did not hear any sound to indicate that R15 had a fall until few minutes later when V24 called her to inform her that R15 fell and was bleeding. When asked about the facility protocol on monitoring or supervision when in the shower room. V26 stated that she was busy doing her own work documenting. Showing that R15 was not monitored or supervised before V24 returned to the shower room. V26 stated R15 was noted bleeding from the side of the head. On 02/20/24 at 1:45pm, V25 NP (Nurse Practitioner) stated in part that she was paged to the 4th floor after the incident, and she examined R15. V25 stated R15 had approximately three (3) inches of laceration to the right side of the head and because R15 stated that (R15) hit the head on the floor and there was a laceration she ordered for R15 to be sent to the hospital for further examination because there is a possibility of other things going on. V25 stated that there was no loss of consciousness reported to her. V25 stated that on 02/11/24 at around 1pm she examined R15 upon return to the facility and there was 7staples applied for closure of the laceration. V25 stated the site is being monitored for swelling, redness and there is no special treatment dressing. V25 stated the staples will be removed in 7 to 14 days. The facility policy on Supervision and Safety dated 3/15 documented in part that the policy strives to make environment as free from hazards as possible, resident safety and supervision are facility-wide priorities. Resident supervision is a core component to resident safety. Staff to decrease safety risk factors as much as possible. The facility Job Description for Maintenance director presented documented in part that the maintenance director is responsible for the day-to -day activities maintenance department in accordance with current Federal, stated, and local standards guidelines and regulations governing the facility and maintained a clean, safe, and comfortable manner. Essential duties listed includes but not limited to maintains the building in good repair, maintain the building and grounds in compliance with federal, state, local, and joint commissions laws and standards. The facility LPN (Licensed Practical Nurses) Job Description presented documented in part that the primary purpose of the job is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by the nursing assistants in accordance with current federal, state, and local standards.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to provide privacy during glucose monitoring and insulin administration for one resident (R23) reviewed for resident rights in th...

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to provide privacy during glucose monitoring and insulin administration for one resident (R23) reviewed for resident rights in the sample. This failure affected R23 whose glucose monitoring, and insulin administration was done in the hallway at the nursing station while peers are present and watching. And has the potential to affect nine residents identified as needing glucose monitoring and insulin administration. Finding include: On 02/15/24 at 1:15pm, V5 LPN (Licensed Practical Nurse) was observed performing blood glucose monitoring for R23 in the hallway by the nursing station while R20 and R21 were present and watching the task being done. At 1:22pm, V5 proceeded to administer insulin medication on R23 abdomen exposing R23 abdomen by asking R23 to lift the clothing while R20 and R21 were still watching. When the surveyor asked V5 about the facility policy on medication administration and privacy resident rights. V5 stated that I (V5) could have taken (R23) to the room. At 3:19pm, V2 DON (Director of Nursing) when asked about the facility expectation of licensed nurses regarding privacy and confidentiality, V2 stated that when nursing care is being provided for any of the resident privacy should be provided and V5 should have perform the accu-check (referring to blood glucose monitoring) in the resident room and that goes for the insulin administration. R23's medical record admission record listed diagnosis includes but not limited to Type 2 diabetes mellitus without complications, chronic kidney disease unspecified, anemia, depressive type insomnia, cough, pain left knee encounter for therapeutic drug level monitoring, and schizoaffective disorder. The Residents' Rights for people in Long Term-Care Facilities pamphlet presented listed rights includes but not limited to the rights to privacy and confidentiality that the facility staff must respect the rights to privacy when given care. The facility policy on Resident Rights presented documented in part that employees shall offer all residents privacy and treat all residents with respect and dignity. To provide an environment of care that supports a positive self-image. Under the policy interpretation and implementation listed documented that the Federal and state laws guarantee basic rights to all residents of this facility that includes but not limited to privacy and confidentiality. The facility policy on Dignity documented that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The policy indicated that it is the responsibility of all the staff in promoting maintaining and protecting resident's privacy, including bodily privacy during assistance with personal care and during treatment procedures.

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, unwitnessed fall with injury for one resident (R1...

Read full inspector narrative →

Based on interview and record review the facility failed to report to IDPH (Illinois Department of Public Health) within the required regulation time, unwitnessed fall with injury for one resident (R15) in the sample reviewed for fall with injury. This failure affected R15 who had an un-witness fall and was bleeding from laceration to the right side of the head. R15 was sent to the hospital where R15 received seven staples application to laceration site, this has the potential to affect all 158 residents residing at the facility. Findings include: R15's medical record showed listed diagnosis that includes Schizophrenia, Unspecified, Acute Kidney Failure, Adjustment disorder with mixed anxiety and depressed mood, Bradycardia, and Vitamin D deficiency. R15's medical record documentation showed that R15 had a fall on 02/09/24 with bleeding noted from the head and was sent to the local hospital where seven (7) stitches were applied to close the laceration from the head. According to facility investigation report, V24 CNA (Certified Nurse's Aide) statement dated 02/09/24 documented that I (V24) took (R15) in the shower room and told him to wait until I come back. I told the other CNA identified by V2 DON (Director of Nurses) as V26 that R15 was in the shower room. V24 stated that when she came back R15 told her that R15 had a fall. At 02/15/24 at 12:15pm, V2 stated that the fall incident occurred on 02/09/24 at 11:09pm and was reported on 02/10/24 at 12:45pm. Showing that it was reported not within the required regulatory time of within 24 hours. V2 then stated I (V2) was not thinking of it like that I was waiting to know the type of injury and extent of the injury. On 02/20/24 at 1:45pm, V25 NP (Nurse Practitioner) stated in part that she was paged to the 4th floor after the incident, and she examined R15. V25 stated R15 had approximately three (3) of laceration to the right side of the head and because R15 stated that (R15) hit the head on the floor and there was a laceration she ordered for R15 to be sent to the hospital for further examination because there is a possibility of other things going on. V25 stated that there was no loss of consciousness reported to her. V25 stated that on 02/11/24 at around 1pm she examined R15 upon return to the facility and there was 7 staples applied for closure of the laceration. V25 stated the site is being monitored for swelling, redness and there is no special treatment dressing. V25 stated the staples will be removed in 7 to 14 days. The facility policy on Incident / Accident Reports documented in part that the report should be completed for all accidents or incidents where there is injury or potential to result in injury. Procedures listed includes but not limited to the administrator, Director of Nursing, Assistant Director of Nursing, or Nursing Supervisor must notify the IDPH by fax as soon as possible within twenty-four hours of the occurrence. Incidents of unknown origin are to be investigated thoroughly to rule out abuse.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure that physician order on medication administrations was followed, failed to document insulin administration and blood gl...

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to ensure that physician order on medication administrations was followed, failed to document insulin administration and blood glucose monitoring as late. This failure affected R23 whose glucose monitoring (accu-check) was done late, and insulin medication was administered. This also have the potential to affect eight other residents identified as dependent on licensed staff to monitor their blood sugar on the 5th floor. Findings include: On 02/15/24 at 1:15pm, R23 came to the nursing station asking V5 to perform glucose monitoring, V5 proceeded in performing the task and it read 162mg/dl. At 1:22pm V5 proceeded in administering one unit of insulin lispro per sliding scale. The surveyor asked R23 whether R23 has eating lunch and R23 stated yes. V5 turned to R23 and stated why did you eat without coming here first to check your blood sugar because you (Referring to R23) know the routine you are not supposed to eat before taken your blood sugar (referring to blood sugar monitoring). The surveyor asked V5 the scheduled time for the insulin, V5 stated it is scheduled for 11am. V5 stated (R23) usually come up to the nurse's station before eating. The surveyor asked whether V5 looked for R23 at the scheduled time V5 stated R23 knows to come to the nurse's station, and to be honest with you (referring to the surveyor) I V5 did not go looking for R23. V5 documented in the electronic MAR as if the task was done as scheduled and insulin administered. R23's medical record MAR showed that R23 is schedule for Humalog 100units (Insulin Lispro) per slinging scale three times daily at 11am. At 1:29pm, when V5 was asked about the facility protocol and policy on medication administration that includes insulin administration and physician orders. V5 stated that I don't have the answer right now, may be to notify the MD (Medical director) and chart that the medication was given late. At 3:17pm when this observation was brought to V2's DON (Director of Nurse's) attention and was asked about facility policy and expectation of licensed nurse regarding insulin administration and physician orders. V2 stated in part that medications should be administered per physician order and follow the standard practice of one hour before and one hour after the scheduled time, but this does not apply to insulin administration acting and duration time. The facility policy on Medication Administration presented documented in part under level of responsibility the licensed nurse's documentation of medication administration is recorded on the MAR (Medication Administration Record) the date, time and initial of the licensed nurse who administered the medication. Medication must be administered in accordance with a physician order and his/her discretion e.g. (for example) right time. The facility LPN (Licensed Practical Nurses) Job Description presented documented in part that the primary purpose of the job is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by the nursing assistants in accordance with current federal, state, and local standards. Essential duties and responsibilities listed includes but not limited to preparing and administer medications and treatment as ordered by physician.

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure that privacy was afforded to one of four residents (R14) with urine collection bag in the sample reviewed for privacy. ...

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to ensure that privacy was afforded to one of four residents (R14) with urine collection bag in the sample reviewed for privacy. This failure affected R14 whose urine bag was visibly exposed to the hallway and with no privacy. Findings include: On 02/15/24 at 1:09pm, R14 was observed in bed with urine draining bag noted visible to the hallway and not covered with a privacy bag. V18 CNA (Certified Nurses Aide) who was present at the time stated the urine collection bag should have a privacy bag and should not be placed where everyone can walk by and notice that R14 has a urine bag for privacy reasons. R14's diagnosis list includes but not limited to Benign Prostatic Hyperplasia without lower urinary tract symptoms, presence of urogenital implants, schizoaffective disorder unspecified, Acute renal failure unspecified and insomnia. V2 DON (Director of Nurses) stated that the urine drainage bag should be kept in a privacy bag for privacy of the resident. The facility policy on Resident Rights presented documented in part that employees shall offer all residents privacy and treat all residents with respect and dignity. To provide an environment of care that supports a positive self-image. Under the policy interpretation and implementation listed documented that the Federal and state laws guarantee basic rights to all residents of this facility that includes but not limited to privacy and confidentiality. The facility policy titled Urinary Catheter Care documented in part that the standards to follow includes but not limited to storing the urine drainage bag in a privacy bag. The facility policy on Dignity documented that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The policy indicated that it is the responsibility of all the staff in promoting maintaining and protecting resident's privacy. And urinary catheter bags shall be covered.

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 that call light is within the reach for four residents (R1, R4, R15 and R16) reviewed for call lights. Findings include...

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to ensure that call light is within the reach for four residents (R1, R4, R15 and R16) reviewed for call lights. Findings include: On 02/14/24 at 10:38am R4 observed in the room sitting on the chair, R4 stated I need you (referring to the surveyor) to call someone for me to help me get the nurse, when the surveyor asked R4 to use the call light, R4 stated is over there pointing to the wall across from the bed. R4 stated in part that there is no need to use it any way because it does not work. V3 (Maintenance Director) who was present at the time was asked to test the call light for functioning and it was confirmed that the call light was not functioning. At 11:06am, R1 was noted in bed with call light not within reach. When V15 who identified self as the assigned CNA (Certified Nurse Aide) was made aware and shown the observation and was asked about the facility protocol and policy on call light. V15 stated it should be placed within reach of the resident attached to the linen. On 02/15/24 at 10:05am, R15 observed in the bed with call light not within the reach behind the bed. At 10:10am, during the same observation on the 4th floor, R16 noted in the shower room with call light not within reach. V16 LPN (Licensed Practical Nurse) when asked about the facility policy on call light stated are to be within the reach of the resident. At 12:17pm, V2 DON (Director of Nurses) stated that call light should be placed within the reach of the residents. R15's fall care plan focus initiated 05/02/23 with revision date of 05/11/2023 documented that R15 is at risk for fall / accidents related to medical complexities, psychotropic medications. Goal indicated that (R15) will not sustain serious injury throughout the review date. Interventions listed includes but not limited to be sure that the resident (R15) call light is within reach. The facility policy on Fall Prevention Program documented in part that the program is to assure the safety of all residents in the facility when possible. under standard fall/safety precautions for all residents includes but not limited to call light being kept within reach.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

Based on observation, interview, record review the facility failed to ensure that the call light system was in a working condition for residents to call for staff assistance. This failure has the pote...

Read full inspector narrative →

Based on observation, interview, record review the facility failed to ensure that the call light system was in a working condition for residents to call for staff assistance. This failure has the potential to affect all the resident residing on the 2nd and 4th floor of the facility. Findings include: On 2/15/24 at 10:05am, the shower room on the 4th floor call light was non-functional when pulled, V22 CNA (Certified Nurses Aide) present at the time stated that the light has not been working it does not light up over the door or make any sound at the nurse's station. At 10:57am, V7 (MDS/Care Plan Coordinator) who identified self as the 4th floor supervisor stated that the call light system as being faulty and V1 (Administrator) is aware. When asked about how long the call light system has been faulty, V7 stated I will have to check with V1 before I (V7) can give you (surveyor) the answer. At 11:09am, when this observation was brought to V3 (Maintenance Director)'s attention. V3 stated that the shower rooms and certain room on the 2nd floor and the 4th floor call light wires are faulty, and the overhead bulbs are broken. The surveyor then asked about the facility policy/protocol on facility maintenance, V3 stated that the call light system should be in working condition and repairs should be made when any-thing is broken. V3 stated that I am (V3) is new and still working on repairing so many things which one of them is the wiring of the lights (referring to call light system. At 12:10pm, the 2nd floor shower room noted not sounding at the nurse's station to notify the staff of residents needing assistance. At 2:39pm, interview with V1 (Administrator) regarding the call light system stated that and how often the maintenance staff checks on the call light systems for functionality. V1 stated we don't check the bathrooms call lights but for the rooms (V1) was aware that some of the rooms have problems with the call light and I bought some bells. V1 was unable to put time to when the problems started. V1 acknowledged that the facility wiring system for the call lights system needed to be repaired and that the cooperate office will be contacted. V1 stated the purpose of the call light is to alert the staff if a staff or resident needs help. The facility Job Description for Maintenance director presented documented in part that the maintenance director is responsible for the day-to -day activities maintenance department in accordance with current Federal, stated, and local standards guidelines and regulations governing the facility and maintained a clean, safe, and comfortable manner. Essential duties listed includes but not limited to maintains the building in good repair, maintain the building and grounds in compliance with federal, state, local, and joint commissions laws and standards.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review the facility failed to provide a safe and functional environment in regard call light for resident's staff assistance. This failure affected all the ...

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to provide a safe and functional environment in regard call light for resident's staff assistance. This failure affected all the residents in Rooms 202, 204, 207, 209, 210, 211, 212, 214, 215, 216, 220, 406, 407, 408, 409, 410, 420, 42 and has the potential to affect all the residents on the 2nd and 4th floor of the facility. Findings include: On 02/15/24 at 10: 05pm to 12: 15pm, the following observation was made regarding call light not being in working order: -Call light does not light up on the call light dashboard in the nursing station and over the door bulb did not light up in multiple rooms. -Rooms 202, 204, 207, 209, 210, 211, 212, 214, 215, 216, 220, 406, 407, 408, 409, 410, 420, 421. -At 10:15am, V16 LPN (Licensed Practical Nurse) stated that we all (referring to the Staff) knows some of these call lights don't work and it does not light up on the dashboard. V4 stated that the facility wiring is off and V1 (Administrator) is aware of the problem, At 12:15pm, V4 ADON (Assistant Director of Nurses) stated the call light is to is for calling the staff for assistance in case they (resident's) need help of fall and it should be within reach and in working condition. At 11:10am, when this observation was brought to V3 (Maintenance Director's) attention and was asked about the facility policy/protocol on facility maintenance. V3 stated in part that the call light system should be in working condition and in good repairs. V3 stated the wiring on the call light is off and will need external service agency for it to be repaired. The facility Job Description for Maintenance director presented documented in part that the maintenance director is responsible for the day-to -day activities maintenance department in accordance with current Federal, stated, and local standards guidelines and regulations governing the facility and maintained a clean, safe, and comfortable manner. Essential duties listed includes but not limited to maintains the building in good repair, maintain the building and grounds in compliance with federal, state, local, and joint commissions laws and standards.

Jan 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure one resident (R2) remained free from verbal abuse. This failure affected one resident (R2) out of three residents reviewed for abuse...

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure one resident (R2) remained free from verbal abuse. This failure affected one resident (R2) out of three residents reviewed for abuse. Findings include: R2's Face sheet documents that R2 has a diagnosis which include but not limited to: chronic kidney disease, dependence on renal dialysis, unspecified protein-calorie malnutrition, malignant neoplasm of liver primary, malignant neoplasm of pancreas peripheral vascular disease, anemia, anorexia, ascites, essential hypertension, acute kidney failure, hyperkalemia, anuria, and oliguria, hydronephrosis with renal and ureteral calculous, weight loss. R2's Brief Mental Status Interview (BIMS) dated 12/21/23 documents R2 has memory problems. The facility's initial Reported Incident submitted by the facility dated on 12/23/23 at 2:32 pm, by V1 documents in part: On 12/23/23 the administration was notified by a facility nurse that a representative from the local hospital called and alleged that a nursing aide accompany R2 for a dialysis appoint was verbally aggressive towards R2. The facility's final Reported Incident submitted by the facility dated on 12/29/23 at 12:55 pm, by V1 documents in part: The facility does have evidence to substantiate the allegations made by R2. R2's undated statement presented by V1 (Administrator) documents in part: V9 interviewed R2 on 12/27/23 and R2 stated, R2 was in so much pain that lady (V7) told me (R2) I (R2) was going to get this d**n dialysis done or she (V7) was going to kick my (R2) a**. He (R2) also stated that (R2) was going to sue because he (R2) slid out the chair and fell. The facility's document dated 12/28/23 at 11:19 am, shows V8 stated R2 came with caregiver (V7) for treatment and when refusal to complete HD (dialysis) tx (treatment), several staff and patient witnessed caregiver (V7) yelling at R2 stating You have to do this we came here, and you are gonna (going to) stay reviewed. On 01/02/24 at 2:13 pm, Surveyor spoke with V7 (CNA). V7 stated, V7 escorted R2 to R2's dialysis appointment on 12/23/23 around noon via Emergency Medical Technicians (EMT) to the local hospital dialysis center. V7 stated that V7 waited in the waiting area while R2 went to the back of the dialysis clinic to receive dialysis. V7 stated after about ten minutes of waiting in the waiting area V8 (R2's Dialysis Nurse, Registered Nurse, RN) informed V7 that R2 was refusing dialysis and that R2 would not be receiving dialysis. V7 then stated that V7 asked V8 to let V7 speak with R2. V7 stated while R2 was in the dialysis clinic sitting in the dialysis chair, V7 asked R2 why R2 was refusing R2's dialysis treatment and that R2 stated, Why do I (R2) need this. I (R2) am going to die anyway. V7 stated that V7 explained to R2 that R2 had a lot of fluid on R2's stomach and needed to receive R2's dialysis. V7 then explained that R2 stated to V7 that R2 was not going to argue with V7. stated that V7 then told R2 that V7 was not arguing with R2 and told R2 again that R2 needed to receive R2 dialysis treatment. V7 then explained that V8 stated to V7 that V8 already canceled R2 dialysis treatment for the day and called the EMT's to transport R2 back to the nursing facility. V7 stated that R2 was then observed sliding down in the dialysis chair and V8 asked V7 to watch R2 so that R2 did not fall out of the dialysis chair. V7 stated that V8 began arguing with V7 regarding R2 sliding in the dialysis chair until the EMT's arrived to transport R2 back to the nursing facility. V7 denied being verbally aggressive, verbally abusive, or threatening towards R2. V7 also denied R2 sustaining a fall from the dialysis chair. On 01/02/24 at 2:43 pm, V8 (R2's Dialysis Nurse, Registered Nurse, RN) stated, R2 was a new admission to the dialysis center on 12/23/23. V8 explained that when V8 started R2's dialysis treatment, R2 began to complain of abdominal pain, discomfort with sitting in the dialysis recliner chair and asked for R2's dialysis treatment to stop. V8 stated that V8 educated R2 regarding the consequences of not receiving R2's dialysis treatment and R2 still refused R2's dialysis treatment. V8 then explained that R2 signed the Against Medical Advice (AMA) form and V8 stopped R2's dialysis treatment and called for EMT's to transport R2 back to the nursing facility. V8 then stated that V8 phoned the nursing home to inform R2's nurse of R2's refusal of dialysis treatment. V8 stated that when V8 returned to R2, V7 was yelling at R2 telling R2 that R2 better get R2's dialysis treatment and to sit up before R2 fell out of the dialysis chair. V8 also stated that several other staff members reported to V8 that V7 was yelling at R2 and being aggressive with R2 while V8 was on the telephone. V8 stated that V8 then asked V7 to step out of the dialysis clinic multiple times and V7 stated to V8 that V7 would step out because V7 was ready to fight. V8 stated that the EMT's arrived and transported R2 back to the nursing facility and that V8 called to report V7 verbal aggressiveness towards R2 to the nursing facility. V8 denied R2 every falling while at the dialysis center. On 01/03/24 at 9:35 am, V2 (Director of Nursing, DON) stated that V2 did not know R2 well and that V9 (Assistant Director of Nursing, ADON) interviewed R2 regarding R2's incident with V7 at the dialysis center on 12/23/23. On 01/03/24 at 10:21 am, V9 (Assistant Director of Nursing, ADON) stated, V9 is familiar with R2. V9 stated, R2 was an alert and oriented times four resident. V9 stated that on 12/27/23, V9 interviewed R2 regarding the occurrence with V7 on 12/23/23 at R2's dialysis appointment. V9 stated when R2 was asked regarding the occurrence at R2's dialysis appointment on 12/232/23, R2 stated that R2 was scared of V7 (CNA) and felt that V7 would harm R2. V9 stated, R2 explained that R2 was in pain and did not want to receive dialysis treatment when V7 began yelling at R2 You (R2) are going to get this done (referring to the dialysis treatment) or I'm (V7) going to kick you're A**(threatening to harm R2). V9 stated, R2 continued verbalizing his fears of V7 threatening to harm R2. Then V9 explained that R2 stated, R2 slid off the chair at dialysis and was going to sue dialysis facility for falling. V9 stated that the facility was unable to verify that R2 sustained a fall at R2's dialysis appointment and that no reports from dialysis was received regarding R2 falling at the dialysis clinic on 12/23/23. On 01/03/24 at 3:20 pm, V1 (Administrator) stated, V1 is the facility's abuse coordinator. V1 stated that abuse in-services are done annually and when there are issues surrounding abuse concerns at the facility. V1 stated, staff is educated to report abuse to V1 immediately. When V1 was asked regarding R2's occurrence with V7 at R2's dialysis appointment on 12/23/23, V1 stated, V1 never spoke directly to R2 regarding the occurrence on 12/23/23 with V7. V1 stated that V1 spoke with V7 (CNA) and V8 (R2's dialysis nurse) regarding R2's occurrence at R2's dialysis appointment on 12/23/23. V1 explained, V9 (ADON) spoke with R2 regarding R2's occurrence on 12/23/23 and that V9 reported to V1 that R2 stated that V7 threatened R2 to receive R2's dialysis on 12/23/23 and that R2 was afraid of V7. V1 stated, staff at the facility are educated regarding abuse to protect the residents from abuse and to prevent abuse from occurring. V1 stated, V7 was in-serviced regarding abuse prior to R2's allegation of verbal abuse. Facility's document dated 04/14 and titled Abuse documents, in part: IV Establishing a Resident Sensitive Environment: This facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. The facility's job description titled Certified Nursing Assistant Job Description documents in part Purpose: To assist the Charge Nurse in providing nursing care to residents as assigned under the direct supervision of the Director of Nursing. Services are to be in accordance with nursing standards, policy and procedure and practices of the facility and state requirements . Duties/Responsibilities: . Must have patient and caring attitude when dealing with 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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to ensure that a resident (R1) who depend on staff's assistance for their ADL (Activities of Daily Living) care received showers, ...

Read full inspector narrative →

Based on observation, interview and record review the facility failed to ensure that a resident (R1) who depend on staff's assistance for their ADL (Activities of Daily Living) care received showers, nail care and grooming. This failure affected one out of three residents reviewed for ADL care and showers. Findings include: R1's Brief Interview for Mental Status (BIMS) dated 11/28/23 shows that R1 has a BIMS score of 9 which indicates that R1 has some cognitive impairments. R1 was able to answer questions appropriately during R1's interview. R1 has a diagnosis which includes but not limited to: quadriplegia unspecified, type 2 diabetes mellitus without complications, malignant neoplasm of pancreas, neuromuscular dysfunction of bladder, pressure ulcer of left hip stage 4, pressure ulcer of right heel stage 4, pressure ulcer of sacral region stage 4, neurogenic bowel , major depressive disorder, abnormal posture, covid 19, dysphagia oral phase, weakness, anemia. On 01/02/24 at 10:45 am, R1 was observed in room in bed awake and alert. R1 was observed ungroomed with R1's hair matted, tangled into a thick mass with particles of dry skin and black dirt particles visible in R1's hair. R1's fingernails were observed long with visible black dirt underneath R1's fingernail beds. R1 was asked regarding the last time R1 received a shower or bed bath at the facility and R1 stated that R1 last received a shower about one month ago and a bed bath about three weeks ago at the facility. R1 explained that when R1 prefers a shower and when R1 request for a shower, R1 is told that the facility's shower chair is broken and that R1 is not able to take a shower. When R1 was asked if R1 is offered a bed bath, R1 stated, No. I (R1) prefer a shower anyway. My (R1) hair needs to be washed. When R1 was asked regarding the last time R1's nails were trimmed, R1 stated that V3 (Certified Nursing Assistant, CNA) clipped R1's nails about three weeks ago. R1 request for R1's nails to be cleaned and R1 is told that the facility does not have nail clippers or nail supplies to provide nail care to the residents. On 01/02/24 at 10:52 am, V3 (CNA) was asked regarding R1's shower schedule and V3 stated that R1 should receive a shower two to three times a week. V3 stated, R1 needs to use the full body shower bed for total assist residents and the shower bed is broken. When V3 was asked how long the shower bed was broken, V3 stated that V3 does not know. When V3 was asked regarding R1's nail care, V3 stated, The facility does not have supplies to do nail care. If I bring my own fingernail clipper then I (V3) will do nail care. On 01/02/24 at 11:32 am, Surveyor observed V4 (Wound Care Nurse, Licensed Practical Nurse, LPN) V4 was asked regarding R1's showers and V4 stated that V4 did not know when the last time R1 received a shower and that R1 could not receive a shower for the last week due to the latch on the shower chair being broken. When V4 was asked regarding how long the shower chair was broken V4 stated that V4 reported the broken shower chair to V2 (Director of Nursing, DON) about one week ago. On 01/03/24 at 9:36 am, V2 (Director of Nursing, DON) stated that the Certified Nursing Assistants (CNA's) provide the residents with Activities of Daily Living (ADL) care and grooming. V2 explained residents are given showers once a week and the residents hair should be washed during shower time. V2 also stated that nail care should be provided to the residents during ADL (Activities of Daily Living) daily and as needed. V2 explained that residents showers are overseen by V4 (Wound Care Nurse, Licensed Practical Nurse, LPN). V2 stated that the residents are given a shower according to the residents shower schedule and that each unit has a shower book with a shower schedule for each resident. V2 stated that it is the expectation of the facility to provide the residents with a shower according to the residents shower schedule and that the Certified Nursing Assistants, (CNA's) document on the shower sheet each shower given to the residents, as well as shower refusals or changes in the residents shower schedule. V2 stated that a couple of weeks ago, staff made V2 aware of the second-floor shower chair not completely broken and that the second-floor shower chair just looked uneven. V2 explained that V2 and V9 (Assistant Director of Nursing, ADON) snap the second-floor shower chair alignment back into place. When V2 was asked if the second-floor shower chair looked safe for residents to use, V2 stated that V2 told the staff that the shower chair was ok to use. V2 also explained that no new shower chair is being order at this time and that the second-floor shower chair was able to be used for showers for the residents. V2 stated that V2 has not heard that the second-floor shower chair was broken since V2 and V9 fixed the second-floor shower chair a couple of weeks ago. V2 denied any knowledge of R1 with concerns of R1 fingernails dirty, R1's hair dirty, or the facility not providing R1 with a bath since R1 admission to the facility over a month ago. When V2 was asked regarding staff having supplies to perform nail care, V2 stated that nail clippers and nail supplies are given to the CNA's to provide nail care. V2 denied any knowledge of staff not having nail care supplies to perform nail care with the residents. V2 explained that the podiatrist clip the diabetic residents fingernails and that CNA's should not clip diabetic residents nails. V2 stated that the CNA's should only be cleaning and filing diabetic residents fingernails during nail care. When V2 was asked regarding the next podiatrist visit to the facility V2 stated that V2 did not know. V2 explained that if a resident wanted to receive a shower outside of the residents shower schedule the resident can receive a shower. V2 stated that it is important for the resident to receive a shower to keep the resident clean. On 01/03/24 at 10:21 am, V9 (Assistant Director of Nursing, ADON) denied any knowledge of facility not given R1 a bath since R1 admitted to the facility over a month ago, R1's fingernails dirty or R1's nails being dirty. V9 stated that staff reported that the second-floor shower chair was broken a few weeks ago and when V9 and V2 assessed the second-floor shower chair, there was a white piece that was needed to be aligned with the frame of the shower chair. V9 stated that V9 and V2 put the second-floor shower chair back into alignment and felt the shower chair was safe to use after V9 had the maintenance director (who no longer works at the facility) to take a look at the shower chair. On 01/03/24 at 11:12 am, V4 (Wound Care Nurse, Licensed Practical Nurse, LPN) stated that V4 oversee the residents showers at the facility. V4 stated that there is no policy for the residents to be give a shower at the facility and that the staff tries to give the residents a shower at least once a week. When V4 was asked regarding the residents shower schedule for each floor V4 stated that the residents are told their shower days according to the shower schedule on each unit and it is the expectation of the facility to follow the residents shower schedule for each unit. V4 stated that CNA's document on the shower sheet each time the CNA provides a shower, the resident refuses a shower or if there has been a change to the residents shower schedule. V4 explained that the shower sheets are kept in the shower book on each unit and the shower sheets are changed each month. V4 stated that if a resident does not receive the residents scheduled shower, V4 informs V2 to follow up with the CNA and the resident regarding the missing shower. R1's Minimum Data Set (MDS) section GG dated 11/28/23 shows that R1 is dependent on staff for personal hygiene, shower, and bathing. R1's care plan dated 11/24/23 documents, in part: Focus: R1 has an ADL Self Care Performance Deficit related to (r/t) Quadriplegia. Interventions: Bathing: R1 is totally dependent on staff for bathing. The facility's undated document titled 2nd Floor Shower Schedule documents, in part: R1 is scheduled for a shower 7 am - PM shift on Wednesday's and Sundays 7 am - PM shift at the facility. The facility's document dated Dec (December) titled Bathing and Skin Report Sheet shows that during the month of December 2023 on 12/06/23 R1 received a shower and on 12/13/23 11 pm- 7 am shift R1 received a bed bath. The facility document dated 02/14 and titled Bath/Shower Schedule documents, in part: Policy: A bath or shower will be given to each resident by a Certified Nurse Assistant two times per week as scheduled and prn. Procedure 1. Charge Nurse to make schedule for Certified Nurse Assistant to include baths or showers that are scheduled for that respective date and shift. 2. Bath and shower schedule is posted on each floor. 3. Certified Nurse Assistant give bath or shower scheduled . 6. Bath/Shower sheets are to be completed by the Certified Nurse Assistant upon each bath/shower scheduled whether accepted or declined. The facility's undated policy titled Care of Nails documents in part: Purpose: To provide cleanliness. To prevent infection. To promote safety. The facility's job description titled Certified Nursing Assistant Job Description documents in part Purpose: To assist the Charge Nurse in providing nursing care to residents as assigned under the direct supervision of the Director of Nursing. Services are to be in accordance with nursing standards, policy and procedure and practices of the facility and state requirements . Duties/Responsibilities: Provide showers and shaves as scheduled and as needed . Report all defective equipment immediately to Charge Nurse or Maintenance. The facility's document dated 04/14 and titled Activities of Daily Living (ADL) documents in part: Purpose: To preserve ADL functions, promote independence and increase self-esteem and dignity . Bathing: Washing and drying the body (excluding back and shampooing hair), including full body sponge bat, planning the task, and gathering supplies and transfer into and out of tub/shower . Grooming: Maintaining personal hygiene, including planning the task and gathering supplies combing and/or styling hair, face, and hands, brushing teeth, shaving, or applying makeup, oral hygiene, self-manicure (safety awareness with nail care) and/or application of deodorant or powder.

Dec 2023 1 deficiency

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected most or all residents

Based on observation and document review the facility failed to provide a clean homelike environment, this failure has the potential to affect all residents Finding include: On 12/15/23, 12/16/23 an...

Read full inspector narrative →

Based on observation and document review the facility failed to provide a clean homelike environment, this failure has the potential to affect all residents Finding include: On 12/15/23, 12/16/23 and 12/17/23 the facility corridor floors on the 2nd, 3rd, 4th, and 5th floor were observed with black soil encrustation in the corridor floor wall junctions and at the floor of resident metal door jams of resident room doors. The facility two passenger elevators were observed with heavy black encrustation in the door tracts at the floor. On 12/17/23 at 10:40AM, V1 (Administrator) stated, we have full time housekeeping staff during week and on weekends cleaning resident rooms and common areas. We are currently stripping resident floors to rewax . V1 stated, I will have staff clean elevator door tracts and the floor wall junctions on all floors. Facility policy titled Housekeeping Guidelines state including:11. Cleaning A. All horizontal surfaces will be cleaned daily and as needed with approved disinfectant.

Nov 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents remain free from staff to resident physical a...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents remain free from staff to resident physical abuse (R2) and staff to resident theft (R3) for two of two residents reviewed for abuse and theft. Findings include: R2's medical record (Face Sheet, MDS-Minimum Data Set) documents R2 is a moderately cognitively impaired [AGE] year-old admitted to the facility with diagnoses including but not limited to: Hemiplegia and hemiparesis following cerebral infarction right dominant side, Type 2 diabetes mellitus, Aphasia following cerebral infarction, and Dysphagia following cerebral infarction. On 11.17.2023 at 4:11 PM, R2 said V3 (Former CNA-Certified Nursing Assistant) slapped her twice on her left arm. On 11.17.2023 at 11:20 AM, V2 (DON-Director of Nursing) said, I believed her (R2) when she said V3 (Former CNA-Certified Nursing Assistant) slapped her. On 11.16.2023 at 3:58 PM V5 (MDS Coordinator/Licensed Practical Nurse) said she was the nurse responsible for R2's care on 10.8.2023 when V3 (Former CNA-Certified Nursing Assistant) allegedly slapped resident. I went to give R2 her meds. R2 said that lady hit me (V5 had seen V3 leave R2's room earlier); resident demonstrated to V5 how V3 slapped R2. V3 was terminated for drinking alcohol while on duty. On 11.17.2023 at 1:17 PM, V6 (CNA-Certified Nursing Assistant), said, after reviewing her statement dated 10.8.2023, that's my statement. I observed V3 (Former CNA-Certified Nursing Assistant) drinking (alcoholic beverage) in a resident's room while on duty. She seemed off, like she was slurring her words, smelled of alcohol. This was my first time working with her. V6 said R2 has never made false accusations against staff that she is aware of, if R2 does not like a staff member, she will refuse care from that staff member. On 11.17.2023 at 1:50 PM, V3 (Former CNA-Certified Nursing Assistant) said, I just gave herR2) care and as I was trying to take her gown off, she swung at me, she took her own gown off, I provided her with care including a bed bath, changed her bed. I was told that she complained that I hit her twice. V3 said there was no drinking, I don't know what they're saying, I didn't have any alcohol on me. On 11.6.2023 V3's Termination Form documents V3 was terminated for drinking liquor on company property/company time. On 10.13.2023 Facility's final incident report documents in part: on 10.8.2023 the administration was notified by facility nurse at (R2) alleged a facility nursing aide (V3) was rough with her when providing care in her 3rd floor room. R2 was checked and noted to be free of injury. R2 was interviewed and stated that V3 slapped her arm when changing her. R2 said she was not injured and there was no witness to the allegation. V3 was interviewed and stated that she was slapped by resident when providing care but did not retaliate. R3's medical record (Face Sheet, MDS-Minimum Data Set) documents R3 is cognitively intact [AGE] year-old admitted to the facility with diagnoses including but not limited to: Severe protein-calorie malnutrition, Alcohol use, Chronic kidney disease, and Alcoholic polyneuropathy. On 11.17.2023 at 3:00 PM, R3 said he gave V4 (Former Activity Aide) his debit card and asked V4 to withdraw $900 from his bank account for R3. R3 said V4 gave R3 $640 not $900. On 11.17.2023 at 2:28 PM, V10 (Social Service Director) said, R3 came to her office on 10.27.2023. R3 said V4 (Former Activity Aide) borrowed money from him and had not paid him back. R3 said it happened sometime in September, resident was unable to provide exact date. R3 said he gave V4 his debit card, asked V4 to withdraw $900 from his account, V4 brought R3 $640 back. I informed V1 right away. Facility employees should not be taking a resident's bank card to withdraw money for a resident. V4 should not have taken money from R3. That's financial abuse. R3 told V10 that he was scared of V4 and was afraid of retaliation. On 11.17.2023 at 3:31 PM, V9 (CNA-Certified Nursing Assistant) said, staff should not take money from residents; you just don't do it, it's financial abuse. On 11.17.2023 at 3:28 PM, V8 (RN-Registered Nurse) said staff members should not take money from residents; it's a form of abuse. V4 was not available for interview. On 10.27.2023 facility's investigation documents in statement to V12 (PRSC-Psychiatric Rehabilitation Services Coordinator) by R3, R3 stated, I asked male staff member if he could go to the ATM for me and bring me back $900 and he said yes. When he came back, he gave me $650. And 3-4 days later, he came back to me asking if he could borrow $140 and he said he would pay me back. On 11.16.2023 concern form documents Resident (R3) stated he loaned Activity staff $50 and his money has not been reimbursed. On 10.27.2023 facility's investigation documents in statement to V10 (Social Service Director) by R3, V10 wrote, (R3) was unable to give actual date, but reports he sure it was the beginning of September 2023. (R3) reported that in September 2023 he asked a male staff member that works with the cigarettes and pass food trays at facility to go to the store and get him some money. (R3) reported that he sent him to the store with his (bank card) to bring him back $900. (R3) stated that the facility worker brought him back $640, and a couple of days later male worker asked to borrow $140. When (R3) called to check his balance, he had .07 cents on his card. (R3) said he had $900 on his card when he sent him. (R3) stated he's scared the male staff will retaliate. Undated text message at 4:22 PM between V1 (Administrator) and V4 (Former Activity Aid), V4 texts, I went to the store for (R3) two months ago to get money off his card at corner store. In (R3) agree to give me $50 for going so I told him no instead of giving me for going no I'll it back on such day which will be the 3rd and he agree and said OK. On 10.31.2023 Corrective Action Form documents on 10.27.2023, V4 (Former Activity Aide) was accused of taking money from a resident. V4 admitted to borrowing $50 from the resident two months ago. V4 was terminated. Facility's Abuse Prevention Program Facility Policy (2011) documents: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation resident property, corporal punishment, and involuntary seclusion. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.

Oct 2023 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/24/2023 at 1:47pm, R1 said on that day (09/18/2023) during dinner, she did not get her dinner tray and she informed sta...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/24/2023 at 1:47pm, R1 said on that day (09/18/2023) during dinner, she did not get her dinner tray and she informed staff (No name provided) about it. R1 said and she was told it wase better for her to go to the kitchen to get her food, so that she can tell the kitchen staff what she wanted. R1 said she went and got V9(Psychiatric Rehabilitation Services Coordinator -PRSC) to take her to the kitchen. R1 said they found V3(Former Cook) in the kitchen and V9 asked her for R1's dinner tray. R1 stated V3 said she would not get R1 any food tray, and if it was up to V3, she would feed R1 cat food than give R1 a sandwich R1. R1 said V9 asked V3 what she (V3) had said, and V3 repeated that she would feed R1 cat food if it was up to her, then give R1 a sandwich. R1 said she and V9 left the kitchen without saying anything, and R1 said she felt hurt, disrespected, and she felt like a nobody, and felt like she was being treated like a child. R1 said she would not eat anything from the kitchen if V3 was still in the kitchen because she was scared V3 might feed her some bad food. R1 said she did not eat that night because she feared something bad might be put in her food. R1 said went and got a bag of potatoes to eat for dinner. R1 said she slept very upset, and she was hungry. On 10/25/2023 at 10:53am V9(Psychiatric Rehabilitation Services Coordinator -PRSC) said stated 09/18/2023, she took R1 to the kitchen to get a sandwich after R1 said she was brought the wrong food than what she had ordered. V9 said V3(Former cook) gave R1 a regular sandwich, but R1 said she wanted a sub sandwich. V9 said V3 got irritated by R1 and instead of V3 deescalating the issue, she escalated the situation by telling R1 that she, V3 would rather feed R1 cat food than give R1 a sub sandwich. V9 said at that point, she asked R1 to go back to the unit and escorted R1 back to the floor to prevent further escalation of the situation. V9 said she went back to the kitchen to speak to V3, and informed V3 that she(V9) was going to call V1(administrator) to inform his about the verbal exchange directed to R1 by V3. V9 said what V3 told R1 is a form of abuse (Verbal& mental) and staff should not tell residents such statements and should be deescalating the situation instead if escalating it. On 10/24/2023 at 1:10pm, (Director of Nursing-DON), said she was the DON when R1 was verbally abused by V3. V2 said V3 telling R1 that she(V3) would rather serve R1 cat food than make her a sandwich is definitely verbal and emotional abuse, and it could have had so many ramifications for R1, such as R1 refusing/stopping to eat from the kitchen for fear of being served cat food. On 10/26/2023 at 11:48am V15(Social Services Director) said R1 come to her office on 09/19/2023 and told V15 that the evening before, V3 had spoken to her(R1) inappropriately. V15 said V9(PRSD) told her that she had witnessed the verbal abuse by V3 towards R1. V15 said what V3 told R1 was verbal abuse and mental and can affect a resident's dignity, and staff should never engage with a resident inappropriately, and staff should deescalate the situation if a resident is agitated. On 10/24/2023 at 1:22 V1(Administrator)said more than likely the verbal abuse happened because a staff member (V9- Psychiatric Rehabilitation Services Coordinator-PRSC), was present when the abuse happened, and V9 said she heard V3 say to R1 that V3 told her she would rather serve her(R1) cat food than make her sandwich. V1 said after the allegation happened, R1 come to V1's office the following day and told V1 him it. Social Service Note dated 9/19/2023 10:46 Documents: -R1 met with V5 and reported she was verbally threatened by V3 on 9/18/2023 around 6pm. Review of V3's HR record with V8 document: -12/08/22- V3 was suspended pending investigation for verbal and emotional abuse to residents (No name/s of the residents) - 9/19/2023, V3 was suspended pending investigation of alleged abuse to R1 Facility Reported Incident Report (FRI) dated 9/19/2023 documents: - R1 told V3 that her food order was wrong, and V3 told R1 that she(V3) would rather serve R1 cat food than make R1 a sandwich. -Facility has evidence to support allegation made by R1. Abuse Prevention Program, Facility Policy Dated 2011 documents: -This facility affirms the right of our residents to be free from abuse, neglect. -The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of the mistreatment, neglect, or abuse of our residents. -Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents of families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but not limited to, threats of harm, saying things to frighten a resident. -Mental abuse includes but not limited to, humiliation, harassment, threats of punishment or deprivation. Based on interview and record review, the facility failed to prevent resident to resident abuse and resident to employee. This failure affected two (R2, R1) residents in a sample of three residents reviewed for abuse. This failure resulted in (R4) with known aggressions striking (R2) in the face causing inury. This failure resulted in R1 being verbally and mentally abused by V3(former cook). Findings include: 1. R2 and R4 are no longer in the facility and were reviewed as closed records. R2's electronic medical record documents that R2 was discharged to the hospital on [DATE] and has not returned back to the facility. R4's electronic medical record documents that R4 was discharged from the facility on 10/02/2023 and has not returned back to the facility. On 10/24/2023 at 12:57PM, V4 (Registered Nurse) stated she started her shift at 11pm on 09/27/2023, the date of the incident between R2 and R4. V4 stated another resident wandered into R4's room and R4 was upset about that. V4 stated that R2 informed her that R2 wanted some water from the dispenser in the hallway on the 4th floor, which was close to R4's room at the time. V4 stated that R2 usually spills water everywhere when R2 tries to get water by himself so V4 went to assist R2. V4 stated that she and R2 were located at the water dispenser and R4 came out of his room and reached over V4 and punched R2 in the face. V4 stated that R4 did not say any words and believed that R4 was responding to internal stimuli. V4 separated R2 and R4 and another staff member assisted R4 to his room. V4 stated she gave R2 first aid for a nose bleed and there was a small amount of blood and took 5 minutes to stop the bleeding. V4 stated that upon her assessment, R2 did not have any nasal swelling and R2's nose did not appear broken. V4 stated she called her supervisor and called 911 to make a report. V4 stated the police came to the facility in less than 10 minutes. The ambulance also arrived and R2 went out to the local hospital to be evaluated and R2 returned to the facility later that night. V4 stated R4 also went out to the hospital. V4 stated she also called the medical director and got the order to send R4 out to the hospital to have a psychiatric evaluation. V4 stated that R4 has a history of being physically aggressive. On 10/26/2023 at 9:27am, V1 (Administrator) stated he is the abuse coordinator, and a staff member called him and informed him that R4 was aggressive towards R2. V1 stated he informed the staff member to separate R2 and R4 and call the doctor to petition to get R4 out to have a psychiatric evaluation. V1 stated R2 was also sent to the local hospital to be medically evaluated. V1 stated R4 has a history of violence towards peers and staff. V1 stated that it was a danger to residents for R4 to continue to be in the facility due to R4's history of physically aggression. V1 stated he witnessed via video the physical abuse that took place between R2 and R4. V1 stated that upon viewing the video himself, he saw that R4 hit R2, unprovoked. R2s' Facesheet documents that R2 has diagnoses not limited to: Schizoaffective disorder, hypothyroidism, epilepsy, alcohol abuse, depression, insomnia, borderline personality disorder, and anxiety disorder. R2's Minimum Data Set/MDS dated [DATE], R2 has a BIMS/Brief Interview for Mental Status of 05, indicating that R2 is cognitively impaired. R2 requires independence with ADL/Activities of Daily Living care. R2 is continent of bowel and bladder, and ambulates via walking. Care plan dated 10/12/2023 documents that R2 is care planned for psychotropic medication, alterations in comfort, risk for metabolic dysfunction, risk for injury, self-care deficit, risk for abuse, mood and anxiety disorder. R2s' care plan states R2 will be treated with respect, dignity, and reside in the facility free of mistreatment (i.e., abuse/neglect) (on-going). R4s' Facesheet documents that R4 has diagnoses not limited to: cognitive communication deficit, schizoaffective disorder, mood disorder with depressive features, paranoid schizophrenia, unspecified psychosis, insomnia, violent behavior, and epilepsy. R4's MDS dated [DATE] documents that R4 has a BIMS of 06, indicating that R4 is cognitively impaired. R4 requires supervision and set-up and one-person physical assist with ADL care. R4 ambulates via walker and is continent of bowel and has an indwelling urinary catheter for bladder incontinence. R4s' care plan dated 07/26/2023 documents that R4 is care planned for physical aggression, risk for injury, risk for altered cardiac function, psychotropic medications, risk for falls, threatening and violent behaviors, severe mental illness, and risk for abuse. R4s' progress notes dated 09/27/2023 reviewed and documents that R4 was physically aggressive towards his peer (identified as R2) and R4 was transferred to a hospital for psychiatric evaluation. Progress notes written by V4 (RN) on 09/27/2023 documents in part, At 01:25, R4 was agitated and became physically aggressive towards peer (R2) punching R2 in the face while R2 was getting water from the water dispenser. Residents were separated. MD, police and administrator notified. Order given to send R4 out to hospital for psychiatric evaluation. ETA for ambulance is between 7-8am. Police report received from Officers, Beat 1522, RD#JG440-661. R4s' care plan states R4 has a history of displaying physical aggression towards his peers. The history includes: threatening behavior, verbal or physical aggression. R4 has been given an IVD (involuntary discharge) due to R4's recent aggressive behavior towards a peer. Facility Reported Incident dated 09/27/2023 documents in part that V4 (RN) witnessed R4 walk up to R2 and hit R2 in the face for no known reason. R2 sustained a bloody nose as a result of R4 hitting R2 in the face. Police report dated 09/27/2023 documents an incident of battery with report # JG440-661. Facility policy, dated 2011, titled Abuse Prevention Program Facility Policy documents in part, This facility affirms the right of our residents to be free from abuse .abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

Sept 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by other residents for two (R1 and R4) out of four residents reviewed for abuse...

Read full inspector narrative →

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by other residents for two (R1 and R4) out of four residents reviewed for abuse. This incident resulted in one (R4) resident having a swollen forehead and bruised eye. Findings include: R4's MDS Section C (07/26/2023) documents in part: BIMS score of 15. Which means R4 is cognitively intact. R4's Care plan documents in part: Medical Diagnosis: violent behavior, psychotic disturbance, mood disturbance, and anxiety, schizophrenia, schizoaffective disorder, bipolar type, depression, anxiety disorder, psychotic disorder. On 09/27/2023 at 11:00 AM, surveyor observed R4 sitting in his room. R4 stated that R3 took his iPad and threw it on the ground and started punching him. R4 stated that he had a swollen forehead and bruised eye. R4 stated that the facility sent R3 to the hospital. R3's MDS Section C (08/23/2023) documents in part: BIMS score of 15. Which means R3 is cognitively intact. R3's Care plan documents in part: type 2 diabetes mellitus with diabetic neuropathy, frostbite with tissue necrosis of right foot. frostbite with tissue necrosis of left foot, acute osteomyelitis, right ankle and foot, other acute osteomyelitis, left ankle and foot, pulmonary embolism without acute cor pulmonale. On 09/27/2023 at 11:15 AM, surveyor observed R3 sitting in his room. R3 stated that R4 has been annoying him with his loud music out of his iPad. R3 stated that he was standing by the elevator and R4 was playing his music. I got so annoyed that I took his iPad out of his hands and threw it on the ground. Surveyor asked R3 if he hit R4, R3 replied, Hell yeah, I punched him right in head. On 09/27/2023 at 11:51 AM, V3 (Social Services Director), stated she has been working at the facility for 1 month. If something happens, we go in and intervene. V3 stated R3 and R4 were by the elevator. Both are wheelchair bound. R4 likes to play his music on his iPad. R3 asked him to turn it down. And then R3 hit R4's tablet out of his hands. R4 tried to hit R3. R3 then hit R4. R4 then had swelling to his head and a black eye. V3 stated that there should be updated interventions by the social services department after each incident. R1's Care plan documents in part: aphasia following cerebral infarction, dysphagia following cerebral infarction, cerebral infarction, personal history of traumatic brain injury hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. On 09/27/2023 at 11:30 AM, surveyor observed R1 sitting on the patio smoking a cigarette. R1 is non-verbal. and was not able to talk. R2's Care Plan documents in part: Medical Diagnosis: violent behavior (psychotic disturbance, mood disturbance, and anxiety, psychosis not due to a substance or known physiological condition, schizoaffective disorder, paranoid schizophrenia, dysphagia. On 09/27/2023 at 11:15 AM, surveyor observed R2 sitting in his room. R2 stated that he has gotten into it with other residents, but he doesn't remember hitting another girl. On 09/27/2023 at 11:51 AM, V3 (Social Services Director) stated. R2 was by the elevator with R1 and he hit her. There was no injury on R1. V3 stated R1 is non-verbal. Each social worker has a floor. And after every incident we are supposed to update the care plan. R1 did not sustain any injuries. V3 stated V7 was the first one to witness the incident. They were separated immediately. Then social service was called. This incident happened before noon because R2 was in my office doing a one on one. We sent R2 out to the hospital after the incident. After doing some research they have said he has done this before. The purpose of the care plan and put in an intervention that is workable for each resident. When he comes out of his room, we are trying to watch him every time. We need to update the care plan with new interventions because the old interventions are not working. On 09/27/2023 at 1:34 PM, V7 (Associate Director of Nursing) stated that she was walking up the stairs and through the door on the 2nd floor. As she was walking down the hallway, she saw R2 trying to talk to R1. V7 stated that suddenly, she saw R2 punch R1 in the face. We immediately intervened and separated the two residents and sent R2 to the hospital. On 09/28/2023 at 2:30 PM, V1 (administrator) stated that R2 hit another resident on 09/26/2023. V1 stated that R2 does have a history so we sent him out. R3's progress note by nurse on duty on 09/11/2023 documents in part: R3 was in a physical altercation with male peer (R4). R4 was sitting next to resident playing music. R3 asked R4 to turn the music off or get away from him. R4 stated he wasn't going to do neither. R3 then snatched R4's iPad and threw it on the floor breaking it. R3 then hit R4. Fight was then broken up by CNA and Nurse. R1's progress note by V7 (Associate Director of Nursing) on 09/07/2023 documents in part: As writer was walking towards the elevator, R1 and (R2) were awaiting the elevator. They began to exchange words and (R2) struck R1 in the face with a closed fist. R2's progress note by nurse on duty (09/27/2023) documents in part: At 01:25, R2 was agitated and became physically aggressive towards peer punching her in the face while peer was getting water from the water dispenser. Reviewed R2's care plan. No updated behavior care plan done after previous abuse incidents. R2 had another abuse incident of assaulting another resident on 07/24/2023 and 09/26/2023. Final Incident Investigation Report between R3 and R4 documents in part: On 09/10/2023 facility's administration was notified by the Social Services Director that R3 and R4 engaged in an altercation in the 5th floor hall. R4 was noted to have swelling to the forehead, scratches to the right side of the neck and bruising to his left eye. R3 is noted to have a history of aggression when angered. Final Incident Investigation Report between R1 and R2 documents in part: On 09/07/2023 facility's administration was notified by facility nurse that R2 was physically aggressive towards R1 in the 2nd floor hall. R2 is noted to have a history of verbal and physical aggression due to his diagnosis of depression/schizophrenia. Facility's Abuse Prevention Program Facility Procedures (undated) documents in part: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Facility's Care Plan policy (undated) documents in part: When a change occurs in a resident's condition, the Care Plan Coordinator is notified by a member of the Interdisciplinary Team. The care plan is then reviewed and updated.

Aug 2023 1 deficiency

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected most or all residents

Based on observations, interviews, and review of records the facility failed to provide residents comfortable environment due to insufficient and inefficient air conditioning system. And failed to fol...

Read full inspector narrative →

Based on observations, interviews, and review of records the facility failed to provide residents comfortable environment due to insufficient and inefficient air conditioning system. And failed to follow policy in identify high risk residents during extreme heat. These failures affects all 159 residents living in the facility that are at potentially at risk of health-related due to extreme heat. Findings include: On 8/24/2023 at 1:10 PM, V2 (Maintenance Director) stated that an outside company will be coming in the facility to provide portable air conditions. At 1:24 PM, V1 (Administrator) stated that the company that regularly check facility main air conditioning system came earlier today (8/24/2023) and told him that in order to fix the problem they have to shut both chillers off so there will be no air condition for the whole building. V1 came back and said that the issue with facility's main air condition was not today (8/24/2023) but was already having problem yesterday (8/23/2023) submitting report from outside vendor identifying the problem. At 1:31 PM, V3 (Project Manager) said that V1 informed him about the air condition was not working. And that the valve needs to be replace. V2 was asked to bring temperature log and thermometer to check all floors. On 8/24/2023 at 1:46 PM V2 brought a document dated 8/24/2023 with time at 12:00 confirming that it was noon today temperature in the log was taken. Log temperatures of different rooms ranges from 78 to 82 Fahrenheit. Upon checking the actual temperature of different areas on all floors where residents are present. Temperatures ranges from 78 to 89 Fahrenheit. Mostly mid 80's were reflecting on the thermometer. Hallways were dark, V2 said that lights were turned off to lessen the heat produced by light and electricity. V2 said the vent on the ceiling is not working because of air conditioning problem and it added to the heat. Residents and facility staff were sweating, V2 begins to sweat also and said, I think it was worsened by humidity. R2 stated that he cannot sleep at night, and this was a continuing problem around from 2 weeks ago. On the hallway V6 (Housekeeping Aide) is seen sweating and grimacing due to heat. And V7 (Facility Staff) was wiping his face that was full of sweat. V7 said that this problem has been going for 3 to 4 days. After checking every floor temperature on different areas. V2 stated that this is not comfortable with the residents. And even if thermostat was set to the lowest position if will still be hot. Ideal temperature should be no higher than 75-degree Fahrenheit. Right now, all the floors is not meeting the standard. At 2:41 PM, V4 (Director of Nursing) was asked for list of residents that are vulnerable because of extreme heat. V4 stated that she does not know how to determine residents that are vulnerable due to extreme heat. Then V2 said, I think all residents can be affected due to extreme heat. On 8/25/2023 at 10:15 AM. V1 said that outside vendor/company installed portable air conditions last night (8/24/2023). And another outside vendor/company is currently working on the main air conditioning system. V1 submitted facility temperature log that list temperature on every floor from 7:00 PM on 8/24/2023 to 8:00 AM on 8/25/2023. On the log temperatures taken on 7:00 PM to 9:00 PM 8/24/2023 were still mostly mid to upper 80s (Fahrenheit). Temperatures gradually decreases to upper 70s to lower 80s (Fahrenheit) starting 12:00 AM to 8:00 AM, 8/25/2023. On 8/25/2023 at 10:19 AM. V4 stated that vital signs were not taken during extreme heat as per policy. And that almost all residents were taking medication documented in the policy. V8 (Director of Clinical Services / Consultant) stated that in times of extreme temperature, what is supposed to be done is to print the list of all residents. Monitor all resident's vital signs. And facility needs to do all residents vital signs. At 2:34 PM, V4 submitted midnight census dated 8/24/2023 that has handwritten vital signs per shift to residents per each floor. V4 stated that although she said that vital signs of residents were not taken. Facility staff did take residents vital signs without her knowing. And that policy was not followed in taking every 2 - 4 hours because it was hard to take all 159 residents. V4 further stated that if residents that are high risk were identified and prioritize. Nursing staff can focus on high-risk residents instead of doing the whole facility. Emergency Plan of facility for extreme hot weather dated 4/14 reads: Under general resident centered measures, identify and monitor high risk residents. High risk residents include the following: - Individuals with circulatory and/or respiratory problems - Individuals who are old, 85 years or older - Individuals receiving certain medications, alcohol, diuretics, anti-hypertensives, sedatives, hypnotics, tricyclics, anticholinergics, phenothiazines, antihistamines, belladonna alkaloids. Takes residents' temperature and vital signs more often (generally every 2 - 4 hours). Frequency will be determined depending on the individual resident's physical condition by the Director of Nursing and/or her designee. On 8/25/2023 at 10:30 AM with V2 and V3, temperatures of different areas on all floors with residents were checked. Temperatures ranges from 74 to 82 Fahrenheit with mostly mid to upper 70's. Each floors have a cylindrical plastic running through the ceiling with holes that emits cooler air. At 11:25 AM V9 (Licensed Practical Nurse) stated that compared to yesterday it feels much better. Yesterday was extremely hot and very uncomfortable. At 11:27 AM R3 stated that it was very hot for days and she was sweating a lot. And that she (R3) did not have a problem with breathing but felt very uncomfortable. At 11:30 AM V10 (Certified Nursing Assistant in training) stated that it was still hot a little but yesterday was worst. And that she has to leave work because of the heat. And that everybody was sweating. V10 stated that in thinking that older people is living in the facility it is not a good place for them (geriatric residents) to live. At 11:35 PM, R4 stated that yesterday was very hot, and she was sweating a lot. At 11:57 AM, V11 (Program Director / Contracted) that she worked from Monday to Friday, and that air condition does not reach her office. And that it feels better than yesterday. Because yesterday, she was sweating a lota and felt very uncomfortable. It was 95 degrees in her office. And for the residents she feels that it was unsafe living condition for the residents. At 12:15 PM. R6 said I was sweating a lot yesterday and feel uncomfortable. It has been like this for few days. Instruction per Air Temperature Log that uses degrees Fahrenheit reads: If any of the temperature / humidity values falls within the shaded area (80 degrees Fahrenheit and above), Extreme Heat Temperature procedure is to be implemented.

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to affirm the right of the resident to be free from verbal abuse. This def...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to affirm the right of the resident to be free from verbal abuse. This deficient practice affected 1 (R1) of 5 residents reviewed for abuse. Findings Include: On 05/25/2023 at 12:25pm, R1 observed sitting in a wheelchair inside of R1's room. R1 observed with left arm amputated as well as right leg amputated. R1 stated Yes, the staff talks to the residents disrespectfully. I have all my senses so I talk back to them disrespectfully just like they do to me. I can't recall in particular the incident involving the staff and the elevator because they talk like that to us so often. When the staff talks like that to me, it doesn't affect me. I'm okay, I feel safe here. I was raised to put my feelings on ice so that my feelings don't get hurt. The staff talks to us like that because they are probably just mad that they have to come to work. On 05/25/2023 at 12:39pm, V7 (Licensed Practical Nurse/LPN) stated, Although I did not witness it, I heard about a situation involving verbal abuse between R1 and V4 (Housekeeping). I think V4 quit and walked off the job that same day. Yes, I was trained on abuse and if abuse is reported to me then I will report it to V1 (Administrator). On 05/25/2023 at 1:31pm V1 (Administrator) stated, I am the abuse coordinator here at the facility. I received a phone call from V10 (Social Services Director) who reported to me that V4 (Housekeeping) had used profanity at R1. V10 separated V4 from R1 and explained to V4 that V4 cannot talk to R1 that way. V4 then started using profanity at V10 and V4 was escorted out of the building. V4 was suspended immediately pending the investigation. I then, reached out to V4 via phone and V4 basically said something about V4's paycheck and V4 refused to give any information to me regarding the incident. I reported this incident to the health department. V4 received abuse training upon hire. V4 has never returned to the facility. Facility incident witness statements dated 05/04/2023 reviewed and documents that V5 (Housekeeping) heard V4 (Housekeeping) call R1 many names and shouted disrespectful words to R1. V5 witness statement also documents that V4 called R1 a b!t@@ and said f**k you to R1. An attempt to contact V5 (Housekeeping) via telephone was made on 05/25/2023 at 2:23pm, voice message left with call back number, awaiting call back. A telephone interview was conducted with V4 (Housekeeper) on 05/25/2023 at 2:31pm. Surveyor asks V4 if it was a good time to talk and V4 stated Sure, absolutely this is a good time to talk. Surveyor inquired about incident related to verbal abuse allegations involving R1. V4 then stated Oh, I didn't know that you were going to ask me that. Can you call me back tomorrow because right now is not a good time, I'm on my way to a graduation. Surveyor agrees to call V4 back on 05/26/2023. A telephone interview was conducted with V4 on 05/26/2023 at 10:22am. V4 (Housekeeper) stated I want you to stop calling me, do you understand me!? Surveyor agrees to stop calling and ends the phone call. On 05/25/2023 at 4:05pm, V10 (Social Services Director), stated I was in my office, which is near the elevators on the first floor of the facility. I heard people shouting things at one another by the elevator. At first I thought it was two residents. I rushed to the elevators immediately and found that it was a staff member V4 (Housekeeping) cursing at R1. R1 was trying to get onto the elevator but V4 wasn't allowing R1 onto the elevator. I immediately separated R1 from V4 by taking R1 into my office while V4 went up on the elevator. I made sure R1 was safe then I went up on the elevator searching for V4. I tried to talk to V4 and explain that V4 cannot use language like that towards the residents. V4 then started talking disrespectfully to me and cursing at me. V4 said things like f**k your @*s and f**k this facility, this is my last day. V4 was upset and had an attitude. I then informed V1 (Administrator) and V1 informed me that V4 needs to leave the facility immediately. V4 was seen by staff leaving the facility. I made sure to follow up with R1 to make sure R1 was okay. V4's (Housekeeping) employee file dated 04/21/2023 reviewed. V4's file documents that V4 signed the facility's abuse policy acknowledgement form on 04/21/2023. V4's employee file documents no prior records of abuse. V4 was hired on 04/21/2023 and terminated on 05/04/2023. Facility Initial Incident Report (dated 04/30/2023) states: It was reported to the administrator on 04/30/2023, that R1 had a verbal altercation with a housekeeping staff member. Social Services immediately intervened and separated R1 and the housekeeping staff member. Housekeeper was immediately suspended, pending investigation. Family and physician notified. Investigation initiated and final report sent to health department. Nursing Progress Note (dated 04/30/2023) documents, writer was informed that R1 alleges that staff was verbally aggressive towards R1, per R1 description I was attempting to get on the elevator and staff member said I couldn't get on so I asked why? that's when the staff member became verbally aggressive towards me. R1 returned to unit for safety adon administrator md and family all made aware. R1's Face Sheet documents that R1 is a [AGE] year-old with diagnoses not limited to: Type 2 diabetes mellitus with foot ulcer, peripheral vascular disease, hyperlipidemia, chronic kidney disease, essential hypertension, absence of left upper limb below elbow, and absence of right leg below knee. Care plan (dated 05/16/2023) documents that R1 is not care planned for abuse that resulted on 04/30/2023. Resident Rights Policy (undated) documents in part, Your rights to safety- You must not be abused, neglected, or exploited by anyone- financially, physically, verbally, mentally, or sexually. Facility abuse policy dated 2011 documents in part, The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.

May 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to submit the final facility-reported incident report to the state agency within 5 working days as per facility policy for one resident (R1). ...

Read full inspector narrative →

Based on interview and record review, the facility failed to submit the final facility-reported incident report to the state agency within 5 working days as per facility policy for one resident (R1). Findings include: On 5/9/23 at approximately 1:55 PM, V3 (DON/Director of Nursing) provided the surveyor with R1's initial and final facility reported incidents that were submitted to the state agency regarding R1's injury of unknown origin. R1's initial facility reported incident confirmation page listed a date of 4/24/2023. R1's final facility reported incident confirmation page listed a date of 5/8/2023. On 5/9/23 at 2:13 PM, V3 (DON/Director of Nursing) confirmed the date that R1's final facility incident report was sent to the state agency acknowledging, It was actually just sent yesterday. V3 added, It's supposed to be 7 days, regarding the timeframe the final report should be sent following the initial report. R1's 4/24/23 progress note documents, in part, Note Text: Resident admitting dx (diagnosis): Subdural hematoma. The 9/14 Incident/Accident Reports policy documents, in part, A. Policy: The Incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents or incident where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors or other, and resident-to-resident physical altercations .B. Procedure: . 3. The Administrator, Director of Nursing, Assistant Director of Nursing or Nursing Supervisor must notify the following if serious injury occurs: a. The Illinois Department of Public Health, by fax, as soon as possible within twenty-four (24) hours of the occurrence .i. A narrative follow-up summary of the incident is to be sent to the Illinois Department of Public Health within five (5) working days.

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 on observation, interview and record review, the facility failed to ensure that one resident (R5) who is dependent on staff for bed mobility and who has a stage III pressure ulcer to the sacrum ...

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure that one resident (R5) who is dependent on staff for bed mobility and who has a stage III pressure ulcer to the sacrum was repositioned every two hours as per facility policy. This failure affected one (R5) out of 3 residents reviewed for repositioning. Findings include: On 5/8/23 at 12:21 PM, R5 was observed lying flat on her (R5) back in the bed with two pillows on either side of R5 and a pillow under R5's feet. The surveyor inquired if R5 is repositioned every two hours. R5 replied, No. I usually call if I need something. On 5/8/23 at 2:25 PM, R5 was observed in the same position as earlier, with the pillows in the same positions. R5 asked the surveyor to move the pillow from under her (R5) feet stating, My heel is sore. The surveyor inquired if anyone had been in the room to reposition R5. R5 answered, No. At approximately 2:27 PM, the surveyor notified V4 (ADON/Assistant Director of Nursing) of R5's request. V4 adjusted R5's pillow so that R5's heels were dangling off the pillow rather than lying on top of the pillow. R5 stated, That's much better. V4 stated that the CNAs should provide repositioning every 2 hours. On 5/10/23 at 3:01 PM, V3 (DON/Director of Nursing) stated that the expectation of staff is to reposition dependent residents every 2 hours and as needed. The surveyor inquired what the risks are of not providing timely repositioning. V3 replied, Skin breakdown. R5's admission Record documents diagnoses including but not limited to unspecified open wound of buttock, anemia, and adult failure to thrive. R5's 3/29/23 BIMS (Brief Interview for Mental Status) determined a score of 15, indicating that R5's cognition is intact. R5's Wound Evaluation and Management Summary authored by V18 (Wound Care Specialist) documents, in part, Stage 3 Pressure Wound sacrum full thickness, wound size (Length x Width x Depth): 3.7 x 1.6 x 0.3 centimeters. Recommendations: Reposition per facility protocol; turn side to side in bed every 1-2 hours if able; off-load wound. R5's 3/29/23 MDS (Minimum Data Set) section G documents, in part, that for the ADL (Activities of Daily Living) task of bed mobility, R5 coded a 2. One-person physical assist for ADL support provided. R5's 5/3/23 Braden Scale (Risk assessment for pressure ulcer development) determined a score of 14, indicating that R5 is a Moderate Risk for developing a pressure ulcer. R5's revised 12/18/21 care plan documents, in part, (R5) has potential risk for pressure ulcer development related to impaired mobility, bowel/bladder incontinence. Interventions include but are not limited to Follow the facility policies/protocols for the prevention/treatment of skin breakdown. The 6/14 Repositioning and Turning facility policy documents, in part, Purpose: To ensure that residents are turned/positioned in accordance with the plan of care to prevent skin breakdown, inhibit the progression of contractures and provide comfort .Policy: It is the policy of the Nursing Department that residents, unable to reposition themselves, will be turned and repositioned every two hours, in accordance with their 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to ensure that fall prevention interventions were in place as care planned for one resident (R3) who is a high risk for falls out...

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure that fall prevention interventions were in place as care planned for one resident (R3) who is a high risk for falls out of 3 residents reviewed for fall prevention interventions. Findings include: On 5/8/23 at 11:30 AM, the surveyor observed R3 lying in bed with R3's red call light string on the floor next to R3's bed. R3's bed was noted to be elevated, not in the lowest position to the ground. R3, who was noted to have aphasia (difficulty forming sentences) but seemed to comprehend questions, shook her (R3) head no when the surveyor asked if R3 could reach the call light. On 5/8/23 at 11:36 AM, these observations were brought to the attention of V6 (RN/Registered Nurse). V6 picked up the call string off the floor and attached the clip to R's bed sheet stating, It fell on the floor. V6 confirmed that the call light should be within reach of the resident. V6 then took the bed control and started lowering the bed to the lowest position. The surveyor inquired if the bed was up too high. V6 replied, Yes. On 5/10/23 at 3:04 PM, V3 (DON/Director of Nursing) stated that nurses and CNAs (Certified Nursing Assistants) should be conducting rounds every 2 hours and as needed to ensure that beds are in the lowest position, call lights and personal items are within reach, there are no wet floors, there is adequate lighting, and making sure residents have proper footwear. V3 stated that the importance of these interventions is, To avoid falls if we can and to avoid injury from a fall. R3's admission Record documents diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, weakness, type 2 diabetes mellitus, and schizoaffective disorder. R3's 3/8/23 BIMS (Brief Interview for Mental Status) determined a score of 10, indicating R3's cognition is moderately impaired. R3's revised 7/7/21 care plan documents, in part, Focus: (R3) is at risk for falls/accidents related to medical complexities, psychotropic and multiple medication use, high risk for fall. Interventions include but are not limited to Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; follow facility fall protocol. The 2/28/14 Fall Prevention Program documents, in part, Policy: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary .Standard Fall/Safety Precautions for all Residents: . 7. Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair . 8. Call lights are kept within reach and answered promptly.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a safe and sanitary environment in the hallway ...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a safe and sanitary environment in the hallway on the 3rd floor and in one resident's (R3) room. This failure has the potential to affect all ambulatory residents residing on the third floor. Findings include: On 5/8/23 at 11:11 AM, the surveyor observed the floor between the nursing station and room [ROOM NUMBER] with an approximately 2-inch wide and approximately foot-long linear hole in the laminate flooring creating a crevice that was accumulating debris. On 5/8/23 at 11:15 AM, this observation was brought to the attention of V7 (Maintenance Assistant) who described the hole as a dent or impression in the floor. V7 added that it was a High risk for a trip or slip. V7 stated that he (V7) was unaware of the hole in the floor until notified by the surveyor. On 5/8/23 at 11:30 AM, a large hole was observed on the bottom of R3's wall behind the bed with a broken board hanging off the middle of the wall. On 5/8/23 at 11:42 AM, V8 (Maintenance assistant) stated that the hole in the wall was approximately 2 feet wide. V8 stated that the board in the middle of the wall is there to prevent the bed from hitting the wall, but because R3's bed was missing a headboard, V8 stated that the damage was most likely caused by the bed being pushed up against the wall. The surveyor inquired what the risk of having a hole in the wall is. V8 replied, May be roaches in there. On 5/8/23 at 2:10 PM, V1 (Administrator) stated that for quite a while they had a maintenance supervisor position open and that there was only one maintenance man for the whole building which has 5 floors and 168 residents per the 5/8/23 Resident List Report. The 5/8/23 Resident List Report lists 43 residents on the 3rd floor. The 11/14 Preventative Maintenance Program documents, in part, Purpose: to conduct regular environmental tours/safety audits to identify areas of concern within the facility .Protocol: . 3. Preventative Maintenance Program will review the following areas during random rounds . 5. All facility areas are kept clean and in safe condition. 6. Floor tiles are assessed for cracking and wear . 13. Paint is free from watermarks and peeling. The Maintenance Director job description documents, in part, . Safety and Sanitation: 1. Assures that assigned work areas are maintained in a safe and attractive manner.

Apr 2023 2 deficiencies

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents were free of abuse/physical assault. This fai...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents were free of abuse/physical assault. This failure affected five residents (R2, R3, R4, R5 and R6) of six residents, reviewed for abuse. Findings include: On 4/18/23 at 12:15pm, V1 (Administrator) was asked about the incidents of abuse allegations within the last three months. V1 stated that the incidents with R2, R3, R4, R5, and R6 were the incidents involving resident versus resident physical altercations, which the facility investigated and reported to the state, and there were no injuries. V1 added that the aggressors were sent out for psychiatric evaluation. V1 presented resident-resident incidents reports which include but are not limited to the following: R2 versus R3 dated 2/21/23; R5 versus R6 dated 3/13/23; and R5 versus R4 dated 3/21/23. R2's progress notes dated 2/21/23 at 12:15pm written by V17(Restorative Nurse) states in part: As his peer entered his room, (R2) walked into his peer's room, threw water on him and made physical contact with his peer by hitting him in the back of his head. He then exited the room and sat in his wheelchair. [NAME] was immediately removed from his peers and placed at the nursing station. Facility's Reported Incident (FRI) dated 2/21/23 corroborated this incident. R3's progress notes dated 2/21/23 at 5:35pm by V17 states in part: His peer came into his room, threw water on him and proceeded to hit (R3). (R3) then went to hit his peer in retaliation. Facility's Reported Incident (FRI) and investigation dated 2/21/23 corroborated this incident. R4's progress notes dated 3/22/23 at 6:30am written by V18(LPN) states in part: Resident was sent to Hospital for Psychiatric evaluation related to slapping another resident, he is still in the emergency room. Facility's Reported Incident (FRI) and investigation dated 3/21/23 corroborated this incident. R5's progress notes dated 3/13/23 at 1:14pm written by V2(Director of Nursing) states in part: Writer was notified that resident hit a peer while in room. FRI and investigation dated 3/13/23 corroborated this incident. R6's progress notes dated 3/13/23 at 4:29pm written by V3 (Social Services Director/Psychiatric Rehabilitation Services Director/PRSD) states in part: Social Services was notified that a resident hit another resident while attempting to drop off his food tray. Resident was asked what happened, resident reported that he asked his peer politely to give way to allow him drop off his tray, immediately the resident turned back and punched him. The BIMS(Basic Interview for Mental Status) scores and Care plans for all 5 residents that were recently involved in resident-to resident physical abuse were reviewed. These care plans show that the residents have behavioral issues and/or aggressive behaviors, and the interventions show that the residents need social skills training, reassurance, and other supportive interventions as needed. The residents' care plans are dated as follows: R2's care plan with latest revision date 1/30/23; BIMS score 14(Cognitively intact). R3's care plan with latest revision date 4/5/23; BIMS score 13(Cognitively intact). R4's care plan with latest revision date 2/7/23; BIMS score 11(Moderate Cognitive impairment). R5's care plan with latest revision date 3/20/23; BIMS score 2(Severe Cognitive impairment). R6's care plan with latest revision date 4/4/23; BIMS score 9(Moderate Cognitive impairment). On 4/18/23 at 11:45am, V3 (Social Services Director/Psychiatric Rehabilitation Services Director/PRSD) was interviewed, with reference to the above listed physical abuse incidents, about the individualized mental health services the facility provides for residents. V3 stated that he currently has two full-time psychiatric rehabilitation services coordinators, PRSCs/social workers (V4 and V5) working with him, with a part-time PRSC that works 4 hours two days a week. V3 explained that the social services department do their best to interact with the residents with the available staff. On 4/18/23 at 12:40pm, V1 was asked about the services of social workers/PRSCs at the facility. V1 stated that right now, V3 (PRSD) is the only social service staff in the building because the PRSC(V4) called off for the day. V1 added that one PRSC quit around November 2022 and the facility is trying to hire two PRSCs, one for day shift and one for afternoon shift. Facility's undated policy titled Abuse Prevention Policy states in part: Residents have the right to be free from abuse, neglect, and exploitation, misappropriation of property or mistreatment. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

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 F0742 (Tag F0742)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to provide appropriate person-centered and individualized psychosocial and mental health services to meet the assessed needs of ...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to provide appropriate person-centered and individualized psychosocial and mental health services to meet the assessed needs of the residents. This failure has the potential to affect 5 residents (R2, R3, R4, R5, and R6) reviewed for psychosocial and behavior health needs, and other residents that require therapeutic interventions from social services staff as stated in the care plan. Findings include: On 4/18/23 at 11:15am after the entrance conference, V1 (Administrator) presented the facility census as 163 residents. V1 later presented the list of 98 residents with diagnoses of severe mental illness (SMI). On 4/18/23 between 11:30am and 1:20pm, residents (including R9 and R10) and nursing staff, including V10 (Licensed Practical Nurse/LPN) and V11 (CNA/Certified Nurse Assistant) were observed and interviewed on the nursing units regarding the availability of social services staff to speak with residents individually. V10 and V11 (on the fourth floor) stated that the social worker was not there on the floor. No staff from social services department was observed on the floor talking with any resident. On 4/18/23 at 11:45am, V3 (Social Services Director/Psychiatric Rehabilitation Services Director/PRSD) was interviewed regarding the individualized mental health services the facility provides for residents. V3 stated that he currently has two full-time psychiatric rehabilitation services coordinators, PRSCs/social workers (V4 and V5) working with him, with a part-time PRSC that works 4 hours two days a week. Inquired from V3 about any of the PRSC/Social worker in the building working with residents; The surveyor informed V3 that there was no PRSC observed on the units talking to any resin the building at the time except him (PRSD) and that they do the best they could do to talk to the residents. V3 added that the facility is in the process of hiring a new PRSC. V3 was asked to present the residents' caseloads for each PRSC. V3 stated that currently, he (PRSD) takes care of all the residents on the third floor, V4(PRSC) takes care of fifth floor, V5(PRSC) takes care of fourth floor, and all three (V3, V4, V5) share the case load and take care of residents on the second floor. On 4/18/23 at 12:40pm, V1 was asked about the services of social workers/PRSCs at the facility. V1 stated that right now, V3 (PRSD) is the only social service staff in the building because the PRSC(V4) called off for the day. V1 added that one PRSC quit around November 2022 and the facility is trying to hire two PRSCs, one for day shift and one for afternoon shift. On 4/20/23 between 10:30am and 11:35am, on the fourth and fifth floors, there was no PRSC/Social worker talking to residents. Residents (R8, R9 and R10) were asked if they have seen the social worker today. All 3 residents denied seeing any social worker. Also, V12(Ancillary Staff on the fifth floor) stated she(V12) has not seen the social worker on the fifth floor so far. On 4/20/23 at 11:45am, V4(PRSC assigned to the fifth floor) was asked why she(V4) has not been to the floor to see residents since the beginning of the shift. V4 responded I have been up and down trying to make up for the floors that have no PRSC since we are only two in the building right now. I have not had a chance to see residents on the fifth floor. On 4/20/23 at 11:55am, both V3 and V4 were called into the conference room to express the concern that the surveyor did not observe social services staff on the nursing units interacting with the residents. V4 explained that in the past, there was one PRSC that quit in November 2022 and no longer works at the facility. On 4/18/23 at 1:45pm, V1 brought the list of all 163 residents with the social worker assigned to them; the list indicated each social worker is assigned an average of 54 residents. V3 was asked how he and the other two staff can provide individualized psychosocial and mental health therapy to an average of 54 residents each; V3 did not respond. At this time, V1 (Administrator) was called in by the surveyor to express the concern that only three social services staff were responsible for 163 residents. V1 stated that they had advertised the positions and made efforts to hire more social workers to meet the needs of the residents. Care plans for all 5 residents that were recently involved in resident-to resident physical abuse were reviewed. These care plans show that the residents have behavioral issues and/or aggressive behaviors, and the interventions show that the residents need social skills training, reassurance, and other supportive interventions as needed. The residents' care plans are dated as follows: R2's care plan with latest revision date 1/30/23. R3's care plan with latest revision date 4/5/23. R4's care plan with latest revision date 2/7/23. R5's care plan with latest revision date 3/20/23. R6's care plan with latest revision date 4/4/23. Facility's undated document titled Responsibilities of the Psychiatric Rehabilitation Service Coordinator (PRSC) states, To provide and/or coordinate the delivery of the psychiatric rehabilitation services programs; to monitor the resident in the areas of self-directed care and for overall compliance with the treatment plan. #13 states to provide active listening with individuals on the assigned case load. The PRSC needs to establish a good rapport with residents and be available to provide behavioral intervention/counseling.

Apr 2023 9 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Based on observations, interviews, and record reviews, the facility failed to provide wheelchair arm rest for 1 (R4) and arm rest pads for 2 (R12, R15) of seven residents reviewed for accommodation of...

Read full inspector narrative →

Based on observations, interviews, and record reviews, the facility failed to provide wheelchair arm rest for 1 (R4) and arm rest pads for 2 (R12, R15) of seven residents reviewed for accommodation of needs. Findings include: On 04/04/23 at 11:41AM, observed R4 sitting in wheelchair with right arm resting on right arm rest, left arm hanging down toward R4's lap tipping R4 slightly forward and R4's left arm rest missing from R4's wheelchair. R4 stated his left arm brace has been missing for a long time and R4 would like it replaced. On 04/04/23 at 11:58 AM, V5 (Restorative Director/Licensed Practical Nurse) stated R4 has a customized chair and that V5 was not aware of anything being wrong with R4's wheelchair. V5 stated R4 can transfer himself from R4's bed into R4's wheelchair but needs the side of the wheelchair open without the arm rest for him to transfer himself and that the staff then puts the arm rest back on after R4 has transferred himself into R4's wheelchair. V5 stated the CNA and the restorative aide told V5 that R4's left arm rest bar was on R4's wheelchair this morning. V5 stated R4 should have both arm rests in place because R4 needs both of them for support. On 04/04/23 at 12:13 PM, observed R15 sitting in wheelchair in R15's room next to R15's bed. Observed R15's right and left arm rest pad missing from R15's wheelchair. Observed 2 holes in the metal arm rest poles where the right arm rest pad should be and a piece of worn black vinyl covering the left arm rest without any padding. R15 stated R15 would like the arm rests fixed. On 04/04/23 at 12:13 PM, V5 stated after looking at R15's left arm rest, that isn't anything but a piece of vinyl, there is no padding. On 04/04/23 at 12:41 PM, observed R12 sitting in wheelchair without arm rest pads. Observed 2 holes in the metal arm rest poles where the arm rest pads should be tightly wrapped in a blue surgical glove around the front hole on the right metal arm rest bar and another blue surgical glove tightly wrapped around the front hole on the left metal arm rest bar. R12 stated that R12 put those blue surgical gloves there because R12's arm was rubbing against the metal holes and it was bothering R12. R12 stated R12 would like arm rests for comfort. On 04/04/23 at 1:04 PM, V5 stated R12 and R15 should have padded arm rests and the facility can add arm rest pads to the metal arm rest poles today because the facility has extra arm rest pads to add to R12 and R15's wheelchairs and R4 will be provided an different wheelchair with two arm rests. On 04/04/23 at 12:25 PM, V22 (Certified Nursing Assistant) stated V22 is taking care of R4 today and R4 did not have both arm rest bars on his wheelchair and that R4 needs both arm rest bars to help R4 with transferring. R4's MDS (Minimum Data Set) dated 02/15/23 BIMS (Brief Interview for Mental Status) score is 11 indicating moderately impaired cognition and section G (Functional Status) documented in part mobility devices normally used wheelchair and supervision required for transfers. R12's MDS (Minimum Data Set) dated 02/22/23 BIMS (Brief Interview for Mental Status) score is 11 indicating moderately impaired cognition and section G (Functional Status) documented in part mobility devices normally used wheelchair and supervision required for transfers. R15's MDS (Minimum Data Set) dated 03/15/23 BIMS (Brief Interview for Mental Status) score is 09 indicating moderately impaired cognition and section G (Functional Status) documented in part mobility devices normally used wheelchair and supervision required for transfers. Facility provided document titled, Preventative Maintenance Program dated 11/14 documents in part, Maintenance Director and/or Housekeeping Director conducts regular environmental tours/safety audits to identify areas of concern within the facility and resident equipment is in working order (i.e.: Hoyer lifts, beds, wheelchairs, etc.) Facility Assessment Tool dated 1/17/23 documents in part ensure equipment is maintained to protect and promote safety of residents with examples including wheelchairs and associated positioning devices.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interviews and records review, the facility failed to address advance directives with residents and ensure documentatio...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interviews and records review, the facility failed to address advance directives with residents and ensure documentation of advance directives status for two residents (R140, R132) reviewed for Advance Directives. This failure has the potential to effect 32 residents reviewed. Findings include: On [DATE] at 11:40am, R140 was observed in room and was alert to person and said, I am ok. On [DATE] at 12:05pm V2(Director of Nursing) said that Social Services are responsible of getting residents to signature the PLOST (Physician Orders for Life-Sustaining Treatment) forms on admission. V2 said after the resident signs the PLOST form, the form is given to V2, then V2 gets the nurse practitioner of the physician to sign it. Once the form is signed, V2 puts it in the physician orders, and it automatically updates on the face sheet and shows what care a resident should receive in case of an emergency. V2 said advance directives are used for life saving procedures and they left Nursing staff know what care to provide to a resident in case of an emergency. V2 said if a resident is a full code, we will do need to do everything we can to safe that person. V2 further said if code status/Advanced directives are not on file, then nurse will be assuming that the resident is a full code because there is no code status on file, and this can be potentially going against resident rights/wishes. On [DATE] at 12:54 PM, V21 (PRSD/Social Service Director) stated When a resident is admitted to the facility, Social Services talks to the resident admissions to find out the resident's wish for life saving care in case of an emergency. V21 said if the resident wants to be resuscitated if there is an emergency, then they fill out and sign the POLST (Practitioner Order for Life-Sustaining Treatment) form. If the resident does not want to be resuscitated, then we write refuse on the POLST form, and the resident checks/clicks the box to say do not resuscitate. V21 further stated that If the resident refuses to sign the POLST form, Social Services takes the POLST form to the DON(Director of Nursing), who then contacts the resident doctor and lets the doctor know the resident refused to sign. V21 said all this is done upon resident admission to the facility, even if it's a re-admission from the hospital, and should be re-done/completed within 24 hours. V21 said it was important for the resident to have advance directives on file to make sure nurses know what kind of care to give to the resident in case of an emergency. V21 said residents have a right to either give permission for CPR (Cardiopulmonary Resuscitation) or refuse CPR to be performed in case the resident experiences a medical emergency. On [DATE] at 3:04pm R140 was observed in R140 room drinking soda from a soda can and eating chips. R140 was oriented to person and when asked how R140 was doing, he said I don't know, I am ok R140's BIMS (Brief Interview for Mental Status) dated [DATE] document R140's BIMS as 8/15, indicating R140 is cognition is moderately impaired. R140's medical records does not document code status/ advance directives. Reviewed R140's medical records with V2(Director of Nursing). V2 said I don't see any Advanced Directives for R140, in physician orders, on face sheet, or on care plan. V2 stated R140 should have advance directives on file so that in case of an emergency, staff will know what care to provide to R140. According to POS(Physician Order Sheet) dated [DATE], R140 was initially admitted to the facility on [DATE]. Facility policy titled: Advance Directives Documents, no date: -At the time of admission each resident will be asked if they have made advanced directives and provided educational information regarding state and federal law Findings include: Review of R132 electronic medical chart indicate: no advance directive/code status on the face sheet dated [DATE]; R132 has no advance directive care plan; no social service note indicating advance directive/code status Facility provided POLST form dated [DATE], after failure was brought to the attention of the facility. Facility policy Advance Directives, no date, documents in part: 5. Copies of the resident's Advanced Directive shall be made and maintained in the resident's clinical record and financial folder. 7. If a resident or health care representative indicates an Advanced Directive regarding CPR, the appropriate forms will be completed. 12. Advanced Directive(s) shall be addressed on the resident's plan of care, physician progress notes, and physician's orders and in Social Service Progress Notes.

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 interview and record review, facility failed to follow their policy to ensure residents are free from physical abuse by providing necessary care in services thus resulting in a female residen...

Read full inspector narrative →

Based on interview and record review, facility failed to follow their policy to ensure residents are free from physical abuse by providing necessary care in services thus resulting in a female resident having injuries of unknown origin for 1 (R24) out of 32 in the sample residents reviewed for abuse. Findings include: R24's Face sheet dated 4/4/23, documents in part: Diagnosis- catatonic and paranoid schizophrenia, dementia with behavioral disturbance. On 04/04/2023 at 11:00 AM, surveyor observed R24 laying on her bed. Surveyor asked R24 if he can speak with her but she (R24) stated, Just get out. R24's MDS(Minimum Data Set) dated 4/20/23 section C, Cognitive Patterns: Documents in part BIMS score assessment not complete due to R24's cognitive impairment. R24's cognitive skills score for daily decision making indicate cognition is severely impaired. R24 has memory problem for short term and long-term memory. R24 is unable to complete brief interview for Mental Status. R24 has inattention and disorganized thinking. On 04/04/2023 at 12:30 PM, V26 (Licensed Practical Nurse) stated, I came into work at 7:00 AM on 3/31/2023. When I came in, I saw R24 had scratches and discoloration underneath her right eye. called and told V1 (administrator) right away. When was working the day before on 3/30/2023, R24 did not have any discoloration or scratches. When I received change of shift staff report on residents on 3/31/2023 from the night nurse, I did not hear anything about falling. R24 is ambulatory and she is a very big wanderer. R24 is not cognitively intact. Statement of witness incident by V28 (Certified Nursing Assistant) for R24's abuse incident on 3/31/2023 documents in part: As I was collecting trays, I heard screams from R24. I then saw V12 (Certified Nursing Assistant) come out of the room. The nurse assigned to R24 was never in the room, the nurse was walking back and forth towards the med cart. Statement of witness incident by V12 (Certified Nursing Assistant) for R24's abuse incident on 3/31/2023 documents in part: When I last saw R24, she was going into resident's room to take another resident's snacks. Then I took her (R24) out of the residents room. But after that I gave her a shower and laid her down, R24 was still going into other residents' rooms. On 04/06/23 at 01:45 PM, V12 (Certified Nursing Assistant) stated that R24 wanders a lot. V12 stated that R24 takes people's things and stuffs them into her (R24) diapers. V12 stated that R115 (a resident on the 3rd floor) told me that he hit her (R24) on the head with the bed remote control. V12 stated R24 is at risk for abuse because she is a wanderer. V12 stated, I have never hit or physically abused R24. Reviewed R24's shower sheet for 03/2023. R24 has no documented shower on 3/30/2023. On 04/06/23 at 1:58 PM, V21 (Director of Social Services) stated he is the social worker for R24. V21 stated, most of the time, R24 wonders into other people's rooms. We try to talk to R24, educate her but because of R24's dementia, she doesn't remember or want to remember. CNAs are constantly redirecting R24. These interventions don't seem to be working for her. V1 stated, R24 wondered into someone's room, that person asked R24 to leave, and R24 had a scratch on her face the next day. V21 stated that V1 (Administrator) told V21 that another resident(R68) scratched R24's eye. V1 stated that R68 is also a resident on the 3rd floor. V21 stated that R24 is at risk for abuse because of her diagnosis and wandering. Statement of witness incident by V29 (Certified Nursing Assistant) for R24's abuse incident on 3/31/2023 documents in part: I came in this morning and seen R24 in the dining room with red marks on her (R24) face. Statement of witness incident by V30 (Certified Nursing Assistant) for R24's abuse incident on 3/31/2023 documents in part: When passing trays in the day room, I (V30) notice R24's eye was dark. I (V30) let the nurse know and they came to see. Statement of witness incident by V31 (Ancillary Staff) for R24's abuse incident on 3/31/2023 documents in part: As I was taking the resident to the day room today, I noticed the bruise on her (R24) face. I then reported it to V26 and V9 (Registered Nurses). Reviewed R24's Behavior care plan dated 9/14/21. The was no update on care plan to monitor for wandering. Also, no documentation of new interventions after R24's abuse incident on 1/9/2023. On 04/06/23 at 12:07 PM, V1 (Administrator) stated that R24 has history of being assaulted. V1 stated, on 1/9/2023, a staff member reported to me that a CNA hit R24 . The incident on 1/9/2023 took place in the dining room at 9:30 AM. That CNA is not working the facility anymore. At the conclusion of the investigation, she was terminated. We just reported the final investigation to the State Agency. V1 stated, someone from the state came, investigated, and cited us for the abuse allegation that happened on 1/9/2023 to R24. V1 stated, I was made aware of R24 having scratches and discoloration on 3/31/2023. V1 stated, she has submitted an initially report to IDPH. As of now the investigation is still on-going. V1 stated that R24 is at risk for abuse. Facility's Abuse Prevention Program Policy undated documents in part: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury with resulting physical harm, pain or mental anguish. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. Federal and state laws and regulations mandate that a nursing home resident has the right to be free from verbal, sexual, physical, and mental abuse. Injury of unknown source are injuries where the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident. The injury is suspicious because of the extent or location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time.

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 observation, interview, and record review the facility failed to provide an environment free from accident hazards by a.) having an exposed light bulb without a cover and no ability for one r...

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to provide an environment free from accident hazards by a.) having an exposed light bulb without a cover and no ability for one resident (R102) to turn the light on and off, b.) not providing supervision or monitoring for one resident (R147) while shaving. These failures affected two (R102, R147) of seven residents reviewed for potential accidental hazards in the survey sample of 32 residents. Findings include: On 04/04/23 at 11:01 AM, observed exposed light bulb installed on the wall over R102's bed without a light cover or pull cord and no overhead light near R102's bed. R102 stated he uses the light at night so he could see. R102 stated, I turn the bulb with my hand to get it on and at night when I turn the light off the light bulb is really hot, so I need to wet my fingers with my spit, so I don't burn my fingers. R102 stated he asked maintenance staff back in January 2023 to fix his light but no one had gotten to it yet. On 04/05/23 at 12:43 PM, V11 (Maintenance Assistant) stated light bulbs should have a cover over them and have a pull string so the residents can turn the light on and off. V11 stated if a resident is touching a light bulb to get the light to turn on and off that is bad because the light bulb could break which could shatter glass everywhere and this could cut a resident. V11 stated the other thing that could happen is the resident could burn themselves. V11 stated V11 was not aware of R102's exposed light bulb and stated there are light covers and pull switches in the building so V11 could fix R102's light. On 04/05/23 at 12:52 PM, V12 (Certified Nursing Aide) viewed R102's light above R102's bed and stated, I don't know how he'd (V12) turn on the light, there is no pull string. Surveyor observed V12 asked R102 how he turns on the light and R102 got up and twisted the light bulb with his hand which turned on the light. V12 then told R102 not to do this because it was not safe and R102 stated, I do it all the time. On 04/06/23 at 2:15 PM, V24 (Maintenance Director) met surveyor in R102's room. V24 observed the light bulb mounted on the wall behind R102's bed. V24 stated that is an outside light and should not have been installed in a resident's room. V24 stated there is no way for R102 to turn the light on or off and V24 was not aware that R102 had this type of light installed in R102's room and the light needed to be removed. V24 stated none of the staff or R102 reported this to the maintenance department. V24 stated the maintenance staff do not go into each resident's rooms when they do round the unit daily, they rely on the unit staff to make them aware of items in need of repair. V24 stated there is no overhead light near R102's bed and that R102 needed the light behind R102's bed to see at night, otherwise the room would be very dark. V24 stated if R102 twisted the light bulb with R102's hand to turn it off R102 could burn R102's hand. R102's MDS (Minimum Data Set) dated 03/22/23 BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognition. Facility provided document titled, Preventative Maintenance Program dated 11/14 documents in part, Maintenance Director and/or Housekeeping Director conducts regular environmental tours/safety audits to identify areas of concern within the facility and all electrical equipment is checked for safety. Facility Assessment Tool dated 1/17/23 documents in part ensure equipment is maintained to protect and promote safety of residents with examples including nightlights. Residents' Rights for People in Long-Term Care Facilities from the Illinois Department on Aging which documents in part that the facility must be safe. Findings include: On 4/4/23 at 11:55 AM, surveyor was in R147's room talking with one of the residents roommate. While inside the room, surveyor heard R147 in the bathroom with the door closed, making noise that sounded like something was being hit against something else. There was no facility staff in the room/vicinity. Surveyor returned to R147's room with V22(Certified Nursing Assistant/CNA). R147 opened the door of the bathroom and said he was shaving. R147 had a blue, stick razor in hand and R147's face was wet. According to MDS (Minimum Data Set) section G, date 2/15/2023, R147 requires supervision with personal hygiene including shaving. R147 diagnoses include but are not limited to schizoaffective disorder, epilepsy, alcohol abuse, generalized anxiety disorder, depression, borderline personality disorder, extrapyramidal and movement disorder. R147 care plan documents in part: R147 has a history of self-harmful ideation (thoughts) and/or behavior. Problems/needs are manifested by: voicing threats of self-harm. Care plan intervention includes: as warranted conduct a room check/search and remove: any sharp objects or similar contraband (razor blades, razors, knives, scissors, hammer, nails, screw driver, screws, needles). On 4/4/23 at 12:03 PM, V22 stated Some residents can shave themselves. All residents should be monitored while shaving. They should be monitored in case they cut themselves. Residents should only have a razor when shaving. On 4/4/23 at 12:10 PM, R147 stated I got the razor from the nurse. They always let me shave by myself. On 4/4/23 at 12:22 PM, Surveyor asked V22 if the razor was retrieved from R147. V22 instructed V27(Certified Nursing Assistant) to retrieve the razor from R147. On 4/4/23 at 12:23 PM, Surveyor observed V27 return from R147's room with 2 blue, stick razors that V27 retrieved from R147. On 4/4/23 at 12:24 PM, V27 stated R147 got the razor from me. R147 asked for a razor to shave. I gave R147 2 razors. This is my first time working on the 4th floor. Some residents need monitoring while shaving. I wasn't aware R147 needed monitoring. I should have asked someone if R147 needed monitoring. The monitoring is needed for safety, to make sure they don't cut themselves or anyone else. On 4/06/23 at 11:13 AM, V5 (Restorative Director) stated R147 has aggressive behaviors. When angry, R147 has a tantrum (cussing, knock something over). I've witnessed R147 throw something. R147 has attempted to pick up a chair to throw it. R147 has good days and bad days. On bad days R147 can be aggressive. R147 spit on a CNA last week. Everyone is supervision with anything that goes in the sharps container. Blue, stick razors with the blades go in the sharps container. A staff person should be in the vicinity of the person shaving and retrieve the razor from the person. The resident should not be in the bathroom with the door closed with the razor. There is potential for self-harm, it is a sharps. Absolutely, there is potential to hurt someone else with the razor. R147 care plan documents in part: R147 is diagnosed with schizoaffective disorder and displays behavioral symptoms related to: severe mental illness, poor and/or ineffective coping skills. These behavioral symptoms are manifested by physical abuse/aggression, socially inappropriate and/or maladaptive/disruptive behavior. Facility policy Supervision and Safety, not dated, documents in part: 4. Resident supervision is a core component to resident safety. 9. Staff to decrease safety risk factors as much as possible.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observations, interviews, and record reviews. The facility failed to A) follow their infection prevention and control policy when staff entered a room of one [R61] resident on transmission-ba...

Read full inspector narrative →

Based on observations, interviews, and record reviews. The facility failed to A) follow their infection prevention and control policy when staff entered a room of one [R61] resident on transmission-based precautions without the appropriate personal protective equipment [PPE], and B) staff failed to perform hand hygiene after touching high touched areas in the isolation room for one [R61] of 32 residents in the sample reviewed of transmission-base precautions. Findings include, On 4/5/23 at 8:30 AM, surveyor observed V18 [Certified Nurse Assistant] walk directly into R61's room with R61's breakfast tray. V18 did not apply any appropriate PPE. V18 was touching R61's personal items moving them on the bedside table to place down the breakfast tray. Also, V18 touched the bed adjusting handle at the foot of R61's bed to rise the head of the bed. V18 exited R61's room without hand washing or applying alcohol gel. On 4/5/23 at 8:35AM, V18 stated, I know R61 is on isolation, but I only went in to give R61 their breakfast tray, I did not provide any personal care. I moved some of R61's personal items around to place the breakfast tray at the bed side. I adjusted R61's bed by physically rolling around the arm and the foot of the bed, to rise R61's head so she can eat. I forgot to wash my hands or use alcohol gel after touching R61's personal items and bed. On 4/5/23 at 8:45 AM, observed V17 [Certified Nurse Assistant] walk into R61's room without applying appropriated PPE. V17 touched some items on R61's food tray, and bed. V17 exited R61's room without handwashing or using alcohol gel. On 4/5/23 at 8:48 AM, V17 stated, I know R61 is on isolation, and I should have placed on a gown and gloves, but just forgot to do it, I apologize. I did not wash my hands because I did not touch R61. I did touch R61's breakfast tray, helping R61 out, I should have washed my hands, leaving out R61's room. On 4/5/23 at 8:56 AM, V19 [Licensed Practical Nurse] stated, R61 is on strict contact isolation because R61 has an infected wound with methicillin-resistant staphylococcus aureus [MRSA]. Anyone that enters the room should place on a gown, and gloves. The staff is already wearing a mask at all times. The staff that enters and exit the resident's room should hand wash or use alcohol gel to prevent the spread of infection. On 4/6/23 at 11:40 AM, V7 [Infection Preventionist] stated, I am the facility's infection preventionist. I am responsible to place the appropriate signage on the isolations room doors. The facility currently has one resident on isolation, R61. The signage on R61's door was placed upon R61's admission in December 2022. Upon R61's admission she only had a surgical wound with no infection. I placed an enhanced barrier precaution, stop sign to check in with the nurse before entering the room, sequence how to apply PPE, and the sequence on how to remove PPE signs on R61's room door. R61 has a physician order dated 3/3/23- Strict isolation for MRSA of the back wound. Once R61 surgical wound opened and was infected with MRSA, I forgot to update the correct signage. I will remove the enhanced barrier precautions sign and place contact isolation signage up on the door. All staff that enter and exit any resident's room on isolation or not, should engaged in handwashing to prevent the spread of known or unknown possible infections. If the staff do not hand wash or wear appropriate PPE, that failure could potentially cause an outbreak, spread infections, and make residents sick. On 4/6/23 at 11:55 AM, V2 [Director of Nursing] stated, All staff should place on the appropriate PPE prior to entering a resident's room and hand wash before and after entering and exiting the room. If the staff is not applying the appropriate PPE and/or handwashing, that could potentially spread infection to other residents. R61's medical record documents in part; admission date 12/30/22. Medical diagnosis of surgical incision of disc displacement, lumbar region, resistant to vancomycin, methicillin resistant staphylococcus aureus infection, and infection following procedure. Physician order dated 3/3/23 strict isolation for MRSA of wound (back). Infection Control Policy dated 9/2014: Documents in part: -It is the policy of this facility to maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to prevent or eliminate, when possible, the development and transmission of disease and infections. -All facility personnel are required to routinely wash hands and use appropriate barrier precautions to prevent transmission of infections -Handwashing is essential. Alcohol based hand rubs/gels is the Gold Standard of Prevention. -Contact precautions in addition to standard precautions will be initiated as specified in the specific isolate policy. Handwashing Policy dated 9/2014 -All facility staff will practice handwashing activities with an antimicrobial agent or water-less antiseptic agent in accordance with this policy. -Handwashing before and after resident contact -Handwashing between tasks and procedures -Handwashing before leaving the room of a resident in an isolation room -Handwashing after handling food or food trays

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

Based on observations, interviews and records review, the facility failed to ensure a safe system of narcotic storage/disposition for four (R26, R50, R22, R57) residents, failed to accurately reconcil...

Read full inspector narrative →

Based on observations, interviews and records review, the facility failed to ensure a safe system of narcotic storage/disposition for four (R26, R50, R22, R57) residents, failed to accurately reconcile controlled medications for one (R147) resident reviewed for narcotic storage and labelling in two of four medication carts reviewed. Findings include: On 4/4/2023 at 10:58am, during medication storage and cart inspection with V4(Licensed Practical Nurse-LPN) on the fifth floor, observed several narcotic medications bingo cards containing residents' medications with security blister backs opened/broken, then taped up. Observed with V4, security seal broken on medications for R26, R50, R22 as follows: -R26's medication Ativan tablet 0.5mg, #30 on bingo card security seal was broken, then taped back to hold the medication in. - R50's medication -Ativan 1MG, open bingo card, #-7,8, 5, 13, 9 27, 28, security seal was broken, then taped back to hold the medication in. On another bingo card of Ativan 1Mg, security seal broken on bingo card number 8 & 9, then broken seal taped to hold the medication in. -R22's medication- Hydrocodone/APAP-10/325mg, security seal broken on bingo on one bingo card containing 30 pills. Broken seal on number 3 &4, taped back to hold medications. On another bingo card for R22's medication- Hydrocodone/APAP-10/325mg, security seal broken on bingo card number 3, 4, 14,15, 10, 18, then taped back. On 4/4/2023 at 10:58am, V4 said that the medications should not be taped back in if or when the security blister is broken because you don't know if that is the same original medication that has been taped back in the bingo cards or if it is another medication that was put in to replace the original medication. V4 said since the nurses don't know for sure what the pill is because of the broken medication security seal, the opened medication should not be taped to keep the medication on the bingo cards because the security seal is broken, and residents should not be receiving these medications because it can be something else other than the original medication and if given to the resident, it might cause an allergic reaction or it might the wrong medication and can have adverse effects on the resident. V4 said if a medication is opened, it should not be taped back but discarded or sent back to pharmacy, then documented on the resident narcotic sheet that the medication was wasted or returned to pharmacy. On 4/4/2023 at 11:48am, during medication cart and storage inspection on the fourth floor with V8 (Licensed Practical Nurse), observed R57's medication Clonazepam Tablet 0.5 mg bingo card with broken seal on #8 & #29, then on another of R57's another bingo card with 30 tablets for Clonazepam 0.5mg tablet open #10, 11, 23s had security seal broken and taped back to hold the medications in on number 10, 11, &23 of the bingo card. V8 said I am from the agency. I am not the one who broke the security seal then taped it back to hold the medications. V8 said the bingo cards with broken medications should be discarded or sent back to pharmacy to get new medication that is properly sealed. V8 said having the unsecured narcotic medications can lead to theft, because the medication can be exchanged, or the medication can lose its potency because of the broken seal and should not be given to residents. On 4/4/2023 at 11:48am, observed with V8, two bingo cards for R147's medication Diazepam 0.5 mg with 30 tablets. Narcotic medication sheet documented 15 tablets and was signed off as containing 15 tablets. V8 said when the nurse receives the medications, the receiving nurse is supposed to reconcile the medications with the narcotic sheet when are medications are delivered. V8 further said it is important to make sure the medication count is correct and matches what is on the narcotic sheet matches what's on the bingo carts, because someone could steal the excess medications. On 4/5/2023 at 12:38pm, V2(Director of Nursing) said narcotics are kept in a locked box so that they are not abused. V2 said any narcotics with broken seals are not safe to be given to residents and should be returned to pharmacy because the medication could be switched out, then the resident would be given the wrong medication. V2 further said that the nurses are supposed to make sure the medications brought by the pharmacy are the correct medications, the right count and right dosage, before signing off the medication. V2 said the nurse messed up on this one, the nurse wrote the wrong amount/number of tablets at hand and should have read the medications ordered and the bingo card then compared with the delivery sheet to make sure the medication was documented correctly. V2 said miscounting the medication can lead to wrong dose and or overdose to the resident, and or theft of the excess medications. Facility policy titled: Medication Storage, dated 2/14 documents: Narcotics should be maintained in the medication cart and counted daily as per policy

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to follow their recipes and give adequate portion sizes. This failure has the potential to affect all 163 residents receiving foo...

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to follow their recipes and give adequate portion sizes. This failure has the potential to affect all 163 residents receiving food prepared in the facility's kitchen. Findings Include: On 04/05/23 at 10:08 AM, V13 (Cook) stated that 1 portion of ham is equal to four slices of ham to yield a 3-ounce portion. V13 stated that she has 8 residents on a pureed diet. Observed V13 count off the number of slices of ham as V13 put them into the blender. V13 stated, I put 16 slices into the blender. Observed V13 add 8 - 3 ounce ladles of ham broth to the sliced ham in the blender and then press the on button. Observed the mixture to be very watery. V13 stated that because the consistency was so thin, V13 needed to add thickener to the mixture to make it thicker. Observed V13 add 4-1 ounce ladle of food thickener to the watery ham mixture one ounce at a time until desired consistency was reached. On 04/05/23 at 10:26 AM, surveyor asked V13 if V13 has access to recipes. V13 stated, there are no recipes for me to follow, I just kind of know what to do. On 04/05/23 at 10:27 AM, V13 stated there are 12 residents on mechanical soft diet and a 3-ounce serving should be served to each resident. Surveyor observed V13 count out 24 slices of ham and put them in a mechanical blender and then transfer to a container in preparation for the tray line. On 04/05/23 at 12:02 PM, observed the tray line in progress and the following serving equipment being used on the tray line: pureed ham (#8 scoop), pureed peas (#12 scoop), ground ham (#8 scoop), regular green peas (4 ounce spoodle), scalloped potatoes (#12 scoop), baked ham (metal tongs). On 04/05/23 at 12:10 PM, observed the tray line in progress and observed the baked ham being served on the tray line to residents on regular consistency diets. Sliced ham appeared uniform in size, and thicker than the ham used to prepare the pureed and ground ham. Each slice of ham was cut in half and every resident on regular diet consistency was given one piece of the baked ham unless they had an order for double portions. The one piece of baked ham being served appeared to be less than 3-ounces as documented on spreadsheets and recipe. Surveyor asked V13 to select a piece of ham from the tray line and put on a plate. Surveyor then asked V6(Food Service Director) to weigh the selected piece of ham. V6 weighed the piece of ham using an industrial kitchen scale and the ham sliced weigh 1.8 ounces. V6 stated, it should be 3 ounces, one slice is not enough. V6 stated if the right portion sizes are not given then the residents could lose weight and they would not receive enough protein. On 04/05/23 at 12:16 PM, surveyor observed 14 residents on the 2nd floor being given 1.8-ounce sized piece of ham. No extra ham or other protein source was offered to the residents. On 04/06/23 at 12:12 PM, V6 stated that the ham used for the pureed was sliced very thin and one slice was equivalent to approximately 1 ounce. V6 stated that the recipe for pureed baked ham documents that to serve 8 portions 1.5 pounds of ham and 1 2/3 cup liquid should be used. V6 stated that 1.5 pounds is equivalent to 24 ounces or 24 slices of ham. Surveyor shared observations from (04/05/23) that V13 used 16 slices to prepare the pureed ham and added 24 ounces of liquid. V6 stated V13 did not use enough meat and too much liquid and that means the residents did not get the right amount of nutrition which could make the food less appealing and lead to weight loss. On 04/06/23 at 12:24 PM, V6 stated that the facility has 22 residents on ground diets, not 12 residents and that 4 pounds 6 ounces of ham should have been used to follow the recipe. Surveyor told V6 that V13 prepared the ground ham on 04/05/23 using 24 slices of ham. V6 stated, that is not enough ham. It should have been 64 slices to give 3 ounces per resident. V6 stated that 24 slices of ham would only serve 8 residents on ground diets and that the facility has more than 8 residents on a ground diet. On 04/06/23 at 12:56 PM, spoke with V25 (Consulting Registered Dietitian) over the phone. V25 stated the menus are approved by a Registered Dietitian from the company that provides food to the kitchen and that it is important for the cook to follow the menus and recipes because the residents need appropriate amounts of calories, protein, vitamins, and minerals. V25 stated if residents should have received 3 ounces of ham based on the recipe but instead was served less than 3 ounces then this would not meet the resident's nutritional needs because it is not enough protein and if this is a consistent issue this could lead to issues with weight loss and worsening skin breakdown. Foods service facility Job Description titled, Cook dated 2017, documents in part, to prepare nutritious and appetizing foods according to menus and recipes, must be able to do basic math calculation, prepare all food as planned on the cycle menu for the clients, prepare all foods for the clients on special diets as planned on the extended menus, follow standardized recipes in food preparation to ensure quality of foods prepared and to prepare the correct amount of food. Kitchen spreadsheets for Wednesday, Week 4 lunch documents 3 oz. baked ham for regular diet consistencies. Kitchen recipe titled, Baked Ham dated 2023 documents in part, 3 ounce serving. Kitchen recipe titled, Pureed Baked Ham w/Gravy dated 2023, documents in part, to yield 8 servings use 1 1/2 pounds baked ham, 1 2/3 cups water and 1 ½ teaspoon chicken base. Kitchen recipe titled, Ground Baked Ham w/Gravy dated 2023, documents in part to yield 22 servings use 4 pounds 6 ounces, 1 quart 3 cups water, 2 ¾ ounce gravy mix.

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 and dated; b.) the facility failed to clean ice machine; c.) the facility failed t...

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to a.) ensure food items were properly labeled and dated; b.) the facility failed to clean ice machine; c.) the facility failed to ensure that cook-service ware were air dried after being sanitized; d.) facility failed to reheat prepared pureed food to 165 degrees. These deficient practices have the potential to affect all 163 residents receiving food prepared in the facility's kitchen. Findings include: On 04/04/23 at 9:24 AM, during initial kitchen tour surveyor with V6 (Food Service Manager), surveyor observed the kitchen ice machine door not fully closed. Surveyor opened and closed the ice machine door and observed that the ice machine door did not fully close or make a tight seal. V6 acknowledged that the door of the ice machine did not close all the way. Surveyor observed the inside of the ice machine with drips of condensation pooling in circles and areas of dark gray-black substance on the top ceiling of the ice machine. V6 stated, that looks like mildew or mold and the risk is that it could drop on the ice and make someone sick. V6 stated that the ice is sent up to the nursing units to be put in coolers with water for residents to drink. V6 stated that the ice machine is cleaned by the kitchen staff once per week and involves the kitchen staff wiping down the outside surface area of the ice machine and around the door opening of the ice machine. V6 stated that kitchen staff does not empty the ice or clean inside the ice machine. V6 stated, I don't have the right kind of staff to do that type of work. V6 stated V6 has been working at the facility for 9 months and the ice machine has not been cleaned professionally by an outside company since V6 has been employed at the facility. On 04/04/23 at 9:31 AM, V6 stated food items should be labeled with a delivery date and then labeled with an open and expiration date once opened by a staff member for use. Surveyor observed large, opened package of sliced American cheese rewrapped in plastic wrap and a plastic bag filled with parsley without a label or date in the walk-in refrigerator and V6 stated, they should be labeled and dated otherwise staff would not know when it was opened or how long the items will last. On 04/04/23 at 9:35 AM, observed opened one gallon container of yellow mustard in the walk-in refrigerator labeled with a delivery date of 07/01/22. Surveyor asked V6 when this items was opened and V6 stated, I don't when it was opened because there is no label or opened date on it, it should be thrown out. On 04/04/23 at 10:01 AM, observed large bins labeled with the words, oatmeal, flour, thickener, rice, and popcorn containing listed foods. None of the bins had the date the item was opened and/or the date by which the item should be discarded or used by. On 04/04/23 at 10:02 AM, observed the plastic lid on top of the bin containing food thickener to be broken with a missing piece of plastic. V6 stated the potential problem with the broken plastic lid is that it creates a risk for pest contamination. On 04/05/23 at 10:15 AM, during pureed food preparation observed V13 (Cook) put the blender container and lid in the dish room area. At 10:17 AM, V14 (Dietary Aide) pulled the blender container and lid out of the clean side of the dishwasher and gave the blender and lid back to V13. Surveyor observed inside of blender dripping wet with water droplets. At 10:18 AM, observed V13 add green peas to the blender and turn on the blender to puree the peas. V13 then covered the pureed peas with foil and put into the kettle which contained a water bath. V13 stated that V13 does this to get the temperature back up to 145 degrees or higher before putting the pureed food on the tray line for service. On 04/05/23 at 10:32 AM, V14 (Dietary Aide) stated dishware and equipment sent through the dishwasher needs to air dry before using. V14 stated that V14 was the one who pulled the blender and lid out of the dishwasher and gave them to V13. V14 stated there was no time for the blender and lid to air dry because the cook (V13) needed it right away. On 04/05/23 at 11:03 AM, observed V6 taking temperatures of food items on the tray line using a thermometer with the following results: Pureed Ham (145 degrees), Pureed Peas (140 degrees). On 04/05/23 at 11:07 AM, V6 stated, you want all the food temperatures to be 145 degrees or higher. On 04/06/23 at 12:17 PM, V6 stated that plate wear and equipment should always be air dried and that there should not be any pooling or drips of liquid. Kitchen policy titled, Chest/Ice Scoop/Ice Machine Cleaning and Disinfecting dated 9/14, documents in part, purpose is to clean and reduce the microorganisms and the ice machine will be cleaned and disinfected monthly by the Dietary department. Standards for the ice machine include disconnect the ice machine, discard all ice and scrub all surfaces of machine using detergent solution. Kitchen policy titled, Labeling and Date Marking Foods dated 2010, documents in part, to decrease the risk of food borne illness and to provide the highest quality of food for the residents, prepared and packaged foods may be marked with the date received, the date opened and/or the date by which the item should be discard and large quantity food items that come in a box or a bag may be removed from the original package and stored in an ingredient bin that is labeled with the common name of the food, the date the item was opened and the date by which the item should be discarded or used by, and if opened the cold food item will be makes with the date opened and the date by which to discard or use by and recommended maximum storage period for opened, refrigerated yellow mustard is one year. Kitchen policy titled, Storage of Dry Goods/Foods dated 2010, documents in part foods stored in bins will be labeled and date unpacked, and open products will be labeled and tightly covered to protect against any contamination including from insects and rodents. Kitchen policy titled, Cleaning Procedure for Equipment and Utensils dated 2017 documents in part equipment and utensils used in food preparation will be cleaned and sanitized according to standard procedure and air-dry blender after sanitized. Kitchen recipe titled, Pureed Baked Ham w/Gravy and Pureed [NAME] Peas :undated documents in part to reheat to >165 degrees for at least 15 seconds.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review, the facility failed to ensure garbage and refuse were disposed of properly by not closing the lids of the dumpsters outside the facility. This defici...

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure garbage and refuse were disposed of properly by not closing the lids of the dumpsters outside the facility. This deficient sanitation practice has the potential to affect all 164 residents who reside in the facility. Findings include: On 04/04/23 at 10:11 AM, an observation of the outside garbage dumpster was conducted with V6 (Food Service Manager). Surveyor observed the lid of the outside garbage dumpster fully opened. On 04/04/23 at 10:12 AM, V6 stated the lids of the dumpster should be closed when not in use and that leaving the lids open is a hazard because rodents could be attracted to the garbage in the dumpster and get into the dumpster. On 04/04/23 at 1:30 PM, surveyor observed outside garbage dumpster lid opened. On 04/05/23 at 11:21 AM, V10 (Assistant Administrator/Housekeeping Supervisor) stated the outside dumpster lid should be kept closed to keep bugs and pests from getting inside the dumpster which could cause an infestation. Kitchen Facility policy titled, Garbage Disposal undated documents in part that the policy is to dispose of garbage and refuse properly with the purpose to reduce the risk of food borne illness and the dumpster should be kept closed at all times.

Mar 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

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 one resident (R1) out of four residents reviewed abuse. This failure resulted in a staff member being verbally...

Read full inspector narrative →

Based on record review and interview the facility failed to follow their abuse policy for one resident (R1) out of four residents reviewed abuse. This failure resulted in a staff member being verbally abusive to R1. The Finding Include: Facility abuse report dated 3/6/23 denotes that social service (V10) heard dietary staff (V1) using inappropriate language towards R1. \ R1's 3/6/2023 21:33 Health Status/Progress Note Text reads: It was reported to the writer that the above resident was verbally aggressed by (dietary) staff, incident was reported to appropriate staff and the staff was sent home due to a pending investigation. Writer assessed resident, no c/o pain nor distress, skin intact, verbal to make wants and needs known. Writer/staff will continue to monitor during shift, all needs met, safety maintained. R1 stated on 3/22/23 at 10:15 am she was in the hallway by the nurses station when she saw V1 drop the top to the ice cooler on the floor. R1 stated she told V1 that he should wipe it off before placing it back onto the cooler. R1 stated that V1 told her to mind your business B****. R1 stated she told the social service (V10) and then he approached V1 and escorted him off the unit. R1 statedv she has not seen V1 since the incident. R1 stated she does not have fear of living in the facility. R1 stated she has not seen V1 and is feeling okay. V10 (Social Worker) he stated 3/22/23 at 12:45 pm was on the floor down the hallway. V10 stated he noticed that V1 get off the elevator and was talking to R1. V10 stated R1 told him that V1 had cursed her out. V10 stated he confronted V1 and he told him he called R1 a B**** and to leave him alone. V10 stated V1 was removed from the area and at that time also since his shift was ending he left the facility. V10 stated he reported the incident also to corporate besides the managers of the facility. V2 (Assistant Administrator) she stated on 3/22/23 at 10:00 am social service (V10) called her and reported that V1 was using inappropriate language towards R1. V2 stated they made sure V1 was sent home and the facility did an abuse investigation. V2 stated V1 admitting to cursing at R1. V2 stated explained to V1 that he signed the abuse form that acknowledging he knew what abuse was and could no longer work for the facility. V1's abuse policy acknowledgment sheet signed a dated 2/15/23 denotes any individual who willfully abuse, mistreats, or neglects a resident will be terminated. V1 employee sheet dated 3/17/23 denotes termination: vile language toward a resident Facility's abuse policy denotes this facility prohibits mistreatment ,neglect, or abuse of its residents and attempted to establish a resident sensitive and resident secure environment. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers and staff from other agencies providing services. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility.

Feb 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

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

Based upon observation, interview and record review the facility failed to ensure accuracy of assessment (re: risk for pressure ulcer) and failed to provide timely incontinence care for one of three r...

Read full inspector narrative →

Based upon observation, interview and record review the facility failed to ensure accuracy of assessment (re: risk for pressure ulcer) and failed to provide timely incontinence care for one of three residents (R1) in the sample. These failures resulted in R1 sustaining MASD (Moisture Associated Skin Damage), linear raw bleeding areas on medial thighs and pain. Findings include: R1's diagnoses include morbid obesity, weakness, hemiplegia and hemiparesis. R1's (2/4/23) POS (Physician Order Sheets) include moisture barrier cream to buttocks and groin areas as needed. R1's (2/7/23) progress notes state resident skin assessed no open area noted. R1's (12/15/22) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact). R1's (12/15/22) functional status affirms (2 person) physical assist is required for toilet use and personal hygiene. On 2/9/23 at 10:55am, R1 stated, I've had a problem with V7 (CNA/Certified Nursing Assistant) changing me. She's (V7) on evenings. When I ask her to change me, she takes her time to do it. Surveyor inquired when R1's incontinence brief was last changed. R1 stated, 5:30 this morning (over 5 hours ago), I actually just asked the CNA to change me and she's helping somebody else right now. On 2/9/23 at 2:07pm, surveyor inquired when R1 was last changed. V5 replied, I changed her (R1) when I got here and again around 9:00am (over 5 hours ago). R1 was transferred from the wheelchair to bed her pants and wheelchair cushion were notably wet. R1 was barely able to stand, pivot, and/or reposition in the bed (due to weakness morbid obesity, hemiplegia and hemiparesis) staff assistance was required. V5 subsequently removed R1's incontinence brief (as requested) which was completely saturated with urine, bright red blood was also noted near the edges of the diaper. R1 stated, My skin, it hurts really bad. MASD (Moisture Associated Skin Damage) and raw linear bleeding areas were observed on R1's medial thighs. Surveyor inquired again when R1's brief was last changed R1 affirmed 5:30 this morning. R1's (2/4/23) assessment for predicting pressure ulcer risk determined a score of 21 (indicating not at risk). Moisture: rarely moist, skin is usually dry. Sensory perception: no impairment. Activity: walks frequently. Mobility: no limitation. R1's (2/9/23) initial skin alteration assessment (documented after surveyor inquiry) includes bilateral inner thigh partial thickness MASD (Moisture Associated Skin Damage) and Serosanguenous (clear-bloody) drainage. On 2/14/23 at 10:01am, surveyor inquired about R1's (2/9/23) skin assessment. V9 (Wound Nurse) stated It's a moisture associated skin damage. The moisture just keeps the skin irritated, it damaged the skin to inner thighs. It could be from the sweating of her thighs or her urine, now it's open. I (V9) saw it (skin damage) this morning (5 days after initial assessment) its open on her (R1) inner thighs and the posterior right thigh. Surveyor inquired if R1's inner thighs were bleeding today. V9 responded, No but on Thursday (2/9/23) it was raw. Surveyor inquired about the requirement for changing incontinent residents. V9 replied, It's before meals, after meals, or when they use the bathroom. Surveyor inquired if R1 Walks frequently (per 2/4/23 assessment). V9 stated, No. She walks but not frequently with assistant. Surveyor inquired if R1 was Rarely moist (per 2/4/23 assessment). V9 responded, I can't speak for what she (staff) put on there (referring to the assessment). Surveyor inquired if incontinent residents are rarely moist. V9 replied No. Surveyor inquired if residents diagnosed with hemiplegia/hemiparesis have sensory perception problems. V9 stated, Yes they do. On 2/14/23 at 12:13pm, surveyor inquired about potential harm to a resident if incontinence briefs are not changed timely. V10 (Medical Director) stated, Potentially they can get urinary tract infection and they can get wounds. The (9/16) pressure injury and skin condition assessment policy states each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the Charge Nurse who will perform the initial assessment. If the resident receives a shower, it will be necessary to have the resident stand or be returned to bed to visualize the buttock area and groin.

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based upon record review and interview the facility failed to ensure accuracy of (risk for skin breakdown) assessment for one of three residents (R1) reviewed for pressure ulcer. Findings include: R1'...

Read full inspector narrative →

Based upon record review and interview the facility failed to ensure accuracy of (risk for skin breakdown) assessment for one of three residents (R1) reviewed for pressure ulcer. Findings include: R1's diagnoses include morbid obesity, weakness, hemiplegia and hemiparesis. R1's (2/4/23) assessment for predicting pressure ulcer risk determined a score of 21 (indicating not at risk). Moisture: rarely moist, skin is usually dry. Sensory perception: no impairment. Activity: walks frequently. Mobility: no limitation [R1's diagnoses include hemiplegia and hemiparesis]. On 2/9/23 at 2:07pm, R1 was transferred from the wheelchair to bed. R1 was barely able to stand, pivot, and/or reposition in the bed (due to weakness, morbid obesity, hemiplegia and hemiparesis) staff assistance was required. V5 subsequently removed R1's incontinence brief (as requested) which was completely saturated with urine. On 2/14/23 at 10:01am, surveyor inquired if R1 Walks frequently (per 2/4/23 assessment) V9 stated, No. She walks but not frequently with assistant. Surveyor inquired if R1 was Rarely moist (per 2/4/23 assessment). V9 responded, I can't speak for what she (staff) put on there (referring to the assessment). Surveyor inquired if incontinent residents are rarely moist. V9 replied, No. Surveyor inquired if residents diagnosed with hemiplegia/hemiparesis have sensory perception problems. V9 stated Yes they do. On 2/14/23 at 2:55pm, V3 (Associate Administrator) stated, we don't have an actual policy for the assessments, but we do have like a check sheet that the Nurse's follow for that (referring to the departmental assessments). The departmental assessments include (risk for skin breakdown) assessment however required accuracy of resident assessment 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

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 ...

Read full inspector narrative →

**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 three dependent residents (R1, R2) in the sample. Findings include: On 2/8/23, IDPH (Illinois Department of Public Health) received allegations regarding resident showers and incontinence care not provided. R1 was admitted [DATE] with diagnoses which include morbid obesity, weakness, hemiplegia and hemiparesis. R1's (12/15/22) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact). R1's (12/15/22) functional status affirms (2 person) physical assist is required for toilet use and personal hygiene. On 2/9/23 at 10:55am, surveyor inquired when R1's incontinence brief was last changed R1 stated 5:30 this morning (over 5 hours ago), I actually just asked the CNA (Certified Nursing Assistant) to change me and she's helping somebody else right now. Surveyor inquired when R1 receives showers. R1 replied, I haven't had a shower since I been here. My shower date is supposed to be Sunday's. On 2/9/23 at 2:07pm, surveyor inquired if R1's brief was recently changed. V5 (CNA) responded, I'm actually taking care of my set and affirmed that she was not assigned to R1. V5 stated, I'm waiting for supplies. She (R1) uses the extra-large diaper we don't have that up here right now. I called to get some (diapers) about 20 minutes ago (R1 requested to be changed over 3 hours ago). Surveyor inquired when R1 was last changed. V5 replied, I changed her (R1) when I got here and again around 9:00am (over 5 hours ago). R1 was transferred from the wheelchair to bed her pants and wheelchair cushion were notably wet. V5 subsequently removed R1's incontinence brief (as requested) which was completely saturated with urine. Surveyor inquired again when R1's brief was last changed R1 affirmed 5:30 this morning. On 2/9/23 at 2:28pm, V5 (CNA) affirmed that R1's showers/baths are scheduled every Thursday & Sunday. Surveyor requested R1's (February 2023) bath/shower documentation. V5 searched the binder and stated, They ain't in here. R1's shower documentation was not received during this survey. __ R2's diagnoses include TIA (Transient Ischemic Attack), weakness, abnormalities of gait/mobility, and history of falling. R2's (12/5/22) BIMS determined a score of 12 (moderately impaired). R2's (12/5/22) functional assessment affirms (2 person) physical assist is required for personal hygiene. Total dependence on staff for bathing. On 2/9/23 at 2:20pm, R2's beard and mustache were notably long. Surveyor inquired about concerns with ADL care. R2 responded, They ain't give me nothing to shave, I'd shave myself if I could. On 2/9/23 at 2:29pm, surveyor requested R2's shower/bath documentation. V5 (CNA) presented R2's (February 2023) bath and skin report sheet which was blank. Surveyor inquired when R2's showers/baths are scheduled. V5 responded, Friday's and Saturday's (consecutive therefore 5 days elapse without a shower/bath scheduled). The (2/14) bath/shower schedule states a bath or shower will be given to each resident by a CNA two times per week as scheduled and PRN (as needed). Bath/Shower sheets are to be completed by the CNA upon each bath/shower scheduled whether accepted or declined. The (9/14) incontinence care policy states incontinent residents will be checked periodically every 2 hours and provided perineal and genital care after each episode. Purpose: to prevent excoriation and skin breakdown, discomfort and maintain dignity.

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 upon observation, interview and record review, the facility failed to follow policies & procedures and failed to ensure that sufficient nursing staff were available to meet the needs for two of ...

Read full inspector narrative →

Based upon observation, interview and record review, the facility failed to follow policies & procedures and failed to ensure that sufficient nursing staff were available to meet the needs for two of three dependent residents (R1, R2) in the sample. These failures have the potential to affect 75 residents residing on 2nd & 5th floor. Findings include: The (2/9/23) census includes 34 (2nd floor) residents and 41 (5th floor) residents. The (2/14/23) CMS (Centers for Medicare & Medicaid Services) 672 affirms the following: 56 residents require staff assistance with bathing. 69 residents require staff assistance with dressing. 49 residents require staff assistance with transferring. 61 residents require staff assistance with toilet use. 14 residents require assistance with eating. R1 was admitted (12/8/22) with diagnoses which include morbid obesity, weakness, hemiplegia and hemiparesis. R1's (12/15/22) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact). R1's (12/15/22) functional status affirms (2 person) physical assist is required for toilet use and personal hygiene. On 2/9/23 at 10:55am, R1 stated, I've had a problem with V7 (CNA/Certified Nursing Assistant) changing me. She's (V7) on evenings. When I ask her to change me, she takes her time to do it. Surveyor inquired when R1's incontinence brief was last changed. R1 stated, 5:30 this morning (over 5 hours ago), I actually just asked the CNA to change me and she's helping somebody else right now. Surveyor inquired when R1 receives showers. R1 replied, I haven't had a shower since I been here. My shower date is supposed to be Sunday's. R1 resides on 2nd floor. On 2/9/23 at 12:17pm, surveyor inquired about the regulatory requirement for staffing. V2 (DON/Director of Nursing) stated, I don't know the actual requirement, but I can find out for you. V2 affirmed that the facility staffing requirement (per corporate) is as follows for the 2nd and 5th floors: 1 Nurse, and 2 CNA's (or 1 CNA with an ancillary assistant). On 2/9/23 at 2:07pm, surveyor inquired if R1's brief was recently changed. V5 (CNA) stated, I'm actually taking care of my set and affirmed that she was not assigned to R1. Surveyor inquired about the current (2nd floor) staffing V5 responded There's 32 patients. I'm waiting for supplies. She (R1) uses the extra-large diaper we don't have that up here right now. I called to get some (diapers) about 20 minutes ago (R1 requested to be changed over 3 hours ago). Surveyor inquired when R1 was last changed V5 replied I changed her (R1) when I got here and again around 9:00am (over 5 hours ago). Surveyor inquired which rooms V5 was assigned to V5 stated 202-217 is my set and I'm only working my side (R1 does not reside in rooms 202-217). Surveyor inquired who's assigned to the rest of the (2nd floor) residents V5 responded Nobody because were short staffed. There's only one (1) CNA and one (1) ancillary and they're (ancillary) not allowed to touch patients, they're not licensed. Surveyor inquired how many (2nd floor) residents are incontinent. V5 replied, Twenty (20) residents on the unit wear diapers. R1 was transferred from the wheelchair to bed her pants and wheelchair cushion were notably wet. V5 subsequently removed R1's incontinence brief (as requested) which was completely saturated with urine, bright red blood was also noted near the edges of the diaper. R1 stated My skin, it hurts really bad. MASD (Moisture Associated Skin Damage) and raw linear bleeding areas were observed on R1's medial thighs. Surveyor inquired again when R1's brief was last changed R1 affirmed 5:30 this morning. On 2/9/23 at 2:28pm, V5 (CNA) affirmed that R1's showers/baths are scheduled every Thursday & Sunday. Surveyor requested R1's (February 2023) bath/shower documentation V5 searched the binder and stated They ain't in here. R1's shower documentation was not received during this survey. __ R2 resides on 2nd floor. R2's diagnoses include TIA (Transient Ischemic Attack), weakness, abnormalities of gait/mobility, and history of falling. R2's (12/5/22) BIMS determined a score of 12 (moderately impaired). R2's (12/5/22) functional assessment affirms (2 person) physical assist is required for personal hygiene. Total dependence on staff for bathing. On 2/9/23 at 2:20pm, R2's beard and mustache were notably long. Surveyor inquired about concerns with ADL (Activities of Daily Living) care R2 responded They ain't give me nothing to shave, I'd shave myself if I could. On 2/9/23 at 2:29pm, surveyor requested R2's shower/bath documentation V5 (CNA) presented R2's (February 2023) bath and skin report sheet which was blank. Surveyor inquired when R2's showers/baths are scheduled V5 responded Friday's and Saturday's (consecutive therefore 5 days elapse without a shower/bath). __ On 2/9/23 at 2:51pm, surveyor inquired about the (5th floor) 7am-3pm staffing V14 (CNA) stated I have 41 residents. It's just me today and a Nurse. I think we had a call off of the ancillary (staff) that was scheduled with me. Surveyor inquired if one (1) Nurse with one (1) CNA was adequate staffing (for 5th floor). V14 responded, No, we need two (2) CNA's. On 2/9/23 at 3:06pm, surveyor inquired about the current (7am-3pm) 2nd and 5th floor staffing V2 (DON) stated,We had call offs. On 2nd floor, we had a CNA on the schedule who wasn't supposed to work today so we had to take them off. There was no replacement for that, but she had an ancillary assistant to help. Surveyor inquired what ancillary assistants are allowed to do. V2 responded, They can do anything a CNA does except for the physical care like shower, change and feed. On the 5th floor, there was one CNA and the ancillary assistant called off last minute. Activities (staff) went up to the 5th floor to help pass trays, but the CNA was managing the floor herself outside of that. Surveyor inquired how many residents V14 (CNA) was managing. V2 responded, I believe it's 41. On 2/14/23 at 12:13pm, surveyor relayed concerns regarding lack of staff at the facility. V10 (Medical Director) responded, A lot of the residents cannot care for themselves that's why they are here. We need to care for them properly. The (2/14) bath/shower schedule states a bath or shower will be given to each resident by a CNA two times per week as scheduled and PRN (as needed). Bath/Shower sheets are to be completed by the CNA upon each bath/shower scheduled whether accepted or declined. The (9/14) incontinence care policy states incontinent residents will be checked periodically every 2 hours and provided perineal and genital care after each episode. Purpose: to prevent excoriation and skin breakdown, discomfort and maintain dignity. The emergency staffing policy states (Nursing): use of overtime is approved at all times. Offer bonuses to pick up extra shifts. Nursing management to work units as necessary.

Feb 2023 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

Based on interview and record review, failed to follow their policy to be free from physical abuse by providing necessary care in services thus resulting in a male resident (R2) physically assaulting ...

Read full inspector narrative →

Based on interview and record review, failed to follow their policy to be free from physical abuse by providing necessary care in services thus resulting in a male resident (R2) physically assaulting another male resident (R1) for two (R1 and R2) out of three residents reviewed for physical abuse. Findings include: On 02/07/23 at 10:40 AM, surveyor observed R1 laying on his bed in his room. R1 was not in any pain or discomfort. On 02/07/23 at 10:40 AM, R1 stated that R2 hit him (R1) on the head, and he (R1) started bleeding. He (R1) stated R2 hit him (R1) on the head with his (R2) cane. R1 stated that he (R1) was sent out to the hospital, and he (R1) needed staples on his (R1) head. On 02/07/23 at 11:00 AM, R2 stated that he (R2) did hit R1 on the head. On 02/07/2023 at 12:11 PM, V2 (Assistant/Interim Administrator) stated that if they have a care plan in place for that particular behavior, we don't update the care plan if we see that behavior. We just follow the interventions. Intervention for R2's behavior was to evaluate, work on improving listening skills, He refuses to take medications, so medication is not an appropriate intervention. If I have a resident is agitated, then I (V2) would reach out to psychiatrist and see what could be changed in his (R2) medications but he (R2) refuses all his medications so that is not an appropriate intervention. R2's current interventions are on-going interventions, to prevent him from being aggressive to anyone. After any incident we don't usually update care plans. V2 stated that R2 acts like he is the boss on his floor. He (R2) tells people what to do. On 02/07/2023 at 12:53 PM, V12 (Registered Nurse) stated that R1 is a resident that eats out of the garbage. So, we have to redirect him (R1) from going through garbage cans. I (V12) was at the nurse's station and there was a garbage can near the nurse's station. I (V12) saw him (R1) go to the garbage can. He (R1) GRABBED a piece of garbage and was about to eat it. He (R1) was determined to eat what he (R1) grabbed. I (V12) took the bag behind the nurse's station and R1 followed me (V12) behind the nurse's station to grab the bag. He (R1) was not trying to attack me. He (R1) was just trying to reach for the bag. R2 saw that and started swearing. R2 then left and then came back and had what looked like in his hands a cane. R2 was yelling at R1 and swearing at him (R1). R2 then swung with the cane and made contact with R1's head. I (V12) then heard a crack. I then saw blood running down R1's neck. I ran into the bathroom and got paper towels to press on his (R1) open wound. I (V12) tried to apply pressure and call a code yellow because I (V12) needed help. The other staff came. We wrapped his (R1) head, called 911 and sent him (R1) out to the hospital and sent R2 out for psych evaluation. V12 stated that R2 is loud and more verbal. I (V12) didn't know that he (R2) had a stick in his (R2) room. They call him (R2) a general and he (R2) thinks he (R2) runs the floor. He (R2) thinks he (R2) is the boss of the floor. If someone gets out of hand, he (R2) usually intervenes and yells at them and they listen. R2's Facesheet documents in part: Diagnosis: Violent Behavior. Facility's Final Abuse Incident Investigation Report (1/12/2023) documents in part: It was reported that R2 hit R1 on the head in an attempt to stop him (R1) from going through the garbage. R1 noted with laceration to his (R1) head. First aid provided, sent to ER for evaluation. R2 and R1 were immediately separated. MD notified and new orders noted and carried out. R1 returned from the ER with 2 staples to his (R1) posterior head. Site being monitored for signs and symptoms of infection. Based on the known facts from medical record review and interviews, the following conclusions have been determined about the original allegation, abuse; is substantiated. Facility reported incident investigation report witness statement by V12 documents in part: I saw R1 come out of his room and go to the garbage can in the hallway on the 4th floor. He (R1) grabbed a bag of garbage and I (V12) took it from him (R1). He (R1) followed me (V12) into the nurse's station and another resident (R2) walked up behind him with a long cane and hit R1 on the back of his (R1) head, causing him (R1) to bleed and receive a head injury. He (R1) received two staples to the back of his (R1) head. Facility's abuse policy documents in part: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Abuse means any physical, mental or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury with resulting by physical harm, pain or mental anguish to a resident. Physical abuse is the infliction of injury upon a resident that occurs by hitting slapping, pinching, kicking, and controlling behavior through corporal punishment.

Nov 2022 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure two residents (R4 and R5) were free from resident-to-resident physical assault. This failure resulted in R5 sustaining a scratch to ...

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure two residents (R4 and R5) were free from resident-to-resident physical assault. This failure resulted in R5 sustaining a scratch to the bridge of R5's nose that bled according to R5. Findings include: On 11/09/2022 at 9:33 AM, R5 (R4's roommate) stated, She (R4) was scratching me and punching me in the face. Before she (R4) attacked me, she (R4) threw the food tray at me. Staff came in and broke it up and moved her (R4) out of the room. I was bleeding from here (pointed to nose). R5 added, She (R4) wouldn't stop picking with me the whole time she (R4) was here. An approximately 1/2 inch long, scabbed-over scratch mark was observed on R5's nose. On 11/09/2022 at 1:21 PM, R6 (R4 and R5's roommate) stated, (R4) threw her (R4) whole tray at her (R5). Plates broke everywhere. I don't remember the tray hitting R5, but then all hell broke loose, and they (R4 and R5) were hitting/punching each other. R5 showed R6 the scratch on her (R5) nose. R6 stated, Oh, is that where you were bleeding from? On 11/09/22 at 3:28 PM, V19 (CNA/Certified Nursing Aide) stated that the incident between R4 and R5 occurred on the morning shift so since she (V19) starts at 3 pm, she (V19) did not witness the event. However, V19 stated that R5 told V19 that, She (R5) was hit somewhere, but it didn't hurt. On 11/10/22 at 9:26 AM, V6 (CNA) stated, (R4) threw her (R4) top from the breakfast tray at R5. R5 had walked over to R4, and they (R4 and R5) had gotten into a confrontation. The surveyor inquired if R4 and R5 had gotten into a physical confrontation. V6 replied, Yes they did, they were pulling each other's hair. V6 denied seeing any injuries on R4 or R5. On 11/09/22 at 12:54 PM, V3 (2nd Assistant Administrator) stated that the administrator (who was out with Covid) is the abuse coordinator but that she (V3) knows how to do reportables, so people come to her (V3) with abuse concerns as well. The surveyor inquired if scratching and punching another resident would be considered physical abuse. V3 replied, Yes. On 11/10/22 at 3:10 PM, the surveyor inquired what are the risks associated with a resident being punched in the face. V26 (R4 and R5's Psychiatrist) stated, If there's any facial trauma from being punched in the face, they would want to do some kind of imaging to make sure there's no fracture. R4's admission Record documents diagnoses including but not limited to paranoid schizophrenia and mild cognitive impairment. R4's 8/10/22 BIMS (Brief Interview for Mental Status) determined a score of 12, indicating R4's cognition is moderately impaired. R4's nursing and social service progress notes indicate that on 11/05/22, R4 had a verbal disagreement with R5 and displayed aggressive behavior. R4 was then petitioned for admission to the hospital due to increased agitation and aggressive behavior towards peers. R5's admission Record documents diagnoses including but not limited to schizophrenia and bipolar II disorder. R5's 10/2/22 BIMS determined a score of 12, indicating R5's cognition is moderately impaired. R6's 10/3/22 BIMS determined a score of 12, indicating R6's cognition is moderately impaired. The 2011 facility Abuse Prevention Program Facility Policy documents, in part, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment .Definitions: Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77IL.Adm.Code300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42CFR 483.13b Interpretive Guidelines.)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

Based on interviews and record review, the facility failed to ensure one resident (R2) was free from misappropriation of resident property by a staff member. Findings include: On 11/07/22 at 10:30 AM...

Read full inspector narrative →

Based on interviews and record review, the facility failed to ensure one resident (R2) was free from misappropriation of resident property by a staff member. Findings include: On 11/07/22 at 10:30 AM, the surveyor was presented by V1 (Assistant Administrator) with the Preliminary and Final Incident Investigation Report Forms with the occurrence date of 10/20/2022. The final report documents, in part, (R2) reported to PRSC (Psychiatric Rehabilitation Services Coordinator) on 10/20/22, that on 10/4/22 he (R2) allowed the alleged perpetrator to use his (R2) credit card to pay for a class online. (R2) was later notified by his (R2) bank of two additional charges made by the alleged perpetrator . V12 (Former PRSC) was interviewed and reported that he (V12) asked (R2) to use his (R2) credit card to pay for a training on-line. (R2) agreed and gave him (V12) his (R2) credit card, but when he (V12) entered the credit card number, it did not go through. He (V12) denies making any other transactions using (R2's) credit card . The facility has determined that there is sufficient evidence to substantiate this allegation. (V12) has been terminated from employment. The police were contacted, and a report was filed. On 11/07/22 at 10:57 AM, R2 did not want to speak with the surveyor about the incident stating, I'm not interested. I already went over everything. It's been taken care of. On 11/07/22 at 3:01 PM, V14 (PRSC) stated that R2 came to her (V14) office on 10/20/22 and reported that he (R2) let V12 use his (R2) credit card to pay for V12's teaching license. R2 stated that V12 told him (R2) that V12 would pay him (R2) back when V12 would get paid. V14 stated that R2 gave her (V14) a copy of R2's bank statement. V14 stated, There were different inquiries that were made by (V12). V14 added that R2 said he (R2) did give him (V12) $30 dollars in cash at a different time as well and never got it back. V14 stated that she (V14) then reported this allegation to the administrator and an investigation was started. On 11/10/22 at 11:29 AM, during a phone interview, V12 stated, I borrowed some cash from him (R2). The surveyor inquired if V12 used R2's credit card. V12 replied, He (R2) gave me permission to. It didn't work so I (V12) gave it back. I (V12) was using it to pay for a suicide prevention training. Review of R2's bank transaction history affirms that three charges were made to R2's credit card. Two charges were made on 10/03/22 in the amounts of $10 and $50 with the charge description of Cash App* (V12's name). One charge was made on 10/04/22 in the amount of $36.72 with the charge description In professional license egov.c. R2's admission Record documents diagnoses including but not limited to bipolar disorder, anxiety disorder, depression and psychoactive substance dependence with psychoactive substance-induced mood disorder. R2's 11/09/22 BIMS (Brief Interview for Mental Status) determined a score of 15, indicating, R2's cognition is intact. The 2011 facility Abuse Prevention Program Facility Policy documents, in part, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment .Definitions: Misappropriation of resident property is the deliberate misplacement, exploitation, 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to report an allegation of resident-to-resident (R4 and R5) physical assault. Findings include: On 11/09/2022 at 9:33 AM, R5 (R4's roommate)...

Read full inspector narrative →

Based on interview and record review, the facility failed to report an allegation of resident-to-resident (R4 and R5) physical assault. Findings include: On 11/09/2022 at 9:33 AM, R5 (R4's roommate) stated, She (R4) was scratching me and punching me in the face. Before she (R4) attacked me, she (R4) threw the food tray at me. Staff came in and broke it up and moved her (R4) out of the room. I was bleeding from here (pointed to nose). An approximately 1/2 inch long, scabbed-over scratch mark was observed on R5's nose. The surveyor inquired which staff member intervened, R5 replied, I can't remember. The surveyor inquired if the staff member saw R5 bleeding. R5 stated, I had taken a tissue to wipe my nose, but I told her she (R4) was beating my face. On 11/09/2022 at 1:21 PM, R6 (R4 and R5's roommate) stated, (R4) threw her (R4) whole tray at her (R5). Plates broke everywhere. I don't remember the tray hitting R5, but then all hell broke loose, and they (R4 and R5) were hitting and punching each other. R5 showed R6 the scratch on her (R5) nose. R6 stated, Oh, is that where you were bleeding from? On 11/10/22 at 9:26 AM, V6 (CNA) stated, (R4) threw her (R4) top from the breakfast tray at R5. R5 had walked over to R4, and they (R4 and R5) had gotten into a confrontation. The surveyor inquired if R4 and R5 had gotten into a physical confrontation. V6 replied, Yes they did, they were pulling each other's hair. V6 denied seeing any injuries on R4 or R5 and stated, I had called the nurse to come over to diffuse the situation. V6 stated that V20 was working on the unit that day. On 11/09/2022 at 11:50 AM, V20 (Wound Care Nurse/LPN-Licensed Practical Nurse) stated that the CNA (Certified Nursing Aide) had called her (V20) and said that R4 and R5 were in the room verbally arguing. The CNA had separated them and brought R4 out of the room per V20. V20 added, I (V20) sat (R4) at the nurse's station. I (V20) went to see (R5) and she (R5) said something about some food they (R4 and R5) were arguing about. (R5) said (R4) wanted to hit her (R4). V20 stated that R4 denied any physical contact and did not have any injuries. V20 denied any CNA reporting to her (V20) that R4 and R6 were physically fighting. V20 stated that social services and V3 (2nd Assistant Administrator) were notified of the incident. On 11/09/22 at 3:28 PM, V19 (CNA/Certified Nursing Aide) stated that the incident between R4 and R5 occurred on the morning shift so since she (V19) starts at 3 pm, she (V19) did not witness the event. However, V19 stated that R5 told V19 that, She (R5) was hit somewhere, but it didn't hurt. The surveyor inquired if V19 reported this allegation to anyone. V19 stated, I told the nurse. I think it was V27 (LPN/Licensed Practical Nurse). The surveyor attempted to reach V27 multiple times by phone but was unsuccessful. On 11/09/22 at 12:54 PM, V3 (2nd Assistant Administrator) stated that the administrator (who was out with Covid) is the abuse coordinator but that she (V3) knows how to do reportables, so people come to her (V3) with abuse concerns as well. The surveyor inquired if scratching and punching another resident would be considered physical abuse. V3 replied, Yes. It has to be reported. The facility reportables were reviewed from August to November 2022 with no reportable filed related to the alleged physical altercation between R4 and R5. On 11/09/22 at 3:16 PM, the surveyor notified V1 (Assistant Administrator/Human Resources Director) and V2 (2nd Assistant Administrator) of the alleged physical altercation between R4 and R5. Both stated that they (V1 and V2) were only aware of a verbal disagreement between R4 and R5 but stated that they will start a formal investigation. R4's admission Record documents diagnoses including but not limited to paranoid schizophrenia and mild cognitive impairment. R4's 8/10/22 BIMS (Brief Interview for Mental Status) determined a score of 12, indicating R4's cognition is moderately impaired. R4's nursing and social service progress notes indicate that on 11/05/22, R4 had a verbal disagreement with R5 and displayed aggressive behavior. R4 was then petitioned for admission to the hospital due to increased agitation and aggressive behavior towards peers. R5's admission Record documents diagnoses including but not limited to schizophrenia and bipolar II disorder. R5's 10/2/22 BIMS determined a score of 12, indicating R5's cognition is moderately impaired. R6's 10/3/22 BIMS determined a score of 12, indicating R6's cognition is moderately impaired. The 11/22/2017 Abuse Prevention Training Program documents, in part, A. Identification: The direct care staff is responsible for reporting the appearance of suspicious bruises, lacerations or other abnormalities of an unknown origin as soon as it is discovered .B. Internal reporting: Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator .V. Reporting and Response: An initial report to the State licensing agency, Illinois Department of Public Health, shall be made immediately after the resident has been assessed an the alleged perpetrator has been removed.

AUSTIN OASIS, THE

The Good

The Bad

The Ugly 74 deficiencies on record

Questions to Ask on Your Visit

Our Honest Assessment

About This Facility

What is Austin Oasis, The's CMS Rating?

How is Austin Oasis, The Staffed?

What Have Inspectors Found at Austin Oasis, The?

Who Owns and Operates Austin Oasis, The?

How Does Austin Oasis, The Compare to Other Illinois Nursing Homes?

What Should Families Ask When Visiting Austin Oasis, The?

Is Austin Oasis, The Safe?

Do Nurses at Austin Oasis, The Stick Around?

Was Austin Oasis, The Ever Fined?

Is Austin Oasis, The on Any Federal Watch List?

AUSTIN OASIS, THE

Strengths

Concerns