What is Complete Care at Margate Park's CMS rating?

Complete Care at Margate Park has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does Complete Care at Margate Park have any serious inspection findings?

Yes, Complete Care at Margate Park has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 98 total deficiencies from recent inspections.

What are the staffing levels at Complete Care at Margate Park?

Complete Care at Margate Park has a one-star staffing rating from CMS with 0.40 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 Complete Care at Margate Park located?

Complete Care at Margate Park is located in CHICAGO, IL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Complete Care at Margate Park have?

Complete Care at Margate Park has 310 certified beds.

Who owns Complete Care at Margate Park?

Complete Care at Margate Park is a for profit - limited liability company facility and is part of the COMPLETE CARE chain.

Is Complete Care at Margate Park safe?

Complete Care at Margate Park has documented safety concerns including a substantiated abuse finding on record, 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Do nurses at Complete Care at Margate Park stick around?

Complete Care at Margate Park has average staff turnover at 44%, which is typical for the nursing home industry.

Was Complete Care at Margate Park ever fined?

Yes, Complete Care at Margate Park has been fined $66,700 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is Complete Care at Margate Park on any federal watch list?

No, Complete Care at Margate Park 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 Complete Care at Margate Park?

Medicare inspectors have found 98 deficiencies at Complete Care at Margate Park: 1 critical, 8 serious, 89 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Complete Care at Margate Park?

Families visiting Complete Care at Margate Park should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Complete Care at Margate Park compare to other nursing homes?

Complete Care at Margate Park 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.

Complete Care at Margate Park | 0/100 (Grade F)

Sept 2025 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

Based on interview and record review, the facility failed to provide adequate supervision for a resident while at the facility. This failure affected 1(R1) resident out of 5 residents reviewed for sup...

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Based on interview and record review, the facility failed to provide adequate supervision for a resident while at the facility. This failure affected 1(R1) resident out of 5 residents reviewed for supervision. R1 incurred a full thickness burn on his left leg with a surface area of 136.90 cm^2 .Findings include:On 09/18/2025 at 3:12pm, V10 (Smoke Monitor/Receptionist) stated that on 07/29/2025, he (V10) was in the dining room, opening the door to the patio for the 3pm smoking time. When V10 saw him (R1) in the dining room, he (V10) said, Wow, he got some burn. V10 stated he sent him (R1) upstairs because he (R1) could not stay in the patio with a big burn on his leg. V10 said there is no way he (R1) got the burn in the patio because it was not hot that day for him to get a huge burn mark. It was like riding a motorcycle and hit the leg on the exhaust of the motorcycle. V10 said he (R1) came in at 3pm to smoke and when he saw the burn mark, he sent him upstairs right away. V10 stated he did not know how he (R1) got the wound. He got the wound somewhere upstairs, on the floor.On 09/18/2025 at 3:27pm, V11 (Agency Registered Nurse) stated she remembers that day. She was supposed to leave at 3pm and while she was waiting for the incoming nurse to come, the resident was brought upstairs, and she saw a skin tear behind his leg. V11 said she was thinking the tear happened while he (R1) was downstairs. V11 stated residents move around a lot, she did not know when he (R1) went downstairs and did not know where he (R1) went downstairs, and R1 came back through the elevator. V11 said she did not know what happened and he (R1) is nonverbal. V11 stated his (R1) wound did not happen while he was on the floor. On 09/18/2025 at 12:56pm, V6 (Wound Care Doctor) stated he has been treating him (R1) for a while. V6 stated he talked to (V3-R1's family member) about his wound and the treatment plan and to get consent for the debridement of the wound. On 09/23/2025 at 2:56pm, V6 (Wound Care Doctor) stated it is a serious injury because it is a full thickness burn. All the layers of the skin, including the epidermis, dermis, and subcutaneous tissue are damaged and because of the size of his wound. On 09/22/2025 at 1:03pm, V2 (Director of Nursing) stated she was not notified of R1's injury on 07/29/2025. V2 could not recall V11 notifying her of R1's injury. V2 said if notified, she would need to investigate it, she would need to talk to any witnesses who potentially working with him (R1) before and after the injury was observed, she would be auditing documentation to make sure family and doctor were notified, make sure the nurse reach out to the doctor for a treatment plan and if in place, to make sure the facility is following the treatment plan, do an in service with the nurses to make sure they are doing the right procedure. V2 stated ‘Yes', it is required of the facility to report to the State injury of unknown origin or a major injury. V2 said the timeframe for reporting is within 24 hours. Injury of unknown origin should be investigated as an allegation of abuse. There should be an abuse investigation. V2 stated she did not know about R1's injury of unknown origin and there was no investigation done, and it was not reported to the State.On 09/22/2025 at 3:30pm, V19 (New Administrator) stated abuse include injury of unknown origin. The procedure is to report it immediately within 2 hours and to initiate the investigation immediately. Immediately means, as soon as the initial reportable was sent to the State, then she (V19) would start interviewing any party that is involved. V19 said anybody who work with the resident who may have in contact with the resident. The purpose is to see the root cause of this and to rule out abuse. V19 stated she sent the reportable today (09/22/2025). V19 said, It means his (R1) injury of unknown origin was not reported and was not investigated. Yes, it should be reported and investigated because facility didn't know how the resident got the injury, and per policy, it should be reported and investigated. V19 (New Administrator) stated a burn is a serious injury. On 09/23/2025 at 4:04pm, V15 (Assistant Director of Nursing) stated she has been at the facility for 1 1/2 years and she sees him (R1) around. (R1) goes up and down the floor using the elevator and he (R1) never uses the stairs. V15 said the nurses and the CNAs are supposed to supervise R1 while he is on the floor. V15 stated she does not know how and still asking herself how the wound happened. V156 said she is not sure if he is supervised while in the elevator because he (R1) knows where he is going and when to comeback on the floor. V15 stated she wishes she could explain how it happened. V15 stated with an injury like that, somebody should know and should report it. V15 said it is not expected of a resident to be injured at the facility, and no one knew about it and somebody should know. V15 stated if no one knew how the injury happened, he (R1) was not supervised adequately. R1's admission Record documented that R1's diagnoses (include but not limited to) deaf, type 2 diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, chronic systolic (congestive) heart failure. R1's (08/05/2025) Minimum Data Set documented, in part: Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired. R1's (07/29/2025) Progress note documented, in part: Resident came up with a skin tear behind his left leg at 3:10pm, wound care book filled up, pls follow up with the wound department for appropriate dressing. Authored by: V11. R1's (07/31/2025) Initial Wound Evaluation & Management Summary documented, in part Focused Wound Exam (Site 1) Burn Wound of The Left Leg Full Thickness. Wound Size (L x W x D): 18.5 x 7.4 x 0.1 cm. Surface Area: 136.90 cm^2. Pain assessment: Described as Severe. Signed by: V6 (Wound Care Doctor). The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. Your facility must provide services to keep your physical and mental health at their highest practicable levels. Your facility must be safe.The (undated) Accidents and Supervision documented, in part Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents.

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a resident's representative was notified of an injury of unknown source. This failure affected 1 (R1) resident reviewed for notifica...

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Based on interview and record review, the facility failed to ensure a resident's representative was notified of an injury of unknown source. This failure affected 1 (R1) resident reviewed for notification of representative in the total sample of 5 residents.Findings include:On 09/18/2025 at 3:12pm, V10 (Smoke Monitor/Receptionist) stated that on 07/29/2025, he (V10) was in the dining room, opening the door to the patio for the 3pm smoking time. When he saw R1 in the dining room, V10 said, Wow, he got some burn. V10 stated he sent him (R1) upstairs because he (R1) cannot stay in the patio with a big burn on his leg. V10 said there is no way he (R1) got the burn in the patio because it was not hot that day for him to get a huge burn mark. It was like riding a motorcycle and hit the leg on the exhaust of the motorcycle. V10 said he (R1) came in at 3pm to smoke and when he saw the burn mark, he sent him upstairs right away. V10 stated he did not know how he (R1) got the wound and that he (R1) got the wound somewhere upstairs, on the floor.On 09/18/2025 at 3:27pm, V11 (Agency Registered Nurse) stated she remembers that day. She was supposed to leave at 3pm and while she was waiting for the incoming nurse to come, the resident was brought upstairs, and she saw a skin tear behind his leg. V11 was thinking the tear happened while he (R1) was downstairs. V11 stated residents move around a lot. V11 did not know when he (R1) went downstairs and did not know where he (R1) went downstairs, and he came back through the elevator. V11 did not know what happened and he (R1) is nonverbal. V11 stated his (R1) wound did not happen while he was on the floor. V11 stated she just wrote the progress note that day and she did not call the family.On 09/18/2025 at 11:16am, V3 (R1's family member) stated the doctor (V6) who was treating his (R1) legs called her and informed her he has a burn on his legs. V3 stated she was not sure when the doctor called her.On 09/18/2025 at 12:56pm, V6 (Wound Care Doctor) stated he talked to (V3-R1's family member) about his (R1) wound, the treatment plan and to get consent for the debridement of the wound. V6 stated he did not remember if it was the first time he had seen him (R1) or when he needed the consent for the debridement of the wound. V6 stated he put a note in the wound rounds that he spoke with the family. On 09/22/2025 at 1:03pm, V2 (Director of Nursing) stated family should be notified of the injury as soon as possible or hopefully immediately, within 24 hours. On 09/22/2025 at 1:16pm, V16 (new DON) stated for any wound that the facility cannot account for, the family should be notified as soon as it is noted or within 24 hours.On 09/23/2025 at 4:04pm, V15 (Assistant Director of Nursing) stated there was no documentation on his electronic health record that his (R1) family was notified of his injury.R1's admission Record documented that R1's contact include V3 (R1's family member) as POA (power of attorney) and that R1's diagnoses (include but not limited to) type 2 diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, chronic systolic (congestive) heart failure.R1's (08/05/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired.R1's (07/29/2025) Progress note documented, in part: Resident came up with a skin tear behind his left leg at 3:10pm, wound care book filled up, pls follow up with the wound department for appropriate dressing. Authored by: V11. R1's (07/31/2025) Initial Wound Evaluation & Management Summary documented, in part Focused Wound Exam (Site 1) Burn Wound of The Left Leg Full Thickness. Wound Size (L x W x D): 18.5 x 7.4 x 0.1 cm. Surface Area: 136.90 cm^2. Pain assessment: Described as Severe. Signed by: V6 (Wound Care Doctor). No note that V3 was notified. R1's (08/11/2025) Wound Evaluation & Management Summary documented, in part Site 1: Surgical Excisional Debridement Procedure. Indication For Procedure: Remove Necrotic Tissue and Establish the Margins of Viable Tissue. Consent For Procedure: Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 08/11/2025 to the patient and health care surrogate: (V3 - R1's family member) who indicated agreement to proceed with the procedure(s). Of note, notification of V3 was done 13 days after the injury was noted. R1's (07/28/2025 - 08/05/2025) Progress notes were reviewed, with no notes of family notification. The (09/22/2025) email correspondence with V15 (Assistant Director of Nursing) documented, in part Unable to locate SBAR for 7/29/25.The (9/1/2024) Notification of changes documented, in part Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: Accidents a. Resulting in injury.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the ...

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Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. This failure affected 1 (R1) resident out of 5 residents reviewed for reporting of injury of unknown source. Findings include:On 09/18/2025 at 3:12pm, V10 (Smoke Monitor/Receptionist) stated that on 07/29/2025, he (V10) was in the dining room, opening the door to the patio for the 3pm smoking time. When he saw R1 in the dining room, V10 said, Wow, he got some burn. V10 stated he sent him (R1) upstairs because he (R1) cannot stay in the patio with a big burn on his leg. V10 said there is no way he (R1) got the burn in the patio because it was not hot that day for him to get a huge burn mark. It was like riding a motorcycle and hit the leg on the exhaust of the motorcycle. V10 said he (R1) came in at 3pm to smoke and when he saw the burn mark, he sent him upstairs right away. V10 stated he did not know how he (R1) got the wound and that he (R1) got the wound somewhere upstairs, on the floor.On 09/18/2025 at 3:27pm, V11 (Agency Registered Nurse) stated she remembers that day. She was supposed to leave at 3pm and while she was waiting for the incoming nurse to come, the resident was brought upstairs, and she saw a skin tear behind his leg. V11 was thinking the tear happened while he (R1) was downstairs. V11 stated she cleansed the wound and informed the incoming nurse and (V2- Director of Nursing) before she left that day. V11 stated she saw the Director of Nursing called the wound department immediately that day when she told her about it. V11 said the wound department should take care of it, and they said they will check it out. V11 stated she told the DON on her way out. V11 did not know what happened; he (R1) was brought up from downstairs; his (R1) wound did not happen while he was on the floor.On 09/18/2025 at 12:56pm, V6 (Wound Care Doctor) he has been treating him (R1) for a while. V6 stated he talked to her (V3-R1's family member) about his wound and the treatment plan and to get consent for the debridement of the wound. On 09/23/2025 at 2:56pm, V6 (Wound Care Doctor) stated it is a serious injury because it is a full thickness burn, all the layers of the skin, including the epidermis, dermis, and subcutaneous tissue are damaged and because of the size of his wound.On 09/22/2025 at 1:03pm, V2 (Director of Nursing) stated she was not notified of R1's injury on 07/29/2025. V2 could not recall V11 notifying her of R1's injury. V2 said if notified, she would need to investigate it, she would need to talk to any witnesses who potentially working with him (R1) before and after the injury was observed. V2 would be auditing documentation to make sure family and doctor were notified, make sure the nurse reaches out to the doctor for a treatment plan and if in place, to make sure the facility is following the treatment plan, do an in-service with the nurses to make sure they are doing the right procedure. V2 stated, ‘Yes', it is required of the facility to report to the State injury of unknown origin or a major injury. V2 said the timeframe for reporting is within 24 hours. Injury of unknown origin should be investigated as an allegation of abuse. There should be an abuse investigation. V2 stated she did not know about R1's injury of unknown origin and there was no investigation done, and it was not reported to the State.On 09/22/2025 at 3:30pm, V19 (New Administrator) stated abuse includes injury of unknown origin. The procedure is to report it immediately within 2 hours and to initiate the investigation immediately. Immediately means, as soon as the initial reportable was sent to the State, then she (V19) would start interviewing any party that is involved. Anybody who work with the resident who may have in contact with the resident. V19 said the purpose is to see the root cause of this and to rule out abuse. V19 stated she sent the reportable today (09/22/2025). V19 stated, It means his (R1) injury of unknown origin was not reported and was not investigated. Yes, it should be reported and investigated because facility didn't know how the resident got the injury, and per policy, it should be reported and investigated. A burn is a serious injury. R1's admission Record documented that R1's diagnoses (include but not limited to) type 2 diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, chronic systolic (congestive) heart failure.R1's (08/05/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired.R1's (07/29/2025) Progress note documented, in part Resident came up with a skin tear behind his left leg at 3:10pm, wound care book filled up, pls follow up with the wound department for appropriate dressing. Authored by: V11. R1's (07/31/2025) Initial Wound Evaluation & Management Summary documented, in part Focused Wound Exam (Site 1) Burn Wound of The Left Leg Full Thickness. Wound Size (L x W x D): 18.5 x 7.4 x 0.1 cm. Surface Area: 136.90 cm^2. Pain assessment: Described as Severe. Signed by: V6 (Wound Care Doctor). The (09/18/2025) email correspondence with V1 (Administrator) documented, in part Do you have any reportables for injury of unknown origin? V1 responded Nothing in the past 90 days, and no injuries of unknown for close to a year maybe more.The (9/1/2024) Abuse, Neglect and Exploitation documented, in part Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure injury of unknown source was thoroughly investigated. This failure affected 1(R1) resident out of 5 residents reviewed for allegatio...

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Based on interview and record review, the facility failed to ensure injury of unknown source was thoroughly investigated. This failure affected 1(R1) resident out of 5 residents reviewed for allegation abuse. Findings include:On 09/18/2025 at 3:12pm, V10 (Smoke Monitor/Receptionist) stated that on 07/29/2025, he (V10) was in the dining room, opening the door to the patio for the 3pm smoking time. When V10 saw him (R1) in the dining room, he (V10) said wow, he got some burn. V10 stated he sent him (R1) upstairs because he (R1) cannot stay in the patio with a big burn on his leg. That there is no way he (R1) got the burn in the patio because it was not hot that day for him to get a huge burn mark. It was like riding a motorcycle and hit the leg on the exhaust of the motorcycle. V10 said he (R1) came in at 3pm to smoke and when he saw the burn mark, he sent him upstairs right away. V10 stated he did not know how he (R1) got the wound. (R1) got the wound somewhere upstairs, on the floor. V10 stated nobody interviewed him on the day the injury was noted. V10 stated he (V1-Administrator) texted him today (09/18/2025) to call him and he (V10) called him (V1) at 1:45pm and he (V10) told him (V1) that he (R1) did not get the wound in the patio. On 09/18/2025 at 3:27pm, V11 (Agency Registered Nurse) stated she remembers that day. She was supposed to leave at 3pm and while she was waiting for the incoming nurse to come, the resident was brought upstairs, and she saw a skin tear behind his leg. V11 was thinking the tear happened while he (R1) was downstairs. V11 stated she cleansed the wound and informed the incoming nurse and (V2- Director of Nursing) before she left that day. V11 stated she saw the Director of Nursing called the wound department immediately that day when she told her about it. V11 said the wound department should take care of it, and they said they will check it out. V11 stated she told the DON on her way out. V11 said she did not know what happened; that he (R1) was brought up from downstairs; that it did not happen on the floor. V11 stated she (V2) did not call her back and V2 did not ask her to write a statement. On 09/18/2025 at 12:56pm, V6 (Wound Care Doctor) he has been treating him (R1) for a while. V6 stated he talked to her (V3-R1's family member) about his wound and the treatment plan and to get consent for the debridement of the wound. On 09/23/2025 at 2:56pm, V6 (Wound Care Doctor) stated it is a serious injury because it is a full thickness burn, all the layers of the skin, including the epidermis, dermis, and subcutaneous tissue are damaged and because of the size of his wound. On 09/22/2025 at 1:03pm, V2 (Director of Nursing) stated she was not notified of R1's injury on 07/29/2025. V2 could not recall V11 notifying her of R1's injury. V2 said if notified, she would need to investigate it, she would need to talk to any witnesses who potentially working with him (R1) before and after the injury was observed, she would be auditing documentation to make sure family and doctor were notified, make sure the nurse reach out to the doctor for a treatment plan and if in place, to make sure the facility is following the treatment plan, do an in service with the nurses to make sure they are doing the right procedure. V2 stated ‘Yes', it is required of the facility to report to the State injury of unknown origin or a major injury. V2 said the timeframe for reporting is within 24 hours. Injury of unknown origin should be investigated as an allegation of abuse. There should be an abuse investigation. V2 stated she did not know about R1's injury of unknown origin and there was no investigation done, and it was not reported to the State. On 09/22/2025 at 3:30pm, V19 (New Administrator) stated abuse include injury of unknown origin. The procedure is to report it immediately within 2 hours and to initiate the investigation immediately. Immediately means, as soon as the initial reportable was sent to the State, then she (V19) would start interviewing any party that is involved. V19 said anybody who work with the resident who may have in contact with the resident. The purpose is to see the root cause of this and to rule out abuse. V19 stated she sent the reportable today (09/22/2025). V19 said, It means his (R1) injury of unknown origin was not reported and was not investigated. Yes, it should be reported and investigated because facility didn't know how the resident got the injury, and per policy, it should be reported and investigated. R1's admission Record documented that R1's diagnoses (include but not limited to) type 2 diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, chronic systolic (congestive) heart failure. R1's (08/05/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired. R1's (07/29/2025) Progress note documented, in part Resident came up with a skin tear behind his left leg at 3:10pm, wound care book filled up, pls follow up with the wound department for appropriate dressing. Authored by: V11. R1's (07/31/2025) Initial Wound Evaluation & Management Summary documented, in part Focused Wound Exam (Site 1) Burn Wound Of The Left Leg Full Thickness. Wound Size (L x W x D): 18.5 x 7.4 x 0.1 cm. Surface Area: 136.90 cm^2. Pain assessment: Described as Severe. Signed by: V6 (Wound Care Doctor). The (09/18/2025) email correspondence with V1 (Administrator) documented, in part Do you have any reportables for injury of unknown origin? V1 responded Nothing in the past 90 days, and no injuries of unknown for close to a year maybe more. The (9/1/2024) Abuse, Neglect and Exploitation documented, in part Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. V. Investigation of Alleged Abuse, Neglect and Exploitation. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: 1. Identifying staff responsible for the investigation, 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 6. Providing complete and thorough documentation of the investigation.

Aug 2025 2 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents are free from abuse for one of three resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents are free from abuse for one of three residents (R1) reviewed for abuse in the sample of nine. R1 suffered a head laceration after being pushed to the floor.Findings include:R1's face sheet documents R1 is a 44 -year-old admitted to the facility on 11.3.2023, with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, Diabetes, Convulsions, and chronic kidney disease. R1's MDS (Minimum Data Set of 5.22.2025) documents a BIMS (Brief Interview for Mental Status) of 15 denoting R1 is cognitively intact.R2's face sheet documents R2 is a [AGE] year-old admitted to the facility on 11.15.2024 with diagnoses including but not limited to: Heart Failure, Peripheral Vascular Disease, Violent Behavior, and Non-Rheumatic Aortic Valve Disorder.R2's MDS (Minimum Data Set of 7.29.2025) documents a BIMS (Brief Interview for Mental Status) of 15 denoting R1 is cognitively intact. On 7.29.2025 at 7:27 pm, R1 said, It happened about eight days ago. I finished smoking; I went into the elevator. It wasn't working, I jumped into the other one. I was in the corner. R2 gets on the elevator as well. My rollator was facing the door. R2 was trying to get out on the 2nd floor. He got in front of me. R2 yelled at me, you a*****e get the f***out of the way. R2 pushed my rollator causing me to fall out of the elevator. I fell down. I hit my head. I hurt my head. I had a bump and a little slash on my head. I had to go to the hospital. They called 911. R2 got sent out for psych. There was resident on the elevator who saw everything, I can't remember his name. I think he's on the 4th floor. A nurse saw it too. I feel safe here. I feel staff acted appropriately.On 7.29.2025 at 8:16 PM, R2 said, I did not push R1, my wheelchair hit him. I was trying to get out of the elevator.8.3.2025 at 1:58 PM, R6 said, I was in the elevator with R1 and R2. When the door opened, R2 rammed R1 with R2's wheelchair. R1 fell out of the elevator.8.3.2025 at 3:34 PM, V4 (RN-Registered Nurse/Restorative Nurse) said, I completed a fall assessment for R1. He had a scratch to his head. R1 told me he was pushed by R2, causing R1 to fall out of the elevator onto the floor.8.4.25 at 10:48 AM, V1 (Administrator) said, No one actually saw any shoving going on. R6 said R1 was not pushed. V5 (LPN-Licensed Practical Nurse) said she couldn't say R1 was pushed but did see him fall out of elevator. R1 insisted he was pushed. R2 said he moved R1's walker. He said he told R1 to leave him alone, that R1 was bugging him.8.4.2025 at 2:09 PM, V15 (Social Service) said, R1 was reluctant to say anything. R1 said he was pushed out of the elevator, but he didn't know who did it. R2 was reluctant to say anything. R2 said he didn't do anything. R6 confirmed that R2 did push R1. R6 said R2 took R2's wheelchair and rammed it into R1.8.5.2025 at 2:50 PM via telephone, V5 (LPN-Licensed Practical Nurse) said, I was at the 2nd floor nurses station, when the elevator door opened. I saw R2 push R1 with his hands (R2 was in his wheelchair). R1 landed on the floor with force.Facility's final incident report of 7.25.2025 documents in part, reported to (V1-Administrator) on 7/21/25 at 7:45pm that (V5 LPN-Licensed Practical Nurse) stated (R2) allegedly pushed fellow resident R2 causing him to fall. (R1) was noted on the floor outside of the elevator with a small laceration on his head. Residents were immediately separated and placed on 1:1 supervision. Doctors were contacted and orders were given to send both residents to the hospital for further observation. Laceration was cleaned and covered and head to toe assessment done with no further concerns noted.R1's progress note of 7.21.2025 at 9:04 PM, documents in part, writer was informed by NOD (Nurse on Duty) that the resident was involved in a dispute with another resident on the elevator. When questioned, convicted that he was punched and pushed off the elevator by another resident. Resident refused to give any other information concerning the incident. Resident was reassessed per this nurse. Open area noted to the right side of the head, small amount of bleeding with slight swollen noted.R2's progress note of 7.21.2025 at 11:03 PM, documents in part, writer was informed by NOD (Nurse on Duty) that the resident was involved in a dispute with another resident on the elevator. When questioned, resident denies that he punched and pushed another resident off the elevator. Resident refused to give any other information concerning the incident. NP (Nurse Practitioner) gave orders to petition resident out to hospital for further evaluation.Abuse Prevention Policy (October 24, 2024) documents in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.Abuse: 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, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident.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.

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Deficiency F0726 (Tag F0726)

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 assess and immediately start CPR (Cardiopulmonary Resuscitation) fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and immediately start CPR (Cardiopulmonary Resuscitation) for resident found unresponsive on the floor for one of one resident (R3) reviewed for CPR in the sample of sample of nine. This failure resulted in R3 being without vital signs and not receiving immediate CPR.Findings include:R3's face sheet documents R3 was a [AGE] year-old admitted to the facility on 9.12.2011, with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, Asthma, Hypertension, and Hyperlipidemia. R3's Order Summary Report (active orders as of 5.28.2025) documents R3 was a full code.R3's progress note of 5.29.2025 at 7:55 AM, documents in part, at about 6:15 AM, while the writer was passing medication, one of the CNAs notified the writer that resident was on the floor in the bathroom. The writer immediately called out the resident's name but he was not responding well. A code blue was indicated through the receptionist and CPR was started. 911 was called during the CPR the vitals are B/P 113/94, pulse 126, R-22, and the blood sugar is 356mg/dl at the time resident transfer to hospital.R3's death certificate documents cause of death as asthma. The immediate cause of death is complete heart block.On 8.4.2025 at 1:10 PM, via telephone, V14 (Former LPN-Licensed Practical Nurse) said, That day I believe I gave R3 her 6:00 am med. I left the room. After a while, a CNA came to tell me R3 was on the floor. I stopped what I was doing and went to R3. She fell in the shower room. Prior to the fall, she was able to walk, she was up and about on the unit. I went there to assess her. We pulled her out of the shower room because she is a tall lady. We started CPR. We called 911. They (911) took her out. I can't remember what time the CNA came to get me; it was during my morning med pass. The first thing I did was to call her name. She did turn her head but did not talk. She looked pale. I called for help but the CNAs that are working with me were with patients. I called a code blue at the nurses' station then went back to her. I checked her. She was not responding well. I called code blue. Me and my coworker did CPR. I don't remember taking vital signs. I don't remember if my coworker did. Somebody started CPR, not me. (Local fire department) came, they took over, and they took her out. I don't remember what time the CNA got me.On 8.4.25 at 2:29 PM, V2 (DON-Director of Nursing) said, V14 (Former LPN-Licensed Practical Nurse) was terminated for not running a code properly. V14 did not bring crash cart or participate in Code Blue for her assigned resident (R3). The Code Blue was initiated, when the other nurses (V6 LPN-Licensed Practical Nurse/Nurse Supervisor and V10 LPN-Licensed Practical Nurse) came. There was no crash in the room. One of them got it. They also said V14 had not initiated CPR. V14 should have initiated CPR when she determined R3 had coded.8.5.2025 at 11:53 AM, via telephone, V2 said per V12 (HR-Human Resources) there is no CPR card in (Nurse) personnel folder.8.4.2025 at 5:54 PM, via telephone, V6 (LPN-Licensed Practical Nurse/Nurse Supervisor) said, At approximately 6:30 AM, I immediately responded to a code blue. I took the stairs; it took me a couple of minutes to get to the unit. V10 (LPN-Licensed Practical Nurse) was with me. R3 was on the ground. There were some CNAs (Certified Nursing Assistants). I didn't see the crash cart in the room. No one was doing compressions, I just wanted them to start compressions. I told them to start CPR. I never saw V14 do CPR. When someone is found unresponsive, you should assess for airway, breathing, circulation. Compressions should be started immediately to get the heart pumping, to get blood and air circulating.8.5.2025 at 2:27 PM, via telephone, V9 (R3's Physician) said, If the resident is a full code, call 911 and start CPR until 911 arrives. The purpose of starting CPR immediately is to get blood to the brain, to push blood to the brain. Compressions won't restart the heart. CPR is continued until 911 arrives and takes over, they can attempt to re-start the heart by administering medications such as epinephrine and shocking the patient. If CPR isn't started immediately severe anoxic encephalopathy (severe brain damage caused by a complete lack of oxygen) could occur.V10's Witness Statement (5.29.2025) documents, writer heard code blue 5th floor via overhead page. Writer along with housekeeping manager went to 5th floor. Writer along with other nurses assessed resident, no pulse noted, CPR initiated. 911 called by nursing staff. (Local Fire Department) on scene and noted vitals and pulse. Resident transferred to ER (Emergency Room) by (Local Fire Department). V10 (LPN-Licensed Practical Nurse) was not available for interview.V14's employee folder (Employee Action/Discipline of 5.29.2025) documents employee called a code blue on a resident but did not bring over needed materials for code and did not participate in code blue for her own assigned resident.Cardiopulmonary Resuscitation (CPR) policy (undated) documents in part, Procedure: 1. In the event a resident is identified unresponsive and upon a thorough A-B-C (Airway, Breathing, Circulation) assessment determines that there is no pulse or respiratory activity and the resident has declared a full code status, a licensed staff member will: a. Simultaneously with the initiation of chest compressions announce a full code per facility policy and direct a staff member to immediately retrieve the crash cart located on the nursing unit.

Jul 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident (R2) from abuse by another resident (R1), in one...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident (R2) from abuse by another resident (R1), in one of three residents reviewed for abuse. As a result, R2 sustained discoloration of the left eye.Findings include:R1 is a [AGE] year-old, originally admitted on [DATE] with medical diagnoses that include and are not limited to: violent behavior, schizophrenia, and schizoaffective disorder. R1 is not currently at the facility.R2 is a [AGE] year-old, originally admitted on [DATE] with medical diagnoses that include and are not limited to: disorders of the brain, chronic obstructive pulmonary disease, and diabetes. On 7-19-2025 at 9:20 am, R2 said, An incident took place several days ago. I was sitting in the dining room waiting for my lunch. (R1) came and told me, you are sitting in my chair. You need to move now. I got up, and (V4 - licensed practical nurse) came and told me: Thank you for letting R1 sit on that spot. I went to my room for a few minutes, and then I came out again. I was going into the dining room when (R1) came running towards me, hit me in my face, (R1) attacked me. I was not expecting that. I was taken off guard; we both ended up on the floor. V4 (Licensed Practical Nurse) and V5 (Certified Nurse Assistant) were in the room and immediately removed R1 and protected me. I went to the hospital. I had a bruise over my right eye.On 7-19-2025 at 10:00 am V4 (Licensed Practical Nurse) said V4 was the nurse in charge when R1 was physically attacked by R2 without provocation. R1 was noted with a slight bruise at the right upper eyelid area. R1 and R2 were immediately separated, and both were sent to the hospital. R2 is back to the facility and is doing well. R1 is still at the hospital. We never expected that R1 was going to be physically aggressive toward others. R2 was admitted with a diagnosis of violent behavior. On 7-19-2025 at 11:40 am V5 (Certified Nurse Assistant), I remember R1, on 6-27-2025, R2 was walking back to the dining room when R1 screamed something and ran towards the dining room door and attacked R2 by hitting her in the face, and both residents fell to the floor. I was not fast enough to intervene, and both residents landed on the floor. V4 was also in the dining room. The social worker took R1 off the floor, and I did not see her again. No physical abuse should be taking place between residents. We are responsible for making sure all residents are safe.On 7-19-2025 at 10:30 am, V2 (Director of Nursing /RN), the incident that took place on 6-27-2025, when R1 attacked R2, was substantiated for abuse.After the incident, R1 was put on 1:1 and taken off the floor and sent to the hospital for evaluation with an involuntary petition. R2 was also sent to the hospital and came back on the same day after all diagnostic tests were negative. We do not want any abuse to take place. We try to prevent abuse from resident to resident. V2 presented policy titled: Abuse Prevention Policy dated: 10-24-2022 reads in part: The purpose of this policy is to assure that the facility is doing all to prevent occurrences of abuse.V2 presented: Petition for involuntary/Judicial admission dated 6-27-2025 reads in part: R1 started hitting R2 in the face and pulling R2's clothes down. R1 will benefit from an evaluation as R1 is a danger to others in the facility.

Jul 2025 3 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

Deficiency F0776 (Tag F0776)

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 had routine preventative screening for 1 res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident had routine preventative screening for 1 resident (R3) out of 3 residents reviewed for routine screenings. This failure resulted in R3 not receiving recommended annual breast mammograms while residing in the facility, which resulted in R3 being diagnosed with stage 4 breast cancer which metastasized to other parts of her body. Findings Include:R3's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Neutropenia, malignant neoplasm of unspecified site of right female breast, secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes, secondary malignant neoplasm of mediastinum, secondary malignant neoplasm of other specified sites. Minimum Data Set Section (MDS) section C (dated 09/26/2024) documents R3 has an Interview for Mental Status (BIMS) score of 11, indicating that R3 had moderate cognitive impairment. Care plan (dated 09/05/2023) documents that R3 has potential for pain related to Dx of left breast cellulitis, bilateral breast mass and right breast cancer with metastasis to right axilla, retro pectoral, mediastinum, spleen, left axilla and liver. Mammogram Policy (revised February 2025) documents in part: Female residents 55 and younger will have mammogram screenings conducted annually unless otherwise indicated by physician. On 07/16/2025 at 11:03AM, V2 (director of nursing) stated R3 was admitted to the facility 07/15/2004. R3 complained of breast pain on 05/30/2023. R3 was assessed due to complaining of tenderness and pain in the right breast. R3 was seen by the nurse practitioner due to pain in the right breast, on 05/30/2023, the same day she complained. Upon assessment, the nurse on the floor noted the right breast to be bigger than the left breast and hardening of the right breast. On 05/30/2023, the nurse practitioner ordered a breast ultrasound for R3 to be done in the hospital, and a consultation with the oncologist. On 06/27/2023, resident was taken to the hospital for the ultrasound appointment. That same day, the radiologist recommended a CT scan of the chest for further evaluation, which was done the same time as the ultrasound. The CT of the chest showed cancer which metastasized to the spleen, liver and axillary area. When R3's breast cancer was found, it was already spread to other parts of the body. R3 was admitted to the hospital from the appointment due to right breast cellulitis. R3 was seen by the oncologist at the hospital while she was admitted . R3 was receiving weekly chemotherapy treatments. When R3's cancer was found, it was treated right away. The breast exams are performed when a resident complains of pain or tenderness at the breast site. The facility's protocol is to perform breast exams when there is a concern voiced by the resident. According to the facility's policy, residents who are [AGE] years old and younger should have a breast mammogram every year. V2 stated, (R3) had a breast mammogram in 2017, and I don't see any mammograms for R3 after the one she had in 2017. (R3) had mental health co-morbidities and she often refused to be touched, refused examinations a lot of the time, and refused tests. (R3) was verbal and a lot of the times she would state that she was fine and refused assessments and examinations. Residents [AGE] years of age and under should have a routine mammogram every year. The only mammogram for (R3) that there is on record is from 06/07/2017, and (R3) was [AGE] years old at the time. (R3) should have had another mammogram after 2017, however, I cannot find a mammogram for (R3) from 2018. (R3) did not pass away in this facility. (R3) was sent out to the hospital on [DATE] for a mental health evaluation, and she did not return to this facility. I don't know where (R3) discharged to. She was receiving weekly chemotherapy treatments and going to see the oncologist on a regular basis while she resided here. On 07/17/2025 at 10:10AM, V12 (nurse practitioner) stated, The last time I seen R3 was on September 24, 2024. On 05/30/2023 R3 complained of breast pain, tenderness and swelling. I placed an order for antibiotic because the breast was swollen and tender and it was suspicious for mastitis. I also ordered an ultrasound of the breast and I ordered R3 an appointment with an oncologist, because I was suspecting breast cancer based on the presentation of the breast. R3's breast appeared to be tender, red, and swollen and I immediately suspected breast cancer. From then on, the oncologist picked right up, and he planned the treatments for R3, and we followed the oncologist's direction. When I see a change of status, take action right away, so I placed interventions for R3 immediately when her right breast was swollen. I do not believe that R3 had a mammogram prior to her breast being tender. The first mammogram for R3 that I know of was 06/20/2023. R3 should have had an annual breast mammogram prior to 06/20/2023. R3 was supposed to have a routine yearly mammogram. There was a breast mammogram done for R3 back in 2017, and it was negative, and it was recommended for R3 to have a repeat mammogram in 2018. From the records that I am looking at, I do not see a mammogram performed for R3 in 2018. The dangers of not performing routine annual breast mammograms are breast cancer and missed diagnosis. If R3 would have had the routine breast mammograms yearly, we would have caught the breast cancer earlier. R3's Mammography Report (dated 06/07/2017) documents in part: No suspicious masses, calcifications or other abnormalities are seen. Routine follow-up mammogram in 1 year is recommended. R3's Progress Note (dated 05/30/2023) documents, Resident reported having pain in the right breast, upon assessment the right breast was noted to be bigger than the left breast and hard to touch. NP notified and came to assess resident with orders for right breast ultrasound and follow up with Dr. C. at community hospital for further evaluation. R3's Progress Note (dated 05/30/2023) documents, A [AGE] year-old AA female with past medical history listed below was seen and examined today 5/30/2023 due to RN reporting that patient is complaining of tenderness and pain of right breast and to follow up on chronic medical conditions management. Patient is observed to be in the hallway and starts yelling and screaming upon trying to assess the right breast lump. RN and social worker assisted during assessment. Patient is known to be non-compliant with medical regimen despite education. Patient denies fever, chills, cough, sore throat, congestion, hoarseness, shortness of breath, HA, chest pain, abdominal pain, NVDC, burning and tingling during urination, change in bowel habits. All available health notes reviewed. BREAST: Swelling, tenderness, hardness noted on right breast. No redness, bleeding, drainage, and dimpling noted. No swollen and hardened axillary lymph nodes palpated. Limited palpation study due to patient complaining of pain. R3's Hospital Records (dated 06/27/2023) documents in part: R-Mastitis, Non-lactational/R-Breast Malignant Mass with Metastasis. CT-chest/A/P showed metastasis to the LNs (axillary, retro-pectoral, mediastinal) spleen and liver. R3's Progress Note (dated 06/27/2023) documents, Resident went to oncology appointment and was admitted to community hospital with dx of Cellulitis to R Breast/Abscess to R Breast. Resident belongings in room. Medication in cart. Sister made aware. So noted. R3's Progress Note (dated 06/30/2023) documents, Resident is a 58 y/o female alert and oriented x 2. Resident has an admitting dx of right breast cellulitis and right breast malignant mass with metastasis to liver, spleen and axillary. Dx/HX of COPD, DM, Anxiety and OP. Resident is a limited assistance of one staff member for ADLs. Resident is continent of bowel and has occasional incontinence of bladder. Resident is able to ambulate without any assistive device. Resident requires cueing for task. Resident has dressing to right side of breast post biopsy. Resident is noted with appointment to follow up with oncology Wednesday. Resident is currently on Clindamycin 300mg every 8 hours for 7 days and Levaquin 750mg PO daily x 7 days. Resident sister informed of transfer in. Medications verified by MD. Resident is acclimated to room. Belongings brought down to new room. So noted.R3's Death Certificate (dated 02/18/2025) indicates that R3's cause of death as breast cancer with metastasis to brain.

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent and protect one (R4) resident from resident-to-resident abu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent and protect one (R4) resident from resident-to-resident abuse out of three residents reviewed for abuse. Findings include:On 07/15/2025 at 11:36AM, R4 stated R5 rammed his walker against his left leg while they were waiting on their smoke break on the first floor of the facility. R4 stated this incident happened approximately 2 to 3 weeks ago. R4 stated R6 was present and witnessed the entire incident. R4 stated he has never seen R5 with alcohol in the facility but R5 gets drunk when out on community pass. R4 stated he informed V4 (Receptionist) and V3 (LPN/Nursing Supervisor) of the altercation between himself and R5. R4 stated V3 took a picture of his leg and told him she would report the incident. R4 stated V3 informed him she reported the altercation to V1 (Administrator). R4 stated he overheard the police were called to the facility, but he did not get a chance to speak with a police officer or file a police report. R4 points to his left leg and surveyor observes a scabbed abrasion on R4's left calf measuring approximately 2 inches in length. R4 stated R5 caused this abrasion when R5 rammed his wheelchair against R4's leg. R4 stated after two days, he did not hear anything from the facility regarding the altercation between himself and R5. R4 stated he then went to talk to V1 (Administrator) to inform V1 R5 rammed his leg with a walker and inquire about what was being done about the altercation. R4 stated V1 acted like he didn't care and was not listening to him. R4 stated that's when he started cursing and became very upset during his conversation with V1. R4 stated he told V1 that V1 needed to report the incident. R4 stated he was sent out to the hospital for psychiatric evaluation instead.R4's MDS/Minimum Data Set, dated [DATE], documents R4 has a BIMS/Brief Interview for Mental Status of 15/15, indicating R4 is cognitively intact.R4's progress note dated 06/29/2025 at 9:13PM, written by V3 (LPN/Nursing Supervisor) documents, Writer was informed by staff and R4 the resident had concerns regarding him and another resident. R4 expressed he had a verbal disagreement with another resident. All of the resident concerns were addressed and both residents separated. DON and social services made aware.On 07/15/2025 at 12:13PM, R6 stated he is a witness to the altercation took place between R4 and R5. R6 stated this incident happened approximately 3 weeks ago. R6 stated he was located on the first floor awaiting his smoke break. R6 stated R5 was using his walker to block R4's path from getting past the elevators so R4 squeezed his way past R5. R6 stated R5 became upset about this and R5 used his rollator walker and rammed it into R4's leg. R6 stated this caused a scar on R4's leg. R6 stated he got in between R4 and R5 and broke them apart. R6 stated surveyor's interview is the first time anyone is inquiring to him about the incident between R4 and R5.R6's MDS/Minimum Data Set, dated [DATE], documents R6 has a BIMS/Brief Interview for Mental Status of 15/15, indicating R6 is cognitively intact.R5's progress note dated 06/29/2025 at 9:19PM, written by V3 (LPN/Nursing Supervisor) documents, Writer was informed by another resident and staff R5 was in a verbal disagreement with another resident. All of the resident concerns were addressed and both residents separated. DON and social services made aware.R5's progress note dated 07/01/2025 at 11:16AM, written by V14 (Social Services) documents, R5 was given a behavior contract and educated on appropriate and acceptable bx with peers, the consequences as well as the risks of consuming alcoholic beverages. R5 was receptive of the education, and requested if he can apologize to the peer, he had a disagreement with. R5 was informed Social Services will remain available for R5's needs or concerns.On 07/15/2025 at 1:12PM, V3 (LPN/Nursing Supervisor) stated she was made aware by V4 (Receptionist) of a verbal altercation between R4 and R5 and R5 called R4 a snitch. V3 stated this altercation occurred approximately 2.5 weeks ago. V3 stated she went to talk to R4 but R4 did not want to provide any information regarding the altercation and refused an assessment. V3 stated, the next day, as she was punching out, she overheard R4 telling a social services staff member about the altercation. V3 stated she then assessed R4's leg and observed there was a superficial scrape on R4' leg with skin intact, no bruising, no bleeding. V3 stated she took a picture of R4's leg and showed it to V2 (Director of Nursing/DON) then V3 left the facility. V3 stated she was going on vacation once she left the facility and have since deleted the picture of R4's leg. V3 stated she is unaware of what happened to R4's leg because R4 did not tell her. V3 stated she informed V2 (DON) so V2 could follow up. V3 stated she later found out R4 tried to get pass R5 but R5 did not move and R4 got a superficial scrape on his leg.On 07/15/2025 at 2:33PM, V2 (DON) stated she was made aware via telephone by V3 (LPN/Nursing Supervisor) of a verbal altercation took place between R4 and R5. V2 stated she was informed R4 and R5 were in the elevator and R4 was trying to come off the elevator and R5 did not move and R4 pushed himself pass R5. V2 stated she asked V3 if she had informed V1 (Administrator) of the incident and V3 said yes. V2 stated she then asked V3 if R4 and R5 were separated and V3 said yes. V2 stated R4 and R5 were informed to stay away from one another. V2 stated the next day she was shown a picture of R4's leg by V3. V2 stated R4's leg appeared to be a superficial scratch with no swelling, no bruising, no bleeding, or redness. V2 stated the superficial scratch on R4's leg appeared to be an older wound and did not look fresh and was scabbed over. V2 stated a couple of hours after she saw the picture of R4's leg, she attempted to ask R4 what happened and R4 told her, Don't worry about it. V2 stated she has never heard of an altercation of R5 taking his rollator walker and ramming it into R4's leg and this would be considered abuse. V2 stated she has never had a conversation with R5 about the altercation took place between R4 and R5. V2 stated R5 has been avoiding her and doesn't come around her much. V2 stated V1 (Administrator) is the abuse coordinator and she reported to V1 a verbal altercation occurred between R4 and R5.R4's progress note dated 07/01/2025 at 1:24PM, written by V2 (Director of Nursing/DON) documents, Writer was notified by staff R4 was on the elevator with another resident and when trying to get passed the other resident, R4 scratched his leg. Assessment was done and scratch noted on right leg. Area was cleaned. R4 was educated he needs to be patient while leaving the elevator.On 07/15/2025 at 2:50PM, V1 (Administrator) stated he has been the abuse coordinator at the facility for one year. V1 stated as the abuse coordinator, he is responsible for ensuring the safety of residents and the prevention of residents being hurt through any form of abuse. V1 stated R4 came into his office screaming and yelling and told him his leg was scratched. V1 stated there was an altercation and R4 was squeezing past R5 and R4 scratched his leg in the process. V1 stated he asked R5 what happened during the altercation and R5 told V1 R4 brushed pass him and R4 scratched his leg on R5's walker. V1 stated he did not think the altercation between R4 and R5 was considered abuse. V1 stated he was never made aware by R4 or anyone else R4 made allegations of R5 ramming his walker against R4's leg. V1 stated this is the first time he is hearing of the allegations and will now report to the state agency. V1 stated he has received abuse training, and it is a requirement for the renewal of his license. V1 stated abuse training is also incorporated into the orientation process upon being hired at the facility. V1 stated he is responsible for reporting allegations of abuse to the state agency within the required time frames.On 07/16/2025 at 9:27AM V4 (Receptionist) stated R4 informed him he was in an altercation with R5. V4 stated R4 reported to him R5 won't leave R4 alone and is messing with R4. V4 stated R4 also reported he felt like R5 was intoxicated and targeting him. V4 stated sometime in June 2025 on a Sunday at approximately 7:30PM-8:00PM, V4 was located at the front lobby desk and R4 reported this to him. V4 stated he received a report on R5's behavior the day prior so he was inclined to believe R4. V4 stated he reported to V3 (LPN) what R4 reported to him. V4 stated the day prior, he received a report from another staff member R5 appeared to be intoxicated with alcohol in the facility. V4 stated R5 smelled like alcohol but he was unsure if R5 was drunk or not. V4 stated R5 previously had an independent community pass but it was restricted due to violations of facility rules related to intoxication. V4 stated R4 informed him R4 would be reporting to V3 about the altercation between him and R5. V4 stated V3 called the police and V3 instructed him to let V3 know when the police arrived. V4 stated approximately 40 minutes later, police arrived at the facility, and he directed the police officer to the floor where V3 was located. V4 stated he assumed a police report was filed but he is not aware of a police report number or the police officer's name/badge number. V4 stated he believed the police was called due to an argument and he was not made aware of any physical altercations between R4 and R5. V4 stated he was informed R4 and R5 should be separated and to keep other residents from being in contact with R5.Ombudsman Residents' Rights for People in Long-Term Care Facilities dated 11/2018 documents in part, You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually.Facility documents dated 10/24/2024, titled Abuse Prevention Policy documents in part, This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to facility staff, other residents.Abuse: 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, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident .The term willful, in this definition of abuse means the individual must have acted deliberately, not the individual must have intended to inflict injury or harm.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegations of physical abuse for one (R4) resident out of t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegations of physical abuse for one (R4) resident out of three residents reviewed for physical abuse. Findings include: On 07/15/2025 at 11:36AM, R4 stated R5 rammed his walker against his left leg while they were waiting on their smoke break on the first floor of the facility. R4 stated this incident happened approximately 2 to 3 weeks ago. R4 stated R6 was present and witnessed the entire incident. R4 stated he has never seen R5 with alcohol in the facility but R5 gets drunk when out on community pass. R4 stated he informed V4 (Receptionist) and V3 (LPN/Nursing Supervisor) of the altercation between himself and R5. R4 stated V3 took a picture of his leg and told him she would report the incident. R4 stated V3 informed him she reported the altercation to V1 (Administrator). R4 stated he overheard the police were called to the facility, but he did not get a chance to speak with a police officer or file a police report. R4 points to his left leg and surveyor observes a scabbed abrasion on R4's left calf measuring approximately 2 inches in length. R4 stated R5 caused this abrasion when R5 rammed his wheelchair against R4's leg. R4 stated after two days, he did not hear anything from the facility regarding the altercation between himself and R5. R4 stated he then went to talk to V1 (Administrator) to inform V1 R5 rammed his leg with a walker and inquire about what was being done about the altercation. R4 stated V1 acted like he didn't care and was not listening to him. R4 stated that's when he started cursing and became very upset during his conversation with V1. R4 stated he told V1 that V1 needed to report the incident. R4 stated he was sent out to the hospital for psychiatric evaluation instead.R4's MDS/Minimum Data Set, dated [DATE], documents R4 has a BIMS/Brief Interview for Mental Status of 15/15, indicating R4 is cognitively intact. On 07/15/2025 at 12:13PM, R6 stated he is a witness to the altercation took place between R4 and R5. R6 stated this incident happened approximately 3 weeks ago. R6 stated he was located on the first floor awaiting his smoke break. R6 stated R5 was using his walker to block R4's path from getting past the elevators so R4 squeezed his way past R5. R6 stated R5 became upset about this and R5 used his rollator walker and rammed it into R4's leg. R6 stated this caused a scar on R4's leg. R6 stated he got in between R4 and R5 and broke them apart. R6 stated surveyor's interview is the first time anyone is inquiring to him about the incident between R4 and R5. R6's MDS/Minimum Data Set, dated [DATE], documents R6 has a BIMS/Brief Interview for Mental Status of 15/15, indicating R6 is cognitively intact.On 07/15/2025 at 1:12PM, V3 (LPN/Nursing Supervisor) stated she was made aware by V4 (Receptionist) of a verbal altercation between R4 and R5 and R5 called R4 a snitch. V3 stated this altercation occurred approximately 2.5 weeks ago. V3 stated she went to talk to R4 but R4 did not want to provide any information regarding the altercation and refused an assessment. V3 stated, the next day, as she was punching out, she overheard R4 telling a social services staff member about the altercation. V3 stated she then assessed R4's leg and observed there was a superficial scrape on R4' leg with skin intact, no bruising, no bleeding. V3 stated she took a picture of R4's leg and showed it to V2 (Director of Nursing/DON) then V3 left the facility. V3 stated she was going on vacation once she left the facility and have since deleted the picture of R4's leg. V3 stated she is unaware of what happened to R4's leg because R4 did not tell her. V3 stated she informed V2 (DON) so V2 could follow up. V3 stated she later found out R4 tried to get past R5 but R5 did not move and R4 got a superficial scrape on his leg.On 07/15/2025 at 2:33PM, V2 (DON) stated she was made aware via telephone by V3 (LPN/Nursing Supervisor) of a verbal altercation took place between R4 and R5. V2 stated she was informed R4 and R5 were in the elevator and R4 was trying to come off the elevator and R5 did not move and R4 pushed himself past R5. V2 stated she asked V3 if she had informed V1 (Administrator) of the incident and V3 said yes. V2 stated she then asked V3 if R4 and R5 were separated and V3 also said yes. V2 stated R4 and R5 were informed to stay away from one another. V2 stated the next day she was shown a picture of R4's leg by V3. V2 stated R4's leg appeared to be a superficial scratch with no swelling, no bruising, no bleeding, or redness. V2 stated the superficial scratch on R4's leg appeared to be an older wound and did not look fresh and was scabbed over. V2 stated a couple of hours after she saw the picture of R4's leg, she attempted to ask R4 what happened and R4 told her, Don't worry about it. V2 stated she has never heard of an altercation of R5 taking his rollator walker and ramming it into R4's leg and this would be considered abuse. V2 stated she has never had a conversation with R5 about the altercation took place between R4 and R5. V2 stated R5 has been avoiding her and doesn't come around her much. V2 stated V1 (Administrator) is the abuse coordinator and she reported to V1 a verbal altercation occurred between R4 and R5.On 07/15/2025 at 1:34PM, V1 (Administrator) provides surveyor with Facility Reported Incidents/FRIs dated 04/14/2025 to 06/28/2025. V1 stated the provided FRIs are all the facility reported incidents during time frame. V1 stated he currently does not have any pending FRIs to be reported to the state agency. V1 stated there are no facility reported incidents for the month of July 2025.Facility Reported Incidents dated 04/14/2025 to 06/28/2025 does not document any reports of alleged assault/abuse involving R4 and R5. On 07/15/2025 at 2:50PM, V1 (Administrator) stated he has been the abuse coordinator at the facility for one year. V1 stated as the abuse coordinator, he is responsible for ensuring the safety of residents and the prevention of residents being hurt through any form of abuse. V1 stated R4 came into his office screaming and yelling and told him his leg was scratched. V1 stated there was an altercation and R4 was squeezing past R5 and R4 scratched his leg in the process. V1 stated he asked R5 what happened during the altercation and R5 told V1 R4 brushed past him and R4 scratched his leg on R5's walker. V1 stated he did not think the altercation between R4 and R5 was considered abuse. V1 stated he was never made aware by R4 or anyone else R4 made allegations of R5 ramming his walker against R4's leg. V1 stated this is the first time he is hearing of the allegations and will now report to the state agency. V1 stated he has received abuse training, and it is a requirement for the renewal of his license. V1 stated abuse training is also incorporated into the orientation process upon being hired at the facility. V1 stated he is responsible for reporting allegations of abuse to the state agency within the required time frames.On 07/16/2025 at 9:27AM V4 (Receptionist) stated R4 informed him he was in an altercation with R5. V4 stated R4 reported to him R5 won't leave R4 alone and is messing with R4. V4 stated R4 also reported he felt like R5 was intoxicated and targeting him. V4 stated sometime in June 2025 on a Sunday at approximately 7:30PM-8:00PM, he was located at the front lobby desk and R4 reported this to him. V4 stated he received a report on R5's behavior the day prior so he was inclined to believe R4. V4 stated he reported to V3 (LPN) what R4 reported to him. V4 stated the day prior, he received a report from another staff member R5 appeared to be intoxicated with alcohol in the facility. V4 stated R5 smelled like alcohol but he was unsure if R5 was drunk or not. V4 stated R5 previously had an independent community pass but it was restricted due to violations of facility rules related to intoxication. V4 stated R4 informed him R4 would be reporting to V3 about the altercation between him and R5. V4 stated V3 called the police and V3 instructed him to let V3 know when the police arrived. V4 stated approximately 40 minutes later, police arrived at the facility, and he directed the police officer to the floor where V3 was located. V4 stated he assumed a police report was filed but he is not aware of a police report number or the police officer's name/badge number. V4 stated he believed the police was called due to an argument and he was not made aware of any physical altercations between R4 and R5. V4 stated he was informed R4 and R5 should be separated and to keep other residents from being in contact with R5.During record review, there is no documentation to show a police report was filed for the assault allegations involving R4 and R5.Facility document dated 10/24/2024, titled Abuse Prevention Policy documents in part, Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations of suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation.

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision and monitoring for residents. As a res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision and monitoring for residents. As a result of these failures, R1 fell in the facility on 06/08/2025 and sustained a temporal laceration with sutures. This failure affects one (R1) out of three residents reviewed for supervision and monitoring. Findings include: R1's Facesheet documents that R1 has diagnoses not limited to: osteophyte, vertebrae, bladder disorder, moderate protein-calorie malnutrition, obstructive and reflux uropathy, osteoarthritis, unspecified convulsions, other symptoms, and signs involving cognitive functions and awareness, unspecified fall, and laceration without foreign body of other part of head. R1's MDS/Minimum Data Set, dated [DATE], documents R1 has a BIMS/Brief Interview for Mental Status of 3/15, indicating R1 is cognitively impaired. R1 requires substantial/maximal assistance with ADL/activities of daily living care. R1 is incontinent of bowel and bladder and ambulates via wheelchair. R1's Fall Risk assessment dated [DATE] documents that R1 is at moderate risk for falls with a fall score of 40. R1's care plan documents that R1 is at risk for falls with interventions to include Anticipate and meet R1's needs and Monitor/document/report PRN s/sx of tremors, rigidity, dizziness, changes in level of consciousness, slurred speech. On 06/17/2025 at 11:47AM, V7 (Licensed Practical Nurse/LPN) stated she is the nurse responsible for caring for R1 today. V7 stated she did not witness R1 fall in the facility. V7 stated she was informed that R1 was located inside the 5th floor dining room when R1 tried to get up from his wheelchair and fell. On 06/17/2025 at 12:45PM, V5 (LPN/Nurse Supervisor) stated the day R1 fell in the facility on 06/08/2025, she was working on the 5th floor of the facility but was not assigned to care for R1. V5 stated an agency nurse (identified as V12/RN) was assigned to care for R1 on 06/08/2025. V5 stated V12 was on a break when R1 fell and V5 was covering the floor during V12's break. V5 stated there was a total of four CNAs/certified nursing assistants assigned to work on the 5th floor of the facility on 06/08/2025 during the 7:00AM to 3:00PM shift. V5 stated R1's incident occurred around lunch time on 06/08/2025 while R1 was located inside the 5th floor dining room. V5 stated all four CNAs were passing meal trays and feeding other residents in their rooms when R1 fell in the dining room. V5 stated she was not located inside of the 5th floor dining room when R1 fell. V5 stated she was located inside of another resident's room flushing a gastrostomy tube/g-tube. V5 stated when she finished flushing the g-tube, she saw R1 lying on his right side inside the 5th floor dining room and R1 was bleeding from his head. V5 stated it appeared R1 was having a seizure because R1 was shaking and staring off into space. V5 stated R1 has a history of seizures, and this was her first time witnessing R1 have seizure-like symptoms. V5 stated when she discovered R1 lying on the 5th floor dining room floor, no staff members were located inside of the 5th floor dining room monitoring the residents. V5 stated R1 experienced an unwitnessed fall and there were no witnesses to the start of R1's seizure-like symptoms. V5 stated there were other residents located inside of the dining room at the time of R1's incident. V5 stated she stayed with R1 and called for help from the CNAs because she did not want to leave R1 alone. V5 stated she asked the CNAs to get her some towels so she could clean R1's blood and head wound. V5 stated there is supposed to be a staff member inside of the dining room always monitoring the residents. V5 stated she is not sure who was responsible for monitoring the dining room during the time R1 fell. V5 stated she believes the CNA responsible for monitoring the dining room left the dining room without first informing the nurse. V5 stated if the staff member monitoring the dining room must leave for any reason, they must first inform someone so they can be relieved, and another staff member can continue monitoring the dining room. V5 stated the CNA staff members are usually responsible for monitoring the dining room in 30-minute increments and their scheduled times are written on the daily CNA assignment sheet. V5 stated she called 911 and R1 was sent out to the hospital to be evaluated. V5 stated R1 returned to the facility with sutures on the right side of his head. On 06/17/2025 at 3:15PM, an attempt to contact V8 (Certified Nursing Assistant/CNA) was made, no answer, left voice message, awaiting call back. On 06/17/2025 at 3:17PM, V9 (CNA) stated she was feeding another resident inside of their room and was not located inside of the dining room when R1 fell. V9 stated she only saw V5 (LPN/Nurse Supervisor) attending to R1 in the dining room after R1 fell. V5 stated she saw that R1 had injuries to the right side of his head and R1 was bleeding. On 06/17/2025 at 3:23PM, V10 (CNA) stated R1's incident occurred at approximately 12:00PM during lunch time. V10 stated she was feeding another resident inside of their room and was not located inside of the dining room when R1 fell. V10 stated she did not witness R1 fall and only saw V5 (LPN/Nurse Supervisor) calling the ambulance for R1. V10 stated she saw V5 inside of the 5th floor dining room with R1 and R1 was bleeding from his head. On 06/17/2025 at 3:32PM, V11 (CNA) stated R1's incident occurred on 06/08/2025 during lunch time. V11 stated he was assigned to feed another resident and was located inside of another resident's room feeding them when R1 fell in the 5th floor dining room. V11 stated he was not located inside of the dining room and did not witness R1 fall. V11 stated once he finished feeding his assigned resident, he began retrieving resident meal trays and saw R1 inside of the dining room on the floor. V11 stated he saw V5 (LPN/Nurse Supervisor) bent over R1 attending to R1. V11 stated he immediately offered his assistance and went to retrieve towels for V5. V11 stated shortly after, the ambulance arrived and took R1 to the hospital. On 06/17/2025 at 3:42PM, V12 (Agency Registered Nurse/RN) stated she was the nurse assigned to care for R1 on 06/08/2025 and was not located on the unit when R1 fell. V12 stated she informed V5 (LPN/Nurse Supervisor) that she was going on break and took her break at approximately 12:05PM to 12:10PM. V12 stated she was on break for approximately 15-20 minutes when she was made aware of R1's incident. V12 stated V5 informed her that R1 experienced an unwitnessed fall while in the dining room. V12 stated she was informed by V5 that R1 had a head laceration and was sent to the hospital. V12 stated when she returned from her break, R1 had already left the facility and was sent to the hospital. V12 stated when she returned from her break, she spoke to the CNA who was assigned to care for R1 (identified as V8). V12 stated V8 informed V12 that he (V8) did not see R1 fall because he was feeding another resident at that time. R1's progress note dated 06/08/2025 at 1:50PM, written by V5 documents R1 was noted on the floor laying on his right side. Assessment initiated. Vital signs as follows: BP:118/110 HR:145 o2:98RA RESP:20. 911 Emergency services called. R1 was transported to ER/emergency room. ADON/assistant director of nursing and NP/nurse practitioner made aware. Family member notified of R1 transfer. Will endorse f/u to oncoming nurse. Facility Reported Incident dated 06/08/2025 documents the facility reported to the state agency that R1 was observed laying on his right lateral side in the dining room with open area to right temporal with minimal bleeding. R1's hospital records dated 06/08/2025 documents R1 was evaluated in the hospital on [DATE] and diagnosed with a right temple laceration and required sutures. Record review documents that V5 (LPN/Nurse Supervisor), V8 (CNA), V9 (CNA), V10 (CNA), V11 (CNA), and V12 (Agency Registered Nurse/RN) were all assigned to work on the 5th floor of the facility on 06/08/2025 during the 7:00AM to 3:00PM shift. CNA assignment sheet dated 06/08/2025 documents V9 was responsible for monitoring the 5th floor dining room from 11:30AM to 12:00PM. V11 was responsible for monitoring the 5th floor dining room from 12:00PM to 12:30PM. V10 was responsible for monitoring the 5th floor dining room from 12:30PM to 1:00PM. V8 was responsible for monitoring the 5th floor dining room from 1:00PM to 1:30PM. Facility policy undated titled Fall Prevention Policy documents in part, It is the policy of the facility to identify residents at risk for falls and to implement a fall prevention approach to reduce the risk of falls and possible injury. Facility policy undated titled Facility Policy Regarding Resident Falls documents in part, It is this facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. Facility policy undated titled Seizure Management documents in part, 1. Resident diagnosed with seizures must be monitored for S/S of seizure activity. Facility policy dated 07/2024 titled Resident Supervision Policy documents in part, 1. All residents will be supervised. The day room will be supervised. 7. Social service staff will be scheduled on each unit during mealtime and medication to provide additional supervision.

Apr 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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 residents remain free from physical abuse and verbal abuse. ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents remain free from physical abuse and verbal abuse. These failures affected R1 who was physically hit by R2 in the arm and R3 who was verbally abused with derogatory words from a staff member in the sample of 7 residents reviewed for abuse. Findings include: 1) On 4/14/25 at 2:13 pm, R1 stated that on 3/26/25 at around 7:00 pm, R1 was wheeling R1's self into the elevator to go downstairs to smoke. R1 said when R1 was wheeling into the elevator, R2 was inside the elevator in R2's wheelchair, and R7 was standing in the elevator. R1 asked R2 to move back for more space, and R2 said no. R1 stated R1 wheeled in on the side of R2 in R2's wheelchair, and R2 grabbed my arm and swung at me. R1 said R2 hit R1's arm. R1 said, (R2) attacked me. On 4/15/25 at 9:50 am, R2 stated on 3/26/25, R2 was already in the elevator going down to smoke break, and R1 wheeled in the elevator next to R2's wheelchair. When asked if R2 hit R1 in the elevator on 3/26/25, R2 stated, Yes, yes. I hit (R1). R2 said, (R1) bumped my wheelchair. R1's admission Record documents, in part, diagnoses of chronic obstructive pulmonary disease, acquired absence of right leg above knee, hereditary and idiopathic neuropathy, hyperlipidemia, anemia, chondrocostal junction syndrome, chronic pain syndrome, acute embolism and thrombosis of deep vein of lower extremity (bilateral), disorder of adrenal gland, restless leg syndrome, phantom limb syndrome with pain, and diverticulosis of large intestine. R1's Minimum Data Set (MDS) dated [DATE] documents, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicates R1 is cognitively intact. R1's Functional Abilities for Mobility Devices is a manual wheelchair. R2's admission Record documents, in part, diagnoses of schizoaffective disorder bipolar type, schizophrenia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hypertensive chronic kidney disease stage 4, hyperlipidemia, bipolar disorder, dysarthria and anarthria, major depressive disorder, generalized anxiety disorder, mood (affective) disorder, insomnia, constipation, hypokalemia, syphilis, violent behavior, patient's noncompliance for medication regimen and medical treatment, and anemia. R2's MDS dated [DATE] documents, in part, a Staff Assessment for Mental Status for Cognitive Skills for Daily Decision Making as moderately impaired. R2's Functional Abilities for Mobility Devices is a manual wheelchair. On 4/15/25 at 9:40 am, when asked if R7 witnessed an incident occurred between R1 and R2 on 3/26/25, R7 said, Yes, I (R7) did. R7 stated it was evening time, and it happened on the elevator. R7 stated, (R2) grabbed (R1's) arm and pushed (R1). When asked for details, R7 stated R2 and R7 were in the elevator already, and R1 wheeled into the elevator. R7 stated R1 asked R2 to move over a little to allow more room for R1's wheelchair, and R2 said, No. R7 said R1 was able to wheel into the elevator next to R2, and R2 hit (R1's) arm. R7 stated R2 used a closed fist to strike R1's arm. R7 stated R7 told R2 to stop from hitting R1, and R2 stopped. R7 stated R1 did not hit R2 back. When asked was there anything proceeded R2 hitting R1, like bumping wheelchairs, R7 stated no. R7's admission Record documents, in part, diagnoses of chronic obstructive pulmonary disease, asthma, tachycardia, hyperlipidemia, dependence on renal dialysis, end stage renal disease, type 2 diabetes mellitus, abdominal pain, chronic systolic (congestive) heart failure, and chronic embolism and thrombosis of other specified veins. R7's MDS dated [DATE] documents, in part, a BIMS score of 15 which indicates R7 is cognitively intact. On 4/15/25 at 2:09 pm, V10 (Psychiatric Rehabilitation Service Coordinator, PRSC) stated V10 responded on 3/26/25 around 7:00 pm to the nurse's station after R1 and R2's incident occurred in the elevator. V10 stated R1, R2 and R7 were present, and V10 stated R2 said R2 grabbed and hit R1 in the elevator. On 4/15/25 at 2:48 pm, V12 (Licensed Practical Nurse, LPN) stated after R1 and R2's incident on 3/26/25, V12 assessed R2 per protocol. V12 stated R2 admitted to V12 saying R2 punched R1. Facility document titled Preliminary 24-hour Incident Investigation Report dated 3/26/25 documents, in part, on 3/26/25 at approximately 7:00 pm, R2 was allegedly noted striking R1 with the incident occurring in the elevator. Facility document titled Final Incident Investigation Report dated 4/1/25 documents, in part, Based on the known facts from medical record review and interviews, the following conclusions have been determined about the allegation: (X) Abuse . is (X) Founded. 2) On 4/14/25 at 2:06 pm, R3 stated on 3/22/25 after midnight, R3 went downstairs to the first-floor lobby via R3's manual wheelchair to get something. When asked if R3 knew V5 (Former Receptionist) prior to this incident, R3 stated R3 knew (V5), and they were friends. When asked what happened on 3/22/25 at 1:45 am when R3 saw V5 at reception desk, R3 stated, I (R3) was talking to my friend (V5) and we had a disagreement. I was about ready to leave. When asked what the disagreement was about, R3 stated, (V5) was saying something, talking about me. When asked what V5 specifically said, R3 stated, That's a personal matter. When asked if V5 said curse words towards R3 during their disagreement, R3 stated, Yeah, (V5) did. R3's admission Record documents, in part, diagnoses of paraplegia, chronic osteomyelitis, pressure ulcer of right buttock stage 4, pressure ulcer of left buttock stage 4, pressure ulcer of right hip stage 4, neuromuscular dysfunction of bladder, encounter for attention to ileostomy, depression, cramp and tension, constipation, visual disturbance, sepsis, low back pain, urinary tract infection, primary generalized osteoarthritis, insomnia, dorsalgia, myositis, adult failure to thrive, peripheral vascular disease, and resistance to multiple antibiotics. R3's MDS, dated [DATE], documents, in part, a BIMS score of 15 which indicates R3 is cognitively intact. R3's Functional Abilities for Mobility Devices is a manual wheelchair. During this investigation, this surveyor attempted to contact V5 (Former Receptionist) for interview, but V5 was not reachable via phone. On 4/16/25 at 9:36 am, V18 (Nursing Supervisor 2, LPN) was the night nursing supervisor on the 3/21/25 to 3/22/25 night shift in the facility. V18 stated, I (V18) was made aware when the night receptionist (V5) over head paged me. I called (V5) back. I was on another floor. V18 stated V5 said R3 wouldn't leave the reception area despite V5 asking R3 to leave. V18 stated V18 went downstairs to the receptionist area (near lobby) and V5 said R3 had been trying to record V5 on R3's phone. V18 stated this behavior was not common from R3, so V18 used V5's receptionist phone to call down V17 for assistance with the situation. V18 stated V17 arrived, along with V11 (Registered Nurse, RN) and V16 (Certified Nursing Assistant, CNA), and R3 and V5 were both talking over each other with their accounts of what was happening. V18 stated V5 told R3 to shut up, and V18 told V5 to not say anything further. When asked if V5 called R3 any derogatory curse names, V18 stated, Yes, I am pretty sure (V5) said something back. This surveyor read to V18 her authored Witness Statement (dated 3/22/25). When asked is V18's statement accurate as the truth, V18 stated, Yes. Facility document titled Witness Statement, V18 (Nursing Supervisor 2, LPN) documents, in part, for R3's incident on 3/22/25 at the front desk/lobby area, V18 was called down to this receptionist area in the front lobby by V5 (Former Receptionist) at approximately 1:45 am. When V18 responded to the receptionist area to address the interaction between V5 and R3, V18 documents, Employee (V5) told resident (R3) 'Shut up b****.' On 4/15/25 at 4:03 pm, V17 (Nursing Supervisor 1, LPN) stated V17 normally works as the nursing supervisor but was working as a staff nurse on one of the resident floors for the night shift of 3/21/25 to 3/22/25. V17 stated on 3/22/25 at 1:50 am, V17 received a call from V18 (Nursing Supervisor 2, LPN) to come down to the 1st floor lobby for assistance. V17 stated V17 went downstairs with V11 (RN) to the lobby and observed R3 in R3's wheelchair with V17, V16 (CNA) and V5 present. V17 stated V17 assisted with separating V5 by staying with V5 as V5 was punching out to leave the facility. V17 stated V5 and R3 were calling each other curse words like b*** and h**, and V17 told V5 to stop talking to R3. This surveyor read V17's authored Witness Statement (3/22/25), and V17 stated, Yes, is my accurate statement. Facility document titled Witness Statement, V17 (Nursing Supervisor 1, LPN) documents, in part, for R3's incident on 3/22/25 at the front desk/lobby area, V17 was called down to this receptionist area in the front lobby by V18 at approximately 1:50 am. When V17 was in the receptionist area watching V5 punching out to leave the facility, V17 documents, The employee (V5) then turned and yelled 'Shut up b****.' Facility document titled Preliminary 24-hour Incident Investigation Report dated 3/22/25 documents, in part, V2 (DON) completed this form for R3 allegedly abused by V5. V2 documents, in part, On 3/22/25 at 1:45 am, in the reception area, resident, (R3), was in (R3's) wheelchair in the lobby area and had verbal argument with staff member, (V5), and this was witnessed by two staff members. Facility document tilted Final Incident Investigation Report dated 3/27/25 documents, in part, Based on the known facts from medical record review and interviews, the following conclusions have been determined about the allegation: (X) Abuse . is (X) Founded . As follows: Following a thorough investigation an allegation of verbal abuse is founded. On 4/16/25 at 11:27 am, V1 (Administrator) stated V1 is the abuse coordinator for the facility. V1 stated, Abuse is reported to me. V1 stated on 3/26/25 after V1 had left the facility, V1 received a phone call from V10 (PRSC) reporting of alleged abuse from R2 towards R1, and the residents had been separated. V1 stated R2 admitted to hitting R1, and this was corroborated by an eyewitness, R7. V1 stated V1 concluded physical abuse occurred towards R1 from R2. V1 stated for the incident occurred between R3 and V5, V1 conducted the abuse investigation. V1 stated V1 utilized the witness statements from V17 and V18; interview with R3; and a text exchange with V5 (Former Employee) who said they (R3 and V5) exchanged words with each other. V1 stated V1 concluded verbal abuse occurred towards R3 from V5. V1 stated V5 was terminated from employment in the facility due to verbal abuse towards a resident. Facility policy dated October 24, 2024 and titled Illinois - Abuse Prevention Policy documents, in part, . affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure the facility is doing all is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: . orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property; establishing an environment promotes resident sensitivity, resident security and prevention of mistreatment . This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment 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. Definitions. The following definitions are based on federal and state laws, regulations and interpretive guidelines . Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines) . Verbal Abuse is the use of oral, written, or gestured language willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Facility policy dated November 2018 and titled Residents' Rights for People in Long-Term Care Facilities documented, in part, Your rights to dignity and respect: . Your facility must treat you with dignity and respect and must care for you in a manner promotes your quality of life . Your rights to safety: You must not be abused, neglected, or exploited by anyone - . physically, verbally.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely submit an initial abuse report to the state agency within 2 ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely submit an initial abuse report to the state agency within 2 hours which affected one resident (R3) in the sample of 7 residents reviewed for abuse. Findings include: On 4/14/25 at 2:06 pm, R3 stated that on 3/22/25 after midnight, R3 went downstairs to the first-floor lobby via R3's manual wheelchair to get something. When asked did R3 know V5 (Former Receptionist) prior to this incident, R3 stated that R3 knew (V5), and they were friends. When asked what happened on 3/22/25 at 1:45 am when R3 saw V5 at reception desk, R3 stated, I (R3) was talking to my friend (V5). And we had a disagreement. I was about ready to leave. When asked what the disagreement was about, R3 stated, (V5) was saying something, talking about me. When asked what V5 specifically said, R3 stated, That's a personal matter. When asked did V5 say curse words towards R3 during their disagreement, R3 stated, Yeah, (V5) did. R3's admission Record documents, in part, diagnoses of paraplegia, chronic osteomyelitis, pressure ulcer of right buttock stage 4, pressure ulcer of left buttock stage 4, pressure ulcer of right hip stage 4, neuromuscular dysfunction of bladder, encounter for attention to ileostomy, depression, cramp and tension, constipation, visual disturbance, sepsis, low back pain, urinary tract infection, primary generalized osteoarthritis, insomnia, dorsalgia, myositis, adult failure to thrive, peripheral vascular disease, and resistance to multiple antibiotics. R3's MDS, dated [DATE], documents, in part, a BIMS score of 15 which indicates that R3 is cognitively intact. R3's Functional Abilities for Mobility Devices is a manual wheelchair. On 4/16/25 at 9:36 am, V18 (Nursing Supervisor 2, LPN) was the night nursing supervisor on the 3/21/25 to 3/22/25 night shift in the facility. V18 stated, I (V18) was made aware when the night receptionist (V5) over head paged me. I called (V5) back. I was on another floor. V18 stated that V5 said that R3 wouldn't leave the reception area despite V5 asking R3 to leave. V18 stated that V18 went downstairs to the receptionist area (near lobby) and that V5 said that R3 had been trying to record V5 on R3's phone. V18 stated that this behavior was not common from R3, so V18 used V5's receptionist phone to call down V17 for assistance with the situation. V18 stated that V17 arrived, along with V11 (LPN) and V16 (CNA), and R3 and V5 were both talking over each other with their accounts of what was happening. V18 stated that V5 told R3 to shut up, and V18 told V5 to not say anything further. When asked did V5 call R3 any derogatory curse names, V18 stated, Yes, I am pretty sure (V5) said something back. This surveyor read to V18 her authored Witness Statement (dated 3/22/25). When asked is V18's statement accurate as the truth, V18 stated, Yes. When asked did V18 notify V1 (Administrator) about the abuse allegation from V5 towards R3, V18 stated that V17 called V1, and V1 did not answer V1's phone. When was this call made by V18, V17 stated, Literally 3-5 minutes afterwards of R3/V5's incident occurring. V18 stated that V18 had left V18's cellular phone upstairs, so for privacy, V17 stepped into V2's office on the first floor to call to report the alleged abuse, while V18 stayed with V5. Facility document titled Witness Statement, V18 (Nursing Supervisor 2, LPN) documents, in part, for R3's incident on 3/22/25 at the front desk/lobby area, that V18 was called down to this receptionist area in the front lobby by V5 (Former Receptionist) at approximately 1:45 am. When V18 responded to the receptionist area to address the interaction between V5 and R3, V18 documents, Employee (V5) told resident (R3) 'Shut up b****.' On 4/15/25 at 4:03 pm, V17 (Nursing Supervisor 1, LPN) stated that V17 normally works as the nursing supervisor but was working as a staff nurse on one of the resident floors for the night shift of 3/21/25 to 3/22/25. V17 stated that on 3/22/25 at 1:50 am, V17 received a call from V18 (Nursing Supervisor 2, LPN) to come down to the 1st floor lobby for assistance. V17 stated that V17 went downstairs with V11 (LPN) to the lobby and observed R3 in R3's wheelchair with V17, V16 (Certified Nursing Assistant, CNA) and V5 present. V17 stated that V17 assisted with separating V5 by staying with V5 as V5 was punching out to leave the facility. V17 stated that V5 and R3 were calling each other curse words like b*** and h**, and V17 told V5 to stop talking to R3. This surveyor read V17's authored Witness Statement (3/22/25), and V17 stated, Yes, that is my accurate statement. When asked about reporting this abuse allegation towards R3 from V5, V17 stated, I (V17) made the direct phone call. I first called (V1). Then send (V1) a text message. Then, I called (V2) since I was not able to get in touch (V1). V17 stated that V17 called and spoke with V2 about the abuse incident, when V2 said that V5 is to be sent home which V5 had already punched out. Facility document titled Witness Statement, V17 (Nursing Supervisor 1, LPN) documents, in part, for R3's incident on 3/22/25 at the front desk/lobby area, that V17 was called down to this receptionist area in the front lobby by V18 at approximately 1:50 am. When V17 was in the receptionist area watching V5 punching out to leave the facility, V17 documents, The employee (V5) then turned and yelled 'Shut up b****.' Facility document, dated 3/22/25 at 8:33 am, indicates that V2 (DON) submit the preliminary abuse report for R3 to the state agency via email. Facility document titled Preliminary 24-hour Incident Investigation Report dated 3/22/25 documents, in part, that V2 (DON) completed this form for R3 allegedly abused by V5. V2 documents, in part, On 3/22/25 at 1:45 am, in the reception area, resident, (R3), was in (R3's) wheelchair in the lobby area and had verbal argument with staff member, (V5), and this was witnessed by two staff members. On 4/16/25 at 10:36 am, V2 (DON) stated that V1 is the abuse coordinator for the facility. V2 stated that on 3/22/25 close to 7:00 am, V2 spoke to V17 (Nursing Supervisor 1, LPN) on the phone who was reporting the abuse allegation towards R3 from V5. V2 stated that V17 reported that V17 had tried to call V1 who was not available, and they (staff) tried to call me, but I miss it (the call). V2 confirmed that V1 was not reachable by phone due to religious holiday on 3/22/25 after the incident occurred in the facility. When asked if V1 is not available, who is the next person that staff should call to report an abuse allegation, V2 stated, Me next. When asked if V2 can't be reached, who are staff to call, and V2 stated, Call (V3, Assistant Administrator). This surveyor showed V2 the preliminary abuse report submission report (emailed confirmation) to the state agency sent on 3/22/25 at 8:33 am. When asked the process of notifying the state agency of an initial abuse allegation, V2 stated that it is to be reported to (state agency) in 2 hours. On 4/16/25 at 11:11 am, when asked about incident between R3 and employee in reception area on 3/22/25, was V3 (Assistant Administrator) notified by staff about this abuse allegation, and V3 stated, No. No. That's (V1). On 4/16/25 at 11:27 am, V1 (Administrator) stated that V1 is the abuse coordinator for the facility. V1 stated, Abuse is reported to me. V1 stated that for the incident that occurred between R3 and V5, V1 was not available via phone due to religious holiday on 3/22/25 at approximately 2:00 am. V1 stated that in V1's absence as the abuse coordinator (V1 is not available via phone), the staff must next report abuse to V2 (DON). When asked if V2 is not reachable, like if V2 misses the staff's phone call during middle of the night, who would the staff contact next to report alleged abuse, and V1 stated that it would be V21 (Chief Operating Officer). When asked the process of reporting of alleged abuse to the state agency, V1 stated, I follow the policy and regulations with allegation of abuse. There's a process for reporting timelines. When asked about these timelines regarding when is V1 to report an abuse allegation to the state agency, V1 stated, Usually 2 hours. Immediately. When are staff to have reported this incident to you (occurring at 1:45-1:50 am), V1 stated, Immediately. This surveyor showed R3's preliminary abuse report submitted to the state agency at 8:33 am on 3/22/25. When asking is this time frame greater than 2 hours, V1 stated, Yes. Facility policy dated October 2024 and titled Illinois - Abuse Prevention Policy documents, in part, . affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: . filing accurate and timely investigative reports . Procedures: . V. Internal Reporting Requirements and Identification of Allegations. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence . Reports will be documented, and a record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours of the allegation of abuse.

Apr 2025 16 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure a resident was not interrupted while eating for a scheduled blood glucose monitoring. This failure affected one residen...

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Based on observation, interview, and record review the facility failed to ensure a resident was not interrupted while eating for a scheduled blood glucose monitoring. This failure affected one resident (R88) reviewed in a sample of 62. Findings include: R88's diagnosis includes but not limited to diabetes, gastro esophageal reflux, long term insulin, heart failure and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R88's (3/7/25) Minimal Data Set (MDS) Section C documents in part, Brief Interview of Mental Status (BIMS) score is 12. R88 has moderate impairment. Section I: Active diagnoses include Diabetes Mellitus. On 3/31/25 at 12:15 pm observed R88 in the dining room eating lunch. R88 had consumed half of the meal when V14 LPN (License Practical Nurse) stopped R88 from eating to take R88 to the room to check R88's blood sugar. R88 was brought back to the dining room after to continue eating. R88's (12/19/24) POS (Physician Order Set) documents in part, Blood Glucose Monitoring three times a day for DM (Diabetic Mellitus). R88's MAR (Medication Administration Record) dated March 2025 documented in part, R88's blood sugar hours 0600 (6:00 am), 1200 (12:00 pm), and 1600 (4:00 pm). R88's Medication Administration Audit Report documents in part, blood glucose monitoring three times a day for 3/31/25 at 12:00 pm, documented time is 12:20 pm. On 4/2/25 at 10:57 am, V2 DON (Director of Nursing) stated that residents should not be interrupted when eating their meals to check blood sugars. Blood sugar checks should be done 6:00 am, 11:00 am, and 4:00 pm, before the meals, or it can depend on the orders. R88's care plan (3/10/25) documented in part, has Diabetes Mellitus. On therapeutic diet, blood glucose monitoring, insulin injections and antidiabetic medication. Facility's job description titled Licensed Practical Nurse (LPN) documents in part, Summary: the LPN is responsible for providing direct nursing care to the residents .Administer professional services such as: . taking blood .

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 3/31/2025 at 11:20am observed brown stains in the ceiling above R180's bed, also observed two blue pads on the floor next...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 3/31/2025 at 11:20am observed brown stains in the ceiling above R180's bed, also observed two blue pads on the floor next to R180's bed. R180 stated, Water leaks from the ceiling above my bed when it rains or snows. Paint chips fall from the ceiling onto my bed. I put the blue pads on the floor to catch the water and the paint chips. The light fixture in the ceiling fills up with water and the maintenance person comes in to drain the water out of the globe attached to the light. In the bathroom, there is a hole under the sink where the pipe meets the wall. Roaches come into the bathroom from the hole underneath the sink. I would like these problems to be fixed. R180's Brief Interview for Mental Status (BIMS) dated 1/31/2025 documents R180 has a BIMS score of 15, which indicates R180's cognition is intact. 3. On 3/31/2025 at 11:30am observed R85's closet door missing in room, R85 had several shirts and coats hanging in the closet. R85 stated, My closet door is missing, and I would like a closet door to prevent my things from being stolen. On 4/02/2025 at 11:14am V24 (Maintenance Director) stated the ceiling was plastered a month ago. V24 stated the area in the ceiling needs to be sanded and painted. V24 was questioned as to why the ceiling area still had brown stains; V24 stated the maintenance staff plastered the ceiling but it still has the brown stains, but the area has been plastered. V24 stated the water coming from the ceiling is from the roof which seeps through the concrete and comes out from the ceiling. V24 stated the closet door was taken down last week and the door has not been replaced. V24 stated, I see the hole in the wall underneath the bathroom sink, I can close the hole by placing plaster around the hole in the wall. R85's Brief Interview for Mental Status (BIMS) dated 1/16/2025 documents R85 has a BIMS score of 12, which indicates R85's cognition is moderately impaired. On 4/02/2025 reviewed the facility's Homelike Environment Policy revised February 2025 which documents in part; The facility's department director and all staff will provide residents with a safe, clean, comfortable environment which emphasizes the person-centered care, resident's comfort, independence and personal needs and preferences. Based on observation, interview, and record review, the facility failed to ensure 1 resident's (R62) bed, with exposed wires, was repaired; failed to ensure 1 resident's (R85) missing closet door was replaced; and failed to repair 1 resident's (R180) leaky ceiling. These failures affected 3 residents (R62, R85 and R180), reviewed for resident's rights to enjoy a homelike environment, in a total sample of 62 residents. Findings include: 1. On 3/31/25 at 11:20am, surveyor observed R62 sitting on the side of his bed. At the end of the bed, the location of the mechanical controls to raise and lower parts of the bed, was broken causing exposed wiring. R62 said, My bed's been broken for weeks. I (R62) told the CNAs (certified nursing assistants) many, many times about my bed because I (R62) don't want to get electrocuted by the wires. They (CNAs) told me to be careful and not to touch the wires. Of course, I'm (R62) not going to touch the wires, but you never know. S*** happens. Hell! Those wires might cause a fire. R62's Face Sheet documents diagnoses that include but are not limited to type 2 diabetes mellitus, chronic obstructive pulmonary disease, mononeuropathy of bilateral lower limbs, acquired absence of other right toe(s), and acquired absence of other left toe(s). R62's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 13 which indicates that R62 is cognitively intact. On 4/01/25 at 1:19pm, while in R62's room, V24 (Maintenance Director) said, The cover is broken to his (R62) bed. Those wires are not shockable wires. I (V24) was not aware of this. Typically, maintenance should fix it. No one told me about it. Yeah, those wires are not supposed to be showing. I'll (V24) get that fixed. Facility policy titled, Equipment Maintenance and Repair, revised date 7/24, documents, in part, All equipment utilized in this facility shall be maintained, operated, and repaired as directed . Daily rounds are conducted (i.e. Guardian Angel), to ensure all equipment is clean and in working condition . If equipment shows signs of needing repair, staff shall immediately stop usage of the equipment and report it to maintenance . Facility presented document titled, RESIDENTS' RIGHTS for People in Long-Term Care Facilities, revised date 11/18, documents, in part, . our facility must be safe, clean, comfortable and homelike . Facility policy titled, STATEMENT OF RESIDENTS' RIGHTS, undated, documents, in part, The facility shall insure that all residents are afforded their right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and care for personal needs and communication with and access to persons and services inside and outside the facility. The facility shall protect and promote the rights of each resident, and shall encourage and assist each resident in the fullest possible exercise of these rights . Facility job description titled, Maintenance Supervisor, undated, documents, in part, The primary purpose of the Maintenance Supervisor is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current, federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner . Repair facility/resident property as necessary . Ensure that supplies, equipment, etc., are maintained to provide safe and comfortable environment. Promptly report equipment or facility damage to the Administrator . Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete Minimum Data Set (MDS) assessments accurately in accordanc...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete Minimum Data Set (MDS) assessments accurately in accordance with the Resident Assessment Instrument (RAI) guidelines. This failure affects 1 resident (R165) in a sample of 61. Findings include: Record review of R165's admission record documents in part the following diagnosis: Record review of R165's MDS ([DATE]) documents in part that R165 has a Brief Interview of Mental Status (BIMS) Summary Score of 8, indicating that R165 has cognitive impairment and that R165 has had wandering occur within the lookback period 4 to 6 days but less than daily. A modification request was completed on [DATE] due to a data entry error. Record review of R165's electronic health record for the lookback period does not document any non-purposeful movement or wandering. On [DATE] at 11:22 AM, R165 denied any non-purposeful movement or wandering within the facility. R165 denied ever getting lost or turned around within the facility. R165 stated that R165 has been in the facility for a while now and knows the way around. On [DATE] at 12:08 PM, V34 (Registered Nurse (RN)/MDS Coordinator) affirmed V34 is the RN assessment coordinator for the facility. V34 explained that V34 reviewed R165's MDS ([DATE]) and it was incorrectly coded by the social worker. V34 completed a modification and transmitted the assessment on [DATE]. V34 affirmed R165 did not have any behavior that met the RAI definition of wandering in the lookback period. V34 stated wandering is defined as non-purposeful movement. Record review of CMS' RAI Version 3.0 Manual (10/2024) documents in part, .E0900: Wandering-Presence and Frequency . Steps for Assessment 1. Review the medical record and interview staff to determine whether wandering occurred during the 7-day look-back period. o Wandering is the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. Wandering may or may not be aimless. The wandering resident may be oblivious to their physical or safety needs. The resident may have a purpose such as searching to find something, but they persist without knowing the exact direction or location of the object, person or place. The behavior may or may not be driven by confused thoughts or delusional ideas (e.g., when a resident believes they must find their parent, who staff know is deceased ). 2. If wandering occurred, determine the frequency of the wandering during the 7-day look-back period. Coding Instructions for E0900 o Code 0, behavior not exhibited: if wandering was not exhibited during the 7-day look-back period. Skip to Change in Behavior or Other Symptoms item (E1100). o Code 1, behavior of this type occurred 1-3 days: if the resident wandered on 1-3 days during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days. Proceed to answer Wandering-Impact item (E1000). o Code 2, behavior of this type occurred 4-6 days, but less than daily: if the resident wandered on 4-6 days during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days. Proceed to answer Wandering-Impact item (E1000). o Code 3, behavior of this type occurred daily: if the resident wandered daily during the 7-day look-back period, regardless of the number of episodes that occurred on any one of those days. Proceed to answer Wandering-Impact item (E1000) .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based upon interview and record review the facility failed to follow policy procedures, failed to ensure the vaccination consent form includes a refusal option, and failed to ensure staff provide info...

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Based upon interview and record review the facility failed to follow policy procedures, failed to ensure the vaccination consent form includes a refusal option, and failed to ensure staff provide informed consent prior to obtaining resident signature for one of five residents (R19) reviewed for immunization administration. Findings include: The facility Vaccination Consent Form includes signature of patient or authorized representative to receive vaccine however refusal of vaccine is excluded. R19's (8/19/24) Pfizer - Covid 19 and Flu Vaccination Consent Form was endorsed (by R19) and states signature of patient to receive vaccine however evidence that R19 received these vaccines was not received (as requested). On 4/1/25 at approximately 12:43pm, surveyor inquired about R19's vaccinations V4 (Infection Preventionist) stated He (R19) had refused the Flu and Covid. Surveyor inquired about R19's (8/19/24) Covid 19 and Flu Vaccination Consent Form which affirms consent to receive the vaccines. V4 responded, The consent is signed it looks like whoever did the clinic put refused on the face sheet and then the signatures on the back of the consent form. Surveyor inquired why the (8/19/24) Vaccination Consent Form excludes refusal if R19 refused the Flu and Covid 19 vaccines. V4 replied, How I do it is that they sign, and I put refuse next to where they sign if they refuse. The (undated) Covid 19 vaccination policy states all residents, employees, and contracted staff will be educated and counseled on the importance of Covid 19 vaccination per CDC guidelines and recommendations. The influenza vaccine policy (revised 10/2024) states resident and/or representative has the right to refuse vaccination. If refused, appropriate entries will be documented in the residents' EHR (Electronic Health Record) indicating the refusal of the influenza vaccination.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to provide ADL (Activity of Daily Living) care to one resident (R138) reviewed for ADL care in a sample of 62. Findings include: ...

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Based on observation, interview, and record review the facility failed to provide ADL (Activity of Daily Living) care to one resident (R138) reviewed for ADL care in a sample of 62. Findings include: R138's diagnoses include but not limited to osteoarthritis, chronic pain syndrome, Transient Ischemic Attack (TIA), artificial shoulder joint, and anxiety. R138's (3/25/25) Brief Interview of Mental Status (BIMS) score is 15. R138 in cognitively intact. R138's functional assessment affirms R138 requires substantial/maximal assistance with personal hygiene (shaving). On 3/31/25 at 11:30 am, R138 was observed in room watching television ungroomed with facial hair on the chin. Surveyor inquired if the facility assists R138 with shaving. R138 stated, Staff never offer to shave me. The hair on my chin makes me feel like a man and I do not like that. On 4/2/25 at 10:57 am, V2 DON (Director of Nursing) stated shaving should be done if the resident request to be shaved or if staff see hair. The staff should ask if the resident wants to be shaved and if the resident does want to be shaved then the staff should do it. A female resident should not have hair on her face if she does not want it. R138's care plan documents in part, R138 has an ADL (Activity of Daily Living) self-care performance deficit related to diagnosis/history . Facilities policy undated and titled ADL Policy documents in part, A. hygiene: a. Resident self-image is maintained. Resident has a right to a beard/facial hair but encouraged to be clean shaven. Staff to assist with grooming of facial hair as needed. Facility's job description titled Certified Nursing Assistant documents in part, Essential Duties and Responsibilities: Provide assistance in personal hygiene by giving . shaves .

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure the low air loss mattress was not layered with multiple linens. This failure affected 1 resident (R16) reviewed for pre...

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Based on observation, interview, and record review the facility failed to ensure the low air loss mattress was not layered with multiple linens. This failure affected 1 resident (R16) reviewed for pressure ulcer/injury prevention and treatment in a sample of 62 residents. Findings include: R16's diagnoses include but not limited to COPD (Chronic Obstructive Pulmonary Disease), hypertension, chronic kidney disease, left tibia fracture, tendinitis of left and right leg. R16's Brief Interview of Mental Status (BIMS) score is 15. R16 is cognitively intact. On 3/31/25 at 10:45 am, R16 was lying on a low air loss mattress with multiple layers between R16 and the low air loss mattress. The layers observed under R16 consisted of a flat sheet, a folded bath sheet folded multiple times, and an incontinent brief. On 4/2/25 at 10:23 am, V30 Wound Care Director stated the low air loss mattress should be layered with a single flat sheet. Surveyor asked V30 if a resident on a low air loss mattress should have a folded bath sheet, flat sheet, and incontinent brief under them. V30 stated, That is way too many layers. That many layers can increase the temperature that will increase perspiration and could cause skin breakdown. That many layers are more than recommended and it will defeat the purpose for the mattress, The purpose for the mattress is to provide repositioning and assist with off-loading pressure. On 4/2/25 at 10:57 am, Surveyor asked V2 (Director of Nursing/DON) if a resident on a low air loss mattress should have a folded bath sheet, flat sheet, and incontinent brief under them. V2 stated, All those layers should not be on an air loss mattress, because the purpose of the mattress is for wounds or potential wounds so the layering could cause a bigger wound or potential for an actual wound if they are at risk. A low air loss mattress layering should just be a flat sheet. R16's (4/2/25) Active Orders Summary Report documented in part, Low Air Loss Mattress in use every shift for prevention .Use flat sheet only . R16's Risk Assessment Profile dated 2/4/25 documents in part, R16's Braden Scale Score is a 15, indicating R16 is at risk for skin breakdown. R16's (3/14/25) care plan documents in part, Focus: R16 has potential for alteration in skin integrity r/t (related to) advance age, fragile skin, and incontinence. The (undated) Operation Manual for the air mattress documented in part, Intended use: to reduce the incidents of pressure ulcer while optimizing patent comfort. Installation: step 2 Cover with a cotton sheet to avoid direct skin contact and reduce friction. Facility policy undated and titled, Pressure Ulcer Prevention and guidelines documented in part, It is the policy of this facility to ensure based on assessment that residents at risk for skin break down are assessed and that preventative measures are implemented.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to follow physician orders, failed to implement care plan interventions, failed to measure/re...

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Based on observation, interview, and record review the facility failed to follow policy procedures, failed to follow physician orders, failed to implement care plan interventions, failed to measure/record urine output, and failed to timely report hematuria to the physician for one of 62 residents (R19) in the sample reviewed for incontinence/catheter. Findings include: R19's diagnoses include neuromuscular dysfunction of bladder and retention of urine. R19's Physician Order Sheets include (12/17/24) Xarelto (anticoagulant) 10 milligrams daily to prevent blood clots. (12/28/24) Indwelling catheter measure and record urinary output, color, clarity, and device status every shift. R19's care plan includes (7/6/22) indwelling catheter related to retention of urine and neurogenic bladder, interventions: monitor/record/report to Medical Doctor signs/symptoms UTI (Urinary Tract Infection): pain, burning, blood-tinged urine. (10/2/24) Resident is on anticoagulant therapy, interventions: Monitor/document/report adverse reactions: blood tinged or red blood in urine. R19's (March 2025) Medication Administration Record includes indwelling catheter - measure and record urinary output, color, clarity, and device status every shift however on 3/31/25, nothing was documented on evening and night shift (both entries are blank). R19's (3/7/25) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). R19's (3/7/25) functional assessment affirms resident requires substantial/maximal assistance with toileting hygiene. On 3/31/25 at 11:20am, hematuria was noted throughout R19's indwelling urinary catheter tubing and bag. Surveyor inquired about R19's catheter R19 stated, They (staff) switched out the bag Friday, they change it every Friday and affirmed he (R19) was unaware that there was blood in his urine. On 3/31/25 at approximately 11:23am, surveyor inquired about the appearance of R19's urine. V10 (Licensed Practical Nurse) stated, The urine is red-like, it's a red-like urine which I have to let the doctor know asap. Surveyor inquired if the staff made V10 aware of R19's hematuria. V10 responded No. R19's 3/31/25 (11:40am) progress note (entered after surveyor inquiry) states during rounds resident (brand name) catheter bag was noted with a cranberry like urine, doctor on file was notified. Resident is on Xarelto 10mg tab, doctor ordered to hold Xarelto and send resident to Hospital for hematuria. The catheter care policy (revised 10/2024) states ensure catheter care is performed to prevent infection and reduce irritation. Documentation must include color, amount, consistency, and odor of urine. Notify the physician of any condition change.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that enteral feed orders include daily total volume, failed to follow physician ord...

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Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that enteral feed orders include daily total volume, failed to follow physician orders, and failed to provide enteral feedings as ordered for one of 62 residents (R122) in the sample reviewed for hydration/nutrition. Findings include: R122's diagnoses include encephalopathy, dysphagia, and gastrostomy. R122's (3/3/25) BIMS (Brief Interview Mental Status) affirms cognitive skills for daily decision making is severely impaired, inattention and disorganized thinking are present. R122's (3/3/25) functional assessment affirms resident is dependent on staff for eating, resident does none of the effort to complete the activity. R122's (3/4/25) Care Plan states resident is NPO (nothing by mouth) and receives nutrition via G (gastrostomy) tube, intervention: provide tube feeding as ordered. R122's (3/19/25) Physician Order Sheets include Nepro 1.8 (enteral feed) administer continuous via Pump 70ml (milliliters) per hour over 21 hours (daily total volume is excluded). Downtime: 6am back on at 9am. On 3/31/25 at 10:28am, R122's Nepro 1.8 was infusing at 70ml per hour (via g-tube) however the start time was 3:40am per label, the bottle appeared full (over 900ml) and only 27ml was delivered (per pump). Surveyor inquired about R122's enteral feeding V10 (Licensed Practical Nurse) stated, She's (R122) supposed to be getting it at 70 per hour and normally when I come in the morning, I start it at 10am. Surveyor asked why R122's tube feeding was hung at 3:40am, if it's started at 10am. V10 responded, It was hung on the night shift. I have to verify the time that they stop it, but I start it at 10 in the morning [1 hour after the prescribed start time]. The tube feeding policy (revised 12/2024) states provide nutrients, fluids, and medications as per physician orders. Prescribed amount of formula volume is given over a specific period of time - 24 hours.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to discard expired medication. This failure has the poten...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to discard expired medication. This failure has the potential to affect three residents (R64, R144, R189) in a sample size of 62. Findings Include: 1. On [DATE] at 10:05 am, the second-floor's medication cart had R189's Insulin Lispro Injection Solution 100 UNIT/ML labeled with an expiration date of [DATE]. R189's admission diagnosis includes but not limited to Type II Diabetes Mellitus, Hypertension, and Obesity. R189's Physician Order Sheet documents in part an active order for Insulin Lispro (Injection Solution 100 Unit/ML) with an order date of [DATE] and start date of [DATE]. R189's Medication Administration Record (MAR) documents in part Insulin Lispro Injection Solution had a check mark indicating administration dates of [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 10:51 am, the fourth-floor's medication cart had R64's Insulin Glargine (Injection 100 Units/ML) labeled with an opening date of [DATE] and expiration date of [DATE]. On [DATE] at 10:13 am, V10 (Licensed Practical Nurse-(LPN) stated that V10 (LPN) cleans the cart every 2 days. V10 stated the Insulin Lispro vials expired between 26 and 28 days. V10 verified the expiration date of R189's Insulin Lispro is [DATE]. V10 stated V10 did not administer R189 Insulin Lispro this morning. 2. R64's admission diagnosis includes but is not limited to Type II Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure Morbid Obesity and Long-Term Use Of Insulin. R64's Physician Order Sheet documents in part an active order for Insulin Glargine (Injection Solution 100 Unit/ML) with an order date of [DATE] and a start date of [DATE]. R64's Medication Administration Record (MAR) documents in part Insulin Glargine Solution 100 UNIT/ML with a check mark indicating administration dates of [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 11:02 am, V29 (Licensed Practical Nurse-(LPN) stated R64's Insulin Glargine has an opening date of [DATE]. V29 (LPN) stated R64's Insulin Glargine Solution is expired and should not be on the medication cart. 3. On [DATE] at 10:59 am, the fourth floor's medication cart had R144's Insulin Glargine Solution Injection 100 Units/ML labeled with an expiration date of [DATE]. R144's admission diagnosis includes but is not limited to Type II Diabetes Mellitus with Diabetic Retinopathy, Type II Diabetes with Chronic Kidney Disease, and Type II Diabetes Mellitus with Diabetic Nephropathy. R144's Physician Order Sheet has an active order for Insulin Glargine Solution 100 UNIT/ML with an order date of [DATE] and start date of [DATE]. R144's Medication Administration Record (MAR) documents in part Insulin Glargine Solution 100 UNIT/ML with a check mark indicating medication administration dates of [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 11:04 am, V29 (Licensed Practical Nurse-(LPN) stated R144's Insulin Glargine Injection Solution has an expiration date of [DATE] and should be discarded. V29 stated Insulin should be discarded from the medication cart 28 days after opening. On [DATE] V2 (Director of Nursing-(DON) at 2:11 PM stated that Insulin should have an opening date and an expiration date. V2 stated Insulin should expire 28 days of opening and insulin should be discarded 28 days after opening. Facility Policy titled Storage of Medications dated [DATE] documents, in part, the following: 1. Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel. Pharmacy personnel, or staff members lawfully authorized to administer medications. 2. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter that the manufacturer's expiration date to insure medication purity and potency. 3. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of if according to procedures for medication disposal if a current order exists. 4. The nurse will check the expiration date for each medication before administering.

CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff report maintenance concerns, failed document maintenance requests/repair...

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Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff report maintenance concerns, failed document maintenance requests/repairs, and failed to repair malfunctioning equipment for one of 62 residents (R63) in the sample. Findings include: R63's (3/10/25) functional assessment includes mobility devices: wheelchair. R63's (3/10/25) BIMS (Brief Interview Mental Status) determined a score of 8 (moderate impairment). On 3/31/25 at 12:40pm, surveyor inquired about concerns R63 stated, My leg rest for my chair (referring to the wheelchair) it's broke. V3 (Assistant Director of Nursing) subsequently placed the left leg rest on R63's wheelchair however was unable to lower the foot pedal. Surveyor inquired if R63's foot pedal was broke V3 responded, It won't move, this part (referring to the foot pedal) doesn't slip down. I can't get this one down. Surveyor inquired if V3 was unable to lower R63's foot pedal V3 replied, It's like it's caught up on here and doesn't go through so I'm gonna have maintenance come take a look at it. On 3/31/25 and 4/1/25, surveyor requested the facility maintenance log however the log was not received. On 4/2/25 at 10:49am, surveyor inquired about facility maintenance requests/repairs V24 (Maintenance Director) stated, Typically they (staff) call us (maintenance), or they text us then we (maintenance staff) fix it, or when we do our rounds, and we see something we fix it. Surveyor inquired about the facility maintenance log which was not received V24 responded, Typically, we don't keep a log, we didn't keep a log of it (maintenance request/repairs). Surveyor inquired if V24 received a call and/or text to repair a broken wheelchair on Monday (3/31/25) V24 replied, No I didn't and advised that V27 (Maintenance) may have received the request. On 4/2/25 at 11:00am, surveyor inquired about facility maintenance requests/repairs V27 (Maintenance) stated, Normally they (staff) call or page us (maintenance) to come to the floor or they text us to come fix stuff. Surveyor inquired where maintenance requests are documented V27 responded, When they call, I just go straight there and fix what they call us to do, I just go straight there. If it happens during the night they always call the department head and let us know in the group message. Surveyor inquired if staff reported R63's broken wheelchair on Monday (3/31/25) V27 replied, No they didn't. The equipment maintenance and repair policy (revised 7/24) states, all equipment utilized in this facility shall be maintained, operated, and repaired as directed. Daily rounds are conducted to ensure all equipment is clean and in working condition. Staff shall use the maintenance requisition form for any concerns or repairs that need to be completed. Each unit shall be provided maintenance requisition forms and/or maintenance log to communicate repairs to maintenance staff.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review the facility failed to ensure that the 4th floor medication cart was locked while unattended. This failure has the potential to affect 51 residents o...

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Based on observation, interview, and record review the facility failed to ensure that the 4th floor medication cart was locked while unattended. This failure has the potential to affect 51 residents on the 4th floor. Findings include: The (3/31/25) census includes 51 (4th floor) residents. On 4/1/2025 at 11:11 am, with V29 (Licensed Practical Nurse-(LPN), during observation of the medication car on the 4th floor, V29 and surveyor walked away from the nursing medication cart to observe the medication refrigerator behind the nursing station. V29 did not lock and secure the nursing medication cart after leaving the nursing medication cart unattended. Surveyor inquired why the medication cart was left unlocked and unattended and V29 replied, I was rushing and forgot to lock the cart. The cart should be locked when unattended. On 4/2/2025 at 2:11pm, V2, (Director of Nursing-(DON), stated the medication cart should be always locked after medication. V2 stated residents can get into unlocked medication carts. Facility policy titled Storage of Medications dated 5/1/2018, document, in part, Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. Facility policy titled Storage of Medications dated 5/1/2018, documents, in part, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

CONCERN (F)

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

Staffing Information (Tag F0732)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review, the facility failed to post required staffing information in a high visibility area and failed to ensure the staffing posting included all required i...

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Based on observation, interview and record review, the facility failed to post required staffing information in a high visibility area and failed to ensure the staffing posting included all required information. This failure has the potential to affect all 192 residents residing within the facility. Findings include: Review of facility-provided census documents in part that 192 residents reside within the facility. On 3/31/2025 at 10:30 AM, facility tour was conducted. Posted staffing information was not noted in any high visibility areas on the resident units, dining rooms, activity rooms, or entry areas. On 3/31/2025 at 12:37 AM, surveyor inquired where the required staffing posting was kept. V36 (Receptionist) stated, We don't have a document that says anything like hours on it, just the staffing schedule. V36 pulled a binder off the side counter of the reception desk area and provided a copy of the facility's nursing schedule from the binder. On 3/31/2025 at 12:39 AM, observed the location of the binder sitting on top of the side counter of the receptionist desk area. No residents were seen within this area throughout the course of the survey. Prior to entering the area where the binder is located, a door identifying a staff entrance is noted. Record review of the staffing posting provided by V36 (dated 3/31/2025) does not document the total number and actual number of hours worked in the shifts. On 4/2/2025 at 11:53 AM, V1 (Administrator) affirmed the staffing notice was not posted on 3/31/2025 and the form was currently posted at the front desk. V1 affirmed that the staffing notice should list the hours worked and should be posted in a high visibility area. V1 stated the facility does not have a policy for staffing posting.

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 foods in the walk-in freezer were labeled with a date indicating when the items were placed in the freezer and labeled ...

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Based on observation, interview, and record review the facility failed to ensure foods in the walk-in freezer were labeled with a date indicating when the items were placed in the freezer and labeled with a use by date to prevent expired foods from being served. This failure has the potential to affect all 188 residents in the facility who are receiving an oral diet. The findings include: On 3/31/2025 at 9:30am observed the Walk-In Freezer #3 accompanied by V17 (Dietary Manager). Observed a 10-pound box of flame broiled rib shaped pork patties (53 count per box) and a 10-pound (2- 5-pound packages) box of diced ham which were not dated with a date the item was stored in the freezer, nor dated with a use by date. On 4/2/2025 at 12:09pm V17 (Dietary Manager) stated all kitchen staff are responsible for labeling food items placed in the freezer with a date indicating when it was placed into the freezer. V17 stated it is my expectation that all kitchen staff are labeling all food items with a date when the food item was received and placed into the freezer. V17 stated the food items are labeled with a date so the staff will know which food items are to be used first; first in/ first out. V17 stated if a food item is placed in the freezer and not dated, then this food item may expire. V17 stated if a food item expires and a resident is served this expired food item, then the resident can get sick. Reviewed the facility's policy titled Food & Nutrition Services Sanitation & Food Safety- Labeling and Dating Foods, which lacks the facility's letterhead and documents in part, Underneath Policy: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded. Reviewed the facility's undated Dietary Manager's Job Description which documents in part, The primary purpose of the Dietary Manager is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Dietary Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Dietary Department is maintained in a clean, safe and sanitary manner.

CONCERN (F)

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

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to develop a QAPI (Quality Assurance Performance Improvement) plan that meets regulatory standards. This failure has the potential to affect a...

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Based on interview and record review, the facility failed to develop a QAPI (Quality Assurance Performance Improvement) plan that meets regulatory standards. This failure has the potential to affect all 192 residents that reside within the facility. Findings include: Review of facility-provided census documents in part that 192 residents reside within the facility. On 4/2/2025 at 10:00 AM, surveyor received QAPI meeting minutes and sign-in sheets for all QAPI activities from 2024 through present. A copy of the facility's QAPI plan was not received and was not received prior to the exit of the survey. On 4/2/2025 at 10:40 AM, V1 (Administrator) provided a copy of the facility's QAPI policy. V1 stated the purpose of QAPI is to have ongoing monitoring of data to ensure quality outcomes. On 4/2/2025 at 1:38 PM, surveyor requested to review the facility's QAPI plan. On 4/2/2025 at 3:02 PM, V1 (Administrator) stated the facility does not have a separate QAPI plan and the QAPI policy is the facility's QAPI plan. Record review of facility policy titled QAPI program (8/2024) documents, Title: QAPI Program Policy: QAPI is the coordinated application of two mutually - reinforcing aspects of quality management systems. Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and date driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home care givers in practical and creative problem solving. QA is the specification of standards for quality of service and outcomes and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is ongoing, both anticipatory and retrospective in its efforts to identify how the organization is performing including where and why the facility performance is at risk or has failed to meet standards. PI (also called quality improvement and performance improvement) is the continuous study and improvement of processes with the intent to better services or outcomes and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systematic problems or barriers to improvement. PI in nursing homes aims to improve to improve processes involved in health care delivery and resident quality of life. PI can make food quality even better. Procedure: 1. The administrator will advise and oversee the duties and responsibilities of the QAPI steering committee. 2. The administrator will appoint staff members to the QAPI steering committee. 3. The administrator and QAPI steering committee are responsible for planning, designing, implementing and coordinating care and services and selecting the QA activities to meet the needs of the resident. 4. The QAPI committee will meet at a minimum quarterly and/or more frequently as deemed by the committee. 5. Minutes of meetings will reflect membership and all attendance of those who participate in the meeting. 6. The QAPI committee will ensure the plans and goals are carried out and are clearly communicated to all staff. 7. Annual training will be conducted to all staff utilizing the annual QAPI report to summarize goals, progress and revisions to performance improvement plans. Revised August, 2024. This policy is not a plan and does not include pertinent information for a QAPI plan, including but not limited to, description of how the facility will ensure care and services delivered meet accepted standards of quality, description of how the facility will identify problems and opportunities for improvement, and ensure progress toward correction or improvement is achieved and sustained; the process for identifying and correcting quality deficiencies (including key components such as tracking and measuring performance, Establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies, identifying and prioritizing quality deficiencies; Systematically analyzing underlying causes of systemic quality deficiencies; Developing and implementing corrective action or performance improvement activities; Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed); describe all systems of care and management practices; include clinical care and resident choice; describes how the facility will utilize the best available evidence to define measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents; and describes the complexities, unique care and services that the facility provides.

CONCERN (F)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to develop policies and procedures on how the facility obtains and uses feedback from residents, resident representatives, and staff to identi...

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Based on interview and record review, the facility failed to develop policies and procedures on how the facility obtains and uses feedback from residents, resident representatives, and staff to identify high-risk, high-volume, or problem prone issues as well as opportunities for improvement; Develop and implement policies and procedures which include how it ensures data is collected, used and monitored for all departments; Develop policies and procedures for how it will identify, report, and track, adverse events, and high risk, high volume, and/or problem-prone concerns; Establish priorities for its improvement activities, focus on high-risk, high- volume or problem-prone areas, as well as resident safety, choice, autonomy, and quality of care; Conduct at least one PIP annually focuses on high-risk or problem prone areas, identified by the facility, through data collection and analysis; and measure the success of actions implemented and track performance to ensure improvements are realized and sustained. This failure has the potential to affect all 192 residents reside within the facility. Findings include: Review of facility-provided census documents in part 192 residents reside within the facility. On 4/2/2025 at 10:00 AM, surveyor received QAPI (Quality Assurance Performance Improvement) meeting minutes and sign-in sheets for all QAPI activities from 2024 through present. A copy of the facility's QAPI plan was not received and was not received prior to the exit of the survey. No records of the completion of a Performance Improvement Plan (PIP) were received prior to the exit of the survey. On 4/2/2025 at 10:10 AM, V35 (Medical Records Director) affirmed V35 is in charge of the QAA/QAPI programming within the facility. V35 stated the facility completes QAPI meetings quarterly and each department brings items to discuss at the meeting. V35 was unsure if there was any specific document identifies what each department is to bring to the meeting. V35 stated the facility completes PIPs after every concern is identified. Surveyor inquired what the process of a completing PIP is and V35 replied, The department manager does corrective action. V35 denied a charter is completed, committee formed, or root cause analysis is completed. V35 denied knowledge of root cause analysis. V35 could not identify what items a formal PIP was completed on within the last year. Surveyor requested records of a PIP completed within the last year from V35 and this was not received by the exit of the survey. V35 reviewed the QAPI meeting minutes and data from the 1/21/2025 meeting (signed and prepared by V35) and the identified concerns/corrective action. No proof of corrective action was documented within the provided QAPI documents (i.e., in-service documents). V35 was unsure if the corrective action was completed as identified in the meeting minutes and notes. Surveyor inquired how V35 and the QAA committee would know the corrective action was completed without documentation, and V35 responded, Yeah, I see what you mean. Surveyor requested documentation of the identified corrective action for all items identified in the 1/25/25 meeting from V35 and the documentation was not received prior to the exit of the survey. On 4/2/2025 at 10:40 AM, V1 (Administrator) affirmed V35 is in charge of the QAPI programming but V1 supervises V35. V1 affirmed V1 participates in the QAPI committee as the governing body. V1 stated the facility had completed a PIP within the last year on falls. V1 could not recall the specifics of the PIP, including but not limited to, data collection, how often data was reviewed, all staff members involved with the PIP. Surveyor requested the documentation from the falls PIP. V1 responded, we do not have documentation of the PIP. Record review of facility policy titled QAPI program (8/2024) documents, Title: QAPI Program Policy: QAPI is the coordinated application of two mutually - reinforcing aspects of quality management systems. Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and date driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home care givers in practical and creative problem solving. QA is the specification of standards for quality of service and outcomes and a process throughout the organization for assuring care is maintained at acceptable levels in relation to those standards. QA is ongoing, both anticipatory and retrospective in its efforts to identify how the organization is performing including where and why the facility performance is at risk or has failed to meet standards. PI (also called quality improvement and performance improvement) is the continuous study and improvement of processes with the intent to better services or outcomes and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systematic problems or barriers to improvement. PI in nursing homes aims to improve to improve processes involved in health care delivery and resident quality of life. PI can make food quality even better. Procedure: 1. The administrator will advise and oversee the duties and responsibilities of the QAPI steering committee. 2. The administrator will appoint staff members to the QAPI steering committee. 3. The administrator and QAPI steering committee are responsible for planning, designing, implementing and coordinating care and services and selecting the QA activities to meet the needs of the resident. 4. The QAPI committee will meet at a minimum quarterly and/or more frequently as deemed by the committee. 5. Minutes of meetings will reflect membership and all attendance of those who participate in the meeting. 6. The QAPI committee will ensure the plans and goals are carried out and are clearly communicated to all staff. 7. Annual training will be conducted to all staff utilizing the annual QAPI report to summarize goals, progress and revisions to performance improvement plans. Revised August, 2024.This policy does not include descriptions of how the facility obtains and uses feedback from residents, resident representatives, and staff to identify high-risk, high-volume, or problem prone issues as well as opportunities for improvement; include how it ensures data is collected, used and monitored for all departments; describe how the facility will identify, report, and track, adverse events, and high risk, high volume, and/or problem-prone concerns; Establish priorities for its improvement activities, focus on high-risk, high- volume or problem-prone areas, as well as resident safety, choice, autonomy, and quality of care. No other related QAPI policy documents were received prior to the exit of the survey.

CONCERN (F)

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

Deficiency F0944 (Tag F0944)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to ensure all staff were trained annually on the facility's QAPI program. This failure has the potential to affect all 192 residents residing ...

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Based on interview and record review, the facility failed to ensure all staff were trained annually on the facility's QAPI program. This failure has the potential to affect all 192 residents residing within the facility. Findings include: Review of facility-provided census documents in part that 192 residents reside within the facility. On 4/2/2025 at 10:16 AM, V35 (Medical Records Director) affirmed V35 manages the QAA and QAPI programming for the facility. V35 stated QAPI stands for Quality assurance performance and . uhh . I don't know. V35 did not know what the term root cause analysis meant. V35 reviewed nearby documents and could not state what QAPI stands for. V35 stated the facility does not train all staff on QAPI as the department heads are the identified staff that participate in QAPI. V35 could not remember the last time V35 had QAPI training, stating it was probably many, many years ago. On 4/2/2025 at 10:40 AM, V1 (Administrator) affirmed V35 is in charge of the QAPI programming but V1 supervises V35. V1 affirmed V1 participates in the QAPI committee as the governing body. V1 stated V1 was unsure the last time the facility completed all staff QAPI training. Surveyor requested the staff in-servicing records regarding required QAPI training, and these records were not received by the end of the survey. On 4/2/2025 at 11:22 AM, V2 (Director of Nursing) stated V2 is a part of the QAA/QAPI committee. V2 could not recall the last time V2 received QAPI training. V2 was unsure if all staff were trained on QAPI annually. Record review of facility policy titled QAPI Program (8/2024) documents in part . 7. Annual training will be conducted to all staff utilizing the annual QAPI report to summarize goals, progress, and revisions to performance improvement plans.

Mar 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interviews the facility failed to support requirements for petition to involuntary admit 1 reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interviews the facility failed to support requirements for petition to involuntary admit 1 resident (R2) out of 4 residents reviewed for transfer and discharge. These failures affected 1 resident (R2) who was twice petitioned to be transferred to the hospital and did not meet regulatory requirement or documentation during both transfers. Findings include: R2 is [AGE] years old, initially admitted to the facility on [DATE]. R2 was twice transferred to hospital via petition for involuntary admission on [DATE] and 02/28/2025. - Per first petition for involuntary admission dated 01/27/2025, signed by V10 (Social Service Director), documents R2 demonstrates ongoing behaviors of medication refusals and non-compliance with care. R2 is also displaying increase irritability, agitation, aggression, and emotional distress coupled with manipulative behavior. Review of R2's notes dated 01/27/2025, the day R2 was sent via petition for involuntary admission to the hospital, shows there was no documentation of R2's behavior as described on the petition. The only notes that were documented related to refusal to take medication were by V5 as an education note. It documents that R2 was educated on refusal of medication in the morning. R2 responded that he will only take stool softener. V5 explained to R2 that R2's blood pressure was high. R2 responded by typing to V5 not to make R2 upset. On 03/26/2025 at 11:08 AM V5 (Social Worker) stated the first time R2 was sent out for involuntary petition was due to refusal of medication. R2's blood pressure was high. V5 said, He just picks and chooses whatever he wants on his medication. He only wants his stool softener. V5 stated the nurse informed her that R2's blood pressure was high. Per nursing schedule dated 01/27/2025, V12 (Licensed Practical Nurse) was the scheduled nurse when R2 was sent to the hospital. On 03/26/2025 at 11:55 AM V12 stated R2 was always non-compliant with medication. R2 has problem with swallowing so his medicines need to be crushed with apple sauce. V12 stated R2 had a lot of behaviors in the past but on the day of R2's petition to be transferred involuntarily to the hospital there was no documentation of behavioral concerns. On 03/27/2025 at 10:42 AM, V10 (Social Service Director) confirmed that V10 signed the petition for involuntary admission for R2 to go to the hospital on [DATE]. V10 read the petition which stated, R2 demonstrating medication refusal, non-compliance with care, displaying increase irritability, agitation and aggression, and emotional distress couple with manipulative behavior. V10 stated R2's behavior manifested that day and manifested over time. V10 explained that R2's behavioral problem was ongoing including non-compliance. V10 stated that refusal of medication on that basis alone does not support involuntary transfer and there needs to be documentation that supports behavioral concerns as basis of the petition. V10 said, On that day he was exhibiting noncompliance but there is no documentation as to his behavior to support involuntary transfer. There needs to be more documentation. It is not that we just transfer resident if they refuse medication. But I see your point. - Per second petition for involuntary admission dated 02/28/2025 signed by V5 (Social Worker) R2 was physically aggressive with the nurse (identified as V6 Registered Nurse) picking up laptop and slammed it to the wall meters away from V6's head. R2 putting his middle finger up at the V6 hitting V6 on the shoulder with the door. There were no notes documented to support that R2 slammed laptop on the wall meters away from V6. On 03/25/2025 at 12:45 PM, V6 could not remember if R2 had laptop but stated that V6 was sure that R2 uses iPad for communication because R2 is nonverbal. On 03/26/2025 at 11:08 AM V5 (Social Worker) stated the second time R2 was sent out for involuntary petition was when the nurse told V5 that R2 pushed the door into the nurse. V5 said, That is when the laptop broke. V5 stated that she did not witness R2 throwing the laptop on the wall. She just saw the laptop on the floor. V5 stated nobody witnessed R2 throwing the laptop. V5 was asked why that on the petition it was documented that R2 picked up laptop and slammed it to the wall meters away from V6's head if V6 does not know that R2 has a laptop, and nobody witnessed the act of throwing the laptop on the wall. What is the basis of this documentation? V5 said nobody witnessed it.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review the facility failed to accurately document on resident records for 2 (R1, R2) out of 4 re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review the facility failed to accurately document on resident records for 2 (R1, R2) out of 4 residents reviewed. These failures affected 2 residents (R1, R2) on correct representation of their resident records. R1's physician order and medication administration have identified inconsistency. R2's petition for involuntary / judicial admission to the hospital documentation have identified inconsistency. These inconsistencies resulted to inaccurate representation of R1 and R2's records. Findings include: 1. R1 currently [AGE] years old, initially admitted on [DATE]. R1's medical diagnosis includes alcoholic cirrhosis of liver with ascites, chronic obstructive pulmonary disease, centrilobular emphysema, malignant neoplasm of trachea, atherosclerotic heart disease of native coronary artery. Per clinical notes dated 03/21/2025 by V3 (Licensed Practical Nurse) R1 was sent to the hospital due to altered mental status, very anxious and restless. On the same day (03/21/2025) V4 (Licensed Practical Nurse) documents she received a call from paramedics around 04:45 PM that R1 will be rerouted to a different hospital due to suspected overdose. At around 10:20 PM, V4 documented that R1 was admitted in the hospital with diagnosis of altered mental status and brought to intensive care unit (ICU). On 03/25/2025 at 02:00 PM V3 (Licensed Practical Nurse) stated when V7 (Nurse Practitioner) was first informed about R1 V7 ordered laboratory blood work for CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Profile) as soon as possible. V3 said, I didn't even enter it as an order. Because I realized I needed to take him to his room. On 03/27/2025 at 11:21 AM, V7 (Nurse Practitioner) confirmed V3 called her regarding R1. V7 stated that V7 ordered CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Profile). On 03/26/2025 at 02:25 PM, V14 (Assistant Director of Nursing) was requested to provide controlled substance form for Methadone medication of R1. V14 provided controlled substance form that read R1's name and room number, give 5 ML PO QD, amount received 14, date received 03/19, nurse signature by V3 (Licensed Practical Nurse). V2 (Director of Nursing) was asked what medication the form was for. There was no medication provided. V2 stated it is for Methadone medication. V2 was asked why Methadone was not written a narcotic medicine. V2 said, I do not know. On 03/27/2025 at 12:11 PM, Medication Administration Record (MAR) of R1 for March 2025 documents R1 has an order of Methadone 5 ML per 30 MG (controlled substance) to receive daily. In March up to the day when R1 was transferred to the hospital was signed as medication being administered except March 4 coded as 7 which means to see nurse's notes. Clinical notes of V3 documents R1 was out to an appointment March 4th. Controlled Substances Proof of Use form for R1 for Methadone does not reflect that the medicine was used on March 18 but MAR on March 18 was signed as medicine administered. V2 (Director of Nursing) stated that it is possible R1 took Methadone when he was in the appointment. V2 made aware that documentation needs to reflect that Methadone was not administered on March 18 due to an appointment instead of signing Methadone as administered in the facility. On 03/27/2025 at 12:55 PM, V2 (Director of Nursing) stated the physician order should have been entered on R1's electronic record when V7 ordered for laboratory blood work (CBC and CMP). V2 stated medications that are not administered in the facility should have been documented as administered. It should have noted that resident went for an appointment. 2. R2 is [AGE] years old, initially admitted in the facility on 01/07/2025. R2 was twice transferred to hospital via petition for involuntary admission on [DATE] and 02/28/2025. - Per first petition for involuntary admission dated 01/27/2025, signed by V10 (Social Service Director), documents R2 demonstrates ongoing behaviors of medication refusals and non-compliance with care. R2 is also displaying increase irritability, agitation, aggression, and emotional distress coupled with manipulative behavior. Review of R2's notes dated 01/27/2025, the day R2 was sent via petition for involuntary admission to the hospital, shows there was no documentation of R2's behavior as described on the petition. On 03/27/2025 at 10:42 AM, V10 (Social Service Director) confirmed that V10 signed the petition for involuntary admission for R2 to go to the hospital on [DATE]. V10 read the petition which stated, R2 demonstrating medication refusal, non-compliance with care, displaying increase irritability, agitation and aggression, and emotional distress couple with manipulative behavior. V10 stated R2's behavior manifested that day and manifested over time. V10 explained that R2's behavioral problem was ongoing including non-compliance. V10 stated that refusal of medication on that basis alone does not support involuntary transfer and there needs to be documentation that supports behavioral concerns as basis of the petition. V10 said, On that day he was exhibiting noncompliance but there is no documentation as to his behavior to support involuntary transfer. There needs to be more documentation. It is not that we just transfer resident if they refuse medication. But I see your point. - Per second petition for involuntary admission dated 02/28/2025 signed by V5 (Social Worker) R2 was physically aggressive with the nurse (identified as V6 Registered Nurse) picking up laptop and slammed it to the wall meters away from V6's head. R2 putting his middle finger up at the V6 hitting V6 on the shoulder with the door. There were no notes documented to support that R2 slammed laptop on the wall meters away from V6. On 03/25/2025 at 12:45 PM, V6 could not remember if R2 had laptop but stated that V6 was sure that R2 uses iPad for communication because R2 is nonverbal. On 03/26/2025 at 11:08 AM V5 (Social Worker) stated the second time R2 was sent out for involuntary petition was when the nurse told V5 that R2 pushed the door into the nurse. V5 said, That is when the laptop broke. V5 stated that she did not witness R2 throwing the laptop on the wall. She just saw the laptop on the floor. V5 stated nobody witnessed R2 throwing the laptop. V5 was asked why that on the petition it was documented that R2 picked up laptop and slammed it to the wall meters away from V6's head if V6 does not know that R2 has a laptop, and nobody witnessed the act of throwing the laptop on the wall. What is the basis of this documentation? V5 said nobody witnessed it.

Mar 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure individualized and appropriate fall interventions were ide...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure individualized and appropriate fall interventions were identified and implemented to provide necessary supervision to prevent a resident from falling for 1 (R1) out of 4 residents reviewed for falls. Findings Include: R1's Fall note dated 2/28/25 at 9:00 PM documented by V4 (Licensed Practical Nurse) reads in part: Noted resident [R1] walking out of room with foley catheter in his hand. [R1] walked in front of the nursing station and fell and hit the back of his head. [R1] unable to give description. Full body assessment with no noted bruises or bumps. Emergency ambulance called and transferred R1 to the hospital. V4's (Licensed Practical Nurse/LPN) witness statement reads in part, Noted resident walking out of room and walk in front of nursing station and fall and hit his back of his head. V5's (LPN) witness statement reads in part, Resident noted walking by nursing station unassisted and lost his balance falling and hit his back and side of head. R1's clinical records show a re-admission to the facility on 1/30/25 with included diagnoses but not limited to chronic obstructive pulmonary disease, schizophrenia, dementia, and restlessness and agitation. R1 had a significant change of condition minimum data set assessment dated [DATE] that revealed R1's preferred language was Cantonese and needed an interpreter. R1 was still able to make his needs known, had moderate impairment with cognition, and required substantial maximal staff assistance for walking, transferring, and toileting. R1's Fall Risk Assessment dated 2/21/25 shows R1 was high risk for falling, had history of falling and had impaired gait. R1's fall comprehensive care plan have the following fall interventions: anticipate and meet R1's needs (initiated 3/1/21), be sure R1's call light is within reach and encourage R1 to use it for assistance as needed, needs prompt response to all requests for assistance (initiated 3/1/21), educate R1/family/caregivers about safety reminders and what to do if a fall occurs (initiated 3/1/21), remind R1 to call for help before getting up and attempting to transfer or ambulate (initiated 3/3/25 post fall), and staff to monitor for behaviors of laying or throwing self on floor (initiated 12/3/24). R1's comprehensive fall care plan was not individualized and revised based on his significant change assessment on 2/26/25 to meet all his needs to prevent him from falling. On 3/18/25 at 12:17 PM, a phone interview was conducted with V4 (LPN) about R1's fall incident that happened on 2/28/25. V4 stated between 9:00 PM and 10:00 PM, V4 saw R1 walked out of his room and walked towards the nurses' station where he lost balance and fell. R1 hit the back of his head. V4 stated R1 used to walk by himself but was not supposed to anymore because R1 has been sick. R1 went to the hospital and came back weak. V4 stated R1 did not speak English, is confused, and bedridden. V4 stated he does not think R1 knew how to use the call light and the last time V4 saw R1 was 20 minutes before the fall when R1 was in bed awake. V4 stated R1 could not explain why he got up from bed. V4 stated, I was not told he [R1] was high risk for falling. I never witnessed him [R1] having any behaviors. When [R1] fell, he was barefoot. He was bedridden. They would not put socks or shoes on a resident who is bedridden. There were no fall interventions in place for him [R1] because he is not considered a fall risk. He [R1] was bedridden and would not be considered at risk for falling. On 3/18/25 at 12:35 PM, V2 (Director of Nursing/Interim Fall Coordinator) stated residents are identified for at risk for falling by checking their history, their gait, cognitive status, and medications that needs to be done on admission, re-admission, post fall, and needs to be re-evaluated quarterly, annually, and with significant change. V2 stated all residents in the facility are at risk for falling. V2 stated fall interventions are initially all standardized. If a resident does not fall, it will all be standard fall interventions. V2 stated R1's fall interventions prior to the 2/28/25 were standardized because R1 never had a fall before. On 3/18/25 at 2:00 PM, V32 (Restorative Director) stated the residents' care plans should be individualized based on the needs of the residents. V32 stated care planning is an interdisciplinary team approach and fall interventions should be based on the team's assessments and reviews. V32 stated fall interventions should address the resident's needs such as language barrier, vision problems, and gait problems. V32 stated it is important for staff to know and follow the resident's fall interventions to prevent resident from falling and prevent the risk of injury. V32 stated R1 was able to walk on his own before and he had been having slow decline. There are days R1 would get up and there are days he would stay in bed. R1 had the tendency to get up by himself because he used to walk on his own. R1 had confusion and had language barrier. V32 stated R1 gets agitated when nobody understands him. R1 knew how to use the call light. R1 forgets to use it at times. V32 stated R1 would need non-skid socks and staff needs to apply them when R1's is in bed in case he gets up without assistance, and it needs to be part of the fall intervention. V32 stated R1's significant change assessment was completed on 2/26/25 because R1 had overall functional decline. V32 stated the fall care plan should have been reviewed and revised after the significant change assessment to reflect his functional decline. V32 stated prior to the 2/28/25 fall, R1 required one staff substantial maximal assistance with transfer, bed mobility, and walking. That means one staff should be assisting R1 and holding him during these activities. The staff is doing more than 50% of the work for R1. V32 stated if staff saw R1 standing and walking by himself, they should right away attend to him and assist him with walking because R1 had unsteady gait and was high risk for falling. The facility's Falls and Fall Prevention policy dated 11/2024 documents in part: To ensure residents admitted are assessed for potential fall risk. To ensure a fall prevention program will include measures which will determine the individual need of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices as indicated based on assessment. Residents who are assessed as at risk for falls will have a care plan initiated to include approaches for the prevention of falls as they apply to the individual resident. The interdisciplinary team will include specific interventions such as but not limited to a recommendation for a low bed, footwear, lighting bed or chair alarm and changing resident's room. Nursing staff will be informed of residents who are at risk of falling. Resident fall risk interventions will be identified on the care plan. Resident care plan intervention will be updated as indicated.

Feb 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident medication was administered as ordere...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident medication was administered as ordered by the physician. This failure affects 1 (R1) out of 3 residents reviewed for medication administration. Findings Include: R1's Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, Aphasia following cerebral infarction, Dysphagia following cerebral infarction, Essential Primary Hypertension, and Hyperlipidemia. On 2/25/25 at 11:05 AM, R1 is non-verbal and R1 uses a tablet (iPad) voice machine to communicate. R1 stated that he was ignored and was not provided morning medications including R1's blood pressure medication on 2/16/25 and today 2/25/25. R1 stated that most nurses give his medication whole, but V6 (Licensed Practical Nurse/LPN) working today decided to crush R1's medication, and he refused to take the medication. R1 stated that on 2/16/25, he requested for his blood pressure medication (Lisinopril 10 mg, 1 tablet daily at 9am) around 11:30AM, and that V6 stated the medication time had passed. R1 stated V6 did not check his blood pressure which is always high. R1 stated R1 has no problem swallowing whole medications, and that the nurses are lying about R1 having problem to swallow whole medication. R1 stated that on 2/17/25 or 2/19/25 R1's blood pressure medication was skipped, and the nurse did not even come to ask R1. R1 stated the nurse lied about him not wanting to be bothered. R1 stated that he never said that he does not want to be bothered to anyone. R1 does not believe the facility did not have R1's medication and has no issues with other shifts just this morning shift, when he needs his blood pressure medication. On 2/25/25 at 12:22 PM, V6 (LPN) stated if a resident refused medication, she would educate, notify the physician regarding the reason for the refusal, and follow up with the physician's order. V6 stated she did not check R1's blood pressure and did not administer blood pressure medication to R1 this morning because R1 gave V6 the middle finger when V6 told R1 that the medication will be crushed. V6 stated she did not notify the physician, but V6 should have notified the physician for a possible new order to change into a liquid form. V6 stated she did not give R1 blood pressure medication on 2/16/25 because R1 asked for the 9 am medication at 11:30 AM. V6 stated since R1 is scheduled to take the blood pressure medication daily at 9am, V6 should have called the physician to change the timing. V6 stated that failure to administer blood pressure medication to R1 has the potential to increase R1's blood pressure and may cause R1 to have another stroke. At 12:40 pm, V6 was ask if V6 attempted again to take R1's blood pressure this morning, V6 stated no, but she will try now. V6 went into R1's room to take R1's blood pressure with a reading of 154/110. V6 stated that she is calling the physician now and will follow up with the surveyor. At 12:52 PM, V6 stated the physician stated V6 should call the pharmacy to convert the blood pressure to liquid or syrup if possible. At 1:40 PM, V6 stated the pharmacy stated the blood pressure medication (Lisinopril 10mg) could not be converted to a liquid form. V6 stated that V6 will notify the physician. At 2:39 PM, V6 stated that the physician gave order to administer R1's medication whole in apple sauce and monitor. At 2:46 pm, V6 stated that V6 administered the blood pressure medication whole in apple sauce to R1 without any difficulty. On 2/25/25 at 3:49 PM, V5 (Assistant Director of Nursing/ADON) stated that nurses should be calling the physician when a resident refuses medication. V5 stated that failure to administer blood pressure medication as ordered by physician could potentially result into high blood pressure that can lead to a medical emergency. On 2/25/25 at 4:18 PM, V10 (LPN) stated that V10 has been working in the facility for over one year, 7AM-3PM shift. V10 stated that V10 worked with R1 on 2/19/24 and V10 gave R1's medications whole without any complaint. V10 stated that V10 did not ignore R1, V10 gave R1 blood pressure medication as scheduled because R1's blood pressure is always high, and R1 did not tell V10 that R1 does not want to be bothered whenever. On 2/25/25 at 4:30 PM, V2 (Director of Nursing/DON) stated that it is V2's expectation nurses would document medication refusal with the reason and notify the physician immediately. V2 stated R1 has been refusing R1's blood pressure medication because R1 does not want R1 medication crushed. V2 stated there was no specific physician order or recommendation from the speech therapist that R1's medication should be crushed. V2 stated constant refusal of the blood pressure medication by R1 could lead to R1 having another stroke. V2 stated the nurse should have notified the physician with the reason for the refusal to prevent another stroke and medical emergency. V2 stated V2 will provide in-service on notifying the physician for any medication refusal and proper communication between the therapist and the nursing staff. Documents Reviewed: R1's Minimum Data Set, dated [DATE] shows R1 is cognitively intact. R1's Physician Order Sheet (POS) shows active order of Lisinopril oral tablet 10mg, give 1 tablet by mouth one time a day for hypertension. R1's Electronic Medical Record (EMR) shows R1 did not receive Lisinopril 10 mg on 2/16/25, 2/17/25, and 2/25/25. There were no documentations that the physician was notified with a reason for the refusal found in R1's EMR. R1's care plan dated 2/20/25 documents in part: R1 has diagnosis of hypertension, goal-R1 will remain free of complications related to hypertension. Intervention: Give anti-hypertensive medications as ordered. Policy on Medication Administration and Storage Policy dated 07/02/18 documents in part: If the resident has refused a medication. State reasons for the refusal. Physician must be notified when medications are not administered as per physician orders.

Feb 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0925 (Tag F0925)

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 the facility is free of insect pests in one re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility is free of insect pests in one resident's (R2) room. This failure affects one resident (R2) reviewed for effective pest control program. Findings include: R2 is aphasic and utilizes a tablet computer to communicate. On 2/10/25 at 11:05am, R2 typed, There's roaches everywhere. Look! R2 pointed to 3 dead roaches on the floor in his room next to the bed and opened the dresser drawer in his room and there was 1 dead roach that was observed by surveyor. R2's Face Sheet documents medical diagnoses that include but are not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; aphasia following cerebral infarction; dysphagia following cerebral infarction; major depressive disorder, recurrent, severe with psychotic symptoms; unspecified psychosis not due to a substance or known physiological condition; irritability and anger. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a brief interview of mental status (BIMS) score of 15 which indicates R2 is cognitively intact. On 2/10/25 at 11:33am, surveyor showed V19 (Licensed Practical Nurse/LPN) the pests on R2's floor and in R2's drawer. V19 said, Ewww! I'll (V19) call housekeeping right away about these cockroaches. On 2/10/25 at 11:46am, R3 said, I (R3) see cockroaches every day. Live cockroaches and dead cockroaches. The live ones come out a night. I just seen a dead one today in the bathroom. It's gross. Surveyor was unable to locate the dead cockroach in R3's bathroom. R3's Face Sheet documents diagnoses that include but are not limited to obstructive sleep apnea; chronic pain syndrome; schizophrenia; unspecified fall; anxiety disorder; major depressive disorder; and type 2 diabetes mellitus. R3's Minimum Data Set (MDS), dated [DATE], documents, in part, a brief interview of mental status (BIMS) score of 12 which indicates R3's cognition is moderately impaired. On 2/10/25 at 11:58am, R4 said, Cockroaches run rampant here. There were ones in the bathroom today. There's a hole on the back wall by the toilet they (roaches) come out of. Yeah, I (R4) seen some today. Surveyor dd not observe any roaches in R4's room or bathroom. R4's Face Sheet documents diagnoses that include but are not limited to chronic obstructive pulmonary disease; type 2 diabetes mellitus; and major depressive disorder. R4's Minimum Data Set (MDS), dated [DATE], documents, in part, a brief interview of mental status (BIMS) score of 15 which indicates R4 is cognitively intact. On 2/10/2025 at 11:15 AM, V6 (Maintenance Director) affirmed that V6 is responsible for pest control in the building. V6 stated that the pest control is coming in weekly to treat for pests, including cockroaches. V6 affirmed that the facility does not have any mice but does see a cockroach from time to time. V6 provided the extermination logbook for review. On 2/10/25 at 1:01pm, when asked if V8 (certified nursing assistant/CNA) has seen cockroaches at the facility recently, V8 shook his (V8) head yes, and replied, I'm not gonna sit here and lie. I've (V8) seen them. On 2/11/25 at 11:33am, V5 (Housekeeping Supervisor) said, Yes, I've (V5) seen roaches. Yesterday I (V5) seen a roach in [a resident's room]. Yes, I (V5) notified the front desk to put it in pest control book. Pest Control comes once a week or every other week. On 2/11/25 at 1:02pm, V2 (Director of Nursing/DON) said, . I'm (V2) not 100 percent sure how often pest control comes . Facility provided document titled, (Company Name) Pest Control, Inc. work date 1/22/25, documents in part, Service Inspection Report . Target Pests: Roaches . Facility policy titled Pest Control Policy, revised date December 2024, documents, in part, . To ensure that the facility is free from refuse, litter, insect, and rodent breeding areas . Maintenance will make routine checks of the building to monitor any pest issues . Housekeeping will monitor on daily cleaning and report to maintenance of pest issues . Facility job description titled, Maintenance Supervisor, undated, documents, in part, . assure that our facility is maintained in a safe and comfortable manner . Facility job description titled, Administrator, revised date 1/05, documents, in part, . Assure that the facility is maintained in a clean and safe manner for resident comfort and convenience . Assure that all residents receive care in a manner and in an environment that maintains or enhances their quality of life . Facility job description titled, Housekeeping / Laundry Aide, undated, documents, in part, . The Housekeeper is responsible to keep the facility clean, safe in accordance with current federal and state standards and comfortable manner . Assure that assigned work areas are maintained in a clean, safe, comfortable, and attractive manner .

Jan 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to follow their Fall Prevention Program policy and procedure to ensure residents fall care plan interventions were revised after each fall for...

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Based on interview and record review, the facility failed to follow their Fall Prevention Program policy and procedure to ensure residents fall care plan interventions were revised after each fall for 2 (R1, R2) out 3 residents reviewed for fall incidents. Findings Include: R1's clinical records revealed R1 had fall incidents on 12/15/24, 12/18/24, and 1/8/25. R1's progress notes dated 12/15/24 at 3:20 PM documents R1 fell going to the bathroom. R1's progress notes dated 12/18/24 at 3:20 AM documents R1 lost balance and fell trying to pick up [R1's] phone on the floor. R1's progress notes dated 1/8/25 documents R1 fell on [R1's] knees trying to go to the bathroom. R1's fall care plan date initiated on 4/10/24 do not show interventions were revised after R1's fall incidents on 12/15/24, 12/18/24, and 1/8/25. R1's care plan history printed on 1/14/25 at 3:28 PM shows V3 (Restorative Director) just created a fall intervention on 1/14/25 that reads, Continue to monitor for behavior of falling. R2's clinical records revealed R2 had a fall incident on 1/4/25. R2's progress notes dated 1/4/25 at 1:57 PM documents R2 was found on the bathroom floor in a sitting position. R2's fall care plan date initiated on 12/26/24 do not show interventions were revised after R2's fall incident on 1/4/25. R2's care plan history printed on 1//14/25 at 3:26 PM shows V3 just created a fall intervention on 1/14/25 that reads, pt/ot [physical therapy/occupational therapy] raised toilet seat. On 1/14/2025 at 10:55 AM, interviewed V3 (Restorative Director) and stated that fall care plan is initiated on admission, updates with any changes, annually, quarterly, significant change, and re-admission. V3 stated that the fall care plan needs to be updated after each fall and interventions are based on the root cause analysis of the fall. On 1/14/25 at 2:23 PM, interviewed V2 (Director of Nursing) and stated that after a fall, the fall care plan interventions should be updated. V2 stated, What we do after a resident's fall is we would have a discussion about it and what intervention should we include in the care plan and then [V3] adds the intervention in the system. That should be done each fall incident. V2 stated that the purpose of the fall interventions is to prevent and reduce risk of falls, and if it's not updated, then staff won't know the fall interventions and residents would be at more risk for falling. The facility's Fall Prevention Program policy dated 11/15/23 documents in part: 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. The fall prevention program includes the following components: Immediate change in interventions that were successful. Care plan incorporates interventions are changed with each fall, as appropriate. The facility's Comprehensive Resident Care Plans policy dated 8/2024 documents in part: Resident's plan of care is reviewed quarterly and as necessary to address the current needs of each resident.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their Fall Prevention Program and a resident's comprehensive...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their Fall Prevention Program and a resident's comprehensive care plan by not providing appropriate staff assistance to the washroom to prevent a resident from falling for 1 (R2) of 3 residents reviewed for fall incidents. This failure resulted in R2's having a fall incident while using the washroom unassisted and was found on the washroom floor. Findings Include: On 1/14/25 at 1:08 PM, interviewed R2 regarding the fall that happened on 1/04/25. R2 was noted to be alert and oriented to person, place, time, and date. R2 stated that after lunch, [R2] was lying in bed. R2 stated that [R2] pressed the call light to ask for help to go to the washroom to brush [R2's] teeth. R2 stated that [R2] was waiting more than 15 minutes for a staff to come, but no one came, so [R2] decided to transfer himself on the wheelchair and wheel himself to the washroom. R2 stated while in the washroom, R2 stood up from the wheelchair, lost balance, fell backwards and sat on the floor. R2 stated [R2] did not feel any pain and did not injure himself. R2 stated [R2] did not hit [R2's] head. R2 stated [R2] pulled the washroom call light, and the nurse came and found [R2] on the floor. On 1/14/2025 at 10:55, interviewed V3 (Restorative Director) and stated that R2 fell on 1/04/25. R2 was observed on the bathroom floor in a sitting position. V3 stated R2's fall risk assessment dated [DATE] indicates R2 is moderate risk for falling. V3 stated R2 requires partial to moderate assist with bed mobility, transfer, toileting, personal hygiene, and walking, which means the staff is physical touching and assisting R2 with activities of daily living (ADL). On 1/14/25 at 11:44 AM, interviewed V4 (Licensed Practical Nurse/LPN) and stated V4 was the nurse in charge when R2 fell on 1/04/25. V4 stated around 2:00 PM after lunch, [V4] heard R2's bathroom call light went off and answered it right away. V4 stated [V4] saw R2 on the bathroom floor. V4 asked R2 what happened and R2 answered that [R2] fell on [R2's] buttocks. V4 stated R2 was not hurt, vital signs were stable, and R2 was transferred back to bed via mechanical lift transfer. V4 stated the last time [V4] saw R2 was around 30 minutes before the incident and R2 was lying in bed. On 1/14/25 at 12:55 PM, interviewed V5 (Certified Nursing Assistant/CNA) and stated V5 was the CNA in charge of R2 the day R2 fell but did not witness the fall because V5 was busy with another resident at that time. V5 stated V4 (LPN) found R2 on the bathroom floor in R2's room. V5 stated 20 minutes before R2 fell, V5 checked on R2 and R2 was in bed resting. V5 stated R2 likes to do everything by himself. V5 stated R2 goes to the toilet by himself and does not need staff assistance. V5 stated R2 does not call for help when [R2] needs to go to the toilet because R2 is independent. On 1/14/25 at 2:23 PM, interviewed V2 (Director of Nursing) and stated all residents in the facility are at risk for falling and their call lights should be within reach. V2 stated staff should be answering call lights within minutes no more than 15 minutes. V2 stated the staff are supposed to be assisting resident to the bathroom if they are at risk for falls. V2 stated if the resident calls for help staff should attend to their needs. R2's face sheet shows an admission date of 12/23/24 with included diagnoses but not limited to End Stage Renal Disease and Primary Osteoarthritis. R2's Minimum Data Set, dated [DATE] shows R2 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15. It also shows that R2 requires partial/moderate assistance with toileting, personal hygiene, and toilet transfer. R2's Fall Risk assessment dated [DATE] shows R2 is moderately at risk for falling, has weak gait and knows own limits. R2's fall care plan date initiated on 12/26/24 indicates that R2 is at risk for falls related to weakness. Interventions include: Anticipate and meet [R2's] needs and Be sure [R2's] call light is within reach and encourage [R2] to use it for assistance as needed. [R2] needs prompt response to all requests for assistance. R2's ADL care plan date initiated on 12/26/24 indicates that R2 has an ADL self-care performance deficit related to weakness due to ESRD with hemodialysis and Left Hemiplegia. R2 is a limited assistance of one staff member for transfers, bed mobility and toileting. R2's progress notes dated 1/04/25 at 1:57 PM documented by V4 reads in part: Call Light came on from [R2's] room. [V4] walk into Resident room to ask what [R2] want. [V4] observed [R2] in the bathroom floor in a sitting position. [R2] verbalized in quote (I was trying to use the bathroom and I fell on my b**t. I am fine. I am not in any pain). Head to Toe assessment was conducted. No injury or skin alterations noted. Vitals taken and are as follows. B/P [blood pressure]- 132/70. P [pulse]-80. RR [respiratory rate]-18. 02SAT [oxygen saturation]-100. TEMP [temperature]-97.6. BS [blood sugar]- 121. [R2] denies any pain at this time. The facility's Fall Prevention Program policy dated 11/15/23 documents in part: 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. Fall/safety interventions may include but are not limited to: Call lights are answered promptly. Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet. Residents at risk for falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care.

Dec 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

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 help a resident maintain their highest practical level...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to help a resident maintain their highest practical level by failing to a.) follow their restorative care policy b.) provide consistent restorative therapy for one (R10) resident out of three residents reviewed for quality of care. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. Findings include: R10 is a [AGE] year-old individual with the following diagnoses but not limited to heart failure, unspecified, peripheral vascular disease, unspecified, acquired absence of right leg below knee, acquired absence of left leg below knee. R10's Minimum Data Set (MDS) Section C, dated [DATE], documents R10 has a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating R10 is cognitively intact. On [DATE], at 11:19 AM, R10 stated that he prefers to speak in Spanish. R10 sitting on his wheelchair. R10's prosthesis at the end of R10's bed, next to the wall. This surveyor was able to converse with R10 in Spanish. R10 reports that he is doing fine but he would be better if they would give him therapy. R10 reports he has asked staff to provide him with a walker so he can practice, but they don't let him have one. R10 stated that it was three months ago that they were giving him restorative therapy consistently. R10 stated it was in the summer but then the facility stopped. R10 reports in this past three months he has received only three therapies, each therapy lasted 15 minutes. R10 stated he clearly remembers returning from those three therapy sessions on separate occasions and his legs hurt because they are not used to it. R10 stated that he uses prosthesis. R10 stated when he does not perform any therapy, he loses his strength and when he goes back, it's like starting all over. R10 stated he is not getting better; in fact, he is getting worse. R10 stated he would like to be able to use his bilateral prosthesis and be able to utilize the walker instead of using a wheelchair. [DATE], 12:35 PM, therapy room in the basement, three paper signs posted on three different areas in front of the therapy room documents: Gym closed until Monday [DATE]. Lights were turned off and doors closed. [DATE], 12:07 PM, V13 (Licensed Practical Nurse) stated R10 is alert and oriented x3 (person, place, time) and able to make his needs known to staff. R10 has bilateral knee amputation, and he can do transfers himself very well from the bed to the wheelchair, and from the wheelchair to the toilet. V13 stated R10 needs minimal assist with ADL (activities of daily living). V13 stated R10 is very compliant with everything. V13 stated she cannot remember the last date when she saw R10 walking with restorative therapy. [DATE], 2:41 PM, V22 (Certified Nursing Assistant) stated she has been working for the facility for 20 years. V22 stated she is familiar with R10. V22 stated, I don't take care of him like I used to, He is very strong, he does transfers with sliding board, someone watching him. I never see him walk. [DATE], 11:07 AM, V23 (Restorative Nurse Assistant) stated she has been working for the facility as restorative aid since 2022. V23 reports she has worked with R10. V23 stated, Restorative isn't actual therapy, we just pick up where therapy leaves them, and we like continue care. It is just the continuing of care. V23 stated, We get pulled all the time. I was getting pulled this morning. I had scheduled to leave early. So, if the CNAs (certified nursing assistants) are short staffed, they pull from our department. V23 stated she cannot say how many times has it been that restorative gets pulled because she cannot remember. V23 stated if staff call in and restorative aids get pulled then the restorative therapy is not happening. V23 stated if residents don't receive consistent restorative therapy, it could affect them in losing strength. V23 stated restorative is all beneficial to them. V23 stated R10 does not have a specific walker in his room. R10 only walks in therapy. [DATE], 12:35 PM, V17 (Rehab Director) stated she has been working for the facility for two months. V17 stated she oversees the speech therapy, physical therapy, and occupational therapy. V17 stated her department they utilize point click care just for medical records, appointment. V17 stated the last time that he was followed by physical therapy (PT) was [DATE]rd, 2024, through [DATE]th, 2024. V17 stated R10's PT stopped due to accommodation of highest level achieved and expired benefits. V17 stated at the time of R10's physical therapy discharge, R10's functional status was the following: Ambulation- walk 10 feet supervision or touching assistance. walk 50 feet with two turns, supervision or touching assistance. [DATE], 11:51 AM, V24 (Restorative Director-LPN) stated R10's current restorative program includes active range of motion which his walking and bike usage falls under active range of motion. V24 stated if the restorative aids are not pulled to work the floor assignments, then the restorative aids usually talk to the residents to develop a schedule which includes time, and days they want to come downstairs to the therapy room. V24 stated the importance of consistent restorative therapy is for residents to get the exercise they need so they can reach or maintain their max capacity. V24 stated R10's restorative program is supposed to be done every day because he likes it that way. V24 stated R10 couldn't come down last week because we had the stomach virus outbreak, all the common areas were closed. V24 stated it is important for resident's assessments to be accurate to get a better picture of the resident without seeing the resident. V24 stated she made error when completing R10's Nursing Restorative Functional assessment dated [DATE], [DATE]. V24 stated she clicked 'no' when asked if R10 has a prosthesis. R10's CCARE - IL Nursing Restorative Functional Assessment - dated [DATE] documents in part, Does the resident wear orthotic device/splint/prosthesis/etc.? response is no. R10's CCARE - IL Nursing Restorative Functional Assessment - dated [DATE] documents in part, Does the resident wear orthotic device/splint/prosthesis/etc.? response is no. R10's CCARE - IL Nursing Restorative Functional Assessment - dated [DATE] documents in part, Does the resident wear orthotic device/splint/prosthesis/etc.? response is yes. R10's MDS section O is in process and not complete yet. R10's MDS section O Special Treatments, procedures, and programs, dated [DATE] documents in part that R10 received 0 days of walking under restorative program. R10's PAST 90 DAYS task walking noted with several days not documented. R10's PAST 90 DAYS task NURSING REHAB: Active ROM documents several days not documented. R10's [DATE], 4:14 PM, Health Status Note documents in part, Resident (R10) is alert, awake and oriented x 3, respiration unlabored, both lungs clear upon auscultation, Incentive spirometer order in place r/t SOB (shortness of breath) d/t (due to) decreased mobility and obesity. R10's physical therapy Discharge summary dated [DATE] documents in part, D/C (discontinue) reason: Highest Practical Level Achieved. Patient will improve ability to safely ambulate 50 feet using two-wheeled walker on level surfaces and under various sensory demand activities with supervision or touching assistance with ability to right self to achieve/maintain balance and with implementation of compensatory strategies in order to facilitate increased participation in functional activity. Patient will safely ambulate 75 feet using two-wheeled walker on level surfaces and under various sensory demand activities with setup or clean-up assistance with ability to right self to achieve/maintain balance and with implementation of compensatory strategies in order to facilitate increased participation in functional activity. Discharge recommendations: Restorative nursing program. Prognosis to maintain CLOF (current level of function) = good with consistent staff follow-through. R10's current care plan documents in part R10 has bilateral below the knee amputation. R10 will exhibit adequate coping skills dealing with loss of limb and rehabilitation through the review date. R10 uses prosthesis for him to ambulate with the use of walker. Extensive assist with 2 staff. Health teaching provided on how to use prosthesis. R10's physician order set does not document an order for restorative therapy. Facility document dated 1/24 titled Physical Therapy/Restorative documents in part, the facility will obtain initial physician order to evaluate and treat. Following the evaluation being conducted by the therapy company, the therapist will provide a therapy recommendation. The physician will then be called by the Restorative nurse and provided the therapy recommendation and obtain physician order. Physician order will then be placed on the POS (physician order set).

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure there are enough restorative nurse aides to provide restorative care and respond to each individual needs as required b...

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Based on observation, interview, and record review the facility failed to ensure there are enough restorative nurse aides to provide restorative care and respond to each individual needs as required by the resident's plan of care. This failure resulted in the resident (R10) missing restorative therapy several times in the past 90 days. Findings include: 12/17/24, 11:19 AM, R10 stated he uses prosthesis. R10 stated when he does not perform any therapy, he loses his strength. R10 stated when he goes back it's like starting all over. R10 stated he is not getting better; in fact, he is getting worse. R10 stated if the other CNAs (certified nursing assistants) call off or they are short, the restorative therapy work on the floor. R10 stated right now the therapy room is closed for the patients to go there. R10 stated someone told him because there is an outbreak. R10 stated he does not recall the name of the person told him. 2/19/24, 1:14 PM, V20 (Lead CNA (Certified Nursing Assistant)/Staffing Coordinator) stated she will ask V24 (Restorative Director/Licensed Practical Nurse) if they (restorative aids) are available if V20 can't get anyone to work. V20 stated if the restorative aids get pulled to the floor, they will get assignment. V20 stated the union stated they cannot do two jobs at once. V20 stated the resident's patient care is priority. V20 stated if she can't find anyone, then pulling restorative to the floor will be her last resort. V20 stated she does not over schedule or under schedule. V20 stated when the restorative aids are pulled to the floor, they cannot do their job and it can affect the residents' range of motion. V20 stated that is because the residents can get contracted. Surveyor questioned V20 when the last time restorative aid was was pulled to the floor. V20 stated. Today is when I asked them, I needed help. I had three call ins this morning. I had gotten someone to come in, two people stayed from night shift. Yesterday too. because the CNA got sick and she went home early, around 11am. 12/19/2024, 11:51 AM, V24 (Restorative Director-LPN) stated she has been working as the restorative director since 2016. V24 stated R10's current restorative program includes active range of motion which his walking and bike usage falls under active range of motion. V24 stated if the restorative aids are not pulled to work the floor assignments, then the restorative aids usually talk to the residents to develop a schedule which includes time, days they want to come downstairs to the therapy room. V24 stated the importance of consistent restorative therapy is for residents to get the exercise they need so they can reach or maintain their max capacity. V24 stated, As of last month, they are on the floor helping the CNAs pass trays, monitoring, they get about 4 hours a day for programming. If they get pulled fully, there is no program for day. My one just got pulled this week. The one had to be on restorative could only do so much. 12/19/2024, 11:07 AM, V23 (Restorative Nurse Assistant) stated she was off all last week because she was sick from a stomach bug. V23 stated when she returned, restorative department had weights for the first of the month still to do. V23 stated. We are behind because of the stomach bug. The facility's gym is still closed because a lot of the PTs (physical therapists) got sick. We get pulled all the time. I was getting pulled this morning. I had scheduled to leave early. So, if the CNAs are short staffed, they pull from our department. V23 stated she cannot say how many times has it been restorative gets pulled because she cannot remember. V23 stated each floor is supposed to have one restorative aid. V23 stated if staff call in and restorative aids get pulled then the restorative therapy is not happening. V23 stated if residents don't receive consistent restorative therapy, it could affect them in loosing strength. Facility's nursing schedule dated 12/1/2024, 12/2/24 only has one restorative aid working. Facility's restorative staff time sheet dated 12/01/2024 and 12/02/24 documents in part there were only one restorative staff working for those dates. R10's Minimum Data Set (MDS) Section C, dated 9/27/2024, documents R10 has a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating R10 is cognitively intact. R10's PAST 90 DAYS task walking noted with several days not documented. R10's PAST 90 DAYS task NURSING REHAB: Active ROM documents several days not documented.

Nov 2024 6 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

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 one resident (R4) was free from staff to resident physical ab...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one resident (R4) was free from staff to resident physical abuse. This failure affected one resident (R4) in a total sample size of three residents (R1, R2 and R4) reviewed for abuse. This deficient practice resulted in harm for one resident (R4) experiencing physical pain and bruising. Findings include: R4's medical diagnoses include but not limited hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, convulsions, chronic obstructive pulmonary disease, essential hypertension, contracture right elbow, major depressive disorder, anxiety disorder. R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 3, which indicates R4's cognition is severely impaired. R4's physician order dated 11/07/24 documents in part, Behavior: Monitor for itching, picking at skin, restlessness, agitation, hitting, kicking, spitting, cursing, elopement, stealing, delusions, hallucinations, refusing care, anxiety, insomnia, depression .Interventions: A. Redirection/Refocus B. Comfort objects .D Remove from situation .F. Offer choices. R4's care plan documents in part, Assessment reveals factors may increase his/her susceptibility to abuse/neglect .R4 will be treated with respect, dignity and reside in the facility free of mistreatment (abuse/neglect) .Assure R4 she is in a safe and secure environment .Provide all interaction and care to R4 with respect, dignity and free of mistreatment. On 11/18/24 at 1:07pm, V29 (R4 family member) stated she was informed by the facility her mom had a bruise on her leg. V29 stated R4 had a purple knot on her right thigh. V29 stated she feels someone from the facility beat her mom's leg. V29 stated she sent R4 back to the hospital two days later because R4 was still complaining of pain to her right leg. R4's hospital report dated 11/10/24 documents in part, Daughter reports the patient is occasionally aggressive and is concerned the nursing staff are hitting R4. R4 has a large bruise on her right thigh .patient with history as stated above presenting to the emergency department for right thigh hematoma and concerns for elder abuse .Diagnoses (Active) Elder abuse, hematoma. On 11/18/24 at 12:34pm, V28 (Certified Nursing Assistant/CNA) stated R4 was very combative when being cleaned and sometimes it took two staff members to clean her. V28 stated one staff member would hold R4 down to prevent R4 from kicking and scratching while the other staff member would clean R4. V28 stated while cleaning and holding R4 down, R4 would tell the staff they are going to jail. On 11/19/24 at 11:55am, V31 (CNA) stated he noticed a tennis size ball size raised purple area on R4's right thigh. V31 stated he had taken care of R4 the day before and the area on R4's right thigh was not there before. On 11/19/24 at 12:15pm V32 (Licensed Practical Nurse/LPN) stated she was informed by V31 of a bruise to R4's thigh. V32 stated she looked at the area and noticed a raised purple area to R4's right thigh. On 11/19/24 at 1:55pm V35 (LPN) stated he examined R4's right thigh and the area was purple and circular with some swelling. V35 stated he can't diagnose but the area reminds him of a hematoma. V35 stated R4 sometimes screams no, no, no when the staff area cleaning her. V35 stated most confused residents say no at the beginning when staff first start cleaning them, but they eventually stop saying no and just allow staff to clean them. On 11/19/24 at 10:55am V4 (Wound Care Coordinator/Nurse Manager) stated, We kind of have to brace her legs down to prevent her (R4) from kicking when we take care of her. On 11/20/24 at 11:50am V2 (Director of Nursing/DON) stated it would be considered abuse if a staff member held a resident down. V2 stated if a resident is saying no to care, then staff should stop caring for the resident and document refusal. Facility's policy dated 10/24/2022 titled, Abuse Prevention Policy documents in part, This facility, Uptown Care and Rehabilitation, affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment .This will be done by: .orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property .establishing an environment promotes resident sensitivity, resident security and prevention of mistreatment .assuring physical restraints are used sparingly and properly .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, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident .The term willful in the definition of abuse means the individual must have acted deliberately, not the individual must have intended to inflict injury or harm. Facility's undated job description titled Certified Nursing Assistant documents in part, Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents .Adhere to professional standards, company policies and procedures, and all federal, state, and local requirements, including JCAHO standards, when applicable. Facility's undated policy titled Statement of Resident's Rights documents in part, Each resident shall have the right to be free from verbal, sexual, mental, or physical abuse: free from corporal punishment and involuntary seclusion: and free from chemical and physical restraints, except those restraints authorized in accordance with applicable federal and state laws and regulations.

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the Care Plan and failed to provide adequate supervision to ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the Care Plan and failed to provide adequate supervision to one resident (R1) who was assessed as a high fall risk which resulted in multiple falls for one resident (R1) reviewed for resident injury, demonstrating inadequate care. This failure resulted in R1 falling on 10/12/2024 and sustaining a head injury which required R1 to be sent to the hospital where R1 received 3 staples to close the laceration to R1's head and again falling on 11/05/2024 which required R1 to be sent to the hospital for evaluation and testing. Findings include: R1's hospital records, dated 10/12/2024, documents, in part, . [AGE] year-old male . brought in by EMS (Emergency Medical Services) for unwitnessed fall at the facility . The wound was irrigated copiously with normal saline or sterile water . Staples were placed using a surgical stapler with approximation of the wound edges. R1's hospital records, dated 11/05/2024, documents, in part, . [AGE] year-old male . brought in by EMS (Emergency Medical Services) for unwitnessed fall at the facility. Facility presented document listing R1's falls for the past year showing that R1 has had 6 falls within the past year. R1 had falls on 4/15/24 at 5:04AM, 6/5/24 at 12:30AM, 10/2/24 at 7:45AM, 10/8/24 at 2:00AM, 10/12/24 at 10:15AM and 11/5/24 at 7:32PM. On 11/18/24 at 1:35pm, with V8 (Activity Aide) interpreting for R1 due to R1's primary language being Spanish, R1 stated, I (R1) fell the day I was sent to the hospital (10/12/24) because I (R1) was trying to get up from the bed. Yes, the call light was by me. I (R1) don't need the call light. I (R1) can do for myself. I'm (R1) fine. They (staff) just need to let me be. R1's Face Sheet, documents, in part, that R1's diagnoses include unspecified lack of coordination; unsteadiness on feet; chronic obstructive pulmonary disease, unspecified; type 2 diabetes mellitus without complications; schizoaffective disorder, bipolar type; anxiety disorder, unspecified; bipolar disorder, unspecified; laceration without foreign body of scalp, subsequent encounter. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, R1's Brief Interview for Mental Status (BIMS) score is 03 which indicates R1's cognition is severely impaired. R1's Functional Status, shows R1 requires Substantial/Maximal Assistance for Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. R1 requires Substantial/Maximal Assistance to walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. R1's Fall Risk Assessment, dated 10/11/24, documents, in part, a score of 55 which is the category of High Risk for Falling with a history of previous falls. R1's Care Plan, date Initiated: 08/23/2019; revision on: 10/26/2024, documents, in part, FALLS: (R1) is at risk for falls r/t (related to) weakness . Resident is an extensive assistance of one staff member for transfer, bed mobility and toileting. Resident is supervision with set up for meals. Resident has functional incontinence of bowel and bladder. Resident ambulates with walker with slow and somewhat steady gait with staff for a short distance. Resident requires rest periods to complete task. Resident utilizes wheelchair as primary mode of transportation. Resident requires cueing for all tasks. Poor safety awareness present. Impulsive behavior presents with unknown cause. close monitoring needed. Care Plan interventions, documents, in part, Move closer to nurse's station. One on One monitoring d/t impulse poor safety awareness behavior. On 11/19/24 at 11:06am, V9 (Restorative Nurse/License Practical Nurse/LPN) said, I (V9) am the fall nurse . pretty much. Yes, I'm familiar with (R1). (R1) has been here for a while. First (R1) came and walked by himself (without assistance). Then he had to use a walker. Then he had to use the wheelchair. So, we're (staff) trying to get him (R1) walking using the walker and then without any assistive device. R1 is on monitoring, close monitoring, monitoring when engaging in activities. Everything is in his (R1) Care Plan. (R1's) bed is by the nurse's station for close monitoring too. (R1) mental status varies. He (R1) knows where he's at. He (R1) always knows when its Sunday and mealtime. Sometimes he knows where he's (R1) at. He (R1) knows familiar faces. That's pretty much how he's (R1) been since he's been here. On 11/19/24 at 12:02pm, V7 (License Practical Nurse/LPN) said, I (V7) had (R1) a few times. I (V7) on October 12th. After passing meds, we (staff) heard a sound from (R1's) room. We ran to the room and seen (R1) on floor on right side. Noticed skin alteration on head . R1 is a pretty confused man. We asked him, but sometimes he's hard to understand. On 11/19/24 at 2:28pm, V7 said, One on one monitoring is when we have a CNA (certified nursing assistant) scheduled for a patient that is fully observed and attends to every needs of a resident . The one on one observed is with the resident at all times . On October 12th, (R1's) room was close to nurse's station . I (V7) would say no, he (R1) was not receiving one on one monitoring. On 11/19/24 at 1:04pm, V16 (License Practical Nurse/LPN) said, He (R1) was my resident for a while. I (V16) worked October 12th when (R1) fell. I (V16) did work but I (V16) was not assigned to him (R1). I (V16) was at the nurse's station, heard a sound close to (R1's) room, ran to room, and seen (R1) on floor with bleeding from his head. We (staff) called an ambulance and sent him (R1) to the hospital. People are prone to fall. He's (R1) forgettable sometimes and forgets to pull call light. On 1/19/24 at 2:15pm, V34 (Nurse Practitioner) said, I'm pretty familiar with him (R1). Been taking care of him for the past 2 years. What I (V34) see in a lot of patients is steady decline. They (patients) don't understand that they're (patients) declining. During that transitional phase, they (patients) either forget or are noncompliant. I (V34) believe that (R1) is going through that right now. We (staff) have to do constant reminders and remind him (R1) to let him (R1) know that he (R1) needs assistance. He's (R1) one person assist. I (V34) wouldn't go for letting him (R1) walk by himself even with a walker. I (V34) do consider sutures serious and harmful to someone especially to the head. Falls can cause brain bleeding. Take it seriously. Any falls could cause fractures. We never know, that's why we take falls very seriously. On 11/19/24 at 2:52pm, V6 (Registered Nurse/RN) said, On November 6th, I (V6) was informed by CNA (certified nursing assistant) that he (R1) was found on floor. He's (R1) a fall risk. Sent him (R1) out to hospital. He (R1) was supposed to have a sitter, but the sitter left before the other sitter came. It (the fall) was not witnessed. One on one monitoring is when someone has to be with them to attend to their needs to maintain safety for the patient to prevent, for instance, issues like the one that transpired. I (V6) was not aware that he (R1) was not receiving his (R1) one on one monitoring. I (V6) did not know the CNA left. I (V6) knew that he (R1) had one on one. Sitter was not present. On 11/20/24 at 11:47am, V2 (Director of Nursing/DON) said, A resident who requires sutures is a serious injury. A resident who requires staples is a serious injury. Both should be reported to Public Health. One on one monitoring would be one person assigned to monitor that one person the whole shift. The person should be with resident at all times. There is no separate paperwork for one on one monitoring. I (V2) will have to find out if there is a policy on one on one monitoring. (R1's) did not have one on one monitoring on October 12th and November 5th due to staffing issues. We didn't have the staff for it. I (V2) believe he needs the one on one monitoring. On 11/20/24 at 12:32 pm, V2 said, I (V2) cannot technically say that (R1's) falls would have not happened if he (R1) had a one on one. He (R1) does get out of bed without asking for help. If they (staff) were doing a one on one I (V2) don't know if they (staff) would be able to catch him. I (V2) just don't know. On 11/20/24 at 12:17pm, V1 (Administrator) said, One on one monitoring is generally exactly that. A staff member that is focused on that one resident. Sometimes can be a group a room and several residents. When asked about the one on one monitoring in R1's Care Plan, V1 replied, So I (V1) was told. The Care Plan was not updated. Facility policy titled, Falls and Fall Prevention, date revised November 2024, documents, in part, 1. To ensure residents admitted are assessed for potential fall risk. 2. To ensure a fall prevention program will include measures which will determine the individual need of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices as indicated based on assessment. 4. Residents who are assessed as at risk for falls will have a care plan initiated to include approaches for the prevention of falls as they apply to the individual resident. 13. The frequency of safety monitoring will be determined by the resident's risk factors and care plan. Facility policy titled, Comprehensive Resident Care Plans, revised August 2024, documents, in part, . Each care plan shall include measurable objectives and time tables to meet all resident needs identified in the comprehensive assessment. Facility presented pamphlet titled, Residents' Rights for People in Long-Term Care, revision date 11/18, documents, in part, . Your facility . must care for you in a manner that promotes your quality of life . Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source . Your facility must provide services to keep your physical and mental health, at their highest practical levels . Facility job description titled, Director of Nursing, undated, documents, in part, . The primary purpose of the Director of Nursing position . to ensure that the highest degree of quality care is maintained at all times . Facility job description titled, Registered Nurse (RN), undated, The RN is responsible for providing direct nursing care to the residents, . to ensure that the highest degree of quality care is maintained at all times . Facility job description titled, Licensed Practical Nurse (LPN), undated, The LPN is responsible for providing direct nursing care to the residents, . to ensure that the highest degree of quality care is maintained at all times .

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 F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to obtain informed consent for psychotropic medication prior to administering the medication. This failure affects 1 resident (R2) in a sample...

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Based on interview and record review, the facility failed to obtain informed consent for psychotropic medication prior to administering the medication. This failure affects 1 resident (R2) in a sample of 3 residents (R2, R3, R5) reviewed for psychotropic medications. Findings include: R2's diagnoses include schizoaffective disorder bipolar, violent behavior, generalized anxiety disorder, paranoid schizophrenia. R2's Minimum Data Set (dated 10/9/2024) documents in part a brief interview of mental status summary score of 9, indicating that R2's cognition is moderately impaired. Review of R2 medication administration record indicate that R2 received Fluphenazine Decanoate intramuscular injection on 10/24/24, 09/25/24, 08/29/24, 07/04/24, 07/8/24. Review of R2' psychotropic consent dated 11/30/23 indicate R2's refusal of psychotropic medication. R2 had no other consent to indicate R2 consented to psychotropic medication. On 11/18/24 at 11:55am R2 stated that she refused to sign the psychotropic consent because she did not want to take the psychotropic medication. On 11/18/24 at 2:23pm, V3 (Assistant Director of Nursing/ADON) stated R2 gave him verbal consent for the psychotropic medications but was unable to provide proof because he did not document the verbal consent. On 11/20/24 at 11:50am V2 (Director of Nursing/DON) stated that a consent for psychotropic medication should be obtained before administration of a psychotropic medication is given. V2 stated that residents have the right to refuse medication. Facility's undated policy titled Psychotropic Medication Consent Policy documents in part, Policy: 1. To ensure residents with physician orders for psychotropic medication administration have signed or given verbal consent for administration of medication .Procedure: 1. Residents newly admitted on psychotropic medication, consent to administer will be obtained from resident and/or legal guardian. 2. Verbal consent will be acceptable with 2 witness staff. 3. Residents with medication change and/or dose change will require a new consent signed. 4. Resident signing with X will be acceptable if witnessed by staff.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report one allegation of abuse to the state survey agency. This fai...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report one allegation of abuse to the state survey agency. This failure has the potential to affect one resident (R4) reviewed for abuse. Findings include: R4's medical diagnoses include but not limited hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, convulsions, chronic obstructive pulmonary disease, essential hypertension, contracture right elbow, major depressive disorder, anxiety disorder. R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 3, which indicates R4's cognition is severely impaired. R4's physician order dated 11/07/24 documents in part, Behavior: Monitor for itching, picking at skin, restlessness, agitation, hitting, kicking, spitting, cursing, elopement, stealing, delusions, hallucinations, refusing care, anxiety, insomnia, depression .Interventions: A. Redirection/Refocus B. Comfort objects .D Remove from situation .F. Offer choices. R4's care plan documents in part, Assessment reveals factors that may increase his/her susceptibility to abuse/neglect .R4 will be treated with respect, dignity and reside in the facility free of mistreatment (abuse/neglect) .Assure R4 that she is in a safe and secure environment .Provide all interaction and care to R4 with respect, dignity and free of mistreatment. On 11/19/24 at 11:55am V31 (Certified Nursing Assistant/CNA) stated that he first noticed the bruise on R4's thigh at approximately 10:30am on 11/10/24 and meant to report it to his nurse but forgot. V31 stated that he remembered he didn't report the bruise to R4's right thigh when he went in to change R4 again at approximately 2pm. V31 stated he reported the bruise to R4's thigh at that time when he finished changing her. R4's progress note dated 11/10/24 documents in part, Resident was sent out to hospital and left facility at 7:30pm. Per A.M. nurse report, a bruise was noted on her right upper thigh. Resident left facility with ambulance with her daughter. At around 7:55pm received a call from resident's daughter informing us that her mother is not coming back to the facility at all. DON (Director of Nursing) informed, and night supervisor made aware. R4's hospital report dated 11/10/24 documents in part, Daughter reports that the patient is occasionally aggressive and is concerned that the nursing staff are hitting R4. R4 has a large bruise on her right thigh .patient with history as stated above presenting to the emergency department for right thigh hematoma and concerns for elder abuse .Diagnoses (Active) Elder abuse, hematoma. On 11/20/24 at 11:50am V2 (Director of Nursing/DON) stated she was informed of the bruise to R4's right thigh late afternoon on 11/10/24 when she had already left the building. V2 stated she did not see the bruise on R4's thigh. V2 stated that at that time she informed V1 (administrator). On 11/20/24 at 12:18pm V1 stated he did not report R4's bruise through the reporting system because he didn't think the bruise came from abuse. Facility's untitled document dated 11/11/24 documents in part, R4 - 11/10/24 contacted by DON with regards to bruising. DON confirmed bruising is not concerning and we are not concerned regarding unknown bruising although R4's daughter is being boisterous and insisting her mom be sent to the hospital. R4's right thigh bruise of unknown origin was discovered on 11/10/24. Facility's preliminary 24-hour incident investigation report is dated 11/19/24. Facility's policy dated 10/24/2022 titled Abuse Prevention Policy documents in part, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: .filing accurate and timely reports .V. Internal Reporting Requirements and Identification of Allegations .Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer .Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours of the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours .The nursing staff is responsible for reporting the appearance of suspicious bruised, laceration, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator or designated individual.

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to thoroughly investigate an incident involving an allegation of injury of unknown origin. This failure affected one resident (R4) out of thre...

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Based on interview and record review, the facility failed to thoroughly investigate an incident involving an allegation of injury of unknown origin. This failure affected one resident (R4) out of three residents reviewed for injury (R1, R2, and R4). Findings include: On 11/18/24 at 1:07pm, V29 (R4 family member) stated she was informed by the facility her mom had a bruise on her leg. V29 stated R4 had a purple knot on her right thigh. V29 stated she feels someone from the facility beat her mom's leg. R4's hospital report dated 11/10/24 documents in part, Daughter (V29) reports the patient is occasionally aggressive and is concerned the nursing staff are hitting R4. R4 has a large bruise on her right thigh .patient with history as stated above presenting to the emergency department for right thigh hematoma and concerns for elder abuse .Diagnoses (Active) Elder abuse, hematoma. Untitled document dated 11/11/24 documents in part, R4 - 11/10/24 contacted by DON (Director of Nursing) with regards to bruising. DON confirmed bruising is not concerning and we are not concerned regarding unknown bruising although daughter V29 is being boisterous and insisting her mom be sent to the hospital. On 11/20/24 at 11:50am V2 (DON) stated any abuse or injury of unknown origin should be reported immediately and investigated. V2 stated she did not see the bruise on R4's thigh because when it was reported to her, she was in the car on her way home. V2 stated when she returned to work the next day, R4 had already left the building. On 11/20/24 at 12:18pm V1 (Administrator) stated he is responsible for investigating all allegations of abuse when they are reported to him. V1 stated he did not investigate abuse for R4 because she is known to thrash around during care which explains the bruise to R4's thigh. V1 stated his definition of boisterous regarding V29 means V29 was making a scene at the facility and wanted her mom (R4) to go to the hospital. Facility's policy dated 10/24/2022 titled Abuse Prevention Policy documents in part, This facility, Uptown Care and Rehabilitation, affirm the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents .The purpose of this policy is to assure the facility is doing all is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents .This will be done by: .implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences .VII. Internal investigation .2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation .3. For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time .Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete Fall Assessments for one resident (R1). This fa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete Fall Assessments for one resident (R1). This failure has the potential to affect one resident (R1) in a sample of 3 residents reviewed for resident injury. Findings include: R1's Facility Reported Incident (IL181167), that occurred on 10/12/24, documents, in part, Incident Date: 10/12/24 . Incident Time: 1015 . Brief description of incident: At 10:15 am nurse on duty observed resident laying on the floor on his right side, in his room close to his bedside. Resident unable to verbalize what happened or how he got on the floor when asked . Action taken: Resident was assessed and noted with a minimal laceration at the back of he's head. Vitals collected and noted to be within normal limits. Writer applied pressure on the cut on the resident's head with a gauze. No other injury noted. Resident was assisted back to his bed with the help of the other nurse on floor. 911 was called. Ambulance arrived and resident was transferred on a stretcher to Hospital . Resident returned to the facility with 3 sutures to the back of the head. R1's, Fall Risk Assessment, effective date 10/13/24, documents, in part, . C. AMBULATORY AID 2. Uses crutches, cane, or walker. E. GAIT IMPAIRED . grasps furniture, person, or aid when ambulating. Cannot walk unassisted. Upon review of R1's Fall Assessment it was observed that Uses Furniture for support was not checked. R1's Post Fall Observation, effective date 10/13/24, documents, in part, E. Usual Mobility Status 1. Independent with or without device. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, Functional Status, shows that R1 requires Substantial/Maximal Assistance for Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. R1 also requires Substantial/Maximal Assistance to walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. R1's Face Sheet, documents, in part, R1's diagnoses include unspecified lack of coordination; unsteadiness on feet; chronic obstructive pulmonary disease, unspecified; type 2 diabetes mellitus without complications; schizoaffective disorder, bipolar type; anxiety disorder, unspecified; bipolar disorder, unspecified; laceration without foreign body of scalp, subsequent encounter. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, R1's Brief Interview for Mental Status (BIMS) score is 03 which indicates R1's cognition is severely impaired. R1's Care Plan, date Initiated: 08/23/2019; revision on: 10/26/2024, documents, in part, FALLS: (R1) is at risk for falls r/t (related to) weakness . Resident is an extensive assistance of one staff member for transfer, bed mobility and toileting. Resident is supervision with set up for meals. Resident has functional incontinence of bowel and bladder. Resident ambulates with walker with slow and somewhat steady gait with staff for a short distance. Resident requires rest periods to complete task. Resident utilizes wheelchair as primary mode of transportation. Resident requires cueing for all tasks. Poor safety awareness present. Impulsive behavior presents with unknown cause. close monitoring. Facility presented document listing R1's falls for the past year showing that R1 has had 6 falls within the past year. R1 had falls on 4/15/24 at 5:04AM, 6/5/24 at 12:30AM, 10/2/24 at 7:45AM, 10/8/24 at 2:00AM, 10/12/24 at 10:15AM and 11/5/24 7:32PM. On 11/20/24 at 11:47am, V2 (Director of Nursing/DON) said, I expect the resident's assessment to be completed with 100% accuracy. No, those Fall Assessments for (R1) (referring to R1's Fall Assessments on 10/13/24) are not right. If the fall assessments are not completed accurately, we (facility) have a potential for more falls and supervision may be an issue. On 11/20/24 at 12:17pm, V1 (Administrator) said, Yes, they (Fall Assessments) should be 100% accurate. If they're (Fall Assessments) not accurate we are potentially not providing the right care. Facility policy titled, Falls and Fall Prevention, date revised November 2024, documents, in part, Policy: 1. To ensure residents admitted are assessed for potential fall risk. 2. To ensure a fall prevention program will include measures which will determine the individual need of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices as indicated based on assessment. Procedure: 2. The fall risk assessment utilized will consist of risk factors as resident characteristics, clinical and medical diagnosis that objectively measure and predict a fall potential. 3. Resident will be reassessed quarterly and after each fall. Facility presented pamphlet titled, Residents' Rights for People in Long-Term Care, revision date 11/18, documents, in part, . Your facility . must care for you in a manner that promotes your quality of life . Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source . Your facility must provide services to keep your physical and mental health, at their highest practical levels . Facility job description titled, Director of Nursing, undated, documents, in part, . The primary purpose of the Director of Nursing position . to ensure that the highest degree of quality care is maintained at all times . Facility job description titled, Registered Nurse (RN), undated, The RN is responsible for providing direct nursing care to the residents, . to ensure that the highest degree of quality care is maintained at all times . Facility job description titled, Licensed Practical Nurse (LPN), undated, The LPN is responsible for providing direct nursing care to the residents, . to ensure that the highest degree of quality care is maintained at all times .

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and provide sufficient supervision to one (R8) ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and provide sufficient supervision to one (R8) resident out of three residents reviewed for improper nursing care. After interviewing staff, the surveyor identified that the facility did not have a physician pass privilege order in place the day the resident signed himself out to the community unaccompanied. Later that day, the resident got lost and the facility ordered the resident a transportation ride back to the facility. This failure has the potential to cause serious harm to a resident. Findings include: R8's current face sheet document R8 is a [AGE] year-old individual admitted to the facility on [DATE]. Current medical diagnosis are listed to include but not limited to: vascular dementia, moderate, with psychotic disturbance, major depressive disorder, generalized anxiety disorder, unspecified psychosis not due to a substance or known. R8's Minimum Data Set (MDS) Section C, dated 10/08/2024, documents R8 has a Brief Interview for Mental Status (BIMS) of 12 out of 15, indicating R8 is moderately cognitive impaired. 10/15/2024, 1:27 PM surveyor asked R8 what happened to him when he left the facility last week on October 7th, 2024. R8 stated he got lost and that he went too far. R8 stated he called 411 and was able to get the facility's phone number. R8 stated the facility sent him transportation to pick him up. R8 stated he had signed himself out by himself. R8 said he probably signed himself out at the front desk, but he can't remember. R8 stated he left the facility that day after 3:00 PM. R8 stated he returned to the facility close to midnight. R8 stated he couldn't walk for a day after that because he was sore from all the walking that he had done when he got lost. 10/15/2024, 2:40 PM, V7 (Licensed Practical Nurse) stated if the residents want to go out to the community independently, she usually refers the residents to social services. V7 stated she worked last Monday, October 7th,2024. V7 does not remember if R8 approached her to inform her that he was going out to the community. V7 stated, He is usually in the room sleeping. He is quiet and calm. I'll give him cues and reminders of medication time. He hasn't given me any problems. 10/15/2024, 3:17 PM, V2 (Director of Nursing) stated R8's room change occurred on 10/7/2024, at 2:02 PM. V2 stated V7 was his assigned nurse after the room change was done until 7:00 PM on October 7, 2024. 10/15/2024, 4:02 PM V8 (Receptionist) stated she worked 3:00 PM to 11:00 PM shift on October 7th, 2024. V8 stated R8 signed himself out and no one was escorting him. V8 stated she was still at work when R8 returned around 11:30 PM. V8 stated R8 told her that he was cold and had been walking around a long time. V8 stated the night shift receptionist who started work at 11:00 PM ordered R8 a transportation ride back to the facility. V8 stated she asked R8 what happened and why R8 missed curfew. V8 stated R8 responded, I got a little lost when I went to get my tacos. 10/17/2024, 9:43 AM, V13 (Registered Nursing) via telephone stated she came to work last Monday at 7:00 PM. V13 stated at 9:00 PM, she was looking for R8. V13 stated she called the front desk to check if he had gone out on pass. V13 stated she was informed by front desk receptionist that R8 had signed out around 5:00 PM. V13 stated she did end up calling his contact number to see what time he was going to come back, and it didn't work. V13 stated she thinks he returned at midnight. V13 stated this was not communicated by the previous nurse. V13 stated R8 has been diagnosed with dementia, there is possibility of getting lost or getting into an accident. V13 stated moving forward she would ask if the resident was in the building or if they have eaten their dinner. V13 stated she will know exactly where the resident is located. 10/17/24, 12:06 PM, V4 (Social Services Director) stated any resident in the facility needs a doctor's order to go out on pass independently. V4 stated she did not check if R8 had an order in place because she had brought it to V2. V4 stated she assumed she was taking care of that. 10/17/24, 11:24 AM V3 stated she doesn't believe that she pulled R8's diagnoses and reviewed them that day when she completed the assessment. V3 stated she had worked several 16 hour shifts previously before completing R8's assessment. R8's nurse's note dated 10/07/2024, 10:55 PM documents in part around 9:00 PM, V13 noted R8 not in the unit. V13 called the front desk and was informed R8 signed out from the facility at 5:00 PM. R8's nurse's note dated 10/08/2024, 12:10 AM documents in part that R8 is back in the facility in stable condition. R8's community skills assessment dated [DATE], is strike out and documents reason for strike out incorrect documentation. R8's community skills assessment dated [DATE], documents in part, the resident does not appear to be capable of unsupervised outside pass privileges at this time. R8's care plan dated 10/4/2024, documents in part R8 has potential for impaired cognitive function related to diagnosis of dementia. Interventions include cue, reorient, and supervise the resident as needed. R8's physician order set does not document a physician pass privilege order. 10/17/24, V2 notified surveyor via email that R8 did not have an order for pass on October 7th, 2024. Facility document, dated 08/2024, titled Resident Pass Privileges documents in part, Policy: to ensure upon admission residents are given pass privileges based on assessment. Physician orders will be obtained 72 hours after admission for pass privileges orders. Physician pass privileges orders will be indicated: May go out on pass independent. May go out on pass with supervision.

Oct 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to properly document one resident's (R9) personal belongings upon adm...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to properly document one resident's (R9) personal belongings upon admission. This failure has resulted in R9 missing clothes. Findings include: R9 is [AGE] year old with diagnosis including but not limited to: Morbid obesity, cerebral palsy, primary osteoarthritis, other reduced mobility and other specified disorder of bone density and structure. During investigation on 10/02/2024 at 11:36 AM, R9 said, I am missing a lot of my clothes and I have seen a few residents wearing my clothes. In the resident council meetings, I have complained about my missing clothes, and nothing has been done so far. At that time, R9 proceeded to show Surveyor photos on his phone of residents wearing his clothes. On 10/08/2024 at 2:35 PM, V26 (Laundry Attendant) said, I don't have any clothes at this time for R9. The only time that clothes become misplaced is when they are sent down to the laundry room with no name labeled on it. Clothes that are not labeled are kept so that residents can come to the laundry room to claim any missing items. The laundry department is not responsible for keeping inventory of resident's personal items. On 10/09/2024 at 3:05 PM, V2/DON (Director of Nursing) stated the facility does not have an initial inventory list on file for R9 and that the 06/05/24 inventory list for R9 was his only belongings list. On 10/09/2024 at 3:05 PM, V2/DON said, It is important to take inventory of resident's personal belonging to ensure that all personal items are accounted for. The CNAs are to take inventory of all resident's clothes upon admission and label their belongings with their name. If no inventory list is on file, the facility will not be responsible for missing items. Resident Council meeting minutes dated September 17, 2024 documents complaints from residents regarding missing clothes. R9's admission Record documents an admission date of 11/12/2020. R9's Inventory list was dated 06/05/2024. Facility policy titled Policy for Clothing and Personal Items documents, upon admission the CNAs (Certified Nurse Assistants) must take inventory and record each and every article that the resident brings in.; the nurse on duty should supervise this process and one the list is completed it is to be put into the system and uploaded to the resident's medical chart. Facility policy titled Resident's Rights documents, facility must try to keep resident's property from being lost or stolen.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a cataract surgery was scheduled for one resident (R13) as ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a cataract surgery was scheduled for one resident (R13) as ordered resulting in R13 experiencing continued visual difficulties and failed to ensure two residents (R2 and R11) attended Doctor's appointment as scheduled. Findings include: R13 is [AGE] year old with diagnosis including but not limited to: Dry eye syndrome of unspecified lacrimal gland, other visual disturbances, prediabetes, major depressive disorder and anxiety. R13's BIMS (Brief Interview of Mental Status) score is 15, which indicated cognitively intact. R11 is 67 old with diagnosis including but not limited to: Contracture of left hand, unspecified lump in breast, unspecified asthma, hypertensive heart and chronic kidney disease with heart failure. R11's BIMS (Brief Interview of Mental Status) score is 15, which indicated cognitively intact. During investigation on 10/01/2024 at 1:33 PM, R13 said she (R13) was still waiting on her eye appointment for cataract surgery and had been experiencing visual problems. On 10/10/2024 at 11:15 AM, DON (Director of Nursing) said, R13 went to the eye Doctor on 08/14/1014 and we (facility) were supposed to receive a call about R13's eye surgery but I don't know what happened with that. I can say that we dropped the ball. We (facility) should have called and followed up with her appointment. On 10/09/2024 at 2:35 PM, R13 stated it had been almost six months that she (R13) had been inquiring about her cataract surgery and that she has difficulty reading and watching television because of her cataracts. At that time, R13 said, When I read, the letters all look zigzag. Also, when I watch television, the picture looks zigzag. On 10/01/2024 at 1:15 PM, R11 stated that he had missed a few doctor's appointments. On 10/07/24 at 10:18 am, V22 (Medical Scheduler and Transportation) stated R11's 09/11/2024 orthopedic follow-up appointment was canceled because R11 did not have an escort. On 10/07/24 at 10:18 am, V22 stated the facility is responsible for providing an escort for medical appointments and that she (V22) schedules escorts for the residents. On 10/07/24 at 11:44am, V22 stated R2 missed several consultation appointments during R2's stay at the facility. V22 presented R2's appointment transportation log that showed on 1/16/24, 1/19/24, 2/09/24, and 5/10/24, R2 missed consultation appointments due to transportation being late. On at 10/09/24 at 4:15pm V2 (DON) stated the facility is going to work with V22 on getting the information to the nurse to have the physician notified and on scheduling alternative transportation because it can be said that the resident did not get necessary care. R11's nursing progress note documents an appointment for hand surgery on 07/11/2024. R11's nursing progress note documents, R11 is back in the facility from surgery to his left hand. R11's Order Summary Report documents the following order entered no 08/21/2024: Follow-up with orthopedic Doctor on 09/11/2024. Facility appointment/transportation schedule documents an appointment for R11 on 09/11/2024. R11's MDS (Minimal Data Set) - Functional Abilities section dated 08/08/2024 documents the following: R11 uses a wheelchair; R11 requires supervision with locomotion via wheelchair; R11 requires maximal assistance with wheelchair transfers. R13's Order Summary report documents an order entered on 7/12/2024 as follows: Ophthalmology Consult due to Cataracts. R13's eye appointment form dated 08/14/2024 documents findings of cataracts. R13's Nursing progress note dated 08/14/2024 documents R13's cataract surgery will be scheduled with a call to indicate and confirm date per ophthalmology office. R13's Care Plan dated 06/10/2021 documents, R13 has potential for impaired vision related to diagnosis of blurred vision and dry eye; Interventions include arranging consultation with eye care practitioner as required. R13's Care Plan dated 08/29/2023 documents, R13 has been determined by comprehensive assessment to have care needs that require supportive services provided by facility; R13 will be provided care to enable her (R13) to function at her highest most practical level. Facility policy titled Resident's Appointment documents, to ensure residents are scheduled for medical appointments as per physician orders; charge nurses will follow-up with resident's physician, as indicated.

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that one resident's (R1) psychotropic medication/ controlle...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that one resident's (R1) psychotropic medication/ controlled substance was properly documented after administration. This failure has the potential to affect all residents who are currently prescribed controlled substances. Findings include: R1 is [AGE] year old with diagnosis including but not limited to: Generalized anxiety disorder, post-traumatic stress disorder, primary insomnia, unspecified asthma, personal history of other mental and behavioral disorders. R1's BIMS (Brief Interview of Mental Status) score is 15, which indicated cognitively intact. During investigation on 10/01/2024 at 2:14 PM, R1 stated that she was administered Lorazepam on three occasions without requesting it and that she was never given Lorazepam at 1:00 am on 08/26/2024 (as indicated by controlled substance accountability record). R1 said, I sleep throughout the night, so I don't know why it is documented that I received it Lorazepam on 08/26/2024 at 1:00 AM. I usually receive all of my medications at the same time right before bed. On 10/07/2024 at 9:45 AM V2 (DON/ Director of Nursing) stated that the MAR was a part of the EHR. On 10/07/2024 at 9:45 AM V2 (DON) said, It is expected that each and every medication is signed off on the MAR to prevent medication error and to account for controlled substances. Surveyor inquired about the signatures for 08/23/24, 08/24/24 and 08/26/24 on the controlled drug accountability record. V2 (DON) stated that the signatures on the controlled drug record were V12 (LPN/ Licensed Practical Nurse) and V13 (LPN). On 10/10/2024 at 2:05 PM, V12 (LPN) stated she administered R1 a 0.5 Lorazepam mg (milligram) tablet on 08/24/2024 at 4:00 PM but forgot to document it in the MAR/EHR (Medication Administration Record/ Electronic Health Record). On 10/10/2024 at 2:09 PM, V13 (LPN) stated she does not recall administering R1 a 0.5 mg tablet of Lorazepam on 08/26/2024 at 1:00 AM. V13 stated she recalls administering R1 a 0.5 Lorazepam mg (milligram) tablet on 08/23/2024 at 9:35 AM but forgot to document it in the MAR/EHR (Medication Administration Record/ Electronic Health Record). On 10/10/2024 at 3:38 PM, V2 (DON) stated she did not have a list of residents talking controlled substances. R1's Order Summary Report dated 10/03/2024 documents the following order active between the dates of 08/19/2024 through 09/02/2024: Lorazepam oral tablet 0.5 MG, give 1 tablet by mouth every 12 hours as needed for anxiety. R1's Controlled Drug Record documents a 0.5 Mg Lorazepam tablet administered to R1 on the following dates: 08/23/2024, 08/24/2024 and 08/26/2024. R1's Medication Administration Record for the period of 08/01/2024 through 08/31/2024 documents no administration of Lorazepam on the following dates: 08/23/2024, 08/24/2024 and 08/26/2024. Facility Nursing Schedule documents the following: V13 assigned to R1's unit on 08/23/2024; V12 assigned to R1's unit on 08/24/2024; and V13 assigned to R1's unit on 08/26/2024. Medication Administration and Storage policy documents, to ensure medications are administered and stored in accordance with Standard of Practice; Narcotics must be signed out in the EHR (electronic health record) and the Narcotic sheet. Oral Medication Administration Policy documents, Chart medication on Medication Administration Record Immediately following each resident's medication administration.

Aug 2024 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

Resident Rights (Tag F0550)

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 develop and implement a policy to address strip/body searches of re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a policy to address strip/body searches of residents. This failure has the potential to affect two of three residents (R13, R4) reviewed for strip searches. This failure resulted in R13 feeling humiliated and ashamed; R4 feeling violated. Findings include: 1. R13's Face Sheet documents R13 is a [AGE] year-old admitted to the facility on 3.14.2024 with diagnoses including: Pain in Left Shoulder, Low Back Pain, Acquired Absence of Other Right Toe(s), and Acquired Absence of Other Left Toe(s). R13's MDS-Minimum Data Set of 6.12.2024 documents a BIMS (Brief Interview for Mental Status) score of 15 denoting resident is cognitively intact. On 8.20.2024 at 12:24 PM, R13 said approximately 1 ½ months ago, he was subjected to a strip search because his former roommates credit card was missing. R13 said he was told by V25 (PRSC-Psychiatric Rehabilitation Services Coordinator) if he did not comply with the search, R13's parole officer would be contacted to obtain an order to return R13 to prison as R13 was on parole at that time. R13 said the search occurred in V25's office; V24 (Restorative Director) was also present. R13 said he took off his shirt, dropped his pants, underpants and bent over and coughed as instructed. R13 said V21 (Former Housekeeping/Laundry Supervisor) briefly stuck his head inside V25's office. R13 said the strip search made him feel humiliated and ashamed. 2. R4's Face Sheet documents R4 is a [AGE] year-old admitted to the facility on 2.8.2024 with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Alcohol-Induced Chronic Pancreatitis, and Iron Deficiency Anemia. R4's MDS-Minimum Data Set of 6.4.2024 documents a BIMS (Brief Interview for Mental Status) score of 15 denoting resident is cognitively intact. On 8.21.2024 3:00 PM, R4 said when she returned to the facility on 6.12.2024, staff at the front desk stopped her to search her purse, R4 refused. R4 said, later V4 (Social Service Director) and V24 (Restorative Nurse) conducted a strip search in V4's office. R4 said, I was told to lift up my shirt, to lift up my bra, they could see my ti**es. R4 said they had me unzip my pants. I felt violated, like she (V4) had all the power. On 8.15.2024 at 4:20 PM V4 (Social Service Director) said she is not aware of any strip searches of any residents. On 8.21.2024 at 11:47 AM V24 (Restorative Director) said, If I'm asked to by Social Service, I do assist to conduct strip searches. I assisted with strip searches of R4 and R13. V4 (Social Service Director) needed me to assist with search of R4's room and to be a witness to R4's strip search. We had R4 pull her shirt and bra away from her body and shake them. R4 was wearing skintight leggings; when she took down her leggings, she had no panties on. I assisted V25 (PRSC-Psychiatric Rehabilitation Services Coordinator) with R13's strip search. R13's former roommate accused R13 of taking his credit or debit card. R13 took off shirt, shook it and placed it on V25's desk; he wasn't wearing an undershirt. R13 took off his shoes/socks off, then took off his pants and boxers down to his knees, then she had resident cough. No contraband was found during the strip searches of R13 and R4. On 8.21.2024 at 12:04 PM V25 (PRSC 6th Floor) said, I do not conduct searches (strip) of resident's bodies; usually nursing does that. I did not complete a search of R13, a nurse (V24) did that when his former roommate said credit or debit card was missing. The search took place in my office because the room is pretty big. Neither V24 nor myself actually touched him. He removed his own clothing. I can't remember if he took his shirt off, I know he lifted it. He did pull his pants down, he had underwear on, he did not take his underwear down or off. If any instructions were given it would have been V24 said, I don't recall V24 telling him bend over and cough. Facility's Routine Resident Checks and Safety Room Checks policy (Reviewed 7/24) documents: 4. To provide safety to all residents, Resident Room checks for unsafe items (contraband such as Alcohol, Medications, drug paraphernalia, and/or items that may be used by resident or others to cause harm). Resident upon entering the facility from independent pass, the facility reserves the right to check bags or resident coat/jacket and pockets. If resident is observed with unapproved items, appears to be under the influence, and/or has a history of safety concerns such as alcohol, illegal substances, etc., the facility will conduct search, with resident present to ensure the resident and other residents in the facility are safe and free from harm. The policy does not address strip search of 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

Investigate Abuse (Tag F0610)

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 conduct interviews as appropriate to the allegations of abuse for...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to conduct interviews as appropriate to the allegations of abuse for one (R1) of four residents reviewed. Findings include: R1's current face sheet documents R1 is a [AGE] year-old individual whose medical diagnosis includes but not limited to acquired absence of right leg above knee, chronic kidney disease, stage 4 (severe), generalized anxiety disorder, nicotine dependence, cigarettes, uncomplicated. R1 left ama (against medical advice) 08/01/2024. R1's Brief Interview for Mental Status (BIMS) dated July 22, 2024, documents R1 has a BIMS score of 15/15, indicating R1 has an intact cognition. On 08/16/2024 at 9:44 am, V5 (Dietary Aide) accompanied V6 (Activity Aide) to interpret for V5 who speaks Spanish. V5 stated he takes breakfast upstairs to the units for residents who leave the facility early in the morning to go to dialysis. V5 takes the food cart upstairs from the first floor where the kitchen is located about 6:10am to 6:15am using the fleet elevators located at the back wall on the Northside of the facility. V5 stated residents can also use these elevators. V5 stated on 08/07/2024, V5 was inside the fleet elevator with one food cart holding eight trays of breakfast and V5 was taking the breakfast to residents who were leaving for dialysis morning. V5 stated as he was positioning the food cart properly into the service elevator. R1 was behind him walking fast to get into the elevator. V5 stated as V5 was getting himself and the food cart into the elevator, R1 was behind V5 and R1 got into the elevator too. It was just V5 and R1 in the elevator, and R1 was looking behind him and outside the elevator as if he was looking for someone else to get into the elevator. V5 stated R1 paused the elevator. V5 stated he thought R1 was looking/waiting for someone to come get into the elevator. V5 stated he (V5) told R1 he had to close the elevator doors and take breakfast food cart to the residents who were leaving for dialysis. V5 stated he was communicating to R1 in the little English V5 can speak. V5 stated R1 told V5, I don't care and R1 got behind V5. R1 pushed the cart out of the elevator, therefore V5 got out of the elevator and R1 closed elevator doors and the elevator went up to the units. V5 waited for the next elevator. V5 stated R1 closed elevator doors and the elevator went up to the units. V5 stated he did not push R1, but R1 is the one who pushed V5. V5 stated no one has come to interview V5 or asked V5 what happened on day (08/07/2024) between R1 and V5, and V5 never discussed it with anyone after the incident happened. On 08/16/2024 at 11:46am, V3 (Patient Escort) stated she remembers an incident involving R1 and was present the day of the incident on 08/07/2024. V3 stated they (R3 and V3) with R1 holding the elevator, were approaching the elevator when V3 saw V5 (Dietary Aide) get onto the elevator with R1. V3 stated V5 was upset R1 was holding the elevator for R3 and V3. V5 got impatient and when R3 and V3 got to the door of the elevator, V5 pushed R3's wheelchair to get it all the way into the elevator. R3's wheelchair hit R1 on R1's prosthetic leg which almost made R1 fall. V3 stated she did not know if V5 pushed the wheelchair roughly to hit R1 or if it was an accident the wheelchair hit R1. V3 stated V5 also pushed the meal cart onto the elevator and at this point, R1 pushed the meal cart back off the elevator. V5 got off the elevator with the meal cart. V3 stated she is not sure if V5's actions were intentional because V5 was trying to make room for the food cart in the elevator when V5 pushed R3's wheelchair hitting R1 on the leg. V3 stated R1 did not suffer any injuries. V3 stated after getting back from the methadone clinic, V3 went to V2's (Director of Nursing-DON) office to report what happened involving R1, R3, and V5. V3 stated V2 and V11 (Overnight supervisor/licensed Practical Nurse-LPN) were in V2's office. V3 stated V2 was on the phone and held up her hand gesturing for V3 to wait until V2 got off the phone. V3 stated V3 left V2's office and went outside. V11 came outside V2's office and asked V3 what happened. V3 stated she reported everything occurred on the elevator involving R1, R3, and V5 to V11. V3 stated she was never officially interviewed and there was no investigation done pertaining to the incident. The facility did not speak to R3 about what occurred either. V3 stated just before speaking with surveyors today, V1(Administrator) pulled V3 into his (V1) office told she (V3) would get into trouble for not reporting the incident involving R1, R3 and V5. V3 stated she had tried to speak to V2 and V1 regarding the situation several times but none of them would speak to her. On 08/16/2024 at 4:24 pm, V4 (Social Services Director) said she was not at the facility during the incident when R1 was on the elevator with R3, V3 and V5. V4 said V2 told V4, V11 told V2 she (V11) was at the back by the fleet elevator, when she (V11) heard the commotion and saw R1 going towards the elevator. V11 was not sure if R1 got into the elevator or not. V4 stated R1, R3 and V3 were on the elevator when V5 came towards the fleet elevator on the first floor and V5 was trying to push the breakfast cart on the elevator. V4 stated she heard R1 pushed the cart off the elevator and in effect pushing V5 off the elevator with the food cart. V4 stated all this was hearsay from V2. V4 stated V11 might have talked to V3 about this incident. V4 said V11 is the one who interviewed R1 because V4 thought words were being said between R1 and V5. V4 stated, I don't know what happened and I did not speak/interview the parties involved. V4 stated she heard after the incident, R1 rode the elevator upstairs. V4 stated she did not try to talk to V3 or V5. V4 stated she was in the building that day, but she (V4) did not talk to V3 stating she (V4) went with what V2 told her. On 08/20/2024 at 1:56pm, V11 (Overnight Supervisor/LPN) was reached via phone and said she was working on 8/7/2024 night shift and started her shift on 8/06/2024 at 7pm and got off 8/7/2024 at about 8-8:30am. V11 stated she was on the elevator with R1 coming from upstairs (5th floor) down to the first level. V11 stated she was going downstairs from the 5th floor and found R1 in the elevator also going downstairs. V11 stated she joined R1 in the elevator. V11 stated R1 was pacing in the elevator, eye rolling, and smirking his lips and R1 stated he was agitated because his orange community pass was restricted. V11 stated R1 was not aggressive towards V11 as they rode the elevator. V11 stated R1 never got out of the elevator once R1 and V11 got to the first floor. V5 was standing right outside the elevator waiting to get into the elevator with a food cart to go upstairs. V11 stated V11 got off the elevator and walked around the corner heading towards V2's office. V11 stated before she could make it to V2's office, V11 heard commotion near the elevator so V11 went back around the corner towards the elevator and at time the elevator doors were closing. V5 was standing outside the elevator with the food cart. V11 stated one of the workers form the kitchen translated to V11 what V5 was saying in Spanish. V11 stated V5 told her R1 pushed V5 out of the elevator with the food cart. V11 then called V2 to inform V2 R1 had just pushed V5 out of the elevator. V11 stated she then left and went home because V2 told V9 V2 did not need V11 to stay. V11 stated she was never interviewed again regarding the incidence between R1 and V5. On 08/20/2024 at 3:22pm V2 (Director of Nursing-DON) stated on 8/7/2024 V2 came into work in the morning about 7:10am. V11 came into to V2's office to give end of/change of shift report. V2 stated V11 told V2 about the incident in the elevator stating R1 pushed V5 out of the elevator. V2 stated V11 told V2 V11 was walking towards V2's office to give V2 a change of shift report, and as V11 was coming around the corner, V11 heard a commotion happening by the back elevator. V2 stated V11 run back towards the elevator and when V11 got back by the elevator, the elevator doors were closing and V11 could see R1 inside the elevator. V11 told V2 she (V11) saw V5 standing right outside of the elevator with the food cart and V5 looked a little frazzled. V11 stated per interpreter, V5 stated he was trying to get on the elevator with the food cart to take the food upstairs and R1 was in the elevator, and R1 pushed the food cart and V5 off the elevator. V2 stated she asked R1 what happened but did not document it. V2 stated while she was coming to the facility morning about 7:10am, she saw R1 and V3 getting into transportation to take R1 to the methadone clinic, and R1 did not look agitated or violent. V2, stated she did not investigate what happened, but she called the psychiatrist and got orders to send R1 out to the hospital based on what V11 told V2. V2 stated, I know the story was funky and I didn't chart when I (V2) spoke to R1, and if it's not documented it's not done. V2 stated she tried to speak with V3 regarding this incident but V3 would not come to V2's office, and V3 was avoiding V2, and to date, V2 has not spoken to V3 about the incident. V2 stated she charted R1's behavior based on what V11 told her. V2 stated she was supposed to investigate allegations, but if the allegations are resident to staff, then facility does not have to report to IDPH. On 08/21/2024 at 10:52am, V2 stated she was in the office with V11 talking about the incident when V3 came to the office after taking R1 to the methadone clinic. V2 stated V3 told V2 V3 wanted to speak with V2 about the incident. V2 stated she told V3, yes we need to talk. V3 walked away because V2 was in the middle of a conversation with V11. V2 stated V11 left V2's office after their meeting and V2 stated V3 never came back to speak to V2. V2 stated she looked for V3 but could not find V3. V2 stated she passed V3 several times in the hallways in the facility but V3 would not talk or look at V2. V2 stated the incidence between R1 and V5 could technically be abuse and should have been investigated by V2 or by V1 to make sure V2 and V1 knew the truth of what happened. V2 stated the importance of investigations is to get all sides of the story so the facility can put the information together, it paints a picture of the true story. V2 stated without an investigation, V2 did not get the whole story and she does not know completely what happened. V2 stated V3 was in the elevator and was a witness and should have been interviewed. V2 stated she did not start an investigation after surveyor informed V2 on 08/20/2024 at 3:30pm because after completing speaking with surveyor, V2 went to another meeting with another surveyor and by the time she was done speaking with the other surveyor, it was 5:30pm and she had to go home. V2 stated she did not investigate the allegation because it was hearsay. On 08/21/2024 at 12:05pm, V15 (Transportation coordinator/Escort) stated on 08/08/2024 at around 12:30pm, she did not know if V3 refused to talk to V2 because V2 did not say V2 tried to talk to V3. On 08/21/2024 at 12:22pm, V1 (Administrator) stated there was no camera footage of the elevator incident between R1 and V5 on 8/7/2024. V1 stated he started working at the facility on July 8th, 2024, as the administer. V1 stated the morning of the incident between R1 and V5 on 8/7/2024, someone (does not remember who) brought it to his attention R1 had shoved the food cart into the V5, but V1 stated he was not given the name of the staff member/dietary aide. V1 stated at time, the situation was being taken care of either nursing or social services. V1 did not investigate because everything he (V1) was told was subjective based on hearsay. V1 stated he was not handling the investigation and nursing, or social services were looking into the matter. V1 stated social services and nursing dealt with the situation and did the investigations and by the time V1 got to the facility the doctor had been contacted and orders given to send R1 to the hospital. V1 stated to date, he has not investigated the allegation. V1 stated he is the abuse coordinator. Facility policy titled Illinois-Abuse Prevention Policy, dated October 24, 2022, documents: -Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations of suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a care plan to address a resident, with histo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a care plan to address a resident, with history of opioid dependence, for one of three residents (R1) reviewed for illegal drug use. Findings include: R1's Face Sheet documents R1 is a [AGE] year-old admitted to the facility on 2.10.2022 with diagnoses including but not limited to: Resistance to Multiple Antibiotics, Chronic Kidney Disease, Stage 4; Acquired Absence of Right Leg, and Opioid Dependence. R1's MDS-Minimum Data Set of 7.2.2024 documents a BIMS (Brief Interview for Mental Status) score of 15 denoting resident is cognitively intact. 8.21.2024 12:28 PM V8 (5th Floor PRSC) said V8 had to take R1's card (orange pass card) away for two weeks due to cocaine and marijuana found in drop (urine drug test). There should be an addiction care plan, I don't remember doing one. He should have had one because he came from 6th floor to 5th floor. I did not update his care plan. 8/1/2024 12:08 Psychosocial Note: Resident placed on restriction after testing positive for Cocaine, Marijuana, and Methadone. This is against the facility policy on substance abuse. Resident was explained to again what the rules are and informed of his 2 weeks restriction and it was suggest again that he attend the facility substance abuse program. Resident denies using and wanted to sign out AMA however after encouragement he retracted the statement. August 15th, 2024, he will be off restriction pending any other issues with the resident. 8/1/2024 00:58 Nurses Note Supervisor Note (in part): Resident agreed to take a drug test. Resident tested positive for cocaine, Marijuana, and Methadone. Resident became upset about the results of the drug test. Resident started yelling and requesting to go AMA. Review of R1's care plans did not document a care plan to address R1's illegal drug use. Facility's Comprehensive Resident Care Plans policy (revised August 2024) documents: Policy: Comprehensive resident care plans will be developed for each resident using the results of the comprehensive assessment. Each care plan shall include measurable objectives and timetables to meet all resident needs identified in the comprehensive assessment. Procedure: 1. Resident's plan of care shall be done within seven days after completion of the comprehensive assessment. 2. Comprehensive care plans must be prepared by the interdisciplinary team. 3. The resident and resident's family or the resident's legal representative to the extent practical. 4. Resident's plan of care shall be reviewed by the interdisciplinary team after each MDS assessment is conducted and revised as necessary to reflect the resident's current care needs. 5. Resident's plan of care are reviewed quarterly and as necessary to address the current needs of each resident.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to provide quality care to one resident (R5) of three residents reviewed by not scheduling a biopsy in a timely manner. Findings include: On 8/...

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Based on interview and record review the facility failed to provide quality care to one resident (R5) of three residents reviewed by not scheduling a biopsy in a timely manner. Findings include: On 8/16/24 at 12:12 PM, V3 (Patient Escort) stated, I'm with R5 a lot. R5 is having trouble with the tongue biopsy. The ENT (Ear Nose Throat) doctor from the hospital requested a tongue biopsy on April 15. A nurse from the hospital said she has sent paperwork to get the biopsy done. Many times, at least three to four times, I have brought the paperwork from the hospital saying that R5 needs a tongue biopsy. We (R5 and I) have gone to the hospital for follow-ups for the tongue biopsy, but nothing has been done because R5 has not gotten the tongue biopsy. Every time we go for an appointment, they send the same paperwork requesting a tongue biopsy. The Oncology doctor also wanted to see the results of the tongue biopsy. I was in the exam room with R5, and the Oncology doctor was looking for the results in R5's chart. The ENT doctor said my boss (V15) is supposed to make the appointment. Sometimes my boss or nurses on the floor make the appointments. I give the paperwork to R5's shift nurse at the time. On 8/16/24 at 3:20 PM, V15 (Transportation Scheduler Medical Appointments) stated, I schedule medical appointments and set up transportation to appointments and provide escorts to the appointments. In April, a tongue biopsy was ordered by the ENT doctor for R5. I tried to schedule R5 at the hospital. I have a couple of patients, not only R5. I don't schedule the lab work. The nurse schedules the lab work/pre-op preparations. The ENT doctor schedules the biopsy after the lab work and medical clearance is done. The medical clearance comes from the primary physician here at the facility. I have a binder of appointments/transportation request forms that nurses fill out of appointments I need to make. When I make the appointment, I put it in the calendar at the nursing station on each floor. The doctors will tell the nurse of an appointment. I tell my escorts to look at the discharge paperwork to tell me of any follow up appointments that I need to schedule. The escort also gives the paperwork to the nurse and the nurse is supposed to put it in the calendar. R5 has not had the biopsy. The ENT doctor said the biopsy appointment has not been made. I tried to make the appointment for the biopsy in April or May. The hospital was transferring me to different departments. The surgery department told me I don't schedule the biopsy it has to be the doctor who ordered it. I relayed the message to a nurse on the fourth floor. I told the nurse that she has to get the prescription for the biopsy from the ENT doctor. I forgot to follow up. No one followed up. I didn't follow up with the ENT doctor because that should have been the nursing department. On July 10, 2024 V2 (Director of Nursing) asked me what was going on with R5's appointments. I made an appointment for R5 to go back to the ENT doctor twice, 8/12 and 7/24, so R5 could find out about the biopsy, why it was not scheduled yet. R5 needed the biopsy for diagnosis of lesions of oral mucosa, to find out if cancer. R5 has a tongue mass. The mass on the tongue was found during a dental appointment. The dentist said R5 needs to see a surgeon. I made an appointment for the surgeon, 3/22. The Surgeon referred R5 to the ENT. First ENT appointment was 4/15/24. On 8/20/24 at 4:28 PM, V2 (Director of Nursing) stated, From what I understand the appointment for the tongue biopsy has been made for R5, on 8/12/24 there was an appointment that R5 went to with the ENT doctor and came back with orders for blood work for consultation of the tongue mass. The lab results came back 8/14. They were relayed to the NP (Nurse Practitioner) with an order to fax everything to the ENT doctor's office. 8/16 as per NP, either the NP or the primary at the facility will write H&P (Health and Physical) for pre-op clearance. The H&P should be faxed to the ENT doctor's office. We need to do a follow up with the ENT doctor. I need to follow up with the NP or the facility primary to see if the H&P was completed or to write it. Nursing has followed thru with blood work orders and relaying info to the NP. The tongue biopsy has not been done. We are working towards it. The original order for the tongue biopsy was ordered by the ENT on 4/15/24. The Nurse manager said every time they went to schedule the biopsy there was something else going on with R5 that required attention. Both the scheduler and nursing can schedule the biopsy. The biopsy appointment has taken a long time. Biopsy appointments don't generally take this long. On 6/18 I messaged V15 about the biopsy. 7/5 I followed up with V15 again who said the appointment was not made yet, V15 needed a physical prescription from the doctor that ordered the biopsy. I messaged V15 again on 7/10. 7/11 V15 responded the ENT was supposed to do the biopsy on 7/24. V15 said R5 did not miss any appointments. R5 had an appointment on 8/16 with ENT. A nursing note dated 8/16 states on 8/15 tracheal chondroma/benign tumor of the trachea was removed. I'm not sure why it took so long to get the biopsy. The mass could have been cancerous. The purpose of the biopsy is because they wanted to check for cancer of the tracheal mass that R5 has. Plan of Treatment from hospital discharge paperwork, 4/15/24, reads in part: I am strongly recommending a biopsy the patient dorsal tongue to help determine the pathology furthermore recommending a biopsy of the left posterior pillar of the tonsil region for possible squamous cell carcinoma. In addition, I would recommend that the patient be referred immediately to a pulmonologist for bronchoscopy and biopsy of the mass noted in the distal trachea. A copy of this note is being provided to the patient and staff to take back to the nursing home. Plan of Treatment from hospital discharge paperwork, 8/12/24, reads in part: I am strongly recommending a biopsy the patient dorsal tongue to help determine the pathology furthermore recommending a biopsy of the left posterior pillar of the tonsil region for possible squamous cell carcinoma. In addition, I would recommend that the patient be referred immediately to a pulmonologist for bronchoscopy and biopsy of the mass noted in the distal trachea. A copy of this note is being provided to the patient and staff to take back to the nursing home. Facility policy Residents Appointment, August 2024, reads in part: Charge nurse and/or designee will schedule resident's appointments and follow-up appointments, as indicated.

Jul 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based upon record review and interview the facility failed to follow the abuse policy procedures, failed to report abuse to IDPH (Illinois Department of Public Health) within regulatory requirements a...

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Based upon record review and interview the facility failed to follow the abuse policy procedures, failed to report abuse to IDPH (Illinois Department of Public Health) within regulatory requirements and failed to report actual time of occurrence for two of four residents (R5, R6) reviewed for abuse. Findings include: R5's (6/9/24) progress notes states (7:08pm) writer observed resident in a verbal altercation with peer. Resident then pushed peer with two hands to the ground, causing peer to fall. The (6/9/24) initial incident report includes Incident Time: Evening [actual time is excluded]. Brief Description of Incident: It was reported that (R5) pushed (R6) on the patio. It was unclear at the time of the cause and what triggered this incident. (R5) was immediately separated from (R6) and the police were called. R5 was sent to the hospital. R6 refused a head-to-toe assessment and confirmed that he had no pain or injury from the incident. He was fine and no further intervention was necessary per the Nurse on duty. (R6) refused any x-ray as well. Analysis/conclusion: after five business days a final report will be sent. IDPH was notified (6/10/24) via facsimile at 11:07am [the following day]. The (6/9/24) final incident report states (R5) was arguing with (R6) about money. (R5) was told by the manager on duty to calm down and deescalate or she would be sent out. (R5) and (R6) went outside into the patio to smoke, both were told to be on the opposite sides of the patio. Right away (R5) lunged for (R6) and pushed him before staff had a chance to intervene. (R5) was not visibly himself and not with it, he was subsequently petitioned out to the hospital for further evaluation. After concluding the investigation abuse cannot be substantiated as (R6) was going through a mental health episode. (R6) was not harmed from the incident, he refused an x-ray, stated he is fine and not interested in any further intervention. IDPH was notified (6/17/24) via facsimile [8 days after the incident]. On 7/23/24 at 1:06pm, surveyor inquired about the regulatory requirements for abuse V1 (Administrator) stated in part, We report to IDPH within 2 hours, we investigate it and submit the final within 5 business days Surveyor inquired about concerns with the (6/9/24) reported incident involving R5 and R6. V1 affirmed that V1 was not employed by the facility at that time. V1 reviewed the initial/final reports and responded, There is no time, it says evening. Surveyor inquired when the (6/9/24) initial incident report was submitted to IDPH, V1 replied The next day, the next morning. It's a late report. Surveyor inquired if the (6/9/24) final report was submitted to IDPH on time V1 stated, It was late. The (undated) facility abuse policy states an initial report to the State licensing agency, IDPH, shall be made immediately after the resident has been assessed and the alleged perpetrator has been removed. The initial report shall include the time and date of the alleged incident. Within five days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken to respond to the allegation, will be sent to IDPH.

Jul 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

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 accommodate the needs of residents by failing to ensur...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accommodate the needs of residents by failing to ensure call lights were within reach of two (R2, R3) of four residents reviewed. Findings include: R2 R2 is an individual with medical diagnosis that include but not limited to: bipolar disorder, current episode depressed, severe, without psychotic features, other muscle spasm, and R2's Brief Interview for Mental Status (BIMS) dated [DATE] is documented as 11/15, indicating R2 has moderate cognitive impairment, and R2's MDS(Minimum Data Set) section GG (Functional Abilities and Goals) dated 2/15/2024 documents R2 requires Substantial/maximal assistance with Shower/bathe, self/Lower/upper body, dressing/Personal hygiene/Sit to stand, and R2 is frequently incontinent of bladder and bowel. On 07/13/2024 at 10;05am, R2 was observed laying in his bed with head of the bed elevated to about 60 degrees. R2 stated he ate breakfast and has already taken his medication. R2 stated he was having a stomachache. R2 stated he had not called the nurse because R2 did not know where his (R2) call light was. R2's call light was observed hanging behind R2's bed, hanging against the wall and touching the floor, and R2 could not reach it. R3 R3's medical conditions as documented in R3's current face sheet include but not limited to: Chronic Systolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary disease. Morbid (Severe) obesity due to excess calories, and R3's Brief Interview for Mental Status (BIMS) dated [DATE] documents R3's BIMS as 15/15, indicating R3 has intact cognition, and R3's MDS (Minimum Data Set) Section GG dated [DATE] documents R3 is dependent on staff to Roll left and right, Sit to lying, Chair/bed-to-chair transfer, tub shower transfer and Toilet transfer was not attempted due to medical condition/safety concerns, and further documents R3 is frequently incontinent for bladder and always incontinent for bowel. On 7/13/2024 at 11:05am, R3 stated he ate breakfast this morning and had a bowel movement and when he was done, he wanted to use his call light to call for staff to come and change him. R3 stated he looked for the call light, but he could not find it. R3's call light was observed on the side of the bed tangled with the bed remote wires and far from reach of R3. R3 stated he could not see or feel/reach the call light when he tried to look for it. On 07/13/2024 at 12:15pm, V5 (Registered Nurse-RN) stated call light should be within reach of a resident so that the resident can reach it and use it when they need to. V5 stated nursing staff should be making sure the call light in within reach for the resident to use in case of an emergency. On 07/13/2024 at 10:15am, V10 (Licensed Practical Nurse-LPN) with surveyor observed R2 laying in his bed awake with the TV on. R2's call light was observed hanging behind the back of R2's bed by the wall. R2 was not able to reach the call light. V10 stated the call light should be within R2's reach so that he can be able to use it in case of an emergency. V10 stated if the call light is not within reach, R2 might not be able to reach staff in case of an emergency. V10 said he will speak to the CNAs (Certified Nursing Assistants) to make sure call light are within resident's reach. On 07/13/2024 at 11:15am, V12 (Certified Nursing Assistant-CNA) with surveyor observed R3's call light on the side of the bed tangled with the bed control button and far from R3's reach. V12 stated call lights should be within reach of residents so they can reach staff in case the residents need anything. V12 stated R3's call light should be placed near R3. On 07/13/2024 at 2:24pm V3 (Director of Nursing-DON) stated call light should be within reach of the resident so that residents can reach staff if resident has an issue/or emergency. V3 stated a resident's call light should be within hands reach and should not be hanging on the back of the bed or tangled with bed remote controller and far from resident. Facility policy titled CALL LIGHT, No date, documents: -When the resident is in bed or confined to a wheelchair, staff shall ensure the call light is within reach of the resident.

Jul 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

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, facility failed to follow professional standards of practice and facility pol...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to follow professional standards of practice and facility policy in documenting post-surgical wound assessment in two residents (R2, R5) out of 15 residents. Findings: On [DATE] at 12:45 PM R5 was interviewed and stated, I saw Dr. V39 (Spine Surgeon) last week. He took out the stitches. No one has looked at my back since then. V39 was upset that no one was looking at the wound after surgery. They (the nursing staff) did not look at the wound but once when I first got here. On [DATE] At 12:45 PM, R5's wound was observed to be well-approximated and healed with no redness, swelling or drainage. On [DATE] at 12:58 PM V22 (LPN) was interviewed and stated that upon a new resident's admission, nursing staff does a full body, head-to-toe skin assessment. V22 stated, We look at the surgical incision or surgical wound at the time of admission and then the wound care team looks at it for assessment and treatment. Wound team will look at the surgical incision one to three times a week. We don't mess around with wounds once wound care is involved. We don't look at resident's incisions or wounds because wound nurses follow them. On [DATE] at 1:15 PM V23 (Wound Director) was interviewed and stated, Every new admission is seen by a wound nurse. If the resident has a wound, the orders come from the doctor. I'm very strict. Once wound nurses are involved, the floor nurse does not manage the wound unless it is a surgical wound or surgical incision. If it is a surgical wound, the floor nurse will monitor the wound and let the wound nurse know if they have any concerns. The wound nurse will enter a 'monitor wound order' for surgical incisions so that the floor nurses assess and document the assessment of the surgical incision. V23 looked at the documentation for R5 in the electronic health record. V23 stated the wound nurse did an assessment on [DATE]. V23 stated, I don't' see a monitor order. We got orders that after the negative pressure wound therapy system died, we were done. The negative pressure wound therapy system was removed on [DATE]. The nurses need to monitor the surgical incision and let me, or the outside physician know if there is a concern. On [DATE] at 1:20 PM V2 (Director of Nursing) was interviewed and stated For surgical wounds, if there are instructions, we follow them. V23's team does not touch surgical wounds unless there are specific instructions or if there are clinical concerns. Nurses on the floor should be monitoring for any issues with the wound. If they can't see the wound because of a dressing or they have instructions not to touch the dressing, the nurses should be documenting on the skin assessment any complaints or pain and assessment of the wound or assessment around the dressing. The nurses should be documenting that assessment in the nurses' notes. On [DATE] at 12:15 PM V2 (Director of Nursing) provided a single nurses note dated [DATE] which stated R5 also complained of itching at her wound site (back). V37 (Physician) was informed with new orders being carried out. V2 stated that the [DATE] note and the [DATE] notes were the only notes that V2 could find in R5's electronic health record relative to R5's surgical incision. V2 stated, The [DATE] note does not state that the wound was assessed, only that the resident complained of itching and that the doctor was called. Policy titled Wound Management Policy was not dated and stated in part: Purpose: To provide guidelines for the assessment, treatment, and management of wounds in residents, ensuring compliance with federal, state and local regulations and promoting the highest quality of care. 4. Infection Control, bullet one: Signs of wound infection will be monitored, including redness, edema, pain, increased exudate and peri wound surface warmth. 5. Documentation and Compliance, bullet one: All wound care activities will be documented in the resident's medical record, including assessments, care plans, interventions and progress noted. Bullet two: Documentation will comply with CMS regulations and professional standards of practice. 5. Staff Qualifications and Training. Bullet one: Wound care will be provided by trained and competent staff, including licensed nurses and wound care specialists.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide therapy services in a timely manner and failed...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide therapy services in a timely manner and failed to follow facility policy for two residents (R1, R5) out 15 residents in the sample. Findings 1. On 7/2/2024 at 10 AM the electronic health record of R1 was reviewed. R1 was admitted to the facility on [DATE]. An order for Physical Therapy to evaluate and treat was entered on 5/7/2024. An order for Speech Therapy to evaluate and treat was entered on 5/7/2024. An order for Occupational Therapy to evaluate and treat was entered on 5/7/2024. An order for Occupational Therapy evaluates and treat related to right hand limited range of motion was entered 5/31/2024. An Occupational Therapy clarification order was entered on 6/17/2024 for Occupational Therapy to evaluate and treat for 2-4 times/week for 41 days to address activities of daily living training, therapeutic exercise, therapeutic activities Neuromuscular Rehabilitation (NMR) and patient education was ordered on 6/17/2024. On 7/2/2024 at 10:30 AM V21 (Director of Rehabilitation Services) was interviewed and stated rehabilitation services are provided depending on the resident's insurance payor. If a resident has Medicare Part A, the resident automatically gets put into the system for Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy. Rehabilitation Services completes a screening of residents with Medicare Part A. Following the screening, Rehabilitation Services determines if the resident needs skills rehabilitation services. For residents who have Medicare Part B, referrals to Rehabilitation Services comes from nursing staff or Restorative Care. If a resident has Medicaid benefits, the facility administrator signs off on any Medicaid referral and the corporate Chief Executive Officer (CEO) also signs off before Rehabilitation Services can complete an assessment of the resident or begin rehabilitation services begin. V21 stated, V1 (Administrator) signs off and then V28 (Corporate CEO) signs off and then we can evaluate the resident. V1 stated if a doctor or nurse practitioner or physician assistant writes an order for therapy, they need to inform Rehabilitation Services they are writing the order. There is no notification in the electronic medical record. V21 stated, We don't get notified of the order unless they tell us they are writing the order. R1's documentation was reviewed by V21. V21 stated R1 was admitted to the facility on [DATE]. V21 stated when R1 was admitted , an initial evaluation for physical therapy and occupational therapy was completed. V21 stated, They did the screening, and it was determined PT and OT were not warranted. V21 went to a white binder and stated she could not find any documentation of the PT or OT screening evaluation. V21 stated the ordering provider would have been notified PT was not warranted. V21 stated she could not produce documentation of provider notification because it would be documented on the screening evaluation documentation. V21 stated, I can't find the documentation. V21 stated Restorative Care recommended OT so OT was started on 6/17/2024. On 7/2/2024 at 11:36 AM V12 (Director of Restorative Nursing) was interviewed and stated V21's department works with Rehabilitation Services. V12 stated, We work to maintain or improve residents' functioning. is our goal. V12 stated if a resident says they want to exercise, they come to Restorative Care and the resident creates attainable goals. V12 stated if V12 believes the resident can benefit from therapy, V12 tells V21. V12 stated R1 came to V12 and said she could not rotate her hand and it was weak. V12 stated R1 wanted therapy. V12 stated, I saw it myself. (R1) had weakness and no grip. V12 went to V21 and V21 started R1 in OT. V12 stated, We are ordering her a hand brace for R1 to see if helps. On 7/2/2024 at 11:52 AM, R1 was interviewed. R1 stated therapy services is now working with her. R1 stated, My son-in-law helped me by reminding me to lift and get my strength back. They (facility) had nothing to do with it. I was here for a month before they would evaluate me. I could have been going through an outside facility's physical therapy program, but they would not tell me anything here. On 7/2/2024 at 1:25 PM V1 (Administrator) stated if a resident has an order for PT, OT or speech therapy, the resident should be assessed by PT, OT and/or Speech Therapy, whatever the order says within 24 hours of the order being placed. V1 stated, The insurance does not make any difference. Whatever is ordered, they get. When V1 was asked if there could be a one to two week delay for Rehabilitation Services to be initiated if the resident has Medicaid, V1 stated, That is not supposed to happen. There should be no delay. V1 stated, R1 was a hiccup in the process. There should not have been a delay. There was an issue, we met, and we tweaked the process. On 7/3/2024 at 11:50 AM V21 (Director of Rehabilitation Services) stated if a resident is Medicare Part A or Part B, the resident is screened upon admission by Rehabilitation Services. If the resident has Medicaid, the resident is screened by Restorative Care and Restorative Care determines if the resident would benefit from Rehabilitation Services. V21 stated, for residents with Medicare A and Medicare B insurance, Most times, the resident is evaluated by PT and OT. They only get a speech therapy evaluation if they have cognitive deficits which is defined as a BIMS of twelve or less or if the resident has dysphagia. V21 stated, R1 did not have a speech evaluation upon admission or since R1 has been at the facility. On 7/3/2024 at 12:05 PM V12 (Director of Restorative Care) presented a list of the Restorative Care staff and their credentials. V12's department is comprised of V12 who an LPN and 6 Certified Nurse's Aides is. V12 stated Rehabilitation Services sees residents upon admission if they have Medicare Part A or Part B. V12 stated Restorative Care sees all residents upon admission regardless of their insurance. V12 stated, If a resident has Medicaid, I send V21 the referral. V12 stated, Rehab does not do evaluations upon admission on any residents with Medicaid. V12 stated, Before V21 started, Rehab services saw everyone, and we worked collaboratively without any problems. Since V21 started, I have to make the referral if a resident has Medicaid. There is no guarantee Rehab will see the resident if they have Medicare either. I have to put in the referral. V12 stated V1 and V2 are aware and trying to find a solution. 2. On 7/2/2204 at 10 AM, the electronic health record of R5 was reviewed. R5 was admitted to the facility on [DATE]. On 6/6/2024, orders were entered for Physical Therapy (PT) to evaluate and treat, Occupational therapy (OT) to evaluate and treat. Speech Therapy to evaluate and treat. On 7/2/2024 at 11 AM V21 (Director of Rehabilitation Services) was interviewed and stated R5 was admitted on [DATE]. R5 had PT, Speech Therapy and OT ordered on 6/6/2024. R5 had an OT evaluation was 6/7/2024. R5's PT evaluation was completed on 6/19/2024. V21 stated R5's PT was not started until 6/19/2024, because we were waiting approval from administration because she is a Medicaid patient. V21 stated, R5 was evaluated by OT, but then the rules at the facility changed and PT needed to get authorization from V1 and V28 before we could do the PT evaluation. Change went into effect on 6/7/2024. The reason the PT evaluation was not done until 6/19/2024 was because we were waiting authorization from the facility. V21 stated, There have been delays. V1, V21 and V28 are talking about how we create a more cohesive process. We are still working through it. Restorative and Rehabilitation Services may try to do more screenings together and we are also trying to get authorization more quickly. On 7/2/2024 at 11:36 AM V12 (Director of Restorative Nursing) was interviewed and stated V12 evaluated R5 on 6/6/2024. V12 stated her recommendations at time was PT and OT. V12 stated R5 needed help with dressing and walking and had potential to go back into the community. R5 was in a wheelchair when she first arrived. R5's goal was to walk and leave the facility. On 7/2/2024 at 12:45 R5 was interviewed and stated, When I first came, the staff introduced themselves, but then nothing was done for a week. I just sat here for a week or so. I talked to a friend who said they would talk to someone. Eventually they (the facility) started working with me. I was in a wheelchair. It is very good now. I have PT twice a week. I'm getting stronger. I walk with a walker. I can go to activities. I just felt like the first week I was just here nothing was getting done. Now it is better. On 7/3/2024 at 11:50 AM V21 (Director of Rehabilitation Services) stated, R5 did not have a speech evaluation upon admission or since R5 has been at the facility. A memo dated 6/1/2024 to all department heads from V28 (Corporate CEO) stated, All therapy requests need to be signed off by admin on the payor verification form. If the payor is Medicaid, the therapy company will reach out to V28 to confirm the approval. Policy titled Physicians Orders Policy dated 1/2018 stated in part: Proper channels of communication are used to ensure accurate delivery of medication and treatments of all residents. This is achieved by using telephone order sheets, physician order sheets, medication administration records, treatment administration records and transfer sheets. Policy titled Therapy Policy with no date stated in part: Purpose: To provide guidelines for the delivery of therapy services, including physical, occupational and speech/language therapy, to residents. This policy ensures compliance with federal, state and local regulations and promotes the highest quality of care. 1. Assessment: Residents will be assessed by licensed therapists (physical, occupational, speech/language) upon admission, quarterly, and as needed based on changes in condition. Assessment includes a comprehensive evaluation of the resident's functional abilities, including mobility, activities of daily living (ADLs), communication and cognitive function. 6. Documentation and Compliance: All therapy services will be documented in the resident's medical record, including assessments, care plans, interventions and progress notes. Documentation will comply with CMS regulations and professional standards of practice. The facility will conduct regular audits to ensure compliance with documentation and care standards. Procedure Referral and Initial Assessment: Upon referral, the appropriate therapist will conduct an initial assessment within 48 hours.

Jun 2024 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to give proper notice requirements per their policy to a resident was ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to give proper notice requirements per their policy to a resident was involuntarily transferred to the hospital for 1 (R1) out of 3 residents reviewed for admissions, transfers, and discharges. These failures affected 1 resident's (R1) right to be informed or notified of the reason for their transfer or discharge. Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1's initial medical diagnosis opioid dependence and mental and behavioral disorder. Per progress notes, R1 was sent to the hospital through involuntary discharge on [DATE]. V6 (Licensed Practical Nurse) and V5 (Social Worker) noted R1 became upset because his community pass was revoked. As a result, aggressive behavior was directed by R1 to V4 (Social Service Director). R1 referral dated 10/22/2023 prior to initial admission in the facility dated 10/27/2023 documents R1 was medically diagnosed with opioid use disorder and substance abuse. On 6/20/2024 at 10:01 AM, V5 (Social Worker) stated R1 is a chronic substance abuser. R1 was involuntarily discharged because R1 threatened and was verbally aggressive to V4 (Social Service Director) on 6/3/2024. V5 stated R1 had a previous involuntary discharge in April this year. R1's aggression started when R1 was informed his out on pass, or community pass was revoked due to not following facility's policy on substance abuse. On 6/20/2024 at 10:33 AM, V4 (Social Service Director) stated in the morning of 6/3/2024, after R1 was informed his community pass was not reinstated, R1 became verbally aggressive with her (V4) calling her vulgar names and screaming and threatening her (V4). V4 stated because of R1 being aggressive, R1 was transferred to the hospital through involuntary discharge. It was not a new involuntary discharge because there was a previous involuntary discharge. At 11:54 AM, V4 during review of facility policy on Involuntary Discharge, V4 said, We did not document notice was given to R1, or the reason notice was given, that part we missed. V4 stated the involuntary petition dated 4/9/2024 was due to R1's welfare unable to be met. The facility could not provide R1's needs related to his continued substance abuse. On 6/20/2024 at 1:29 PM, V3 (admission Director) stated the hospital called informing her (R1) was coming back to the facility. V2 (Director of Nursing) and V4 (Social Service Director) told her (V3) R1 was not supposed to come back because R1 was sent to the hospital via IVD (Involuntary Discharge). R1's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents dated 4/9/2024 shows, Federal Proceeding. Indicated reason: Your welfare and needs cannot be met in the facility, as documented in your clinical record by your physician. Document was signed by V5 (Social Worker). Petition for Involuntary/Judicial admission dated 6/3/2024 for R1 documents the following: - R1 a person with mental illness who; because of his illness is reasonably expected, unless treated on an inpatient basis to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed. - That R1 a person with mental illness who; because of his illness is unable to provide his basic physical needs so as to guard himself from serious harm without the assistance of family or others, unless treated on an inpatient basis. - That R1 a person with mental illness who refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his illness is unable to understand his needs for treatment; and if not treated on an inpatient basis is expected; after such deterioration. R1 needs immediate hospitalization for the prevention of such harm. Notes: Staff reports R1 was a danger to others. R1 followed V4 around the facility. R1 was verbally aggressive and threatening V4 because V4 removed community access due to non-compliant of substance abuse policy. Document was signed by V5 (Social Worker) witnessed by V4 (Social Service Director) and V6 (Licensed Practical Nurse). Page 5 of the document needs certification R1 was provided a copy of the petition or form paged 1-5 was left blank. R1's progress notes for the months of April, May and June 2024 were presented and there was no documentation R1 was notified for both 4/9/2024 Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents and 6/3/2024 Petition for Involuntary/Judicial Admission. Involuntary Discharge Policy dated 1/16, reads: To ensure compliance with State and Federal regulations and guidelines for involuntary discharge / transfer. Under documentation, Social Services will document in the resident medical record the following: - A 30-day notice has been given to the resident. - The reason for the 30-day notice being issued. - Public health was informed via certified mail. - The resident was given a stamped addressed envelope to appeal the 30-day notice.

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 F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of records the facility failed to provide a copy of Bed Reserve Notification as per policy during...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of records the facility failed to provide a copy of Bed Reserve Notification as per policy during involuntary transfer of 1 (R1) out of 3 residents reviewed for admissions, transfers, and discharges. This failure affected 1 resident (R1) on knowing the rights afforded to residents during transfers. Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1's initial medical diagnosis opioid dependence and mental and behavioral disorder. Per progress notes, R1 was sent to the hospital through involuntary discharge on [DATE]. V6 (Licensed Practical Nurse) and V5 (Social Worker) noted R1 became upset because his community pass was revoked. As a result, aggressive behavior was directed by R1 to V4 (Social Service Director). On 6/20/2024 at 10:01 AM, V5 (Social Worker) stated R1 is a chronic substance abuser. R1 was involuntarily discharged because R1 threatened and was verbally aggressive to V4 (Social Service Director) on 6/3/2024. V5 stated R1 had a previous involuntary discharge in April this year. R1's aggression started when R1 was informed his out on pass or community pass was revoked due to not following facility's policy on substance abuse. On 6/20/2024 at 10:33 AM, V4 (Social Service Director) stated in the morning of 6/3/2024, after R1 was informed his community pass was not reinstated. R1 became verbally aggressive with her (V4) calling her vulgar names and screaming and threatening her (V4). V4 stated because of R1 being aggressive, R1 was transferred to the hospital through involuntary discharge. It was not a new involuntary discharge because there was a previous involuntary discharge. At 11:54 AM, V4 during review of facility policy on Involuntary Discharge. V4 said, We did not document notice was given to R1, or the reason notice was given. part we missed. V4 stated the involuntary petition dated 4/9/2024 was due to R1's welfare cannot be met, and needs cannot be met. And the facility cannot provide R1's needs related to his continued substance abuse. At 12:06 PM, V4 was asked if R1 was given a bed hold notice? V4 stated What bed hold notice?! As far as I know there was no notice to R1 about any bed hold. On 6/20/2024 at 1:29 PM, V3 (admission Director) stated the hospital called informing her (R1) was coming back to the facility. V2 (Director of Nursing) and V4 (Social Service Director) told her (V3) R1 was not supposed to come back because R1 was sent to the hospital via IVD (Involuntary Discharge). R1's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents dated 4/9/2024 shows, Federal Proceeding. Indicated reason: Your welfare and needs cannot be met in the facility, as documented in your clinical record by your physician. Document was signed by V5 (Social Worker). Petition for Involuntary/Judicial admission dated 6/3/2024 for R1 documents the following: - R1 a person with mental illness who; because of his illness is reasonably expected, unless treated on an inpatient basis to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed. - That R1 a person with mental illness who; because of his illness is unable to provide his basic physical needs so as to guard himself from serious harm without the assistance of family or others, unless treated on an inpatient basis. - That R1 a person with mental illness who refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his illness is unable to understand his needs for treatment; and if not treated on an inpatient basis is expected; after such deterioration. R1 needs immediate hospitalization for the prevention of such harm. Notes: Staff reports R1 was a danger to others. R1 followed V4 around the facility. R1 was verbally aggressive and threatening V4 because V4 removed community access due to non-compliant of substance abuse policy. Document was signed by V5 (Social Worker) witnessed by V4 (Social Service Director) and V6 (Licensed Practical Nurse). Page 5 of the document needs certification R1 was provided a copy of the petition or form paged 1-5 was left blank. R1's progress notes for the months of April, May and June 2024 were presented and there was no documentation bed hold notice was given to R1. Policy on Bed Reserve dated 2008, reads: This Bed Reserve Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. Facility policy on Notice of Bed Hold and Return dated 11/20/2017, reads: Before the nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident or resident representative specifies the duration of the state bed-hold policy of 10 days during which the resident is permitted to return and resume residence in the nursing facility. At the time of transfer of a resident for hospitalization or therapeutic leave, the nursing facility will provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy of 10 days. The nursing facility's bed-hold policies apply to all residents. The first notice of bed-hold policies will be given well in advance of any transfer during the admission process. A second notice of the facilities bed hold policy is issued to the resident at the time of transfer and includes the resident's bed will be held for 10 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

Safe Transfer (Tag F0626)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of records the facility failed to permit 1 (R1) out of 3 residents from returning back to the fac...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of records the facility failed to permit 1 (R1) out of 3 residents from returning back to the facility after hospitalization in accordance with their policy. This failure affected 1 resident (R1) to their right to return to the facility they considered as home. Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1's initial medical diagnosis opioid dependence and mental and behavioral disorder. Per progress notes, R1 was sent to the hospital through involuntary discharge on [DATE]. V6 (Licensed Practical Nurse) and V5 (Social Worker) noted R1 became upset because his community pass was revoked. As a result, aggressive behavior was directed by R1 to V4 (Social Service Director). On 6/20/2024 at 10:01 AM, V5 (Social Worker) stated R1 is a chronic substance abuser. R1 was involuntarily discharged because R1 threatened and was verbally aggressive to V4 (Social Service Director) on 6/3/2024. V5 stated R1 had a previous involuntary discharge in April this year. R1's aggression started when R1 was informed his out on pass, or community pass was revoked due to not following facility's policy on substance abuse. On 6/20/2024 at 10:33 AM, V4 (Social Service Director) stated in the morning of 6/3/2024, after R1 was informed his community pass was not reinstated, R1 became verbally aggressive with her (V4) calling her vulgar names and screaming and threatening her (V4). V4 stated because of R1 being aggressive, R1 was transferred to the hospital through involuntary discharge. It was not a new involuntary discharge because there was a previous involuntary discharge. At 11:54 AM, V4 during review of facility policy on Involuntary Discharge, V4 said, We did not document notice was given to R1, or the reason notice was given, that part we missed. V4 stated the involuntary petition dated 4/9/2024 was due to R1's welfare unable to be met. The facility could not provide R1's needs related to his continued substance abuse. R1 referral dated 10/22/2023 prior to initial admission in the facility dated 10/27/2023 documents R1 was medically diagnosed with opioid use disorder and substance abuse. On 6/20/2024 at 1:29 PM, V3 (admission Director) stated the hospital called informing her (R1) was coming back to the facility. V2 (Director of Nursing) and V4 (Social Service Director) told her (V3) R1 was not supposed to come back because R1 was sent to the hospital via IVD (Involuntary Discharge). R1's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents dated 4/9/2024 shows, Federal Proceeding. Indicated reason: Your welfare and needs cannot be met in the facility, as documented in your clinical record by your physician. Document was signed by V5 (Social Worker). Petition for Involuntary/Judicial admission dated 6/3/2024 for R1 documents the following: - R1 a person with mental illness who; because of his illness is reasonably expected, unless treated on an inpatient basis to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed. - That R1 a person with mental illness who; because of his illness is unable to provide his basic physical needs so as to guard himself from serious harm without the assistance of family or others, unless treated on an inpatient basis. - That R1 a person with mental illness who refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his illness is unable to understand his needs for treatment; and if not treated on an inpatient basis is expected; after such deterioration. R1 needs immediate hospitalization for the prevention of such harm. Notes: Staff reports R1 was a danger to others. R1 followed V4 around the facility. R1 was verbally aggressive and threatening V4 because V4 removed community access due to non-compliant of substance abuse policy. Document was signed by V5 (Social Worker) witnessed by V4 (Social Service Director) and V6 (Licensed Practical Nurse). Page 5 of the document needs certification R1 was provided a copy of the petition or form paged 1-5 was left blank. V4 (Social Service Director) provided email correspondence between her (V4) and V11 (Attorney of Facility) dated 6/5/2024 reads as follows: V4 informed V11 that R1 was petitioned out to the hospital due to threats against her (V4). V11 responded amendment / change was made to Notice to discharge due to safety reasons. The facility will not take R1 back. On 6/21/2024 at 11:21 AM, V1 (Administrator) stated the original petition was the facility cannot meet R1's needs. According to V1, the original petition was appealed by R1. V1 stated after the incident on 6/3/2024 when R1 was threatening to V4 (Social Service Director), the facility change the petition R1 based on the incident happened on 6/3/2024. V1 said, The reason why facility did not accept R1 back was because R1 was threatening V4. V1 was asked if there was an effort by the facility or coordination with the hospital to determine R1's status after R1 was hospitalized . V1 responded, To be honest with you, it was because of the advise of our attorney (V11) not to accept R1. V1 said he will reach out to V11 to let V11 speak to writer. At 1:46 PM, V1 stated V11 is on vacation. V1 restated the reason why R1 was not accepted to return to the facility was due to advised from their attorney (V11). Facility policy on Notice of Bed Hold and Return dated 11/20/2017, reads: Before the nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident or resident representative specifies the duration of the state bed-hold policy of 10 days during which the resident is permitted to return and resume residence in the nursing facility. If a resident, whose hospitalization, or therapeutic leave exceeds the bed-hold period, the resident is allowed to return to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of records, and interviews the facility failed to document physician coordination of medications no...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of records, and interviews the facility failed to document physician coordination of medications not received by resident per medication administration policy. Facility also failed to administer insulin as ordered by physician for 1 (R2) out of 3 residents reviewed for facility pharmaceutical services. These failures have the potential to affect 1 resident (R2) has history of stroke/cerebral infarction and diabetes mellitus in maintaining stable health condition. Findings include: R2 is [AGE] years old, initially admitted on [DATE] with medical diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and diabetes mellitus. On 6/18/2024 at 12:03 PM, R2 was seen on the hallway near the nurse's station sitting on his wheelchair. R2 was alert and verbally able to express his thoughts and agreed to talk to his room. R2 stated his concern was his medication not given because he has swelling on his left lower leg. R2 took his left shoe off and swelling was observed on the left foot. Review of R2 MAR (medication administration records) for the month April, May and June 2024 documents multiple medication for diabetes and hypertension was coded as not given due to multiple reasons including drug refused, hold of medication, other reason, or no documentation. Per the same MAR (medication administration record), R2 blood pressure results and blood sugar results were not controlled. R2's systolic blood pressure went as high as 200. Diastolic blood pressure went as high as 110. R2's blood sugar results want as high as 268. Per MAR (medication administration records) and progress notes of R2, on May 23, 2024, Humalog was held by the nurse because blood sugar result was 145. Per physician order hold if blood sugar is less than 100. Per MAR (medication administration records) June 2024 documents for Humalog insulin majority of days of the month R2 did not receive the insulin. Per physician's order instructions, R2 needs to take 13 units four (4) times a day. On 6/18/2024 at 2:46 PM, V2 (Director of Nursing) was informed multiple medications of R2 including insulin and blood pressure medications are documented on the MAR as not given. V2 stated when medication is refused, nurses need to notify the physician. V2 was also informed R2's blood pressure and blood sugar were not controlled. Per MAR, R2's systolic blood pressure elevated to 180 or more, and R2 was not receiving blood pressure medications and insulins on multiple days. V2 stated, Really? I will check R2's MAR and check if the nurses informed the doctor. On 6/20/2024 at 12:06 PM, with V2 (Director of Nursing) and V9 (Assistant Director of Nursing). V2 stated in cases of residents refusing medication, there needs to be education. MD (medical doctor) needs to be notified. V2 was asked if R2's doctor was notified when R2 refused medication. V2 stated she needs to review documentation of R2 to see if nursing staff notified the doctor. V2 stated R2 had a history of a stroke. R2 high blood pressure may put him at risk of recurrent stroke. Medication Administration Record (MAR) policy not dated, reads: Under procedure, if a resident refuses medication initial the box and circle your initial; if the resident continues to refuse medication, the physician should be notified and have the medication discontinued, change, or give other orders. It is up to the discretion of the physician to discontinue the medication. Documentation of medication refusal is also to be done in the Nurse's Notes.

Feb 2024 7 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that R173's and R124's indwelling catheter drain...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that R173's and R124's indwelling catheter drainage bags were covered. This failure affected two residents (R173 and R124) reviewed for dignity in the sample of 56 residents. Finding Include: 1. R173's admission record includes diagnoses of pressure ulcer, pleural effusion, cerebral infarction, diabetes, atrial fibrillation, venous insufficiency, and chronic kidney disease. On 2/26/24 at 11:10 am, surveyor observed (R173's) indwelling catheter drainage bag not covered on right side of bed facing the hallway. On 2/28/24 at 2:25 pm, V2 DON (Director of Nursing) stated the Indwelling catheter should be covered in a privacy bag, to provide dignity to the residents. R173's (Active orders as of 2/27/24) Order Summary Report documented, in part, Indwelling Catheter 16 F (French), 10 ml (milliliter) filled balloon. R173's (11/22/23) Minimum Data Set, documents, in part, a Brief interview for Mental Status (BIMS) score is 15 which indicates that R1 is cognitively intact. Section H: Bladder and Bowel indicates R173 has an Indwelling catheter. R173 (Revision 1/15/23) Care plan documents, in part Focus: R173 has an indwelling Catheter relates to Dx (Diagnosis) of BPH (Benign Prostatic Hyperplasia) and Retention of urine. The (Undated) Residents Rights documents, in part, 2. The right to respect for bodily privacy and dignity at all times especially during care and treatment. Facility job description titled Registered Nurse, documents in part, Essential Duties and Responsibilities: Must be knowledgeable of nursing and medical practices and procedures, as well as law, regulation, and guidelines pertain to nursing care facilities. Facility job description titled Licensed Practical Nurse (LPN), documents in part, Essential Duties and Responsibilities: Must be knowledgeable of nursing and medical practices and procedures, as well as law, regulation, and guidelines pertain to nursing care facilities. Facility job description titled Certified Nursing Assistant (CNA), documents in part, Essential Duties and Responsibilities: Adhere to professional standards, company policies and procedures, and all federal, state, and local requirements . 2. R124's diagnosis include but are not limited to, Hallervorden-[NAME] disease, functional quadriplegia, pressure ulcer of sacral region, stage 4, contracture, right hand, encounter for attention to gastrostomy, dysphagia, unspecified, expressive language disorder, dystonia, unspecified, unspecified convulsions, adult failure to thrive, dependence on supplemental oxygen, carrier of carbapenem-resistant Acinetobacter Baumannii, klebsiella pneumoniae [k. pneumoniae] as the cause of diseases classified elsewhere, major depressive disorder, recurrent, unspecified, encounter for fitting and adjustment of urinary device, psychomotor deficit, vomiting, unspecified, schizophrenia, unspecified, delusional disorders, catatonic schizophrenia, bipolar disorder, unspecified, tachycardia, unspecified, personal history of covid-19, long term (current) use of anticoagulants, gastro-esophageal reflux disease without esophagitis, anemia, unspecified, anxiety disorder, unspecified, constipation, unspecified, and schizoaffective disorder, depressive type. R124's (2/23/2024) Resident Assessment Instrument documents, in part Section C. C1000. Cognitive Skills for Daily Decision Making 3. Severely Impaired-never/rarely made decisions. Section GG. Functional Abilities and Goals C. Toileting hygiene 01. Dependent. Section H. Bladder and Bowel: H0100. Appliances check all that apply: A. Indwelling Catheter. R124's (active orders as of: 02/27/2024) Order Summary Report documents in part, Indwelling Catheter Type, 16fr (French) with 10cc (cubic centimeters) balloon for Diagnosis of stage 4 sacral wound. Indwelling Catheter-measure and record urinary output, color, clarity, and device status Q(every) shift, every day and night shift. R124's (2/28/2024) Care plan documents in part, Focus: R124 has an indwelling foley catheter related to DX (diagnosis) of retention of urine and bladder outlet obstruction. On 02/26/2024 at 11:15am, surveyor observed R124's indwelling catheter drainage bag hanging on the lower right side of the bed visible from the hallway; the drainage bag was not covered with a privacy bag. On 02/26/2024 at 11:20am, surveyor inquired if R124's catheter drainage bag should be covered. V10(CNA/Certified Nursing Assistant) stated the catheter drainage bag is supposed to be in a privacy bag. I am responsible for draining the urine from the bag and placing the privacy cover on the drainage bag. V10 stated I drain the urine from the bag every two hours when I reposition the resident. On 02/28/2024 at 2:21pm V3(DON/Director of Nursing) stated the catheter drainage bag is to be checked by the staff every shift and upon rounds. V3 stated the catheter drainage bag should be in a privacy bag, this is done for the resident's dignity.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to provide ADL (Activity of Daily Living) for 2 dependent residents (R77, R138). This failure has the potential to affect all 56 r...

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Based on observation, interview and record review the facility failed to provide ADL (Activity of Daily Living) for 2 dependent residents (R77, R138). This failure has the potential to affect all 56 residents in the sample. Findings Include: R77 has a diagnosis of but not limited Encephalopathy, Quadriplegia, Interstitial Pulmonary Disease, Lack of Coordination, and Abnormal Posture. R77's Brief Interview of Mental Status score is 15. R138 has a diagnosis of but not limited Metabolic Encephalopathy, Acute Respiratory Failure, Type 2 Diabetes Mellitus and Need for Assistance with Personal Care. R138's Brief Interview of Mental Status score is blank. On 2/26/2024 at 12:30pm surveyor observed R77 with facial hair. R77 stated he would like to be shaved and that not being shaved makes him feel 'like a bum'. On 2/26/2024 at 12:41pm V9 (Certified Nursing Assistant) stated shaving the residents should be offered and done when a shower is given and as needed. On 2/26/2024 at 12:45pm surveyor observed R138 with an unshaven long beard that extended down to midway of the neck. On 2/26/2024 at 12:50pm V13 (Licensed Practical Nurse) stated for residents that are not alert and oriented we will call the POA (Power of Attorney) to request permission to shave the facial hair. On 2/27/2024 at 11:17am via phone V31 (Family Member) stated she has not been contacted to request R138 be shaved. On 2/28/2024 at 2:25pm V3 (Director of Nursing-DON) stated resident shaving should be done weekly, on shower days and as needed. R77's MDS (Minimum Data Set) section GG documents admission performance as a 1 (Dependent) for personal hygiene: the ability to maintain personal hygiene including shaving. R138's care plan focus: ADLs documents, in part, R138 has an ADL self-care performance deficit r/t weakness and limited ROM d/t/hx. (related to/history of) Metabolic Encephalopathy and R138 requires constant cueing and hand over hand technique to complete task. R138's MDS (Minimum Data Set) section GG documents admission performance as a 1 (Dependent) for personal hygiene: the ability to maintain personal hygiene including shaving. Undated Personal Care Service Policy documents, in part, each resident shall receive nursing care based on individual needs and each resident shall show evidence of good personal hygiene. Undated job description for Certified Nursing Assistant documents, in part, provide assistance in personal hygiene by giving shaves.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide timely urinary catheter care for one resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide timely urinary catheter care for one resident (R111), who depends on staff for perineal care. This failure affected one resident reviewed for care from a sample 56 residents. Findings include: R111 is [AGE] year old with diagnosis including but not limited to: Benign prostatic hyperplasia, mild neurocognitive disorder, encounter for fitting and adjustment of urinary device, adult failure to thrive, polyneuropathy, cramp, and spasm. On 02/27/2024 at 9:18 AM, Surveyor observed R111 lying in bed with urinary catheter and urinary bag attached to R111's bed. R111's urinary catheter was darkish brown in color and R111's urinary bag contained 100 milliliters of urine with visible sediment in the bag. At that time, Surveyor asked R111's nurse V18 (LPN/Licensed Practical Nurse) when R111's urinary bag and catheter was last changed. On 02/27/2024 at 9:20 AM, V18 (LPN) said, I'm not sure when R111's urinary catheter and bag was last changed, but I believe it is done on the night shift once a month and prn (as needed). Any nurse can change the catheter though. On 02/27/2024 at 9:20 AM, V18 (LPN) said, The urinary tubing looks discolored, like a reddish color and there is sediment in the bag. I have been off, but I will be sure to change it today. It could possibly cause an infection if it is not changed regularly. On 02/28/2024 at 2:25 PM, V3 (DON/Director of Nursing) said, The urinary catheters and bags should be checked every shift and upon rounds. I think they should be changed once per week and urinary care should be rendered once per shift and as needed. The nurse and CNA (Certified Nurse Assistant) should be observing for color, sediment and blood in the urinary bag. The nurse is responsible for changing the catheter. On 02/28/2024 at 2:25 PM, V3 (DON) said, I saw R111's tubing and the tubing didn't look clean. If a urinary tube is discolored or if there is sediment in a urinary bag or tubing, it could indicate infection or that the tubing had not been changed as scheduled. R111' Physician order sheet documents, indwelling catheter please change every three months to prevent infection; Catheter care every shift and as needed; Indwelling catheter- change indwelling catheter drainage bag and flush every 24 hours. R111's Section H- Bowel and Bladder assessment documents, indwelling catheter used by R111. Facility policy titled Registered Nurse documents, Essential duties and responsibilities: administer professional services such as catheterization, tube feedings, suction, applying and changing dressing/ bandages, packs, colostomy and drainage bags, etc. Facility policy titled Licensed Practical Nurse documents, Essential duties and responsibilities: administer professional services such as catheterization, tube feedings, suction, applying and changing dressing/ bandages, packs, colostomy and drainage bags, etc. Facility policy titled Indwelling Catheter Assessment documents, Physician's order will be obtained for routine catheter care, which will include frequency of catheter change and irrigation of catheter.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

R156 admission diagnoses of but not limited to respiratory failure, dependence on supplemental oxygen, acute embolism, and thrombosis. R156's (1/19/24) Brief Interview of Mental Status (BIMS) score is...

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R156 admission diagnoses of but not limited to respiratory failure, dependence on supplemental oxygen, acute embolism, and thrombosis. R156's (1/19/24) Brief Interview of Mental Status (BIMS) score is 8. R156 has moderate cognitive impairment. On 2/26/23 at 12:05 pm R156 was lying in bed sleeping with oxygen not being administered as order. The oxygen tubing was on the floor under the bed. On 2/27/23 at 2:05 pm, R156 observed lying in bed with oxygen tubing laying on the night stand next to the bed. R156 was asked where R156's oxygen tubing was. R156 stated, I don't know where it is. Surveyor asked V27 LPN (License Practical Nurse) if R156 was supposed to have on oxygen. V27 stated, Yes R156 supposed to have on oxygen, I think he (R156) supposed to have it on continuous. On 2/28/24 at 2:25 pm, V2 DON (Director of Nursing) stated, Yes oxygen should be on resident if orders are continuous. Surveyor asked DON if it is acceptable for the oxygen tubing be on the floor under the resident's bed. DON stated, Absolutely not. It should not be under the bed or on floor. R156's (Active orders as of 2/27/24) Order Summary Report documented, in part, Oxygen Continuous 1 L (Liter) Via Nasal Cannula every shift related to Respiratory Failure, Unspecified, whether Hypoxia or Hypercapnia. R156's care plan (revised 1/22/24) documents, in part, Focus: R156 is on continuous oxygen therapy related to Dx (Diagnosis) of Respiratory Failure. (Revised 10/30/23) Focus: R156 has potential for altered respiratory status/difficulty breathing related to Dx (Diagnosis) of Respiratory failure. On continuous oxygen therapy. Facility policy (undated) and titled, Oxygen Administration documents in part, Purpose: To administer oxygen to the resident. 10. At regular intervals check liter flow, contents of oxygen cylinder and assess. Based on observation, interview and record review the facility failed to ensure a nasal cannula was changed weekly and secured when not in use for one resident (R45) and failed to administer oxygen for one resident (R156). This failure has the potential to affect all 31 resident who use oxygen therapy. Findings include: R45 has a diagnosis of but not limited to Quadriplegia, Chronic Obstructive Pulmonary Disease, Asthma, Type 2 Diabetes, and Pulmonary Embolism without Acute Cor Pulmonale. On 2/26/2024 at 11:30am surveyor observed R45's nasal cannula sitting on top of the concentrator not in a bag with a date of 2/05/2024. On 2/26/2023 at 11:34am V13 (RN/Infection Control Nurse) stated R45's nasal cannula should be in a bag to prevent infection control issues. On 2/28/2024 at 2:25pm V3 (Director of Nursing-DON) stated the nasal cannula should be in a plastic bag and stored near the equipment when not in use. R45's Order Summary Report with active orders as of 2/28/2024 documents, oxygen tubing change 1x (time) weekly and as needed. Undated policy titled Oxygen Administration documents, in part, when equipment not in use, equipment and tubing should be placed in a plastic bag and stored in a room temperature area. Undated job description for Registered and Licensed Practical Nurse documents, in part, prepare and administer medications as ordered by the physician.

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 observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure ha...

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Based on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 4 residents on the sixth floor (team 1) medication cart who are prescribed controlled substances, 4 residents on the fifth floor (team 1) medication cart who are prescribed controlled substances, 5 residents on the fourth floor (team 2) medication cart who are prescribed controlled substances, 7 residents on the fourth floor (team 1) medication cart who are prescribed controlled substances and 7 residents on the third floor medication cart who are prescribed controlled substances. Findings include: On 02/28/2024 at 10:39 am review of the sixth-floor team 1 medication cart with V23(LPN/Licensed Practical Nurse) surveyor observed the shift change controlled substances check form for February 2024. The Nurse Off box was left blank for February 19, 2024 (7am-7pm shift). The Nurse On box was left blank for February 25, 2024(7am-7pm shift). On 02/28/2024 at 11:10 am review of the fifth-floor team 1 medication cart with V15(LPN/Licensed Practical Nurse) surveyor observed the shift change controlled substances check form for February 2024. The Nurse Off box was left blank for February 22, 2024 (7am-7pm shift). On 02/28/2024 at 12:03 pm review of the fourth-floor team 2 medication cart with V18(LPN/Licensed Practical Nurse) surveyor observed the shift change controlled substances check form for February 2024. The Nurse Off box was left blank for February 01, 2024 (7pm-7am shift). The Nurse On box was left blank for February 12, 2024(7am-7pm shift). The Nurse On box was left blank for February 17, 2024(7am-7pm shift). The Nurse On box was left blank for February 18, 2024(7am-7pm shift). The Nurse On box was left blank for February 19, 2024(7am-7pm shift). The Nurse Off box was left blank for February 20, 2024 (7pm-7am shift). The Nurse Off box was left blank for February 22, 2024(7a-7pm shift). The Nurse On box was left blank for February 23, 2024(7am-7pm shift). The Nurse Off box was left blank for February 24, 2024(7pm-7am shift). On 02/28/2024 at 12:29 pm review of the fourth-floor team 1 medication cart with V24(LPN/Licensed Practical Nurse) surveyor observed the shift change controlled substances check form for February 2024. The Nurse On and Nurse Off box was left blank for February 01, 2024 (7pm-7am shift). The Nurse Off box was left blank for February 01, 2024(7am-7pm shift). The Nurse Off box was left blank for February 05, 2024(7pm-7am shift). The Nurse On box was left blank for February 18, 2024(7am-7pm shift). The Nurse Off box was left blank for February 19, 2024(7pm-7am shift). On 02/28/2024 at 1:10 pm review of the third-floor medication cart with V26(RN/Registered Nurse) surveyor observed the shift change controlled substances check form for February 2024. The Nurse On box was left blank for February 04, 2024 (7am-7pm shift). The Nurse Off box was left blank for February 05, 2024(7pm-7am shift). The Nurse Off box was left blank for February 11, 2024(7pm-7am shift). The Nurse On box was left blank for February 20, 2024(7am-7pm shift). The blank spaces on the facility's-controlled substances check form indicate the controlled substances were not reconciled at the end and beginning of the shift on the specified days. On 02/28/2024 at 11:10am V15 (LPN/Licensed Practical Nurse) stated it is protocol for the nurse leaving the shift to count the number of controlled substance tablets in the medication packs or the controlled substance liquid with the nurse coming on the shift. V15 stated the nurses are checking for the accountability of the controlled substances. V15 stated this is the purpose of the controlled substances shift to shift check form. On 02/28/2024 at 12:03pm V18 (LPN/Licensed Practical Nurse) stated the nurse coming on shift and the nurse going off shift are to count the controlled substances together. V18 stated this is done so that two nurses can witness the count of the controlled substances. V18 stated once the count for the controlled substances is correct, both nurses sign the controlled substances shift to shift check form. On 2/28/2024 at 2:21pm V3 (DON/Director of Nursing) stated all the nurses on the floor are responsible for completing the shift-to-shift controlled substances count forms. V3 stated the purpose of the shift-to shift controlled substances count form is to make sure the counts for the controlled substances are correct. V3 stated the incoming and outgoing nurses count the controlled substance medications together and sign the controlled substance shift-to shift check form, indicating the count for the controlled substances is correct. V3 stated if there are missing initials from a nurse on the nurse on and/or the nurse off spaces on the controlled substance shift-to shift check form this would indicate that the nurse forgot to sign the form or that the nurses did not count the controlled substances together. On 2/28/2024 reviewed the facility's Medication Administration and Storage Policy with a revised date of 07/02/2018, which documents in part, 11. Narcotics and all class II (2) drugs must be recorded when given on the individual sheet for same and balance on hand must be verified at each change of shifts by the charge nurse. On 2/28/2024 reviewed the facility's undated RN (Registered Nurse) job description which documents in part, Underneath Essential Duties and Responsibilities: Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. On 2/28/2024 reviewed the facility's undated LPN (Licensed Practical Nurse) job description which documents in part, Underneath Essential Duties and Responsibilities: Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.

CONCERN (E)

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 ensure that the two community shower rooms on the sixth floor were in good repair. This failure has the potential to affect a...

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Based on observation, interview, and record review, the facility failed to ensure that the two community shower rooms on the sixth floor were in good repair. This failure has the potential to affect all 53 residents on the sixth floor of the facility. Findings include: On 2/26/24 at 9:50am during the entrance conference with V1(Administrator), the facility census shows there are 53 residents on the sixth floor. On 2/26/24 at 11:20am during observation of residents on the sixth floor with V5 (LPN/Licensed Practical Nurse), the male community shower room ceiling light cover was observed falling off the ceiling half-way hanging down. V5 stated, I will call maintenance to come and fix it. During observation of the female community shower room with V5, the surveyor and V5 observed several missing wall tiles on both the right and left sides of the bathroom. V5 stated, I have not noticed the walls have so many tiles missing. The surveyor asked V5 if there is a logbook for maintenance repairs list, V5 stated that they just usually call maintenance. On 2/27/24 at 12:50pm, V14 (Maintenance Director) stated he (V14) and the Maintenance Assistant go around every morning and the nurses will let them know what needs to be fixed. V14 stated he (V14) was not aware of the repairs needed in the male and female bathrooms on the sixth floor. On 2/27/24 at 1:25pm, V1 (Administrator) stated that the maintenance staff usually fixes the urgent repairs first. Facility's undated document Maintenance and Repair states in part: The building shall be maintained and repaired as necessary. Staff shall notify maintenance of any items that are in need of repair. Maintenance shall make rounds and check for items that are in need of repair/attention. Facility's Job Description for Maintenance Supervisor states in part: Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly. Ensure that supplies, equipment, etc. are maintained to provide safe and comfortable environment. Promptly report equipment or facility damage to the Administrator.

CONCERN (E)

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

Deficiency F0924 (Tag F0924)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure that the corridor handrails across from the nursing station on the sixth floor were firmly affixed to the wall. This f...

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Based on observation, interview, and record review, the facility failed to ensure that the corridor handrails across from the nursing station on the sixth floor were firmly affixed to the wall. This failure has the potential to affect all 53 residents on the sixth floor of the facility. Findings include: On 2/26/24 at 9:50am during the entrance conference with V1(Administrator), the facility census shows there are 53 residents on the sixth floor. On 2/26/24 at 11:30am during observation of residents on the sixth floor with V5 (LPN/Licensed Practical Nurse), the following were observed: The corridor handrails by the elevator across from the nursing station to the right and to the left, and the handrails were observed to be loose and shaking. The surveyor asked V5 how maintenance gets notified of repairs on the floor, and if there is a logbook for maintenance repairs list. V5 stated that they just usually call maintenance for any repairs needed. V5 stated she would call maintenance. On 2/27/24 at 12:50pm, V14 (Maintenance Director) stated he and the Maintenance Assistant go around every morning and the nurses will let them know what needs to be fixed. V14 stated he was not aware that the handrails were loose on the sixth floor. On 2/27/24 at 1:25pm, V1(Administrator) stated the maintenance staff usually fixes the urgent repairs first. Facility's undated document Maintenance and Repair states in part: The building shall be maintained and repaired as necessary. Staff shall notify maintenance of any items that are in need of repair. Maintenance shall make rounds and check for items that are in need of repair/attention. Facility's Job Description for Maintenance Supervisor states in part: Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly. Ensure that supplies, equipment, etc. are maintained to provide safe and comfortable environment. Promptly report equipment or facility damage to the Administrator.

Feb 2024 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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

Based upon record review and interview the facility failed to provide (R1, R2) timely services; failed to ensure R1's belongings were inventoried; failed to ensure R1 was provided a wheelchair with fu...

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Based upon record review and interview the facility failed to provide (R1, R2) timely services; failed to ensure R1's belongings were inventoried; failed to ensure R1 was provided a wheelchair with functioning brakes; and failed to provide adequate reimbursement to one of five residents (R2) reviewed for missing belongings. Findings include: On 2/5/24, IDPH (Illinois Department of Public Health) received allegations regarding lost/stolen clothing and personal wheelchair replaced with another wheelchair in poor condition (upon return from the hospital). 1. R1's diagnoses include hemiplegia and hemiparesis. R1's (2/5/24) functional assessment includes mobility devices: wheelchair. R1's census affirms (11/2/23) hospital leave and (11/10/23) return to the facility. R1's (2/5/24) BIMS (Brief Interview Mental Status) determined a score of 12 (moderate impairment). R1's (11/10/23) record of complaint includes missing wheelchair. Looked for an inventory list, asked to search his room for items, he refused. Per floor staff he only came with the wheelchair that he's currently using. On 2/21/24 at 12:54pm, R1 stated, When I was in the hospital, they (facility staff) took my wheelchair. I told the Director as soon as I came back from the hospital. Surveyor inquired if the wheelchair was returned and/or replaced when the concern was reported. R1 responded, He (unidentified director) just gives me the runaround. Surveyor affirmed there was a wheelchair in R1's possession. R1 replied, This is garbage, the brakes don't work. They (facility staff) took my good wheelchair and gave me this. R1 engaged both wheelchair locks however the wheels were able to move. R1 subsequently stood up from the bed and sat on the wheelchair, the wheelchair (rapidly) moved backwards (affirming the wheelchair brakes were malfunctioning). On 2/22/24 at 9:48am, surveyor inquired about R1's wheelchair. V2 (DON/Director of Nursing) stated, He (R1) told me (yesterday) his wheelchair was missing (when R1 returned from the hospital). The wheelchair that's in his (R1) room is his wheelchair. Surveyor inquired if R1 has an inventory log to affirm whether he had a personal wheelchair. V2 responded, I couldn't find one for him. Surveyor relayed concerns with R1's malfunctioning wheelchair. V2 replied, I can have somebody come and take a look at it. On 2/22/24 at approximately 1:00pm, V2 (DON) presented (2/22/24) emails to/from an equipment supplier which state requesting a 20 high back wheelchair asap (as soon as possible) for (R1). Response: Please be advised order has been placed and affirmed that the facility ordered R1 a new wheelchair today (roughly 3.5 months after reporting concern). ___ 2. R2's (1/25/24) BIMS determined a score of 15 (cognitively intact). R2's (11/7/23 & 11/8/23) personal belonging inventory includes the following clothing items: 11 shirts, 1 sweater, 14 pants, 10 undergarments, 3 pairs of socks, and 1 jacket. On 2/21/24 at 12:34pm, surveyor inquired about clothing concerns. R2 stated, I sent my laundry downstairs 4 weeks ago and they didn't give em to me. I tell the Administrator (V1). He told me to check downstairs. The staff from the laundry checked every single thing and couldn't find it. I been wearing these pants for 5 days, the other pants I have don't fit me. He (V1) told me the day before yesterday. 'I'm gonna give you a check'. I go down there yesterday. He (V1) told me he never said anything about checks. Today I said, hey I need my stuff. He (V1) said he would give me a check. R2 affirmed this was after IDPH (Illinois Department of Public Health) surveyor entrance. Surveyor inquired if R2's clothing is labeled. R2 responded, Every single item I have is labeled except socks because you cannot label black socks. R2's (2/9/24) record of complaint includes missing clothing from laundry: (3) jeans, (5) shirts, (7) underwear, (7) pair of socks, and (5) undershirts. Writer requested a check from corporate office after resident gave some time to look for clothes however a resolution was excluded. On 2/22/24 at 12:15pm surveyor inquired if the (2/9/24) complaint was resolved. R2 stated, He (V1) did give me a check yesterday (12 days after the complaint) for $117 but I told him the total was $181. R2 affirmed he agreed to accept this amount only because he needed clothes as soon as possible. On 2/22/24 at 12:43pm, surveyor inquired why R2 was reimbursed only $117 if he (R2) determined the total replacement value was $181. V1 affirmed he (V1) checked on Amazon to determine a total for R2's missing clothing. V1 also affirmed that R2 requested jeans valued at $20 however on Amazon they were only $15, therefore that's what was offered for each pair of jeans when determining the amount. Considering reasonable person concept, the cost of clothing items, sales tax (roughly 10%), and shipping the replacement value of $181 for R2's missing clothing (27 items) was likely reasonable, however V1 reimbursed (R2) $64 less than that amount. The (undated) notification of policy regarding personal property includes lost or misplaced personal items: we (facility) make every attempt to assure that your possessions are not lost, misplaced or stolen. Investigating lost personal items: if you are missing an item, or an apparent theft has taken place, report the incident to the Nurse in charge with the exact description of the missing item and the last time and place you saw it. Follow-up on the reported loss by also contacting either the Administrator or Designee. [a timeframe to address concerns regarding lost personal items is excluded].

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 F0558 (Tag F0558)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview and record review the facility failed to follow policies/ procedures, failed to ensure R1 was ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview and record review the facility failed to follow policies/ procedures, failed to ensure R1 was provided a wheelchair with functioning brakes, failed to ensure R1 and R4 belongings were inventoried, failed to ensure R2, R3 and R5 have clean clothing available, and failed to ensure that basic clothing requirements were met for two of five residents (R3, R5) in the sample. These failures have the potential to affect 212 residents residing in the facility. Findings include: The (2/21/24) census includes 212 residents. On 2/5/24, IDPH (Illinois Department of Public Health) received allegations regarding lost/ stolen clothing and personal wheelchair replaced with another wheelchair in poor condition (upon return from the hospital). 1. R1's diagnoses include hemiplegia and hemiparesis. R1's (2/5/24) functional assessment includes mobility devices: wheelchair. R1's census affirms (11/2/23) hospital leave and (11/10/23) return to the facility. R1's (2/5/24) BIMS (Brief Interview Mental Status) determined a score of 12 (moderate impairment). R1's (11/10/23) record of complaint includes missing wheelchair. Looked for an inventory list, asked to search his room for items, he refused. Per floor staff he only came with the wheelchair he's currently using. On 2/21/24 at 12:54pm, R1 stated, When I was in the hospital, they (facility staff) took my wheelchair. I told the Director as soon as I came back from the hospital. Surveyor inquired if the wheelchair was returned and/or replaced when the concern was reported. R1 responded, He (unidentified director) just gives me the runaround. Surveyor affirmed there was a wheelchair in R1's possession R1 replied, This is garbage, the brakes don't work. They (facility staff) took my good wheelchair and gave me this. R1 engaged both wheelchair locks however the wheels were able to move. R1 subsequently stood up from the bed and sat on the wheelchair, the wheelchair (rapidly) moved backwards (affirming the wheelchair brakes were malfunctioning). On 2/22/24 at 9:48am, surveyor inquired about R1's wheelchair V2 (DON/Director of Nursing) stated he (R1) told me (yesterday) his wheelchair was missing (when R1 returned from the hospital). The wheelchair that's in his (R1) room is his wheelchair. Surveyor inquired if R1 has an inventory log to affirm whether he had a personal wheelchair. V2 responded, I couldn't find one for him. Surveyor relayed concerns with R1's malfunctioning wheelchair. V2 replied, I can have somebody come and take a look at it. V2 affirmed on 2/22/24 that the facility ordered R1 a new wheelchair (roughly 3.5 months after the concern was reported). ___ The (undated) personal property policy includes basic clothing requirements: Each resident of this facility should have at least six (6) changes of clothing, including underwear, socks, and outer garments. If the resident does not have any clothing the facility will reach out to laundry to see if there any donations or go to the thrift store and purchase some clothing for the resident. 2. R3 was admitted on [DATE] (3.5 months ago). R3 resides on 4th floor. R3's diagnoses include disorganized schizophrenia. R3's (2/2/24) BIMS determined a score of 9 (moderate impairment). R3's (2/2/24) functional assessment affirms supervision and/or touching assistance is required for dressing. R3's (11/9/23) personal belonging inventory includes the following clothing items: 3 shirts, 2 pants, 1 pajama set, 1 underwear, 3 pairs of socks, 1 hoodie and 1 jacket (therefore basic clothing requirements per facility policy were not met). On 2/21/24 at 12:14pm, surveyor inquired about R3's cognitive status. V3 (LPN/Licensed Practical Nurse) stated, She's oriented times 2. On 2/21/24 at 12:16pm, R3 was observed sitting in a wheelchair wearing a zipped hooded jacket and an incontinence brief. A folded sheet was lying atop of R4's thighs however her legs and brief were exposed. Surveyor inquired if R3 was wearing a shirt beneath the jacket. R3 stated, I got an athletic bra on and affirmed she was not wearing a shirt. Surveyor inspected R3's dresser and closet for clothing however only a winter jacket was present. Surveyor inquired where R3's clothing was located. R3 responded, The housekeeper or laundry and affirmed she was unsure. Surveyor inquired if R3 was missing clothing items. R3 replied, Some of that's missing. My sister said I should let her take it home and wash it. On 2/21/24 at 12:19pm, surveyor inquired if R3 has any clean clothes in the dresser or closet V4 (CNA/Certified Nursing Assistant) searched to no avail and stated, No pants is here, no shirt is there. Surveyor inquired why R3 was not wearing any pants and/or shirt V4 responded, They (staff) took her clothes at the laundry to wash. Surveyor inquired what staff are supposed to do if residents have no clean clothing available. V4 replied, We have to ask the laundry people. If they (laundry) don't have them, I call the supervisor. Surveyor inquired if V4 called the supervisor to report that R3 did not have any pants or a shirt available today. V4 stated, She's not in her office, so I have to go and get in the laundry, go get her clothes and bring it up. I cannot wait for them for the whole day, she has to have pants on her. On 2/22/24 at approximately 9:48am, surveyor relayed concerns with R3's lack of clothing. V2 (DON) stated, This morning when I went up to see her (R3), she (R3) was fully clothed so they (staff) must have gotten some stuff for her. I'll have to take a look and see if there's any more yet. Surveyor inquired who's responsible for making sure that residents have clothing available. V2 responded, The CNAS should be making sure that the residents have clothes. We have stuff that we can get as far as donation clothes or ask family to bring in more stuff. Surveyor inquired if clothing donation and/or staff communication with family members should be documented. V2 replied, It should be documented. The (undated) notification of policy regarding personal property states: Periodically, this facility will check each resident's clothing and shoes. Families will be notified as to what each resident needs, if anything. If this facility is not able to contact a family, or if the requested clothing is not brought in by the requested date, the needed items will be purchased by the facility and billed to the resident/authorized representative or the resident's trust fund account. R3's (11/9/23-2/21/24) social service progress notes exclude notification to R3 and/or POA (Power of Attorney) inclusive on R3's face sheet, requesting that clothing be brought in and/or authorization to bill R3 and/or POA for clothing purchase. ___ 3. R5 was admitted [DATE] (4 months ago). R5 resides on 4th floor. R5's (12/13/23) BIMS determined a score of 15 (cognitively intact). R5's personal belonging inventory includes the following clothing items: 2 tops, 1 pant, 1 bra, and 2 pairs of socks (therefore basic clothing requirements per facility policy were not met). R5's (8/20/23-2/21/24) social service progress notes exclude notification to R5 and/or family member inclusive on R5's face sheet, requesting that clothing be brought in and/or authorization to bill R5 and/or family member for clothing purchase. On 2/21/24 at 12:21pm, R5 stated, Can you help me? Can I get some pants? I don't have any pants. R5 was noted to be wearing a (fleece) 1/4 zip jacket (it was extremely hot in the building at this time) and pants however the only clothing observed in R5's closet or dresser was a winter coat. Surveyor inquired if R5 was wearing a shirt underneath the jacket. R5 responded, I have no shirt under here. On 2/21/24 at 12:23pm, surveyor inquired if R5 had any clothing in the dresser and/or closet. V4 (CNA) picked up a small bag of clothing on the floor and stated, It's not clean, it needs washed. She (R5) only has a jacket. Surveyor inquired why R5's soiled laundry was not sent to the laundry. V4 responded, We (CNAs) shouldn't put the laundry down, they (Laundry staff) should pick it up and affirmed that each unit has a specific laundry day. Surveyor inquired about the laundry turnaround time. V4 replie,d If you send it down today, you get it back the next day. On (Wednesday) 2/21/24 at 12:28pm, surveyor inquired about resident soiled clothing. V5 (Licensed Practical Nurse) stated, Each floor has a day that they do laundry, on this floor (4th floor) it's Monday. Surveyor inquired if soiled clothing is sent to the laundry on Monday, when is it returned to the resident? V5 responded. I don't know. They (facility) do it floor by floor now, instead of just sending it down like we used to. Considering reasonable person concept, if the 4th floor laundry day is on Monday's and clothing is returned to residents the following day, then R3 and R5 likely must wait until the following Tuesday (6 days from now) to receive their clean clothing. ___ 4. R2's (2/9/24) record of complaint states missing clothing from laundry: including several shirts, undershirts, jeans, socks, and underwear. Writer requested a check from corporate office after resident gave some time to look for clothes. R2's (11/7/23 & 11/8/23) personal belonging inventory includes the following clothing items: 11 shirts, 1 sweater, 14 pants, 10 undergarments, 3 pairs of socks, and 1 jacket. R2's (1/25/24) BIMS determined a score of 15 (cognitively intact). On 2/21/24 at 12:34pm, surveyor inquired about clothing concerns. R2 stated, I sent my laundry downstairs 4 weeks ago and they didn't give em to me. I tell the Administrator (V1). He told me to check downstairs. The staff from the laundry checked every single thing and couldn't find it. I been wearing these pants for 5 days. The other pants I have don't fit me. Surveyor inquired if R2's clothing is labeled. R2 responded, Every single item I have is labeled except socks because you cannot label black socks. Surveyor observed one pair of pants in R2's possession. R2 responded, Those are size 32 waist, I wear a 36. On 2/22/24 at 12:15pm, surveyor inquired how often R2 prefers to change his clothes. R2 stated, I usually take a shower every day and when I take my showers that's when I change my clothes. __ 5. R4 resides on 4th floor. R4's (1/5/24) BIMS determined a score of 12 (moderate impairment). On 2/21/24 at 12:04pm, surveyor inquired if R4 was missing any clothing. R4 stated, All I know is 2 bags is gone and affirmed that facility staff were made aware. On (Wednesday) 2/21/24 at 12:12pm, surveyor inquired about R4's cognitive status. V3 (Licensed Practical Nurse) stated, She's alert and oriented times 3. Surveyor inquired if R4 reported that she was missing clothing. V3 responded, She (R4) reported she hasn't got laundry back but they're (staff) washing it right now. Surveyor inquired when R4's soiled clothing was sent to the laundry. V3 replied, Our (4th floor) collection day is Monday [2 days prior]. The (undated) laundry policy and procedure states clothes brought down to the laundry in the A.M. will be returned to the resident the evening of the same day. On 2/21/24 at approximately 2:00pm, V2 affirmed that R4 does not have an inventory list as warranted.

Jan 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to notify the resident's (POA) Power of Attorney for Healthcare of changes in condition/treatment which affected one (R1) resident reviewed fo...

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Based on interview and record review, the facility failed to notify the resident's (POA) Power of Attorney for Healthcare of changes in condition/treatment which affected one (R1) resident reviewed for policy and procedure in a total sample of 7 residents. Findings include: R1's admission Record documented R1's diagnoses include but not limited to hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body); abnormalities of gait and mobility; lack of coordination; contracture; and systemic lupus erythematous. Contacts. V29 (R1's POA (Power of Attorney for Healthcare). The (undated) facility provided document titled Wound Care Log: Skin Issues documented, in part Patient Name: R1. Area of Concern: Right buttock. Nurse Name: V8 (Licensed Practice Nurse). Date: 12/17/23. R1's Progress Note documented, in part Effective Date: 12/21/2023. Writer spoke with (MD) regarding order r/t (related to wounds and incontinence. Dr. gave order for foley. Orders carried out and NOD (nurse on duty) notified. Author: V2 (Director of Nursing). Of note, there was no documentation of POA (Power of Attorney) - HealthCare notification written for the wound noted on 12/17/23 by V8 and for the indwelling catheter ordered on 12/21/2023. On 01/08/2024 at 1:15pm, V8 (LPN) stated, The CNA for (R1) called me (V8) and told me (V8) he (R1) has a wound. I (V8) looked, and he (R1) has an opening, like a skin tear, on the right buttock. I (V8) noticed it on 12/17/2023. It is expected of me to inform the wound care, doctor and family. I (V8) informed the wound care using the wound care log. The doctor was made aware also. I (V8) informed the doctor on the same day 12/17/2023. I (V8) tried to call (V29) but I (V8) was not able to inform her (V29). I (V8) don't remember if I (V8) documented that. The principle of documentation is if it is not documented, it means it is not done. On 01/16/2024 at 11:41am, V16 (Licensed Practice Nurse) stated, (R1) was having a lot of friction from him (R1) being moved and we want to prevent the wound from happening. The wound doctor told the wound nurse to get an order for indwelling catheter, then the wound nurse told me (V16). (V2, Director of Nursing) got the order to insert indwelling catheter on the resident. On 01/16/2024 at 1:07pm, V16 stated, We (facility) have to notify the family if a resident is going to be inserted with a catheter. So, they will know the treatment of their loved ones. No, I (V16) did not notify (R1) family. I (V16) was busy during that time. On 01/16/2024 at 2:34pm, V2 (Director of Nursing) stated the expectation is to notify the family if a catheter is to be inserted. Notification is done prior to insertion of catheter; it is a basic procedure. Indwelling catheter insertion is an invasive procedure. On 01/16/2024 at 2:37pm, V2 stated, With any changes in condition, including wound, the POA should be notified within that day. The same day we noticed the wound, no matter the resident was not seen by the wound doctor yet. It is expected of the staff nurse to notify the family on the day it was noted. The (Revised: 1/17) Change in a Resident's Condition or Status documented, in part It is the policy of this facility, except in medical emergencies, to notify the resident, his or her attending physician, and guardian of changes in the resident's condition and/or status. Procedure. 2. Nursing services will notify the resident, his/her next of kin, or guardian as each care may apply, when: g. There is a significant change in the resident's physical, mental or psychosocial status. 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours. 5. All changes in the resident's medical condition will be recorded in the resident's medical record in accordance with our charting and documentation policies and 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure serious bodily injury was reported to the State Agency within...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure serious bodily injury was reported to the State Agency within the mandated time frame and failed to develop policies and procedures which ensures reporting of serious bodily injury within the mandated time frame. These failures affected 1 (R3) resident reviewed for reporting of incident and accident in the total sample of 7 residents. Findings include: R3's (12/21/2023 at 10:26pm) Health Status Note documented, in part readmitted this [AGE] year-old female from hospital with diagnosis (es) of AMS (altered mental status), STATUS POST FALL, RIB FIX (fracture). R3's (Visit Date: 12/17/2023) Inpatient Discharge Instruction documented, in part, Your diagnosis: Rib Fracture. History of Present Illness: Patient from (facility) presents for evaluation of altered mental status s/p (status post) fall. At ED (Emergency Department) Chest x-ray: Right 6th rib fracture. Consultation Notes: History of Present Illness. The patient is a poor historian, does not recall the incident. The (12/22/23) Facility Fax cover sheet For R3's injury documented, in part Date/Time: transmission was completed on 12/22/23 at 13:25 (1:25pm). Destination: to State Agency. State Report. Analysis/Conclusion: Resident was readmitted to the facility on [DATE] at 2226 (10:26pm), with discharge paperwork from the hospital. Discharge paper work showed an Xray of the chest was completed and Xray results showed a mildly displaced posterior right six rib fracture. On 01/16/2024 at 2:13pm, V2 (Director of Nursing) stated she (R3) returned on 12/21/23 at 10:26pm, I (V2) learned about the fracture the next morning of 12/22/2023 when I (V2) went through her (R3) Hospital discharge paper work. I (V2) reviewed the Hospital Discharge paperwork around 7:30am, and I (V2) read she (R3) has a fracture of the rib. What prompted me to report to IDPH was I (V2) was looking to see if she (R3) has chronic or acute fracture which I (V2) did not see that she (R3) had any chronic fracture. I (V2) also looked in our radiology result in (electronic health record) if she (R3) has an x-ray of the ribs. No radiology result of fracture of the rib. She (R3) has chest Xray in the past with no fracture of the rib that made me (V2) think the fracture of the rib was acute. I (V2) notified the administrator (V1). I (V2) notified him (V1) between 8:30am and 9am. Then I (V2) started the reportable and send it over. Transmission time per this (referring to the transmission sheet of the fax report) fax says the report was transmitted to IDPH at 1:25pm. Our policy is to report the serious injury within 24 hours. That is the policy I was given by the (V1) Administrator. The (undated) Incident/Accident Report Policy documented, in part Purpose: To accurately document the events of an incident/accident involving residents, visitors and employees. Procedure: 5. Information recorded should include the description of how the accident/incident occurred and the names of any witnesses. 15. Report will be faxed to State Agency within 24hours of each serious incident by the DON (Director of Nursing) or designee. The (undated) Resident Incident documented, in part Policy: To provide accurate reporting and recording of all residents' incidents. Procedure: A. any incident includes but is not limited to the following: Unexplained injuries. Reporting. The Department of Public Health must be informed of serious incident and accidents that cause physical harm or injury to a resident. The facility shall fax, or phone notify the Regional Office with 24hours after each reportable serious incident or accident. The (Rev. 211, 02-03-23) State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities documented, in part F609 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established 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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the low air loss mattresses were set on app...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the low air loss mattresses were set on appropriate setting for 2 residents (R4 and R5) reviewed for pressure ulcer prevention in the total sample of 7 residents. Findings include: On 01/04/2024 at 11:22am, this surveyor and V3 (Licensed Practice Nurse) checked on R4. R4 was lying on a low air loss mattress, The setting of the low air loss mattress was at 420lbs, alternating every 10 minutes. V3 stated setting is at 420lbs. (R4) has a sacral wound. On 01/04/2024 at 11:27am, V3 stated she (R4) weighed 97.6lbs on 12/09/2023. On 01/04/2024 at 12:14pm, this surveyor and V6 (Certified Nursing Assistant) checked R5. R5 was lying on a low air loss mattress. The setting of the low air loss mattress was at 490lbs, alternating every 25 minutes. V6 stated I (V6) don't know why the setting is at 490lbs. Setting is based on resident's weight. On 01/04/2024 at 1:05pm, V7 (Wound Care Coordinator/RN) stated the setting of the low air loss mattress is based on the resident's weight to make sure the low air loss mattress is not too firm or not too soft, so the weight is distributed throughout the mattress. The purpose of setting the low air loss mattress based on the resident's weight so it will not cause too much pressure on resident's high pressure point areas, preventing the development of pressure injuries or ulcer or preventing it from getting worst. On 01/08/2023 at 2:15pm, V7 (Wound Care Coordinator/RN) stated the low air loss mattress we use does not allow us to set the mattress according to the resident's weight but the setting of the low air loss mattress should be close to the resident's weight, it could be 20-30lbs over but not over 100lbs. R4's admission Record documented that R4's diagnoses include but not limited to polyneuropathy; type 2 diabetes mellitus; pressure ulcer of sacral region, stage 4; hyperlipidemia; and essential hypertension. R4's (12/15/2023) Minimum Data Set documented, in part, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 9. Indicating R4's mental status as moderately impaired. Section M. Skin Conditions. M0100. Determination of Pressure Ulcer/Injury Risk. A. Resident has a pressure ulcer/injury. M1200. Skin and Ulcer/ Injury Treatments. B. Pressure reducing device for bed. Of note, wound was present during admission. R4's (1/17/2024) Order Details documented, in part, Low air loss mattress in use every shift for prevention. Ensure settings are set to patients' weight. R4's (01/04/2024) Weight and Vital summary documented that R4 weighed 97.6lbs on 12/09/2023 and weighed 98lbs on 01/04/2024. R5's admission Record documented that R 5's diagnoses include but not limited to hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body); pressure ulcer of sacral region, stage 4. R5's (12/08/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-term Memory Ok. 0. Memory OK. Section M. Skin Conditions. M0100. Determination of Pressure Ulcer/Injury Risk. A. Resident has a pressure ulcer/injury. Of note, no additional information provided. R5's (01/04/2024) Weights and Vitals Summary documented that R5's weighed 142.3lbs on 01/02/2024. R5's (1/17/2024) Order Details documented, in part, LOW air loss mattress in use every shift for prevention. Ensure setting are set per manufacturer's instructions. R5's (11/13/2023) Order Details documented, in part, LOW AIR LOSS MATTRESS IN USE (LAL/LAM) every day shift for PREVENTION ENSURE SETTINGS ARE SET PER MANUFACTURERS INSTRUCTIONS. R5's (10/12/2023) Care Plan documented, in part R5 [NAME] has potential for alterations in skin integrity r/t bed mobility and incontinence. Goal: will maintain or develop clean and intact skin by the review date. Interventions: needs pressure relieving/reducing mattress, pillows or wedges, to protect the skin while up IN CHAIR or IN BED. The (undated) Low Air Loss/Alternating Pressure Bariatric Mattress System documented, in part General: The P**** A*** 8*** pump and mattress is high quality and affordable air mattress system suitable for medium and high risk pressure ulcer treatment. They have been specifically designed for the prevention of bedsores and offer an affordable solution to 24-hour pressure area care. Product function: Press Pressure Range. 20-65mmHg adjustable pressure range selected by patient's weight guide listed on panel providing pressure range options. Operation. Pressure Set up. NOTE. It is recommended to press Auto Firm on the panel when the mattress is first inflated. Users can then easily adjust the air mattress to a desired firmness according to the patient's weight and comfort. The (undated) Pressure Ulcer prevention documented, in part Policy: It is the policy of this facility to ensure based on an admission comprehensive assessment, that the resident's risk for skin breakdown is assessed and that preventive measures are implemented. Procedure: 2. Resident assessed for high risk (score of 12 or above) the following preventive measure will be implemented upon admission: 2.2 Preventive mattress. 3. Residents assessed for moderate risk (score of 13-14): 3.2 Preventive mattress. The (Revised: 11/18) Wound Assessment documented, in part, It is the policy of this facility to do a systemic ongoing wound assessment on all wounds in order to determine the response to nursing care and treatment modalities. Procedure: 5. Resident needing a low air loss mattress based on assessment: a. the air loss mattress will be ordered. b. the air loss mattress manufacturer's instructions will be followed.

Dec 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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 follow their policy to be free from physical abuse by providing necessa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to follow their policy to be free from physical abuse by providing necessary care in services thus resulting in a male resident (R4) verbally and mentally abusing another female resident (R2) for two out of three residents reviewed for physical abuse. Findings include: On 12/21/2023 at 12:00 PM, R2 was seen laying on her back side. R2 stated yesterday, another resident (R4), looking like [NAME], came in and called her a N .r B h. R2 stated when she yelled, R4 snapped at her and swore at her. R4 told her (R2) to shut up and threated her by saying if she yelled again, he wound 'beat the shit out of her'. R2 stated she was traumatized because she is scared R4 will come into her room and hit her. R2 stated she is so scared she requested to get transferred out to another facility. On 12/21/2023 at 12:37 PM, V5 (Certified Nursing Assistant) stated she was R2's CNA on Tuesday 12/19/2023. V5 stated she started her shift at 7:00 AM and worked until 3 PM. V5 stated she was in R2's room when a big commotion happened. V5 stated R2 alleged another resident (R4) came into her room and called her the N word and B word. V5 stated R2 said she yelled and then R4 threatened to punch her if she yelled again. V5 stated R2 described how resident looked. V5 stated R2 described the resident looking like [NAME]. V5 stated once she said I knew exactly who she was talking about. V5 said, (R2) is talking about is (R4), and truth be told, I believe this actually happened because (R2) has no reason to lie. Also (R4) has made many derogatory statements and swore at me too multiple times in the past. V5 stated V1 (Administrator) and V2 (Director of Nursing) all know about the incident. On 12/21/2023 at 2:13 PM, V1 (Administrator) stated he brought R4 to R2's room and R2 identified R4 as the person. V1 also stated R2 had requested to be transferred out. On 12/22/2023 at 1: 30 PM, V6 (Restorative Aide) stated she is familiar with R4. V6 stated she has seen R4 yell and swear at other residents. Reviewed R4's care plan. No documentation of aggressive behavior. R2's progress note by V10 (Social Worker) on 12/19/2023, documents in part: Spoke with resident (R2) and family members on multiple occasions today to calm resident and family regarding the incident resident claims she (R2) saw and heard this morning. Investigation was begun. SSD spoke with resident who reported the incident happened around 6am. She (R2) reported to the SSD the man was taller than SSD (who is 53') and is medium build and is bald. Resident stated man was white and wearing a blue shirt. She (R2) reported man threatened her and made racial comments. Resident (R2) stated she would like to be referred to another facility and did not want to stay here anymore. SSD got the names of other facilities from Resident's sister she would like a referral made to. SSD is working on sending referrals to these facilities. Facility abuse policy (10/2022) documents in part: The facility affirms the right of our residents 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. Verbal abuse is the use of oral, written or gestured language willfully includes disparaging and derogatory terms to residents. Examples of verbal abuse include but not limited to, threats of harm, saying things to frighten a resident.

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on observations, interviews and record reviews, facility failed to ensure wound orders are followed in order to prevent the deterioration of pressure ulcers for one (R1) out of three residents r...

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Based on observations, interviews and record reviews, facility failed to ensure wound orders are followed in order to prevent the deterioration of pressure ulcers for one (R1) out of three residents review for pressure ulcer prevention. Findings include: On 12/21/2023 at 12:00 PM, R1 was seen laying on her left side. R1 is not responsive and non-verbal. On 12/22/2023, R1 was observed from 10:30 AM to 1:00 PM. At 10:30 AM, R1 was seen laying on her back. At 11:37 AM, surveyor observed V7 (Licensed Practical Nurse) go into R1's room but did not turn or reposition R1. From 10:30 AM to 1:00 PM, other than V7 no staff member went into R1's room to check if R1 was soiled or turn and reposition her. At 1:00 PM, R1 was still laying on her back. On 12/22/2023 at 1:05 PM, V7 (Licensed Practical Nurse) stated she is the nurse for R1. V7 stated she is the nurse, and she did not change or reposition R1 recently. On 12/22/2023 at 1: 30 PM, V6 (Restorative Aide) stated she is the nurse for R1. V6 stated R1 does have a sacral wound. V6 stated the last time she changed and repositioned R1 was around 9:00 AM with the wound care team. V6 stated it is expected to check up on and reposition residents every two hours. R1's physician order sheet documents in part: Turn and reposition every 2 hours. Every shift for prevention. R1's care plan (12/08/2023) documents in part: Check every two hours for incontinence. Wash, rinse, and dry soiled areas. No interventions documented for turning and repositioning. R1's December Treatment Administration Record (12/2023) documents in part: Missing documentation for turning and repositioning on 12/11/2023, 12/12/2023, 12/18/2023, 12/19/2023, 12/21/2023, 12/24/2023, 12/25/2023, and 12/26/2023.

Nov 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** Based on observation, interview, and record review, the facility failed to provide timely care to three of five residents (R2, R...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely care to three of five residents (R2, R3, R4). Two of these residents (R3, R4) had to hold their feces and/or urine for multiple hours before they were able to relieve themselves or receive care. This put residents at risk for harm due to holding their feces and/or urine. R3 had a swollen, distended stomach due to holding his feces, causing him severe pain. The failure affects three (R2, R3, R4) of five residents reviewed for neglect. Findings include: According to current POS (Physician Order Sheet), R2 is a [AGE] year-old female. R2's diagnoses are but not limited to quadriplegia, lung disorders, asthma, pressure ulcer of sacral region, lung clots, diabetes, high blood pressure, and high cholesterol. MDS (Minimum Data Set) dated 10/06/2023, notes R2 is alert and needs extensive assistance. According to current POS (Physician Order Sheet), R3 is a [AGE] year-old male. R3's diagnoses are but not limited to respiratory failure, lung disease, heart failure, kidney disease, pressure ulcer of the right heel, diabetes, heart disease, obesity, high cholesterol, depression, anxiety disorder, and constipation. MDS dated [DATE], notes R3 is alert and requires two-person total assistance. According to current POS (Physician Order Sheet), R4 is a [AGE] year-old male. R4's diagnoses are but not limited to cellulitis, clot in the right leg, lung disorder, heart failure, chronic lung clots, diabetes, major depressive disorder, kidney disease, fluid overload, and anxiety disorder. MDS dated [DATE], notes R4 is alert and requires total two-person assistance. On 11/18/2023, at 12:50 PM, R2 stated, The CNA (Certified Nursing Assistant) has not come to change me yet. On 11/18/2023, at 1:02 PM, V5 (Certified Nursing Assistant) stated, I came to check on R2 at 7:00 AM. R2 was sleeping. On 11/18/2023, at 1:10 PM, V5 came to change R2. No previous attempts to change R2 were made by V5 before 1:10 PM. On 11/18/2023, at 1:31 PM, R3 stated, I have been holding my urine and feces since this morning. No one wants to do their job. I hold my urine and feces all the time. My stomach is very swollen and it hurts. I would rate it a six out of ten. This has happened on many occasions. If one of the staff needs to go to the bathroom they can. I must wait for them. V5 had an attitude so I told her to get out. During this interview, R3's stomach was very swollen and full of flatus (gas). R3 rated R3's pain level high due to the gas. On 11/18/2023, at 1:45 PM, surveyor overheard V5 tell V6 (Registered Nurse) that V5 had not changed R4 yet. On 11/18/2023, at 1:51 PM, R4 stated, I have not been changed today. I have been asking to be changed for hours. Other days I always call the supervisors. The staff argues in front of my door. The staff that know what to do, they move them. If a person needed help, they would be dead. The other day they forgot to give me an aide. I was holding it. I need my bandage changed. I need someone to help me because I cannot walk. They need more than two people on this floor. There is a couple of times they have left me in my feces because they go home. This happens all night. The third shift sleeps. I have not seen my aide all day. They came in with an attitude this morning. I have not seen anyone, and I have not washed up. This happens frequently. I am just tired of it. I deal with this all the time. I just hold it because I just do not want to lay in my stuff. They take all my money, and I cannot get anyone in here to wipe my butt? My stomach hurts and I am just tired of all of this. On 11/18/2023, at 2:30 PM, surveyor asked V6 about care for the residents. V6 replied, Everyone is upset. What can I do? On 11/18/2023, at 3:04 PM, V7 (Lead CNA) stated, I expect staff to change the residents every two hours. On 11/18/2023, at 4:05 PM, V9 (Certified Nursing Assistant) stated, There are some residents that urinate frequently. We need to keep changing them. When I work on the second floor, I have eight residents that are total care. The facility is short staffed. On 11/19/2023, at 5:05 PM, V10 (Director of Nursing) stated, I expect the staff to round every two hours on the residents. They are also supposed to answer the call lights to see what is going on. Facility policy titled Abuse Policy, dated 1/23, notes each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Sept 2023 1 deficiency 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

Based on observation, interview and record review the facility failed to ensure resident safety by allowing a resident (R1) out on a community pass unsupervised. This failure resulted in staff not fol...

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Based on observation, interview and record review the facility failed to ensure resident safety by allowing a resident (R1) out on a community pass unsupervised. This failure resulted in staff not following the proper protocol procedures for residents with community pass privileges, which allowed R1, who can only go out on community pass supervised, to sign out on community pass on 8/31/23 unsupervised. R1 has not returned to the facility. This situation was identified as an immediate jeopardy. The Administrator was notified and presented with the immediate jeopardy template on 09/12/2023. The immediate jeopardy began on 8/31/2023 and removed on 9/15/2023. The facility presented an acceptable removal plan on 9/15/2023. However, the deficiency remains out of compliance at the second level of harm until the facility evaluates the effectiveness of the removal plan. Findings Include: R1's physician order sheet dated 5/2/23 denotes R1 may go out on pass supervised. On 8/31/23 R1 was allowed to sign out on community pass unsupervised but R1 is on supervised community pass privileges only. On 8/31/23 staff (V5) did not check R1's community pass privileges before allowing R1 to sign out and leave the facility. R1 has a diagnosis that includes bipolar disorder and paranoid schizophrenia and has not returned to the facility. R1 was also receiving treatment for a wound to R1's left foot and did not finish her wound care and antibiotic therapy. R1's was reported missing to the police department on 8/31/23. R1's whereabouts are unknown at this time. Facility incident report, dated 8/31/23, denotes staff member (V5) was covering the front desk for the regular receptionist when receptionist went on lunch. Staff member let R1 out of the facility. R1 did not have unsupervised pass privileges. Facility immediately took discipline action against employee. Police were called. R1's daughter was notified as well. R1's 8/31/2023 19:15 Nurses Note Text states: Staff reported seeing resident (R1) walking down the street on when she (staff) was out to lunch at approximately 1:20 pm. R1 remains out at this time. DON (Director of Nursing) aware. R1's 8/22/2023 10:13 Psychiatry Progress Note states: MENTAL STATUS EXAMINATION - Appearance/Behaviors: Consistent with stated age. Chief Complaint: Review psychosis symptoms response to a current psychopharmacology. History of Present Illness: (R1) has a psychiatric history of schizoaffective-bipolar type and nicotine dependence. Declares mood is OK. Denies changes in eating or sleeping patterns. The patient does not verbalize or exhibit any depression or anxious symptoms. There were no reports of psychotic or manic symptoms during this visit. Denies auditory or visual hallucination. Suicidal and homicidal ideation are both negative. Denies any paranoid thoughts. There are no reports of obsessive, intrusive, and persistent thoughts, or compulsive, ritualistic activities. Medication was well tolerated, with no reported side effects. R1's 8/24/2023 18:33 Health Status Note Text states: HISTORY OF PRESENT ILLNESS: (R1) was seen and examined today 8/24/2023 to follow up on wound culture results. Due to patient reporting toe pain and noncompliance to medication at times. To follow up on chronic medical condition management. Patient is observed to be walking around the hallway. Patient is calm and cooperative but withdrawn and not willing to engage in conversations. Calm Speech: Clear, normal volume, rate, and tone. Motor: no psychomotor agitation, no psychomotor retardation, no tics Thought Process: Linear Associations: Fair Thought Content: Denies SI, HI, AVH, no paranoid content elicited Mood: OK Attention: Fair Insight: Fair Judgment: Fair Sensorium: Alert Orientation: Self, place, time R1's 8/27/2023 15:46 Nurses Note Text reads: . continues ABT Cipro 750mg Q 12 hours till 09/21/23 for wound to left foot. No noted distress. Resident denies any pain @ this time. T=97.6 During interview on 9/6/23 at 9:25 am V12 (Wound Doctor) R1's wound on her left foot did not look infected and was at a week away from healing. V12 stated there is a chance it could close on his own or chance that it could deteriorate. V12 stated it all depends on how R1 takes care of herself. During interview on 9/6/23 at 9:45 am V8 (Nurse Practitioner) stated R1 had a wound culture that showed a bacterium which mean she had an infection or colonization of bacteria. V8 stated V8 wanted the antibiotics to be given to R1 four weeks prophylactically preventative. V8 stated the antibiotics were prescribed to help the wound heal. V8 stated she ordered the antibiotics to be given as prescribed for four weeks which were to be started on 8/24/23. During interview on 9/6/23 at 10:05 am V5 (Central Supply Director) stated he has been working at the facility for almost 15 years. V5 stated the last couple of years, when the main receptionist (V4) goes on break he covers the front desk. V5 stated when a resident wants to go out into the community on pass by themselves, V5 checks their pass card which is orange and has their picture on it. V5 stated when R1 came down to go out into the community R1 resembled another resident, that regularly goes out every day and V5 had R1 sign out. V5 stated while sitting at the front desk a few minutes later, another staff member (V9) reported they saw R1 outside the building. V5 stated he told V9 that it was not R1 but thought it was another resident that looked like R1. V5 stated immediately after speaking with V9, V5 was contacted by social services and the administrator. V5 stated he was told by management that V5 made a mistake letting R1 sign herself out. V5 stated the managers went outside and drove around to look for R1. V5 stated he knew he should for check for the community pass before letting a resident sign out but didn't and now has been not allowed to work at the facility. V5 stated he feels horrible and will be looking for employment elsewhere. State surveyor observed video on 9/7/23 at 12:15 pm in V2's office, showing R1 walk to front lobby at 1:08 pm on 8/31/23. V5 was observed sitting at front desk. R1 was seen to sign out, then leave the facility unaccompanied. During interview on 9/6/23 at 10:35 am V9 (Certified Nurse Aide) stated V9 was on lunch break driving and saw someone that looked like R1 walking down the street. V9 stated when she returned to the facility about 10 minutes later, V5 was sitting at the front desk. V9 stated V9 told V5 she might have saw someone that looked like R1 walking down the street. V9 stated the managers were informed, and they went outside looking for R1. V9 stated as of today (9/6/23) R1 has not returned to the facility. During interview on 9/6/23 at 10:55 am V10 (Social Worker) stated R1 has been in her caseload for a few months. V10 stated R1 can be lucid when having conversations. V10 stated R1 has delusions that R1 thinks R1 is a doctor or a lawyer. V10 stated R1 goes from being lucid to having delusions. V10 stated she assessed R1 for community access privilege and determined that she required supervision if she went on pass into community. V10 stated residents that require supervision into the community can go out with a staff or family member. V10 stated after residents are assessed to be able to go into the community with or without supervision, the nurses obtain a physician's order and put the order in the residents' electronic chart. V10 stated residents that can go out on pass unsupervised receive an orange card with their picture on it. V10 stated the card is supposed to be presented to the front desk staff so they know who can go out unsupervised. V10 stated on the day that R1 left, the aide (V9) told them she saw R1 walking down the street. V10 stated she approached V5 and asked him what happen and V5 told V10 that V5 thought R1 was another resident that normally goes out on pass every day. V10 stated the managers immediately went outside looking for R1 in different cars. V10 stated R1 never told V10 she wanted to leave or that R1 did not want to stay in the facility. V10 stated R1 had never tried eloping or leaving before without permission. During interview on 9/6/23 at 12:25 am V3 (Social Service Director) stated V3 has been working at the facility five months. V3 stated all residents with passes into the community are on a list that is given to the front desk. V3 stated the list includes residents with supervision and no supervision. V3 stated she updates the list every week and puts it at the front desk. V3 stated R1 has been in the facility for a few months. V3 stated R1 has some mental health diagnosis such as Schizophrenia and Bi-polar. V3 stated R1 was assessed to have a community pass with supervision only. V3 stated pass with supervision means that person is only allowed to go into the community with a family or staff. V3 stated residents that have unsupervised pass privileges are given an orange card that has their name and picture on it to show at the front desk when they want to go out into the community. V3 stated not too long after R1 left the facility a staff member witnessed R1 outside. V3 stated they then drove around the neighborhood for hours trying to locate R1. V3 stated they have a system in place that works but human error by V5 allowed R1 to elope. During interview on 9/6/23 at 1:15 pm V14 (License Practical Nurse) stated V14 has worked at the facility for 17 years. V14 stated R1 was pleasant, withdrawn to herself and liked to smoke. V14 stated R1 would at times get delusional but most of the time she made sense when she talked. V14 stated the day R1 left it was lunchtime and she asked for an Ensure (supplement drink) then went downstairs. V14 stated after lunch V9 reported to her and social service that R1 was seen outside. V14 stated they started looking inside and outside for R1 but could not locate R1. V14 stated from what she remembered R1 had an order in her chart for outside pass with supervision. V14 stated if an order is in the chart or medical records, they are to follow it. V14 stated social service made the determination that R1 needed supervision if she went out on pass. During interview on 9/6/23 at 1:35 pm V2 (Administrator) stated all the doors have alarms including the front door. V2 stated the only way out the front door is to be buzzed out or let out by the receptionist. V2 stated the only residents that go out the front door are residents with pass privileges. V2 stated the main receptionist (V4) was on break and another staff member, who is central supply (V5) normally covers for V4 when V4 goes on break. V2 stated V4 has been working at the facility over ten years and when V4 goes on lunch V5 covers the front desk which he has been doing for years. V2 stated V5 stated V5 knows to look for the orange card before a resident is allowed out of the facility. V2 stated he reviewed the building camera and it seemed that V5 did not check to see if R1 had an orange pass card. V5 allowed R1 to sign out of the facility. V2 stated they had to discipline V5 and V5 is no longer working at the facility because he did not follow the facility rules. V2 stated as soon as they realized R1 had left, staff went driving around looking for R1. V2 stated all pertinent people were notified including the police. V2 stated they have system in place that works and as long as staff follow the rules there are no issues. V2 stated they are replacing V5 and going to hire full time security guard that will check the residents in/out of the facility instead on receptionist. During interview on 9/6/23 at 1:45 pm V4 (Receptionist) stated he has worked at the facility for 27 years. V4 stated they had instituted the orange pass card system several years ago. V4 stated social service has been strict to make sure staff follows the rule of residents showing their orange card before they can go outside alone. V4 stated he has been taking his lunch break for years at the same time 1-2pm. V4 stated for the last five years, V5 would cover the front desk when V4 goes to lunch. V4 stated on 8/31/23 he went to lunch at 1:00pm and returned at 2 pm. V4 stated he was told R1 left the facility. V4 said he saw a lot of staff driving and walking around looking for R1. V4 stated he got off work at 3:00pm and still saw some of the staff driving around looking for R1. During interview on 9/6/23 at 2:10 pm V7 (Doctor) stated the staff felt from their assessment, that R1 needed supervision to go out on pass. V7 stated staff put the order in R1's electronic record. V7 stated typically if there is an order in a resident record the expectation is for staff to follow what the order says. V7 stated in the case with R1, R1 signed out on her own cognizant at the front desk and did not return. V7 stated in the medical community that it is called leaving AMA (against medical advice). V7 stated having a psyche diagnosis does not mean you cannot function. V7 stated R1 has Schizophrenia but was alert and oriented enough to still make her own medical decisions. During interview on 9/6/23 at 2:45 pm V11 (Psychiatrist) stated if a person is not cognitively impaired or does not have a guardian, he or she is able to make medical decisions. V11 stated residents with schizophrenia have good days and bad. V11 stated when he assessed R1, R1 was alert and oriented times three. V11 stated even though R1 had some psychiatric diagnosis, R1 was her own decision-maker from V11's perspective. V11 stated there was no justification in his mind, that R1 should have been in a locked unit in the facility or locked into the facility. V11 stated if R1 was demented or had dementia it would been a very serious thing that the facility allowed her to leave. V11 stated residents with Dementia must be, sometimes, in a secure or locked unit. V11 stated if the facility fails to keep a demented resident from leaving the facility it shows they failed to keep that resident safe. V11 stated if R1 wanted to leave AMA V11 would have to let her, and staff should have told V1 if they knew. Facility physician order policy denotes proper channels of communication are used to ensure accurate delivery of medications and treatments to all residents. Orders must be checked for completion including indication for use, or telephone order. Medication dosage, route of administration, number of days or doses, indication for use of PRN medication, date, and physician signature, time of day to be given, and any special instructions. Facility out on pass policy denotes physician order must be obtained indicating Pass Privileges. The Immediate Jeopardy that began on 8/31/23 was removed on 9/15/23 when the facility took the following actions to remove the immediacy: The Facility reasonably assures that the resident environment remains as accident free as possible. 1.) Immediate action taken following the incident on 8/31/23. a.) V5 is no longer an employer at the facility as of 9/1/23 b.) Administrator ensured community pass verification was re-initiated on 8/31/23 due to being informed it was not checked by V5 when R1 signed out of the facility to go on community pass. c.) Administrator immediately reviewed resident census with nurses of each floor and confirmed all residents accounted for. Confirmed with the front desk that they are ensuring all residents who are leaving the building have been assessed for community access, have orders that they can leave unsupervised, have shown the front desk their orange pass card and have checked off that they confirmed it. d.) The facility immediately notified the family, MD, law enforcement and IDPH about the incident. 2.) Statement regarding residents that have the potential of being affected. a) On 9/12/23 Administrator and Social Services Director reviewed the community pass assessments of all residents who are assessed as high risk for elopement, have diagnoses that make them unacceptable for community passes, have medical issues that render them unsafe to have a community pass or who have had their community passes revoked or limited will be identified and have their photo included in lists kept at every nurses' station and at the front desk. 3) Measures the facility will take to ensure the issue will be corrected and will not recur. In-Servicing and Staff Re-Education Initiated. In services were initiated on 9/12/23 and will conclude on 9/15/23. a.) From 9/12/23 on, the front desk employee will confirm that they observed and saw the resident's orange out on pass card for all residents who have out on pass privileges and check off on the resident sign out sheet that the resident showed the front desk employee their orange pass card. Administrator will monitor this for full compliance effective 9/12/23. b.) On 09/12/23, an in-service will be held with all Facility staff. The in-services will be conducted by the Administrator and/or designee CNA Supervisor to include: - Review of the requirement that the Facility reasonably assures that residents' environment remains as accident free as possible. - Review of the Facility's policies and procedures on community passes. - Review of how to check for community pass privileges. c.) Staff who work at the front desk, including the staff that cover for the main receptionist when he/she goes on break, will be in serviced immediately regarding the need to check the orange card pass of each and every resident to ensure they can leave unsupervised before they leave the facility, and to check off and confirm that they saw the orange card pass. All staff will be in-serviced regarding the community pass procedure by 9/15/23. d.) All staff will be in-service before they begin their next shift beginning 9/12/23 by Administrator and designee CNA Supervisor. e.) Any temporary personnel will be in serviced on these policies and protocols immediately before they begin their first shifts including those out sick and on vacation by Administrator and designee CNA Supervisor. 4.) The Administrator, or designee DON, will monitor continued compliance via the following Quality Improvement Programs: (QA met on 9/14/23). a) A QA tool will be developed to demonstrate the staff's knowledge of the facility's community pass procedures on a daily basis, for the next four weeks, during facility rounds, the Administrator, or designee, DON , will randomly quiz and monitor staff member on Pass Procedures 3 times per week for 30 days, and then once a week for an additional 30 days. Initiated: 9/12/23. b) The results of the monitoring completed will be submitted to the QA/QI Committee Quarterly for review and follow-up. Quality Assurance Committee will meet to assure that systems are in place and are effective in preventing residents from having community passes that should not have or who are susceptible to elopement. This will be done weekly for the first month, and then monthly for the next 3 months, then quarterly thereafter, unless additional meetings are deemed appropriate or necessary to prevent unauthorized community passes and/or elopement. The facility presented a plan to remove the immediacy on 9/12/23. The survey team reviewed the abetment plan and was unable to accept the plan to remove the immediacy. The abetment plan was returned to the facility for revisions. The facility presented a revised plan on 9/13/23 and 9/14/23. The survey team accepted the plan on 9/14/23. On 9/14/23-9/15/23 the surveyor, via observation, interview and record confirmed the implementation of facility's removal plan. On 9/14/23-9/15/23 observed staff checking for proper orange ID then sign off that they checked before residents were allowed to go out on pass. During interview on 9/14/23 at 2:00pm V4 (Receptionist) stated he had to be in-serviced on pass policy and how to check for community pass. V4 stated they must see the orange pass and sign that saw it. R2, R3, R6, R7, R8 on 9/15/23 at 10:30-10:45am stated they have to show their orange pass to the front desk before they can go out on pass. On 9/15/23 at 9:45-10am V9, V15, V16 (Certified Nurse Aides) stated they had an in-service on the pass policy and how to check for community pass. On 9/15/23 at 10:20 am V18 (Housekeeper) stated when he or his team cover the front desk for V4's lunch break they must see the orange pass and sign that saw it before resident can leave the building. V18 had in-servicing on the pass policy and how to check for community pass. On 9/15/23 at 10:30am V19 (Housekeeper) stated when they cover the front desk for V4's lunch break they must see the orange pass and sign that they saw it before resident can leave the building. V19 had in-servicing on the pass policy and how to check for community pass. On 9/15/23 at 10:45am V20 (Housekeeper) stated when covering the front desk for V4's lunch break they must see the orange pass and sign that they saw it before resident can leave the building. V20 had in-servicing on the pass policy and how to check for community pass.

Jul 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident received adequate supervision to prevent an acci...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident received adequate supervision to prevent an accident in 1 (R3) of 3 residents (R1, R3, R4) in the sample by not providing adequate supervision to a resident (R3) which resulted in a minor injury. Findings include: R3 is a [AGE] year-old male with a diagnosis including COPD, Convulsions, Schizophrenia, Unsteadiness on Feet and Pulmonary Embolism. R3 has a BIMS (Brief Interview for Mental Status) score of 8/15 - moderately impaired. R3 was admitted to the facility on [DATE]. R3's care plan includes elopement risk and an ankle bracelet. R4 is a [AGE] year-old male with a diagnosis including Epilepsy, Bipolar Disorder, Strange and inexplicable Disorder, Psychoactive Substance Abuse, Acute Respiratory Behavior and Personal History of Other Mental Disorders. R4 has a Brief Interview for Mental Status of 12/15 Moderately Impaired. R4 was admitted to the facility on [DATE]. Facility incident report dated 6/25/23 shows on the night of June 24/23, R3 was found on the 2nd floor wandering multiple times. He was redirected each time back to the 4th floor without any issue. When R3 entered into R4's room, R4 was in doorway. R4 stated all R4 did was put up his hand to stop R3 from entering and in no way did R4 strike or hit R3. R4 stated, I would never hit someone. R4's roommate did not recall R4 hitting R3. None of the staff members witnessed anything as well. V17 (Nurse on Duty) found R3 on the floor and immediately separated R4 and R3 and told R4 to go to his room. V17 then brought R3 up to fourth floor and the nurse on 4th floor treated R3. R3 did not complain of any pain or discomfort and V17 carried out Drs orders. Social services made aware and will monitor. 6/25/23 R4 health status note states resident (R3) from another floor with no safety awareness kept entering resident's room through the night and resident (R4) repeatedly asked resident (R3) to leave room, this happened about 5 or 6 times. Writer repeatedly redirected resident (R3) but resident ignoring writer's attempts. Around 4 am, resident (R3) entered resident's (R4) room and he (R4) pushed resident (R3) out of his room. Writer was passing medication at this time and upon hearing incident, residents separated immediately and (R3) taken back to the 4th floor Nurse Practitioner notified of resident incident with orders to monitor resident. Will continue to monitor per staff. On 7/28/23 at 1:12PM V7 (LPN) stated, I was the nurse the night of the incident between R3 and R4. R3 wanders all the time. R3 has a wander guard to prevent him from eloping from the facility. He always has to be redirected. On the night of incident R3 left his 4th floor and went to the 2nd floor. The floor nurse had R3 with her. R3 had a small scratch on his nose. I called the doctor and he ordered Bacitracin to be applied. R3 did not have to go to the hospital. I went into R4's room and asked what happened. R4 stated he was awoken by R3 standing over him. R4 pushed R3 with his hand and R3 fell. I think the scratch came from R4's hand on R3's face. On 7/28/23 at 12:51PM R4 stated, I was asleep and I was woken up and was startled. R3 was standing over me. I pushed him away by his face with my hand and he fell to the ground. That is all I can remember that night. R3 was always wandering into my room. He wanders all over the facility. I always have to tell him to leave my room. In the last month I have not seen him. On 7/28/23 at 1PM R3 stated, I don't want to talk to you. Leave me alone. On 7/28/23 at 10-11AM R3 was observed on the 4th floor. R3 was wandering from room to room and leaving on the elevator. Staff did not attempt to redirect him. R3 progress note dated 6/24/23 4:30AM shows, resident responsible for self, noted with abrasion to nose, per resident, nothing happened to me and I have no pain but I need to smoke so give me cigarettes with non-compliant to any assessment. Writer called MD with order to apply bacitracin x 2 daily on top of the nose, make resident fall risk / have therapy see resident. Facility policy titled Daily Rounds Policy states including 5) Residents will be supervised as necessary.

Jun 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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the smoking care plan was revised to reflect the status and c...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the smoking care plan was revised to reflect the status and care needs required during smoking for 1 (R3) of 4 (R5, R9, R11) residents reviewed for smoking. Findings Include: R3 has diagnosis not limited to Burn of Second Degree of Head, Face and Neck, Insomnia, Nicotine Dependence, Anxiety Disorder, Major Depressive Disorder, Nasal Congestion, Lobar Pneumonia, Acute and Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Dependence on Supplemental Oxygen. R3 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. On 06/27/23 at 02:24 PM R3 stated, I don't always use the oxygen. I broke my glasses and had a meeting to go to for an apartment. I tried to repair the glasses and used a lighter to try to melt the plastic on the glasses. The oxygen sign only says no smoking. The oxygen tubing caught on fire, I ripped it off and threw it on the floor. It burnt my beard, mustache, eyebrows, lips, left side of my cheek and above the lips. Progress note dated 05/15/23 document in part: Health Status Note Text: This writer smelled something burning around R3's room, when approached R3's room, sensed a heavy burning smell there, upon assessment R3 was noted with redness around the mouth, nose, and left side of the face. When asked what happened R3 stated, I'm not smoking, I don't know how, but I got burned in my face and hair. Noted small part of R3's pillow, sheet and blanket were burnt. Smoking - Safety Screen dated 04/10/23 document in part: R3 does not have any impairments that affect his ability to be a safe smoker. Resident is able to smoke with staff supervision. Smoking - Safety Screen dated 05/16/23 document in part: Due to the current incident R3 is not able to safely use his lighter. Facility Final Report dated 05/19/23 document in part: Resident's care plan has been updated, the facility will continue to provide a safe environment for resident and will continue to meet his needs. Care plan document in part: Focus: R3 is a smoker. Date Initiated: 04/06/19 Revision on: 08/30/21. Intervention: R3 is able to utilize and carry his own smoking materials. Date Initiated: 04/06/19. Revision on: 08/10/21. Care Plan presented to the surveyor on 06/28/23 document in part: Intervention revision dated 06/27/23 document in part: R3 can smoke with SUPERVISED. Revision on: 06/27/23 - R3 is not able to utilize and carry his own smoking materials. His smoking materials will be kept by the facility. Revision on: 06/27/23. On 06/27/23 at 02:47 PM V17 (Social Service Director) stated, R3 was sent to the hospital after what appeared to be burns on his face. We updated the smoking assessment and care plan. R3 can't hold his own lighter or smoking material but R3 can still go downstairs to smoke. R3 is still on my smoking list. On 06/28/23 at 01:56 PM V17 (Social Service Director) stated, The social worker on the floor is responsible for updating the care plan. The purpose of updating the care plan is to ensure that it meets the needs of the individual. The incident with R3 occurred on 05/15/23 and the care should have been updated when R3 came back from the hospital on [DATE]. I just updated the care on 06/27/23. On 06/28/23 at 02:18 PM V21 (Social Service Aide) stated, On 05/15/23 R3 was sent to the hospital and returned to the facility on [DATE] in the morning. The changes made when R3 returned was we were taking the lighter from R3, but the nurse had already done that. That would have been a new intervention for R3, that R3 cannot keep his lighter. His care plan should have been updated at that time. It was the social service director responsibility to update R3 care plan at that time. Policy: Titled Smoking Policy reviewed 01/22 document 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. It is also the objective of this policy to communicate each resident that they are responsible for following each rule and on-going compliance with this policy. Consequences of non-compliance: 1. Residents will be instructed, educated, and counseled about their inappropriate behavior. Safe, appropriate behavior will be stressed. Documentation, including reassessment, chart entries, and care plans will be added/updated and entered in the record, as appropriate. Titled Resident Care Planning revised 01/17 document in part: Each resident has a resident care plan that is current, individualized, and consistent with the medical regimen. Resident care plans are initiated by the interdisciplinary care team. Following interdisciplinary team conferences completed quarterly and as needed, the interdisciplinary team update goals and actions that were discussed. Procedure: Staff will utilize care plans to assure that each resident's needs are met through appropriate and individualized staff interventions in a timely manner. Printed care plans may be updated manually to show dated updated for reviewers other than staff.

Mar 2023 18 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to ensure privacy was maintained during glucometer test and the administration of insulin for 4 out of 4 (R18, R33, R71, R491) res...

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Based on observation, interview and record review the facility failed to ensure privacy was maintained during glucometer test and the administration of insulin for 4 out of 4 (R18, R33, R71, R491) residents reviewed for privacy in a sample of 35. Findings Include: On 03/14/23 at 11:00 AM V8 (Licensed Practical Nurse) returned to the nurse station with the medication cart and proceeded to take R71 blood glucose while standing by the medication cart at the nurse station with the result of 160. On 03/14/23 at 11:25 AM R33 approached V8 (Licensed Practical Nurse) at the medication cart near the nurse station. V8 retrieved the glucometer from the medication cart drawer and checked R33 blood glucose while standing at the medication cart near the nurse station, with the result of 85. R33 Physician order dated 12/23/19 document in part: Blood Glucose Monitoring before meals. R33 Care Plan document in part: R33 has a Dx (Diagnosis) of Diabetes Mellitus. On therapeutic diet, blood glucose monitoring, insulin, and antidiabetic medication. Date Initiated: 11/04/2019 On 03/14/23 at 11:29 AM V8 (Licensed Practical Nurse) took R18 blood glucose while standing at the medication cart near the nurse station with the results of 77. On 03/14/23 at 11:35 AM R491 approached V8 (Licensed Practical Nurse) at the medication cart near the nurse station. V8 retrieved the unclean glucometer from the top of the medication cart and checked R491 blood glucose while standing at the medication cart near the nurse station with the result of 196. V8 (Licensed Practical Nurse) retrieved an insulin syringe and R491 insulin from the medication cart. V8 drew up 1 unit of Lispro insulin into the insulin syringe the administered the insulin into R491 abdomen while standing near the medication cart at the nurse station. R491 Physician order dated 03/01/23 document in part: Blood Glucose Monitoring 3 x daily three times a day. R491 Care plan document in part: R491 has a Dx (Diagnosis) of Diabetes Mellitus. On blood glucose monitoring, antidiabetic medication and insulin. Date Initiated: 03/01/2023 On 03/14/23 at 11:46 AM V8 (Licensed Practical Nurse) stated, Insulin should not be given in the hallway; everything should be given in the residents' room. On 03/16/23 at 10:02 AM V2 (Director of Nursing) stated, When a resident blood glucose is being checked I expect for the nurse to provide privacy. If privacy is not provided the resident rights to privacy is violated. Policy: Titled Policy and Procedure undated document in part: Subject: Diabetes Management. Policy: It is the policy of this facility to provide optimal nursing care for diabetic patients. 5. Blood Glucose check: d. The procedure is explained to the resident, and privacy is maintained. Titled Rights and Privileges of the Resident undated document in part: The residents have the right to exercise individualities and to develop their capabilities in all facets of life. We consider it our duty and privilege to assist then in this ongoing process. 11. The resident has the right to privacy in his room. 29. All staff of the facility will know and understand the rights and privileges of the resident.

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 follow their Call Light policy and have call lights within reach of the residents for 3 (R22, R64, R148) out of a total sa...

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Based on observations, interviews, and record reviews, the facility failed to follow their Call Light policy and have call lights within reach of the residents for 3 (R22, R64, R148) out of a total sample of 35 residents. Findings include: On 03/14/2023 at 10:47 AM, surveyor was in the hallway when surveyor heard R22 calling for someone. R22 was alert and oriented to person, city, and month. R22 stated [R22] was calling for one of the activity aides. R22 stated [R22] does not have a phone and cannot reach the call light from the bed. Observed the call light string hanging from the wall behind R22's bed. It was not within reach of R22. R22's Call Light Ability Screen, effective 03/01/2023 12:52 PM, documents in part: Resident is able to use the call light after the screening process. R22's comprehensive care plan contains a focus initiated on 04/23/2018 that documents in part that R22 is at risk for falls. One of the interventions documents in part: Be sure [R22's] call light is within reach and encourage [R22] to use it for assistance as needed. [R22] needs prompt response to all requests for assistance. On 03/14/2023 at 10:38 AM, surveyor went into R64's room for interview. R64 was alert and oriented to person, nursing home, and month. Observed R64's call light hanging from the wall near roommate's bed. R64 stated [R64] cannot reach it from bed. R64's Call Light Ability Screen, effective 11/25/2022 11:21 AM, documents in part: Resident is able to use the call light after the screening process. R64's comprehensive care plan contains a focus initiated on 09/25/2020 that documents in part that R64 is at risk for falls. One of the interventions initiated 9/25/2020 documents in part: Be sure [R64's] call light is within reach and encourage [R64] to use it for assistance as needed. [R64] needs prompt response to all requests for assistance. On 03/14/2023 at 11:06 AM, surveyor entered R148's room for interview. R148 is alert and oriented to person, place, and time. R148 stated [R148] uses the call light to call for help but could not reach it from bed. Observed call light string tied to a hole on the curtain dividing R148's bed from the roommate. R148 stated could not reach the curtain from bed. R148's Call Light Ability Screen, effective 02/28/2023 12:29 PM, documents in part: Resident is able to use the call light after the screening process. R148's comprehensive care plan contains a focus initiated on 10/05/2020 that documents in part that R148 is at risk for falls. One of the interventions initiated 10/05/2020 documents in part: Be sure [R148's] call light is within reach and encourage [R148] to use it for assistance as needed. [R148] needs prompt response to all requests for assistance. Facility's undated Call Light policy documents in part: When the resident is in bed or confined to a chair, staff shall ensure the call light is within reach of the resident.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to ensure an oxygen therapy care plan was updated for 1 (R123) out of 4 (R8, R120, R168) residents reviewed for care plans in a sample of 35. T...

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Based on interview and record review the facility failed to ensure an oxygen therapy care plan was updated for 1 (R123) out of 4 (R8, R120, R168) residents reviewed for care plans in a sample of 35. This failure resulted in R123 receiving oxygen therapy after the oxygen was discontinued. Findings Include: On 03/14/23 at 12:02 PM surveyor entered R123 room and observed R123 with oxygen in use per nasal cannula. Physician order dated 06/22/20 Oxygen @ 2L (Liters) Per Nasal Cannula as needed for shortness of breath, end date 05/24/22. Care Plan document in part: R123 has a Dx (Diagnosis) of COPD (Chronic Obstructive Pulmonary Disease) and pulmonary embolism. Encouraged/assisted to have the head of his (R123) bed elevated to prevent shortness of breath when lying flat in bed. On scheduled inhaler and nebulization treatment. Date Initiated: 09/22/2020 Revision on: 08/24/2021. OXYGEN SETTINGS: O2 (Oxygen) via nasal cannula at 2L as needed. Date Initiated: 09/22/2020 Revision on: 08/10/2021. On 03/16/23 at 11:55 AM V39 (MDS Director) stated, If resident orders change, I update the care plan, just on the nursing side. Each department has their own care plan that they update. I would update the care plan if there was a change in the order. If the oxygen was ordered or discontinued, we will update the care plan. V39 was asked by the surveyor to looked at R123 orders to check if there is an oxygen order. V39 stated, There is no order for oxygen. Care plan document Oxygen at 2 liters per nasal cannula as needed, was initiated 09/22/20 and revised 08/10/21. Surveyor and V39 reviewed R123 discontinued orders in the computer. V39 stated, The oxygen was discontinued on 05/24/22, I should have updated the care plan. If the care plan is not updated there is a potential the nurse may give the resident oxygen because it is still on the care plan. They nurse should have checked the orders. If a resident is receiving oxygen and the oxygen is not ordered, it might lead to complications. Progress note dated 02/27/23 11:20 document in part: Nurses Note: R123 using O2 2L via nasal canula. Patient reported some shortness of breath and some cough that he (R123) is not able to bring it up. Document titled Order Audit Report document in part: Oxygen @ 2L Per Nasal Cannula as Needed for shortness of breath as needed related to Chronic Obstructive Pulmonary Disease, order date 06/22/20 13:37, Discontinue 05/24/22 09:28. Policy: Titled Resident Care Planning undated document in part: Policy: Each resident has a resident care plan that is current, individualized, and consistent with the medical regimen. Resident care plans are initiated by the interdisciplinary care team. The interdisciplinary team update goals and actions that were discussed. Each discipline is responsible for following the established format for care planning. Staff will utilize care plans to assure that each resident's need are met through appropriate and individualized staff interventions in a timely manner. Titled Oxygen and Nebulizer Administration and Storage updated 03/23 document in part: Purpose: To administer oxygen and Nebulizer treatment to the resident. Procedure: Oxygen Administration. Check physician's order for liter flow and method of administration. 11. When oxygen therapy is discontinued dispose of all equipment properly.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to a.) follow their policy and procedure on use of lin...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to a.) follow their policy and procedure on use of linen with an air loss mattress for 1 (R12) resident, b.) failed to follow manufacturers setting guidelines for air loss mattress system for 1 (R129) resident and c.) failed to provide wound treatments as prescribed by wound care physician for 2 (R12, R129) out of 3 residents reviewed for pressure wound treatment services. Findings include: On 03/14/23 at 12:04 PM, surveyor observed R129 lying in bed on air loss mattress with dial setting set between 250-280 pounds. On 03/15/23 at 10:07 AM, surveyor observed R129 lying in bed on air loss mattress with dial setting set at 250 pounds. On 03/15/23 at 10:35 AM, surveyor observed R12 lying in bed on air loss mattress. R12 observed lying on top of a fitted sheet and a fabric bed pad while wearing a disposable incontinence brief. On 03/15/23 at 10:55 AM, V23 (Wound Care Technician) stated that if a resident is using an air loss mattress there should not be a fitted sheet used. V23 stated a flat sheet could be used and there should not be a fabric bed pad used if a resident is wearing a disposable incontinent brief. V23 stated that it should either be a flat sheet and a disposable incontinence brief or a flat sheet and a fabric bed pad but never a flat sheet, fabric bed pad and a disposable incontinent brief. On 03/15/23 at 11:00 AM, V6 (Licensed Practical Nurse) stated that a flat sheet should be used on air loss mattresses, not a fitted sheet and that a resident may wear or use either an incontinence brief or a fabric bed pad but not both. V22 stated that the purpose of the air loss mattress is to redistribute a resident's body weight around using air movement. V22 stated that if a resident has too much linen underneath them, then this could prevent air movement and create a bed sore. V22 stated that if the low air loss mattress has too much pressure in it, it could be too firm and prevent air movement. On 03/16/23 at 11:35 AM, V2 (Director of Nursing) stated that the purpose of the air loss mattress is to either prevent the creation of a wound or to try to prevent an existing pressure wound from getting worse. V2 stated that the air loss mattress can reposition the resident, to make sure they are not in one constant position of pressure. V2 stated that the air loss mattresses setting should be based on the resident's weight. V2 stated that there should only be a flat sheet under a resident using an air loss mattress because a fitted sheet constricts the air movement. V2 stated that there should not be a fabric bed pad and a disposable incontinent brief because they would add extra layers and the resident would be farther away from the air movement. V2 stated that too much linen would defeat the purpose of the air mattress and prevent the resident from redistributing their weight. V2 stated that if too much linen is under a resident lying on an air loss mattress there is a potential for the wound to get worse because the resident is not getting repositioned. R12 has diagnoses not limited to Sepsis, Pneumonia due to Coronavirus, Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Vitamin Deficiency, Pressure Ulcer of Right Heel (Unstageable), Pressure Ulcer of Other Site (Unstageable), Pressure Ulcer of Sacral Region (Stage 4), Pressure Ulcer of Left Ankle (Unstageable), Schizophrenia, Anxiety Disorder, Heart Failure, Dysphagia. R12's MDS (Minimum Data Set) dated 01/10/23 BIMS (Brief Interview for Mental Status) score is 09 indicating moderate cognitive impairment. R12's MDS dated [DATE] section G (Functional Status) documents in part R12 requires extensive assistance with bed mobility. R12's Wound/Skin Assessment and Wound Evaluation, Management Summary dated 03/16/23 document in part R12 has stage 4 pressure wound to sacrum, unstageable pressure injuries to left heel and left lateral ankle, and deep tissue injury to right lateral heel. R12's physician order for low loss air mattress on 02/07/23 and daily treatment orders as of 03/15/23 for wounds to sacral region (stage 4), left heel (unstageable), left lateral ankle (unstageable), left lateral foot (DTI), right lateral heel (DTI). Reviewed R12's treatment administration record for the month of February 2023 with the following dates missing treatments for pressure ulcers to sacral region (stage 4), left heel (unstageable), left lateral ankle (unstageable), left lateral foot (DTI), right lateral heel (DTI) on: 02/11/23, 02/16/23, 02/18/23, 02/19/23, and 02/25/23. Reviewed R12's treatment administration record for the month of March 2023 with the following dates missing treatments for pressure ulcers to sacral region (stage 4), left heel (unstageable), left lateral ankle (unstageable), left lateral foot (DTI), right lateral heel (DTI) on: 03/4/23, 03/05/23, 03/11/23. R129 has diagnoses not limited to Hallervorden-[NAME] Disease, Pressure Ulcer of Right Elbow (Stage 4), Pressure Ulcer of Sacral Region (Stage 4), Expressive Language Disorder, Dystonia, Dysphagia, Adult Failure to Thrive, Psychomotor Deficit, Schizoaffective Disorder, Bipolar Disorder, Anxiety, Depression, Anemia. R129's MDS (Minimum Data Set) dated 01/01/23 BIMS (Brief Interview for Mental Status) indicates resident is rarely/never understood. R12's MDS dated [DATE] section G (Functional Status) documents in part R129 requires extensive assistance with bed mobility. R129's care plan on stage 4 pressure injury dated 11/14/22 documents in part, R129 requires low air loss mattress to bed for pressure redistribution. R129's Wound/Skin Assessment and Wound Evaluation, Management Summary dated 03/16/23 document in part R129 has stage 4 pressure wound to coccyx. R129's physician order for low loss air mattress on 11/12/22 and daily treatment orders dated 03/15/23 for wound to sacral region (stage 4). Reviewed R129's treatment administration record for the month of February 2023 with the following dates missing treatments for pressure ulcer to sacral region (stage 4) on: 02/02/23, 02/04/23, 02/05/23, 02/11/23, 02/12/23, 02/18/23, 02/19/23, and 02/25/23. Reviewed R129's treatment administration record for the month of March 2023 with the following dates missing treatment for pressure ulcer to sacral region (stage 4) on: 03/04/23, 03/05/23, and 03/11/23. On 03/16/23 at 11:18 AM, V2 (Director of Nursing) stated that if a resident has physician orders for wound treatments it is documented on the treatment records in the facilities electronic medical records (EMR) by the nurse. V2 stated that the wound care nurse and the floor nurses have access to EMR and therefore follow the orders listed in the treatment orders and document once the treatment orders are completed. V2 stated that the orders need to be signed every time the treatment order is done. V2 stated that the wound care nurse does the wound treatments during the week (Monday-Friday) and the floor nurses do the wound treatments on the weekend or as needed (for example, if soiled). V2 stated that if there is blank area on the treatment records then that means the treatment was not provided. V2 stated, if it's not documented then it's not done. V2 stated that if the wound treatments are not being done daily as ordered then there is a potential the wound could get worse, bigger in size and could also get infected. On 03/16/23 at 01:44 PM, V41 (Wound Care Physician, MD) stated that if there is an order for a daily wound treatment then that order needs to be done every day. V41 stated that if the wound treatment order is not done daily then that could negatively impact the condition of the wound. V41 stated that it is important for staff to check the wound daily to monitor the wound for any changes (increased drainage, signs of infection). V41 stated that if someone is not looking at the wound every day, they would not know to notify V41 of any changes or deterioration in the condition of the wound. V41 stated that other interventions to support wound healing may include off loading, repositioning, heal boots, air loss mattress. V41 stated that the purpose of the air loss mattress is to cool the skin and reduce moisture to the skin. V41 stated that extra bedding would defeat the purpose of the air loss mattress as the air loss mattress is designed to release air and if too much bedding is used then air is not able to ventilate through the skin and do its job. V41 stated that the air loss mattress is typically set based on the resident's weight and that if the bed setting is set wrong the bed wound be too ridged and not cushion the resident's wound. Facility document titled, Monthly Weight Report dated 03/16/23 documents in part, R129's weights as follows: (3/2023) 134 pounds, (2/2023) 134.2 pounds, (1/2023) 135.4 pounds., Manufacturer's Operational Manual for R129's air loss mattress documents in part, to determine the patient's weight and set the control knob to that weight setting on the control unit. Facility policy titled, Wound Assessment dated 11/2018 documents in part, the air loss mattress manufacturers' instructions will be followed and to ensure effectiveness of the air loss mattress only one sheet will be applied, no extra padding. Facility policy and procedure titled, Wound Treatment Procedure undated, documents in part to document as part of the procedure steps. Resident #170 Pressure Ulcer/Injury 03/15/23 09:00 AM stage 3 pressure injury to R posterior thigh per wound report. 03/15/23 09:21 AM interviewed Wound Care Nurse 03/15/23 09:54 AM observed wound care treatment/dressing change. MD orders followed. Wound looks red, clean, no odor. R170 denies pain. Wound care nurse used appropriate hand hygiene. R170 observed to be laying on air loss mattress (waffle type) covered in a fitted sheet with fabric patted bed pad laying on top of the fitted sheet and R170 was wearing a disposable incontinent brief. Low air loss mattress was set at #5. Wedge under heels observed for off loading. Facility could not provide manufacturer's information on waffle mattress to check appropriate bed setting. R170 receives wound care treatment off site. The wound care MD who consults with the facility and is onsite weekly does not see R170.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on observations and record reviews, the facility failed to follow a resident's (R90) comprehensive care plan and provide adequate supervision to a resident (R90) with a diagnosis of dysphagia fo...

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Based on observations and record reviews, the facility failed to follow a resident's (R90) comprehensive care plan and provide adequate supervision to a resident (R90) with a diagnosis of dysphagia for 1 out of a total sample of 35 residents. Findings include: R90's medical diagnoses include hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side and dysphagia (difficulty swallowing). V38's (Physician) progress note, dated 03/03/2023 2:51 PM, documents in part to maintain aspiration precautions due to R90's increased risks. R90's comprehensive care plan contains a focus initiated on 04/23/2022 that documents in part that R90 has a swallowing problem related to diagnosis of dysphagia. Interventions initiated 04/25/2022 include but are not limited to: Instruct [R90] to eat in an upright position, to eat slowly, and to chew each bite thoroughly, Monitor for shortness of breath, choking, labored respirations, lung congestion, and Monitor/document/report PRN (as needed) any s/s (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. On 03/14/2023 at 12:20 PM, surveyor was doing unit observations when [surveyor] observed R90 sitting at the edge of the bed and torso almost falling back on the bed. R90 was able to catch self and rock back to upright position. R90 had bedside table with lunch tray in front of [R90]. R90 was holding spoon in left hand. Surveyor entered room for interview and further observations. R90 was rocking up and down throughout the meal attempting to grab food and prevent falling back on the bed. No staff observed in the room. At 12:27 PM and 12:31 PM there were no staff at bedside monitoring R90 eat. At 12:31 PM, R90 took a bite, fell back about 45 degrees, and coughed. At 12:38 PM, R90 ate at least 75% of meal and no staff at bedside. Facility's Aspiration/Swallowing Precautions policy, last revised in 2008, documents in part that the purpose of the policy is To ensure that residents at risk are properly identified and swallowing precautions are followed as ordered/or evaluation. It also documents in part that Swallowing precaution will be followed and observed per M.D. (Medical Doctor) order. Facility's Resident Care Planning policy documents in part: Staff will utilize care plans to assure that each resident's need are met through appropriate and individualized staff interventions in a timely manner.

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedures to (a) ensure a resident was assessed prior to the use of any side rails, (b) re-assess...

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Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedures to (a) ensure a resident was assessed prior to the use of any side rails, (b) re-assess side rails use on a quarterly basis, (c) obtain a consent prior to using the side rails, (d) implement an individualized care plan addressing the use of side rails, and (e) obtain a doctor's order for the use of side rails. These failures affected 1 (R160) of 1 resident reviewed for side rails in a sample of 35. Findings Include: 03/14/23 11:42 AM during an initial tour on the 4th floor, surveyor observed R160 sleeping in bed with two full side rails up. At 11:48 AM, V28 (Licensed Practical Nurse) stated that R160 has periods of confusion but still able to verbalize needs. V28 stated R160 needs assistance with repositioning. V28 stated V28 has seen R160 uses side rails but is not sure if it's full or half side rail. At 2:28 PM, V9 (MDS Coordinator/Care Plan Coordinator) stated that V11 (Restorative Nurse) does the side rail assessments upon admission, quarterly, annually, and with significant change. V9 stated V11 does the determination if resident requires side rails. V9 stated, As far as I know, the facility does not use 2 full side rails because that's considered restraint. That could cause skin injury, skin alteration, and accidents. V9 stated that side rails documentation can be found in the resident's electronic health record (EHR) under assessment. V9 stated that R160 does not use side rails but should have the assessment on admission. Surveyor checked R160's EHR with V9. There was no assessment, or any documentation found regarding use of side rails, and no side rail consent was found. R160's comprehensive care plan was also reviewed, and the use of side rails was not addressed in the care plan. V9 stated that R160's side rail assessment was not done. On 3/15/23 at approximately 10:30 AM, surveyor conducted a 2nd observation with R160. R160 was lying comfortably in bed with one full side rail up on R160's right side of the bed. At 12:38 PM, V11 stated that side rails assessment is done upon admission and the resident should be cognitively intact enough to use the side rail. V11 stated that consents should be obtained before using any side rails on the resident. V11 stated that use of side rails is re-assessed for quarterly, annually, and with significant change assessment. Surveyor requested from V11 a list of residents who are utilizing full side rails, but V11 never provided the list. On 3/16/23 at 11:25 AM, V1 (Administrator) stated that it's the facility's policy to assess the resident prior to using side rails and that it should also be implemented in the care plan. V1 also stated that if the side rails are used for bed mobility, a consent is not obtained. V1 stated R160 has no consent for the use of side rails. V1 provided a printed copy of R160's ECG-(Restorative) Side Rail Evaluation signed on 3/16/23 and stated that the assessment was just completed today. V1 also provided a printed copy of R160's side rail care plan with no date. Surveyor and V1 checked R160's side rail care plan in R160's EHR and it shows that the care plan was just initiated today (3/16/23). R160's EHR shows an initial admission date of 6/22/21 with listed diagnoses not limited to Dementia, Bipolar Disorder, Anxiety Disorder, and Adult Failure to Thrive. R160's Minimum Data Set (MDS) with assessment reference date of 3/6/23 shows R160 is cognitively intact and requires extensive one staff assist with bed mobility. R160's physician order sheet (POS) does not show an order for side rails. R160's ECG-(Restorative) Side Rail Evaluation signed on 3/16/23 shows R160 utilizes side rail for mobility with one or two side half rails. This assessment does not indicate the use of two full side rails. The facility's policy titled; POLICY ON SIDE RAILS ASSESSMENT with no date reads in part: 1. It is the policy of this facility, that residents will be assessed prior to the use of any side rails. 2. This assessment will be done initially or when there is any change in the side rail order. 3. Regular documentation will be done on a quarterly basis. 4. A written consent for side rails will be obtained from the resident, family member and/or legal guardian. 5. A doctor's order will be obtained.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to maintain a medication error rate of less than 5% for 2 (R78, R97) out of 6 (R27, R45, R176, R491) residents that received medic...

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Based on observation, interview and record review the facility failed to maintain a medication error rate of less than 5% for 2 (R78, R97) out of 6 (R27, R45, R176, R491) residents that received medications over one hour past the scheduled time and for 1 (R78) resident that received the incorrect medication that had an expiration date of 10/22 during medication administration. This deficient practice resulted in a medication error rate of 36%. Findings Include: On 03/14/23 at 10:23 AM V8 (Licensed Practical Nurse) proceeded down the hallway with the medication cart to R97 room. V8 entered R97 room with the blood pressure/pulse oximeter/temperature machine, R97 stated I didn't realize it was so late. I never knew that you make rounds like this. V8 proceeded to take R97 vital signs then exited R97 room, returned to the medication cart, clicked on the computer screen in which R97 name was highlighted in pink and began to prepare R97 medications. On 03/14/23 at 10:31 AM V8 (Licensed Practical Nurse) entered R97 room giving R97 the scheduled 09:00 AM medications. Enalapril Maleate 5 MG (Milligram) Twice a day, Metformin Tablet 1000 MG Twice a day and Metoprolol Tartrate Tablet 50 MG every 12 hours. R97 Document titled Administration History Report dated 03/16/23 document in part: Enalapril Maleate 5 MG documented 03/14/23 at 10:34, Metformin Tablet 1000 MG documented 03/14/23 at 10:34 and Metoprolol Tartrate Tablet 50 MG documented 03/14/23 at 10:34. On 03/14/23 at 10:33 AM V8 (Licensed Practical Nurse) proceeded to R78 room with the blood pressure machine. V8 entered R78 room with the blood pressure/pulse oximeter/temperature machine and took R78 vital signs. V8 then exited R78 room, returned to the medication cart, clicked on the computer screen in which R78 name was highlighted in pink and began to prepare R78 medications. On 03/14/23 at 10:43 AM V8 (Licensed Practical Nurse) entered R78 room giving R78 the scheduled 09:00 AM medications. Levetiracetam Tablet 500 MG Twice a day, Quetiapine Fumarate Tablet 50 MG Twice a day, Cyclobenzaprine HCl (Hydrochloride) Oral Tablet 10 MG Three times a day, Dilantin Capsule 100 MG Three times a day (Scheduled for 08:00 AM), Gabapentin Tablet 600 MG Three times a day and Cetirizine 10 MG with an expiration date of 10/22 Daily (instead of Loratadine Tablet 10 MG Daily). R78 Document titled Administration History Report dated 03/16/23 document in part Levetiracetam Tablet 500 MG Twice a day, Quetiapine Fumarate Tablet 50 MG Twice a day, Cyclobenzaprine HCl Oral Tablet 10 MG Three times a day, Dilantin Capsule 100 MG Three times a day (Scheduled for 08:00 AM), Gabapentin Tablet 600 MG Three times a day and Cetirizine 10 MG with an expiration date of 10/22 Daily (instead of Loratadine Tablet 10 MG Daily). On 03/14/23 at 10:46 AM surveyor observed multiple resident names highlighted pink. Surveyor asked V8 (Licensed Practical Nurse) what the pink screen means. V8 (Licensed Practical Nurse) stated the pink screens on the computer screen mean the medication is overdue and it should be given by 09:00 AM. On 03/14/23 at 11:46 AM surveyor asked V8 (Licensed Practical Nurse) to open the top drawer of the sixth-floor team two medication cart to retrieve the pill bottle containing Cetirizine 10 MG (Milligram) that was given to R78. V8 retrieved the medication bottle as was asked by the surveyor to read the expiration date. V8 responded, the expiration date is 10/22. I will throw it out. Before giving medications, we are supposed to check the expiration date. If expired medications are given the resident may have a reaction. If the computer screen is pink that mean that the resident medications are past due. I will sometimes give the medications and come back later to chart. You are supposed to chart the medications when they are given. On 03/15/23 at 03:31 PM V2 (Director of Nursing) stated, The pharmacy come to clean the medication cart and take the expired medications. The medication expiration date should be checked before administration to make sure the medications are not expired. There is a potential the resident can get sick or have an adverse react to the medications if the medication is expired. Surveyor asked V2 can Cetirizine 10 mg be used to replace Loratadine Tablet 10 MG. V2 stated I will call the pharmacy to see if Cetirizine can be used in place of the Loratadine. When the computer screen turns pink the medications are late, more than one hour from the scheduled time. If the medications are given late depending on the type of medication, there is a potential the resident may react to the delay of pain medication by being in pain longer. Diabetic medication can affect the blood sugar. Blood pressure medication can affect the blood pressure. Notify the doctor if medication is given late to see if it is ok to give it at that time. Medications should be signed for right after it is given. On 03/16/23 at 10:02 AM V2 (Director of Nursing) stated Cetirizine cannot be used in place of Loratadine. Policy: Titled Medication Administration and Storage Policy revised 07/02/18 document in part: Policy: To ensure medications are administered & stared in accordance with Standard of Practice. Procedure: 2. Medications shall be given within one (1) hour of the specified time. 8. House stocked medications should not be administered after expiration date located on the manufacturer's bottle. 15. Nurses are to wash their hands prior to the start of the medication pass procedure. A) After any resident contact. 20. Physician must be notified when medications are not administered as per physician order. 22. Medication that are not administered as per physician orders must be documented in the drop-down box and/or progress note. Titled Storage of Medication revised 05/01/18 document in part: Medication and biologicals are stored safely, securely, and properly. H. Outdated, contaminated, or deteriorated medications and those containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. Expiration Dating: D. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached. F. The nurse will check the expiration date of each medication before administering. G. No expired medication will be administered to a resident. H. All expired medications will be removed from the active supply and destroyed in the facility.

CONCERN (D)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

Based on interview and record reviews, the facility failed to provide education and failed to maintain resident's medical record including documentation indicating resident or resident representative ...

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Based on interview and record reviews, the facility failed to provide education and failed to maintain resident's medical record including documentation indicating resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine to 3 (R191, R178, R115) of 5 residents that refused the COVID-19 vaccine. Findings include: On 3/14/23 at 9:25 AM surveyors entered the facility, survey team discussed to V1 (administrator) that list of residents and their COVID-19 vaccination status should be provided by facility within 4 hours of entrance. Followed up the list of residents and their COVID-19 vaccination status at 2:03 PM, 2:29 PM and 3:45 PM but V1 was not able to provide the needed and requested document. On 3/15/23 at 1:20 PM V2 (Director of Nursing (DON) / Infection Preventionist (IP) nurse) was interviewed and stated that the previous IP nurse resigned or did not show up a week ago. V2 stated no proper endorsement was done by previous IP nurse and facility was not able to contact the previous IP. V2 stated, I am trying to gather documents pertaining to Infection Control and vaccination status of residents. V2 stated that she (V2) prioritized to complete IP certification which was completed on 3/13/23. V2 stated that COVID-19 vaccine should be offered to all residents. V2 stated that education should be provided when resident is refusing to receive the vaccine and should be documented in EHR. V2 stated that consent should be obtained prior to giving the vaccine. V2 stated that the potential effect of not getting COVID-19 vaccine is that resident could miss the benefits of the vaccine and resident could easily acquire the virus. V2 stated that as a rule in nursing if it was not documented it was not done. V2 presented the list of residents and their COVID-19 vaccination status and was reviewed with V2. 1. R191 facility's record documented unvaccinated. R191 admission date was on 3/5/23 with diagnosis not limited to Hypertension, anemia, type 2 diabetes mellitus. R191 electronic health record (EHR) reviewed with V2 and stated that R191 has no record found for COVID 19 vaccine. V2 confirmed no education found in R191's immunization EHR. 2. R178 facility's record documented unvaccinated. R178 admission date was on 9/21/22 with diagnosis not limited to Unspecified convulsions, COVID 19, Bipolar disorder, Hypertension. R178 physician order sheet (POS) as of 3/16/23 documented in part: COVID 19 vaccine as needed with order date of 1/16/23. R178 EHR was reviewed with V2 and stated that R178 has no record found for COVID-19 vaccine. V2 confirmed no education found in R178's immunization EHR. 3. R115 facility's record documented unvaccinated. R115 admission date was on 1/20/23 with diagnosis not limited to Multiple sclerosis, Spinal stenosis, Personal history of Covid 19. R115 EHR was reviewed with V2 and stated that R115 has no record found for COVID 19 vaccine. V2 confirmed no education found in R115's immunization EHR. Reviewed R191, R178, R115 electronic interdisciplinary team progress notes, no documentation found regarding education and counseling related to COVID-19 vaccination refusal and physician was made aware. Facility's policy COVID-19 vaccination revised 2/22 documented in part: to ensure compliance with emergency regulation requiring COVID-19 vaccination for healthcare workers and residents that live in a LTC facility. Residents must be educated and counseled on the importance of being vaccinated. Following education of vaccine, if resident chooses to be vaccinated, the facility must provide access to vaccination for resident. 7. If a resident refuses vaccine following education and counseling, the physician will be made aware.

CONCERN (D)

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

Deficiency F0888 (Tag F0888)

Could have caused harm · This affected 1 resident

Based on interview and record reviews the facility failed to ensure a process to track and securely document COVID-19 vaccination status for all staff (in-house and contracted staff) providing care or...

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Based on interview and record reviews the facility failed to ensure a process to track and securely document COVID-19 vaccination status for all staff (in-house and contracted staff) providing care or services to residents was available. Findings include: On 3/14/23 at 9:25 AM surveyors entered the facility, survey team discussed to V1 (administrator) and V2 (Director of Nursing / Infection Preventionist Nurse) that COVID-19 Staff Vaccination Matrix should be provided by facility within 4 hours of entrance. Followed up COVID-19 Staff Vaccination Matrix at 2:03 PM, 2:29 PM AND 3:45 PM but V1 and V2 were not able to provide the needed and requested document. V1 and V2 stated that they (V1, V2) are still working on it. On 3/15/23 at 1:20 PM V2 (Director of Nursing (DON) / Infection Preventionist (IP) nurse) was interviewed and stated that the previous IP nurse resigned or did not show up a week ago. V2 stated no proper endorsement was done by previous IP nurse and facility was not able to contact the previous IP. V2 stated, I am trying to gather documents pertaining to Infection Control and vaccination status of residents. V2 stated that she (V2) prioritized to complete IP certification which was completed on 3/13/23. V2 and V1 presented COVID-19 Staff Vaccination Matrix. V2 stated that as a rule in nursing if it was not documented it was not done. Reviewed COVID-19 Staff Vaccination Matrix with V2 and confirmed that V15 (CNA) , V32 (Dialysis Nurse) , V33 (CNA), V36 (CNA), V47 (CNA), V48 (CNA) , V49 (CNA) were not included. V2 stated that facility has an in-house dialysis service, when asked about the COVID-19 vaccination status for dialysis staff facility was not able to provide. V2 stated that laboratory personnel are coming to the facility Monday through Friday and as needed on weekend to draw blood from residents as ordered by physician. V2 unable to provide COVID-19 vaccination status for laboratory personnel. V2 stated that maybe COVID-19 Staff Vaccination Matrix for in-house and contracted was not updated especially for those newly hired staff. On 3/16/23 at 10:10am V1 provided COVID-19 vaccination status of laboratory personnel. Reviewed facility's policy for COVID-19 vaccination revised on 2/22 documented in part: To ensure compliance with emergency regulation requiring COVID-19 vaccination for healthcare workers. All eligible staff must receive the first dose of a two-dose COVID 19 vaccines prior to providing any care, treatment or other services.

CONCERN (E)

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

Deficiency F0688 (Tag F0688)

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 apply splints for 2 (R24, R129) residents and compl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to apply splints for 2 (R24, R129) residents and complete quarterly restorative assessments that detail the progress or lack of progress in the restorative services for 2 (R32, R150) of 4 residents reviewed for limited range of motion and restorative services in a sample of 35. Findings Include: On 03/14/23 at 12:04 PM, surveyor observed R129 lying in bed with bilateral hand contractures. R129 was not wearing any type of hand splints. R129's right arm was in an elbow pad cushion. On 03/14/23 at 12:48 PM, surveyor observed R24 lying in bed. R24 was not wearing hand splints. R24 unable to move 3 fingers on left hand but able to move left index finger and thumb in a pinching grasp motion. R24 stated that R24 used to wear splints but that R24 has not worn them for 3 months or more. On 03/15/23 at 10:07 AM, surveyor observed R129 lying in bed. R129 was not wearing any type of hand splints. On 03/15/23 at 01:20 PM, surveyor observed R129 lying in bed. R129 was not wearing any type of hand splints. On 03/15/23 at 1:05 PM, V11 (Restorative Nurse) stated that all residents have an Occupational Therapy (OT) evaluation upon admission and the OT is the one who makes the recommendation for a splint or brace. V11 stated that the OT's recommendations are entered into the Electronic Medical Record (EMR) as part of the physician orders and the restorative staff responsible for putting the brace or splints on a resident. V11 stated that the restorative aides document if the splints or brace was worn and document the number of minutes the splint or brace was worn during that shift. V11 stated that if a resident is non-complaint or refuses to wear the splint or brace this would get documented in V11's progress notes. V11 stated that there is also a not applicable or refusal option for the restorative aides to document if a resident refuses to wear a splint. V11 would also document in the resident's restorative care plan that the resident is resistant to care or needs encouragement. V11 reviewed V11's restorative progress notes on R24 and stated that R24's non-compliance with wearing the hand splint was not included in V11's documentation or in R24's restorative care plan. On 03/16/23 at 9:07AM, V40 (Occupational Therapist, Director of Therapy) stated that there are various reasons an OT may recommend a splint for a resident. A splint could be used if a resident has low or high tone because it puts them at a higher risk for injury, or if a resident is having pain, or if a resident has a contracture or as a preventative measure to developing contractures. V40 stated that if an OT recommends use of a splint for a resident, then the OT trains the restorative staff on how to use the splint and that it is the restorative staff responsibility to put the splint on as prescribed. V40 stated that use of a splint would be part of the OT discharge orders and be ordered by the physician. V40 stated that if a resident had an order for a splint but the splint was not being put on daily as ordered then this could cause an increase in pain, further arthritis changes, loss of strength and increase risk for contractures. V40 stated that contractures can be painful for the residents and inhibit ADL/hygiene care. V40 stated that if a resident refuses to wear a splint or removes the splint then the restorative staff would document this and refer the resident back to therapy as needed to re-evaluate. V40 stated that OT recommendation for R24 was to wear a modified hand splint on left hand only for up to 2 hours daily. V40 stated that R129's discharge OT recommendations was to wear bilateral hand splints up to 4 hours per day. On 03/16/23 at 11:18 AM, V2 (Director of Nursing) stated that it is the responsibility of the restorative aides to make sure the residents are wearing the hand splints as ordered. V2 stated that if a resident needs a splint, it would be ordered by the physician and that the treatment would come up as a TASK under POC response so the restorative aide can document that the splint was put on. V2 stated that if there is no documentation, then there is no proof the splint was put on the resident that day. V2 confirmed R129 has an order for bilateral hand splints to be worn daily for up to 4 hours. Surveyor asked V2 to review V129's POC response over the past 30 days and V2 verbalized that R129 wore hand splints 11 out of 30 days. V2 stated that the potential problem if a resident has an order for a splint but is not receiving it as ordered then the resident would not receive the therapeutic effects that the hand splints would have provided. V2 stated that V2 does not know why the aide would check not applicable because the resident has an order for the splint so the splints must be applicable. R24 has diagnosis not limited to End Stage Renal Disease, Dependence on Renal Dialysis, Polyneuropathy, Chronic Pain Syndrome, Osteoarthritis (Unspecified Site), Peripheral Vascular Disease, Acquired Absence of Left Leg Above Knee, Obesity. R24's MDS (Minimum Data Set) dated 01/01/23 BIMS (Brief Interview for Mental Status) score 15 indicates R24 cognition is intact. R24's Occupational Therapy (OT) Progress and Discharge summary dated [DATE] documents in part OT educated patient/caregiver in application of left resting hand splint to decrease further risk of contracture, applied passive stretch to left digits and wrist to decrease stiffness in joints necessary for self-care/transfer tasks. R24 completed 2 hours tolerance to left resting hand splint and OT discharged to facility and transition to restorative care to focus on splinting. R24's active orders as of 03/15/23 documents in part, left hand resting splint ordered 12/03/22. R24's care plan dated 12/11/20, revised 03/15/23 documents in part, R24 has impaired mobility and requires the use of left-hand splint for therapy treatment. R24's document titled, POC Response History for the task of assistance with splint or brace over the past 30 days from 03/15/23 documents (02/18/23) resident refused, (02/22/23) 15 minutes (amount of minutes spent providing splint or brace assistance), (02/24/23) not applicable, (03/01/23) not applicable, (03/09/23) not applicable, (03/10/23) not applicable. R129 has diagnoses not limited to Hallervorden-[NAME] Disease, Pressure Ulcer of Right Elbow (Stage 4), Pressure Ulcer of Sacral Region (Stage 4), Expressive Language Disorder, Dystonia, Dysphagia, Adult Failure to Thrive, Psychomotor Deficit, Schizoaffective Disorder, Bipolar Disorder, Anxiety, Depression, Anemia. R129's MDS (Minimum Data Set) dated 01/01/23 BIMS (Brief Interview for Mental Status) indicates resident is rarely/never understood. R129's Occupational Therapy Evaluation and Plan of Treatment dated 11/15/2022 documents in part R129 presents with impairments of both wrists and finger contractures requiring functional splint. R129's Occupational Therapy Discharge summary dated [DATE] documents in part R129 will safely wear least restrictive splinting/orthotic device (functional splint) during daily tasks in order to inhibit abnormal reflex patterns and reduce abnormal tone for 4 hours on/4 hours off and bilateral hand splints for prevention of further deformities and contractures on bilateral upper extremity and R129 is currently dependent in splint care and wearing. R129's active orders as of 03/15/23 documents in part, bilateral hand splints ordered 12/03/22. R129's care plan revised 08/29/22 documents in part, R129 has impaired mobility and requires the use of a splint on bilateral hands related to limited range of motion due to diagnosis of Hallervodren-[NAME] and R129 would benefit from usage of splints to prevent further decline in limbs. R129's document titled, POC Response History for the task of assistance with splint or brace: bilateral hands for four hours over the past 30 days from 03/15/23 documents the amount of minutes spent providing splint or brace assistance on (02/15/23) 15 minutes, (02/16/23) 15 minutes, (02/17/23) 15 minutes, (02/18/23) 15 minutes, (02/20/23) 15 minutes, (02/24/23) not applicable, (03/01/23) not applicable, (03/07/23) 15 minutes, (03/09/23) 15 minutes, (03/10/23) 15 minutes, (03/11/23) 15 minutes, (03/12/23) 15 minutes, (03/13/23) not applicable. Facility policy titled, Contracture Prevention Policy dated 2008 documents in part the assigned Certified Nursing Assistant applies and removes all contracture prevention appliances such as splints per doctors' orders and application of appliances is documented daily. On 3/14/23 at 11:31 AM, R32 was sitting on the wheelchair in the dining room alert and able to verbalize needs. R32 was noted with range of motion limitation on R32's left arm and hand with no assistive device in place. R32 stated R32 does not use splint or brace for R32's left upper extremity. At approximately 11:40 AM, R150 was observed lying in bed alert and able to verbalize needs. R150 was noted with range of motion limitations on both lower legs. R150 denied staff providing range of motion exercises. R32's face sheet shows an initial admission date of 6/8/21 with listed diagnoses not limited to Chronic Obstructive Pulmonary Disease, Unspecified Lack of Coordination, Other Abnormalities of Gait and Mobility, and Unsteadiness on Feet. R32's Annual Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 1/4/23 shows R32 is moderately impaired in cognition and has functional limitation in range of motion to one side of R32's upper extremity. It also shows that R32 is on Restorative Nursing Programs of Active Range of Motion (AROM), Splint/Brace, Transfer, and Dressing/Grooming. R32's ECG-(Restorative) ADLs & Program Review - V1 signed late on 3/15/23 does not detail the progress or lack of progress in the restorative services for R32. R32's progress notes were reviewed within the lookback period of R32's 1/4/23 Annual MDS assessment but no restorative note was found that details the progress or lack of progress in the restorative programs for R32. R150's face sheet shows an initial admission date of 5/3/22 with listed diagnoses not limited to Paraplegia, Chronic Respiratory Failure, Right Knee Contracture, and Dorsalgia. R150's Annual MDS assessment with ARD of 1/18/23 shows R150 is cognitively intact and has functional limitations in range of motion to both lower extremities. It also shows that R150 is on Restorative Nursing Programs of Passive Range of Motion (PROM), Bed Mobility, and Dressing/Grooming. There was no Restorative assessment found in R150's electronic health record (EHR) within the lookback period of this Annual MDS assessment. The last and recent Restorative assessment found was dated on 5/5/22. R150's ECG-(Restorative) ADLs & Program Review - V1 signed on 5/5/22 does not detail the progress or lack of progress in the restorative services for R150. R150's progress notes were reviewed within the lookback period of R150's 1/18/23 Annual MDS assessment but no restorative note was found that details the progress or lack of progress in the restorative programs for R150. On 3/15/23 at 12:38 PM, interviewed V11 (Restorative Nurse) and stated that restorative programs are documented in the resident's restorative assessment. V11 stated there is no set schedule to complete a resident's restorative assessment. V11 stated, It could be quarterly or after their therapy. It depends. V11 stated that if there is no issue with the resident's restorative programs, V11 does not document the progress or lack of progress of the resident with their restorative programs. The facility's policy titled; Restorative Protocol with no date reads in part: 1) Upon admission, restorative nurse has 72 hours to assess resident and determine restorative program and care plan needs. If resident is independent, document this status on functional assessment. Inactivate CNA documentation then reassess quarterly. 2) If a resident requires supervision or more assistance, initiate programs and a plan of care and complete Nurse Instructions. Reassess resident every quarter during 7 day look-back, update/review Nurse Instructions, activate CNA assignments during 7 day look-back, and place program needs/care plan over bed.

CONCERN (E)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

On 3/14/23 at 11:19 AM, R120 was lying in bed alert and awake. Noted with slight congestion. R120 stated R120 uses oxygen for difficulty breathing. Noted R120's oxygen concentrator was turned on but t...

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On 3/14/23 at 11:19 AM, R120 was lying in bed alert and awake. Noted with slight congestion. R120 stated R120 uses oxygen for difficulty breathing. Noted R120's oxygen concentrator was turned on but the connector was not connected to R120's oxygen tubing. Also noted R120's oxygen tubing and humidifier bottle had no dates labeled when they were last changed. At approximately 11:25 AM, surveyor requested V29's (Licensed Practical Nurse) assistance in R120's room. V29 confirmed R120's oxygen tubing was not connected to the oxygen concentrator. V29 stated that V29 needs to re-connect and fix R120's oxygen. V29 stated that R120 is receiving supplemental oxygen related to R120's respiratory medical condition. V29 stated R120 could stop breathing if oxygen is not connected properly to the concentrator. V29 also stated that oxygen tubing and humidifier bottle should be changed weekly or as needed and should be dated when they were last changed. At 11:36 AM, R8 was sleeping in bed and noted R8's receiving supplemental oxygen at 3 liters per minute (LPM) via nasal cannula. R8's oxygen tubing and humidifier bottle were not dated. R120's face sheet shows an initial admission date of 8/2/19 with listed diagnoses not limited to Pneumonia, Bronchiectasis, Chronic Obstructive Pulmonary Disease, and Malignant Neoplasm of Unspecified Part of Right Bronchus or Lung. R120's physician order sheet (POS) shows an order of oxygen per nasal cannula as needed every 24 hours and to change oxygen tubing weekly and as needed. R8's face sheet shows an initial admission date of 5/3/10 with listed diagnoses not limited to Chronic Obstructive Pulmonary Disease, Unspecified Asthma, and Generalized Anxiety Disorder. R8's POS shows an order of continuous oxygen at 2-3LPM via nasal cannula and to change oxygen tubing weekly. Based on observations, interviews and record reviews, the facility failed to ensure oxygen tubing, humidifier bottles, and nebulizer equipment were properly dated and stored to prevent cross-contamination for 4 (R8, R120, R123, R168) residents; and failed to ensure a resident's oxygen tubing was properly connected to the oxygen concentrator for 1 (R120) of 4 residents receiving supplemental oxygen out of 35 sampled residents reviewed for respiratory care. Findings Include: On 03/14/23 at 12:02 PM surveyor entered R123 room and observed R123 with oxygen in use per nasal cannula. Oxygen tubing was observed undated. Nebulizer mask, tubing and handheld nebulizer were observed laying on the bedside table undated and not stored in a protective bag. R123's Physician order dated 03/06/23 document in part: Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 8 hours as needed. R123's Physician order dated 06/22/20 Oxygen @ 2L (Liters) Per Nasal Cannula as Needed for shortness of breath, end date 05/24/22. Care Plan document in part: o R123 has a Dx (Diagnosis) of COPD (Chronic Obstructive Pulmonary Disease) and pulmonary embolism. Encouraged/assisted to have the head of his (R123) bed elevated to prevent shortness of breath when lying flat in bed. On scheduled inhaler and nebulization treatment. Date Initiated: 09/22/2020 Revision on: 08/24/2021. o OXYGEN SETTINGS: O2 (oxygen) via nasal cannula at 2L as needed. Date Initiated: 09/22/2020 Revision on: 08/10/2021. On 03/14/23 at 12:40 PM surveyor entered R168 room and observed R168 oxygen tubing nasal cannula hanging on an electrical cord plugged into an outlet on the wall. Oxygen tubing was observed undated and not stored in a protective bag. R168 stated I use the oxygen every day. R168's Physician order dated 02/08/23 document in part: Oxygen Continuous 2L/min (Liters/minute) Via Nasal Cannula every shift. Care Plan document in part: o R168 has a Dx (Diagnosis) of COPD (Chronic Obstructive Pulmonary Disease). Encourage/assist R168 to have the head of her bed elevate to avoid shortness of breath when lying flat in bed. On continuous oxygen therapy. Date Initiated: 02/09/2023. R168 has oxygen therapy related to Dx of COPD, Pneumonia and Pleural Effusion. Date Initiated: 02/09/2023 On 03/15/23 at 03:31 PM V2 (Director of Nursing) stated, When the oxygen tubing is changed it should be labeled and dated. On 03/16/23 at 10:02 AM V2 (Director of Nursing) stated, The Oxygen tubing is changed on the night shift and as needed and should be labeled and dated. If the oxygen tubing is not labeled and dated there is no way to keep track of how long, it has been in use. When not in use the oxygen tubing and nebulizer should be stored in a Zip-lock bag to keep it clean and prevent infection. Policy: Titled Infection Control Program revised 06/95 document in part: There is an active facility-wide infection control program with effective measures to identify, control, and prevent infections acquired or brought into the long-term care facility from community or other health care facilities. Policies address preventive/control procedures, including surveillance of sterilization and disinfection practices. Titled Oxygen Administration undated document in part: Purpose to administer oxygen to the resident. Procedure: 1. Check physician's order for liter flow and method of administration. 11. When oxygen therapy is discontinued dispose of all disposable equipment properly. Titled Oxygen and Nebulizer Administration and Storage updated 03/23 document in part: Purpose: To administer oxygen and Nebulizer treatment to the resident. Procedure: Oxygen Administration. Check physician's order for liter flow and method of administration. 11. When oxygen therapy is discontinued dispose of all equipment properly. 12. When oxygen tubing is not in use, tubing and/or oxygen mask will be stored in a clean storage bag as provided by the facility. 13. Change and label oxygen tubing and mask every 72 hours and as needed. Care of Nebulizer equipment when not in use: C. Store mask and tubing in facility provided storage bag and store until next use. D. Change and label tubing and mask every 72 hours and as needed.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review the facility failed to ensure a.) medications were labeled with an open date for 2 (R10, R91) of 2 residents, b.) expired medications were removed and...

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Based on observation, interview and record review the facility failed to ensure a.) medications were labeled with an open date for 2 (R10, R91) of 2 residents, b.) expired medications were removed and discarded in 1 of 4 medication carts and 1 of 2 medication rooms and c.) the medication refrigerators had a lock in 2 of 2 medications rooms during the review of the medication carts and medication storage rooms in a sample of 35 residents. Findings Include: On 03/14/23 at 10:43 AM V8 (Licensed Practical Nurse) entered R78 room giving R78 the scheduled 09:00 AM medications. Cetirizine 10 MG Expiration date 10/22 (instead of Loratadine Tablet 10 MG). On 03/14/23 at 11:46 AM surveyor asked V8 (Licensed Practical Nurse) to open the top drawer of the sixth-floor team two medication cart to retrieve the pill bottle containing Cetirizine 10 MG (Milligram) that was given to R78. V8 retrieved the medication bottle as was asked by the surveyor to read the expiration date. V8 responded, the expiration date is 10/22. I will throw it out. Before giving medications, we are supposed to check the expiration date. If expired medications are given the resident may have a reaction. On 03/15/23 at 10:02 AM the second-floor medication room was checked with V30 (Registered Nurse). The refrigerator was observed without a lock, five 650 mg (Milligrams) acetaminophen suppositories were observed in the refrigerator with an expiration date of 12/22. V30 stated, The expired medications are given the Director of Nursing or sent back to the pharmacy. I will have to call our supply guy to get another lock for the refrigerator. House stock intravenous fluid 5% Dextrose/ 0.9 % Sodium chloride 1000 ml (Milliliters) was observed on the bottom cabinet shelf of the medication room with an expiration date of 09/22. On 03/15/23 at 10:27 the fourth-floor medication room was checked with V11 (Licensed Practical Nurse). The refrigerator was observed to be without a lock. V11 stated, I will call maintenance to get a lock for the refrigerator in the medication room. On 03/15/23 at 10:40 AM the fifth-floor team two medication cart was checked with V7 (Registered Nurse). R91 polymyxin solution instill one drop into both eyes every 3 hours for 10 days, dispensed 03/10/23 and R10 Fluphenazine Decanoate 125 mg/ml (Milligram/Milliliter) 25 mg/ml 5 ml vial dispensed 10/08/22 were observed in the top drawer of the team 2 medication cart open and undated. V7 stated, When the multi-dose medication is opened it is labeled with the open date. On 03/15/23 at 03:31 PM V2 (Director of Nursing) stated, The pharmacy come to clean the medication cart and take the expired medications. The medication expiration date should be checked to before administration make sure the medications are not expired. There is a potential the resident can get sick or have an adverse react to the medications if the medication is expired. Surveyor asked V2 if Cetirizine 10 mg be used to replace Loratadine Tablet 10 MG. V2 stated, I will call the pharmacy to see Cetirizine can be used in place of the Loratadine. On 03/16/23 at 10:02 AM V2 (Director of Nursing) stated, Cetirizine cannot be used in place of Loratadine. On 03/16/23 at 02:28 V2 (Director of Nursing) surveyor requested Medication refrigerator lock and expired medication policies. The policies were not provided. Policy: Titled Medication Administration and Storage Policy revised 07/02/18 document in part: Policy: To ensure medications are administered & stared in accordance with Standard of Practice. Procedure: 2. Medications shall be given within one (1) hour of the specified time. 8. House stocked medications should not be administered after expiration date located on the manufacturer's bottle. 15. Nurses are to wash their hands prior to the start of the medication pass procedure. A) After any resident contact. 20. Physician must be notified when medications are not administered as per physician order. 22. Medication that are not administered as per physician orders must be documented in the drop-down box and/or progress note. Titled Storage of Medication revised 05/01/18 document in part: Medication and biologicals are stored safely, securely, and properly. H. Outdated, contaminated, or deteriorated medications and those containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. Expiration Dating: C. Certain medications or package types, such as IV (Intravenous) solutions, multiple dose injectables, ophthalmic once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. D. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: An ophthalmic medication. E. When the original seal of a manufacturer's container or vial is initially broken, the container will be dated. 1. The nurse will place a date opened sticker on the medication and enter the date opened and the new date of expiration. F. The nurse will check the expiration date of each medication before administering. G. No expired medication will be administered to a resident. H All expired medications will be removed from the active supply and destroyed in the facility.

CONCERN (E)

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

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to ensure there are no more than 14 hours between the evening meal and breakfast the following day and failed to serve a nourishing snack at b...

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Based on interview and record review, the facility failed to ensure there are no more than 14 hours between the evening meal and breakfast the following day and failed to serve a nourishing snack at bedtime to residents who do not have a specific order for evening snacks. This deficient food service practice has the potential to affect 85 residents in a total sample size of 186 residents receiving an oral diet from the facilities kitchen. Findings include: On 03/14/23 after initial kitchen tour and tray line observation, V14 (Food Service Manager) provided schedule for mealtimes which documents range of mealtimes between 7:15-8:15 AM for breakfast, 11:25-12:25 PM for lunch, and 4:25-5:25 PM for dinner and that the nursing units are scheduled to be delivered in the same order for every meal (first the Main Dining Room, then the 5th Floor, then the 6th Floor, then the 4th Floor, and lastly the 2nd Floor). The mealtime schedule documents in part, that the Main Dining Room receives dinner at 4:25 PM and breakfast at 7:15 AM, the 5th Floor receives dinner at 4:40 PM and breakfast at 7:30 AM, the 6th Floor receives dinner at 4:55 PM and breakfast at 7:45 AM, the 4th Floor receives dinner at 5:15 PM and breakfast at 8:00 AM, and the 2nd Floor receives dinner at 5:25 PM and breakfast at 8:15 AM. On 03/14/23 at 02:24 AM, V14 stated that some of the residents receive individual labeled evening snacks after the dinner meal if they are specifically ordered by the physician or the Registered Dietitian. V14 stated that if a resident does not have a specific order for an evening snack, then they would not get a snack. V14 stated that there are no bulk snacks sent to the units in the evening after dinner service. V14 provided a printed-out list of residents who receive evening snacks as prepared on 03/14/23. On 03/14/23 at 05:05 PM, surveyor observed dinner tray line in progress and V14 stated that the tray line is working on the last unit (2nd Floor) for dinner service. On 03/15/23 at 04:23 PM, V14 stated that there should be no more than 14 hours between the resident's dinner and breakfast meals and that some of the residents receive evening snacks but not all the residents get a snack after dinner. V14 stated, that V14 would not want to go that long without eating something. On 03/15/23 at 4:33 PM, surveyor conducted interview with V35 (Consulting Registered Dietitian) over the phone and V35 stated that there should be no more than 14 hours between the dinner and breakfast meal. Surveyor read off the dinner and breakfast mealtimes to V35 and V35 stated that the time between dinner and breakfast comes up to approximately 15 hours which is greater than 14 hours. On 03/15/23 surveyor reviewed Resident Council Meeting Minutes provided by V1 (Administrator) and there was no mention of resident request or approval for mealtimes to be extend beyond 14 hours lapse time between dinner and breakfast meal. On 03/15/23 at 5:25 PM, V1 stated that the residents have not requested different mealtimes. Kitchen facility policy titled, Meal Time undated, documents in part no more than a 14 hour span between supper and breakfast will occur and snacks will be served at bedtime.

CONCERN (E)

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

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review the facility failed to (A) ensure resident's personal refrigerators temperatures were maintained at 41 degrees Fahrenheit; (B) clean personal refrige...

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Based on observation, interview, and record review the facility failed to (A) ensure resident's personal refrigerators temperatures were maintained at 41 degrees Fahrenheit; (B) clean personal refrigerators regularly to maintain a safe and sanitary environment for food storage; (C) ensure resident's refrigerator is properly working; (D) date/label food items; and (E) Discard expired food items after 3 days for 5 [R59, R104, R132, R166, R170] of 5 residents reviewed for personal refrigerators in the sample of 35 residents. Finding include, On 3/14/23 at 10:15 AM, surveyor and V7 [Registered Nurse] entered R132's room and surveyed R132's personal refrigerator. Observed ice buildup along the back of the refrigerator with a pack of raw duck breast, raw pork meat, a metal spoon with dried white and green particles in the scoop part of the spoon. V7 stated, Nursing is not responsible for residents' personal refrigerators. There is no thermometer in this refrigerator, and no dates or labels on the food items. The duck breast and pork need to be discarded; the food does not feel cold to touch. I will ask housekeeping to come clean up all the dried-up old food spills and crumbs. On 3/14/23 at 10:21 AM, surveyor and V7 [Registered Nurse] entered R59's room and surveyed R59's personal refrigerator. Observed open half-filled Miracle Whip, turkey breast lunch meat, cook fried chicken, rice with beans, thawed out breakfast box with breakfast sausage, two containers of Chinese food. V7 stated, R59's refrigerator has a foul odor, and the food items are all room temperature. There is no thermometer in the refrigerator. I will ask housekeeping to come clean out all the food spills. On 3/14/23 at 10:47 AM, V26 [Director of Housekeeping] stated, I will have someone clean R132, and R59's personal refrigerator, but housekeeping will not discard any food items, that is for nursing staff to do. I will let maintenance know there is no thermometer in the personal refrigerator. On 3/14/23 at 11:02 AM, surveyor and V28 [Licensed Practical Nurse] entered R166's room and surveyed R166's personal refrigerator and observed melted ice cream, wet hot dog buns, brown and black spills all inside the refrigerator. V28 stated, Housekeeping is responsible to keep the personal refrigerators cleaned out. I do not know the temperature, there is no thermometer in this refrigerator. I will have housekeeping clean the refrigerator out. I will have them throw out the melted ice cream. On 3/14/23 at 11:15 AM, surveyor and V28 entered R170's room and surveyed R170's personal refrigerator. Observed dried brown and yellow spots all in the refrigerator and freezer. Noted veggie sausage that was thawed in the freezer. V28 stated, There is no thermometer in the refrigerator or top freezer part. R170 have a strict diet due to his religion and prefer to stock his [R170] food. I will have housekeeping clean out the freezer and refrigerator. On 3/14/23 at 11:20 AM, surveyor and V29 [Licensed Practical Nurse] surveyed R104's personal refrigerator. Observed dried dark brown, red, and black colored spills with brown and serve breakfast thawed to room temperature. V29 stated, Housekeeping was to keep the person refrigerators clean. I do not know the temperature of the refrigerator, there is no thermometer in the refrigerator. On 3/15/23 at 2:52 PM, V27 [Maintenance Director] stated, The maintenance department is responsible to make sure thermometers are in each personal refrigerator and to monitor the temperature every day and record their findings. Housekeeping is responsible to clean the personal refrigerators every day. Certified nurse assistance is responsible to label, date, and discard expired food daily. If the personal refrigerators temperature is not being monitored by the thermometers, foods not dated and discarded, it could potentially make the residents sick. On 3/16/23 at 10:11 AM, V2 [Director of Nursing] stated, The resident personal refrigerators, food items should be dated and labeled properly with the date the food was stored and date to discard the expired food items. Cooked food stored in the refrigerator should be dated and discarded after two days. The dating and labeling of stored food in the resident's room is completed by the certified nurse assistants. Housekeeping is responsible to clean the refrigerators. Maintenance is responsible for monitoring the temperatures on the thermometer in the refrigerators and keeping a log of the recordings. If the food is not kept and the correct temperatures, not dated properly, and expired food not discarded, it could potentially cause the resident to become sick with a food borne illness. Policy documents in part: Food obtained from Outside Sources (No date) -Personal cold storage (refrigerator) temperature should be maintained at 41 degrees Fahrenheit or below. Refrigerators should be cleaned regularly to maintain a safe and sanitary environment for food storage -Perishable potentially hazardous foods should be discarded on the sixth day after it was prepared or opened Refrigerators (Resident) (No date) -Ensure that all resident refrigerators are in proper working order and kept clean -The maintenance and housekeeping staff is responsible for ensuring that a resident's refrigerator is in proper working order and clean -The certified nurse assistant is responsible for overseeing care for a resident with a refrigerator and will check all contents for proper date of food items and check for cleanliness of the refrigerator on a weekly basis -Food or beverages brought in by family or visitors may be stored in the resident's refrigerator, food will be discarded after 3 days

CONCERN (E)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

Based on interview and record reviews, the facility failed to follow policy on Influenza and Pneumococcal Vaccine for 5 (R24, R21, R179, R191, R241) residents out of 5 residents who did not receive in...

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Based on interview and record reviews, the facility failed to follow policy on Influenza and Pneumococcal Vaccine for 5 (R24, R21, R179, R191, R241) residents out of 5 residents who did not receive influenza and/or pneumococcal vaccination, and failed to document person, time and date of education provided prior to refusal. These failures affect 5 residents out of 5 (R24, R21, R179, R191, R241) residents reviewed for vaccine(s). Findings include: On 3/15/23 at 1:20 PM V2 (Director of Nursing (DON) / Infection Preventionist (IP) nurse) was interviewed and stated that the previous IP nurse resigned or did not show up a week ago. V2 stated no proper endorsement was done by previous IP nurse and facility was not able to contact the previous IP. V2 stated, I am trying to gather documents pertaining to Infection Control. V2 stated that she (V2) prioritized to complete IP certification which was completed on 3/13/23. V2 stated that Influenza and Pneumococcal vaccine should be offered to all residents. V2 stated that education should be provided when resident is refusing to receive the vaccine and should be documented in EHR. V2 stated that consent should be obtained prior to giving the vaccine. V2 stated that the potential effect of not getting the vaccines is that resident could miss the benefits of the vaccines and resident could easily acquire the virus. V2 stated that as a rule in nursing if it was not documented it was not done. Record review of facility's immunization tracker for flu and pneumococcal documented the following residents did not receive and / or refused flu and pneumococcal vaccine: 1. R24 refused flu and pneumococcal vaccine. R24 admission date was on 9/13/22 with diagnosis not limited to End stage renal disease, Asthma, Anemia, Heart failure, Type 2 Diabetes Mellitus, Sleep apnea, Personal history of Covid 19. R24 physician order sheet (POS) for March 2023 documented in part: Influenza vaccine annually with order date of 9/15/22. R24 electronic health record (EHR) reviewed with V2 and stated that R24 refused flu and pneumococcal vaccine. V2 confirmed no education found in R24's immunization EHR. 2. R21 refused flu vaccine. R21 admission date was on 2/11/22 with diagnosis not limited to Chronic obstructive pulmonary disease, Hemiplegia and hemiparesis following cerebral infarction, Heart failure, Hypertensive heart disease, Chronic kidney disease. R21 EHR reviewed with V2 and stated that R24 refused flu vaccine. V2 confirmed no education found in R21's immunization EHR. 3. R179 has no record documented in flu and pneumococcal tracker. R179 admission date was on 10/20/22 with diagnosis not limited to End stage renal disease, chronic obstructive pulmonary disease, asthma, anemia, type 2 diabetes mellitus. R179 POS for March 2023 documented in part: Influenza vaccine annually with order date of 10/21/22. May have pneumonia vaccine every 5 years as applicable / appropriate with order date of 10/21/22. R179 EHR reviewed with V2 and stated that R179 has no record found for flu and pneumococcal vaccines. V2 confirmed no education found in R179's immunization EHR. 4. R191 has no record documented in flu and pneumococcal tracker. R191 admission date was on 3/5/23 with diagnosis not limited to Hypertension, anemia, type 2 diabetes mellitus. R191 POS for March 2023 documented in part: Influenza vaccine annually with order date of 3/7/23. May have pneumonia vaccine every 5 years as applicable / appropriate with order date of 3/7/23. R191 EHR reviewed with V2 and stated that R191 has no record found for flu and pneumococcal vaccines. V2 confirmed no education found in R191's immunization EHR. 5. R241 refused flu vaccine and has no record for pneumococcal vaccine documented in flu and pneumococcal tracker. R241 admission date was on 12/31/22 with diagnosis not limited to Chronic obstructive pulmonary disease, Congestive heart failure, anemia. R241 POS for March 2023 documented in part: Influenza vaccine annually with order date of 1/2/23. May have pneumonia vaccine every 5 years as applicable / appropriate with order date of 1/2/23. R241 EHR reviewed with V2 and stated that R241 has no record found for pneumococcal vaccine and R241 had refused flu vaccine. V2 confirmed no education found in R241's immunization EHR. Facility's immunization policy with no date documented in part: In order to minimize the risk of residents acquiring, transmitting or experiencing complications from influenza and pneumococcal pneumonia, it is the policy of this facility to offer influenza and pneumococcal vaccination for all residents. 1. Each resident or the resident's representatives will receive education regarding the benefits and potential effects of influenza immunization. 4. The resident's medical record will indicate: a. that the resident or resident's legal representatives was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunization.

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 cooking equipment was properly sanitized. This deficient food service practice has the potential to affect all 186 resi...

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Based on observation, interview and record review, the facility failed to ensure cooking equipment was properly sanitized. This deficient food service practice has the potential to affect all 186 residents receiving oral diets from the facility's kitchen. Findings include: On 03/14/23 at 10:09 AM, surveyor observed V17 (Chef) measure out portions of green beans into metal blender container as part of the pureed vegetable preparation. After V17 finished pureeing the green beans, surveyor observed V17 place the metal blender container and lid near the 1st of the 3-compartment sinks, near the kitchen prep area. On 03/14/23 at 10:16 AM, surveyor observed V18 (Cook) take the metal blender container and lid and wash them by hand in the 1st compartment sink. Then surveyor observed V18 rinse each item in the 2nd compartment sink. The 3rd compartment sink was empty (not filled with any water or sanitizing solution). Surveyor observed V18 put the metal blender container and lid on the side of the 3rd compartment sink. On 03/14/23 at 10:17 AM, surveyor asked V18 if there was any sanitizer in the 3rd compartment sink and V18 replied, no. On 03/14/23 at 10:19 AM, surveyor observed V17 pick up the metal blender container from the area next to the 3rd compartment sink and began to add diced chicken portions into the blender. Surveyor then observed V17 putting the lid on top of the metal blender container and brings it to the blender motor base to begin the process of pureeing the chicken. On 03/14/23 at 10:22 AM, surveyor observed the V18 filling the 3rd compartment sink with sanitizing solution. V18 stated that the 1st sink is for cleaning, the 2nd sink is for rinsing ( and only contains water), and the 3rd sink is the last step and contains a disinfectant to sanitize the cooking equipment. V18 stated, you need to dip the equipment in there for 5 seconds to sanitize it. On 03/14/23 at 11:29 AM, observed V19 (Dietary Aide) hand wash 2- gray handled scoops in the 1st sink, then dip them each into the 2nd sink and then dip each of them into the 3rd sink for less than 10 seconds. Surveyor then observed V19 put the 2- gray handled scoops back into the 2nd sink and then ran both scoops under running water from the faucet. On 03/14/23 at 11:30 AM, surveyor observed V19 bring the 2-gray handled scoops to the tray line for use. On 03/14/23 at 11:35 AM, V19 observed using 1 of the gray handled scoops to portion out the pureed chicken and the other gray handled scoop to portion out the pureed green beans on the tray line. On 03/14/23 at 11:36 AM, surveyor observed V21 (Dietary Aide/Pot Washer) washing white handled scoop in the 1st compartment sink, then rinsed it in the 2nd compartment sink and then dip it in the 3rd compartment sink for less than 5 seconds. On 03/14/23 at 11:42 AM, surveyor observed V21 washing large metal container in the 1st compartment sink, then rinse in the 2nd compartment sink and then dip the container into the 3rd compartment sink for 3 seconds before placing the item on the side of the sink. On 03/14/23 at 11:42 AM, surveyor observed V21 take another large metal container and began to wash it in the 1st compartment sink, then rinsed it in the 2nd compartment sink, then dipped the container into the 3rd compartment sink for less than 5 seconds and then placed the item on the side of the sink. On 03/14/23 at 11:46 AM, V21 stated that the purpose of submerging the equipment into the 3rd sink is to sanitize the item so that it removes all the germs that the rinse water did not get. V21 stated that it is not enough to just wash and rinse the equipment, that all items need to be placed in the sanitizing solution. V21 stated that there is not a specific amount of time the item should be left submerged in the sanitizing solution. V21 stated maybe 10 seconds? I usually dip it a couple of times. On 03/15/23 at 3:40 PM, V14 (Food Service Manager) stated that regarding the 3-compartment sink the 1st sink is used to wash cooking equipment and contains only soapy water, the 2nd sink is used to rinse the items and contains only water, no sanitizer and the 3rd sink contains a sanitizer to disinfect the cooking equipment. V14 stated that the cooking equipment being washed needs to be submerged into the sanitizing solution in the 3rd sink for 10 seconds. V14 stated that it is important to sanitize the cooking equipment to avoid bacteria growth and prevent food borne illness. V14 stated that the kitchen uses a Quaternary type of sanitizer, and the manufacturer guidelines are followed. V12 (Dietary Technician) walked with surveyor to the 3-compartment sink and V12 read out loud the manufacturers guidelines for sanitation in the 3rd compartment since which documented, immerse utensils in sanitizer sink for a full minute. V14 confirmed that the manufactures guidelines posted above the 3-compartment sink is the current manufacturer sanitation product used by the kitchen. V14 stated that V14 misunderstood the surveyor's initial question and stated that yes, the item being washed needs to be submerged in the 3rd compartment sink containing the sanitizing solution for 1 minute and that if the item is in the sanitizing solution for less than a minute the item would not be sanitized. Kitchen policy titled Manual Sanitizing undated, documents in part that utensils and equipment will be exposed to the final chemical sanitizing rinse in accordance with manufacturer's specifications for time and for QAC space (Quaternary) contact time per Manufacturer's instructions. Manufacturer document titled, Procedures for 3 Compartment Sinks documents in part, immerse utensils in sanitizer sink for a full minute.

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 observations, interviews, and record reviews, the facility failed to (a) ensure PPE (Personal Protective Equipment) was worn properly by staff to prevent the transmission of infections; (b) f...

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Based on observations, interviews, and record reviews, the facility failed to (a) ensure PPE (Personal Protective Equipment) was worn properly by staff to prevent the transmission of infections; (b) failed to clean reusable equipment, the glucometer and perform hand hygiene during medication administration; (c) failed to review their Infection Prevention and Control Program (IPCP) policy at least annually; (d) failed to handle, store, process, and transport linens so as to prevent the spread of infection. These failures have the potential to affect all 188 residents as of census dated 3/14/23 residing in the facility reviewed for infection prevention and control and infection surveillance. Findings include: On 3/14/23 at 12:15 PM surveyor observed R163's room with isolation signage by the door. PPE (Personal Protective Equipment) supplies were available outside of the room. V5 (Activity Aide) was observed inside R163's room with no gown and gloves. V5 exited R163's room and was interviewed. V5 observed with face mask. V5 stated she (V5) was not providing direct care and she (V5) was away from R163 when she (V5) was talking to R163 so she (V5) thought she (V5) did not need to wear proper PPE. V5 confirmed she saw the door signage with instructions to wear proper PPE such as gown, gloves and mask. V5 confirmed PPE supplies upon entrance to R163's room. V5 stated she is not aware of the type of isolation for R163. V6 (Licensed Practical Nurse) assigned nurse was present when V5 was not wearing proper PPE inside R163's room. V6 stated, V5 was supposed to wear proper PPE such as gown, gloves and mask to prevent cross contamination or spread of infection. V6 stated, R163 is on contact isolation for CRE (Carbapenem-Resistant Enterobacteriaceae) in urine. R163's admission date was on 6/23/22 with diagnosis not limited to End Stage Renal Disease; Chronic obstructive pulmonary disease; Type 2 Diabetes Mellitus; Atrial Fibrillation; Peripheral vascular disease; Anemia; Benign Prostatic Hypertrophy; Heart Failure; Resistance to other specified beta lactam antibiotics. R163's physician order sheet (POS) with order date of 3/8/23 documented in part: Isolation: Contact Precautions (CRE) every shift. R163 care plan documented in part: R163 is on contact isolation indefinitely related to CRE; R163 has infection related to Dx of CRE. Placed on isolation. R163 care plan interventions include but not limited to: Explain reason for contact isolation; importance of wearing PPE; Explain importance of hand washing; Monitor compliance in observing isolation precaution protocol; Provide health teaching about contact isolation to family and staff and importance of wearing appropriate PPE. On 3/15/23 at 9:20 PM V10 (Assistant Activity Director) stated she (V10) is the acting activity director and responsible in assigning activity staff. V10 stated, each activity aide staff is assigned to each floor. V10 stated V5 is assigned to 2nd floor where R163 is at. V10 stated activity aide staff were provided with in services / education regarding proper use of PPEs. V10 stated V5 is aware that upon entering resident room should look at the signage by the door and should wear proper PPE if resident is on contact isolation precautions. V10 stated if staff is not wearing proper PPEs can cause cross contamination or spread of infection. On 3/15/23 at 1:20 PM V2 (Director of Nursing (DON) / Infection Preventionist (IP) nurse) was interviewed and stated the previous IP nurse resigned or did not show up a week ago. V2 stated no proper endorsement was done by previous IP nurse and facility was not able to contact the previous IP. V2 stated, I am trying to gather documents pertaining to Infection Control. V2 stated she (V2) prioritized to complete IP certification which was completed on 3/13/23. V2 presented only 1 in-service training record regarding infection control signed by nurses only (RN - Registered Nurse and LPN - Licensed Practical Nurse) dated 1/5/23. V2 stated this is the only in-service / education she (V2) did. V2 stated she was not able to obtain other in services / education provided by previous IP nurse. V2 stated that staff are expected to wear proper PPEs to prevent spread of infection. V2 stated that continuous education or in services should be provided to staff regarding infection prevention and control. On 3/16/23 at 10:44am Laundry room and chute room toured with V36 (Certified Nursing Assistant). Chute room observed with broken blue bin with tape on it. Surveyor observed blue bin with overflowing clear plastic bag of soiled linens on the floor, some clear plastic bags of soiled linens were not tied properly, observed soiled pillow cases and linens on the floor. Observed a piece of cloth on the floor with blood on it, V36 confirmed it is a pillow case and stated the bag was not properly tied. Observed 3 yellow bag packed with items on the floor, V36 stated it is resident's belongings. Observed used / soiled disposable gloves on the floor. Survey team made several requests on 3/14/23 at 2:03 PM, at 2:29 PM and at 3:45 PM; on 3/15/23 at 1:20 PM and 3/16/23 regarding policy for Transmission Based Precautions; Infection Prevention and Control Program (IPCP). V1 (Administrator) was able to provide Infection control program policy on 3/16/23 after multiple requests. Facility provided policy General Infection Control Policies with revised date on 2/1/00 documented in part: Purpose - to establish guidelines to follow in the prevention and control of contagious, infectious or communicable diseases. Orientation: 1. All personnel are required to undergo orientation to these policies and procedures within the first two (2) weeks of employment and / or job assignment. 2. Records shall be maintained to reflect the actual dates such programs were begun and completed. 3. No personnel will be assigned to an isolation resident until they are oriented to and familiar with the infection control policies and procedures. In-service training: 1. All personnel in all departments shall be required to attend an in-service on infection control at least annually. 2. On the unit infection control in-services will be held as needed. 3. Records shall be maintained of all such in-services to include those personnel attending, program content, and shall be filed in accordance with established administrative policies. 4. Training will include handwashing techniques, isolation techniques, and use of personal protective equipment. Facility's policy Infection Control Program (no date) documented in part: The purpose of infection control is to prevent or control the transmission of disease. To have an effective infection control program, all staff must first, understand the purpose of infection control; second, understand their specific responsibilities as it relates to infection control; and third, execute procedures as instructed. Staff should become familiar with the policies and procedures included in the infection control policies and procedures manual. The primary purpose is to care for and protect the residents in the facility. On 03/14/23 at 10:14 AM upon exiting the elevator on the fifth floor of the facility the surveyor observed V3 (Licensed Practical Nurse) sitting at the nurse station with her (V3) mask positioned below the chin. On 03/14/23 at 10:16 AM upon exiting the elevator on the sixth floor of the facility the surveyor observed V8 (Licensed Practical Nurse) standing at the medication cart near the nurse station with no mask on. V8 stated, I do not have a mask on because I have taken the COVID (Coronavirus) booster, and it is hard for me to breath with the mask on. On 03/14/23 at 10:21 AM V8 (Licensed Practical Nurse) went behind the nurse station, retrieved, and put on a face mask. On 03/14/23 at 10:23 AM V8 (Licensed Practical Nurse) entered R97 room with the blood pressure/pulse oximeter/temperature machine. V8 proceeded to take R97 vital signs then exited R97 room, returned to the medication cart, and began to prepare R97 medications without performing hand hygiene. On 03/14/23 at 10:33 AM V8 (Licensed Practical Nurse) proceeded to R78 room with the blood pressure machine. V8 entered R78 room with the blood pressure/pulse oximeter/temperature machine and took R78 vital signs without cleaning the blood pressure/pulse oximeter/temperature machine after taking R97 vital signs with the same machine. On 03/14/23 at 10:44 AM V8 (Licensed Practical Nurse) proceeded to and entered R102 room with the blood pressure/pulse oximeter/temperature machine and took R102 vital signs without cleaning the blood pressure/pulse oximeter/temperature machine after taking R78 vital signs with the same machine. V8 then exited R102 room, returned to the medication cart without performing hand hygiene or cleaning the blood pressure/pulse oximeter/temperature machine. On 03/14/23 at 10:47 AM V8 (Licensed Practical Nurse) entered R61 room with the blood pressure/pulse oximeter/temperature machine and took R61 vital signs without cleaning the blood pressure/pulse oximeter/temperature machine after taking R102 vital signs with the same machine. V8 then exited R61 room, returned to the medication cart without performing hand hygiene or cleaning the blood pressure/pulse oximeter/temperature machine and began to prepare R61 09:00 AM medications. On 03/14/23 at 11:00 AM V8 (Licensed Practical Nurse) returned to the nurse station with the medication cart and proceeded to take R71 blood glucose while standing by the medication cart at the nurse station with the result of 160. V8 (Licensed Practical Nurse) then wrapped the glucometer in a sanitizing wipe and placed it in the medication cart drawer without cleaning the glucometer. On 03/14/23 at 11:07 AM R77 was observed sitting in the hallway in his wheelchair grunting. V8 (Licensed Practical Nurse) approached R77 and pushed the wheelchair into R77 room. V8 retrieved the blood pressure/pulse oximeter/temperature machine and took R77 vital signs without cleaning the blood pressure/pulse oximeter/temperature machine after taking R61 vital signs with the same machine. On 03/14/23 at 11:25 AM R33 approached V8 (Licensed Practical Nurse) at the medication cart near the nurse station. V8 retrieved the glucometer from the medication cart drawer and checked R33 blood glucose while standing at the medication cart near the nurse station, with the result of 85. V8 (Licensed Practical Nurse) wrapped the glucometer in a sanitizing wipe then placed it in the top drawer of the medication cart. On 03/14/23 at 11:29 AM V8 (Licensed Practical Nurse) took R18 blood pressure without cleaning the blood pressure/pulse oximeter/temperature machine after taking R77 vital signs with the same machine and blood glucose while standing at the medication cart near the nurse station with the results of 109/74 - 81 blood glucose 77. V8 placed the glucometer on top of the medication cart. V8 did not perform hand hygiene or clean the glucometer. On 03/14/23 at 11:35 AM R491 approached V8 (Licensed Practical Nurse) at the medication cart near the nurse station. V8 retrieved the unclean glucometer from the top of the medication cart and checked R491 blood glucose while standing at the medication cart near the nurse station with the result of 196. V8 (Licensed Practical Nurse) wrapped the glucometer in a sanitizing wipe then placed it in the top drawer of the medication cart. On 03/14/23 at 11:46 AM V8 (Licensed Practical Nurse) stated, Hand hygiene should be done before and after giving the resident their medication. The glucometer is cleaned with bleach wipes, and it should be wiped. There is a potential for infection, and you don't want to transfer any bacteria or anything from one person to another. The policy is that we must wear a face mask. Working in healthcare there is a potential for a high risk of catching COVD (Coronavirus) or spreading infection from me to another resident. The policy for reusable equipment is to clean it between residents, not to transmit infections and bacteria from one resident to another. On 03/15/23 at 11:39 AM V30 (Registered Nurse) stated, The glucometer is cleaned after every resident use. The glucometer is wiped with the disinfecting wipes for 30 seconds and 2 minutes of contact with the wipe. On 03/15/23 at 03:31 PM V2 (Director of Nursing) stated, During medication administration, hand hygiene is done if there was contact. I would expect the nurse to wash their hands or us hand sanitizer to prevent the spread of infection. When the nurse goes from one resident room to the next, I would expect them to wash their hands or use hand sanitizer. When using the Vital sign monitor my expectation is to clean the vital sign monitor between patient with the disinfecting wipes, to prevent the transfer of bacteria from one person to the other. The face mask should be worn at all times with the nose and the mouth covered. If the face mask is not worn properly there is a potential for the spread of infections or contracting infections. The Glucometer is supposed to be cleaned between residents. The entire surface of the glucometer is supposed to be visibly wet with the disinfecting wipe. There is a potential for the spread of infection. On 03/16/23 at 10:02 AM V2 (Director of Nursing) stated, When not in use, the oxygen tubing and nebulizer should be stored in a bag to keep it clean and prevent infection. On 03/16/23 at 02:28 V2 (Director of Nursing) surveyor requested cleaning reusable equipment (Blood Pressure Monitor) policy. Policy was not provided. Policy: Titled Policy and Procedure undated document in part: Subject: Diabetes Management. Policy: It is the policy of this facility to provide optimal nursing care for diabetic patients. 5. Blood Glucose check: E. Hand hygiene is performed by washing hands with soap and water or using an alcohol-based hand sanitizer. q. Clean and disinfect reusable equipment's (glucose monitoring machine) after each use using Clorox Healthcare Bleached Germicidal Wipes for three (3) minutes. The nurse will use gloves and wipe the glucometer with Clorox Healthcare Germicidal Wipes while ensuring it stays wet at all times. The nurse may clean and wrap it then with the Clorox Healthcare Germicidal Wipes for a total of three (3) minutes. The nurse will then lay the disinfected glucometer on a piece of clean surface and let it dry completely. Titled Glucometer Policy written 09/10 document in part: It is the policy of this facility to maintain infection control practices when using glucometer machines. Glucometer machines will be cleaned and disinfected after each use with disinfectant towels with bleach. Procedure: Apply pre-moistened towel to glucometer after resident use and let stand 1 minute. Proceed to the next resident with 2nd glucometer and repeat process after Accuchecks done. 1. Wash hands, 2. Obtain 2 glucometers, 3. Clean both glucometers utilizing pre-moistened towel allowing one minute to dry. Titled Glucometer Cleaning and Disinfection revised 03/20 document in part: Policy: To minimize the risk of transmitting blood-borne pathogens. Clean and disinfect reusable equipment's (glucose monitoring machine) before and after each resident use using Facility's Germicidal Wipes for 1-3 minutes. The nurse will use gloves and wipe the glucometer with Germicidal Wipes while ensuring it stays wet at all times. The nurse may remove excess germicidal solution from the disinfectant wipes when using it on electronic equipment such as glucometer as necessary as long as the glucometer surface stays wet for 1-3 minutes. The nurse may clean and wrap it then with the approved germicidal wipes for a total of 1-3 minutes. The nurse will then lay the disinfected Glucometer on a piece of clean surface and let it dry completely. Titled Personal Protective Equipment revised 01/17 document in part: Personal Protective Equipment (PPE) is that which prevents blood or other potentially infectious material from passing through or contacting the employee's work or street clothing, undergarments, skin, eyes, mouth, or other mucous membranes. Procedure: The employee shall use appropriate personal protective equipment whenever required. Titled Mask Use undated document in part: Purpose: To prevent the transmission of infectious agents through the air. Prevents: The inhalation of large particle aerosols that are transmitted by close contact and generally travel only short distances. The inhalation of small particles that might remain suspended in the air then travel long distances. Transmission of some infections are spread by direct contact with mucous membranes. Procedure: Make sure your mask covers your nose and mouth. Titled Infection Control Program revised 06/95 document in part: There is an active facility-wide infection control program with effective measures to identify, control, and prevent infections acquired or brought into the long-term care facility from community or other health care facilities. Policies address preventive/control procedures, including surveillance of sterilization and disinfection practices. Titled Protocol on Handwashing undated document in part: It is the protocol of the facility that staff will do hand washing as a means of preventing spread of infection. Titled Hand Hygiene Policy Procedure reviewed 09/17 document in part: Effective hand hygiene reduces the incidence of healthcare-associated infections. A indications for Handwashing 3. Handwashing may also be used for routinely decontaminating hands in the following clinical situations: Before having direct contact with patients. After contact with patient's intact skin (e.g. (example) when taking a pulse or blood pressure and lifting a patient). After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. After removing gloves. Titled Oxygen and Nebulizer Administration and Storage updated 03/23 document in part: Purpose: To administer oxygen and Nebulizer treatment to the resident. Procedure: Oxygen Administration. Check physician's order for liter flow and method of administration. 11. When oxygen therapy is discontinued dispose of all equipment properly. 12. When oxygen tubing is not in use, tubing and/or oxygen mask will be stored in a clean storage bag as provided by the facility. 13. Change and label oxygen tubing and mask every 72 hours and as needed. Care of Nebulizer equipment when not in use: C. Store mask and tubing in facility provided storage bag and store until next use. D. Change and label tubing and mask every 72 hours and as needed.

CONCERN (F)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected most or all residents

Based on interview and record reviews, the facility failed to establish an infection prevention and control program (IPCP) that include an antibiotic stewardship program protocol and a system to monit...

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Based on interview and record reviews, the facility failed to establish an infection prevention and control program (IPCP) that include an antibiotic stewardship program protocol and a system to monitor antibiotic use for 4 residents (R41, R490, R176, R89) reviewed for antibiotic use. These failures can potentially affect all188 residents per facility census dated 3/14/23. Findings include: On 3/15/23 at 1:20 PM V2 (Director of Nursing (DON) / Infection Preventionist (IP) nurse) was interviewed and stated that the previous IP nurse resigned or did not show up a week ago. V2 stated no proper endorsement was done by previous IP nurse and facility was not able to contact the previous IP. V2 stated, I am trying to gather documents pertaining to Infection Control. V2 stated that she (V2) prioritized to complete IP certification which was completed on 3/13/23. V2 stated no antibiotic stewardship program and no policy available at this time. V2 stated that nurses are expected to document in EHR (Electronic Health Record) of resident for antibiotic use every shift on daily basis while on antibiotic to monitor use and its side effects. V2 provided a list of residents on antibiotic. Surveyor made multiple requests for antibiotic stewardship program policy on 3/14/23 at 2:03 pm, at 2:29 pm, at 3:45 pm; on 3/15/23 and was not provided. 1. Reviewed EHR with V2 and confirmed that R41 is on antibiotic. R1 Physician order sheet (POS) documented in part: Daptomycin 1020mg Intravenous one time a day every Friday for left foot osteomyelitis with end date of 4/1/23. Daptomycin 680mg Intravenous one time a day every Monday, Tuesday, Thursday for left foot osteomyelitis with end date of 4/1/23. R41 electronic record of nursing progress notes dated 3/11/23, 3/12/23, 3/13/23, 3/14/23 and 3/15/23 reviewed with V2 unable to find nursing documentation every shift for use of antibiotic. 2. R490 POS documented in part: Amoxicillin-Pot Clavulanate oral tab 875-125mg 1 tablet by mouth two times a day for Hidradenitis with end date of 3/20/23. R490 nursing progress notes dated 3/11/23, 3/12/23, 3/13/23, 3/14/23 and 3/15/23 reviewed with V2 unable to find nursing documentation every shift for use of antibiotic. 3. R176 POS: Ampicillin-Sulbactam Sodium intravenous solution 3gm intravenously four times a day for bacteria infection related to sepsis with end date of 3/24/23. Ceftriaxone sodium intravenous solution 2gm intravenously one time a day for sepsis with end date of 3/24/23. R176 nursing progress notes dated 3/11/23, 3/12/23, 3/13/23, 3/14/23 and 3/15/23 reviewed with V2 unable to find nursing documentation every shift for use of antibiotic. 4. R89 POS: Metronidazole intravenous solution 500mg intravenously every 8 hours for sepsis secondary to aspiration pneumonia. End date 3/19/23. R89 nursing progress notes dated 3/11/23, 3/12/23, 3/13/23, 3/14/23 and 3/15/23 reviewed with V2 unable to find nursing documentation every shift for use of antibiotic. V2 stated that resident should have a charting on antibiotic use every shift daily in electronic health record. V2 stated that potential effect of not documenting antibiotic use, side effects are not monitored. V2 stated that as a rule in nursing if it was not documented it was not done. V2 stated no antibiotic stewardship program and no policy available at this time. No policy for antibiotic stewardship program provided despite several request made by SA team. V2 stated that nurses are expected to document in resident's health record every shift for those residents on antibiotic to monitor its use and side effects. R41, R490, R176, R89's EHR reviewed with V2 no nursing notes documentation regarding use antibiotic on 3/11/23, 3/12/23, 3/13/23, 3/14/23 and 3/15/23. Surveyor was unable to review the facility's policy on antibiotic stewardship program because it was not provided after multiple requests.

Nov 2022 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise and monitor a resident (R1) with a known history of alcoh...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise and monitor a resident (R1) with a known history of alcohol abuse. This failure resulted in R1 being hospitalized after passing out from intoxication on the outside patio of the facility. Findings include: R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: UNSPECIFIED FRACTURE OF RIGHT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING, HEPATIC FAILURE, UNSPECIFIED WITHOUT COMA, EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUS, BIPOLAR DISORDER, CURRENT EPISODE MANIC SEVERE WITH PSYCHOTIC FEATURES, TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY, PAIN IN RIGHT LEG. R1's Care plan (dated 09/06/2022) documents R1 is a smoker. R1's Care plan (dated 06/03/2022) documents R1 has alcoholic hepatitis without ascites. Substance Use Policy (Revised 01/05/2022) states: The facility reserves the right to protect all residents, staff, and visitors from the negative effects of substance abuse. The facility will take all precautions necessary to prevent residents from using alcohol or illegal substances. On 11/05/2022 at 9:15am, R1 stated, I was hospitalized on the beginning of October. They were saying that I wasn't acting right, and they were accusing me of drinking. I was drinking but I don't remember what happened because I passed out in my wheelchair, and they sent me to the hospital. I also drank alcohol 2 to 3 months ago, I had me a couple of shots of vodka. It's my preferred choice of alcohol and it makes me feel relaxed and more fun. Somebody had the alcohol here at the facility and they gave it to me. I came to find that the alcohol was in the building because I saw residents with it out on the patio. The facility does not allow me to have alcohol here. On 11/05/2022 at 9:59am R2 stated, The facility does not allow us to drink alcohol while we are residents. They do not allow the residents to bring in alcohol into the facility, if they catch you with it, they will take it. I consumed alcohol on several occasions outside on the patio. It is risky to drink outside on the patio of the facility, but I have consumed alcohol on the patio maybe I had a couple shots. A couple of other residents have consumed alcohol on the patio on many occasions. I have seen R1 drinking on the outside patio on several occasions. On 11/05/2022 at 11:34am, V4 (social worker) stated, R1 is a drinker. R1 is definitely a big drinker and R1 is care planned for it. R1 is also under the care of a psychiatrist. Everybody in this building is under the care of a psychiatrist. To be in this building you have to be under the care of a psychiatrist. A resident in this building cannot refuse the care of a psychiatrist. There is a smoking room monitor outside and it is managed through the housekeeping director. Whenever that patio/smoke house is open there is a staff monitor outside at the same time. R1 is asking many residents to buy alcohol for R1 and R1 also gives alcohol to other residents. We prohibit alcohol in the building and on the patio. We do monitor residents and we check bags when the residents return from being out on pass. On 11/06/2022 at 11:48am V5 (social service director), R1 has a history of ordering alcohol through uber. We educated R1 pertaining to the facility policy prohibiting alcohol, however, R1 ask other residents for alcohol. R1 has a debit card that R1's mother provided R1 with and at times R1 uses the money on the card to pay for alcohol. R1 has a history of alcohol abuse and is cared planned for it. We monitor R1 when R1 is outside on the patio, however, it happens that residents may sneak the alcohol. Since the incident that occurred on 10/02/2022 with R1 passing out in R1's wheelchair on the outside patio due to the alcohol consumption, we implemented more communication, more frequent monitoring of R1's behavior, room sweep. R1 has a history of ordering alcohol through uber so we monitor that as well. We educated R1 pertaining to the facility policy prohibiting alcohol, however, R1 asks other residents for alcohol. There is a smoking schedule on the patio and there are monitors out there during smoking times. There is staff present during smoking times so there is someone looking at these residents at all times. I've been told in the past by some residents that alcohol is brought into the outdoor patio. Those residents are not oriented and those are the residents who reported that some residents are drinking. One resident reported that residents are drinking out on the patio. I have confiscated one resident's alcohol in the past when the resident was just leaving the back patio and had the liquor on the back patio. The residents at the facility are not allowed to have alcohol on the back patio or inside the facility. Progress note (dated 10/02/2022 9:38) documents, R1 returned from hospital via wheelchair. Resident was noted ambulating with rollator with improper balance and gait. Resident was asked to get in wheelchair and resident refused. Resident was noted with alcohol still on breath. Resident went downstairs to smoke patio and was belligerent with staff and was ask to go upstairs and lay down. Resident refused and proceeded to become aggressive with staff. This writer called NP and new order to send to Hospital ER on petition. Progress note (dated 10/02/2022 8:05pm) documents, R1 was sent out to hospital by petition. Mother (POA) was informed. NP was informed as well. Patient personals belonging were packed (one box, two purses) and kept at the nursing station.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to ensure adequate staffing for the 2nd, 5th and 6th floor of the facility. This failure resulted in 2 of the 6 floors of the fac...

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Based on observation, interview and record review, the facility failed to ensure adequate staffing for the 2nd, 5th and 6th floor of the facility. This failure resulted in 2 of the 6 floors of the facility not having adequate staffing to provide resident care. Findings include: On 11/05/2022 at 11:34am, V4 (social worker) stated, I have had residents complain to me that staffing is an issue at the facility. Residents have vented frustration pertaining to lack of staff. On 11/05/2022 at 1:06pm V2 (restorative director) stated, I am the house supervisor on the weekends. We staff adequately, we just don't control their call ins. When we make the monthly schedule, we are fully staffed when we do out daily schedule. Sometimes people call in and that may make us short staffed due to call ins. Basically if we see a pattern of call ins, especially frequent call ins, we don't follow up with that staff member. We should be having the director of nursing, or the administrator should be following up with that person and basically say if you are not consistent, we cannot put you on the schedule because we cannot depend on you to come in. We should be following up with that staff member who calls off a lot and say to them that we cannot put you on the schedule because you are not dependable. We have not had any call offs today so far. The worst weekend is payday weekend because some staff who call off, call of on the weekend that we get paid so that they can go and spend their money. This facility does not utilize a staffing agency. We advertise on different websites to hire more staff. We also recruit CNAs at CNA class, CNA schools. The facility offers are given to staff who stays over and picks up. This is their way of showing employees that they appreciate them. We do not utilize a staffing agency. There is a RN scheduled on each shift every day. The evening shift is more challenging with CNA shortages. On 11/05/2022 at 12:37pm, V6 (registered nurse) stated, Here on the second floor there are 23 residents in total. Currently, there is only 1 nurse on duty because I am a nurse in training. I just started working here and I am currently in orientation. There are 3 certified nursing assistants. There should be 2 nurses on the second floor, but during this 7am to 3 pm shift there is only 1. Most of the residents are bed bound and totally dependent, so we definitely need more staff here. On 11/05/2022 at 12:42pm, V7 stated, On the 4th floor we have a total of 52 residents. Currently, there are 2 nurses and 5 certified assistants. We are well staffed on this floor. On 11/05/2022 at 1:00pm V9 (licensed practical nurse) stated, There are a total of 57 residents on the 5th floor. There are 4 CNAs and 2 nurses. Staffing is a concern in this facility, and we are always working short. They continue to schedule staff that are constantly calling off and it results in staffing shortages. The constantly schedule CNAs who won't show up for their scheduled shift and won't even call in and as a result we have to fill in and it's exhausting. The 5th floor is a heavy acuity floor and there should be more help especially because we have dementia residents and many residents who require feeding. On 11/05/2022 at 1:05pm V8 (certified nursing assistant) stated, I am the only C.N.A here on the 6th floor and there are a total of 51 residents. There are 2 nurses here but the facility only schedules 1 CNA. I feel that there should be another CNA because it's hard to assist all the residents by myself, despite the residents being mostly dependent. On 11/05/2022 during the 7am to 3pm shift, surveyor observed the second floor of the facility to be short of 1 nurse. Surveyor observed the second floor to be a heavy resident acuity floor. Surveyor observed the 5th floor to be a heavy acuity resident floor and noted that staff are overwhelmed with providing timely resident care. Surveyor observed the 6th floor to be short 1 certified nursing assistant. Surveyor noted that the 6th floor is full and observed the C.N.A rendering care to residents to be overwhelmed with resident requests for assistance. Staffing Policy (undated) states: The facility shall schedule nursing personnel so that the nursing needs of all residents are met accordingly. The number of staff who provide direct care who are needed at any time in the facility shall be based on the needs of the residents and shall be determined by figuring the number of hours of direct care each resident needs on each shift of the day. Resident Council Minutes (dated August 23,2022) documents that residents are asking for more nurses and certified nursing assistants.

Complete Care at Margate Park

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Complete Care at Margate Park

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