MADO HEALTHCARE - UPTOWN
For profit - Corporation
132 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#575 of 665 in IL
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Mado Healthcare - Uptown has received a Trust Grade of F, indicating poor performance with significant concerns about the quality of care provided. It ranks #575 out of 665 facilities in Illinois, placing it in the bottom half, and #179 out of 201 in Cook County, meaning there are very few local options that perform worse. Although the facility is improving, with issues decreasing from 9 in 2024 to 3 in 2025, it still has many areas of concern, including 30 total issues noted in recent inspections, with one critical incident related to safeguarding residents' funds that led to fraudulent transactions. Staffing is somewhat stable with a turnover rate of 37%, which is below the state average, but the facility has an overall staffing rating of just 1 out of 5 stars. Additionally, there were findings indicating that a qualified licensed nurse was not overseeing the restorative nursing program and that proper background checks on new employees were not conducted, which raises safety concerns.
- Trust Score
- F
- In Illinois
- #575/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 37% turnover. Near Illinois's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $122,973 in fines. Higher than 96% of Illinois facilities. Major compliance failures.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Illinois. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 14%
Review needed
9 → 3 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 3 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below Illinois average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 37%
Near Illinois avg (46%)
Typical for the industry
Federal Fines: $122,973
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 30 deficiencies on record
1 life-threatening
May 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 follow their policy by failing to notify the nurse on...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy by failing to notify the nurse on duty of a resident fall and failed to ensure that a resident was immediately assessed by a nurse after sustaining a fall. This failure effected 1 resident (R1) out of 5 residents reviewed for falls in a total sample of seven residents.
Findings include:
Facility Final Incident Investigation (dated 04/25/2025) documents in part: The certified nursing assistant stated that in the morning he went to the room of R1 and he was sitting on the floor. He tried to get him up from the floor. Staff denied being physically aggressive towards R1. He denied causing any harm to R1. The facility is unable to substantiate the allegation of physical abuse. There was no ill-intentions or intentional act towards R1. R1 sustained a close fracture of the right shoulder. Staff were in-serviced on 04/22/2025, on appropriate transfer practices.
Fall Prevention Policy (undated) documents in part: It is the policy of this facility to provide the highest quality care in the safest environment for the individuals residing in the facility. Immediate action when a resident is found on the floor: do not move the individual; Call for assistance. Do not leave the individual alone; The nurse will immediately assess the individual for injury.
R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: nondisplaced fracture of surgical neck of right humerus, initial encounter for closed fracture, pain in right shoulder, bipolar disorder, primary osteoarthritis left shoulder.
Minimum Data Set Section (MDS) section C (dated March 04, 2025) documents that R1 has an Interview for Mental Status (BIMS) score of 14, indicating that R1's cognition is intact.
Care plan (03/04/2025) documents that R1 has potential for joint pain/discomfort due to diagnosis of osteoarthritis left shoulder.
On 05/03/2025, at 10:14 AM, surveyor observed R1 lying in bed on his left side. R1 was observed with a bruise on the right arm. Surveyor interviewed R1 about the fracture of the right shoulder that R1 sustained from a fall on 04/21/2025.
On 05/03/2025, at 12:09 PM, V3 (S1/certified nursing assistant) stated, I was the certified nursing assistant that was assigned to R1 on 04/21/2025. R1 is a resident that I care for regularly. Around 9:00 AM, I gave R1 a towel because R1 was going to shower. That day was not R1's scheduled shower day, but I shower R1 every day. R1 is ambulatory and walks to the bathroom independently. When R1 has a bowel movement, R1 does not wipe his buttocks after the bowel movement. I was going to shower R1 because he just finished having a bowel movement and he did not wipe his buttocks. After I handed R1 the towel, I told him to go to the shower room and I told him that I'm coming. I had to go and attend to another resident who could not walk. I was with the other resident about 8 to 10 minutes and then I went to the shower room to meet R1, but R1 was not in the shower room. I went to R1's room, I observed R1 sitting on the floor with his legs straight. R1 was wearing pants and gym shoes while R1 was sitting on the floor. When I walked out of R1's room to check on another resident, R1 was sitting on the bed. When I returned to R1's room, R1 was sitting on the floor. I asked R1 why he was still in his room. R1 told me that he is suffering from his right arm. I grabbed R1's pants from the back and I got him up. R1 stood up. When R1 stood up, I pulled R1's pants and diaper down and R1 was full of poop. R1 said that he is not going to shower because R1's right arm hurts too much. I cleaned R1 up while R1 was standing up. After I changed R1, I told R1 to sit on the bed. R1 eats downstairs, so I told R1 to go and eat downstairs. R1 said that R1 does not want to go because his arm is in too much pain. When R1 told me that he's not going to go eat downstairs, I told my nurse. I told the nurse on duty, V7 (licensed practical nurse), that R1 cannot go downstairs to eat and that R1 broke his arm. I went downstairs and brought R1 his tray. I asked R1 what he was doing on the floor, but he did not respond to me, so I asked him what he was still doing in his room. He said that his right arm hurts. R1 did not tell me how he fell. I would always go and supervise R1 in the shower room because R1 would go and wet the towel and pretend that he was taking the shower. R1 is needs supervision in the shower room. Normally I go with R1, but I needed to mop the floor because another resident peed in the hallway. When I see the resident on the floor, I am not supposed to pick up the resident from the floor without a nursing assessment. Picking up R1 from the floor was the mistake I made. I informed the nurse that R1 had a fall after R1 was already in bed and after R1 told me that R1 is going to stay in bed for breakfast due to his right arm pain. When a resident has a fall, the policy is to inform the nurse right away, which I did not do. After I informed the nurse that R1 had a fall and that R1's arm was hurting, V7 went to assess the resident. R1 was sent to the hospital. The mistakes I made is that I transferred R1 post fall without informing the nurses and without the nurse's assessment. R1 slipped off the bed and fell on his right arm. I never stretched is arm and never pulled on his shoulder when I was getting R1 up. I just pulled R1 by his pants. I did not ask for assistance from other staff to transfer R1 to bed post fall, I lifted him by myself.
On 05/03/2025, at 2:41 PM, V1 (administrator) stated, I investigated the incident that occurred on 04/21/2025. I got a call from the hospital that R1 was claiming that R1 was physically abused by the staff. I immediately initiated the investigation. V3 (S1/certified nursing assistant) was the certified nursing assistant that was assigned to R1. V3 was immediately suspended and sent home, pending investigation. R1 was not in the building at the time that the investigation was started, R1 was in the hospital. Then I got another call around 4:30 PM from R1's V12 (primary physician). He verbalized what the resident was claiming about the incident. I explained to the physician that I initiated the investigation and the physician shared that he had spoken to the emergency room doctor. The emergency room doctor had concluded that R1's right arm fracture was not as a result of physician abuse. V12 recommended that we in-service nursing staff and certified nursing assistants on proper transfer techniques. We spoke to the physical therapist to initiate the in-services. The resident was readmitted to the facility later that day. The following day on 04/22/25, I interviewed R1. R1 shared that he was on the floor and V3 lifted him up from the back. His hand gave out when the C.N.A. lifted him up. When he was asked if he feels it was an intentional physical aggression, R1 said no, it was not intentional. R1 was re-interviewed by me. He stated that he was sitting on the edge of the bed and the C.N.A tried to lift him up by his arm and that's how R1 sustained the fracture. He again said that he doesn't think it was intentional. We interviewed other residents and residents never accused this particular C.N.A. of being abusive or aggressive towards the resident. Staff were interviewed on abuse and reporting of abuse. All the staff in the facility receive abuse prevention training monthly and as needed. A C.N.A should not pick up a resident after a resident sustained a fall because it can cause injury without a nursing assessment. V3 should have first notified the nurse on duty to assess R1 when R1 fell. Based on the recommendation from the nurse, we can get then get the resident up from the floor. It is never ok for a C.N.A to pick up a resident from the floor post fall without notifying the nurse and without nursing assessment.
On 05/03/25, at 3:03 PM, V2 (director of nursing) stated, After interviewing V3 (S1/certified nursing assistant), we educated V3 about proper transfers. V3 says that R1 was sitting on the floor, however, V3 and other staff should never assist a resident from the floor alone without notification of the nurse. The nurse must complete an assessment first to see if it is safe to transfer the resident from the floor post fall. We educated V3 on never assisting a resident post fall alone, without other staff assistance. All the nursing staff were educated about proper transfers and therapy demonstrated proper and safe transfers.
On 05/03/2025, at 3:12 PM, V13 (restorative director) stated, R1 transfers independently with stand-by supervision. R1 requires stand-by assistance for showers. R1 is moderate assistance with shower. R1 requires staff encouragement for showers. R1 did not have any prior falls, prior to 04/21/2025. R1 did not tell me that he had a fall. I asked R1 if he had a fall, but R1 did not confirm that R1 fell. R1 just told me that he went to the hospital.
On 05/03/2025, at 3:34 PM, V7 (licensed practical nurse) stated, On 04/21/2025, I was working on the 4th and 5th floor. While I was on the 5th floor, V3 (S1/certified nursing assistant) alerted me that a resident is hurt. I went to assess R1. R1 was sleeping in his bed. I opened the resident's chart to see if he has any pain medications. I see that R1 has a prescription for pain medications for shoulder pain. I got the pain cream and I went to R1's room to apply the cream. That's when R1 told me that the shoulder that the cream is prescribed for is not what was causing the pain. I was not told that the resident had a fall. I was told by V3 that R1 is having pain. When the resident told me that his right arm is hurting, that's when I did the assessment. While I was assessing R1, that's when R1 alleged that V3 twisted his arm. I was still not informed about a fall; I was only informed by the resident that the C.N.A twisted R1's arm. R1's right arm was visibly swollen. R1 was not able to do range of motion and move his arm due to excruciating pain. I asked R1 how long R1 was having this pain. R1 told me that he was having pain since this morning. I followed the facility protocol and if there is an alleged abuse allegation, we report it to the abuse coordinator who is the administrator. From there the administrator will give me the directives on what to do next. The whole time during R1's assessment, I was not informed at all that a had had taken place. R1 only reported an alleged abuse allegation that V3 twisted his arm, but the C.N.A never told me that a fall occurred. V3 only told me that R1 is having difficulty moving his arm.
R1's Progress Note (dated 04/21/2025) documents, Resident complained of right arm swelling. Assessment done. Swelling noted on said arm. He admits to excruciating pain. Range of motion is limited. Resident cannot abduct right arm. Physician notified and responded with order to send resident to community hospital for medical evaluation. Nurse to nurse report given and an estimated time of arrival of 30 min obtained from ambulance. Resident left the facility accompanied by 2 EMT (emergency medical transport) staff without incident. Family member notified via voice mail.
R1's Progress Note (dated 04/21/2025) documents, Follow up call made to community hospital regarding patient's status. Spoke with the nurse. That resident will be returning to facility. That patient will be on a sling. Incoming to follow up with return.
R1's Progress Note (dated 04/21/2025) documents, Resident returned back to the facility via medical transport. Arrived with 2-person assist on a stretcher. Received alert and oriented at baseline. emergency room discharge documentation confirmed fracture to the right arm with sling in place. Assessment of swelling noted around the scapula region, resident denies pain at this time. No facial grimacing observed. Discharge order for resident is to schedule an appointment with physician (Orthopedic surgery). Physician notified of resident's return, new order for Tylenol 325mg; take 2 tabs by mouth every six hours hours as needed for pain. Order received and carried out. Director of nursing notified. Message left for emergency contact (daughter). Monitoring in place. Vitals stable.
R1's Emergency Record (dated 04/21/2025) documents that R1's diagnosis was closed fracture of right shoulder.
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 protect resident's right to be free from physical abuse. This failu...
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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 resident's right to be free from physical abuse. This failure affected one (R1) out of three residents reviewed for abuse.
Findings include:
On 04/22/25 at 11:30 AM, R1 stated R2 tried to choke him when R1 was in the 1st floor dining room doing activities. R1 stated, R2 came up from behind R1 and grabbed R1 around the neck with R2's arm. R1 stated he was not expecting it, so he was surprised when R2 did that. R1 stated one of the staff got R1 off R2 and R2 was removed from the room. R1 does not remember if R2 said anything as he was trying to choke R1. R1 stated R2 did not look angry and I don't know why he did that.
On 04/22/25 at 11:10 AM, observed R2 sitting in his bedroom looking at an opened bible on his bedside table. V21 (Business Office Manager) acted as translator because R2's primary language is Spanish. R2 stated via V21 that God, told me to choke him (R1) so I did and God told me to do this because he (R1) was going to try to choke me first. R2 stated via V21 that R1 never touched or threatened R2 and the only reason R2 tried to choke R1 was because God told R1 to do it.
On 04/23/25 at 11:10 AM, via phone interview V3 (Former Activity Aide) stated he was running the activity group in the morning in the 1st floor dining room on the day R2 tried to choke R1. V3 stated that on that day R2 walked into the 1st floor dining room and came up from behind R1 and got R1 in a head lock using his arms. V3 stated he could see that R2 was trying to choke R1. V3 stated he had to pull R2's arm off from around R1's neck. V3 stated once he separated them, R2 told V3 that God told R2 to kill somebody, not specifically R1, just somebody. V3 stated he was the only staff in the room when this happened, and he does not remember the names of the other residents in the room at the time.
On 04/23/25 at 12:22 PM, V21 (Business Office Manager) stated on 02/04/25, the former administrator called her downstairs to translate for R2 after the altercation had occurred between R1 and R2. V21 stated R2 told her that he (R2) was trying to kill R1 because God told him to. V21 stated R2 said he put his arm around R1's neck to choke him. V21 stated R2 said R2 did that because R1 was going to hurt R2, so God told R2 to hurt R1 first. V21 stated R2 said he was trying to kill R1, not just hurt R1. V21 stated R2's story on 02/04/25 was the same he told us yesterday (04/22/25), no changes.
On 04/22/25 at 10:51 AM, V5 (Licensed Practical Nurse) stated on 02/04/25, she was notified that there had been an altercation between R1 and R2 and she assessed each of them. V5 stated R1 told her, R2 grabbed me from behind. V5 stated R1 denied being in pain anywhere and there were no signs or symptoms of any injury. V5 stated R1 told her I don't know, muchacha, I don't know, muchacha and R2 was calm, not agitated. V5 stated R2 does have a history of schizophrenia and does hallucinate saying things like God told me I need to drink water or God told me
On 04/23/25 at 11:45 AM, V1 (Administrator) stated he is the abuse coordinator at the facility and has been working at the facility for two months. V1 stated the main goal is to prevent abuse and to keep the residents free from abuse. V1 stated the residents living at the facility are a vulnerable population and it is the staff/facilities responsibility to advocate for the residents and keep them safe from abuse. V1 stated R2 choking R1 is physical abuse. V1 stated he does not think the action was intentional, but it was willful on R2's part because R2 was responding to the inner voice inside his head telling R2 to take the action of trying to choke R1.
R2's nursing progress note dated 02/04/25 entered by V5 documented, Writer was notified at about 11am that resident was aggressive and meet criteria for psychiatric evaluation. Resident is to be sent to St Mary's Hospital for psychiatric evaluation and indicated that R2's son, primary care provider, and psychiatric nurse practitioner were notified.
R2's Petition for Involuntary/Judicial admission dated 02/04/25, 11:30 AM documented in part, client is presenting below baseline. Displaying socially intrusive and aggressive behavior directed toward people in immediate environment secondary to psychosis. Client choked a co-peer believing God told him to. In need of immediate hospitalization for psych evaluation and to prevent harm to others.
Facility reported incident written witness statement received 02/04/25 at 11:00 AM documented in part, I, (V3) witnessed R2 choking R1 around the neck in a choke hold yelling, God told me to kill him. The written statement also the incident happened in the dining room during morning group at 10:15.
R1's admission record indicates admission date on 01/03/25 with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Chronic Sinusitis, Dysarthria and Anarthria, Schizophrenia, Osteoarthritis of Knee, Insomnia, Slurred Speech, Essential (Primary) Hypertension. R1's MDS ([NAME] Data Set) dated 01/21/25 indicates intact cognition. R1 has care plan in place stating R1 is at risk for abuse/neglect.
R2's admission record indicates admission date on 11/24/21 with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Unspecified Severity, with Other Behavioral Disturbance, Mild Cognitive Impairment of Uncertain or Unknown Etiology, Essential (Primary) Hypertension, Unspecified Schizophrenia, Schizoaffective Disorder, Bipolar Type, Alcohol Dependence, In Remission. R2's MDS dated [DATE] indicates intact cognition. R2 has care plans in place for audio hallucination/preoccupation with religion, felony history for aggravated stalking and risk for abuse/neglect.
Facility provided document titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long Term Care Facilities dated 11/18 documents in part, your rights to safety: You must not be abused, neglected, or exploited by anyone- financially, physically, verbally, mentally, financially or sexually.
Facility provided document titled, Abuse Policy dated 01/04/24 which documents in part, that each resident will be free from Abuse Abuse can include verbal, mental, sexual, or physical abuse . Additionally, resident will be protected from abuse, neglect, and harm while they are residing at the facility.
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 interview and record review, the facility failed to (a) assess and document pressure ulcer characteristics and measurement on a weekly basis and (b) ensure that the orders provided by wound n...
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Based on interview and record review, the facility failed to (a) assess and document pressure ulcer characteristics and measurement on a weekly basis and (b) ensure that the orders provided by wound nurse practitioner (NP) were performed to 1 (R3) out of 3 residents reviewed for Improper nursing care.
The findings include:
R3's admission record showed initial admission date on 5/19/2021 with diagnoses not limited to Acute respiratory failure with hypoxia, Pressure ulcer of right heel stage 3, Morbid (severe) obesity due to excess calories, Chronic respiratory failure with hypoxia, Pressure ulcer of right buttock stage 2, Unspecified diastolic (congestive) heart failure, Acute embolism and thrombosis of unspecified deep veins of right lower extremity, Unspecified urinary incontinence, Type 2 diabetes mellitus, Schizoaffective disorder, Chronic obstructive pulmonary disease. R3 was discharged from the facility on 4/15/2025.
On 4/22/25 at 10:25AM V5 (LPN / Licensed Practical Nurse) stated wound treatment is done by nurse on duty, had regularly worked and provided treatment to R3's wounds (Sacrum and Right heel). She said R3 had wound on sacrum area and treatment was Santyl and Foam dressing. V5 said R3 's wound to right heel, treatment was Xeroform.
On 4/22/25 at 11:22am V10 (MDS coordinator, LPN) stated R3 had 2 pressure ulcers, 1 Stage 2 to sacral / right buttock and 1 Stage 3 to Right heel and were present upon readmission.
On 4/22/25 At 1:04PM V8 (Wound NP) stated has been servicing the facility for 2 years and seeing wounds in the facility. Stated he has been following R3's wounds. Surveyor reviewed R3's EHR (Electronic health record) with V8 and said R3 had pressure ulcers, Stage 2 to sacrum and Stage 3 to right heel. Reviewed V8's wound documentation dated 4/8/25 and said treatment for sacrum and right heel was Hydrofera. V8 stated is it important to follow treatment order to promote wound healing and prevent complication like worsening or deterioration of wound. V8 stated the purpose of Hydrofera treatment is to keep the wound moist and promote healing. He said Santyl is a chemical debriding agent. V8 said Santyl to Right buttock / Sacrum should have been discontinued and changed to Hydrofera. He said R3's wound visit was on 3/1/25 then 3/26/25 and 4/8/25. V8 stated no wound visit on 3/8/25, 3/15/25, 3/22/25 and 4/1/25. He said it is important to assess wound and document at least weekly to monitor if treatment is appropriate and if need to be changed, it will also monitor progress of the wound and if the wound is not improving treatment should be changed.
On 4/22/25 At 2:36pm V2 (DON / Director of Nursing) stated it is important to carry out and follow wound NP's order for wound treatment. She said wound NP's order should be placed in POS (Physician order sheet) and TAR (Treatment administration record). V2 said purpose of wound treatment is to promote healing of the wound. She said if wound treatment is not followed, potentially can lead to wound deterioration / complications. V2 said it is important to assess and document wound at least weekly to monitor the progress of the wound.
MDS (Minimum Data Set) dated 3/4/25 showed R3's cognition was intact. She needed Substantial / maximal assistance with oral hygiene, upper body dressing; Dependent with toileting and personal hygiene, shower / bathe self, lower body dressing, chair / bed and toilet transfer. R3 was always incontinent of bladder and frequently incontinent of bowel. MDS showed R3 had 1 Stage 2 and 1 Stage 3 pressure ulcers that were present upon admission.
V8 (Wound NP/Nurse Practitioner) follow up wound documentation dated 4/8/25 showed in part:
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Sacrum pressure ulcer Stage 2 orders: cleanse wound using normal saline solution, pat dry using gauze. Apply Hydrofera on wound bed. Apply ABD pad on wound and secure with tape.
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Right heel pressure ulcer Stage 3 orders: cleanse wound using normal saline solution, pat dry using gauze. Apply Hydrofera on wound bed. Apply Hydrofera on wound bed. Apply rolled gauze and secure with tape.
R3's order summary report dated 4/22/25 with order not limited to:
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Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Sacrum topically one time a day related to pressure ulcer of right buttock Stage 2. Cleanse sacrum with NS, apply Santyl ointment, cover with gauze, secure with ABD pad.
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Xeroform Petrolat Patch 2 (Bismuth Tribromophenate-Petrolatum) Apply to Right heel topically one time a day related to pressure ulcer of right heel, stage 3. Apply to right heel topically every day shift for wound treatment on the right heel post saline cleansing then cover with gauze dressing and wrap with kerlix until healed.
R3's TAR (Treatment Administration Record) schedule for April 2025 showed in part:
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Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Sacrum topically one time a day related to pressure ulcer of right buttock Stage 2. Cleanse sacrum with NS, apply Santyl ointment, cover with gauze, secure with ABD pad. Start date 3/26/25. Discontinue date 4/16/25.
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Xeroform Petrolat Patch 2 (Bismuth Tribromophenate-Petrolatum) Apply to Right heel topically one time a day related to pressure ulcer of right heel, stage 3. Apply to right heel topically every day shift for wound treatment on the right heel post saline cleansing then cover with gauze dressing and wrap with kerlix until healed. Start date 3/6/25. Discontinue date 4/16/25.
Care plan dated 3/18/2025 showed in part: R3 has alteration in skin integrity related to Breakdown (right buttock wound, right heel wound). Conduct wound assessment and observation per facility protocol
Facility was not able to provide R3's weekly wound assessment / documentation on 3/8/25, 3/15/25, 3/22/25, and 4/1/25.
Facility's skin management guidelines policy dated 3/2016 documented in part: Document findings, wound characteristics, stage (if applicable), wound measurements in centimeters (cm), pain associated with wound on the weekly wound documentation form. Notify the physician, obtain treatment orders and document orders on TAR (Treatment administration record).
Facility's wound care / prevention policy dated 1/2025 showed in part: Ensure that the orders provided by physician are performed as ordered.
Nov 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to discard an expired medication. This failure has a potential to affect one resident (R74) in a sample size of 57 residents.
Fi...
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Based on observation, interview, and record review the facility failed to discard an expired medication. This failure has a potential to affect one resident (R74) in a sample size of 57 residents.
Findings Include:
On 11/17/24 at 12:20 pm, the third-floor medication cart had R74's Breo Ellipta (Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath) that was labeled to use by 11/14/24.
R74's admission diagnosis includes but not limited to asthma, COPD (Chronic Obstructive Pulmonary Disease), and congestive heart failure.
R74's active orders as of 11/18/24 documents in part, Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 200-25 MCG/ACT 1 puff inhale orally one time a day for Antiasthma.
R74's MAR (Medication Administration Record) documented in part, (Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath) had a check mark indicating administered on 11/15/24, 11/16/24 and 11/17/24.
On 11/17/24 at 12:21 pm, V15 RN (Registered Nurse) stated, I cleaned the cart and missed that. Observed V15 take the inhaler out of the medication cart.
On 11/19/24 10:48 am, V2 DON (Director of Nursing) stated that expired medications should not be in the medication cart. The nurse on duty should take the medication out of the cart.
Facility's policy dated 1/21/24 and titled Medication Discard and Labeling documented in part, Expired medications will be removed from the cart or refrigerator and returned to the pharmacy. Nurse on duty or supervisor will re-order expired meds as needed.
Facility's (undated) job description titled Register Nurse, RN documents in part, Essential Duties and Responsibilities: 10. Prepare and administer medications as ordered by the physician. 11. Order prescribed medications, supplies, and equipment as necessary, and in accordance with our established policies.
Facility's (undated) job description titled Licensed Practical Nurse documents in part, Characteristic Duties: 10. Order prescribed medications, supplies, and equipment as necessary, and in accordance with our established policies.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure an Enhanced Barrier precaution (EBP) sign is posted for a resident on EBP and failed to ensure a PPE (personal protect...
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Based on observation, interview, and record review, the facility failed to ensure an Enhanced Barrier precaution (EBP) sign is posted for a resident on EBP and failed to ensure a PPE (personal protective equipment) bin is available for resident on EBP. These failures affected 1 (R76) resident reviewed for infection control.
Findings include:
On 11/17/2024 at 10:25 AM on 3rd floor, there was an EBP sign posted by the door with R76's room identifier. A PPE bin was also available outside of the room with R76's room identifier. The room was located at the end of the hallway. This surveyor knocked on the door. No one was in the room.
On 11/17/2024 at 10:46 AM, R76 was in a room located right across the 3rd floor's nurse's station in the middle of the hallway. The room identifier did not indicate R76 was residing in that room. There was no EBP sign nor PPE bin on site.
ON 11/17/2024 at 11:36 am, on the end hallway on 3rd floor with V15 (Agency Registered Nurse) this surveyor pointed to the EBP sign posted on the door and the PPE bin outside of the room and inquired who was the resident on EBP. V15, looking at the name identifiers on the door frame, stated the only resident I could think of on EBP is (R76) because she has a g-tube. But she was moved to a new room. I don't know when.
ON 11/17/24 at 11:39 AM, by room right across the nurse's station where R76 was observed, this surveyor requested V15 to check for EBP sign and PPE bin. V15 stated there was no EBP sign posted and no PPE bin outside of (R76)'s room. When she moved to a different room, the EBP sign and the PPE bin should move with her so the staff would know the precautions. Anyone caring for her and in contact with her g-tube will take precautions. The main purpose is prevention of infection.
ON 11/19/2024 at 12:22 pm, V13 (Maintenance Supervisor) stated we have to paint her (R76) room that's why we moved her (R76) last Friday (11/15/2024) and moved her back last Sunday (11/17/2024) around 5pm.
On 11/18/2024 at 11:19 am, V2 (Director of Nursing) stated I think they were doing something in her (R76) room that's why they had to move her. The policy is to move the EBP sign and PPE bin with her. The purpose of moving the EBP sign and the PPE bin is to make the staff aware that the resident is on precautions; so, anyone who is taking care of the resident is taking precautions. Main purpose of moving the EBP sign and the PPE bin with her is for infection control.
R76's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) dysphagia and gastrostomy status. Order Summary: Feeding formula six times a day. 1 can per feeding PGT (per gtube). Active. Order Date: 08/20/2024. Enhance(d) Barrier Precautions to be observed and utilized when providing high-contact resident care activities to prevent spread of infectious germs secondary to risk colonization due to resident having indwelling devices. Order Date: 08/10/2024. PEG tube flush with 250ml Q6 (every 6) hours for routine order. Order Date: 08/19/2024.
R76's (08/23/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 00. Indicating R74's mental status as severely impaired. Section GG. Functional Abilities and Goals. GG0130. A. Eating -1 dependent. E. Shower - 1 dependent. F. upper body dressing - 1 dependent, G. Lower body dressing - 1 dependent. I. personal hygiene - 1 dependent.
R76's (08/10/2024) care plan documented, in part Focus: at an increased risk for spreading possible multi-drug resistant organism (MDRO) secondary to indwelling medical devise regardless of MDRO colonization status. Goal: will decrease risk of spreading possible MDRO to other staff or residents through use of recommended precautions and PPE (personal protective equipment). Interventions: ensure proper signage to inform staff of precautions.
The (11/17/2024) Residents on Enhance(d) Barrier Precautions indicated R76 was on the list. Of note, the room listed for R76 was not where R76 was observed on 11/17/24.
The (undated) Enhanced Barrier Precautions from CDC (Centers for Disease Control and Prevention) documented, in part Providers and staff must: wear gloves and a gown for the following High-Contact Resident Care Activities: Device care or use: feeding tube.
The Enhanced Barrier Precautions (EBP) policy and procedure dated 2/12/2024 documented, in part the purpose of enhanced barrier precautions is to prevent opportunities for transfer of MDRO's (multi drug resistant organism) to employees' hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or bod fluids. Policy: it is the policy of this facility that enhanced barrier precautions, in addition to Standard And Contact Precautions will be implemented during high contact resident activities when caring for resident with indwelling medical devices. High Contact Resident Care Activities include: Device care or use: feeding tube. When initiating EBP: post EBP signage at the door. Ensure PPE and disinfectant are present, ordered, and restocked routinely and placed at the entrance of room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to provide functioning call device for residents requiring assistance from staff. This failure affected 2 (R91, R98) resident...
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Based on observations, interviews, and record reviews, the facility failed to provide functioning call device for residents requiring assistance from staff. This failure affected 2 (R91, R98) residents reviewed for resident call system in the total sample of 57 residents.
Findings include:
On 11/17/2024 at 10:40 AM, V12 (Certified Nursing Assistant) checked R91's call device and stated the call light is broken; the call light box is not lit to indicate it is working.
On 11/17/2024 at 10:49 AM, V12 checked R98's call device and stated the call light box is not lit to indicate it is working.
ON 11/17/2024 between 10:52am and 11:05am, V13 (Maintenance Supervisor) checked R91's and R98's call devices and corroborated the observations done by this surveyor with V12.
On 11/17/2024 at 11:09 AM, V13 stated it is expected to have a properly functioning call light to let the nursing staff know the resident needs assistance. How can they ask for assistance if the call light is broken.
On 11/18/2024 at 11:23am, V2 (Director of Nursing) stated we should provide a functioning call device to the resident. Call device is a lifeline to our residents, and it must remain functional at all times. Anything could have happened if the call device is not functioning, including death. I am just stating the worst-case scenario.
On 11/19/2024 at 2:53pm, V1 (Administrator) stated we don't have call light assessment.
R91's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) Obsessive Compulsive disorder and epilepsy.
R91's (10/22/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R91's mental status as cognitively intact.
R91's (Target date: 01/10/2025) care plan documented, in part Focus: Alteration in ADL's r/t (related to) medical and psych (conditions). Requires assistance with dressing, grooming, mobility, bathing, toileting & personal hygiene. Goals: All ADL's will be met on a daily basis, with the resident doing as much as possible for self within limits of medical and psych conditions. Interventions: Anticipate resident needs while giving routine care. Answer call light as quickly as possible. Ensure safety at all times. Keep call light within reach and instruct the resident in the proper use of call light.
R98'S (Active Order as Of: 11/19/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) essential hypertension, extrapyramidal and movement disorder, unsteadiness on feet.
R98's (10/17/24) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating R98's mental status as moderately impaired. Section GG. Functional Abilities. GG0130. C. toileting hygiene: 1 - dependent.
R98's (Target date: 11/20/2024) care plan documented, in part Focus: Alteration in ADL's r/t (related to) medical condition(s). Requires assistance with grooming & personal hygiene, transfers, mobility, toileting, and eating. Goals: All ADL's will be met on a daily basis, with the resident doing as much as possible for self within limits of medical condition. Interventions: Anticipate resident needs while giving routine care. Answer call light as quickly as possible. Ensure safety at all times. Keep call light within reach and instruct the resident in the proper use of call light.
The Call Light Policy dated 1/1/2024 documented, in part When call light system is not working, all nursing staff will implement 30-minute rounds to ensure all resident are provided care as needed. When call light system is not working, maintenance needs to be notified immediately.
The (9/21/2024) untitled facility provided document reads as follows the purpose of a functioning call light system is to enable residents to ask for assistance. Safety and satisfaction: the system should enhance patient safety by enabling quick response and quick access to assistance, and reducing the risk of unattended emergencies.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure window blinds are not missing blind panels/sla...
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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 window blinds are not missing blind panels/slats in an effort to provide a homelike environment to residents. This failure affected 5 (R53, R74, R76, R82, R91) residents reviewed for homelike environment in the total sample of 57 residents.
Findings include:
On 11/17/2024 at 10:27 AM, inside R82's room, the vertical window blinds have missing panels/slats. There were no panels/slats on the floor.
On 11/17/2024 at 10:29 AM, inside R91's room, the vertical window blinds have missing panels/slats. There were no panels/slats on the floor.
On 11/17/2024 at 10:35 AM, V12 (Certified Nursing Assistant) was requested to check R82's window blinds. V12 stated the window blinds should have more coverage to provide privacy; there were missing panels (slats). I don't know how long it has been like that. No, I don't see any window blind panels (slats) on the floor.
On 11/17/2024 at 10:38 AM, V12 (Certified Nursing Assistant) checked R91's window blinds and stated there's a lot of missing panels. I don't see panels on the floor.
On 11/17/2024 at 10:41 AM, V12 checked R74's window blinds and stated the vertical window blind has missing panels/slats. No panels on the floor.
On 11/17/2024 at 10:46 AM, V12 checked R76's window blinds and stated the window blinds has no panels/slats at all. I don't see any panels/slats on the floor.
ON 11/17/2024 between 10:52am and 11:11am, V13 (Maintenance Supervisor) checked R74's, R76's, R82's, and R91's window blinds and corroborated the observations done by this surveyor with V12.
On 11/17/2024 at 11:11 AM, V13 (Maintenance Supervisor) stated we are expected to provide a homelike environment to our residents. If something is broken in my home, I will fix it right away. I knew about the missing panels (slats) on the window blinds about two months ago now. I have a lot of work to do and it is just me and the Maintenance Director. Every day, I have to fix something; like a broken toilet, leaking water, and clogged drain. I never get the chance to fix all the window blinds that are broken or with missing panels.
On 11/18/2024 at 11:16am, V2 (Director of Nursing) stated we are not providing a homelike environment if there are missing panels on the window blinds. Window blinds are used for privacy. If missing, we are not providing coverage or privacy to the residents.
R74's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) bipolar disorder, major depressive disorder, copd (chronic obstructive pulmonary disease).
R74's (Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R74's mental status as cognitively intact.
R76's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) dysphagia and gastrostomy status.
R76's (08/23/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 00. Indicating R74's mental status as severely impaired.
R82's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) Type 2 Diabetes Mellitus, essential hypertension.
R82's (10/01/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R82's mental status as cognitively intact.
R91's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) Obsessive Compulsive disorder and epilepsy.
R91's (10/22/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R91's mental status as cognitively intact.
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 be safe, clean, comfortable, and homelike.
The Resident Right - Safe/clean/comfortable/Homelike dated 01/01/2024 documented, in part Intent: It is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect resident rights. Procedure: 1. The resident has a right to a safe, clean, comfortable, and homelike environment. 2. The facility must provide a safe, clean, comfortable, and homelike environment. 3. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
On 11/17/2024 at 10:30am surveyor observed the blinds in room [ROOM NUMBER] to be tethered and bent.
On 11/17/2024 at 10:50am surveyor observed the blinds in room [ROOM NUMBER] to be tethered with a brown substance that had been spilled on the blinds.
On 11/19/2024 at 12:17am R53 stated that the blinds are broken, and it would be nice to have them fixed.
On 11/19/2024 at 12:22pm V21 (Licensed Practical Nurse) stated that when blinds need to be changed we call maintenance and make them aware.
Policy dated 1/21/2024 titled Maintenance Department documents, in part, it is the policy of the maintenance department to provide for maintenance and other equipment.
Job Description for Maintenance Director dated 1/04/2024 documents, in part, the Maintenance Worker is responsible for the maintenance and repair of the facility and grounds and perform troubleshooting and repairs for items/structures.
Surveyor: [NAME], Criselda
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure oxygen signs were placed on the resident's door and failed to properly label and date oxygen tubing. This failure affects 3 resident...
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Based on interview and record review, the facility failed to ensure oxygen signs were placed on the resident's door and failed to properly label and date oxygen tubing. This failure affects 3 residents (R86, R93, R25) and has the potential to affect all 25 residents that reside on the 5th floor.
Findings include:
On 11/17/24 at 10:47 AM, R25 was observed lying in bed with nasal cannula in R25's nostrils. R25 had an oxygen concentrator on next to R25's bed, delivering oxygen to R25. No oxygen in use signage was observed on the resident's door or in any place of high visibility on the unit.
On 11/17/24 at 10:52 AM, V10 (Agency Licensed Practical Nurse) affirmed that there was no sign on R25's door. V10 stated that V10 was unsure if there is supposed to be oxygen signage on the door to alert others to R25's oxygen use. V10 stated that oxygen is flammable and can combust if exposed to flames.
On 11/19/24 at 10:27 AM, V1 (Administrator) stated when residents are undergoing oxygen therapy, the facility standard is that the resident should have a sign on their door stating that oxygen is in use. V1 affirmed that 25 residents reside on the 5th floor.
R25's physician orders document in part an order for 2 liters of oxygen via nasal cannula as needed for shortness of breath.
Facility policy titled OXYGEN Storage (updated 1/4/2024) documents in part, .7. And Sign should post on resident door when use.
R86's face sheet shows that R86 has a diagnosis which includes but not limited chronic obstructive pulmonary disease, vitamin D deficiency, bipolar disorder, disorder of bone, and history falling.
R86's Brief Interview for Mental Status (BIMS) dated 09/24/24 shows a BIMS score of 15 which indicates that R86 is cognitively intact.
On 11/17/24 at 10:40 am, R86's room was observed with a nasal cannula (NC) concentrator that had NC oxygen tubing undated, and uncontained next to R86's bed.
R86's Physicians Order Sheet (POS) dated 03/15/2024 shows that R86 has orders for Oxygen (2 L) (2 liters) per minute via nasal cannula as needed for Shortness of breath.
R93's face sheet shows that R93 has a diagnosis which includes but not limited chronic obstructive pulmonary disease (COPD), unspecified asthma, osteoarthritis of knee, pure hypercholesterolemia, paranoid schizophrenia, essential primary hypertension, atherosclerotic heart disease, and urinary incontinence.
R93's Brief Interview for Mental Status (BIMS) dated 10/15/24 shows a BIMS score of 15 which indicates that R93 is cognitively intact.
On 11/17/24 at 10:48 am, R93's room was observed with a NC concentrator that had oxygen tubing undated, and uncontained next to R93's bed. R93 stated that R93 uses oxygen as need for shortness of breath every day at the facility. When R93 was asked how often R93's oxygen tubing is changed R93 stated, Whenever It (referring to R3's humidifier bottle) gets empty.
R93's Physicians Order Sheet (POS) dated 10/09/2024 shows that R93 has orders for Oxygen (2 L) (2 liters) per minute via nasal cannula as needed for Shortness of breath d/t (due to) COPD.
On 11/18/24 at 2:11 pm, V2 (Director of Nursing, DON) was asked regarding oxygen tubing and V2 stated, Oxygen tubing is changed daily. It should be dated with a date and placed in a plastic bag when not in use. When V2 was asked regarding the importance of labeling oxygen tubing with a date and placing the oxygen tubing in a bag when not in use and V2 stated, For infection control.
The facility's document dated 01/04/2024 and titled Oxygen Storage documents, in part: Procedure: 1. When the Oxygen is at bedside, not in use, tubings (tubing) must be contained in a clear plastic bag. 2. Tubing must be discarded and replace every 72 hours and prn (as needed). 5. Label all tubings and bubble humidifier with a date and nurses initials.
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 that the controlled drugs-count record form was not prematurely signed by in and outgoing nurses. These failures have t...
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Based on observation, interview, and record review the facility failed to ensure that the controlled drugs-count record form was not prematurely signed by in and outgoing nurses. These failures have the potential to affect all residents on the second, fourth, fifth, and six floors receiving medications.
Findings Include:
On 11/17/24 at 12:40 pm, on the second floor the controlled drugs- count record sheet was prematurely signed for the outgoing nurse.
On 11/17/24 at 12:41 pm, surveyor inquired to V9 LPN (License Practical Nurse) why is the controlled drugs- count sheet prematurely sign for the outgoing nurse? V9 stated, I always sign for outgoing when I sign for incoming because there are no medications in there. Surveyor inquired to V9 if it is checked with the incoming nurse at the beginning and ending of each shift. V9 stated, that's how I do it, I sign both when I come in because nothing is in there.
On 11/17/24 at 1:45 pm, surveyor requested the controlled drug-count records for all resident floors. V2 DON (Director of Nursing) gave the third, fourth, fifth and six floor's sheets. The fourth, fifth and six floors were all prematurely signed for the outgoing nurse.
On 11/19/24 10:48 am, V2 (DON) stated, The narcotic sheet should be sign when the nurses come in and when they go out. They (Nurses) should not sign the sheet before the end of their shift. The nurses should look in the narcotic box even if nothing is there. They should not sign before their shift is over because they still need to confirm that there is nothing in the box and to also make sure the count is right if there is something there.
Facility's policy (2/21/24) titled Medication and Narcotic Storage documented in part, Procedure: 10. Narcotic count will be done every shift with in and outgoing nurse and sign by the nurses.
Facility's policy (1/21/24) titled Medication Narcotic Count Policy documented in part, Narcotic count will be done every shift with in and outgoing nurse and sign by the nurses. In the event that there's no narcotic on that floor nurses still have to sign that there's none.
Facility's (undated) job description titled Registered Nurse, RN documents in part, Essential Duties and Responsibilities: 2. Ensure that the written policies and procedures that govern the day-to-day functions of the nursing department are followed by all nursing personal assigned .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0659
(Tag F0659)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to have a qualified licensed nurse oversee the facility's restorative nursing program. The failure has the potential to affect all 120 residen...
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Based on interview and record review, the facility failed to have a qualified licensed nurse oversee the facility's restorative nursing program. The failure has the potential to affect all 120 residents that receive restorative programming.
Findings include:
On 11/17/24 at 10:25 AM, V5 (Restorative Director) stated that V5 is the restorative director and that V5 is a COTA (Certified Occupational Therapist Assistant).
On 11/18/24 at 9:55 AM, V1 (Administrator) stated that V5 supervises the restorative programming in the facility.
On 11/18/24 at 12:22 PM, V5 stated that V5 creates and evaluates all restorative programs in the facility. V5 explained that V5 is responsible for assessing residents for restorative need and creating a restorative care plan. V5 stated that all restorative certified nursing assistant aides report to and are supervised by V5 and V5 completes all the training on restorative for staff members. V5 stated that V5 was qualified to supervise the restorative nursing program because V5 had taken a course on restorative nursing.
On 11/19/24 at 10:09 AM, V2 (Director of Nursing) stated that the facility does not have a restorative nurse. V2 affirmed that V5 oversees the restorative nursing program. V2 stated that V2 isn't familiar with restorative nursing services so V2 does not provide supervision to V5. V2 stated that V2 was unsure if a restorative nursing program could be supervised by a staff member that was not a licensed nurse.
On 11/19/24 at 10:27 AM, V1 stated that V5 oversees and supervises the restorative nursing program in addition to assessing and completing restorative assessments. V1 affirmed that V5 was a COTA and not a licensed nurse. V1 affirmed that V5 is qualified to supervise the restorative nursing program because V5 has taken a class in restorative nursing. V1 affirmed that the facility uses the RAI (Resident Assessment Instrument) to guide resident assessment and care.
Record review of list of residents on restorative program documents in part that 120 residents receive restorative nursing programming.
Record review of job description titled, Restorative Director (dated 1/21/24) documents in part . the Restorative Director plays a critical role in providing superior customer service and nursing care to all residents. The Restorative director implements and directs the facility's restorative nursing program with the goal of helping residents reach and maintain their full mobility potential. Essential Functions -Develops, implements directs and evaluates the facility's Restorative Nursing Program. -Meets and consults with the facility's interdisciplinary team on a regular basis to develop and maintain restorative care standards. Ensures restorative nursing program complies with applicable laws, regulations, and national restorative nursing standards and requirements .
Record review of CMS's RAI Version 3.0 Manual Chapter 3 MDS Items [O] (10/2024) Page O-51 documents in part, .A registered nurse or a licensed practical (vocational) nurse must supervise the activities in a restorative nursing program. Sometimes, under licensed nurse supervision, other staff and volunteers will be assigned to work with specific residents . Although therapists may participate, members of the nursing staff are still responsible for overall coordination and supervision of restorative nursing programs.
Sept 2024
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0602
(Tag F0602)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system of accounting for resident's funds and safeguard...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system of accounting for resident's funds and safeguarding resident's funds against theft, failed to follow their system of updating resident's belongings, and failed to ensure shipping address of online purchase for the resident was to the facility. These failures resulted on R1 and R6 incurring fraudulent debit card transactions on R1's and R6's bank accounts.
These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 03/25/2024 when V14 (R1's family member) completed a concern form regarding unexplained activities on R1's bank account.
On 09/16/2024 at 10:45am, V1 was notified of the Immediate Jeopardy. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 09/23/2024. Although the immediacy was removed, the deficiency remains at a level 2 until the facility can determine the effectiveness of the implementation of removal and effectiveness of the in-service trainings.
Findings include:
1. On 09/04/2024 at 10:15am, with V11 (PRSC Psychiatric Rehabilitation Services Coordinator) R1 stated I felt less safe this month than last month. This surveyor requested R1 to elaborate. R1 stated I don't want to talk to you anymore.
On 09/04/2024 at 2:58pm, V4 (Business Office Manager/Payroll Specialist) stated (R1)'s wallet was given to (V4) by (V6- Admissions Coordinator) on 06/19/2023 for safekeeping.
On 09/17/2024 at 12:02pm, V6 (Admissions Coordinator) stated it was (V27 R1's Former PRSC) who gave me (R1)'s wallet and I told (V27) it is not my department; it was (V4). I wrote the date it was handed to me by (V27). I handed it to (V4) the same day. I did not take anything from the wallet. I did not check what's in the wallet. I just handed it to (V4). (V4) and I did not check what was in the wallet.
On 09/03/2024 at 12:46pm, V4 stated when residents come with their wallet and IDs, I keep them in my office right away. I have (R1)'s wallet unless he needed the wallet to go to the bank to withdraw money himself and buy stuff from the store. The social service will go with him to withdraw money from the bank or go to store to buy clothes or snacks from the store. For (R1) it was (V5- PRSC Psychiatric Rehabilitation Services Coordinator).
On 09/05/2024 at 10:05am, V4 (Business Office Manager/Payroll Specialist) stated I don't have a log for the cabinet where I keep (R1)'s and other resident's wallet. I and (V1 - Administrator) have access to the wallet. We both have keys. When (R1) needs his wallet, I don't take the wallet out of the manila envelope. I give the whole manila envelope to (V5- PRSC). When they (R1 and V5) bring the manila envelope back, I don't look if (R1)'s debit and credit cards are there. Only (V5) takes the manila envelope from me. (V5) was in charge of 3rd and 4th floors, so whenever (R1) goes to store it falls on (V5) to take him. (V11- PRSC) is now assigned to 4th floor and (V5) continues to still go with (R1) to the store and it is also (V5) who would bring the whole manila envelope back to me. I did not check to make sure everything is in the wallet when the manila envelope was returned to me and when I gave it to (V5), I did not show (V5) what was in the wallet. I should have made a binder, so they sign what they take to avoid any theft, honestly to avoid theft of residents' items. I never took (R1)'s wallet and made ATM withdrawals. It is possible the debit card was not in the wallet when it was returned to me because I did not check the contents of (R1)'s wallet.
On 09/04/2024 at 3:22pm, this surveyor showed V5 (PRSC Psychiatric Rehabilitation Services Coordinator) R1's Release of Responsibility For Leave Of Absence Forms, dated 02/2024 to 08/2024, and inquired if (V5) recognized the signature/staff on the space provided for PATIENT OR NEAREST RELATIVE. V5 stated that's me. This surveyor requested V5 to review the PRSC notes on 03/07/2024. V5 stated these (items) are something that we (V5 and R1) got from R***. We (V5 and R1) went out on that day. Some of them were returned because it was too big or not his style. I can't recall how many were returned.
On 09/04/2024 at 3:35pm, V5 stated (R1) made withdrawals mostly at (R1's bank). I never recall any withdrawals outside of (R1's bank). I always keep an eye on (R1) because he did not have a steady gait and I don't want (R1) to fall. When I went out with (R1), there was never a time (R1) withdrew money from outside of (R1's bank). I was with (R1) all the time. I am probably 5 feet away from (R1). (R1) would put the money in his wallet, then inside the manila envelope. I don't know how much (R1) takes from the ATM. This surveyor showed V5 R1's bank statement and pointed out to V5 the transaction that was done on 03/07/2024 at (non R1's Bank) ATM withdrawal in the amount of $244.80 and asked if (V5) could explain the transaction. V5 stated I have no explanation for that, I don't know. This surveyor inquired if V5 has knowingly purchased any items using R1's debit card. V5 stated No. This surveyor inquired if he threatened a resident to get what he needed from the resident. V5 stated I am a very nice guy.
R1's admission Record documented that R1's diagnoses include but not limited to bipolar disorder, essential hypertension, and depression.
R1's untitled (complaint) form, dated 03/25/2024, documented, in part Person sharing the concern: (V14, R1's family member). Nature and description of the concern: (R1)'s bank account has some unexplain(ed) activity. Description of investigation: Bank was called (to) investigate and replace(d) most of the funding.
R1's State Initial Reportable, dated 09/03/2024, documented, in part It was reported by state surveyor that resident's family member reported unusual activity on bank account.
R1's State Final Reportable, dated 09/09/2024, documented, in part Investigation revealed that electronic payment method/debit card was used for what appear to be unauthorized charges.
R1's A***** Order Details, dated 03/06/2024, documented, in part Shipping Address. (V5 and non-facility address) Payment method. (R1)'s bank account number ending in (last 4 numbers). Of note, shipping address was not of the facility.
On 09/05/2024 at 11:26am, V15 (PRSD Psychiatric Rehabilitation Services Director) stated not sure if R1 has an A***** account. PRSC's ordering for residents online, the shipping address should be the facility's address and not the PRSC address. Why ship stuff to the PRSC address if we are open for 24 hours. The expectation is everything should be shipped to this building (facility).
On 09/17/2024 1:18pm, V15 (PRSD (Psychiatric Rehabilitation Services Director) stated I know for sure (R1) has no A***** account. (R1) is not that tech savvy. He refused to use the smart phone provided by 'T****y.
R1's Bank statement, dated 01/27/2024 - 02/27/2024, is marked with a handwritten note documenting PIN # (4-digit number).
R1's Bank statement, dated 02/28/2024 - 03/26/2024, documented the following, in part.
Deposit and Addition:
03/07 Purchase Returns (bank card last 4 digits) in the amount of $252.29
3/14 ATM Cash deposit in the amount of $400.00.
3/19 Card Purchase Return (bank card last 4 digits) in the amount of $15.24
3/26 Reversal: (Pet Store) in the amount of $119.06.
The total amount returned was $786.59.
ATM and Debit card withdrawals:
1. (12x) Non-(Bank) ATM withdrawals (bank card last 4 digits) with a total amount of $2,881.05.
2. (2x) ATM Withdrawals (bank card last 4 digits) with a total amount of $400.00.
3. (6x) Online food orders on 03/10/24, 03/12/24, 03/14/24, and 03/18/24 (bank card last 4 digits) with a total amount of $367.44.
4. (2x) W****** purchases (bank card last 4 digits) with a total amount of $187.33.
5. (2x) C**part purchases (bank card last 4 digits) with a total amount of $264.84.
6. (1x) T***** purchase + cash back (bank card last 4 digits) with a total amount of $67.98.
7. (11x) A***** purchases (bank card last 4 digits) with a total amount of $413.97.
8. (1x) Card purchase with pin (Pet Store) (bank card last 4 digits) in the amount of $119.06.
Of note, the total amount of purchases and withdrawals without receipts = $4701.67.
9. (7x) purchases (bank card last 4 digits) with receipts provided by the facility with a total amount of $4,483.60.
The (09/06/2024) email correspondence with V1 in response to the inquiry of this surveyor Do you have additional receipts for (R1) aside from the 03/07/24 and 03/11/2024 R*** Receipts; 3/7/24 U****n A** hardware receipt; 03/11/24 (x2) E** L*** CEMETERY RECEIPTS; 03/07/24 (x2) and 03/25/24 A****n receipts? V1 wrote in response No I gave you everything we have.
On 09/17/2024 1:18pm, V15 (PRSD (Psychiatric Rehabilitation Services Director) stated (R1) has no car and has no pet.
The R*** receipt dated 03/07/2024 at 10:46am, documented 19 sold items. The R*** receipt dated 03/07/2024 at 1:52pm, documents 16 returned items. The R*** receipt dated 03/07/2024 at 2:12pm, documents 6 sold items. Of note, 9 items were retained by R1.
R1's Additional Items (Patient's Clothes and Personal Belongings) list, dated 03/12/2024, documented in part Clothing Retained by Patient: Shoes x 2 and 1 magic shine sponge. Of note, 6 items were missing.
R1's Personal Belonging list, dated 09/05/2024, documented in part 2 trousers and 1 Polo. Of note, no additional belonging list after 03/12/2024 and before 09/05/2024 was provided by the facility to this surveyor.
The Daily Staffing dated 03/10/24, 03/12/24, 03/14/24, and 03/18/24, documented that V12 (Administrator Assistant/Front Desk), V19 (Security/Front Desk), V20 (Security/Front Desk) and V21 (Security/Front Desk) worked on these days either the 8am - 4pm shift or the 4pm-12pm shift or 12am - 8am shift.
On 09/05/2024 at 9:49am, V12 stated I started in October 2022, I work Monday thru Friday, 7am-4pm. Part of my job is to call up the floor and tell the resident to pick up food order. I never had any circumstance calling (R1) to pick up his food.
On 09/06/2024 at 11:57am, V19 (Security/Front Desk) stated I have been working at the facility for 27 years as security or front desk staff. I work different shifts; 8am-4pm, 4pm-12am, and 12am-8pm shifts. I know (R1). I never received any online food order from G*****b for (R1).
On 09/06/2024 at 4:43pm, V22 (Security/Front Desk) stated I started here in 2021 or 2022. I am familiar with (R1). I never received any food order from G*****b or any A***** packages for him (R1).
On 09/17/2024 at 4:12pm, V21 (Security/Front Desk) stated I have never received any online food order or any A***** packages for (R1).
On 09/03/2024 at 3:34pm, V1 (Administrator) stated I called (V14 - R1's family member). V14 said it would take the bank 8-10 weeks before he could hear from them. I would be mad if I were not able to touch my money for that long.
On 09/05/2024 at 11:54am, V1 (Administrator) stated no one should be stealing the resident's money. I am the Administrator; I have the key to (V4)'s office. There was never a time I took (R1)'s wallet from (V4)'s office. I spoke with him (V14 - R1's family member) and he said he will not hear from the bank for 8-10 weeks. This surveyor inquired how would V1 feel not having access to her money in the bank for 8-10 weeks. V1 stated, I would be mad.
On 09/05/2024 at 12:02pm, reading the charges on R1's March 2024 bank statement, this surveyor inquired if V1 could explain the withdrawals in the statement, V1 stated I cannot explain them.
On 09/16/2024 at 11:03am, V1 (Administrator) stated I hired an outside team of Private Investigator to check on the situation, on anything that has to do with financial abuse.
On 09/16/2024 at 11:27am, V25 (President - (Private Investigator's) Group) stated they (V1) did searches of (V5)'s office, and they saw (R1)'s bank statement with a PIN written on it.
On 09/16/2024 at 2:38pm, V1 (Administrator) stated I have to search (V5)'s office regardless. I ended up searching his whole office. There was a bank statement for R1. I know it is a PIN number because it has word PIN written on it.
The (09/18/2024) email correspondence with V1 (Administrator) documented, in part Here is the list of residents' items retrieved from (V5)'s office. (R1) Assurance wireless notice, bank statement dating January 27th thru February 27th.
2. On 09/16/2024 at 11:27am, V25 (President-(Private Investigator's) Group) stated another resident (R6) gave her debit card to (V5) who told her he will take care of her finances for her.
On 09/16/2024 at 2:48pm, R6 stated I have about $2000 on my bank card. I gave my bank card to (V5) probably in December of last year. (V5) is keeping my bank card in case I need something from the store. (V5) did not tell me I could have (V4) keep the bank card for me. (V5) said let me have your bank card and I will take care of your financial stuff. (V5) knew I have a bank card because whenever I need stuff from the store, I would give him my bank card. I never received my bank statement here because I don't want these people to know my finances. I called the bank today and they said I have a dollar in my account. Surveyor inquired how R6 felt about her missing bank card and having a dollar in her (R6) account. R6 stated, I am so pissed I can pee. It means I am very mad; (V5) took all my money. This surveyor inquired who was sending money to R6. R6 stated I get a pension every month. I wrote my PIN on a piece of paper and handed it to (V5).
On 09/17/2024 at 1:20pm, V15 stated I have never seen the card; but (R6) is not going to say falsely about it. I know from time to time (V5) would go to the store to buy whatever miscellaneous things (R6) needs. When I asked (R6) does anybody have access to your card? (R6) said yes, (V5) has access and he knows the pin to the card. I asked why and (R6) said because (V5) is going to take care of my finances for me. At that point, I told (R6) Stop we are going down to (V1)'s office. In (V1)'s office, I made (V1) aware of the situation and called (R6)'s bank. We (V1, V15, and R6) canceled the card and we asked for 90 days' worth of bank statements. I asked for the last 10 transactions. Most of them occurred on 09/03/2024. (R6) was shocked because she had a deposit made on 09/03. The customer service mentioned that some of the transactions were (Person to Person mobile payment application), there were at least 2 transactions of $200. It appeared, whoever is doing it, is just cleaning out the account, emptying the bank account. There were couple A***** transactions. (R6) said she did not consent to those transactions. While (R6) was listening to this, she was so shocked. (R6) was saying Oh, my God! Oh, my God! Oh, my God! It is not expected of PRSC or staff, per se, to take the card with them without the resident present. (V5) was trying to help (R6) out but he has too much access to resident information like the resident's PIN number.
On 09/23/2024 at 2:29pm, V15 stated we just received (R6)'s bank statement. V15 showed this surveyor the transactions on R6's (07/2024- 09/2024) bank account. V15 stated (R6) has $750 deposit on 09/03. On the same day (09/03) there were multiple (Person to Person mobile payment application) transactions to K*****h C****. According to (V1), K*****h is (V5's) middle name. There were 9 transactions on 9/03 and 1 transaction on 09/04. (R6) will not make those transactions because she had not realized that she has that money yet on the 09/03. Obviously, (R6) is getting $750 at the beginning of the month. I don't think (R6) has (Online Music Streaming Service). That is an online streaming app for music. I can guarantee you, (R6) did not have a (Online Music Streaming Service).
R6's Bank statement dated 07/10/24, documented, in part Deposits and credits: 7/01 benefit payment deposit - $750. Checks and other debits: 7/01- (Online Music Streaming Service) $10.99. Checking account Summary and Detail: ending balance: $65.29.
R6's Bank statement dated 08/09/24, documented, in part Deposits and credits: 8/01 benefit payment deposit - $750. Checks and other debits: 8/01 - ATM W/D Card # $408.00. 8/08 (Online Music Streaming Service) - $11.99. Checking account Summary and Detail: ending balance: $60.13.
R6's (09/10/24) bank statement documented, in part Deposits and credits: 9/03 benefit payment deposit - $750. Checks and other debits: 9/03 Cash App * K*****h C**** - $15.00. 9/03 (Person to Person mobile payment application), K*****h C**** $80.00. 9/03 (Person to Person mobile payment application), K*****h C**** $200.00. 9/03 (Person to Person mobile payment application), K*****h C**** $200.00. 9/03 (Delivery and Ride Service Subscription) $96.00. Checking account Summary and Detail: ending balance: $1.85.
R6 admission Record documented that R6's diagnoses include but not limited to chronic obstructive pulmonary disease, unspecified; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
R6's census list documented that R6 was moved to the 6th floor on 11/29/2023.
R6's Minimum Data Set, dated [DATE], documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 14. Indicating R6's mental status as cognitively intact. Section GG. GG0170. Mobility. J. Walk 50 feet with two turns: 88 - not attempted due to medical condition or safety concerns.
R6's State initial reportable dated 09/10/2024, documented, in part Resident reported that her bank card is missing.
R6's State Final reportable dated 09/17/2024, documented, in part The following is a response to an incident that occurred on 09/10/24 whereby a resident (R6) reported that her bank card was missing. (R6) stated last person that had (the bank card) was (V5). Investigation revealed that electronic payment method/debit card was used for what appear to be unauthorized charges.
R6's PRSC Progress note dated 12/25/2023 at 9:16, documented, in part Resident present with a history of frivolous money management. PRSC will educate resident on setting goals to handle finances, savings, possible investing.
R6's Care plan dated 09/16/2024, documented, in part Resident is at increased risk or has experienced financial abuse secondary to psychological and/or medical diagnosis. Will be free of any financial abuse occurrences. Assist resident with addressing financial situations with business office.
The (09/06/2024) email correspondence with V1 (Administrator) in response to the inquiry of this surveyor Do you have Ethics policy and procedure in reference to receiving gifts (monetary/kinds/goods) from residents? If you do not have a policy, what are your expectations? V1 wrote in response In our employee handbook it is said that no personnel or persons associated with the facility will accept gifts of money or goods of material value, favors remuneration or other compensation from any client.
The CNA Supervisor job Description dated 4/21/23, documented, in part Ensure that Resident Belonging is completed upon admission and as needed and up to date.
The PRSC (Psychiatric Rehabilitation Services Coordinator) Job Description (Undated) documented, in part Summary: In keeping with our organization's goal of improving the lives of the Guests we serve, the PRSC is responsible for the overall administration, coordination, and evaluation of the social services function to meet and maintain the mental and psychosocial well-being for (of) each Guest. Essential Functions: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 4. Coordinates the inspection of guests belongings to ensure they are properly labeled and inventoried.
The Front desk/Security Job Description dated 1/26/2024, documented, in part Summary: The front desk/security staff attend to visitors by greeting, welcoming, and directing them appropriately; notifies company personnel of visitor arrival; maintains security and telecommunications system. Essential Responsibilities: 5. Monitor entrance and departure of employees. This includes overseeing the log-in and log-out books. Ensure staff and responsible party are signing resident out when leaving the facility.
The Personal Property Policy and Procedure dated 01/24/2024-4163, documented, in part It is the policy of the (Facility) to permit residents to retain personal property items as long as they do not infringe upon the rights of other residents or affect the safety and well-being of the residents. Procedure. 5. The belonging list shall be updated as needed upon receiving new item.
The Signing Patients Out When Leaving the Building policy dated 01/01/2024, documented, in part Intent: Signing patients out when staff are taking residents out of the building. Procedure: This policy ensures that when any resident is taken out of the building by a staff member, that staff member is to sign the patient in and out at the front desk with a date and time.
The Ordering Items for Residents policy dated 01/01/2024, documented, in part This policy ensures that items ordered for residents by staff in the facility are done properly and complies with any (Facility) Healthcare policies. Procedure: If staff orders items online for the residents, they are to be shipped and received to the facility.
The Abuse Policy dated 1/4/24, documented, in part It is the policy of the facility that each resident will be free from abuse. Abuse can include misappropriation of resident property and exploitation. Additionally, residents will be protected from abuse while they are residing at the facility. No abuse or harm of any type will be tolerated.
The facility presented a removal plan on 09/16/2024 at 3:18pm and was not approved. A revised Removal Plan was submitted on 09/17/2024 at 12:26pm and was not approved. A revised Removal Plan was submitted on 09/18/2024 at 2:52pm and was not approved. A revised Removal Plan was submitted on 09/18/2024 at 3:36pm and was approved.
On 09/19/2024 at 12:37pm, further review of the revised Removal Plan that was submitted on 09/18/2024 at 3:36pm documented no in-services for abuse and resident's belonging which was previously noted on the revised Removal Plan submitted on 09/17/2024 at 12:26pm.
On 09/19/2024 at 2:58pm, V1 was informed of the discrepancies on the removal plan provided to this surveyor. V1 stated I don't know what happened let me ask (V29 - Management Consultant).
A revised removal plan was submitted on 09/20/2024 at 9:26am and was not approved. A revised removal plan was submitted on 09/20/2024 at 3:20pm and was approved.
The Immediate Jeopardy that began on 03/25/2024 was removed and the deficiency remains at a level 2 on 09/23/2024.
On 09/23/2024 at 4:29pm, V1 (Administrator) stated I initiated in-services again, and still ongoing about abuse and resident's belongings when you first came here on 09/03/2024.
Surveyor confirmed the following:
The (09/03/2024) Abuse in-service was reviewed with no issue noted. Attached documents 7signs of nursing home abuse, how to prevent abuse, and abuse policy and procedure.
The (09/03/2024) Resident Belongings in-service was reviewed with no issue noted. Attached Resident belonging documented, in part No one is allowed to hold any resident's wallet, cards, or money.
On 09/19/2024, V26 (Activities Aide), V30 (Maintenance Assistant), V31 (Maintenance Director), V32 (CNA), V33 (PRSC (Psychiatric Rehabilitation Services Coordinator), V34 (Housekeeping/Maintenance), V35 (Housekeeping/Laundry Supervisor), and V36 (Dietary Supervisor) all affirmed in-services were received in the month of September about abuse and resident belongings.
The (revised 09/04/2024 and 09/09/2024) personal property policy and procedure, The (09/16/2024) new employee health care worker background check, and the (09/19/2024) Online Purchase for Resident were reviewed and appropriate revisions were made that were included in the removal plan.
V1 Removed V5 from the facility on September 4, 2024, suspended without pay pending investigation as part of actions to mitigate risks to R1 and any other resident. Suspension status will remain until investigation concludes. If facts are founded, V5 will be terminated immediately with appropriate reporting to Health Care Worker Registry.
On 09/19/2024 at 9:54am, V1 (Administrator) stated V5's time sheet and the write up are my proofs that he is not at the facility at this time. It still an ongoing investigation and we get outside help to make sure we thoroughly go through the situation, and it does not happen again and to find out who did it.
V5's Employee Disciplinary Action dated 09/04/2024, documented, in part Type of offense: Possible fraudulent activities in multiple occasions. PRSC (V5) has taken resident out to the bank multiple times and on all these dates there are suspicious activities in which the patient (R1) states that he does not recognize. (V5) is suspended pending investigation.
V5's Timecard from 09/01/2024-09/19/2024 indicated no entry since 09/05/2024.
On September 4, 2024, V1 implemented a revised personal items log to account for resident personal items such as debit, credit, ID, and wallet. (see attached Exhibit F Personal Items Log which includes the date, personal items requested, resident name, employee name, date/time of personal item given to resident, date/time of personal item returned from resident, as well as the purpose of the request).
The Resident In and out log (Debit card, ID, and Wallet), (undated), was reviewed with no issue noted.
R7's Resident in and out log (Debit Card, ID, and Wallet) dated 09/12/24 and 09/16/24, provided date, employee name, resident name, out, in and purpose with attached [NAME] and bank withdrawal receipts.
On 09/19/2024 at 11:44am, V4 unlocked the office on the 5th floor with a key. Inside the room, V4 showed her desk with 3 drawers on the left side. The 2nd drawer was locked. V4 stated only the administrator and myself have the key to the second drawer. V4 attempted to open the drawer with no luck. Unable to open the drawer by just pulling the door handle of the drawer. V4 opened the drawer using a key and showed this surveyor R1's and R6's valuables.
On September 4, V1 Revised the resident personal property policy to include the following language regarding investigating misappropriation of resident funds/property (see attached Exhibit G - (Facility) Personal Property Policy and Procedure)
In the event a claim is made regarding misappropriated funds or property, the Administrator will be made aware immediately and any potentially involved employees will be removed immediately from the building with an immediate independent investigation conducted to mitigate any potential risks to residents. All other prudent measures will be taken to mitigate risks including canceling accounts with questionable charges until investigations are complete. The revised personal items log in addition to the requirements of the new policy requiring witnesses and receipts, and a detailed log of community visits including the staff members who accompanied the resident, date and time will address concerns regarding not only accounting for resident and staff going out on community pass but also Accounting for resident belongings and safeguarding against theft.
In addition, the revised policy includes that once the investigation is complete, the facility will assist the resident in retrieving any loss of value owed to the resident. The actions address a system of investigating the potential misappropriation of resident funds.
The Personal Property policy and procedure dated 09/04/2024, documented, in part 9. In the event a claim is made regarding misappropriated funds or property, the Administrator will be made aware immediately and any potentially involved employees will be removed immediately from the building with an immediate independent investigation conducted to mitigate any potential risks to residents. once the investigation is complete, the facility will assist the resident in retrieving any loss of value owed to the resident. The actions address a system of investigating the potential misappropriation of resident funds. 10. All other prudent measures will be taken to mitigate risks including canceling accounts with questionable charges until investigations are complete.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to follow their own policy to conduct a complete background check of employees prior to working with residents. This failure has the potential...
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Based on interview and record review, the facility failed to follow their own policy to conduct a complete background check of employees prior to working with residents. This failure has the potential to affect all the residents at the facility.
Findings include:
The (Effective as of 08/29/2024) untitled document indicated that V5 (PRSC) was hired on 07/31/2023, V7 (CNA Supervisor) was hired on 04/01/2024, V8 (Certified Nursing Assistant) was hired on 06/27/2024, V9 (CNA) was hired on 08/01/2024, V10 (CNA) was hired on 04/30/2024, and V11 (PRSC) was hired on 03/31/2024.
The (09/06/2024) email correspondence with V1 (Administrator) documented that V5 works on the 3rd floor, V7 works on all the floors, V8 works on any floor, V9 works on the 2nd and 3rd floor, V10 works on the 3rd floor, and V11 works on the 4th floor.
On 09/04/2024 at 10:33am, V4 (Office Manager/HR Director) stated the purpose of the healthcare worker background check is to see if staff are eligible to work in a nursing home facility. To make sure the correct kind of people with good character are working here at the facility to prevent abuse. When applicants come to fill out the application form, I do the background check. Our policy is to do it after I receive the application. Before hiring, to know if they are eligible or not, to work at the facility to prevent abuse to our residents. If they are hired today, healthcare background should be done today. Applicants can't be hired until background check is in good standing.
On 09/04/2024 from 10:35am -10:50am, during the review of V5, V7, V8, V9, V10, and V11 personnel file, this surveyor inquired for the result of V5's, V7's, V8's, V9's, V10's, and V11's Illinois Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries. V4 stated I don't have them. When I got the position, I was taught to check in IDPH worker registry. I was not taught to check employees on those registries that you mentioned. I am not completely checking the background of the employees and it put residents at risk to anything that the staff may have on their background that I don't know of because I did not check staff on those registries.
Review of V5's personnel file indicated that background check was initiated on 09/03/2024. Of note, no results provided for (State) Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries.
Review of V7's personnel file indicated that background check was initiated on 09/03/2024. Of note, no results provided for Illinois Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries.
Review of V8's personnel file indicated that background check was initiated on 06/27/2024. Of note, no results provided for (State) Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries.
Review of V9's personnel file indicated that background check was initiated on 08/01/2024. Of note, no results provided for (State) Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries.
Review of V10's personnel file indicated that background check was initiated on 03/26/2024. Of note, no results provided for (State) Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries.
Review of V11's personnel file indicated that background check was initiated but date could not be determined due to printing. Of note, no results provided for (Sate) Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries.
The (undated) Business Office Manager/Payroll Specialist documented, in part As business office manager/payroll specialist you will operate as the first line of assistance to employee within the facility; supporting operations, department heads and employees alike. Responsible for monitoring and processing facility payroll, including: maintains employee personnel files. Completes background checks.
The Abuse Policy, dated 1/4/24, documented, in part It is the policy of the facility that each resident will be free from abuse. Abuse can include misappropriation of resident property and exploitation. Additionally, residents will be protected from abuse while they are residing at the facility. No abuse or harm of any type will be tolerated. Overview of Seven Components. A. Screening. Abuse policy requirements: it is the policy of this facility to screen employees prior to working with residents. Screening components include criminal background check. Procedure: 1. Employee screening and training. The facility will not hire an employee who was found guilty of abuse, exploitation or misappropriation of property by a court of law; or who has a finding in the state nurse aid registry concerning abuse, exploitation, or misappropriation of resident property. For prospective employees, reviewing documentation of status and any disciplinary actions from other registries. A. Nurse aides: the facility will not employ an individual who has a finding entered in the state nurse aid registry concerning abuse, exploitation, or misappropriation of residence property. C. A criminal background check will be conducted on all prospective employees as provided by the facilities policy on criminal background checks.
Dec 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure the call light device was within reach for one resident (R19). This failure has the potential to affect one resident (R1...
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Based on observation, interview and record review the facility failed to ensure the call light device was within reach for one resident (R19). This failure has the potential to affect one resident (R19) out of a sample of 44.
Findings include:
R19 has a diagnosis of but not limited to Epilepsy, Schizophrenia, Alzheimer's Disease, and Pure Hypercholesterolemia. R19 has a Brief Interview of Mental Status score of 00.
Care plan focus: ADL's related to medical and psychiatric condition (4/21/2022) documents in interventions to keep call light within reach and instruct the resident in the proper use of the call light.
Call light assessment had not been completed for R19.
On 12/04/23 at 10:57 am, surveyor observed R19 in the bed with call light device on the floor behind the night stand and not within reach of the resident. R19 stated Don't know when asked where her call light was.
On 12/04/2023 at 10:59 am, V20 (CNA) stated R19's call light was on her bed, as he was looking for the call light, and then said he does not see R19's call light.
On 12/04/2023 at 11:01 am, V21 (LPN) stated, no, R19 does not have a call light and we will have to move R19.
On 12/05/23 at about 2:00 pm, surveyor observed R19's bed in the same spot with the call light on the floor behind the nightstand not within reach of the resident.
On 12/05/2023 at 2:30 pm, V12 (LPN) stated no, but the housekeeper came to clean the room and moved it.
On 12/06/2023 at about 12:29 pm, V1 (Administrator/RN) stated call lights should be attached to the residents and should be within reach of the resident.
Undated policy for call light documents, in part, if a resident is in bed the call light should be accessible and call light should be attach to their bed within reach.
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 provide ADL (Activities of Daily Living) to one resident (R28) reviewed for ADL's in the sample of 44.
Findings include:
R28 has ...
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Based on observation, interview and record review the facility failed provide ADL (Activities of Daily Living) to one resident (R28) reviewed for ADL's in the sample of 44.
Findings include:
R28 has a diagnosis of but not limited to Pneumonia, Moderate Protein-Calorie Malnutrition, Epilepsy, Schizoaffective Disorder, Allergic Contact Dermatitis and Chronic Obstructive Pulmonary Disease. R28 has a Brief Interview for Mental Status score of 11.
On 12/4/2023 at 11:17 am, surveyor observed R28's fingernails to be long on both hands. R28 stated that his nails are too long for a man and would like them to be trimmed.
On 12/5/2023 at 2:42 pm, surveyor observed R28's fingernails to be long on both hands.
On 12/05/2023 at 2:46 pm, V16 (CNA) stated resident's fingernails are trimmed every time she notices that they are dirty and or long and nail care is provided with showers.
On 12/06/2023 at 12:34 pm, V1 (Administrator) stated staff are expected to provide nail care when providing ADL care, during showers and as needed.
Activities of Daily Living Policy dated 1/4/2023 documents, in part, the facility will provide care and services for the following activities of daily living: hygiene-nail care.
Care plan focus for ADL self care dated 5/31/2023 documents, in part, check nail length and trim and clean on bath day and as necessary.
Job Description titled Nursing Assistant with an updated date of 1/4/2023 documents, in part, provides personal care, trim nails.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to provide supervision while shaving for one resident (R...
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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 supervision while shaving for one resident (R5), reviewed in a sample of 44.
Findings include:
R5 is [AGE] year old with diagnosis including but not limited to: Schizoaffective Disorder, Schizophrenia, Chronic Obstructive Pulmonary Disease, Age-related Osteoporosis and Cataract Extraction.
On 12/5/23 at 10:04 AM, R5 was observed in bathroom located in day room on the fifth floor.
The bathroom door was cracked and Surveyor observed R5 inside of the bathroom shaving with a manual cartridge razor.
No staff members were observed in or near the bathroom with R5.
On 12/5/23 at 10:10 AM, Surveyor observed V10 (Certified Nurse Assistant /CNA) enter the bathroom with R5 to retrieve the razor.
On 12/06/2023 V1, (Administrator) said, The residents cannot shave themselves. We (staff) have to shave them (residents) or stand near and supervise them while they are shaving for safety reasons. There are no orders for shaving. Everyone has the right to shave as long as they are supervised.
On 12/5/23 at 10:10 AM, V10 (CNA) said, Usually I am with R5 while he shaves, but I (V10) went to the restroom. He (R5) can shave himself, but he just needs supervision while shaving for safety.
R5's care plan with target date of 2/21/2024 documents, Focus: resident (R5) has a history of self-harm; R5 presents with altered thought processes evidenced by hallucination, delusions, exaggerated responses related to inability to process and synthesize information, inability to evaluate reality.
R5's Minimal Data Set, Functional Status dated August 29, 2023 documents R5 requires limited assistance (staff provide guided maneuvering of limbs or other non- weight bearing assistance) and One person physical assist with personal hygiene including shaving.
R5's Minimal Data Set, Functional Abilities and Goals dated November 21, 2023 documents R5 requires Supervision or touching assistance with personal hygiene including shaving.
Facility Policy titled Activities of Daily Living documents, the facility will provide care and services for the following activities of daily living: Hygiene- bathing, dressing, grooming including shaving, oral care, and fingernail care.
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 ensure a medication administration error rate of less than 5 percent for 2 of 7 residents (R119, R3) reviewed for medication a...
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Based on observation, interview and record review, the facility failed to ensure a medication administration error rate of less than 5 percent for 2 of 7 residents (R119, R3) reviewed for medication administration. There were 33 opportunities and 3 errors resulting in a 9.09% medication administration error rate.
Findings include:
R3's diagnosis includes but are not limited to chronic obstructive pulmonary disease, unspecified, difficulty in walking, not elsewhere classified, unsteadiness on feet, other abnormalities of gait and mobility, abnormal posture, unspecified lack of coordination, hyperlipidemia, unspecified, anemia, unspecified, bipolar disorder, unspecified, pure hypercholesterolemia, unspecified, essential (primary) hypertension, history of falling, vitamin deficiency, unspecified, osteoarthritis of hip, unspecified , unspecified asthma, uncomplicated, schizophrenia, unspecified, muscle weakness (generalized), and altered mental status, unspecified.
R3's Brief Interview for Mental Status (BIMS) dated 10/31/2023 documents R3 has a BIMS score of 13 which indicates R3's cognition is intact.
R119's diagnosis includes but are not limited to other fracture of right lower leg, subsequent encounter for closed fracture with routine healing, bronchitis, not specified as acute or chronic, unsteadiness on feet, schizophrenia, unspecified, unspecified convulsions and pain in right ankle and joints of right foot.
R119's Brief Interview for Mental Status (BIMS) dated 10/31/2023 documents R119 has a BIMS score of 12 which indicates R119's cognition is moderately impaired.
On 12/5/2023 at 8:50 am, V6 (LPN/Licensed Practical Nurse) started dispensing the following medications for R119:
Clozaril (Clozapine) Oral Tablet 50mg (milligrams)-Give one tablet by mouth two times a day.
Valproic Acid Oral Capsule 250mg (milligrams)-Give two capsules by mouth every 12 hours.
On 12/5/2023 at 8:55 am, V6 (LPN/Licensed Practical Nurse) stated R119 does not have a medication package with Clozaril Oral Tablet 50mg available for 12/5/2023 at 9:00 am. V6 was not able to administer R119 the scheduled 9am dose of Clozaril Oral Tablet 50mg.
On 12/5/2023 at 9:05 am, V6 (LPN/Licensed Practical Nurse) made a call to the pharmacy to inquire about R119's missing Clozaril 50mg tablet for 12/5/2023 scheduled to be given at 9:00 am. V6 stated the pharmacy representative stated the Clozaril 50mg Tablet for 12/5/2023 to be given at 9:00 am was sent to the facility.
On 12/5/2023 at 9:25am, V6 (LPN) notified V2 (DON/Director of Nursing) of the missing dose of Clozaril 50mg Tablet for R119's 9:00am scheduled dose.
On 12/5/2023 at 9:30 am, V6 (LPN/Licensed Practical Nurse) started dispensing the following medications for R3:
Multivitamin Oral Tablet-Give one tablet by mouth one time a day.
Lithium Carbonate Capsule 300mg-Give one capsule by mouth two times a day.
On 12/5/2023 at 9:35 am, V6 (LPN) stated R3 does not have a medication package with a Multivitamin Oral Tablet and a Lithium Carbonate Capsule 300mg available for 12/5/2023 at 9:00 am. V6 was not able to administer R3 the scheduled 9am doses of Multivitamin Oral Tablet and Lithium Carbonate Capsule 300mg.
On 12/5/2023 at 9:40 am, V6 (LPN) made a call to the pharmacy to inquire about R3's missing Multivitamin Oral Tablet and Lithium Carbonate Capsule 300mg scheduled to be given at 9:00 am on 12/5/2023. V6 stated the pharmacy representative stated the Multivitamin Oral Tablet and Lithium Carbonate Capsule 300mg to be given at 9:00 am was sent to the facility.
On 12/5/2023 at 9:45 am, V6 (LPN) notified V2 (DON/Director of Nursing) of the missing doses of Multivitamin Oral Tablet and Lithium Carbonate Capsule 300mg for R3's 9:00am scheduled dose.
On 12/5/2023 at 2:19 pm, V6 (LPN/Licensed Practical Nurse) stated the nursing supervisor is responsible for making sure all residents medications are here at the facility on time. V6 stated it is my expectation that the medication is available for the residents when the medication is scheduled to be given to the resident. V6 stated the night nurse is to check to make sure the times on the resident's medication packages match the resident's medication administration record.
On 12/5/2023 at 3:08 pm, V2 (DON/Director of Nursing) stated the medication cycle starts every Monday, the pharmacy delivers the medication to the facility every Monday. V2 stated the Multivitamin Oral Tablet (scheduled for administration at 9am) and Lithium Carbonate Capsule 300mg (scheduled for administration at 9am ) for R3 and the Clozaril Oral Tablet 50mg for R119 (scheduled to be administered at 9:00am) were delivered by the pharmacy. V2 stated the pharmacy delivered the medication packages with 6:00am printed on the package instead of 9:00 am for this medication cycle.
On 12/5/2023 at 3:30 pm, reviewed R3's nursing progress note dated 12/05/2023 14:44 by V2 (DON/Director of Nursing) which documents in part, Writer made aware by NOD (nurse on duty) regarding discrepancy in time for Lithium. Pharmacy contacted secondary to discrepancy in time for lithium medication administration which did not match with time in MAR (medication administration record) and as ordered. Medication was being packed for 6am administration but order states to be given at 9am. Pharmacy stated that it was their mistake and that it would be corrected for next distribution/cycle. Dr.(doctor) made aware and stated to change administration time to 6am. Pharmacy made aware. Administrator notified.
On 12/5/2023 at 3:35 pm, reviewed R119's nursing progress note dated 12/05/2023 at 15:15 by V2 (DON/Director of Nursing) which documents in part, Writer made aware by NOD (nurse on duty) regarding discrepancy in time for Clozapine. Pharmacy contacted secondary to discrepancy in time for Clozapine medication administration which did not match with time in MAR (medication administration record) and as ordered. Medication was being packed for 6am administration but order states to be given at 9am. Pharmacy stated that it was their mistake and that it would be corrected for next distribution/cycle. Dr.(doctor) made aware and stated to change administration time to 6am. Pharmacy made aware. Administrator, notified.
On 12/6/2023 at 2:21 pm, V2 (DON/Director of Nursing) stated the facility nurses are responsible for following the rights of medication administration. V2 stated the nurses are to make sure the medication is administered to the right patient, at the right time, that it is the right medication, right amount/dosage and the medication is being administered by the right route. V2 stated the nurse administering the medication should be looking at the medication administration record before administering a resident's medication.
On 12/6/2023 reviewed the facility's Policy and Procedure dated 1/4/2023, Subject: Medication Errors/Missing Medications documents in part, it is the policy of facility that all its residents will be free from medication errors that may cause discomfort and jeopardize the resident's health and safety. Underneath Procedure: Missing Dose, In the event of a missing dose the nurse has to notify the physician for further order if a resident takes less than 100% of the dosage, or if you withhold it for some reason, document in the MAR (medication administration record) or nurse's note and notify the physician.
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, interviews, and record review the facility failed to ensure that expired eye medication was removed from t...
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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 ensure that expired eye medication was removed from the medication cart for one resident (R54) from a sample of 44.
Findings include:
R54 is [AGE] year old with diagnosis including but not limited to: Primary Open- Angle Glaucoma, Chronic Obstructive Pulmonary Disease, Hyperlipidemia, and Schizoaffective Disorder.
On [DATE] during investigation, Surveyor observed an expired eye medication on the third floor medication cart.
The expired eye medication was Latanoprost .005% and was labeled with R54's name.
The Latanoprost medication had a sticker on the bottle that documented, use by [DATE].
On [DATE] at 10:50 AM, V12 (Licensed Practical Nurse/ LPN) said, The medication (eye drops) expired on [DATE]. I (V12) will discard this and reorder a new one.
Surveyor inquired about the possible outcomes of a resident using expired eye medication.
On [DATE] at 10:50 AM, V12 (LPN) said, The expired medication may cause adverse (unfavorable) effects for the patient.
On [DATE] at 2:56 PM, V30 (Pharmacist) said, When we (Pharmacy) send eye drop medication to the facility, it will come with a sticker. The sticker will indicate the expiration date once opened. The Latanoprost is good for around 42 days after opened. If the medication is used after expiration date, it reduces the effectiveness of the medication. The medication won't work.
R54's Physician Order Sheet documents includes the following active order: Latanoprost Emulsion 0.005% instill one drop in both eyes at bedtime.
Facility Policy titled Eye Drop Medications documents: It is the policy of the facility to ensure eye drop medications are discarded after their expiration date based on the pharmacy recommendations.
Facility Policy titled Medication Storage documents: The Director of Nursing and or designee conducts random inspections of all nursing care units or other areas of the Nursing Home where medications are dispensed, administered, or stored; the pharmaceutical vendor checks medication carts, treatment cart and medication rooms to make sure all drugs are current and available.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0914
(Tag F0914)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure three residents had a privacy curtain which extended around the bed. This failure affected three residents (R110, R421...
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Based on observation, interview, and record review, the facility failed to ensure three residents had a privacy curtain which extended around the bed. This failure affected three residents (R110, R421, R4) (residing in the same room) in a sample of 44 residents.
Findings include:
R110's diagnosis includes but are not limited to other drug induced secondary parkinsonism, supraventricular tachycardia, unspecified, extrapyramidal and movement disorder, unspecified, gastro-esophageal reflux disease without esophagitis, vitamin D deficiency, unspecified, schizoaffective disorder, unspecified, disorder of teeth and supporting structures, unspecified, acquired absence of left great toe, acquired absence of other left toe(s), bipolar disorder, unspecified, essential (primary) hypertension, cognitive communication deficit, other lack of coordination, history of falling, thrombocytopenia, unspecified.
R110's Brief Interview for Mental Status (BIMS) dated 11/06/2023 documents R110 has a BIMS score of 12 which indicates R110 has some moderate cognitive impairment.
R4's diagnosis includes but are not limited to gastro-esophageal reflux disease without esophagitis, unspecified osteoarthritis, unspecified site, chronic obstructive pulmonary disease, unspecified, type 2 diabetes mellitus without complications, essential (primary) hypertension, pure hypercholesterolemia, unspecified, schizophrenia, unspecified, hyperlipidemia, unspecified, insomnia, unspecified.
R4's Brief Interview for Mental Status (BIMS) dated 11/02/2023 documents R4 has a BIMS score of 13 which indicates R4's cognition is intact.
R421's diagnosis includes but are not limited to multiple fractures of ribs, left side, subsequent encounter for fracture with routine healing, heart failure, unspecified, gastro-esophageal reflux disease without esophagitis, benign prostatic hyperplasia without lower urinary tract symptom, non-pressure chronic ulcer of other part of right lower leg with unspecified severity, wedge compression fracture of T7-T8 vertebra, subsequent encounter for fracture with routine healing, chronic kidney disease, stage 3 unspecified, extrapyramidal and movement disorder, unspecified, hypothyroidism, unspecified, schizophrenia, unspecified, vitamin D deficiency, unspecified, polyneuropathy, unspecified, hyperlipidemia, unspecified, essential (primary) hypertension, peripheral vascular disease, unspecified, chronic obstructive pulmonary disease, unspecified, constipation, unspecified, bipolar disorder, unspecified , liver disease, unspecified, history of falling, and difficulty in walking, not elsewhere classified.
R421's Brief Interview for Mental Status (BIMS) dated 11/14/2023 documents R421 has a BIMS score of 15 which indicates R421's cognition is intact.
On 12/04/2023 at 11:30 am, surveyor observed three beds in the same room. No privacy curtains were observed hanging from the ceiling for each of the three beds.
On 12/04/2023 at 11:50 am, R110 stated I never had a privacy curtain in the room, I don't need a curtain.
On 12/06/2023 at 1:42 pm, V23 (Maintenance Director) stated the curtains were placed in the room on Monday December 4, 2023. V23 stated I took the privacy curtains down to wash them, but I forgot to put the privacy curtains back up. V23 stated the privacy curtains are used to provide privacy for each resident in the room.
On 12/06/2023 reviewed the Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities Policy (Rev. 11/18) presented to the surveyor by facility which documents in part, You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure the Daily Nurse Staffing was conspicuously posted in a prominent place readily accessible to residents and visitors. Th...
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Based on observation, interview and record review, the facility failed to ensure the Daily Nurse Staffing was conspicuously posted in a prominent place readily accessible to residents and visitors. This failure has the potential to affect all 120 residents residing in the facility.
Findings include:
On 12/04/2023, V1 (Administrator) presented a facility census of 120 residents.
On 12/04/2023 at 9:10 am, surveyors enter the facility and did not observe the Daily Nurse Staffing that included the facility name, date, residents census and hours worked per shift for licensed and unlicensed staff responsible for resident care posted visibly in a prominent place in the facility.
On 12/04/23 at 1:08 pm, Surveyor requested V1 (Administrator) to locate the daily staff posting for the facility and V1 stated, We (referring to the facility) don't have one. When V1 was asked the importance of the Daily Staff Posting for the facility V1 stated So everyone knows how many staff are in the building. V1 explained that a schedule is kept at the receptionist desk however there is no posting for visitors or residents to see daily nurse staffing in the building each day. V1 stated no staff is assigned to post the daily nurse staffing in the facility and that V1 would make sure the nurse staffing is posting in the facility moving forward.
The (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) State Operations Manual documented, in part
§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(iv) Resident census.
§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.
GUIDANCE §483.35(g)
The facility's staffing data document may be a form or spreadsheet, as long as all the required information is displayed clearly and in a visible place.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. These failures hav...
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Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. These failures have the potential to affect all residents who consume food prepared by the facility.
Findings include:
On 12/04/23 at 10:06 AM, the food service area toured. Floor of food service area has ceramic floor tiles missing and cracked in front of the dishwasher and steam table. Grout between tiles throughout food service area are heavily soiled from black encrustation and not easily cleanable. The entrance/interior of walk in cooler has ceramic tiles missing and cracked on the floor. The floor is not easily cleanable.
On 12/04/23 at 10:10 AM, The dietary hand sink located next to coffee machine has cleaned silverware under coffee machine on shelf. The silverware and coffee machine are subject to splash from the handwashing sink when in use. Staff were observed using the handwashing sink during this observation.
On 12/4/23 at 10:08 AM, the dry food storage room was observed with two plastic bulk containers. One container had a 25 pound opened bag of sugar. The container was not labeled with content description. The opened bag of sugar did not have package delivered date attached. The other plastic container had a 25 pound bag of flour opened with no delivered date attached. The container was not labeled with content description.
On 12/6/23 at 12:10 PM, V3 (Food Service Supervisor) stated we have limited space in the food service area and we will have to relocate the coffee machine and shelf system. V3 stated I am aware of the bulk food containers in dry food storage room with no label and package delivered dates. They were labeled and dated.
The facility failed to follow its policy.
Policy titled Food Date and Labeling (December 2023) Policy includes It is the policy of this facility to label & date all foods not stored in its original packaging. It is also the policy of this facility to date all food in its original packaging upon delivery to the facility.
Policy titled Dietary Infection Control Policy (December 2023) states including, It is the policy of this facility Dietary Department to follow proper infection control procedures to help prevent the transmission of infectious diseases.
Oct 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement their fall protocol by failing to re-assess ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement their fall protocol by failing to re-assess a resident after a fall and failed to implement care plan interventions for one (R1) of three residents reviewed for falls.
Findings include:
R1's medical record (Face Sheet) documents R1 is a [AGE] year-old female admitted to the facility on 5.25.2022 with diagnoses including but not limited to: Epilepsy, Bipolar Disorder, Paranoid Schizophrenia, Lack of Coordination, and Difficulty in Walking. R1's MDS (Minimum Data Set of 7-7-2023) documents R1 is moderately cognitively impaired and experiences hallucinations and exhibits delusions.
On 9-30-2023 at 12:05 PM, R1 was observed awake and alert sitting on the side of her bed eating lunch. A soft helmet was noted on R1's head; a CAM (controlled ankle movement) boot was noted on R1's left lower extremity. There were no floor mats noted on the floor in front of resident's bed.
On 9-30-2023 at 3:55 PM, V8 (Restorative Supervisor) said, fall assessments should be completed upon admission, quarterly, after a fall incident, and when there is a significant change in condition. A fall assessment was not completed after R1's fall (in August).
On 9-30-2023 at 5:05 PM, V8 (Restorative Supervisor) said, R1's floor mats should be in place when she is lying in or sitting on R1's bed.
On 9-30-2023 at 5:59 PM, V1 (Administrator) said, R1 does have a history of falls; all falls were related to seizure activity. We monitor her every 15 minutes, placed her in a low bed, encouraged her to call for assistance. After the fall, we put a leaf on her headboard (to alert staff she is a fall risk), moved her closer to the Nurses Station, placed mat on floor. The mat should be in place when she is in bed or sitting on bed. Fall risk assessments should be completed upon admission, quarterly, after a fall, and when there is a change in condition.
R1's care plan: Resident has had multiple falls and is deemed a high fall risk due to diagnosis of seizures without clear warning signs or ability to verbalize when seizures may occur secondary to psych diagnosis (revised 9-16-2023) documents the following intervention: Floor mats to be placed around bed.
Restorative Fall Protocol and Policy (1-1-2023) documents: The following protocol/policy is to provide guidance for new and current residents at (facility) to prevent and reduce injury to residents due to a fall. 1. Complete a multifactorial fall risk assessment for all new residents upon admission and current residents quarterly, change in status, or incident basis. 4. Implement interventions for those at risk for falling: Use of floor mats.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain accurately documented medical records for one (R1) of three residents reviewed for documentation of medical records.
Findings inc...
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Based on interview and record review, the facility failed to maintain accurately documented medical records for one (R1) of three residents reviewed for documentation of medical records.
Findings include:
On 10-2-2023 at 11:39 AM, via return phone call by V19 (Agency LPN-Licensed Practical Nurse) to Surveyor, V19 said, I wasn't there when R1 had a seizure. PT (Physical Therapy) and CNA (Certified Nursing Assistant) said there was something off about R1. That's when they said she may have had a seizure and fell. I assessed her; there was a difference in size between her ankles, the left ankle was swollen, larger than the right. The seizure happened somewhere before my shift started on the midnight shift. She wasn't experiencing excruciating pain, there was no obvious deformity to extremity noted. I tried to look back on 24-hour report, I didn't see anything in the communication book about a seizure. The off-going nurse never reported to me that R1 had a seizure on the midnight shift.
V20 (Agency LPN-Licensed Practical Nurse) was not available for interview (overseas per V1-Administrator).
V20's (Agency LPN-Licensed Practical Nurse) progress notes from 8-7-2023 at 7:37 AM, documents: Resident had a seizure that lasted for 5 mins in the day room on 2nd floor. All seizure precautions in place. Resident placed on left side. Resident was assessed for injury. No physical injury noted. VS-BP 128/80, T-97.3, R-18, P-90, SPO2-95% RA (room air). Resident was assisted by 2 staff via wheelchair to her room. Bed placed on lowest position. Call light within reach. Nod (Nurse on duty) will continue to monitor.
V1's (Administrator) progress notes from 8-10-2023 at 3:19 PM, documents: After final investigation/patient/staff interview, NOD (Nurse on Duty) states the approximate time for possible seizure was no more than 2 minutes and seizure was not witnessed. MD and POA was made aware.
Documentation Basics policy (2021) documents: Documentation must be accurate and appropriate in content.
Feb 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to enter a do not resuscitate (DNR) code status order under the physic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to enter a do not resuscitate (DNR) code status order under the physician orders which affected one resident (R1) in a sample of 45 residents reviewed for advance directives.
Findings include:
R1 is a [AGE] year old female with diagnosis including but not limited to: Chronic obstructive pulmonary disease, Unspecified dementia, schizoaffective disorder, epilepsy, hypothyroidism, and dysphagia.
R1's MDS (Minimal Data Sheet) - Section C, BIMS (Brief Interview for Mental Status) score is documented 0 which indicates severe cognitive impairment.
On 02/06/23 at 12:53 pm, during record review, R1's Order Summary Report documents R1's active orders as of 02/05/2023.
An active order for 'Full Code' was noted in R1's Physician orders dated 12/16/20. Subsequently, R1's EHR (electronic hospital record) profile read, Full Code as well.
On 02/07/23 at 09:51 am, R1's POLST (Practitioner Order for Life- Sustaining Treatment) form was received from V1 (Administrator), signed and dated 1/27/23 by R1's guardian a witness, and an Authorized Practitioner. R1's POLST read, DNR (Do Not Attempt Resuscitation).
R1's code status was listed as Full code for the period of 1/27/23- 2/6/23, after R1's POLST was signed on 1/27/23 and indicated a code status DNR.
On 2/7/23 at 12:35 pm, V24 stated, I don't quite remember placing the order for code status in R1's chart, but I'm sure that I confirmed it with his medical records and doctors orders. The code status is based on the resident and family's decision. The way we know a resident's code status is by the doctors order and by the resident's profile in EHR. R1 has been a full code.
On 2/7/23 at 12:45 pm, V3 (Nurse Manager) said, The social worker offers the POLST form to the patient and family. Every Monday, the doctor comes to the facility and signs any documents that we need signed. We just got the POLST for R1 signed. Until the doctor signs the POLST, the resident is still considered a Full Code. The code status is on the patients face sheet and in their orders in the system.
On 2/7/23 at 1:00 pm, V37 (Social Service Director) said, I spoke to the brother a week ago who wanted to change the code status to DNR. He signed and dated it on 1/27/23.
We usually change the code status in the system once we get a signature from the doctor
Facility policy: Identification of Residents with DNR orders, updated 1/4/2023 reads, all residents with DNR orders shall be easily identified during a code call.
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 a resident's injury of unknown source (left ankle fractures)...
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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 a resident's injury of unknown source (left ankle fractures) to the state agency which affected one resident (R165) in the sample of 45 residents.
Findings include:
R165's admission Record, documents, in part, that R165's diagnoses include COPD (Chronic Obstructive Pulmonary Disease) and Schizoaffective disorder.
R165's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R165 is cognitively intact.
This surveyor reviewed the facility's incident reports sent to the state agency from April 2022 to February 2023 with one report (initial on 12/18/22 and final on 12/22/22) noted for R165.
On 2/6/23 at 11:12 am, V10 (Agency Licensed Practical Nurse, LPN) stated that on 12/18/22, V10 was at the nurse's station and that R165 was walking out of R165's room then fell to the floor. V10 stated that V10 then ran to R165 and V25 (Certified Nursing Assistant, CNA) was already bending down to check on R165. V10 stated, V10 did the head to toe assessment and checked level of consciousness (which R165 was alert). V10 stated, R165 was initially talking incoherent and that R165 could not remember R165's name. V10 stated, this was a change for (R165), big change. V10 stated, V10 called 911 and emergently sent out R165 to hospital #1. When asked about the assessment of R165, V10 stated, R165 was moving R165's arms and legs, began talking clearly, denied pain and had a bump on the back of R165's head. V10 stated, R165 did not return from hospital #1 to the facility on V10's shift on 12/18/22.
On 2/7/23 at 10:36 am, V24 (Registered Nurse, RN) stated, V24 was R165's nurse on 12/18/22 when R165 returned from hospital #1 after R165's fall in the facility. V24 stated that V10 had given report that R165 had fallen earlier in the day, sent to hospital #1, and was to be coming back. V24 stated, R165's report from hospital #1 is that R165 was cleared to return to the facility later that evening. V24 stated that V24 assessed R165; that R165 was alert and oriented times; and that R165's head to toe assessment showed that R165 had no changes in neurological status and no complaints of pain.
Facility document for R165, titled Accident/Incident Report and dated 12/18/22, documents, in part, Incident Description: Resident was walking out of (R165's) room when (R165) slipped and fell on (R165) buttocks .Note a slight bump at the back of (R165's) head . No injury noted.
Facility document for R165, titled Incident Follow-Up/Final Report and date of submission to state agency on 12/22/22 at 2:21 pm, R165's reportable on 12/22/22, V1 (Administrator) documents, in part, by The following is a response to an incident that occurred on 12/18/22, whereby (R165) was noted walking out (R165's) room when (R165) lost balance and fell on (R165) buttock. (R165) states (R165) was trying to come out of my room and lost my balance. (R165) was attending to immediately by staff. (R165) was assessed and noted with a slight bump on the back of (R165's) head with no loss of consciousness and no bleeding. (R165) stated 'I'm ok.' Vital signs was as follow: BP 134/88, T 97.7, HR 80, RR 20. Body assessment completed, and no other injuries noted. Resident is able to move all extremities. (V38, Attending Physician) made aware and obtained orders to send (R165) to emergency room for further evaluation and medical treatment . (R165) returned in stable condition, with negative CT scan of the head. (R165) was placed on 72 hour fall incident charting and close monitoring. (R165) was educated on the importance of calling staff for assistance when need. Staff will continue to monitor and make frequent rounds and assist (R165) as needed.
On 2/6/23 at 11:12 am, V10 stated, V10 was R165's nurse for the day shift on 12/19/22. V10 stated, V28 (CNA) was performing incontinence care for R165 slightly around 10 am and asked V10 to see R165. V10 stated, R165 was kind of lethargic. Drooling. Struggling to say something. V10 stated, V10 called a rapid response and then called 911. V10 stated, all nursing staff came to R165's room, vital signs were done, oxygen was applied and a neurological exam done. V10 stated, R165 was not performing hand grasps and not following commands. V19 stated, R165 was then emergently transferred to hospital #2.
R165's medical records from hospital #2 that were scanned into R165's facility electronic medical record (EMR) were reviewed by this surveyor. R165's hospital #2 records, titled Discharge Documentation for admission on [DATE] and discharge on [DATE], documented, in part: . Left Medial malleolar and distal fibular fracture in the setting of recent fall history. R165's X-ray of left ankle (12/20/22) documents, in part, Medial malleolar and distal fibular fracture. R165's hospital #2 records were documented as printed on 1/3/23, and R165's EMR show that R165's hospital #2 record was uploaded into R165's chart on 1/3/23.
On 2/7/23 at 2:22 pm, V1 (Administrator) stated that whenever the resident has a fall with injury, the staff will inform V1, and an initial report is submitted to the state agency within 2 hours. V1 stated, Regardless, if there's an injury at the time, as long as they (the resident) are leaving (to the hospital), I (V1) will do the investigation. V1 stated, on 12/18/22, it was reported to V1 that R165 was coming out of R165's room and lost balance and fell back. V1 stated, At that time, there were no injuries. (R165) hit (R165's) head, and (R165) was sent out to the hospital (hospital #1). V1 stated, R165 then came back to the facility hours later from hospital #1. V1 stated, when a resident is sent out to the hospital, V1 will follow up with the resident's hospital records, such as X-rays or CT (computerized tomography) scans, and review the hospital records. V1 stated, V1 looked at R165's hospital #1 records from the 12/18/22 hospital visit and that R165 had no injuries. V1 stated, on 12/19/22, V28 (CNA) told V10 (Agency LPN) that V28 said, R165 wasn't R165's self and was in an out of consciousness. V1 stated, V10 called down to V3's (Nursing Manager) office to notify of R165's status, and V3 went up immediately to see R165. V1 stated, since V1 is a nurse, V1 went up to see R165 as well. V1 stated, R165 was sent out emergently via 911 to hospital #2 with a diagnosis of encephalopathy. V1 stated, I (V1) requested (R165's) medical records from 12/19/22 (hospital #2) admission. V1 stated, I (R165) did review it (R165's hospital #2 records from 12/19/22 admission). There was no diagnosis pertaining to an injury. I (V1) looked.
On 2/7/23 at 2:54 pm, when this surveyor showed V1 the hospital #2 medical records from the 12/19/22 admission with R165's left ankle fractures, V1 stated, when V1 performed the hospital #2 medical record review for R165, V1 did not see any fractures. Asked if V1 had reported R165's left ankle fractures to the state agency, V1 stated No, I (V1) didn't see that one (left ankle fractures diagnosis).
On 2/7/23 at 12:06 pm, when asked about R165's hospital #2 records for the 12/19/22 admission, with the left ankle fractures, would V1 consider this an injury of an unknown source? V1 stated, Yes. When asked with this injury of unknown source (in R165's hospital #2 records from 12/19/22), did V1 do an investigation for R165's left ankle fractures, and V1 stated, No. When asked with R165's injury of unknown source, with or without a fall incident, did V1 do an investigation for R165's ankle fractures from the imaging results done on R165's hospital #2 admission, and V1 stated, No. I (V1) went back to the fall from the first time (hospital #1 medical records on 12/18/22).
This surveyor reviewed R165's hospital #1 medical records (that were scanned into R165's EMR). No imaging tests (X-rays or CT scans) were performed on R165's lower legs, ankles or feet.
Facility policy and procedure, titled Abuse Reporting and dated 1/4/23, documents, in part, Policy Statement: It is the policy of (facility) that all personnel promptly report any incident or suspected incident or resident abuse, including injuries of an unknown source . Procedure: . 2. Any alleged violation involving mistreatment, neglect or abuse including, injuries of an unknown source . must be immediately reported to the Administrator . 8. When an incident of a resident abuse is suspected or determined, such incident must be reported to the Charge Nurse regardless of time lapse since the incident occurred.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure a resident was supervised while smoking. This...
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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 ensure a resident was supervised while smoking. This affected one resident (R32) in the sample of 45 residents reviewed for smoking.
Findings include:
R32 is [AGE] year old female with diagnosis of but not limited to: nicotine dependence, epilepsy, chronic obstructive pulmonary disease, schizophrenia, cognitive communication deficit and schizophrenia.
R32's MDS (Minimal Data Sheet), Section C - documents a BIMS score (Brief Interview of Mental Status) of 13, which indicates cognitively intact.
On 02/06/2023 at 10:28am, surveyor observed R32 with several large holes on the front of R32's coat. Surveyor asked R32 about the holes in R32's coat. R32 stated, I had an accident with my cigarette.
R32's Clinical Care Plan dated 4/11/2022 reads, Resident is at risk for ineffective health maintenance related to lack of interest in improving health behavior as evidenced by verbal report and resident's continued desire to smoke . Goal: Resident will not suffer from unsafe smoking practices .Interventions: Observe clothing and skin for signs of cigarette burns.
On 2/07/2023 at 1:15 pm, R32 was observed outside smoking under the smoking tent with other residents and a staff member V35 (Smoke monitor).
On 2/07/2023 at 1:30 pm, surveyor observed V35 proceeded to assist a resident back into the building and observed R32 was left unsupervised as V35 assisted other residents inside of the facility.
On 2/07/2023 at 1:32 pm surveyor observed V35 come back outside of the facility. V35 stated, Usually one of us stays with the residents and another staff member will take them inside to the elevator. Sometimes it gets so crowded by the door because some residents are done smoking and want to be taken in, so I just go ahead and help them so that they don't fall over in their wheelchair. V35 stated, No, they (residents) should not be left alone. They should be supervised at all times.
On 2/07/2023 at 1:45 pm, surveyor observed V36 come outside to the smoking area. V36 stated, Usually it's always two of us supervising while the residents smoke. They should not be left alone at any time. R32 has burned holes in her coat on purpose when she gets agitated. We always keep an eye on her. We have a few residents that use the smoking apron, but R32 does not use the apron.
On 2/07/2023 at 1:58 pm, V37 (Social Service Director) said, I've noticed the burns on her (R32) coat this winter. I didn't notice before because she didn't wear the coat until it got cold. If we see someone carelessly smoking, we use a smoking apron. I didn't know where the burns came from. R32 can absolutely benefit from a smoking apron. The smoking aprons are kept in the activity room for residents that need them. In the summer time, they are outside hanging on the gate under the smoking tent. Smoking monitors should never leave the tent when there are residents there.
On 2/07/2023 at 2:25, pm V17 (Behavior Coordinator Supervisor) said, I oversee the smoking program. We do have smoking aprons. We place them on the residents who require them as we head to the smoking tent. R32 does have burn holes on her coat but I'm not sure where they came from. R32 does not use a smoking apron. A Smoke monitor is expected to stay with the residents at all times.
R32's Smoking- Safety Screen completed on 11/15/2022 indicates the need for supervision while smoking. R32's Smoking- Safety Screen also indicates that R32 does not have any behaviors that affects safe smoking.
Facility document: Residents Requiring Smoking Aprons revised 1/1/2023, listed the names of residents requiring smoking aprons and excludes R32.
Facility policy: Safe Smoking Program, dated 1/1/2023 reads, Residents that want to smoke are assessed using the Smoke Safety Screen and/or Resident Smoking Assessment to focus on each resident's ability to smoke safely with supervision, need a protector for his/ her clothing or adaptive equipment All residents are to be supervised while smoking.
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 date opened multi-dose medications with open and expi...
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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 date opened multi-dose medications with open and expiration dates and discard expired eye drops for 3 residents (R9, R36 and R58), residing on the 3rd and 6th floor. This failure has the potential to affect 23 residents residing on the 3rd floor and 22 residents residing on the 6th floor.
Findings include:
On [DATE] at 11:15 am, surveyor observed R36's Timolol Malaete Solution 0.5% with no expiration date.
On [DATE] at 11:16 am, surveyor observed R9's Latanoprost sol 0.005% with a label that states, Do not use after [DATE].
On [DATE] at 11:19 surveyor asked V9 (LPN) what R9's label says. V9 said, Do not use after [DATE] and No, this is February and we should not use after the date on the label. V9 also stated that R9's eyedrops should have a Do Not Use date too.
On [DATE] at about 12:15 pm, surveyor observed R58's Latanoprost Emulsion 0.005% with a label that stated Do Not Use after [DATE].
On [DATE] at 12:20 pm, V33 said, No, it should not be used, and I should follow what the labels says about how long the med is good for.
On [DATE] at 2:52 pm, V2 (DON) stated eye drops should not be used after the date on the label and eye drops should have a label on it that indicates a Do Not Use Date.
Policy titled Medication Storage and Labeling with an updated date of [DATE] states, in part, it shall be the policy that all medications are to be stored and label in compliance with the manufacturer's directions for storage and label.
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 implement safeguards and systems, to ensure records are accurately maintained and a periodic reconciliation is conducted, for ...
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Based on observation, interview and record review, the facility failed to implement safeguards and systems, to ensure records are accurately maintained and a periodic reconciliation is conducted, for controlled medications stored in one of one medication carts on the sixth floor.
Findings include:
On 2/07/2023 at 11:23 am, surveyor observed the Controlled Drugs-Count Record for February 2023 with blank boxes for 02/04/2023 2nd shift (4pm-12 midnight) and 3rd shift (12 midnight-8:00am); 02/05/2023 1st shift (8:00am-4:00pm) and 2nd shift; 2/06/2023 1st shift (8:00am-4:00pm) and 2/07/2023 first shift (8:00am-4:00pm).
On 2/07/2023 at 11:30 am, V9 stated, Controlled Drugs-Count Record should be completed (initialed) at the start and end of every shift and the purpose of the form to confirm that the narc count is accurate and correct.
On 2/07/2023 at 2:52 pm, V2 (DON) stated that the nurses are supposed to sign the Controlled Drugs-Count Record at the beginning and end of the shift on a daily basis.
Policy titled Medication and Narcotic Storage with an updated date of 1/04/2023 states, in part, Narcotic count will be done Q (every) shift with in and outgoing nurse and sign by the nurses.
Undated Notice from Nursing Management states, in part, again, remember to be counting at each change of shift and mark the Narcotic Count Log Sheet.
Job Description titled LPN/RN states, in part, perform routine charting duties as required, and in accordance with, our established policies and procedures.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that handrail on the 2nd floor was firmly secu...
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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 handrail on the 2nd floor was firmly secured to the wall. This failure has the potential to affect all 26 residents on the second floor.
Findings include:
The (02/05/2023) resident census in 2nd floor was 26.
On 02/05/23 at 10:39 AM, the handrail between rooms [ROOM NUMBERS] was not secured to the wall.
On 02/05/23 at 10:40 AM, this observation was pointed out to V14 (Maintenance Director). V14 checked the handrail and stated, The screw is coming out. This surveyor inquired if the handrail is safe for the resident to use. V14 stated, No.
On 02/05/23 at 11:10 AM, this surveyor pointed out the observation to V17 (Behavior Coordinator Supervisor) and inquired if it was safe for resident to use the handrail. V17 stated, No, because it is loose. The residents could have fallen if they (residents) use it.
The (undated) Maintenance Department documented, in part Policy. It is the policy of the maintenance department to provide for maintenance, repair or installation of .handrails . Maintenance will make daily round to ensure that the physical plant needs are met.
The (undated) Handrail policy documented, in part It is the policy of the maintenance department to provide for maintenance, repair of all structure in the physical plant. Handrails are structure in the facility that need to be secure(d) at all time. Maintenance should check handrails periodically and as needed, to ensure safety.
The (undated) Residents' Rights for People in the Long-Term Care Facilities documented, in part Your rights to safety. Your facility must be safe .
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 label food items with open date, failed to maintain daily refrigerator and freezer temperature logs, and failed to store food 6...
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Based on observation, interview and record review the facility failed to label food items with open date, failed to maintain daily refrigerator and freezer temperature logs, and failed to store food 6 inches off the floor in effort to prevent foodborne illness. These failures have the potential to affect all 111 residents receiving oral nourishment in the facility.
Findings include:
The (02/05/2023) facility census was 111.
The (02/08/2023) email correspondence with V1 (Administrator) documented, in part There are currently no NPO (nothing per mouth) residents.
On 02/05/2023 at 9:23 am, the last entry on the reach-in Vegetable Freezer and reach-in Milk Cooler temperature logs in the kitchen was on 02/02/2023. This surveyor pointed out the observation to V5 (Cook). V5 checked the logs and stated, The last entry is 2/2/23. Purpose of checking the temperature is to ensure refrigerated food items are stored properly.
On 02/05/2023 at 9:25am, inside the reach-in Vegetable Freezer, there were 3 sandwiches that were not dated. V5 stated, We (facility) are supposed to have a date on these. To follow principle of FIFO (first in, first out). So we (facility) don't give residents old food products, spoiled food products. Residents could get sick if we (facility) are to give them spoiled products.
On 02/05/2023 at 9:27 am, inside the reach-in Milk Cooler was an open gallon of Whole Milk with no open date. This observation was pointed out to V5. V5 stated, The gallon of milk is open with no open date.
On 02/05/2023 at 9:29 am, inside the walk-in Cooler were 2 stacks of crates of 2% milk, one crate on top of the other crate, the bottom crate was touching the floor, not 6 inches off the floor. V5 stated, This (pointing to the crates of 2% milk) should be 6 'inches off the floor so they don't get contaminated. The floor is contaminated. We (facility) serve food to the residents and we (facility) don't want to give them (residents) contaminated food.
On 02/05/2023 at 9:31 am, the last entry on the temperature logs for walk-in Cooler and walk-in freezer was on 02/02/2023.
On 02/06/2023 at 9:53 am, inside the dry storage room, the rice bin has no date. This surveyor pointed this observation to V22 (Dietary Manager). V22 stated, We (facility) are supposed to label this with open date so we (facility) know if it is safe to use or consumed by residents.
On 02/07/2023 at 2:55 pm, surveyor inquired about storing of food off the floor. V23 (Consultant Dietitian) stated, It should be 6 inches off the floor for proper cleaning, to prevent splashing and food contamination because the floor is contaminated.
On 02/07/2023 at 2:57 pm, surveyor inquired about labeling of food. V22 stated, So we know what date the food came and the date the food containers were opened to prevent serving spoiled food to residents. V23 added, To prevent potential food borne illnesses.
The (January 2023) Food Date and Labeling documented, in part Policy: It is the policy of the (Facility) to label date all foods not stored in its original packaging. It is also the policy of .to date all food on its original packaging upon delivery to the facility. Procedure: 2. All food in the dry storage, refrigerators, and freezers must be labeled with the date that it was delivered to the facility immediately after delivery. 3. All food take out of its original packaging must be stored in a clean, covered container and labeled with the common item name. The item must also be dated. 8. All food, once open(ed), must have a use by date written on the label.
The (January 2023) Recording Refrigerator and Freezer Temperatures documented, in part Policy. It is the policy of . to record refrigerator and freezer temperatures on posted temperature logs twice daily. Procedure. 3. Temperatures for refrigerators should be between 35 to 40F. Thermometers should be checked as least two times each day by the cooks. The AM (morning) cook will record the temperature of each refrigerator at the beginning of his/her shift. The PM (afternoon) cook will record the temperature of each refrigerator at the close of his/her shift. 4. Frozen foods must be maintained at a temperature to keep the food frozen solid. The AM (morning) cook will record the temperature of each freezer at the beginning of his/her shift. The PM (afternoon) cook will record the temperature of each freezer at the close of his/her shift.
The (January 2023) Policy for Storage of all foods Six Inches above the floor documented, in part Policy: It is the policy . Dietary Services to store all perishable and non-perishable foods 6 inches or more above the floor for proper cleaning and to ensure food is kept safe, wholesome, and appetizing. Procedure: 1. Food is stored at a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall on clean racks or other clean surfaces, and is protected from splashes, overhead pipes, or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.
The (January 2023) Dating of Milk Policy documented, in part Policy: It is the policy of . Dietary Services to store perishable foods so that it is kept safe, wholesome, and appetizing. Procedure: 3. Once milk is opened and used, if any is left remaining, then an open date must be written on the milk container.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the outside dumpster's were closed and failed to...
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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 outside dumpster's were closed and failed to ensure construction dumpster has no kitchen refuse in an effort to prevent pest and rodents from entering into the facility. These failures have the potential to affect all 111 residents in the facility.
Findings include.
On 02/06/2023 at 9:00 am, there were 2 outside dumpster's that were overflowing with trash and were open. There was a big dumpster close to the smoking patio that had food refuse and had no cover.
On 02/06/2023 at 9:31 am, this surveyor pointed out to V15 (Maintenance Supervisor) the two dumpsters overflowing with trash and were open. V15 stated, The trash guys are coming anytime to pick them up (garbage). It (dumpster's) is supposedly not open like that. It can attract pest and come to the facility.
On 02/06/2023 at 9:33 am, this surveyor also pointed out to V15 the big dumpster close to the smoking patio with food refuse. V15 stated, That's our construction dumpster, but the kitchen guy throws the garbage there. I (V15) think because it is closer to the kitchen.
On 02/07/2023 at 2:24 pm, surveyor showed the 01/07/2023 and 01/23/2023 Pest Control Inspection Reports to V15 and inquired what 'Pest Activity' and 'Exterior Rodent Bait Station Activity' mean. V15 stated, Activity means that 'Rats' were seen outside of the building within the vicinity of the facility. This surveyor followed up the inquiry with what could have been the reason behind the 'Activity'. V15 stated, Because there is food or garbage somewhere. The open garbage and the food refuse in the construction dumpster could have caused the rats to be seen in the exterior of the building.
The (01/07/2023) Inspection Report documented, in part Pest Activity: Rats. Pest Totals: 1. Inspection Detail: Exterior. Exterior Rodent Bait Station. Activity. RATS.
The (01/23/2023) Inspection Report documented, in part Pest Activity: Rats. Pest Totals: 1. Inspection Detail: Exterior. Exterior rodent Bait Station. Activity. RATS.
The (January 2023) Waste Disposal documented, in part Policy: All garbage will be disposed of daily and as needed throughout the day. Procedure: 2 . Trash will be deposited into as sealed container outside the premises. Trash will not be disposed of into containers that are not covered.
The (01/2023) Dumpster Disposal documented, in part Policy: It is the policy of this facility that Garbage is picked up daily. In the event of the overflow or excess of garbage, garbage will be place(d) in a Gandola ([NAME]) cart, covered and place (d) adjacent to the warehouse Thru the garage door until picked up by waist (Waste) management . No garbage should be disposed in the construction dumpster. The construction dumpster is solely for maintenance use only. Procedure: 2 . Trash will not be disposed of into containers that are not covered.
The (undated) Pest Control documented, in part Policy. The facility maintains an effective pest control program to remain free of pest and rodents. Facility-wide pest-control strategies are developed emphasizing kitchens, cafeterias, laundries, central sterile supply areas, loading docks, garbage storage areas, construction activities, and other regions prone to pest infestations. 6. Maintain garbage storage area (s) in sanitary condition to prevent harborage and feeding of pests.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 37% turnover. Below Illinois's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), $122,973 in fines. Review inspection reports carefully.
- • 30 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $122,973 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Mado Healthcare - Uptown's CMS Rating?
CMS assigns MADO HEALTHCARE - UPTOWN an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Mado Healthcare - Uptown Staffed?
CMS rates MADO HEALTHCARE - UPTOWN's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 37%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Mado Healthcare - Uptown?
State health inspectors documented 30 deficiencies at MADO HEALTHCARE - UPTOWN during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 29 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Mado Healthcare - Uptown?
MADO HEALTHCARE - UPTOWN is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 132 certified beds and approximately 114 residents (about 86% occupancy), it is a mid-sized facility located in CHICAGO, Illinois.
How Does Mado Healthcare - Uptown Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, MADO HEALTHCARE - UPTOWN's overall rating (1 stars) is below the state average of 2.5, staff turnover (37%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Mado Healthcare - Uptown?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Mado Healthcare - Uptown Safe?
Based on CMS inspection data, MADO HEALTHCARE - UPTOWN has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Mado Healthcare - Uptown Stick Around?
MADO HEALTHCARE - UPTOWN has a staff turnover rate of 37%, which is about average for Illinois nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Mado Healthcare - Uptown Ever Fined?
MADO HEALTHCARE - UPTOWN has been fined $122,973 across 2 penalty actions. This is 3.6x the Illinois average of $34,309. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Mado Healthcare - Uptown on Any Federal Watch List?
MADO HEALTHCARE - UPTOWN is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.