MORGAN PARK HEALTHCARE
For profit - Limited Liability company
294 Beds
SABA HEALTHCARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#582 of 665 in IL
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Morgan Park Healthcare has received an F trust grade, indicating poor performance with significant concerns regarding care. It ranks #582 out of 665 facilities in Illinois, placing it in the bottom half, and #180 of 201 in Cook County, meaning there are many better options nearby. The facility is showing some improvement in its issues, decreasing from 40 in 2024 to 14 in 2025, but still has high staffing turnover at 58%, which is above the state average, suggesting challenges in maintaining consistent care. Notably, the home has faced $437,799 in fines, which is concerning and points to ongoing compliance problems. Specific incidents have raised serious alarms, including a resident suffering severe physical abuse by staff and another resident who sustained a fractured leg due to improper transfer procedures, highlighting both critical safety issues and the need for better oversight. While there are some positive aspects, such as a trend towards fewer issues, families should weigh these serious weaknesses carefully.
- Trust Score
- F
- In Illinois
- #582/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 58% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $437,799 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 107 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 13%
Review needed
40 → 14 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 40 issues
2025: 14 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 58%
12pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $437,799
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: SABA HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (58%)
10 points above Illinois average of 48%
The Ugly 107 deficiencies on record
2 life-threatening 12 actual harm
Aug 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
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to provide a resident's tube feeding in accordance with the physician's order for 1 of 1 resident (R44) reviewed for tube feeding ...
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Based on observation, interview and record review the facility failed to provide a resident's tube feeding in accordance with the physician's order for 1 of 1 resident (R44) reviewed for tube feeding in a sample of 37.Findings Include:R44 has diagnosis not limited to Gastrostomy, Asthma, Essential (Primary) Hypertension, Seizures, Encephalopathy, Chronic Pain, Tachycardia, Dysphagia, Cognitive Social or Emotional Deficit Following Unspecified Cerebrovascular Disease and Abdominal Pain, Vascular Dementia. MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 03 indicating severe cognitive impact. Care Plan document in part: Focus: The resident is receiving a tube feeding and it has been determined medically necessary. Focus: The resident may be at risk for weight loss related to NPO (Nothing by Mouth) diet. Interventions: Prepare/serve the resident's nutritional diet as ordered.On 07/30/25 at 11:24 R44 was observed in bed with a feeding pump at the bedside turned off. A bottle of Jevity 1.2 was hanging on the feeding pump with the tubing connected to R44.On 07/30/25 at 11:32 surveyor asked V6 (Registered Nurse) to enter R44's room. Surveyor asked V6 was the feeding pump on. V6 proceed to the feeding pump then began pushing buttons on the feeding pump. The feeding pump then displayed 55 ml/hr. (milliliters/hour) and volume infused 1025 on the feeding pump screen. Surveyor asked was the feeding pump turned off. V6 responded yes. The feeding is ongoing for my shift and runs 24 hours ongoing. The feeding tube is flushed with water every 4 hours and I flushed it at 10:00 AM. I think when the certified nurse assistant was doing patient care they turned it off. They usually call me to pause the feeding pump so that R44 will not aspirate and when we entered R44's room the feeding pump was off. If the feeding pump is off that means R44 is not getting the right amount of calories and volume.On 07/31/25 at 10:11 AM V3 (Director of Nursing/Registered Nurse) stated If a resident has a gastric tube feeding, care should be provided every shift, the feeding should be hung as ordered with the head of the bed elevated. The feeding pump is turned off for therapy and ADL (Activities of Daily Living) care. Once the ADL care or therapy is completed the feeding pump should be turned back on. The nurse on the unit is responsible for turning the feeding pump on and off. The staff should come get the nurse once care is completed. If the tube feeding pump is turned off when the feeding should be infusing, there is a potential that the resident is not getting the scheduled feeding.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, facility failed to follow their policy to accommodate resident's needs by ensuring call light is within reach for 4 (R2, R127, R156, R203) out of 8 ...
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Based on observation, interview, and record review, facility failed to follow their policy to accommodate resident's needs by ensuring call light is within reach for 4 (R2, R127, R156, R203) out of 8 residents reviewed for call lights as well as provide an adequately sized wheelchair for 1 (R92) resident out of 8 reviewed for appropriate wheelchairs in a sample of 37.R203 has diagnosis not limited to Unspecified Dementia, Severe Protein-Calorie Malnutrition, Encephalopathy, Adult Failure to Thrive, Alcohol Dependence with Unspecified Alcohol-Induced Disorder, Essential (Primary) Hypertension, Anemia, Muscle Wasting and Atrophy, Vitamin D Deficiency, Polyneuropathy, Abnormal Weight Gain, Restlessness and Agitation and Gastro-Esophageal Reflux Disease. R203’s MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 03 indicating severe cognitive impact.
R203’s Care plan document in part: Focus: R203 is (low) risk for falls related to weakness. Interventions: Be sure R203’s call light is within reach and encourage the resident to us it for assistance as needed. Focus: R203 has a self-care deficit (ADLs (Activities of Daily Living/Mobility) generalized weakness. Interventions: Call light within reach; encourage resident to use prior to attempting self-care.
On 07/29/25 at 11:06 AM R203 was observed lying in bed in a low position with the call light laying on the left side of the bed on the floor mat out of reach. V31 (Certified Nurse Assistant) was observed sitting in the hallway. V31 stated “R203 is alert and oriented x 1-2 depending on the time of day.” Surveyor asked V31 is R203 able to use the call light. V31 responded, “I don’t think so, I am not sure.” When asked if she (V31) could tell the surveyor where R203 call light was located V31 responded “I don’t have that room. The call light should be next to the resident in bed and in a place that they can reach it. It is supposed to be two call lights in that room and there is only one call light in the room.”
On 07/29/25 at 11:12 AM surveyor asked V15 (Licensed Practical Nurse) the location of R203’s call light. V15 proceeded to pick R203’s call light up from the floor mat. V15 responded, it doesn’t look like R203 have one.” V15 then placed the call light on the bed next to R203. V15 stated “the call light should be placed on the bed in R203’s hand or next to her so that she can call us. R203 is alert and oriented x 1 and unable to use the call light. We check R203 frequently, other than that we can get R203 up. R203 has no history of falls. There are not two call lights, maintenance must have taken it out and did not tell us. The policy is if the resident is in the room the call light should be in reach.” Two beds were observed in the room with bed 2 call light observed to be missing. The light on the outside of R203’s room was illuminated and flashing.
On 07/29/25 at 11:18 AM a staff member instructed V31 (Certified Nurse Assistant) to answer the call light in R203’s room and V31 said the call light is not working.
On 07/29/25 at 11:59 AM the illuminated call light located above R203’s door continues to flash with no sound.
On 07/31/25 at 08:12 AM R156 was observed lying in bed with the call light located at the foot of the bed. Surveyor asked R156 did he know the location of his call light. R156 responded, I don’t know where my call light is at.
On 07/31/25 at 08:19 AM surveyor entered R156’s room and observed the call light at the foot of the bed. Surveyor asked R156 did he know where his call light was located. R156 looked around and said “no.”
On 07/31/25 at 08:21 AM V15 (Licensed Practical Nurse) entered R156’s room with the surveyor and when asked the location of R156’s call light, V15 looked and pulled at a cord on the left side between the R156’s bed and the wall. V15 walked toward the foot of R156’s bed, picked it up then said R156’s call light was at the foot of the bed.
On 07/31/25 at 10:11 AM V3 (Director of Nursing/Registered Nurse) stated “the call light should be answered in a timely manner and the placement should be within reach. The call light should be within reach because someone could be in distress and cannot call for help. If a resident is unable to use the call light everyone should be rounding every hour.”
Policy Titled “Call Light” dated 09/19 document in part: Equipment: Functioning Nurse Call System. 1. All residents shall have the nurse call light system available and within easy accessibility to the resident at the bedside or other reasonable accessible location. 6. Call bell system defects will be reported promptly to the Maintenance Department. 8. Check room frequently until system is repaired, per management guidance. Request repair promptly.
Policy Titled “Preventive Maintenance Program” dated 11/22 document in part: Purpose: To conduct regular environmental tours/safety audits to identify areas of concern within the facility. 3. Preventive Maintenance Program will review the following areas during random rounds: 10. The call light system is in working condition.
On 07/29/2025 at 11:22 AM, surveyor observed R127's call light was on the floor and not within reach of the resident. R127 had no idea where his call light was. Surveyor asked V13 (Certified Nursing Assistant) to come into the room. V13 stated R127’s call light should be clipped to his bed so he can make his needs known. V13 stated if R127’s call light is not within reach he cannot call for help. Surveyor observed V13 place R127’s call light on his bed.
07/29/2025 12:56 PM Surveyor observed R2 in her room. R2's call light was lodged underneath her bed between the wall and the wheel. Surveyor asked V14 (Certified Nursing Assistant) to come into the room and find R2's call light. V14 saw R2's call light lodged underneath her bed. V14 unlocked R2's bed and moved it to dislodge the call light and place it on R2's bed. V14 stated that R2’s call light should be on her bed.
On 07/31/2025 at 9:50 AM, V3 (Director of Nursing) stated that call lights are expected to be within reach. V2 stated that if call light is not within reach, the residents cannot call for help if they need assistance. Which is a risk for falls.
R127’s fall care plan (1/15/2024) documents in part: Be sure R127’s call light is within reach and encourage R127 to use it for assistance as needed.
R2’s care plan (9/12/2023) documents in part: Be sure R2’s call light is within reach and encourage R2 to use it for assistance as needed.
On 7/29/2025 at 11:40 AM, R92 was sitting up in a wheelchair in [R92’s] room. R92 stated the wheelchair was uncomfortable and wanted a wider one. R92 stated asking staff for at least a month to locate a bigger wheelchair for [R92] but have not provided one. R92 stated the wheelchair was rubbing on [R92’s] thighs on both sides. R92 lifted the hospital gown to show surveyor. R92’s bilateral hips and thighs were snug against the wheelchair. R92 stated already having a pressure sore to the right posterior thigh and didn’t want any further skin breakdown.
R92’s Weights and Vitals Summary document a weight of 267 pounds on 6/05/2025.
R92’s Care Plan Report documents in part that R92 is at increased risk for alteration in skin integrity (revision 2/24/2025). Interventions include to follow facility policies/protocols for the prevention of skin breakdown (revision 2/24/2025).
On 7/30/2025 at 10:56 AM, V3 (Director of Nursing) stated a proper fitted wheelchair for someone is one that fits comfortable within the wheelchair. V3 stated if a resident’s sides are rubbing on both sides of the wheelchair, it’s not comfortable or proper fitting.
On 7/30/2025 at 11:49 AM, V20 (Nurse) went into R92’s room with surveyor. R92 was sitting up in a wheelchair. V20 checked R92’s sides and stated the wheelchair was small for R92.
Facility provided survey team with a copy of the Illinois Long-Term Care Ombudsman Program “Residents’ Rights for People in Long-Term Care Facilities” document (Rev. 11/18). It documents in part: “Your facility must be safe, clean, comfortable and homelike.”
Jul 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 keep a resident free of sexual abuse from a resident. This failure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep a resident free of sexual abuse from a resident. This failure affects two of three residents (R1 and R2) in a total sample of three residents. Findings include:This Survey was conducted on-site in the facility from 7/18/25 to 7/20/25. R1 is [AGE] years old and admitted to the facility 10/1/2024 with a diagnosis of chronic kidney disease and is dependent on renal dialysis. Minimum Data Sets (MDS) reviewed on admission [DATE] and most recent of 4/18/2025 indicate that R1 has been assessed to be alert and oriented without cognitive deficit. The MDS also indicates that R1 has not been assessed to exhibit any behavioral or psychotic symptoms.R2 is [AGE] years old and has been a resident of the facility since 2/23/22. R2 has diagnoses that include but are not limited to schizoaffective disorder and Cognitive Communication Deficit. According to R2's MDS dated [DATE] R2 was assessed with mild cognitive impairment. On 7/18/2025 at 7:30pm, R1 was observed independently functioning on their assigned unit, alert, oriented and properly groomed. At 7:40PM, R1 spoke with the Surveyor and expressed concerns regarding several past incidents with another resident (R2) and staff. R1 said that beginning in January of this year, R2, another resident, has come into R1's room several times uninvited, exhibiting sexually inappropriate behavior toward R1; including verbal aggressions and touching R1's genitals. R1 said that he would tell facility staff about these incidents and that no one intervened until one CNA (Certified Nursing Assistant) listened and told the nurse on duty. R1 said a police investigation was conducted and R1 produced a document from the officer who took the report on 4/27/25 that included an allegation of criminal sexual assault. The document included the names of R1 and R2 as well as the police report number associated with the complaint. R1 expressed concerns that the facility's administration is not doing enough to prevent R2 from interacting with R1 as R2 frequently comes to R1's assigned unit and stares at R1 intensely, making R1 feel uncomfortable. R1 also mentioned that there have been some staff nurses who were aware of R1's complaints about R2 and the staff members jokingly dismissed R1's concerns without intervention. R1 said this has made him distrust certain staff and is uncomfortable receiving care from them.On 7/19/25 at 1:19PM R2 was observed participating in activities, alert and oriented to situation. R2 admitted to grabbing R1's genitals while in the hallway listening to music and said that R1 became angry. R2 said they were friends before that incident. R2 said when R1 called the police their friendship ended and R2 was moved to another unit and floor. R2 said that sometimes they try to return to the unit were R1 is assigned but is restricted by the social services department.On 7/19/25 at 1:57pm V3 LPN said they were on duty as the primary nurse for R1 and R2 on 4/27/25. V3 said an unknown CNA notified V3 that R1 alleged R2 was sexually inappropriate with R1. V3 said when speaking to R1 about the incident, R1 said that this had happened multiple times during that week and earlier in the day, and R1 expressed being fed up with it and told the CNA. V3 said when they initially went to speak with R2, R2 did not deny the allegation and immediately apologized. V3 completed a petition for involuntary admission for psychiatric evaluation on 4/27/25. Care plans for R1 and R2 were reviewed and neither included care plans for consensual relationships.On 7/19/25 at 1:47pm V4 PRSD (Psychiatric Rehabilitative Services Director) said that the incident of 4/27/25 occurred prior to V4 working in the facility, however, V4 would expect for consensual relationships to be reported or at least discussed with the Social Services Department. V4 said that this is important to follow-up with residents regarding safe consensual practice should they choose to engage and also notifies that staff of the relationship should any behavior issues arise. Facility reported incident dated 4/27/25 summarized that R1 alleged R2 engaged in inappropriate behavior towards R1.Facility policy and procedure titled Abuse Prevention Program (no revision date) states in part: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms.Establishing a Resident Sensitive Environment This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Concern Identification and Follow-up: Resident and family concerns will be recorded, reviewed, addressed, and responded to using the facility's concern identification procedures. Residents and families will be informed of the facility's concern identification procedures. An essential element of customer satisfaction is a timely response back to the family or resident to concerns expressed. At least quarterly, the reported concerns from residents and families, and the facility response, will be reviewed by the facility Quality Management committee to assure that individual concerns are being addressed and to assess any patterns that might indicate needed changes in facility practices.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure for reporting an allegation of re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure for reporting an allegation of resident-to-resident abuse. Findings include: This Survey was conducted on-site in the facility from 7/18/25 to 7/20/25. R1 is [AGE] years old and admitted to the facility 10/1/2024 with a diagnosis of chronic kidney disease and is dependent on renal dialysis. Minimum Data Sets (MDS) reviewed on admission [DATE] and most recent of 4/18/2025 indicate that R1 has been assessed to be alert and oriented without cognitive deficit. The MDS also indicates that R1 has not been assessed to exhibit any behavioral or psychotic symptoms.R2 is [AGE] years old and has been a resident of the facility since 2/23/22. R2 has diagnoses that include but are not limited to schizoaffective disorder and Cognitive Communication Deficit. According to R2's MDS dated [DATE] R2 was assessed with mild cognitive impairment. The electronic health record was reviewed for R1 and R2. Progress notes dated 4/27/25 for R1 states: Resident [R1] alleges that co-peer engaged in inappropriate behavior toward him. Residents immediately separated. Co-peer placed on 1:1 monitoring. Body check initiated without findings or complaints of pain. [Medical Doctor], family and police notified. Wellbeing initiated by social services where resident continues to feel safe in the facility. A progress note for R2 on 4/27/25 states: It was alleged that the resident engaged in inappropriate behavior towards co-peer. Residents immediately separated, resident was placed on 1:1 monitoring and will be sent out for an evaluation. MD, family, and police notified.A petition for involuntary admission was completed and signed for R2 on 4/27/25 and included that R2 needed immediate hospitalization to alleged unwanted physical sexual contact to another resident.Facility Incident Report and Investigation were requested from V1 (Administrator) for the alleged incident of 4/27/25. V1 included in the report that both the initial and final investigation were reported to IDPH (Illinois Department of Public Health) on 7/17/25.On 7/19/25 at 2:14PM V1 (Administrator) said that all staff are expected to directly report any allegations of abuse immediately to V1 as they arise as such to begin the investigation and send notification to IDPH. V1 confirmed that this allegation that occurred 4/27/25 is a reportable incident.Facility policy and procedure titled Abuse Prevention Program (no revision date) states in part: 1. Initial Reporting of Allegations - When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported and is being investigated. The report shall include the following information, if known at the time of the report: Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated or from whom property was misappropriated Type of alleged abuse reported (physical, sexual, neglect, verbal or mental abuse, misappropriation of resident property) Date, time, location and circumstances of the alleged incident Any obvious injuries or complaints of injury Steps the facility has taken to protect the resident This report shall be made immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or resulted in serious bodily injury; or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious bodily injury. The resident or resident's representative will also be informed of the report of an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property and that an investigation is being conducted. 2. Five-day Final Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview, and record review the facility failed to investigate an incident involving a verbal argument and physical contact between a resident and employee to rule out abuse. This failure af...
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Based on interview, and record review the facility failed to investigate an incident involving a verbal argument and physical contact between a resident and employee to rule out abuse. This failure affected one resident (R1) of three residents reviewed for abuse in a total sample of five residents.
Findings include:
On 4/29/25, at 2:11 PM, R1 said the incident was on 2/26/25. R1 said R1 felt like V3 (Maintenance Director) was harassing R1 a little bit. R1 and V3 got into an argument. R1 and V3 got into a fight. V3 was calling R1 a fat ass. On the elevator, V3 told R1 to move. V3 got into R1's face downstairs after getting off the elevator. R1 and V3 started swinging on each other. V3 hit R1 a few times on the back of the head and on the right side. R1 was in pain on the right side. R1 said R1 has been on restriction two months for the incident. R1 said V3 does not bother R1. R1 and V3 talk to each other. V3 helped R1 with a fan.
On 4/29/25, at 3:12 PM, V3 (Maintenance Director) stated on 2/26/25, I was on the third floor. I noticed and assisted a staff member move a bed onto the elevator. The resident (R1) was in the elevator. CNAs (Certified Nursing Assistants) and nurses were also in the elevator. The resident (R1) was ranting about getting out of here. R1 was on restriction at that time. The nursing staff was trying to calm R1 down. I asked the resident (R1) to move over so I could pull the bed inside and we could all fit. The resident (R1) started to go off on me, cussing. The elevator doors closed, and the resident (R1) continued to rant. We went to level 2. I pushed the bed off the elevator and housekeeping staff got off the elevator with the bed. The elevator went to level one. A resident asked me for a remote control. I went to get the remote control from my office and returned to the third floor about 15 minutes later. The resident (R1) confronted me as I passed on the third floor to deliver the remote control. R1 was saying You looking for me?. Nursing staff came and got R1 out of my face. I took the stairs down to the first floor to avoid R1. By the time I got to my office on the first floor, R1 was coming off the elevator and came straight to me. R1 said come out of the camera so I can beat your a**. R1 swung at me about six to seven times, and one landed on my face. I had a contusion on the inside of my lip. I kept dodging/ducking the swings and pushing R1's elbows away. I was against the wall and had to maneuver out of the corner. I ripped my calf muscle. By that time, staff was coming and took R1 outside to calm down. I reported to human resources, who told me to call an employee hotline for medical attention (x-rays, ultrasound, CAT scan on my leg). I reported it to the Administrator. An investigation was done. I had abuse training the day before the incident. I was trying to deescalate R1. We had been cordial before the incident. R1 is quiet but was going through something that day. I have had normal interactions with R1 since the incident. R1 asked me to put a fan together so I did. The abuse coordinator is the administrator. Forms of abuse include verbal, physical, financial, sexual, neglect.
On 4/29/25, at 4:14 PM, V2 (Human Resource/Assistant Administrator) stated I was made aware of the 2/26/25 incident because V3 (Maintenance Director) needed to fill out a workers compensation injury report. I received a call stating V3 needed to report a workplace injury because V3 was beat-up by a resident (R1). I was not in the building. The protocol is to call the injury hotline and gather witness statements. V3 was injured and going back and forth to the medical clinic for visits and therapy.
On 4/30/25, at 9:42 AM, V1 (Administrator) stated I did not report the incident on 2/26/25 because it was the resident (R1). R1 became aggressive towards V3 (Maintenance Director). We sent the resident (R1) out to the hospital for the behavior exhibited. It was not reported that V3 was aggressive or initiated any form of violence. R1 actually injured the employee. V3 was hurt pretty bad. The resident (R1) was not injured. I did not investigate the behavior of the resident. V3 asked the resident (R1) to move over while on the elevator, the resident (R1) became verbally threatening and then physical. I did not have a reason to look at it as abuse. The staff that were around stated that the resident became physically aggressive towards the maintenance director. I did not talk to the resident. R1 was separated, placed on a one to one, and then sent to the hospital. I was not in the building when it happened. I went by what the staff present stated to me. I am the abuse coordinator. All types, forms, incidents, allegations, suspicions of abuse should be reported to me. I do abuse training for the staff monthly. Training topics include abuse identification, abuse prevention, and protection of the resident as it pertains to abuse. Types of abuse include mental, verbal, involuntary seclusion, exploitation, physical, sexual, misappropriation of funds. Abuse includes resident to resident and staff to resident. It includes resident to staff. I never report a resident being belligerent or abusive to staff to public health. We do put interventions in place. The resident may be placed on a one to one, prescribed something/medication by the physician, and or sent out to the hospital.
Facility Policy and Procedure Abuse Prevention Program, 1/24, documents in part: Incidents will be reviewed, investigated and documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Investigation Procedures. The investigator will attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable.
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
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 two residents (R5 and R6) that receive sup...
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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 two residents (R5 and R6) that receive supplemental oxygen in the facility had active Doctor's orders. This failure has the potential to affect 31 residents currently receiving oxygen in the facility.
Findings include:
R5 is [AGE] year old with diagnosis including but not limited to: chronic obstructive pulmonary disease, morbid obesity, anemia, congestive heart failure and nicotine dependence. R5 has a BIMS of 15, which indicates cognitively intact.
R6 is [AGE] year old with diagnosis including but not limited to: chronic obstructive pulmonary disease, malignant neoplasm of unspecified part of left bronchus or lung, malignant neoplasm of upper respiratory tract, angina pectoris and muscle wasting. R6 has a BIMs of 14, which indicates cognitively intact.
During investigation on 4/22/2025 at 12:05 PM, R6 was observed in bed receiving supplemental oxygen (O2) via nasal cannula at 4 LPM (Liters per minute). R6 stated that he had been receiving oxygen in the facility since his admission on [DATE].
Surveyor inquired about R6's O2 order.
On 4/22/25 at 12:11 PM, V5 (LPN/ Licensed Practical Nurse) said that R6 did not have an active order for oxygen.
On 4/22/25 at 12:32 PM, R5 said, I've been using oxygen now for about six months. I don't need it all the time, but I use it sometimes at bedtime because I feel short of breath.
At that time, V5 (LPN) said that R5 did not have an active order for oxygen and that the purpose of the oxygen orders are to ensure that everyone (nursing staff) is aware of the need for oxygen.
On 4/22/2025 at 12:33 PM, Surveyor and V5 noted an O2 concentrator at R5's bedside and oxygen tubing lying on her bed. R5 stated that the oxygen tubing on her bed and the oxygen concentrator at the side of her bed was hers.
On 4/23/2025 at 1:10 PM, V2 (DON/ Director of Nursing) said that an oxygen order from a physician is needed to administer oxygen to a resident in the facility. Surveyor asked if R5 and R6 had been receiving O2. V2 said that she was unsure how long R5 and R6 had been receiving oxygen in the facility. Surveyor asked if obesity, COPD or malignant neoplasm possibly warrant the need for supplementary oxygen.
On 4/23/2025 at 1:10 PM, V2 said, Yes, if a person had COPD with another diagnosis such as obesity or malignant neoplasm of the lung, he/ she could become short of breath and require oxygen at times. A resident could go into respiratory distress if the correct O2 order is not obtained or followed.
Facility Oxygen report dated 4/22/2025 includes R5 and R6 as residents receiving supplementary oxygen in the facility.
R5's Order Summary Report dated 4/22/2025 excludes any order for oxygen; R5's admission record documents an admission date of 11/08/2016.
R6's Order Summary Report dated 4/22/2025 excludes any order for oxygen; R6's admission record documents and admission date of 3/15/2025.
Facility policy titled Physician orders documents, to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards.
Facility policy titled admission policy document, prior to or at the time of admission, the resident's attending physician must provide the facility with information needed for the immediate care of the resident.
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure that the environment remains free of hazards and was a homelike environment. The facility failed ensure the wall paint ...
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Based on observation, interview, and record review the facility failed to ensure that the environment remains free of hazards and was a homelike environment. The facility failed ensure the wall paint in residents' rooms was not chipped and damaged exposing the drywall and failed to ensure ceiling and wall tiles in the shower room were repaired or replaced. This failure has the potential to affect 101 residents residing on the second floor.
Findings include:
On 04/08/25 at 01:12 PM Chipped paint was observed along the lower part of R1's south wall and along the side of R1's bed.
On 04/08/25 at 02:26 PM Chipped paint was observed on the lower south wall in R6's room and at the head of R6's bed. R6 said it is probably due to them pushing my roommate in the wheelchair and bumping the wall.
On 04/09/25 01:05 PM V2 (Director of Nursing) stated Plastered areas on the walls need to be painted.
On 04/10/25 at 10:59 AM V5 (Maintenance) stated I have worked here for about a year. I started repairs from the first floor up everywhere there were holes in the walls. It is from residents and staff neglect of pushing the bed into the wall and the wheelchairs damaging the walls. If the residents are on restriction they will damage the walls. A lot of stuff has been neglected and I am trying to play catch up. It is harder to get in the resident rooms because some of them don't get up. I describe it (the damage) as dents from the beds or holes in the wall not so much the paint but the drywall.
On 04/10/25 at 11:19 AM During the facility tour with V5 (Maintenance) the wall at the head of R12's bed was scrapped exposing the dry wall, and the electrical outlet near the window was missing the outlet cover. When V5 turned on the water in the sink it did not drain and R5 said yeah, its clogged. V5 said if the nurse doesn't put it in the work order book, I don't know the work needs to be done. The second-floor south shower room corner of wall was observed with broken off plaster. V5 said that is from the wheelchair. Hanging, peeling paint was observed on the bathroom ceiling in R13's room. V5 said that is from a leak or something. We have to sand and paint, and the resident cannot be in the room. A brown stain was observed around the base of the toilet in R15's bathroom. V5 said the brown is from a previous leak and need to be cleaned up. Four loose ceiling tiles, 4 ceiling tiles with brown spots, and a missing wall tile with a hole in the wall was observed in the 2 north shower room. One missing hand railing was observed on the west wall on 2 south. On the wall on the side of R2's bed, the pant was scraped off the wall exposing the drywall. V5 said this is real bad, all the rooms need attention. The paint on wall on the side of R1's bed was scraped exposing the dry wall. The lower part of the north wall was observed with scrapes exposing the dry wall. V5 said that is from years of neglect, it is not a matter of fixing it but keeping it fixed. The wallpaper was observed to be peeling off the wall in the soul kitchen below the window and above the outlet on the east wall above the electrical outlet.
On 04/10/25 at 04:39pm V1 (Administrator) stated I heard about the environment concerns; it needs a lot of sprucing, and they need to put the money in it.
Residents' Rights for People in Long-Term Care Facilities document in part: Your facility must be safe, clean, comfortable, and homelike.
Policy: Titled Preventive Maintenance Program reviewed 11/23 document in part: To conduct regular environmental tours/safety audits to identify areas of concern within the facility. 3. Preventive management program will review the following areas during random rounds: 6. Floor tiles are assessed for cracking and wear. 8. Are handrails present and in working condition. 12. All electrical equipment is checked for safety. 14. Ceiling tiles are free from watermarks or spots. 15. Wall coverings are intact and free of tears or loose seams. 17. Drains are clean and free of debris.
Policy: Titled Safety and Supervision of Residents reviewed 11/24 document in part: our facility strives to make the environment as free from accident hazards as possible. 2. Safety risks and environmental hazards are identified on an ongoing basis.
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to follow their abuse policy for two residents (R1, R2,) out of four residents reviewed for abuse. This failure resulted in staff members not i...
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Based on record review and interview the facility failed to follow their abuse policy for two residents (R1, R2,) out of four residents reviewed for abuse. This failure resulted in staff members not immediately intervening in a situation before residents became abusive to each other. Staff did not intervene in time thus allowing R1 and R2 to put scratches on each other's face, neck and arms.
Finding Include:
Facility's abuse policy denotes residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse; corporal punishment; and involuntary seclusion. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical abuse and mental abuse.
R1's 3/25/2025 21:40 Health Status/Progress Note Text reads: Upon entering room, resident noted yelling at another resident, residents separated, head to toe assessment noted, scratches present to face, lip, hand and wrist, medicated for pain, orders received for antibiotic ointment. Labs and Urinalysis, all orders noted and carried.
R2's 3/25/2025 20:26 Health Status/Progress Note Text reads: Resident noted yelling in another residents room, upon entering room, resident noted yelling with scratches to face, unable to verbalize what happened, resident placed in supervised area, head to toe assessment completed no additional alterations noted, Np made aware, labs and Ua ordered, Emergency contact made aware, Administration also made aware, resident medication with prn for pain and Agitation.
V7 (Licensed Practical Nurse) stated she was working on 3/25/25 on the pm shift. V7 was in the pantry getting one of her residents a snack when she heard someone yelling. V7 stated they immediately came out of the pantry and went to where she heard the noise. V7 stated when she went down the hall, she saw R2 coming out of R1's room with scratches on her face and saw her nurse (V6) assessing R1. V7 stated that V7 was asked by V6 to look at R2's face. V7 stated they noticed that R2 had some scratches on her face. V7 stated they asked R2 what happened and R2 told her she did not know, and nothing happened. V7 stated they went back to R1's room and they asked R1 what happened. R1 told V7 that her and R2 were talking when R2 suddenly started to scratch her. V7 stated they gave them first aide and notified the Nurse Practitioner. V7 stated this was the first time that R1 and R2 had got into an altercation.
V6 (Licensed Practical Nurse) stated on 3/28/25 at 5:15pm she was working on the evening of 3/25/25 and remembers that R1's daughter had just left the facility. V6 stated about 15 minutes after she left, V6 was passing medications and walked into R1's room and noticed that R1 and R2 had scratches on their face. V6 stated they asked them what happened and R1 told her that they were fighting. V6 stated they asked R1 why and R1 told her she did not know why. V6 stated they asked R2 but due to her poor cognition could not explain what had happened. V6 stated they notified the NP (nurse practitioner) and got an order for bacitracin ointment to be applied to the scratches on both residents. V6 stated it was hard to believe what had happened since R1 and R2 were friends. V6 stated now they will not allow R2 to go visit R1 anymore since that incident happened.
V4 (Certified Nurse Aide) stated on 3/28/25 at 5:25pm she was on the unit in the evening of 3/25/25 doing resident care and heard some commotion. V4 stated they stepped out of the room and headed to R1's rooms where she heard the noise. V4 stated they saw the two nurses in R1's room and saw R2 walking out of R1's room with scratches on her face and neck. V4 stated she was told to escort R2 to her room. V4 stated later on towards the end of the shift when she did see R1, she noted a small bruise on her lips and several scratches on her face. V4 stated V4 has worked on the floor for a few months and never seen R2 attack another resident.
V2 (Certified Nurse Aide) stated on 3/28/25 at 5:40pm she was working on her regular pm shift the evening of 3/25/25 when V2 was suddenly called by V6 to R1's room. V2 stated when she entered R1's room she noticed R1 had scratches under her eye and on her lips. V2 stated R1 called her daughter and V6 told the daughter that R1 had an altercation with R2. V2 stated she had never heard of R2 attacking or fighting with R1 before. V2 stated at the time of the incident V2 was doing patient care in another resident's room.
V1 (Administrator) stated on 3/28/25 at 5:55pm that R1 was involved in an altercation with another resident (R2). V1 stated both residents sustained scratches on their face. V1 stated R2 used to live a few doors down from R1 but after the incident was moved to another section of the Dementia unit.
V8 (Nurse Practitioner) stated on 4/1/25 at 2:30pm they were notified that R1 and R2 had an altercation resulting in scratches. V8 stated V8 saw both residents and noted that the scratches were superficial, and they did not require any hospitalization.
Mar 2025
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure a resident was transferred as per assessment...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure a resident was transferred as per assessment, care plan, and proper procedure/use of equipment (Hoyer lift) for 1 (R1) out of 3 residents reviewed for the right of every resident to be safe and free of accidents. These failures affected 1 resident (R1) resulting in R1 sustaining a fractured left leg and undergoing surgery on the left leg (left leg nailing procedure) with three (3) separate incisions with staples.
Findings include:
R1 is [AGE] years old initially admitted in the facility on 02/14/2024. R1 diagnosis includes Alzheimer's Disease, anxiety disorder, left below the knee amputation, and more recent sustained fracture of lower end of left femur. R1 has an intact cognition with a score of 12 on her Brief Interview of Mental Status (BIMS) dated 02/10/2025.
On 03/18/2025 at 12:01 PM, R1 was seen on her bed in her room. R1 able to express thoughts well within topic during conversation. R1 stated she had a fracture on her left leg. R1 took off the sheet that covers her left leg with below the knee amputation. R1 has three incisions on her left leg. R1 stated that when she came back from dialysis, the staff that help her lost her balance. R1 said, I guess, I am too heavy for her. R1 stated that the staff that helped her did not use a gait belt. And both the staff and her (R1) hit the floor. R1 stated that she was sitting on a dialysis chair (Geri chair) when she was transferred to the bed and fell. R1 stated that it takes two (2) people to transfer her. But when she fell it was only us (her and the staff) because the staff cannot find anybody. R1 said, Sometimes they use equipment (Hoyer lift) if it is available. But sometimes it just disappears. It is from another unit. R1 stated that she knows that she needs Hoyer lift or at least two (2) people when she transfers. R1 stated that she weighs two hundred forty-three pounds (243 LBS.). R1 said, I think it's safer if I use the lift. It is safer if two people help me that is how I see it. R1 stated that somedays they have don't have CNAs (Certified Nursing Assistants). And there are times they only have one (1) CNA, but they do not come inside her room. When asked why only one (1) staff helped her. R1 said, I really don't know why she was the only one who helped me.
On 03/18/2025 at 12:22 PM, V4 (Licensed Practical Nurse) stated that she was informed by V5 (Certified Nursing Assistant) that R1 slide to the fall mat. And that V5 was transferring R1 from chair to bed. V4 stated that V5 was by herself when she transferred R1. V4 stated that R1 needs Hoyer lift because the facility does not use lifting of resident by staff. V4 said, There is no lifting of residents by staff policy in facility. V4 stated that she did not remember if she asked V5 why she was not using a Hoyer lift. And stated that it may be that someone else was using the Hoyer lift that time.
On 03/18/2025 at 12:39 PM, V5 (Certified Nursing Assistant) stated that she was the staff that transferred R1 when she fell. V5 stated that it was nighttime and time for R1 to go back to bed, V5 stated that she went to look for the Hoyer lift and it was not working at that time. She looked for another staff to help her transfer R1 but was not able to find anyone. V5 stated that she transferred R1 by herself. V5 said, I was gonna pivot her (R1) to slide her over to the bed because I cannot lift her. And you are not supposed to lift her. I did it myself. I tried to slide her, and she ended up sliding from the chair and slide on the mat. V5 stated that all of facility's Hoyer lifts were not working or not charged. V5 said, I know that I should have made safety the first priority and will not transfer her again by myself.
On 03/19/2025 at 10:24 AM, V6 (Restorative Manager / Fall Prevention Coordinator / Licensed Practical Nurse) stated that R1 is a total assist and needs to be transfered with the Hoyer Lift in and out of her wheelchair or dialysis chair (Geri chair). V6 said, R1 is an amputee, and her transfer ability is not strong, and it is not safe to transfer when not using Hoyer lift. V6 confirmed that under MDS (Minimum Data Set) assessment sit to stand was not done during assessment because of R1's medical conditions and safety concerns. V6 stated that facility has a Safe Lifting Policy as part of nursing staff education. And the same policy needs to be signed before starting to work with residents or new hires. V6 said, Staff needs to follow the policy.
On 03/19/2025 at 11:47 AM, with V2 (Director of Nursing) and V7 (Nurse Consultant). V7 stated that probably R1 needs to be with mechanical lift during transfers. V2 stated that she did not do the investigation. And that she does not know anything about it. V2 stated that during that time she was the Assistant Director of Nursing (ADON).
R1's MDS (Minimum Data Set) assessment dated [DATE] on functional abilities sit to stand: the ability to come to a standing position from siting in a chair, wheelchair, or on the side of the bed. Assessed as 88 that means not attempted due to medical condition or safety concerns.
R1's Care Plan for activities of daily living (ADL) and mobility dated 02/15/2024 is to transfer with mechanical lift (Hoyer) with two (2) persons.
R1's notes documents history of falls on 08/30/2024, V8 (Registered Nurse) clinical notes reads that R1 slide out of her bed while CNA (Certified Nursing Assistant) providing care. On 12/14/2024 V8's (Registered Nurse) note reads that R1 fell in the dining room.
On 03/19/2025 at 01:09 PM, with V9 (Certified Nurse Assistant) the facility was found to have only one (1) mechanical (Hoyer) lift available to use on the floor. V9 cannot locate the second mechanical lift. Per V9 the facility has only two (2) mechanical lifts for all the residents. V9 stated that she is assigned to nine (9) residents and two (2) of the residents needs a lift. V9 said, the 2nd floor alone has around eighty (80) to ninety (90) residents. V9 was asked if with only one (1) lift available would that be enough for residents to use? V9 replied, That would be a problem.
At 01:50 PM, V6 (Restorative Manager / Fall Prevention Coordinator / Licensed Practical Nurse) stated an estimated thirty (30) residents need a Hoyer lift for transfer. Per facility's census dated 03/18/2025, facility has three hundred (300) available beds. Two hundred eleven (211) are occupied by residents.
R1's X-Ray result dated 2/11/2025 reads: Fracture on the left leg. (Acute, mildly comminuted nondisplaced distal femoral fracture).
R1's hospital record dated 02/11/2025 documents as follows: Description: R1 status post left below knee amputation fell while being helped from a wheelchair bringing down facility staff too. R1 sustained left femur (leg) fracture. Admitting diagnosis, mechanical fall at the nursing home resulting in left femoral fracture. Under pain assessment, R1 screams and yells in pain upon therapist application to left lower extremities. Procedure or surgery done due to left femur fracture: Intermedullary nailing left distal femur fracture (femoral nailing).
Safe Lifting Policy for all employees in nursing department reads: The Safe Lifting Policy exists to ensure a safe working environment for resident handlers. The policy is to be reviewed and signed by all staff that performs or may perform resident handling. The safety committee will review this policy annually with changes made accordingly. Under process and procedure: Total Lift Transfers needs Hoyer type of lift with 2 or more caregivers.
Fall Prevention Policy dated 02/18/2014, reads: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.
Transfer conveyances shall be used to transfer residents in accordance with the plan of care. Per R1's care plan she needs Hoyer lift with two (2) persons assisting with the transfer.
Centers for Disease Control and Prevention on Safe Lifting and Movement of Nursing Home Resident dated February 2006 reads: Safe resident lifting programs that incorporate mechanical lifting equipment can protect workers from injury, reduce workers' compensation costs, and improve the quality of care delivered to residents.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to accurately record the fall incident of 1 (R1) out of 3 residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to accurately record the fall incident of 1 (R1) out of 3 residents reviewed for incident record. This failure affected the accuracy of 1 resident's (R1) record, with inaccurate documentation of the chronological occurrence of the incident, impacting the credibility of facility staff documentation on resident's record.
Findings include:
R1 is a [AGE] year old resident in facility. R1 initially admitted in the facility on 02/14/2024. R1's diagnosis includes Alzheimer's disease, anxiety disorder, left below the knee amputation, and more recent sustained fracture of lower end of left femur/leg. R1 has an intact cognition with a score of 12 on her Brief Interview of Mental Status (BIMS) dated 02/10/2025.
On 03/18/2025 at 12:01 PM, R1 was seen on her bed in her room. R1 able to express thoughts well within topic during conversation. R1 stated she had a fracture on her left leg. R1 took off the sheet that covers her left leg with below the knee amputation. R1 has three incisions on her left leg. With eleven (11) staples, five (5) and four (4) staples. R1 stated that when she came back from dialysis, the staff that help her lost her balance. R1 said, I guess, I am too heavy for her. R1 stated that the staff that helped her did not use a gait belt. And both the staff and her (R1) hit the floor. R1 stated that she was sitting on a dialysis chair (Geri chair) when she was transferred to the bed and fell. R1 stated that it takes two (2) people to transfer her. But when she fell it was only us (her and the staff) because the staff cannot find anybody else. R1 said, Sometimes they use equipment (Hoyer lift) if it is available. But sometimes it just disappears. It is from another unit. R1 stated that she knows that she needs Hoyer lift or at least two (2) people when she transfers. R1 stated that she weighs two hundred forty-three pounds (243 LBS.). R1 said, I think it's safer if I use the lift. It is safer if two people help me. That is how I see it. R1 stated that somedays they have don't have CNAs (Certified Nursing Assistants). And there are times they only have one (1) CNA, but they do not come inside her room. When asked why only one (1) staff helped her. R1 said, I really don't know why she was the only one who helped me.
On 03/18/2025 at 12:22 PM, V4 (Licensed Practical Nurse) stated that she was informed by V5 (Certified Nursing Assistant) that R1 fell on [DATE] and was informed by V5 around nine (9) o'clock PM about the fall. V4 stated that she documented the day after. V4 read her notes on electronic health records and was asked if her notes dated 02/11/2025 was accurate. V4 said, I might be confused with somebody else. She (R1) fell on the 11th not 10th.
On 03/18/2025 at 12:39 PM, V5 (Certified Nursing Assistant) stated that she was the staff that transferred R1 when she fell. V5 was asked what day the incident happened. V5 said, I did not work on the 11th, I worked on the 10th. I did a double morning and evening on the 10th.
On 03/19/2025 at 11:47 AM, with V2 (Director of Nursing) and V7 (Nurse Consultant). Both V2 and V7 were asked about documentation inaccuracy for R1's incident report and clinical notes dated the incident of the fall on 02/11/2025; staff statements (V4 and V5) saying it happened on 02/10/2025; and nursing schedule also reads that V5 worked on 02/10/2025 not 02/11/2025. V2 and V7 stated they will look into it. V1 (Administrator), emailed V5's time sheet that reads V5 worked double on 02/10/2025 and did not work on 02/11/2025. V1 was emailed to clarify when R1's fall happened (02/10/2025 or 02/11/2025). V1 did not reply to the email.
During review, inconsistencies of resident record were also identified. Facility's incident report dated occurrence of incident on 02/11/2025. Report also documents that V5 (Certified Nursing Assistant) was the facility staff that transferred R1 during the fall. R1's clinical notes by V4 (Licensed Practical Nurse) documents that incident happened on 02/11/2025. Facility nursing schedule and V5's time sheet documents that V5 did not worked on 02/11/2025. V1 (Administrator) and V2 (Director of Nursing) were asked to clarify the inconsistencies but were not able to provide information.
Mar 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide all 205 residents residing in the facility with needed supplies for activities of daily living such as towels and lin...
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Based on observation, interview, and record review, the facility failed to provide all 205 residents residing in the facility with needed supplies for activities of daily living such as towels and linen.
Findings include:
Observations made 3/11/25 and 3/12/25 of the utility closets and rolling linen carts where clean supplies are stored revealed very few linens and towels in them. Some had no gowns, pads, or linen.
On 3/11/25, at 8:52 AM, V6 (Licensed Practical Nurse) stated sometimes there is not enough linen and towels. The CNAs (Certified Nursing Assistants) will complain there is no linen and towels so they cannot do their work.
On 3/11/25, at 9:00 AM, V9 (Certified Nursing Assistant) stated V9 has worked at the facility 14 years. V9 stated we have not gotten any linen today. We should have linen and towels by now at 9:00 AM. We use wet wipes if there are no towels. We change linen daily and as needed. At 9:00 AM it's time to get residents cleaned, showered, dressed, out of bed, and change linen. Each shift gets towels and linen at the beginning of the shift. If there are no towels and or wet wipes, then we have to wait to clean the residents.
On 3/11/25, at 12:43 PM, V11 stated I provide quality patient care. There are not enough linen and towels available when needed. I will cut sheets to make towels. I have to do something to get the residents clean. The facility does not have wet wipes. I have purchased wet wipes myself before. I have had to wait to clean a resident due to not having towels. Even when laundry is delivered it is only a few items. Bath towels, face towels, flat and fitted sheets, pads, gowns are split between four CNA's.
On 3/11/25, at 1:23 PM, V12 (Licensed Practical Nurse) stated the CNA's (Certified Nursing Assistants) complain there are not enough linen and towels. I have observed that there are not enough towels for the residents. Then I go search for towels.
On 3/12/25. at 9:54 AM, V11 (Certified Nursing Assistant) stated no linen and towels had been delivered for the morning shift.
On 3/12/25, at 10:00 AM, V13 (Licensed Practical Nurse) stated not having enough linen and towels has been an ongoing issue for the CNAs to perform patient care. There is a shortage of towels and linen.
On 3/12/25, at 10:21 AM, R6 said it happens a lot that I've been told I can't get cleaned because of no towels and linen. I have to wait if I'm soiled and for a bed bath. It makes me mad. It may take until 11:00 AM to get cleaned.
On 3/12/25, at 10:27 AM, R7 said the majority of the time they don't have towels. I have to wait to get cleaned if they don't have towels. It makes me feel nasty.
On 3/12/25, at 10:33 AM, R8 said it has been happening a lot lately that the facility does not have towels and linen. I have to wait to get cleaned, maybe an hour, because of no towels. If I have a bowel movement I have to wait. It does not make me feel good at all.
On 3/12/25, at 10:43 AM, V14 (Certified Nursing Assistant) stated we are cutting up sheets to use as towels. I have had to wait to clean residents because of no towels available. I have purchased towels with my money to use for the residents.
On 3/12/25, at 11:17 AM, observed the laundry room. Writer did not observe an abundance of supplies, linen, and towels. The storage room for excess supplies had approximately eight dozen bath towels, 360 face towels and a small garbage bag of approximately 30 pillowcases.
On 3/12/25, at 11:17 AM, V15 (Director of Housekeeping) stated we are out of gowns, pads, fitted sheets, flat sheets. We need to order more linen and towels. I place the order however the owner has to approve the order. My budget is $600 per month. A 12 pack of bath towels is $13.99. A 60 pack of face cloths is $2.99. A 6 pack of fitted sheets is $54.95. A 12 pack of flat sheets is $54.99. A 12 pack of pads is $54.95. A 6 pack of gowns is $28.95. A 12 pack of pillowcases is $13.95. Laundry is two shifts, 5:00 AM to 1:00 PM and 2:00 PM to 10:00 PM.
On 3/12/25, at 11:18 AM, V16 (Laundry) stated I work 5:00 AM to 1:00 PM. I pull the heaviest units first. The same amount of dirty linen and towels and supplies I take from the unit is the same amount given back to the unit after it is cleaned. Linen is distributed according to what is picked up in dirty. We sweep the resident rooms for towels and linen. I deliver my first load of laundry approximately at 8:30 AM. We need more linen ordered.
On 3/12/25, at 1:00 PM, V17 (Central Supply) stated I started two months ago. We do not have body wipes to clean the residents with. Body wipes are not routinely ordered. I have not ordered any since I started. There are no replacements for towels in central supply.
On 3/13/25, at 3:39 PM, V2 (Assistant Director of Nursing) stated I started here 10/1/2024, as ADON (Assistant Director of Nursing). My expectation is for the residents to be cleaned in a timely manner. CNAs have said they are waiting for linen to arrive to the floor.
On 3/13/25, at 3:56 PM, V1 (Administrator) stated if residents are dirty/soiled, they should be cleaned timely. I have not been told that residents are not able to be cleaned due to not having linen and towels. I have been told there is not enough linen and towels, that we need more linen and towels.
According to facility daily census provided by the facility, there are 205 active residents.
Facility policy Laundry Services, no date, reads in part: Clean Linen a. An adequate supply of clean linen will be maintained for resident care.
Facility policy Dignity, 1/25, reads in part: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.
Mar 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to a.) ensure medications were administered as ordered by the residents' physician, b.) ensure medications were locked and secur...
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Based on observation, interview, and record review, the facility failed to a.) ensure medications were administered as ordered by the residents' physician, b.) ensure medications were locked and secured while unattended, c.) provide sufficient nursing coverage to ensure adequate resident care and support, and d.) provide care and services that meet professional standards. These failures have the potential to affect 103 residents residing in the facility. The facility also failed to provide timely incontinence brief changing to a resident due to not providing linen to staff. This failure affects one of three residents (R17) reviewed for ADL care in a total sample of 17 residents.
Findings include:
On 3/01/2025, all the floors were reviewed for staffing. One nurse did not show up for the morning shift on 3/01/2025.
On 3/01/2025, at 10:49 AM, V3 (Licensed Practical Nurse) stated, there was one nurse from the night shift that I reported to today. There was a nurse on duty for the night shift last night. At times, there are times I come in and there is no nurse for the night shift. It is not often but it does happen. I work from 7:00 AM until 3:00 PM. Administration will call people and ask them to come in. There are methadone residents that are looking for their methadone on the night shift. But that is not on my side.
On 3/01/2025, at 11:10 AM, R17 stated, I have not been changed yet today. I do have sores on my bottom. I need cream for my bottom as well.
On 3/01/2025, at 11:41 AM, V5 (Certified Nursing Assistant) stated, I have not changed R17 yet today due to not having any linen. Staff are waiting for linen too long. I am about to change her now.
On 3/01/2025, at 12:50 PM, V9 (Assisitant Director of Nursing) stated, the residents say that they did not have a nurse on a Monday morning. If the DON or I are aware, the Director of Nursing or I must come in and cover shifts. I have only been here four months. I have had to do it maybe two or three times.
On 3/01/2025, at 1:11 PM, V8 (Laundry Aide) stated, I am the only one working today for the laundry department. There is not enough linen in the building period. They need to purchase more linen for this building, all linens. There are three shifts for the laundry aides. I am working the 2:00 PM to 11:00 PM shift. The shift before me was 5:00 AM to 2:00 PM. I will build a linen cart for the entire unit around 3:00 PM. The aides will need more linen around 5:00 PM or 6:00 PM. There is a cart at 7:00 AM. After that around 9:00 AM or 10:00 AM, the staff will need more linen. I have brought the concern to my boss. The way it goes, is some kind of chain of command. He will order five cases and they give him one. It is neglect. There is not enough linen to care for the residents. You cannot blame the aides because they are doing the best they can do.
On 3/01/2025, V15 (Housekeeping Supervisor) refused to be interviewed by the surveyor during this investigation.
On 03/01/2025, at 1:46 PM, V14 (Staffing Coordinator) stated, I was made aware that there was no nurse on 2 south today. She no called no showed. When I am made aware of this I reach out to the person, and I try to replace them. I reach out to the ADON and DON. If no one else can come in they are expected to cover the shift. Usually, I can over the shift with staff. There is always a scheduled nurse. There may be times when someone is running late. There have been one or two nurses that leave before the morning shifts starts. In mid-January there was no night nurse. Then in February the supervisor had to work the cart. I am an aide. When there is a call in or staff running late, I can assist.
On 3/01/2025, at 3:53 PM, V10 (DON) stated, it is not true. If there are no nurses, we must come and help. If we are not notified, we will not know what happens. There is always going to be a nurse there on the floor.
On 3/01/2025, at 4:07 PM, V18 (Former Administrator) stated, I would try to do as much as I could when I was there. Yes, there were allegations of a nurse not working. I am not going to lie about that.
February 20th, 2025, resident council meeting minutes documents there is no linen on night shifts. Resident voiced concerns there has been no nursing on second or third shift. Residents expressed that the overnight shift does not do anything.
On 3/01/2025, staffing sheets were provided to the surveyor. On 2/15/2025 and 2/16/2025, there were nurses scheduled for the evening and night shifts. V14 (Staffing Coordinator) was unable to provide the punch documentation to provide the nurses did work their shifts. V14 was unable to provide the documentation sheet that contains staff signatures when they work their shifts.
On 03/01/2025 at 10:12 AM, surveyor located on the second floor of the facility with V7 (Licensed Practical Nurse/LPN). V7 states she is currently the only nurse working on the second floor 2 North unit. V7 states she started her shift at approximately 7:00 AM this morning and there is supposed to be another nurse scheduled to work on the 2 North unit with her. V7 states management is aware, and she is awaiting another nurse to arrive to assist with resident care. V7 states she began her medication administration pass at approximately 8:30 AM. V7 states she is only responsible for administering medications to her assigned residents. V7 states she will not be administering medications to all of the residents residing on the 2 North unit. V7 observed with three clear medication cups sitting on top of the medication cart with medications inside of them. V7 states she prepared the medications for 3 different residents at the same time. V7 states she is aware that resident medications should not be prepared all at once because there is potential for medication errors and for residents to receive the wrong medications. V7 states this could be dangerous for the residents.
On 03/01/2025, at approximately 10:15 AM, V7 is observed walking away from her medication cart leaving the cart unlocked and unattended. V7 also leaves a residents' electronic medication administration record/eMAR deployed on the computer screen. Staff and residents observed walking past the medication cart and can potentially gain access to residents' medications. Surveyor makes V7 aware of the unlocked medication cart and resident eMAR being visible on the computer while V7 walked away. V7 states she is responsible for the medication cart that is unlocked and unattended and only left the cart temporarily because surveyor was standing there. Surveyor makes V7 aware that surveyor is not responsible for monitoring her medication cart when V7 leaves the cart unlocked and unattended. V7 states if a medication cart is left unlocked and unattended, then residents can gain access and have adverse reactions and possibly overdose. V7 states if a residents' eMAR is left deployed for anyone to see, then resident privacy and HIPAA/Health Insurance Portability and Accountability Act rules are violated.
On 3/1/2025, at 11:46 AM, V1 (LPN/Restorative Manager) observed arriving on the second floor 2 North unit and administering medications to residents. V1 states she is not the nurse originally scheduled to work and was recently informed that the scheduled nurse did not arrive to work the shift. V1 states she will not be administering medications to residents that were scheduled at 9:00 AM or this morning. V1 states this is because the facility is allowed the time frame of one hour before and one hour after the scheduled time to administer medications to residents. V1 states she is only administering medications to residents on the 2 North unit that are scheduled for the afternoon time frame. R11 and other residents standing in the medication line verbalizes concerns with not receiving their morning medications stating, it's not our fault.
On 03/01/2025, at 12:57 PM, V9 (Assistant Director of Nursing/ADON) states if medications are left unlocked and unattended, then a resident could be harmed by taking the wrong medications and overdosing.
R4, R11, R13, and other residents verbalize not receiving their morning medications today on 03/01/2025.
Surveyor observes V1's assigned residents' eMARs deployed on the computer on top of the medication cart. Surveyor observes that morning medications scheduled at 9:00 AM are red in color. V1 states the red color on the residents' eMAR indicates that the medications are not signed off and are now late.
Facility census dated 03/01/2025 documents that a total of 103 residents reside on the second floor of the facility.
Surveyor requests the facility's HIPAA policy from V9 (ADON) on 03/01/2025 at approximately 1:00 PM. Surveyor inquires with V9 about the facility's HIPAA policy again on 03/01/2025 at approximately 3:15 PM. V9 states she is still awaiting the policy from the corporate office. Facility does not provide surveyor with HIPAA policy during this survey.
Surveyor requests the facility's medication audit report dated 03/01/2025, from V2 (Administrator) on 03/01/2025 at approximately 2:00 PM. V2 states she is awaiting the audit report to be sent. Facility does not provide surveyor with the medication audit report dated 03/01/2025, during this survey.
Facility policy dated 10/25/2014 titled, Medication Administration documents in part, 2. Medications are administered in accordance with written orders of the prescriber . 4. When medications are administered by mobile cart taken to the residents' location (room, dining area, etc.) medications are administered at the time they are prepared . 12. Medications are administered within 60 minutes of scheduled time . 16. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. In addition, privacy is maintained at all times for all resident information (e.g., MAR) [by closing the MAR book/covering the MAR sheet or computer screen] when not in use.
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
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 a brown substance was not on the bathroom ...
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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 a brown substance was not on the bathroom wall of three residents (R4, R5, and R10). This failure has affected three of four residents reviewed for homelike environment.
Findings include:
R4 is a [AGE] year old with diagnosis including but not limited to: Urinary tract infection, anxiety, epilepsy, insomnia and chronic kidney disease. R4 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively impaired.
R5 is a [AGE] year old with diagnosis including but not limited to: Type 2 diabetes mellitus, asthma, pain, acquired absence of right great toe and essential hypertension.
R10 is a [AGE] year old with diagnosis including but not limited to: Heart failure, constipation, hypoglycemia, muscle weakness and edema.
On 01/21/25 at 11:55 AM, R5 complained about brown stains on her bathroom wall and said that she believes the stains are feces from a previous roommate.
Surveyor went to observe R5's bathroom, which was also connected to R4 and R10's bedroom.
On 01/21/25 at 11:55 AM, Surveyor noted brown stains on R4, R5 and R10's bathroom. At that time, R4 entered the bathroom from her room and said, This is disgusting. Its feces on our bathroom wall and I told a tall guy in housekeeping about this last week. I was told that the stains would be cleaned from our wall. I don't even like using the restroom because it's nasty.
On 01/21/25 at 11:55 AM, at 12:07 PM, V5 (AM Housekeeper) entered the resident's bathroom with Surveyor and observed the stains on the wall. At that time, V5 said that she did not know about the brown stains on R4, R5 and R10's bathroom wall and did not know what the brown substance was.
On 01/21/25 at 1:40 PM, V16 (Housekeeping Director) said that it was the duty of the housekeeping staff to clean and disinfect any stains or marks on resident's bathroom walls for sanitary purposes.
On 01/27/25 at 10:10 AM, V2 (DON/ Director of Nursing) said that there should never be brown stains on a resident's bathroom walls and that the expectation of the facility is to maintain a clean, homelike environment for the residents.
Facility housekeeping policy documents, purpose to provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that one dependent resident (R7) received tim...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that one dependent resident (R7) received timely incontinent care. This failure resulted in R7 waiting an hour, sitting in her feces before being cleaned.
Findings include:
R7 is a [AGE] year old with diagnosis including but not limited to: acquired absence of right leg above knee, acquired absence of left leg above the knee, diarrhea, obesity, muscle wasting and atrophy. R7 has a BIMS (Brief Interview of Mental Status) score of 15, indicating cognitively intact.
On 01/21/2025 at 12:30 PM, Surveyor observed R7 on the second floor in the hallway complaining that she was soiled with feces and had been waiting since 12:00 PM to be cleaned by her CNA (Certified Nurse Assistant). At that time, R7 said that V9 (CNA) told her (R7) that the mechanical lift was not charged and that R7 would have to wait until it charges to be transferred to the bed and cleaned.
On 01/21/2025 at 12:45 PM, V7 (LPN/ Licensed Practical Nurse) said. R7 told me at 12:00 PM that she needed to be changed. She hasn't been changed yet because the mechanical lift is not working or not charged. V9 (CNA) went to see if the lift was charged a while ago. I haven't been able follow-up about the lift.
On 01/21/2025 at 1:00 PM, R7 complained that her buttocks were itching and that she is concerned about her hemorrhoids worsening for being soiled for so long.
On 01/21/2025 at 1:06 PM, V9 (CNA) brought a mechanical lift from another unit to transfer R7 and render incontinent care. At that time, V9 said that the mechanical lift was not charged and that he (R7) had to wait because the battery does not charge quickly.
On 01/22/25 at 10:50 AM, V2 (DON/ Director of Nursing) said that the expectation is that if the patient is visibly soiled, or has stated that they are soiled, the patient is changed as soon as possible to prevent skin breakdown and to maintain dignity.
Surveyor inquired about the mechanical lifts in the facility.
On 01/21/25 at 2:30 PM, V11 (CNA) said that there was only one working mechanical lift on the second floor and that sometimes residents have to wait to receive incontinent care.
On 01/27/25 at 1:10 PM, V8 (Restorative Director) said that the expectation is for the mechanical lifts to be charged after each use and in the event that the lifts are not charged, the facility has a manual mechanical lift that could be used.
R7's care plan documents the following: R7 has an ADL self-care performance deficit related to impaired mobility; R7 requires total assist via mechanical lift with two-person staff participation for transfers and to use toilet; R7 requires extensive, one person staff participation with personal hygiene and oral care.
Facility policy titled Activities of Daily Living (ADLs) documents, purpose to preserve ADL function, promote independence, and increase self-esteem and dignity.
Facility policy titled Incontinency Care documents, purpose to prevent excoriation and skin breakdown, discomfort and maintain dignity.
Dec 2024
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Incontinence Care
(Tag F0690)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that indwel...
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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 follow policy procedures, failed to ensure that indwelling urinary catheters/urine drainage bags are monitored, and failed to document when indwelling urinary catheters are inserted and/or urine drainage bags are changed for three of three residents (R2, R3, R4) reviewed for catheters. These failures resulted in R2 sustaining (10/14/24) abdominal pain and UTI (Urinary Tract Infection). R3 and R4 sustained Purple Urine Bag Syndrome which is a rare phenomenon where the urine drainage bag turns purple due to a chemical reaction between bacteria in the urine and the plastic of the bag often associated with UTI's in patients using long-term catheters.
Findings include:
On 11/22/24, IDPH (Illinois Department of Public Health) received allegations regarding the facility's lack of catheter care resulting in R2's UTI.
1. R2 was admitted to the facility on [DATE] and discharged on 11/29/24.
R2's diagnoses include flaccid neuropathic bladder.
R2's care plan states (8/9/24) resident has indwelling catheter related to diagnosis of flaccid neuropathic bladder. Intervention: Change indwelling catheter and urinary drainage bag as needed per MD (Medical Doctor) orders. Monitor for signs/symptoms of pain/discomfort. (10/23/24) Resident is on antibiotic for urine infection.
R2's POS (Physician Order Sheets) include (6/26/24) Change urinary catheter as needed if displaced, clogged, or there is no urinary output. Change urinary drainage bag with each catheter change as needed. (7/2/24) Catheter size 18 FR (French) indication obstructive uropathy.
R2's progress notes include (10/14/24) resident discharged to hospital. Reason for transfer: Abdominal Pain. (10/22/24) admitted from hospital. Primary Admitting Diagnoses: UTI, Abdominal Pain.
On 12/4/24 at 10:41am, V2 (DON/Director of Nursing) presented R2's (September-November 2024) MARS (Medication Administration Records) and stated He (R2) didn't have no TARS. [Treatment orders should be transcribed on the TAR, not the MAR].
R2's (September & October 2024) MARS include Change urinary catheter as needed if displaced, clogged, or there is no urinary output. Change urinary drainage bag with each catheter change as needed for catheter care however the required catheter size is excluded, and nothing is documented on either MAR. In addition, R2's (November 2024) MAR excludes any catheter care.
On 12/4/24 at 2:26pm, surveyor inquired where indwelling urinary catheter orders are supposed to be transcribed and V2 stated Some of the orders go to the MAR and some of them go to the TAR. Surveyor inquired what the MAR is used for V2 responded That is the medication administration. Surveyor inquired if catheters belong on the MAR and V2 replied They can go on the MAR because the template allows it to go on the MAR. [The MAR is for prescribed medication]. Surveyor inquired how often urine drainage bags should be changed V2 stated Drainage bags are changed um, I know that one of the orders is every 30 days, and PRN (as needed) if there is any leakage, color changes of the bag like sediment or any obstruction and it's not draining properly. Surveyor inquired when R2's indwelling urinary catheter was placed V2 responded Let me look it up, I think he had it for a while they said. V2 reviewed R2's EMR (Electronic Medical Records) and stated I think he came here with the catheter; I would have to go through all of his records. I know that he went out maybe like October and it was changed then because he had a UTI. Surveyor inquired if the size or type of catheter is on R2's MAR V2 responded He had a suprapubic catheter but I'm not seeing a size or the site on there. Surveyor inquired when R2's urinary drainage bag was changed (prior to developing the UTI) V2 replied I can't even see when the bag was changed. (R2 was admitted in March 2024 - 7 months prior). Surveyor inquired if R2's (November 2024) MAR includes catheter care V2 stated No, I seen that it was missing when I pulled it. Yeah, it's not there. Surveyor inquired why R2 was transferred to the hospital on [DATE] V2 responded He had abdominal pain. Surveyor inquired why R2 was admitted to the hospital and V2 replied He had a UTI.
2. R3's diagnoses include neuromuscular dysfunction of bladder.
R3's (11/29/23) care plan states resident has an indwelling urinary catheter related to neuromuscular dysfunction of the bladder. Interventions: Change catheter and urinary drainage bag as needed per Medical Doctors orders.
R3's POS includes (2/12/24) May change urinary drainage bag as needed (schedule as PRN). (6/26/24) Foley catheter 18Fr diagnosis neuromuscular dysfunction of bladder. May change urinary catheter if displaced, clogged, or no urinary output as needed.
R3's (November-December 2024) MARS include the following: Change urinary catheter as needed [the required catheter size (18Fr) is excluded]. May change urinary drainage bag as needed however nothing is documented.
R3's (9/9/24) BIMS determined a score of 15 (cognition intact).
On 12/2/24 at 2:00pm, Surveyor inquired if R3 acquired a UTI at the facility R3 stated No however R3's urinary catheter bag and tubing appeared purple (discolored), and sediment was noted in the tubing. The contents in the catheter bag were barely visible due to dark discoloration. Surveyor inquired when R3's catheter was placed and R3 responded That was April. Surveyor inquired when R3's catheter bag was last changed R3 replied I don't even know.
On 12/4/24 at 2:26pm, Surveyor inquired what color indwelling urinary catheter tubing and/or bags are supposed to be and V2 (Director of Nursing) stated The tubing should be clear, the bag should be clear as well unless there's urine in it and it should have no sediment in it or anything.
On 12/4/24 at 2:51pm, surveyor inquired when R3's indwelling urinary catheter was placed V2 stated I'm not sure when the catheter was placed, I see the order at the beginning of the year January 4. Surveyor inquired when R3's urine drainage bag was changed V2 responded I don't see where it's changed at, I just see the order for PRN.
On 12/4/24 at 3:05pm, V2 inspected R3's indwelling urinary catheter (as requested). Surveyor inquired what color is R3's urine drainage bag? V2 stated Purple. R3 responded Nobody came in here and changed it. Surveyor inquired about the contents in R3's catheter tubing V2 replied I see a little sediment. R3 responded They (staff) should have changed this a long time ago. V2 exited R3's room and affirmed That needs changed bad.
3. R4's diagnoses include hydronephrosis with ureteral stricture.
R4's (9/10/24) care plan states resident has a suprapubic catheter. Interventions: monitor and report to Medical Doctor signs/symptoms of UTI.
R4's (7/2/24) POS includes suprapubic catheter 20Fr for obstructive uropathy. May change urinary drainage bag as needed for prevention when unable to observe urine contents in the urinary drainage bag/tubing or as ordered by the physician (schedule as PRN). [Change suprapubic catheter if occluded is excluded].
On 12/2/24 at 3:20pm, V2 (DON) presented R4's (November 2024) MAR. Surveyor inquired about R4's requested (November 2024) TAR V2 stated He (R4) don't have a TAR, just the MAR.
R4's (November- December 2024) MARS exclude change suprapubic catheter (20Fr) and nothing is documented for urinary drainage bag change.
On 12/2/24 at 1:40pm, surveyor inquired when indwelling urinary catheters are changed at the facility V6 (LPN/Licensed Practical Nurse) stated About every week. I know it's due on the night shift. Surveyor inquired when R4's catheter bag was last changed and V6 accessed R4's EMR (Electronic Medical Records) and stated, It's not coming up on the TAR but there's an order for it. V6 and surveyor subsequently inspected R4, his urinary catheter bag and tubing appeared purple (discolored) and thick sediment was noted in the tubing. The contents in the bag were barely visible due to dark discoloration.
On 12/4/24 at 2:58pm, surveyor inquired when R4's indwelling urinary catheter was placed V2 stated I don't have a date for him either. Surveyor inquired when R4's urine drainage bag was changed V2 responded It's nothing documented. Surveyor inquired what a purple discoloration of the urinary drainage bag is indicative of V2 replied It could be hydration, like the tea looking color or some sediments that set in for a while.
On 12/4/24 at 3:10pm, (2 days after the initial inspection) V2 inspected R4's catheter (as requested). Surveyor inquired what color is R4's urine drainage bag V2 stated It's purple. Surveyor inquired about the contents in R4's catheter tubing V2 responded It's sediment in the tubing. It's um, white milky sediment.
The (10/31/18) catheter care policy includes Policy: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Urinary catheter and tubing will be removed and reinserted when any of the following are observed: inability to observe urine contents in the urinary drainage bag or tubing.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed ensure that fall risk assessments were accurate for two of four residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed ensure that fall risk assessments were accurate for two of four residents (R2, R3) reviewed for falls.
Findings include:
The fall prevention and management policy states residents will be reassessed for fall risk at least quarterly or more frequently if there is a change in their condition. Reassessment will be conducted by the interdisciplinary care team.
1. R2's (11/14/24) functional assessment states upper and lower extremity functional limitation (on one side) was identified.
R2's (11/18/24) incident report affirms resident stated that the CNA (Certified Nursing Assistant) was trying to help him get into the bed. When he stood up, he lost his balance and fell.
R2's (11/18/24) post fall risk review determined a score of 9 (moderate risk) however the following concerns were identified: the Gait Analysis section includes Exhibits loss of balance while standing however it was not selected [R2 lost his balance when he fell]. Decrease in muscle coordination was also not selected [R2 diagnoses include reduced mobility, muscle wasting/atrophy, hemiplegia/hemiparesis and R2's functional assessment affirms upper and lower extremity limitations].
On 12/4/24 at 2:17pm, surveyor inquired about R2's functional status V2 (Director of Nursing) stated He (R2) did use a wheelchair and needed a 1 person assist. Surveyor inquired about R2's (11/18/24) fall V2 (DON/Director of Nursing) responded The CNA was trying to transfer him to the bed. She (CNA) said that when she stood him (R2) up his leg buckled, he lost his balance, fell forward on her, and they both went down. Surveyor inquired if R2's (11/18/24) post-fall risk assessment was accurate V2 reviewed R2's EMR (Electronic Medical Records) and replied Yeah. Surveyor inquired if Exhibits loss of balance while standing was selected on R2's assessment V2 stated Oh, no that's not checked. Surveyor inquired if Decrease in muscle coordination was selected V2 responded No, that was based off the Nurse assessment, but he does have a diagnosis of hemiplegia and hemiparesis. Surveyor inquired why R2's (11/18/24) risk assessment was determined to be moderate risk after he fell V2 stated Usually if they (residents) fall, they become a high fall risk.
2. R3's (11/30/24) incident report affirms resident stated he fell on his buttock when trying to get out of bed.
R3's (11/30/24) fall risk review determined a score of 4 (moderate risk) however the following concerns were identified: History of Falls within last 3 months is marked No History [R3 fell on [DATE]] and for Ambulatory/Elimination Status Ambulatory/ Continent was selected [R3's diagnoses include paraplegia and neuromuscular dysfunction of bladder. R3 also uses a wheelchair and has an indwelling urinary catheter].
On 12/4/24 at 2:46pm, surveyor inquired about R3's (11/30/24) fall and V2 (DON) stated The Nurse said she was passing medication and when she walked past the room, she said that he (R3) was sitting next to his bed. He (R3) stated that he was trying to get in his chair to go to the bathroom. Surveyor inquired if R3's (11/30/24) fall risk assessment was accurate V2 stated No, it should have been 1-2 falls within the last 3 months because he just fell. Surveyor inquired if R3 is ambulatory V2 responded No, he uses the wheelchair. Surveyor inquired if R3 is continent and V2 stated He has a (Brand Name catheter) as well.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected most or all residents
Deficiency Text Not Available
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Deficiency Text Not Available
Oct 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure that the community shower room on the third floor North-Wing is maintained in good repair and a sanitary manner. This ...
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Based on observation, interview, and record review, the facility failed to ensure that the community shower room on the third floor North-Wing is maintained in good repair and a sanitary manner. This failure has the potential to affect all 53 residents on the third floor North-Wing.
Findings include:
On 10/15/24 at 10am after the entrance conference, V1(Administrator) presented the census that shows that unit 3 North has 53 residents.
On 10/15/24 at 10:40am, the following were observed in the 3-North community shower room:
The hand-washing sink was leaking water and not properly affixed to the wall.
Two visably soiled wet towels were on the floor of the shower stall.
Missing Ceiling tiles.
Broken soap dispenser by the sink and there was no soap available for handwashing.
At this time, V8 (Housekeeper) was called to observe all the above. V8 stated that the lack of hot water, handwashing sink issue, missing ceiling tiles and broken soap dispenser are all maintenance issues. V8 stated If the soap dispenser was not broken, I would have put soap in there (pointing to the soap dispenser). V8 added I will let them know to come fix everything.
On 10/15/24 at 12:24pm, V7(Maintenance Director) stated that no one told him about the soap dispenser and other issues. V7 stated that he was working on the hot water issue. Inquired from V7 how many shower rooms are on unit 3 North in case a resident needs to take a bath. V7 stated that there is one shower room on 3 North and one shower room on each of the other units also.
Facility's policy titled Preventative Maintenance Program states in part: Purpose -To conduct regular environmental tours/safety audits to identify areas of concern within the facility. Preventative Maintenance Program will review the following areas during random rounds: #14: Ceiling tiles are free from water marks or spots.
Oct 2024
14 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Infection Control
(Tag F0880)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the doctor's wound care order and keep a wound...
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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 follow the doctor's wound care order and keep a wound clean and dry for one resident (R442) and failed to follow policies for proper handling of garbage for 7 residents reviewed in a sample of 35. This failure caused harm to R442, who was admitted with a diagnosed surgical wound and hospital discharge orders for IV (Intravenous therapy) antibiotics for skin and soft tissue infection. R442's wounds were not cleaned, and wounds' dressings changed as ordered, causing the resident's wound dressing and wound to appear uncleaned increasing the risk of further infection/delaying the healing progress.
Findings include:
1. On 10/01/2024, 12:38 PM R442 states that his needs are not being met. He says he has a lot of pain to his left leg. R442 states that he had surgery to his left leg, and he that the leg has about 71 staples. R442 states that he takes pain medication, and it does help. R442 states that they are not doing the wound care and he states that he has been in the facility over a week, and it's been 3 or 4 days since the dressing has been changed. R442 states that he asked the wound care nurse about the dressing being changed and he states that wound care told him that they would be back next Monday. One large dressing covering R442's left lower leg (back) noted with what appears like large amounts of dark brown color drainage (fluid that comes out of a wound). Another large dressing covering R442's left lower leg (shin area) noted with what appears like large amounts of dark brown color drainage. No labels with date or time of dressing change are on the dressings.
R442's current face sheet document R442 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: disruption of external operation (surgical) wound.
R442's current physician order sheet (POS) documents in part: Left Lower Leg Fasciotomy Sites (Medial and Lateral Calf) Clean with normal saline pat dry apply Xeroform cover with a dry dressing. One time a day every Mon, Wed, Fri related to disruption of external operation (surgical) wound, order start date 09/27/2024.
R442's current physician order sheet documents in part: ceFAZolin in Sodium Chloride Intravenous Solution 2-0.9 GM/100ML-% (Cefazolin Sodium in Sodium Chloride) Use 2 gram intravenously every 8 hours for skin and soft tissue infection for 8 Days, order start date 09/26/2024.
On 10/02/2024, 10:11 AM R442 is lying on his bed. One large dressing covering R442's left lower leg (back) noted with what appears like large amounts of dark brown color drainage (fluid that comes out of a wound). Another large dressing covering R442's left lower leg (shin area) noted with what appears like large amounts of dark brown color drainage. No labels with date or time of dressing change are on the dressings. R442 states that his wound dressings have not been changed and his wounds have not been cleaned. R442 states that he mostly has pain in the nighttime.
On 10/03/2024, 9:50 AM, one large dressing was covering R442's left lower leg (back) noted with what appears like large amounts of dark brown color drainage (fluid that comes out of a wound). Another large dressing was covering R442's left lower leg (shin area) noted with what appears like large amounts of dark brown color drainage. No labels with date or time of dressing change are on the dressings. R442 states that the dressing has not been changed at all since last week. R442 states that the dressing has been hanging off. R442's left upper inner leg noted with multiple staples, dry dressing hanging off.
On 10/03/2024, 10:36 AM, V16 (Wound Care/Licensed Practical Nurse) states that she has worked for the facility for almost a month. She has been the wound care nurse for a week. V16 states that the wound care team is aware that there are residents that are in the facility that need an initial skin assessment done. V16 states that the importance for the resident to have a complete skin assessment by wound care team is to prevent skin breakdown and to check if the resident doesn't have any wounds coming from the hospital or from home. V16 states that she has not performed any wound care for R442. V16 states that if wound care is not done as ordered, the wound can be exposed to further infection and the wound can get worse. V16 states that an infected wound can appear with mucus, color, bleeding, odor, and is hot to touch. V16 states that the resident can experience fevers, chills, pain, and possibly signs of sepsis. V16 states that it is important to follow wound care orders to prevent further harm or infection.
On 10/03/2024, 11:05 AM V17 (Wound Care Coordinator/Licensed Practical Nurse) states that this her 4th day working as the wound care coordinator. V17 states that she has previous wound care experience. V17 states that she has not seen R442. V17 states she would like to go and confirm she hasn't seen R442 yet.
On 10/03/2024,11:16 AM V17 states that she can confirm that she has not seen R442 and is not familiar with his orders. V17 states that she was provided the wound care list yesterday, since the report is due on Friday. V17 states that she also did not have access to the computer the past 3 days, and she will review everyone on the list and see them. V17 states that if the wound care treatment is not done, a wound can get infected. V17 states that the signs of infection are swelling, pain, redness, warmth, elevated temperature, and odor. V17 states that they do not have to have all these signs to be infected. V17 states they are just indicators. V17 states that residents that were supposed to be seen yesterday for wound care, were not seen.
On 10/03/2024, 12:03 PM V16 and V17 explained to R442 what they were there to do his wound care. V17 assessed R442 for pain. R442 states that his pain level is a 7 on a 0 to 10 pain scale. V17 called R442's nurse to administer his pain medication. R442 agreed for V17 to start wound care. One large dressing covering R442's left lower leg (back) noted with what appears like large amounts of dark brown color drainage (fluid that comes out of a wound). Another large dressing covering R442's left lower leg (shin area) noted with what appears like large amounts of dark brown color drainage. V17 states that he felt numbness to his shin area. R442 felt some areas of his left lower leg. Observed V17 removing one dressing at a time, slowly due to being very stuck to the wounds. V17 using normal saline to wet areas and slowly removing dressings. V17 was asked to describe what she sees and V17 states that without knowing what it is, she said it can be collagen, eschar, dead skin, or dried blood. V17 asked R442 if he had a skin graft done and R442 responded no, and he said it was just covered. R442 states that when he got to the facility, they looked at it and it did not look like this. R442 states that when he saw it when he first got to the facility, it looked like a fresh wound, and it didn't look black like how it looks now. R442 asked V17 why the wounds looked black and V16 states it looks like old blood. V17 states that it feels like it is a dressing, and it could be blood and the drainage mixed. V17 informed surveyor that this removal of dressing can take some time and V17 states that she wants to make sure that she takes her time removing the dressings. Surveyor got closer to the wounds, and they smelled malodorous. V17 states that the dressings appear saturated with drainage. As surveyor was walking out, V17 states that surveyor can look at the wound bed for the wound on the shin area, V17 states that the top of the wound noted with eschar, wound bed is dark pink granulated skin. V17 states that the dressing looked like black to dark burgundy possibly because of dried blood. V17 states that the dressings are long overdue to be changed.
Reviewed R442's care plan, assessments. No skin assessment or wound care assessments noted. No wound care progress notes noted.
R442's Minimum Data Set (MDS), dated [DATE], documents R442 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R442 is cognitively intact.
R442's Minimum Data Set (MDS), section M dated 9/26/2024, documents in part R442 has a surgical wound.
R442's treatment administration record (TAR) for September 2024, shows documentation that wound care treatment was signed off as administered. Discrepancies noted with R442's treatment administration record (TAR) for October 2024. It documents that V16 signed for wound care treatment on 10/02/2024. When interviewed V16, she states that she denies seeing R442 and providing him with any wound care treatment.
R442's Nurse Practitioner Narrative/Physician Assistant note dated 9/30/2024 5:37 PM documents in part the resident (R442) was treated in the hospital for lower extremity revascularization with acute limb ischemia f/p (follow post) LLE (left lower extremity) thromboembolectomy and compartment fasciotomies. ASSESSMENT/PLAN: SURGICAL WOUND LEFT LEG
-Wound care to see
-keep area clean and dry
-fall precautions
-PT/OT (physical therapy/occupational therapy) consult
-Cefazolin IV Q8h
-Amoxicillin 875-125 mg Q8h
On 10/04/2024, V1(Administrator) via email noted that R442 does not have any completed skin assessments done.
Facility document dated 11/2023, titled Wound Policy documents in part: To promote healing of existing pressure and non-pressure ulcers . Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee . The goals of wound treatment are to: a. Keep the ulcer bed moist and the surrounding skin dry, b. Protect the ulcer from contamination, and c. Promote healing.
2. On 10/01/2024 at 12:10pm, V38 (Housekeeping) was observed dragging on the floor of the second-floor North unit hallway a large clear plastic bag, which was not tied or secured. Observed in the bag was soiled incontinence wear and garbage. V38 stated the garbage bag was too heavy for her, therefore she dragged it around the unit collecting garbage from residents' room and then put it in the dirty utility room. V38 stated she was moving too fast and should not have filled the garbage so much to a point where she could not carry it. V38 stated it is unsanitary to drag garbage on the unit because that is cross contamination and can spread germs in the unit.
On 10/03/2024, at 3:41pm, V24 (Housekeeping Director) stated housekeepers are supposed to carry garbage upright and not drag it in the hallway because garbage and can spread bacteria and lead to infection control issues and residents can get sick. V24 said V38 (Housekeeping) should not have loaded garbage up so heavy that she could not carry it or lift it. V24 stated the garbage V38 was dragging in the hallway of the second floor North unit consisted of used incontinence wear and garbage from residents rooms and should not be dragged across the hall way. It should have been put it in the housekeeping cart which has a compartment for garbage, then the garbage cart emptied in the soiled utility room to prevent cross contamination in the units which could cause germs to spread which can make residents sick.
Facility Policy titled Housekeeping Guidelines, no date, documents: Waste handling and disposal will be in accordance with local and state regulations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor its call light system and answer call lights ...
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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 monitor its call light system and answer call lights within a timely manner for two (R62, R182) residents in a total sample of 35 residents reviewed.
Findings include:
On 10/01/2024, at 12:25PM, R62's call light was illuminating above R62's room door. There was an audible sound heard from the call light. Housekeeping staff were seen passing by R62's room and did not answer R62's call light.
On 10/01/2024, at 12:34PM, R62's call light was still illuminating above R62's room door. No audible sound was heard from the call light.
On 10/01/2024, at 12:48PM, R62 states she had a bowel movement and urinated. She has been waiting for someone to change her incontinence brief for a long time. R62 states she is unable to go to the bathroom on her own and toilet herself. R62 states a CNA (Certified Nursing Assistant) staff member came into her room about 1 hour ago. CNA informed R62 that the CNA would be back to change R62. R62 states no one ever came back to her room to change her incontinence brief and she is still soiled in urine and feces.
On 10/01/2024, at 1:23PM, R62's call light observed off. Surveyor is located inside of R62's room. R62 states a nurse (identified as V7/LPN) came into her room about 10 minutes ago and turned her call light off. R62 states she made V7 aware that she was soiled with feces and urine. R62 stated that she needed to be changed. R62 states V7 told her okay and left the room.
On 10/01/2024, at 1:48PM, V6 (CNA) states she is responsible for caring for R62. V6 states the facility's call light system does not have an audible sound but only a light that illuminates when a resident presses their call light button. V6 states she monitors the halls to check for any illuminated call lights.
On 10/01/2024, at 1:50PM, V7 states she did answer R62's call light. R62 did make her aware that R62 was soiled and needed to be changed. V7 states she went to look for R62's assigned CNA to make her aware that R62 needed to be changed but V7 could not find the CNA.
On 10/01/2024, at 1:54PM, V7 and surveyor located inside of R62's room. R62 makes V7 aware that she is still soiled, and no one has answered her call light and came to her room to change her incontinence briefs.
R62s' Face sheet documents that R62 was admitted to the facility on [DATE], with diagnoses not limited to: cerebral infarction, hemiplegia and hemiparesis.
R62's Minimum Data Set/MDS dated [DATE], documents that R62 has a Brief Interview for Mental Status/BIMS of 15/15, indicating that R62 is cognitively intact. R62's MDS documents that R62 is dependent with ADL (Activities of Daily Living) care and personal hygiene. R62 is incontinent of bowel and bladder.
On 10/01/2024, at 1:17PM, R182 states he often has to wait for long periods of time to have his call light answered. R182 states he waited two hours to have his call light answered about 1 week ago.
R182s' Face sheet documents that R182 was admitted to the facility on [DATE], with diagnoses not limited to: obesity, history of falls, chronic kidney disease, and cellulitis.
R182's Minimum Data Set/MDS dated [DATE], documents that R182 has a Brief Interview for Mental Status/BIMS of 15/15, indicating that R182 is cognitively intact. R182's MDS documents that R182 is dependent with ADL care and personal hygiene. R182 is incontinent of bowel and bladder.
Facility policy dated 09/2019 titled Call Light documents in part, Purpose: To respond to resident's requests and needs in a timely and courteous manner. Policy: All call lights will be answered by any staff within their scope pf practice. 4. Requests shall be responded to in a courteous and professional manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to follow the Pre-admission Screening and Resident Review (PASRR) poli...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to follow the Pre-admission Screening and Resident Review (PASRR) policy for 2 of 8 residents (R12 and R49) in a total sample of 35 residents reviewed for PASRR assessment requirements. This failure has the potential to affect 2 residents (R12 and R49) in the correct determination of placement based on proper PASRR assessment.
Findings include:
R12 is [AGE] years old, initially admitted in the facility on 09/12/2024, with diagnosis that includes paranoid schizophrenia, dementia with behavioral disturbance, schizoaffective disorder, bipolar type, suicidal ideations. R12's psychotropic medication includes the following: Hydroxyzine Hydrochloride (antianxiety), Risperidone (antipsychotic), Trazodone (antidepressant).
R12's care plan includes the following: R12 present signs and symptoms of depression, suicidal ideation (self-harmful behavior), and severe mental illness.
R49 is [AGE] years old, initially admitted on [DATE]. R49's diagnosis includes bipolar disorder. R49's psychotropic medication includes the following: Ativan (antianxiety) and Mirtazapine (antidepressant).
R49's care plan includes the following: R49 has behavioral symptoms of dysregulation related to psychopathology, drug seeking and level of anger, severe mental illness, and bipolar disorder.
On 10/02/2024, at 02:45 PM, V13 (Social Service Director) stated that there is no PASRR screening done for both R12 and R49. V13 stated the employee that tracks all PASRR is no longer connected to the facility. All residents must have PASRR level 1 prior to admission. This should have been done in the hospital with the coordination of the facility. Per V13, PASRR level 1 and level 2 is important to determine level of care of a resident before admitting in the facility. It is required for all residents.
Pre-admission Screening and Resident Review (PASRR) policy dated 12/2023, reads: In accordance with Federal and State of Illinois regulatory standards and recommended practices, this organization requires each resident to be screened for Level 1 prior to or shortly thereafter admission. As of March 14, 2022, the Illinois system has changed to Maximus Assessment Pro (AP) and Path Tracker (PT). There is no longer an OBRA form. The facility makes reasonable efforts to make sure the required screening documents are in the AP/PT system prior to admission or shortly after the time of the individual's arrival. It is the policy of this facility to comply with Federal, State and appointed screening agency Maximus, in standards addressing the PASRR assessment/screening process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and records review the facility failed to provide an individualized care plan to include an identified hygiene concern related to a tracheostomy of 1 (R49) of 35 resi...
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Based on observation, interviews, and records review the facility failed to provide an individualized care plan to include an identified hygiene concern related to a tracheostomy of 1 (R49) of 35 residents in a total sample of 35 residents reviewed for planning of care. This failure has the potential to affect 1 resident (R49) in maintaining hygiene of the tracheostomy area.
Findings include:
On 10/01/2024, at 12:05 PM, R49 was found sleeping on his bed with his right hand holding a transparent tube. After calling his first name, R49 woke and can verbalize. R49 stated that he has something in his hand and inserted the transparent tube inside of his tracheostomy opening.
On 10/02/2024, at 12:41 PM, upon seeing R49's ability to take off the inner cannula of his tracheostomy and re-insert the same; V23 (Licensed Practical Nurse) was asked if it is common for R49 to take off his tracheostomy inner cannula and reinsert it back? V23 stated that R49 takes off his tracheostomy inner tube often and sometimes sucks on it.
On 10/03/2024, at 11:05 AM, V22 (Licensed Practical Nurse) stated that R49 does take out his tracheostomy inner cannula (tube) and put it back in. When staff see it, they clean it. But since she works only a single shift, she cannot attest to those shifts that she was not working. V22 stated that there is a need to monitor, clean the inner cannula, and other interventions to maintain the cleanliness of R49's tracheostomy including addressing it in the care plan.
Review of R49's history of antibiotic orders, documents that R49 received multiple antibiotics for respiratory infections including: Tobramycin Inhalation Capsule (Tobramycin) 300 mg three separate orders by physician for upper respiratory infections. Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) for Sputum found to have proteus and Acinetobacter baumanni which causes bacterial infection.
On 10/03/2024, at 01:01 PM, V2 (Director of Nursing) stated that R49's taking off his tracheostomy inner cannula is not hygienic. Her expectation for nursing staff is to notify R49's doctor and notify family. Also, redirect R49 when the behavior happens. It needs to be care planed as well.
On 10/03/2024, at 12:51 PM, V15 (Minimum Data Set/MDS Coordinator) stated, I am not aware that R49 takes out the inner cannula of his tracheostomy. If I was aware, it should be care plan. Staff are supposed to notify the doctor. It needs to be cleaned to reduce potential infection and clogging.
Care plan policy dated 4/2024, reads: All residents will have a comprehensive assessment and an individualized plan of care developed to assist them in achieving and maintaining their optimal status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure an accurate count of narcotic medication for two residents (R3 and R141) in a sample of 35 reviewed for medication stor...
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Based on observation, interview and record review, the facility failed to ensure an accurate count of narcotic medication for two residents (R3 and R141) in a sample of 35 reviewed for medication storage.
Findings include:
On 10/1/24, reviewed 3 North #2 medication cart with V11 (Licensed Practical Nurse). Observed six packages of buprenorphine and naloxone sublingual film 8mg/2mg for R3 in the narcotic box. According to the Controlled Drug Receipt/Record/Disposition Form, the amount left is 7. Observed eleven packages of buprenorphine and naloxone sublingual film 4mg/1mg for R141 in the narcotic box. According to the Controlled Drug Receipt/Record/Disposition Form, the amount left is 12.
R3's physician order summary printed by facility 10/3/24, documents in part: suboxone sublingual film 8-2 MG (milligram) (buprenorphine HCL-naloxone HCL dihydrate) give 1 tablet sublingually three times a day.
R141's physician order summary printed by facility 10/3/24, documents in part: suboxone sublingual film 4-1 MG (buprenorphine HCL-naloxone HCL dihydrate) give 1 film sublingually two times a day.
On 10/2/24, at 10:29 AM, V23 (Licensed Practical Nurse) stated I write controlled substance out immediately in the book after administering to the resident, so I don't forget to sign it out. Signing the controlled substance out keeps up with what time you are giving it and the amount left over.
On 10/2/24, at 11:00 AM, V35 (Licensed Practical Nurse) stated the nurse should complete the controlled substance sheet in the book with what was given and what is left over immediately after administering the controlled substance. This is to make sure the controlled substance count is accurate, and the next nurse knows the controlled substance was given to the resident so not overdosing the resident.
On 10/3/24, at 12:42 PM, V30 (Licensed Practical Nurse) stated once the nurse administers a controlled substance it is signed out in the narcotic book immediately. It is done immediately so you don't forget what was administered and you know the count is correct.
On 10/3/24, at 1:09 PM, V36 (Licensed Practical Nurse) stated controlled substances should be signed out in the book as soon as you pop the medication out.
On 10/3/24, at 3:50 PM, V2 (Director of Nursing) stated the narcotic should be signed out in the book once the medication is swallowed by the patient. It's for accuracy of the narcotic count. Staff should not be waiting until later in the shift to sign it out.
Facility policy Narcotics, no date, documents in part: When a narcotic medication is administered, it should be signed out in the narcotic sign out sheet and MAR (Medical Administration Record).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure the potency of insulin medications by not labeling the medications with the dates they were opened and the dates they w...
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Based on observation, interview and record review, the facility failed to ensure the potency of insulin medications by not labeling the medications with the dates they were opened and the dates they were to be discarded for three residents (R21, R80 and R169) of 35 residents reviewed for medication storage.
Findings include:
On 10/1/24, reviewed 3 North #2 medication cart with V11 (Licensed Practical Nurse).
-The cart was not locked, and the cart was not in V11's view.
-observed insulin lispro injection vial for R21 not sealed, not labeled with opened and/or discard dates.
-observed fiasp (insulin aspart) injection vial for R80 not sealed, not labeled with opened and/or discard dates.
-observed Humalog (insulin lispro) injection vial for R21 not sealed, not labeled with opened and/or discard dates.
-observed insulin lispro injection vial for R169 not sealed, not labeled with opened and/or discard dates.
-observed basaglar kwik pen for R80 not sealed, not labeled with opened and/or discard dates.
On 10/1/24, reviewed 3 North medication room with V11.
-observed in the refrigerator, Humalog (insulin lispro) injection vial for R21 not sealed, not labeled with opened and/or discard dates.
R21's physician order summary reads in part: Humalog solution 100unit/ml (milliliter) (insulin lispro) inject 8 unit subcutaneously three times a day; insulin lispro injection solution (insulin lispro) inject as per sliding scale subcutaneously two times a day.
R80's physician order summary reads in part: basaglar kwikpen subcutaneous solution pen-injector 100 unit/ml (insulin glargine) inject 15 unit subcutaneously at bedtime.
R169's physician order summary reads in part: Humalog injection solution 100 unit/ml (insulin lispro) inject as per sliding scale subcutaneously with meals.
On 10/2/24, at 10:29 AM, V23 (Licensed Practical Nurse) stated once insulin is unsealed, label it with the date it was opened and with the expiration date which is 28 days from opening it. Insulin should be labeled so we are not giving expired medications. When the nurse is not at the medication cart the cart should be locked and the computer screen should be hidden or closed. The cart should be locked so no one enters the cart and takes any of the medications out.
On 10/2/24, at 11:00 AM, V35 (Licensed Practical Nurse) stated when the nurse is away from the medication cart, when the cart is out of site, it should be locked for patient safety and confidentiality. If the medication cart is not locked patients can take the medications, access needles and liquids. Insulin should be labeled with the date it was open and the expiration date which is 28 days after unsealing. If it is not labeled, then you don't know when it was opened and when to discard it.
On 10/3/24, at 12:42 PM, V30 (Licensed Practical Nurse) stated when insulin is unsealed, it should be dated with the date opened and the date for 30 days after opening.
On 10/3/24, at 1:09 PM, V36 (Licensed Practical Nurse) stated the medication cart should be locked whenever the nurse is away from it or turned around from it. When unsealed, insulin needs to be dated with the opened and discard dates.
On 10/3/24, at 3:50 PM, V2 (Director of Nursing) stated the medication cart should be locked anytime the nurse walks away or the cart is not in eye view. It's for safety for the residents, so no one unauthorized can come take medications out. Insulin should be labeled with the open date and end/expiration date, for the potency of the medication.
Facility policy Storage of Medications, 5/1/2018, documents in part: Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. Certain medication or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency.
According to document Pharmacy Audit Assistance Service, Insulin Medication, no date, Fiasp insulin aspart, Humalog insulin lispro, Basaglar insulin glargine kwikpen have Beyond Use Date per pen or vial of 28 days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to refer six (R21, R79, R97, R120, R127, R135) out of six residents re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to refer six (R21, R79, R97, R120, R127, R135) out of six residents reviewed with newly evident or a possible serious mental disorder to the appropriate state-designated authority for review, in a total sample of 35.
Findings include:
10/02/2024, 11:29 AM V13 (Social Service Director) states that she handles the Pre-admission Screening and Resident Review (PASRR) level I and level II. V13 states that someone else from corporate takes care of the initial PASRR level I when a resident is newly admitted to the facility. She reviews the tracker, and it will let her know who is triggered for a level II. The tracker will show to refer a resident to level II screening. V13 states that a PASRR level II is for serious mental illness and is used to determine the need of level of the resident. V13 says that she waits for instructions on who is referred to PASRR level II. She was not aware that once a resident is given a new serious mental illness, they are to be referred to have a PASRR level II done.
10/02/2024, 2:45 PM, V13 states that there is no level I or level II for R21 and R127.
R21's Face sheet documents that R21 is a [AGE] year-old individual admitted to the facility on [DATE], who has diagnoses not limited to: schizoaffective disorder, bipolar type, schizophrenia, bipolar disorder.
There is no documentation to show that R21 was screened for a Pre-admission Screening and Resident Review (PASRR) level II.
R127's current face sheet document R127 is a [AGE] year-old individual admitted to the facility on [DATE], and has diagnoses not limited to: bipolar disorder, mood disorder.
There is no documentation to show that R127 was screened for a Pre-admission Screening and Resident Review (PASRR) level II.
Facility policy date December 2023, titled Pre-admission Screening and Resident Review (PASRR) documents in part, It is the policy of this facility to: Comply with Federal, State and the appointed screening agency, in standards addressing the PASRR assessment/screening process .Review the PASRR documents to help assess/ascertain what type of problems, needs and issues need to be addressed to help the resident function at his/her maximum level of well-being.
R135's current face sheet documents R135 was admitted on [DATE], and his medical diagnosis during admission included but not limited to schizophrenia, unspecified. Brief Interview for Mental Status (BIMS) dated [DATE]th, 2024, is 15/15, indicating R135 has intact cognition.
R135's Face sheet documents: 2/11/2022, schizophrenia, unspecified, and further documents R135 was readmitted to the facility on [DATE].
10/02/24, 2:47 PM V13 (Social Services Director) stated corporate told her the employee who was working on the patch tracker is no longer working at the facility. V13 stated every resident needs a PASARR I before admission and determines if a PASARR II is needed. V13 stated PASARR II helps determine the level of care or treatments a resident needs including interventions such as psychotherapy and care plan interventions a resident need. V13 stated she did not know what would happen if a resident did not have a level I & II PASARR.
On 10/02/2024, at 4:50 PM, V1(Administrator) stated the corporate office for the facility takes care of PASARRs for the residents and provides the facility with the PASARR information. V1 said R135's PASARR I & II are not on file in his medical records and stated, someone dropped the ball on the PASARRs.
Policy titled Pre-admission Screening and Resident Review (PASRR, dates Dec,2023 documents:
Obtaining the necessary screening documents for persons who have resided in previous nursing homes is a complex problem and a new Level 1 screen in the Maximus AP system should be completed.
It is the policy of this facility to:
1.
Comply with Federal, State and the appointed screening agency, Maximus, in standards addressing the PASRR assessment/screening process.
2.
Request full and complete PASRR materials (Level 1 and 2) from each referral source prior to or soon following admission.
3.
Review the PASRR documents to help assess/ascertain what type of problems, needs and issues need to be addressed to help the resident function at his/her maximum level of well-being.
4.
Place the PASRR paperwork in the resident's business file and/or scan it into the EMR.
5.
A facility representative shall request the complete screening from the referral source.
R79 face sheet printed 10/2/2024, by facility indicates R79 has diagnoses that include but are not limited to schizoaffective disorder. The onset date is 7/15/2023.
R79 Notice of PASRR Level I Screen Outcome, 11/8/2022, documents in part: Level I Outcome: No Level II Required - No SMI/ID/RC. Rationale: The Level I screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted.
R97 face sheet printed 10/2/24, by facility indicates R97 has diagnoses that include but are not limited to bipolar disorder, onset date 7/26/2022; major depressive disorder, onset date 1/13/2023.
R97 Notice of PASRR Level I Screen Outcome, 7/25/2022, documents in part: Level I Outcome: No Level II Required - No SMI/ID/RC. Rationale: The Level I screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted.
R120 face sheet printed 10/2/2024, by facility indicates R120 has diagnoses that include but are not limited to schizophrenia, bipolar disorder, major depressive disorder, all with onset date 1/17/2024.
The facility was not able to provide a Notice of PASRR Level I or Level II Screen Outcome for R120.
10/2/24, at 2:57 PM, V13 (Social Services Director) stated I started on 2/24/2024. I did not find a level I for R120. The resident was a transferred from another facility. Each resident should have at least a level I when admitted . It is needed to determine their need level. Level I determines if the facility is proper placement for the resident. Because R120's documents cannot be found, then I don't know if here is the correct placement. The level II determines the treatment the resident needs or interventions to be put in place for them. Level II focuses on mental illness, diagnoses, medications, substance abuse, medical diagnosis that trigger mental health behaviors. Level II is needed/triggered based on psych diagnosis and medications from level I. I called Maximus. They said they do not have a level I or level II for R120.
Facility policy Pre-admission Screening and Resident Review (PASRR), 12/2023, documents in part: It is the policy of this facility to: 1. Comply with Federal, State and the appointed screening agency, Maximus, in standards addressing the PASRR assessment/screening process. 2. Request full and complete PASRR materials (Level 1 and 2) from each referral source prior to or soon following admission.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide incontinence care for three (R56, R62, R94) r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide incontinence care for three (R56, R62, R94) residents and failed to provide scheduled showers for one (R87) resident. These failures affect four residents who are dependent for Activities of Daily Living/ADL care in a total sample of 35 residents reviewed.
Findings include:
On 10/01/2024, at 12:03PM, R87 states she has not received a shower in the facility for approximately 3 weeks. R87 states this is due to inconsistent water temperatures in the shower rooms in the facility. R87 states she has been requesting to have a shower but the water in the shower rooms are sometimes too cold to take a shower. R87 states she knows her body is not cleaned how it is supposed to be.
On 10/02/2024, at 12:06PM, V6 (Certified Nursing Assistant/CNA) states the water on the second floor was cold when she checked it this morning and was not able to give R87 a shower today.
On 10/02/2024, at 11:40AM, V7 (Licensed Practical Nurse/LPN) states she primarily works on the second floor of the facility and is consistently assigned to care for R87. V7 states that V6 (CNA) reported to her on 10/01/2024, that V6 was unable to provide R87 a shower due to cold water temperatures. V7 states R87 reported to V7 on 10/01/2024, that R87 has not received a shower in the facility for approximately one month. V7 states this is the first time she is hearing that R87 has not received a shower in a long period of time. V7 states the protocol for showers is for the CNAs to check the resident shower schedule, provide residents with a shower, and once the resident is inside the shower room, the nurse is supposed to go into the shower room and perform a skin assessment to observe for any skin tears or wounds. V7 states after the nurse performs the skin assessment, the nurse signs a shower sheet form indicating if any skin tears or wounds were found. V7 states the nurse's signature also indicates that the shower was performed for the resident. V7 states she has been assigned to care for R87 for the past month and has not seen any of the CNA staff provide a shower for R87. V7 states she also has not signed a shower sheet for R87 for the past month.
R87s' Face sheet documents that R87 was admitted to the facility on [DATE], with diagnoses not limited to: type 2 diabetes mellitus, acquired absence of left leg above knee, acquired absence of right leg above knee, and peripheral vascular disease.
R87's Minimum Data Set/MDS dated [DATE], documents that R87 has a Brief Interview for Mental Status/BIMS of 15/15, indicating that R87 is cognitively intact. R87's MDS documents that R87 is dependent with ADL care, showers and bathing, and personal hygiene.
Facility shower schedule titled 2 North Shower Schedule documents that R87 is scheduled to receive a shower in the facility twice a week on Mondays and Wednesdays.
R87's shower sheets requested from V1 (Administrator) on 10/02/2024, at approximately 4:30 PM.
On 10/03/2024, at 1:02PM, V1 (Administrator) states there are no documentation of shower sheets for R87.
R87s' care plan dated 07/29/2024, documents that R87 is care planned for ADL self care deficit.
Facility policy undated, titled Activities of Daily Living, documents in part, Hygiene: 6. Showers or baths will be scheduled per facility protocol while incorporating residents shower/bath preferences.
On 10/01/2024, at 12:36PM, R56 states his incontinence briefs were not changed since yesterday at approximately 6:00 PM. R56 states he was wearing the same incontinence briefs and was left in his own feces for hours. R56 states a CNA just recently changed his incontinence briefs about two hours ago. R56 states he does have wounds on his rear end that he does not want to get worse.
R56s' Face sheet documents that R56 was admitted to the facility on [DATE], with diagnoses not limited to: paraplegia, injury at unspecified level of cervical spinal cord, stage three pressure ulcer, muscles wasting and atrophy.
R56's Minimum Data Set/MDS dated [DATE], documents that R56 has a Brief Interview for Mental Status/BIMS of 15/15, indicating that R56 is cognitively intact. R56's MDS documents that R56 is dependent with ADL care and personal hygiene. R56 is incontinent of bowel.
On 10/01/2024, at 12:48 PM, R62 states she had a bowel movement and urinated. She has been waiting for someone to change her incontinence briefs for a long time. R62 states she is unable to go to the bathroom on her own and toilet herself. R62 states a CNA staff member came into her room about 1 hour ago and informed R62 that the CNA would be back to change R62. R62 states no one ever came back to her room to change her incontinence briefs and she is still soiled in urine and feces.
On 10/01/2024, at 1:54 PM, V7 (LPN) and surveyor located inside of R62's room. R62 makes V7 aware that she is still soiled with urine and feces, and no one has come to her room to change her incontinence briefs.
On 10/01/2024, at 1:56 PM, V7 (LPN) makes V6 (CNA) aware that R62 is soiled and needs to be changed.
On 10/01/2024, at 3:40PM, V6 (CNA) states she changed R62's incontinence briefs after V7 made her aware. V6 states when she changed R62, R62 was soiled with urine and feces.
R62s' Face sheet documents that R62 was admitted to the facility on [DATE], with diagnoses not limited to: cerebral infarction, hemiplegia and hemiparesis.
R62's Minimum Data Set/MDS dated [DATE] documents that R62 has a Brief Interview for Mental Status/BIMS of 15/15, indicating that R62 is cognitively intact. R62's MDS documents that R62 is dependent with ADL care and personal hygiene. R62 is incontinent of bowel and bladder.
On 10/02/2024, at 10:38 AM, V29 (Registered Nurse/RN) and surveyor located inside of R94's room. Surveyor and V29 observes that R94's incontinence briefs and bed sheets are visibly soiled. R94 is not interviewable. V29 states the staff are expected to check on the residents at least every two hours and as needed in order to meet the resident's needs. V29 states since R94 has soiled through her incontinence briefs and onto her bed sheets, it is likely that it has been more than 2 hours since R94's incontinence briefs were changed.
On 10/02/2024, at 10:43AM, V31 (CNA) and surveyor located inside of R94's room and V31 observes that R94's incontinence briefs and bed sheets are visibly soiled. V31 states she is aware that R94's incontinence briefs and bed sheets are soiled. V31 states she started her work shift at 7:00 AM and has not provided incontinence care for R94 today because she did not have any towels to wash R94. V31 states if residents are left in urine and feces for prolonged periods of time, this can cause the resident's skin to breakdown. V31 states she will now change R94's incontinence briefs because the laundry department just brought up some more towels.
R94s' Face sheet documents that R94 was admitted to the facility on [DATE], with diagnoses not limited to: cerebral infarction, hemiplegia, hemiparesis, aphasia, and unspecified dementia.
R94's Minimum Data Set/MDS dated [DATE] documents that R94 has a Brief Interview for Mental Status/BIMS of 06/15, indicating that R94 is cognitively impaired. R94's MDS documents that R94 requires partial/moderate assistance with ADL care and personal hygiene. R94 is incontinent of bowel and bladder.
Facility policy undated, titled Incontinency Care documents in part, Policy: Incontinent resident will be checked periodically every two hours and provided perineal and genital care after each episode. Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R96's current face sheet documents R96 is a [AGE] year-old individual with medical diagnosis that includes but not limited to: c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R96's current face sheet documents R96 is a [AGE] year-old individual with medical diagnosis that includes but not limited to: chronic obstructive pulmonary disease, unspecified, chronic obstructive pulmonary disease with (acute) exacerbation, emphysema, unspecified, acute, and chronic respiratory failure with hypoxia. R96's MDS (Minimum Data Set) documents R96's Brief Interview for Mental Status (BIMS) dated [DATE], as 14/15, indicating R96 has intact cognition.
On 10/01/2024, at 12:15 PM, R96 was observed laying in bed watching television and was on oxygen (O2) via nasal cannula. O2 was running at 2 LPM (liters per minute). R96's O2 tubing was observed not labelled with date or time it was changed. R96 stated nurses does not label tubing when they change it.
R96's Physician Order Sheet (POS) documents:
Active
9/20/2024 05:00-change oxygen tubing weekly every 7 day(s)
Active
9/19/2024 21:42 Oxygen every shift at 2LPM continuously per nasal cannula
R8's current face sheet documents R8 is a [AGE] year-old individual with medical diagnosis that include but not limited to acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified, spina bifida, unspecified, hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side. R8's MDS (Minimum Data Set) documents R8 Brief Interview for Mental Status (BIMS) dated Sep 2, 2024, as 15/15, indicating R8 has intact cognition.
On 10/01/2024, at 12:19pm, R8 was observed sitting on her bed and was on oxygen (O2) via nasal cannula. O2 was running at 2 LPM (liters per minute). R8's O2 tubing was observed not labelled with date or time it was changed. R8 stated the nurse labeled the water humidifier bottle yesterday but not the O2 tubing.
R8's Physician Order Sheet (POS) documents:
Active
8/15/2024 7:00 AM Oxygen (02) @ 2 Liters/Minute per nasal cannula, Maintain 02 Saturation @ 95% or greater every shift for sob (Shortness of Breath).
R124's current face sheet documents R124 is a [AGE] year-old individual with medical diagnosis that includes but not limited to: other pulmonary embolism without acute cor pulmonale, hypoxemia, chronic obstructive pulmonary disease, unspecified, dependence on supplemental oxygen.
R124's MDS (Minimum Data Set) documents R124's Brief Interview for Mental Status (BIMS) dated Sep 11, 2024, as 15/15, indicating R124 has intact cognition.
R124's Physician Order Sheet (POS) documents:
Active 1/24/2022 Oxygen (02) @ 2 Liters/Minute per nasal cannula. Maintain 02 Saturation @ 92 or greater. No directions specified for order.
On 10/01/2024, at 12:24pm, R124's oxygen tubing was observed not labelled with the date and time it was last changed. R124 stated the tubing was changed the day before but was not labeled.
On 10/012024, at 12:24pm, V7 (Licensed Practical Nurse-LPN) come into R8 and R96's room and observed both their oxygen tubing were not labelled. V7 stated the facility protocol is to label the oxygen tubing when it is changed to let nurses know when to next change the tubing. V7 stated she did not know what would happen if the Oxygen tubing were not changed on time.
On 10/03/2024, at 12:48pm, V2 (Director of Nursing) stated oxygen tubing should be dated with the date and time the tubing was changed and when not in use, it should be stored in a plastic bag to prevent contamination. V2 stated the oxygen tubing is changed once a week, therefore it should be labeled so that the nurse can know when to change it next. V2 stated that if the tubing is not labeled and changed on time, residents can develop respiratory infections and the tubing can also kink since it is old, and the resident might not get the amount of oxygen they require leading to lack of oxygen complications such as shortness of breath.
Facility policy titled Oxygen Equipment, no date, documents: -Facility will use disposable nasal cannula and face masks. Equipment will be changed weekly and prn on date of facility's choice and dated.
Based on observations, interviews, and record reviews the facility failed to follow the tracheostomy care policy for maintaining a clean environment around a tracheostomy opening for 1 out of 1 resident (R49) and failed to label and date oxygen tubing for 3 out of 7 residents (R8, R96, R124) for a total sample of 35 residents reviewed for respiratory care.
These failures have the potential to affect 4 residents (R8, R49, R96, R124) in avoiding respiratory health risk.
Findings include:
R49 is [AGE] years old, initially admitted on [DATE]. R49's medical diagnosis includes bacterial pneumonia and bacterial infections.
On 10/01/2024, at 12:05 PM, R49 was found sleeping on his bed with his right hand holding a transparent tube. After calling his first name, R49 woke and can verbalize. R49 stated that he has something in his hand and inserted the transparent tube inside in his tracheostomy opening.
On 10/02/2024, at 12:41 PM, after seeing R49's ability to take off the inner cannula of his tracheostomy and re-insert it, V23 (Licensed Practical Nurse) was asked if it is common for R49 to take off his tracheostomy inner cannula and reinsert it back? V23 stated that R49 takes off his tracheostomy inner tube often and sometimes sucks on it.
V3 (Assistant Director of Nursing) stated that she is not familiar with R49 since she just started working in the facility, but said V3 wou;d call the nurse that takes care of R49 often.
On 10/03/2024, at 11:05 AM, V22 (Licensed Practical Nurse) stated that R49 does takes out his tracheostomy inner cannula (tube) and put it back in. When staff see it, they clean it. But since she works only a single shift, she cannot attest to those shifts that she was not working. V22 stated that there is a need to monitor and clean the inner cannula, and other interventions to maintain the cleanliness of R49 tracheostomy including addressing it in the care plan.
Review of R49's history of antibiotic orders, documents that R49 received multiple antibiotics for respiratory infections including: Tobramycin Inhalation Capsule (Tobramycin) 300 mg (three separate orders) by physician for upper respiratory infections; and, Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) for Sputum found to have proteus and Acinetobacter baumanni which causes bacterial infection.
On 10/03/2024, at 01:01 PM, V2 (Director of Nursing) stated that R49's taking off his tracheostomy inner cannula is not hygienic. And her expectation to nursing staff is to notify R49's doctor and notify familt, and redirect R49 when behavior happens. It needs to be care plan as well.
Per R49's care plan dated 5/25/2023 for bacterial pneumonia infection, R49 is at risk for contracting infections due to impaired immune status. Keep the environment clean and people with infection away.
Tracheostomy Care policy dated 1/2024, reads:
The purpose of the policy is to maintain clean environment around tracheostomy opening. There are multiple procedure in the policy that help maintaining clean tracheostomy. Including the following: When cleaning inner cannula it should maintain in sterile condition. When removing inner cannula from tracheostomy tube it will be place in hydrogen peroxide. And should be place on sterile waterproof surface when taken out of the tracheostomy. During suctioning to prevent microorganisms into trachea. Sterile suctioning catheter should be used each time.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/02/24 10:36 AM during resident council meeting, R81, R79, R120, R158 stated there are no linens for residents to use in th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/02/24 10:36 AM during resident council meeting, R81, R79, R120, R158 stated there are no linens for residents to use in the morning and most of the times. Residents have to wait for the morning shift to wash the towels before residents are able to take a shower in the morning.
R129 (Resident council president) stated residents have told him that there are not enough linen in the facility, and R129 has brought it to the attention of V1(Administrator).
R81 stated she likes to take her showers/baths first thing in the morning after she wakes up but there are not towels at that time and R81 has to wait until the towels are washed. R81 stated even then towels are not enough. R81 stated she does not like going for breakfast before taking a shower, but most of the times she has to because there are no towels in the unit.
Based on observation, interview, and record review the facility failed to provide an adequate amount of linen and towels to provide for resident care needs. This failure affects all 197 residents residing in the facility.
Findings include:
On 10/1/24, at 1:20 PM, V32 (Certified Nursing Assistant) stated there is no linen on the floor/unit (3 South) now. There is never enough linen. The beds should be changed daily on the morning shift. The Linen/Supplies closet holds the fitted, flat sheets, pillowcases, bath and face towels, gowns, and pads. Surveyor reviewed the contents of the supply closet for 3 South. Surveyor observed no flat or fitted sheets, 3 big towels, 2 small towels, 3 pillowcases, 7 gowns and 3 pads. Surveyor reviewed the two linen carts on 3 South with V32. Surveyor observed one cart was empty and the other cart had 2 pillowcases, 1 gown, 1 blanket, 1 flat sheet, 1 fitted sheet, 1 pad, 1 bath towel, 1 small towel that was stained with frayed edges and looked to be cut from a bigger towel.
On 10/1/24, at 1:35 PM, surveyor observed resident room [ROOM NUMBER] with two beds with no sheets on them and resident room [ROOM NUMBER] with one bed with no sheets on it. V33 (Certified Nursing Assistant) stated the beds in rooms [ROOM NUMBERS] are not made up because there is not enough linen to do the beds. Typically, the beds would be made by now. It has been a pattern of not having enough linen for the unit (3 South).
On 10/3/24, at 9:10 AM, reviewed the laundry department. In the dirty section of the laundry department, observed two bins with linen inside. V25 (Laundry Aide) stated one had sheets inside, and the other had pads, gowns, and blankets. Observed linen in a dryer. V25 stated it was towels and pillowcases. V25 (Laundry Aide) stated I have worked here for 15 years. We go up to the floors to retrieve the dirty laundry. We could use more supply of linen and towels. We get complaints that there is not enough linen. We get calls from the floors asking for towels, linen.
On 10/3/24, at 9:12 AM, V26 (Laundry Aide) stated we could use more linen and towels.
On 10/3/24, at 9:15 AM, reviewed a linen storage area with V24 (Housekeeping Director). Observed one package of washed clothes. V24 stated there are 60 washcloths per package. Observed one package of fitted sheets. V24 stated there are 12 sheets per package. Observed nine pillowcases. V24 stated staff are cutting the linen to use on the residents because there is a lack of linen. I only have a $500 budget. The $500 budget is for fitted sheets, flat sheets, pillowcases, blankets, bath towels, face towels, gowns, and pads. One package of sheets, one dozen pads cost $54.95 per package.
On 10/3/24, at 12:17 PM, observed the Linen/Supplies closet on 2 South to be empty of linen and towels.
On 10/3/24, at 1:20 PM, V37 (Certified Nursing Assistant) stated typically we do not have enough linen and towels. When I need to make beds, I don't always have the linen needed. I have seen cut up towels.
On 10/3/24, at 1:33 PM, V1 (Administrator) stated I have been made aware that there is not enough linen. My housekeeping supervisor orders on a monthly basis. The linen company sends linen monthly. I am now monitoring what is going on with the linen, the linen that comes in, and I'm trying to order an extra three-day supply.
On 10/3/24, at 3:50 PM, V2 (Director of Nursing) stated I expect the staff to have enough linen, towels so they can provide care at the start of shift and during the shift.
On 10/02/2024, at 10:23AM, V29 (Registered Nurse) states he usually works the 11:00 PM-7:00 AM shift at the facility. V29 states he has heard of complaints that residents do not have enough linen to use in the facility. V29 states he is aware that some of the CNA (Certified Nursing Assistant) staff cut or tear the sheets into pieces in order to make a small towel like cloth in order to wash the residents. V29 states he is also aware of some of the CNA staff going to the store and buying towels with their own money to purchase towels for resident use in the facility.
On 10/02/2024, at 11:40AM, V7 (LPN) states she has witnessed the CNA staff improvise and cut and tear sheets and blankets in order to make a small towel like cloth to wash the residents with. V7 states the amount of linen in the facility is not sufficient for resident use.
On 10/03/2024, at 9:39AM, V25 (Laundry Aide) states when she starts her shift, she stocks the linen cart for each floor and takes them to the designated floors. V25 states there is one linen cart she stocks and takes it to both floors of the facility. V25 states the facility has two resident floors that are divided into two units each. V25 states today she delivered linen to the facility units as follows:
Face towels: 15
Bath towels: 10
Fitted sheets: 4
Flat sheets: 6
Underpads: 10
Gowns: 7
Pillowcases: 2
Facility census dated 10/01/2024, documents a total of 197 residents reside in the facility.
On 10/03/2024, at 9:40AM, V24 (Housekeeping Director) states he is allowed a budget of approximately $500-$600 dollars a month to order linen for the residents in the facility. V24 states he is aware that staff are cutting up sheets and blankets in order to make towels for the residents to use. V24 states he is aware that there is a lack of linen supply in the facility and the allowed linen budget can only do so much.
There is no documentation/invoices to show that the facility is actively and consistently ordering linen for resident use.
Facility policy titled Laundry Services documents in part, 1. Clean Linen a. An adequate supply of clean linen will be maintained for resident care.
Facility policy titled Resident Rights documents in part, Rights to a Dignified Existence- A homelike environment, and use of personal belongings when possible.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to secure Soiled Utility rooms that contained sharps and infectious waste materials. These deficient practices have the potentia...
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Based on observation, interview, and record review, the facility failed to secure Soiled Utility rooms that contained sharps and infectious waste materials. These deficient practices have the potential to affect all residents that reside in the facility.
Findings include:
On 10/2/24, at 8:59 AM, the door to the Soiled Utility room on 3 North was wide open. The door had a push button code entry lock on it. Inside the Soiled Utility room was a biohazard box with a red biohazard bag in it. There was clothes, or linen, inside the red bag. The room also had a hopper, an oxygen concentrator and five bins used for dirty laundry and trash. V42 (Floor Tech) stated the door is supposed to be closed at all times. V42 stated the door was already open when V42 arrived at the room. V42 did not know who opened the door.
On 10/2/24, at 10:48 AM, surveyor opened the door of the Soiled Utility room on two South. The room did not have a lock on the door. The room had a cube size refrigerator (empty) that is used for urine and stool specimens. On the refrigerator was posted Do not refrigerate blood cultures. Did you label all specimens with: patient name and DOB (date of birth ), date and time of collection, specimen source or site. The room also contained a hopper, two yellow dirty laundry bins and two grey garbage bins. V23 (Licensed Practical Nurse) stated the room is not kept locked. The refrigerator is for urine specimens and full sharps containers are kept in the room.
On 10/2/24, at 11:00 AM, V35 (Licensed Practical Nurse) stated the refrigerator in the Soiled Utility room is the sample collection fridge. Samples of bowel and urine are kept in it. Dirty laundry, trash, full sharps containers are kept in the soiled utility room. Residents should not be in the soiled utility room.
On 10/3/24, at 12:39 PM, the door of the Soiled Utility room on 3 North was wide open. Inside of the room were 2 grey garbage bins, 1 blue bin, 2 yellow dirty laundry bins, a full sharps container (V30 (Licensed Practical Nurse) shook the container to confirm it was full), a red biohazard bag with something in it inside of a box with the Biohazard sign printed on it and the box read May Contain Sharps.
On 10/3/24, at 12:42 PM, V30 (Licensed Practical Nurse) stated the Soiled Utility room is supposed to be closed and locked. Residents should not have access to the room. We keep dirty laundry and trash in the room. There is a full sharps container inside the room. There is a biohazard box and bag inside of the room. Residents should not have access to full sharps containers because it is a safety hazard. They can stick themselves and others. Red bags are used for biohazard materials so residents should not have access to them because it is a safety hazard. It's infectious and contaminated.
On 10/3/24, at 1:03 PM, the Soiled Utility room on 3 South did not have a lock and the door was ajar. Inside of the room was a 1-gallon container of Floor Stripper, a 1-gallon container of Glass and Surface Cleaner, a stick razor, 2 gray trash bins, 2 yellow dirty laundry bins, and 1 blue bin.
On 10/3/24, at 1:09 PM, V36 (Licensed Practical Nurse) stated residents should not have access to the Soiled Utility room due to health hazards that are in there such as soiled linen. Residents should not be in there for their safety. Soiled linen and full sharps containers are kept in the room.
On 10/3/24, at 1:33 PM, V1 (Administrator) stated soiled clothing and garbage is kept in the Soiled Utility rooms. Residents should not have access to the soiled utility rooms. Items that may cause harm may be located in there. For safety purposes residents should not be in the soiled utility rooms.
On 10/3/24, at 3:50 PM, V2 (Director of Nursing) stated 3 South has dementia residents. 3 North has independent with substance abuse residents. 2 South and 2 North is skilled residents. I cannot speak specifically on what this facility keeps in the soiled utility rooms. I just started 9/30/24. If infectious waste, biohazard bags/boxes are in the soiled utility room the residents should not have access to the room. Residents should not have access if full sharps containers are in the room. Residents should not have access to the specimen refrigerator. Residents should not have access to floor stripper and surface cleaner.
Facility policy Supervision and Safety, 3/24, documents in part: Our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility-wide priorities. Our facility-oriented approach to safety addresses risks for groups of residents such as wanders, behaviors, aggressiveness, confusion, etc.
Facility policy Sharp Object Disposal, 1/24, documents in part: Once removed, filled sharps receptacles are placed in the designated place for appropriate storage.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record reviews the facility failed to maintain all fans and portable air conditioners used that circulate air in the kitchen in clean and sanitary condition; fai...
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Based on observations, interviews, and record reviews the facility failed to maintain all fans and portable air conditioners used that circulate air in the kitchen in clean and sanitary condition; failed to ensure that testing strips were available to be used in the three-compartment sink that sanitizes equipment used for food preparation are not expired; failed to maintain the kitchen areas without stagnant water that attracts insects; failed to maintain all areas in the kitchen in a clean and hygienic status free from dirt and food wrappers including below the shelves, stoves, dishwasher, and three-sink compartment. These failures have the potential to affect all 196 residents with 1 resident not taking food by mouth.
Findings include:
On 10/01/2024, at 10:03 AM. With V18 (Food Service Director/Dietary Director):
At the food preparation area, two fans were seen one on the floor and the other on the wall. There was also a portable air conditioner besides the fan on the floor. All equipment were seen to have dirt sticking on the grills. V18 stated that it should be clean because air that circulates when using the fan and air conditioner that is not clean can affect food that is being prepared.
At the three-compartment sink, V18 was asked how do staff test the concentration of chemical used to clean equipment in the three-compartment sink is correct? V18 stated that staff use a strip to check chemical concentration. V18 went to find the strip on the three-compartment sink to find testing strip. Since there was none available strip, V18 went to her office and took a strip that was expired dated 10/15/2022. After checking, V18 was informed that the strip was expired. V18 then went back to her office and searched the drawer. V18 found two more strips that were expired dated 1/1/2022 and 5/15/2019. V18 checked the strips and searched further for a testing strip that was not expired but could not find any. V18 stated they would contact the company that supplies the strip and stated that she (V18) had no idea that testing strips should be checked because they expire. V18 stated that three-compartment sink cleans all equipment used in the kitchen like pots and pans that are used for food preparation.
At the dishwasher area there were four (4) fans. Three fans hanging on the wall and one on the floor besides a portable air conditioner approximately between the dishwasher and the three-compartment sink. All equipment (fans and portable air condition) have dirt on the grills. Underneath the dishwasher, three-compartment sink, and stove were dirt and food wrappers. V18 was asked when was the last time staff cleaned the area? V18 stated I think it was last week but I'm not sure if staff cleaned all areas. After pointing at the fan V18 stated, I know it needs to be clean.
After passing a small room near the walk-in freezer, inside the room were brooms and dustpans. A dustpan near the sink was seen full of dirty water grayish in color with a plastic cup floating and insects (similar to flies) flying over the stagnant water. V18 was informed and took the dustpan filed with stagnant water out. Multiple insects flew out of the room and some went into the food preparation area. V18 stated Why did they do this? V18 stated that the room is called the equipment room. The room was full of dirt. and equipment was not clean. V18 was asked why was there stagnant water inside the dustpan? V18 stated that staff should not leave a dustpan in that condition.
On 10/02/2024, at 11:09 AM, V14 (Maintenance Director) was asked about fans in the dietary area. V14 stated that he cleaned them up because they were all dusty. And that responsibility is for dietary and housekeeping staff and the fans should be clean. At 11:15 AM, V18 stated that it is not dietary or housekeeping staff that needs to clean the fans but maintenance staff. V18 stated, Who would take out the screw?
Per Manual Sanitizing in Three-Compartment Sink policy and procedure dated 2016, reads: The most common chemical sanitizers are chlorine, iodine, and quaternary ammonia. The manufacturers label referenced for the appropriate concentration of the sanitizing solution and for length of submersion time.
Upon request for policy related to environmental cleaning in the kitchen facility was not able to present.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to have functional and comfortable hot water for four (R90, R141, R154, R162,) residents and failed to have a safe environment f...
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Based on observation, interview, and record review, the facility failed to have functional and comfortable hot water for four (R90, R141, R154, R162,) residents and failed to have a safe environment for one (R443) resident. These deficient practices have the potential to affect all residents that reside in the facility.
Findings include:
On 10/01/2024, 12:52 PM R141 states that that the only concern she has is the hot water doesn't work and doesn't get hot. R141 states that she took a shower at 7:00 AM and the water was not hot. R141 states that the managers were made aware.
On 10/01/2024, 12:58 PM R90 states that she does have an issue with the shower water not working and that she has showered with cold water. R90 states that the maintenance director has told her that he fixed it but R90 states that it is lukewarm and that she doesn't know if it works, and it has been like this for a long time.
On 10/01/2024, 1:08 PM R162 states that the shower water is cold, and she would like to take a shower but not with cold water. R162 states that this has been going on for about 11 days or two weeks now.
On 10/01/2024, 1:27 PM R154 states that the hot water in the rooms and shower do not work.
On 10/02/2024, 11:02 AM V14 (Maintenance Director) states that the water temperature for hot water should be around 100 degrees Fahrenheit to 135 degrees Fahrenheit. When asked if there are any issues with the hot water temperature in the shower rooms, V14 states that there were a few issues and said that they are installing another water heater. V14 states because some residents were complaining that the water was not hot enough. V14 states that when there is one water heater, it was not enough. V14 states that if many residents are showering, the water would just be lukewarm. V14 states that this has been going on maybe for the past two weeks. V14 states that residents were asking him why the water was not warm enough. V14 states that by the end of this day the second water heater will be installed. V14 states that this system will contribute to the whole building.
On 10/03/2024, 4:22 PM V14 (Maintenance Director) states we must disconnect one boiler to connect another since one another one is being installed. Today there is no warm water. We are working on that. V14 states that the facility always has had two water boilers but one had stopped being functional and the water was not staying hot long enough. V14 states that it is time for a new one because V14 states that if many people are using the shower water at once, and by the last few showers, they would have to wait to feel warm enough water. V14 states that this started maybe three weeks ago, and it was noticed because the residents were telling the CNAs (certified nursing assistants) and nurses.
On 10/03/2024, 5:19 PM V14 states that it usually takes 1 to 2 minutes for the water to warm up. V14 turned on the hot water handle and he waited about 1 minute before checking the water temperature of the 2nd north shower room water, V14 states that the temperature reads 73 Degrees Fahrenheit. V14 states that is kind of cool.
On 10/03/2024, 5:23 PM V14 turns on the 2nd south shower hot water handle and checked the water temperature, V14 states it reads 69 degrees Fahrenheit.
On 10/03/2024, 5:26 PM V14 states that the 3rd North shower hot water is turned off right now. V14 states that for 3rd South shower water it is the one that maintenance is testing, and it is also off. V14 tried to turn on the hot water handle but it did not turn on. V14 states that he tried to look for the water temperature logs but was unable to locate them and he states that his assistance is out of work already until tomorrow.
On 10/01/2024, 12:23 PM R443 is lying in bed, alert and responsive. R443's bed is very close to a window air conditioner unit, no cover is on the air conditioner unit, and there are metal sharp edges noted. R443 states that it has been like that since he has been in this room, and he states that it is dangerous. R443 states that he has been in this room since two days after Labor Day. R443 states that when he sleeps, and he moves it can pinch and poke his skin.
On 10/02/2024, 10: 15 AM R443 is lying on his bed, next to the window air conditioner unit without a cover, exposed to metal edges and wires observed. Air conditioner not plugged in.
On 10/02/2024, 10:25 AM V12 (Certified Nursing Assistant) states that she is going to let maintenance know about R443's air conditioner being without a cover and R443 being exposed to it. V12 states that the air conditioner is not plugged in. V12 states that she doesn't know how long that the broken air conditioner has been like that for.
On 10/02/2024, 11:02 AM V14 (Maintenance Director) states that the air conditioning units are not functioning. They are there to cover the window holes. V14 states that he has ordered 22 new ones and is waiting for the manufacturer to produce them. V14 states that he is aware of R443's air conditioner status and the air conditioner does not have a cover. V14 states that what is exposed is metal but V14 states that R443 is not in danger because the air conditioner is not in use and not plugged in. V14 states that maybe the sharp edges can be hazardous. V14 states that the air conditioners problem was here before he started working for the facility.
Facility policy date 11/2023 titled Preventative Maintenance Program documents in part, Purpose: To conduct regular environmental tours/safety audits to identify areas of concern within the facility . Preventative Maintenance Program will review the following areas during random rounds: All facility areas are kept clean and in safe condition. The water is at the appropriate temperature.
Facility policy not dated, titled Supervision and Safety documents in part, Policy: Our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility-wide priorities . Safety risks and environmental hazards are identified on an ongoing basis through employee training conducted upon hire, annually and as needed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R8's current face sheet documents R8 is a [AGE] year-old individual with medical diagnosis that include but not limited to acute...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R8's current face sheet documents R8 is a [AGE] year-old individual with medical diagnosis that include but not limited to acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified, spina bifida, unspecified, hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side. R8's MDS (Minimum Data Set) documents R8 Brief Interview for Mental Status (BIMS) dated Sep 2, 2024, as 15/15, indicating R8 has intact cognition.
R96's current face sheet documents R96 is a [AGE] year-old individual with medical diagnosis that include but not limited to: chronic obstructive pulmonary disease, unspecified, chronic obstructive pulmonary disease with (acute) exacerbation, emphysema, unspecified, acute, and chronic respiratory failure with hypoxia. R96's MDS (Minimum Data Set) documents R96 Brief Interview for Mental Status (BIMS) dated July 2, 2024, as 14/15, indicating R96 has intact cognition.
On 10/012024, at 12:24pm, V7 (Licensed Practical Nurse-LPN) come into R96's room and was observed trying to unkink R96's spirometer tubing which was on the floor and was caught between R96's clothes and other belongings. V7 tried to pull the spirometer tubing free, and as V7 was moving R96's belongings a pest (roach) was observed crawling on the floor of the room and was observed going into the bathroom. V17 stated she does not know what that was and she does not work in the maintenance department to know what different pests or insects were, and it was up to maintenance department to take care of.
On 10/03/2024, at 1:19pm, R8 and R96 were observed in their beds and stated they have seen roaches in their room and have informed staff. R8 and R96 stated they did not know if the pests were being treated or not, and stated they did not like bugs and/or pests in their room.
On 10/03/2024, at 4:09pm, V14 (Maintenance Director) stated he has only been here working at the facility since March 2024, and the outside pest control company come two times a month unless called when pests or rodents have been sighted at the facility. V14 stated each unit has a pest control log that nursing staff document when they see pest activity, then the outside vender, who comes twice a month looks at the pest log to determine where to apply treatments V14 stated the pest control company has been coming a little bit more often than usual because there had been pest activity in the building a month ago. V14 stated the outside company has not changed the chemicals they have been using since V14 started.
V14 stated he does not inspect for any kind of pests in the building, and the inspections are done by the pest control company when they come to the building two times a month.
V14 stated pests/rodents/insects can bring and spread diseases in the building and can also contaminate foods in the facility which can make residents sick.
Facility Policy titled Housekeeping Guidelines, no date, documents: -The pest control service will be monitored by housekeeping personnel and pesticides used will be in compliance with federal, state and local laws. Housekeeping personnel shall report any problems or needs concerning pest control to the administrator and contact will be made to the outside service.
Based on observations, interviews, and record reviews the facility failed to maintain an effective pest control program, failed to follow the pest control policy in maintaining the kitchen environment clean to prevent harborage of pests and failed to maintain areas free from pests for 2 residents (R8 and R94) rooms. These failures have the potential to affect all the facility residents.
Findings include:
On 10/01/2024, at 10:03 AM with V18 (Food Service Director/Dietary Director) underneath the dishwasher, three-compartment sink, and stove there were dirt and food wrappers. V18 was asked when was the last time staff cleaned the area? V18 stated I think it was last week but I am not sure if staff cleaned all areas. In a small room near the walk-in freezer, there were brooms and dustpans. A dustpan near the sink was full of dirty water that was grayish in color with a plastic cup floating and insects (similar to flies) flying over stagnant water. V18 was informed and took the dustpan filed with stagnant water out. Multiple insects flew out of the room and some went into the food preparation area. V18 stated Why did they do this? V18 stated that the room is called the equipment room. The room was full of dirt and the equipment was not cleaned. V18 was asked why was there stagnant water inside the dustpan? V18 stated that staff should not leave the dustpan in that condition.
On 10/02/2024, at 11:45 AM, during tray line food preparation with the following dietary staff V20 (Cook), V21 (Dietary Staff), V21 (Dietary Staff) a small cockroach from the three-compartment sink was seen moving towards the food preparation area where staff are doing the tray line. When V21 saw the cockroach V21 was surprised and screamed. V18 upon entering the kitchen was informed about the cockroach and stated she will inform V14 (Maintenance Director). V18 stated that V14 told her that pest control came yesterday.
On 10/02/2024, at 1:24 PM, V14 presented a pest control company document dated 10/01/2024 that does not indicate areas where services were done. V14 stated that he cannot explain why there is not information on the specific areas that was serviced. A pest control company receipt dated 9/16/2024 documents that there were activities in the main kitchen area of German roaches including food carts. V14 was asked if there were traps installed per documentation of pest control company dated 9/16/2024. V14 stated, there might be traps in the kitchen. V14 then went to the kitchen to look at areas including the bottom of the food preparation area but could not find any traps.
Facility Pest Control Policy dated 11/14, reads: The purpose is to prevent or control insects and rodents from spreading disease. The facility shall be kept in such cleaning condition and cleaning procedures used to prevent harborage or feeding insects or rodents. Floors and wall finishes in the food preparation, storage, and utensil washing areas, walk in refrigerating units, dressing rooms, lockers, toilet which may be washed and cleaned.
Sept 2024
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
Based on record review and interview the facility failed to implement care plan interventions, failed to conduct a physical assessment, failed to obtain vital signs, failed to contact the Physician/Nu...
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Based on record review and interview the facility failed to implement care plan interventions, failed to conduct a physical assessment, failed to obtain vital signs, failed to contact the Physician/Nurse Practitioner, failed to ensure that a Nurse was on the unit when EMS (Emergency Medical Services) arrived, failed to follow Physician orders, and/or failed to provide timely care to three of three residents (R2, R3, R4) reviewed for change in condition. These failures resulted in: R2 sustaining abdominal pain secondary to small bowel obstruction and death caused by septic shock with multi organ failure likely from ischemic bowel. In addition, R3 sustained excruciating pain due to pulmonary embolism.
Findings include:
1. On 9/19/24, IDPH (Illinois Department of Public Health) received allegations that the facility failed to send a resident to the hospital (for emergency care) in a timely manner.
R2's diagnoses include but not limited to schizoaffective disorder, dementia, rhabdomyolysis, CKD (Chronic Kidney Disease), hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left side.
R2's (10/2/23) functional assessment affirms supervision or touching assistance is required for eating and partial moderate assistance is required for toileting.
R2's care plan includes (6/2/21) Resident is at risk for renal insufficiency related to history of CKD and rhabdomyolysis. Intervention: monitor and report any signs of vomiting, muscle discomfort, fever, and generalized weakness. Monitor and report changes in mental status.
R2's (2/16/23) POS (Physician Order Sheets) include anti-psychotic medication use: observe closely for significant side effects, sedation, loss of appetite, and constipation. Enter the number of times side effect noted (requires progress note of physician notification for each occurrence).
R2's (10/2/23) progress notes state 12:29pm, Chief complaint: review of depression symptoms. Patient reports mood is Ok. She appears confused but can answer simple questions. Claims to feel sad because her son passed away a week ago. No notes seen about her son's recent passing. Appetite is less because of feeling sad. 9:12pm, Writer made aware that family member (V5) in residents' room has phoned 911 for resident complaining of not feeling well. Unit supervisor made aware; PCP (Primary Care Physician) paged to make aware. Appropriate paperwork given to EMT's (Emergency Medical Technicians) patient transferred via gurney x2 [vital signs and physical assessment are excluded].
On 9/26/24 at 1:02pm, surveyor requested R2's (10/2/23) SBAR (Situation Background Assessment Recommendation) and/or change in condition report (which include vital signs at time of transfer) however neither were received during this survey.
On 9/26/24 at 2:15pm, surveyor inquired from V5 (Family) about R2's (10/2/23) change in condition. V5 stated, I (V5) went up there (facility) and my mother (R2) looked like her normal self, but she (R2) wasn't asking for food, and she usually likes to eat. She (R2) said that she was nauseated and hadn't eaten in a while, so I (V5) told the Nurse, and the Nurse seemed a little lax about it. My brother (V6) went up there around 9:00 at night and said she (R2) still didn't eat so I (V5) told him (V6) to call 911. When the EMT's got there they said ain't nobody up on the floor to give them any paperwork. When I (V5) got to the hospital, I found out she (R2) hadn't pooped for 2 weeks, and the doctor told me she threw up her bowels in the CT (Computed Tomography) scan. She (R2) had a bowel obstruction that led to sepsis. The nursing home was supposed to be recording her bowel movements and her eating. If they (facility staff) knew that there was a problem ahead of time, why did the family have to get her (R2) out of there (facility). Nurses are supposed to know the signs that something is wrong and be monitoring your input and output. It's basically a case of neglect. She passed away October 4th, 2023.
On 9/26/24 at 2:21pm, surveyor requested R2's September/October (2023) input and output (including bowel movements) documentation however neither were received during this survey.
On 9/30/24 at 10:12am, surveyor inquired about R2's (10/2/23) change in condition, V8 (LPN/Licensed Practical Nurse) stated I (V8) was not taking care of her (R2) that day. I was called downstairs by the CNA (Certified Nursing Assistant) to take care of some paperwork for her (R2). The Nurse was out on a lunch break to my understanding. The family was at the bedside and called 911 to have her (R2) sent out to the hospital. I printed out the face sheet and the orders, those are the necessary documents when you send somebody out [SBAR and/or change in condition report were excluded]. Surveyor inquired if V8 assessed R2 prior to transfer, V8 responded No, she was already on the gurney to be transferred when I came down. Surveyor inquired if V8 obtained R2's vital signs prior to transfer, V8 replied No, she was already on the gurney for transfer. Surveyor inquired who covers the unit while the Nurse goes on break, V8 stated The other Nurses are supposed to be made aware when you go on break so they can cover for you. Surveyor inquired if there was a Nurse manager on duty that day, V8 responded I don't recall. Surveyor inquired how many (evening shift) Nurses are assigned to each floor, V8 replied There's 2 on each unit. Surveyor inquired if any Nurses were present on R2's unit during change in condition and/or transfer, V8 stated Not on that unit when I arrived, no.
R2's (10/2/23) history & physical states resident presented to the ED (Emergency Department) with abdominal pain and vomiting. Report obtained from EMS states that patient was on a non- nursing floor at her nursing home with no providers on the floor when she was found vomiting profusely complaining of left lower quadrant abdominal pain. CT (Computed Tomography) scan was obtained with signs of bowel obstruction. While in CT scan patient had an episode of emesis which was presumed to be aspirated because afterwards, she became slightly more hypoxic. General surgery evaluated the patient and placed an NG (Nasogastric) tube with brownish output. After placement of NG tube patient's clinical status deteriorated becoming increasingly hypoxic and tachycardic and as the patient has a contraindication to BiPAP with the persistent vomiting a decision was made to intubate for this hypoxia. Notable labs include elevated creatinine from baseline, elevated lactate 6.5 and slight leukocytosis 13.7. While in the ER, blood pressures were difficult to obtain with the most readily available pressure reading of 140/auscultation with subsequent decline to 80/auscultation. She was started on Levophed (vasoconstrictor used to treat life-threatening low blood pressure) at that time and quickly escalated to max dose.
R2's (10/3/23) surgery consult states patient presented from nursing home with 2 weeks of abdominal pain and poor oral intake. Patient reports she had 2 weeks of abdominal pain, and no bowel movements though continues to pass gas. CT abdomen and pelvis finding concerning for small bowel obstruction.
R2's (10/3/23) history of present illness states resident presented to ER from nursing home due to abdominal pain with vomiting. Per notes, for two weeks. Patient was revealed to have a small bowel obstruction with an NG tube placed. However, patient's condition worsened and required intubation due to hypoxia which the patient started to vomit fecal material. Patient was started on IV Zosyn (Antibiotic) and Doxycycline (Antibiotic) for aspiration pneumonia.
R2's (10/4/23) discharge summary states despite full life-sustaining measures patient gradually became PEA (Pulseless Electrical Activity) and time of death pronounced at 11:00am. Cause of death septic shock with multi organ failure likely from ischemic bowel.
On 9/30/24 at 12:43pm, surveyor inquired about the expectation of Nurse's when residents experience a change in condition V7 (Medical Director) stated The Nurse should be at minimum getting vital signs, reviewing any obvious history of the patient and calling the physician. Surveyor inquired if a resident has not had a bowel movement for 2 weeks what's the potential harm, V7 responded The potential for harm is it can lead to fecal impaction, horrible pain, decreased appetite, or a bowel obstruction. Surveyor inquired if a resident vomits feces what's the potential harm, V7 replied I think there's a lot of potential for harm, they can have pneumonia or upper GI (Gastrointestinal) pain, but I think the biggest thing would be aspiration pneumonia.
2. R3's diagnoses include COPD (Chronic Obstructive Pulmonary Disease).
R3's (6/14/24) care plan states resident has the potential for impaired gas exchange related to COPD. Intervention: monitor and report signs/symptoms of respiratory distress unrelieved with treatment to medical doctor. Monitor resident for shortness of breath and implement interventions as ordered if needed.
R3's POS includes (6/14/24) oxycodone 5mg every 4 hours as needed for moderate pain and (7/1/24) stat left rib x-ray.
R3's progress notes include (7/1/24) 12:30pm, resident complained of pain in chest upon inhalation causing him to have a hard time breathing deeply. Information relayed to Nurse Practitioner who gave order for a chest x-ray of the left rib. Order noted and carried out. Writer scheduled x-ray with (provider) who was unable to provide an ETA (Estimated Time of Arrival). 8:30pm, [8 hours later] resident complained of pain to exterior left side of chest wall. Resident informed nursing staff on AM shift, orders received for stat CXR (Chest X-ray). While resident was awaiting arrival for CXR to be complete, resident proceeded to call 911 using his personal phone. Resident CXR was not completed as ordered. Pain 5/10, resident receives oxycodone 5mg (milligrams) per orders. (7/2/24) Resident admitted to ICU (Intensive Care Unit) diagnosis pulmonary embolism.
R3's (9/20/24) BIMS determined a score of 15 (cognition intact).
On 9/25/24 at 3:36pm, surveyor inquired about R3's (7/1/24) change in condition. R3 stated That's when I had the blood clot. I had to call and go to the hospital; the pain was too bad for me to breathe and move around. Surveyor inquired what the staff implemented when they were made aware of R3's change in condition R3 responded The 2nd shift called someone, and they supposed to be sending someone to do some x-ray, but they never showed up. When it came to the 3rd shift, I was in excruciating pain. I had asked them (staff) to call the doctor, but they kept saying what the other shift did, so I had to call 911 myself. The doctor said I had a blood clot.
On 9/30/24 at 10:45am, surveyor inquired about R3's (7/1/24) change in condition, V10 (LPN) stated He (R3) was complaining about chest pain that day, only when he breathed in deep, he said he had a sharp pain. So, I (V10) listened to his (R3) heart sounds, lung sounds everything sounded clear, and his oxygen saturation was fine. I called the doctor and let her (doctor) know that he was in pain, she (doctor) ordered a stat chest x-ray. I called to schedule the x-ray and charted that he (x-ray provider) was unable to provide an ETA. Surveyor inquired if V10 contacted the doctor to report that the x-ray provider was unable to provide an ETA for R3's x-ray (which was ordered stat), V10 responded No.
On 9/30/24 at 12:48, surveyor inquired if a procedure is ordered stat what's the expected turnaround time, V7 (Medical Director) stated I would say like 2 hours for someone to draw blood or get an x-ray because we need to call somebody to come and do that. Surveyor inquired if an x-ray is ordered stat and the provider is unable to do it stat what should be done, V7 responded I would recommend the patient go to the hospital to get more immediate care. Surveyor inquired if a resident has chest pain upon inspiration and difficulty breathing what's the potential cause, V7 replied Two potential causes could be a heart attack or could be a pulmonary embolism. Surveyor inquired if a pulmonary embolism is not treated timely what's the potential harm, V7 stated death.
3. R4's diagnoses include obesity, hemiplegia affecting right dominant side, constipation, and cognitive communication deficit.
R4's (6/28/23) care plan states resident has a diagnosis of constipation. Interventions: Monitor/document/report to medical doctor signs and symptoms of complications related to constipation.
R4's (7/21/24) POS includes stat KUB (Kidney Ureter Bladder).
R4's (7/21/24) progress notes state 10:00am, resident observed projectile vomiting x2. Bowel sounds normal in all 4 quadrants. No distention noted. When asked if resident was nauseous or in pain, she shook her head no. Writer relayed this information to NP (Nurse Practitioner) who gave the order to get a stat KUB. (X-ray provider) phoned to schedule stat KUB and gave an estimated time of arrival 4-6 hours. 10:25pm, Writer relayed results of resident's KUB to NP.
R4's (7/21/24) abdomen x-ray results affirm it was electronically signed at 8:03pm [x-ray performed time is excluded].
R4's (7/12/24) BIMS affirms resident is rarely/never understood.
On 9/24/24 at 2:39pm, surveyor spoke to R4 however received no verbal response.
On 9/30/24 at 10:28am, V10 (LPN) stated Whenever there's any change in condition you will do an SBAR. Surveyor inquired when R4's (7/21/24) KUB was obtained, V10 stated I scheduled a stat KUB, and they (x-ray provider) gave an ETA of 4 to 6 hours. Surveyor inquired about stat turnaround time, V10 responded I believe it's between 2 to 4 hours. Surveyor inquired if V10 contacted the Nurse Practitioner to report that the x-ray providers ETA was going to be 4 to 6 hours (therefore not stat), V10 replied No, I should have called the doctor. Surveyor inquired when R4's (7/21/24) KUB was obtained, V10 stated I'm not sure but it says I relayed the results at 10:25pm [roughly 12 hours after orders were received]. I'm not exactly sure what time they (x-ray provider) came.
The change in resident's condition policy (reviewed 11/2023) states Nursing will notify the resident's physician or nurse practitioner when: there is significant change in the resident's physical, mental or emotional status. It is deemed necessary or appropriate in the best interest of the resident. Communication with the resident and their responsible party as well as the physician/NP will be documented in the resident's medical record or other appropriate documents.
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
Grievances
(Tag F0585)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to ensure that residents and staff are aware of the grievance process and failed to ensure that a grievance form and/or resolutions were provid...
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Based on record review and interview the facility failed to ensure that residents and staff are aware of the grievance process and failed to ensure that a grievance form and/or resolutions were provided to one of four residents (R1) in the sample. These failures have the potential to affect 198 residents.
Findings include:
On 9/6/24, IDPH (Illinois Department of Public Health) received allegations that staff were neglecting residents.
The 9/24/24 census includes 198 residents.
On 9/24/24 at 2:11pm, surveyor inquired about concerns at the facility, R1 stated I reported them (staff) for not doing their job. They had a resident sitting in feces for three and a half hours. Surveyor inquired who the concerns were reported to, R1 affirmed it was miss (V2's last name). [V2 is the DON/Director of Nursing].
On 9/25/24 at 9:54am, surveyor inquired about R1's reported allegations, V2 stated Making sure that staff was changing the patients in a timely fashion and answer the call lights. Surveyor inquired if a grievance form was provided to R1 and/or documented for R1's reported concerns, V2 responded No, I didn't think it was necessary. Surveyor inquired about the facility grievance process, V2 replied If it's a concern with a resident then a lot of times Social Service gives a form, or if we (staff) hear it, we just address the problem. Surveyor inquired if Social Service staff are the only staff providing grievance forms to residents, V2 stated Absolutely not, Nurses can hand out grievances if its needed. [The facility policy states all concerns will be documented].
On 9/25/24 at 10:16am, surveyor inquired if V4 (Licensed Practical Nurse) was aware of the facility grievance process, V4 affirmed that she was not.
R3's (9/20/24) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 9/25/24 at 3:36pm, surveyor inquired if R3 was aware of the facility grievance process, R3 stated No I didn't know about that.
The (9/20) grievance policy states all staff will be made aware of the location of the concerns forms. All concerns will be documented in writing. The Director of Social Services will review and maintain concerns through resolution. All departments and facility staff members are required to participate in the investigation and follow up that is required to resolve each concern. The facility concerns will be maintained in the concern/grievance binder.
Aug 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on interview and record review, the facility failed to protect a resident (R3) from physical abuse from staff which affected one resident (R3) out of three residents reviewed for abuse. This fai...
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Based on interview and record review, the facility failed to protect a resident (R3) from physical abuse from staff which affected one resident (R3) out of three residents reviewed for abuse. This failure caused R3 to suffer bilateral mandibular fractures to R3's face requiring oral and maxillofacial surgery.
Findings include:
R3's Brief Interview for Mental Status dated 07/18/24 shows that R3 has a BIMS score of 15 which indicates that R3 is cognitively intact.
R3's face sheet shows that R3 has a diagnosis which includes but not limited to chronic systolic congestive heart failure, chronic obstructive pulmonary disease, asthma, presence of automatic implantable cardiac defibrillator, essential primary hypertension, polyneuropathy in diseases classified elsewhere, acute kidney failure, seizures, hyperkalemia, polyneuropathy due to other toxic agents, diarrhea, hypotension, opioid dependence.
R3's Initial Facility Reported Incident dated 07/14/24 at 8:39 pm, documents in part R3 informed staff that R3's assigned Certified Nursing Assistant (CNA) V6 displayed behaviors inconsistent with facility standards. V6 was immediately suspended pending investigation. R3 was assessed for injuries. R3's family and physician were notified of the allegations and assessment findings. The local policy were notified of the allegations. A full investigation has been initiated and a final report will follow timely.
R3's Final Facility Reported Incident dated 07/19/24 at 11:21 pm, documents in part Analysis and Conclusion: R3 informed the visitor that a guy with tattoos on his neck punched R3 in the face and knocked R3's tooth out . R3 was admitted to the local (sic) with bilateral mandibular fractures . V6 attempted to redirect R3 in R3's room to calm down. R3's behaviors escalated and R3 grabbed V6 and began tussling with R3. V6 is no longer employed at the facility.
On 07/30/24 at 10:21 am, R8 (R3's Roommate) stated that R8 recalls R3 having an altercation with a male staff a few weeks ago. R8 stated that R8 was resting in R8's bed and heard a verbal altercation between R3 and a male Certified Nursing Assistant (CNA). R8 stated that when the male CNA left R3 and R8's room, R3 stated that R3 got hit in the mouth by the male staff and R8 observed blood on the floor near R8's bed. R8 was unable to give a description of the male CNA.
On 07/31/24 at 9:30 am, V3 (Human Resource Director) was questioned regarding V6 (CNA) employment status at the facility and V6 stated that R6's reason for termination was abuse allegation involving R3 that was substantiated.
On 07/31/2024 at 10:02 am, V6 (Certified Nursing Assistant, CNA) stated that about two weeks ago V6 observed R3 sitting on the edge of R3's bed in R3's room when V6 brought R3's meal tray into R3's room. V6 stated as V6 was sitting R3's meal tray on R3's over bed table, R3 shoved R3's meal tray as V6 was attempting to set R3's meal tray down, spilling R3's meal tray onto V6's clothing. V6 then explained that R3 then stood up about one foot in front of V6 and spit onto V6 clothes, shirt, neck, and face. V6 stated that V6 then turned around and left R3's room to go clean up himself (V6). V6 stated that as V6 left R3's room V6 heard R3 cussing and very mad. V6 then stated that after V6 cleaned the spit and food off V6, V6 returned to R3's doorway and observed R3 still cussing and mad. V6 stated that V6 then informed V7 (Licensed Practical Nurse, LPN, R3's nurse) that R3 was agitated and to check on R3. V6 then explained that V6 was not certain when V7 went to check on R3. V6 stated that one hour and a half later after the V6 interaction with R3 spitting on V6, V2 (Director of Nursing, DON) called the facility and informed V6 that R3 stated that V6 put his hands on R3 and instructed V6 to make a statement regarding the interaction with R3 and to clock out and leave the facility. V6 stated that V6 followed V2 instructions and left the facility. V6 also explained that V6 was not R3's assigned CNA on 07/14/24 and that V6 was only bringing R3, R3's meal tray. V6 denied physically assaulting or having a verbal altercation with R3. V6 stated that on 07/15/24 V2 informed V6 that R3 suffered a broken jaw injury to R3's jaw. V6 denies having any knowledge as to how R3 sustained a broken jaw.
On 07/31/24 at 10:35 am, V7 (Licensed Practical Nurse, LPN) stated that a few weeks ago during V7's 3:00 pm - 11:00 pm shift at the facility, while V7 was passing medications, V30 (Certified Nursing Assistant, CNA) informed V7 that as V30 was walking pass R3's room, V30 saw R3's mouth bleeding. V7 stated that V7 asked V12 (LPN) to come with V7 to assess R3. V7 stated V7 assessed R3 with injuries to R3's face. V7 stated that V7 observed R3's mouth bleeding with lacerations to R3's lower lip, R3's mouth with a tooth missing that looked as if R3's missing tooth came from R3's lower mouth, and the right side of R3's face swollen. V7 stated that R3 informed V7 that a male staff member with tattoos (V6, CNA) beat up R3 and hit R3 in the mouth. V7 stated that V6 was the staff with tattoos identified by R3 and that V7 then followed the facilities protocol for abuse by calling V1 (Administrator), the on-call physician for R3, the local police and phoned V2 (Director of Nursing, DON) who then called the building and gave directives for V6 to leave the facility. V7 then stated that V6 was not an assigned CNA working on V7's unit. V7 said they never spoke with V6 and never reported any changes in R3 condition such as agitation, R3 shoving R3's lunch tray or spitting on V6 or V7, and ever seeing V6 working on V7's unit on 07/14/24.
On 07/31/24 11:35 am, V28 (R3's physician) stated that V28 did not receive the call that R3 was in an altercation with a staff member at the facility. V28 stated that V28 was informed regarding R3's altercation with a staff member after V28 came to visit R3 at the facility and learned that R3 was in the local hospital with bilateral mandibular fractures due to an altercation with a staff member at the facility. V28 stated that V28 did not have any further details due to V28 learning about the altercation two days after R3 was sent to the local hospital. V28 denied that R3 was a combative resident, ever displayed self-inflicting injuries and that R3 was always pleasant. V28 was asked regarding how a resident could sustained a bilateral mandibular fracture and V28 stated, If a resident suffers a hard blow/strike to one side of the jaw the impact could fracture the other side of the resident's mouth as well.
On 07/31/24 at 11:51 am, V2 (Director of Nursing, DON) stated that the altercation with R3 and V6 took place on Sunday 07/14/24 and that V2 was not in the facility and did not observe the altercation. V2 stated that V25 (Restorative Nurse) informed V2 that V25 observed blood on the floor in R3's room and that R3 stated to V25 that R3 was hit by a staff member V6 (CNA) who R3 named Ken. V2 stated that V2 instructed V25 to inform V6 that V6 was involved in an investigation and to leave the facility. V2 stated that V2 then informed V1 of the abuse allegation. V2 also stated that V2 questioned V7 (Licensed Practical Nurse, LPN, R3's nurse) what transpired between R3 and V6 and that V7 stated that V7 did not witness anything between V6 and R3. V2 stated that V7 explained that V7 was down the hallway from R3's room passing medications prior to V7 learning about the altercation with R3 and V6. V2 explained that R3 was alert and oriented and not known to be a combative resident with staff or other residents and was easily able to be redirected.
On 07/31/24 at 2:27 pm, V1(Administrator) stated that V1 is the abuse coordinator and it is V1's first week working at facility. V1 received a call from V2 stating there was a possible abuse case at the facility. V1 stated that V1 instructed V2 to send the person in question home, interview the resident immediately, and if there was a physical harm to call the police as well as to send the resident out to the local hospital. V1 stated that V1 was informed that the staff member involved in the abuse allegation was V6 (CNA) and that V6 had already left the facility before V2 (DON) could instruct V6 to leave. V1 stated that V1 was informed that a family member reported to a nurse on the unit that R3 was bleeding and hurt. V1 stated that a police report was conducted, and the incident was labeled as a Simple Battery V1 explained that the local hospital determined that R3 suffered bilateral jaw fractures. V1 then explained that V1 concluded V1's investigation with R3 and V6 by substantiating abuse due to R3 being an alert, oriented resident, V6 being on the schedule during the time of the incident, R3 being able to describe V6 as the male staff with tattoos and as the person who assaulted him (R3). V1 stated that V6 fit the description of R3's perpetrator. V1 also stated that R8 (R3's Roommate) could not give an accurate definition but stated that R8 heard the argument between R3 and V6 on 07/14/24.
R3's progress notes dated 07/14/24 at 8:17 pm, authored by V7 (Licensed Practical Nurse, LPN) documents in part, Reported physical altercation, observed facial injury. Head to toe observation shows right jaw swelling, laceration to inner lip with blood present . Cold compress applied to jaw. Abuse protocol initiated; administration & management made aware via phone. CPD (Chicago Police Department) phoned, is in route to the facility.
The facility's document dated 07/15/24 and titled Corrective Action Notice documents in part: V6 failed to follow abuse policy of the facility on 07/14/24, violation of union policy of Abuse page (pg.) 38#7 first offense discharge. Termination. Unable to serve to employee due to refusing to come to facility after completion of investigation.
R3's police report record dated 07/14/2024, documents in part Incident: Simple Battery.
R3's hospital record dated 07/15/24 documents in part chief complaint: Trauma. R3 brought in by Emergency Medical Service (EMS) from nursing home when R3 got into a fight with a staff member and got punched in the face. Per EMS R3 has bilateral mandibular jaw fx (fractures).
R3's hospital record dated 07/15/24 documents in part: Principle Problem: Bilateral mandibular fracture, closed, initial encounter . Assault . Minimally displaced oblique fractures of the left mandibular symphysis and posterior right mandibular body are in unchanged alignment. Fracture line extends to the roots of the left mandibular central and lateral incisors . Operating Room (OR) with OMFS (Oral and Maxillofacial Surgery) . Subjective: . Head to toe trauma examination redemonstrated pain and swelling and tenderness to the mandibles and difficulty moving jaw.
The facility's document dated January 4, 2018, and titled Abuse Prevention Program Facility Policy and Procedure documents in part: Introduction: abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. V1. Protection of Residents: the facility will take steps to prevent potential abuse while the investigation is underway. Internal Investigation: 7. Final investigation report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within 5 working days of the reported incident. The final investigation reports shall contain the following if the allegation is determined to be valid and the perpetrator is an employee, include on a separate sheet the employees name, address, phone number, title, date of hire, copies of previous disciplinary actions, and current status.
Jun 2024
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review the facility failed to follow policy procedures, failed to conduct a thorough assessment, failed to implement care plan interventions, failed to time...
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Based on observation, interview, and record review the facility failed to follow policy procedures, failed to conduct a thorough assessment, failed to implement care plan interventions, failed to timely notify the Physician/Nurse Practitioner of resident change in condition, failed to document orders received, failed to request appropriate orders, and failed to determine the root cause of pain for one of four residents (R1) reviewed for change in condition. These failures resulted in R1 sustaining pain rated 50 (on a 1-10 scale), emotional distress (crying), WBC (White Blood Cell) count 17.4 (High), UTI (Urinary Tract Infection), and fecal impaction.
The facility also failed to ensure that R1's (3/29/24) referral for Neurosurgery consult was transcribed in the physician orders and failed to ensure that orders for R1's GI (Gastrointestinal) consult were obtained prior to surveyor inquiry.
Findings include:
On (6/11/24) IDPH (Illinois Department of Public Health) received allegations that R1 was not sent to the ER (Emergency Room) in a timely manner for head and abdominal pain.
R1's diagnoses include but not limited to encephalopathy, spina bifida, pain in unspecified joint, cutaneous abscess of right axilla, constipation, and UTI (Urinary Tract Infection).
R1's Physician Order Sheets include (10/8/21) Tramadol 50 mg (milligrams) every 6 hours as needed for pain. (3/11/24) pain assessment every shift, record actual score (0-10) every shift.
R1's care plan includes (6/14/21) resident is at risk for alteration in comfort. Interventions: Complete pain assessment. Administer medication as ordered and monitor for effectiveness of relief. Notify medical doctor if current pain medication management is not effective. (7/7/23) Resident is taking medication to treat constipation. Interventions: monitor, document, report to medical doctor signs/symptoms of complications related to constipation.
R1's (June 2024) Medication Administration Record affirms on 6/6/24 at 1:53am, R1 received Tramadol (Opioid Analgesic) for pain rated 5. On 6/8/24 at 1:45pm, R1 received Tramadol for pain rated 4. On 6/9/24 at 10:33am, R1 received Tramadol for pain rated 5. [R1's pain was rated 0 prior to 6/6/24 therefore change in condition occurred at this time].
R1's progress notes state (6/9/24) 8:07am, resident expressed to writer that she has pain over entire body, and she would like to go to the hospital. Writer offered pain medication, but resident denied. The resident was assessed by the writer, vital signs within normal limits [Physical Assessment was excluded]. Call placed to on-call service for (Physician) and was made aware that NP (Nurse Practitioner) would return a call to the facility. [A return call from the NP was not documented]. (6/11/24) 11:51am, Resident complained of general malaise, pain, and a boil under the left arm. Writer contacted NP and new orders were given to send resident to the hospital for evaluation [2 days after initial request for evaluation]. Reason for transfer: General Malaise, complaints of pain, boil under left arm, and shunt pain. 2:10pm, ambulance personnel arrived at the facility to escort resident to the hospital. (6/12/24) Patient was admitted for abdominal pain and UTI.
On 6/13/24 at 3:02pm, surveyor inquired about R1's (6/9/24) change in condition, V4 (Family) stated She (R1) has problems with her stomach, bowel movements, headaches, and she said that she couldn't see one day last week. She was in a lot of distress both physically and emotionally. Yesterday, she was hysterical because of the pain and feelings of abandonment. She was going to have an upper and lower GI (gastrointestinal) test and I think she's going to have surgery as well.
R1's (4/1/24) BIMS (Brief Interview Mental Status) determined a score of 11 (moderate impairment).
On 6/17/24 at 2:32pm, R1 was alert, oriented, and appropriate during interview. Surveyor inquired about R1's (6/9/24) change in condition, R1 began to speak, and an overwhelming feces odor was noted. R1 stated I was born with spinal bifida and have a VP (ventriculoperitoneal) shunt (cerebral shunt that drains excess cerebrospinal fluid). I was sick and kept having headaches, I thought my shunt was malfunctioning. I went out to an appointment about a month ago to see the neurosurgeon for my head, but they (staff) took me to the wrong office, it was the one for seizures (neurologist), so they had to bring me back and reschedule. I don't know when it was rescheduled for. Before I was sent out to the hospital, I got my stool (feces) pulled out here (facility) they (staff) only removed some of it. I was in pain for 2 weeks, I was having pain in my stomach and having headaches. Surveyor inquired how much pain R2 was experiencing prior to hospital transfer (based on a 1-10 scale), R1 responded I was crying I was in so much pain, it was 50. I asked to be sent to the hospital and the Nurse Practitioner said to keep giving me the stool softener pill and pain medicine. The Tramadol (Pain Medication) was constipating me. I was crying, throwing up a little bit and having pain so I asked my Nurse to send me out. Surveyor inquired if R1 remains constipated, R1 replied Yes, the bowel smell that's coming from my mouth means I'm constipated. The plan is to have a bag placed for my bladder (urostomy) and place a colostomy bag for my bowel.
R1's (6/11/24) history & physical states patient with history of VP shunt and chronic constipation presenting to the Emergency Department with report of abdominal pain now for about the past 2 weeks. Patient states she has some pain in the right side of her abdomen which is typically the case when she has a UTI. She reports that she normally gets pain in her mid-abdomen when she is constipated and that is present. [Physical exam abdominal: there is abdominal tenderness]. Patient also notes that she has been having chronic, intermittent headaches not acutely changed. She notes that she has had a VP shunt for many years but has not been following up with a neurosurgeon. Urinalysis abnormal: turbid, WBC (White Blood Cells) many, bacteria many, urine yeast present. Abdominal CT (Computed Tomography) includes prolapse of the rectum by at least 9cm (centimeters). Fecal impaction at that site with rectal diameters up to 9.3 cm. Severe urinary bladder wall thickening, reflective of cystitis. There is urothelial thickening and enhancement at the right renal calyces, suggestive of an ascending urinary tract infection. [NAME] blood cells 17.4 (High). Clinical Impression: Abdominal pain, acute UTI, constipation, fecal impaction in rectum.
On 6/17/24 at 2:53pm, surveyor inquired about R1's (6/9/24) change in condition, V6 (ADON/Assistant Director of Nursing) stated As far as I know, she said that she just didn't feel good and wanted to go to the hospital. Surveyor inquired why R1 was sent to the hospital 2 days after her request, V6 responded I wasn't aware that she requested to go to the hospital 2 days prior, so I can't answer that. Surveyor inquired if the Physician and/or Nurse Practitioner were made aware of R1's (6/9/24) change in condition and/ or request to go to the hospital, V6 accessed R1's electronic medical records and stated It says that a call was placed to the on-call doctor and the NP would call back. I see they gave pain medicine; I do not see a follow-up call. Surveyor inquired about the facility policy for resident change in condition, V6 responded The protocol is that you should alert the Physician or Nurse Practitioner, let them know what's going on, see if they want to get some labs or diagnostic tests or whatever. We follow through with that and document. Surveyor inquired if Physician or Nurse Practitioner notification was documented (6/9/24) in R1's medical records, V6 replied Unfortunately, I'm going to have to say no. Surveyor inquired about the plan for R1 post return to the facility, V6 stated She came back yesterday. It says that were going to be continuing with the current plan of care. [Surgical consultation for colostomy and/or urostomy were excluded].
On 6/18/24 at 10:17am, surveyor inquired about R1's (6/9/24) change in condition, V5 (Licensed Practical Nurse) stated When I (V5) went in the room, she (R1) said that she had pain all over her body and she wanted to go to the hospital. I did offer her pain medication; she didn't want it. I did call the on-call service and I was waiting for him (NP) to return the phone call. Surveyor inquired if the NP returned the (6/9/24) call, V5 responded He (NP) did call back I did not document that. He said don't send her out, offer pain meds again and if she refuses get a psych (Psychiatric) consult [labs and/or x-rays orders were not received to determine root cause of R1's pain]. I offered pain meds again, she accepted. The day she was sent out (6/11/24) she was complaining again, and she said that she wanted to go to the hospital. I called the NP, I didn't get an answer, so the ADON called and got a response, and she (ADON) got the order to send her to the hospital. Surveyor inquired about R1's (6/11/24) assessment, V5 stated She (R1) just said she was uncomfortable and just hurting everywhere and expressed she had pain from a boil. Surveyor inquired about the smell of R1's breath, V5 replied I didn't smell anything. Surveyor inquired if R1 reported abdominal pain on 6/11/24, V5 responded She didn't complain of abdominal pain [incongruent with R1's 6/11/24 history and physical]. Surveyor inquired what R1 was diagnosed with post (6/11/24) hospitalization, V5 replied I believe it was fecal impaction. Surveyor inquired about staff requirements for resident change in condition, V5 stated in part Alert the doctor, and we document it. Surveyor inquired if R5 documented the alleged (6/9/24) NP notification, V5 responded I got busy and I forgot to document that.
On 6/18/24, surveyor inquired about R1's missed Neurosurgery appointment, V8 (Nurse Consultant) affirmed that she would check into it. At 12:09pm, V8 presented R1's encounter summary from hospital clinic and stated She (R1) was seen by the neurologist on 3/29/24 and there's a follow-up appointment with neurosurgery on 7/24/24. R1's (3/29/24) neurology consult includes Neurosurgery referral for headache disorder. Plan of Treatment: ambulatory referral to Neurosurgery. Order schedule: 7/24/24. [R1's physician orders exclude the Neurosurgery consult]. Surveyor inquired about R1's surgical consult for urostomy and/or colostomy placement, V8 affirmed that the facility was unaware that she needed a consult and would check into it. At 1:49pm, V8 stated The appointment for the GI consult is scheduled for 7/22/24 and affirmed it was scheduled after surveyor inquiry.
On 6/18/24 at 2:10pm, surveyor inquired about staff requirements for outpatient referrals, V7 (Medical Director) stated We write the referral, and the expectation is that the staff execute the appointment. Surveyor inquired about staff requirements for resident change in condition, V7 responded They should call the primary care doctor immediately. Surveyor inquired what staff should be reporting to the Physician, V7 replied They should have vital signs and any pertinent physical exam findings. Surveyor inquired about potential harm to a resident with hydrocephalus status-post shunt reporting ongoing headaches and acute pain over their entire body, V7 responded a stroke.
The resident admission packet (revised December 2023) states a facility must immediately inform the resident; consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s), when there is a significant change in the resident's physical, mental, or psychosocial status. When making notification, the facility must ensure that all pertinent information is available and provided upon request to the physician.
The change in resident's condition policy (reviewed 2/1/24) states Nursing will notify the resident's Physician or Nurse Practitioner when: there is a significant change in the resident's physical, mental or emotional status: It is deemed necessary or appropriate in the best interest of the resident. Appropriate assessment and documentation will be completed based on the resident's change in condition or indication. The communication with the resident and their responsible party as well as the Physician/NP will be documented in the resident's medical record.
The (2/2024) pain management policy states pain management is a multidisciplinary care process that includes the following: observing for potential pain. Effectively recognizing the presence of pain. Identifying pain characteristics. Addressing the underlying causes of the pain. Monitoring effectiveness of interventions. Modifying approaches as necessary. Conduct a pain assessment upon admission to the facility, quarterly and with any significant changes in condition. Licensed Nurses may notify the healthcare provider of any new development of pain, change in pain, or change in condition that could potentially cause pain.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to acknowledge resident rights and failed to comply with hospital transfer request (timely) for one of four residents (R1) in the sample.
Find...
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Based on record review and interview the facility failed to acknowledge resident rights and failed to comply with hospital transfer request (timely) for one of four residents (R1) in the sample.
Findings include:
On (6/11/24) IDPH (Illinois Department of Public Health) received allegations that R1 was not sent to the hospital as requested for pain and care is being delayed against her wishes.
R1's progress notes state (6/9/24) resident expressed to writer (V5/Licensed Practical Nurse) that she has pain over entire body, and she would like to go to the hospital. Writer offered pain medication, but resident denied. Call placed to on call service for (Physician) and was made aware that NP (Nurse Practitioner) would return a call to the facility. [A return call from the NP was not documented]. (6/11/24) Resident complained of general malaise, pain, and a boil under the left arm. Writer contacted NP and new orders were given to send resident to the hospital for evaluation [2 days after initial request]. Patient was admitted for abdominal pain and UTI (Urinary Tract Infection).
On 6/17/24 at 2:32pm, surveyor inquired about R1's (6/9/24) change in condition, R1 stated in part Before I (R1) was sent out to the hospital, I got my stool (feces) pulled out here (facility) they (staff) only removed some of it. I was in pain for 2 weeks, I was having pain in my stomach and having headaches. I asked to be sent to the hospital and the Nurse Practitioner said to keep giving me (R1) the stool softener pill and pain medicine. The Tramadol (Pain Medication) was constipating me. I was crying, throwing up a little bit and having pain so I asked my nurse to send me out.
On 6/18/24 at 10:17am, V5 (Licensed Practical Nurse) affirmed (on 6/9/24) she (V5) spoke with the Nurse Practitioner regarding R1's pain and request for hospital transfer however forgot to document that. Surveyor inquired why R1 was not transferred to the hospital (on 6/9/24) as requested, V5 stated He (NP) said don't send her (R1) out, offer pain meds again and if she (R1) refuses get a psych (psychiatric) consult.
On 6/18/24 at 2:10pm, surveyor inquired if residents have the right to request a hospital evaluation, V7 (Medical Director) stated Yeah, when patients request an evaluation, I send them out. If they feel like something needs immediate intervention, I send them to the hospital.
R1's (6/11/24) history & physical states patient with history of VP shunt and chronic constipation presenting to the Emergency Department with report of abdominal pain now for about the past 2 weeks. Patient states she has some pain in the right side of her abdomen which is typically the case when she has a UTI (Urinary Tract Infection). She reports that she normally gets pain in her mid-abdomen when she is constipated and that is present. Patient also notes that she has been having chronic, intermittent headaches not acutely changed. Urinalysis abnormal: turbid, WBC (White Blood Cells) many, bacteria many, urine yeast present. Abdominal CT (Computed Tomography) includes prolapse of the rectum by at least 9cm (centimeters). Fecal impaction at that site with rectal diameters up to 9.3 cm. Clinical Impression: Abdominal pain, acute UTI, constipation, fecal impaction in rectum.
Considering reasonable person concept, R1's diffuse pain, and (6/11/24) clinical impression a psychiatric consult was likely not warranted however hospital evaluation and treatment were (as requested).
The resident admission packet (revised December 2023) includes Resident Rights: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. The resident has the right to be informed of, and participate in, his or her treatment including: the right to request, refuse, and or discontinue treatment.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to follow policy procedures, failed to notify family of resident change in condition, and failed to document communication with the Nurse Pract...
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Based on record review and interview the facility failed to follow policy procedures, failed to notify family of resident change in condition, and failed to document communication with the Nurse Practitioner regarding change in condition for one of four residents (R1) in the sample.
Findings include:
R1's face sheet includes emergency contact (V9/Family) and phone number.
R1's progress notes state (6/9/24) resident expressed to writer (V5/Licensed Practical Nurse) that she has pain over entire body, and she would like to go to the hospital. Call placed to on call service for (Physician) and was made aware that NP (Nurse Practitioner) would return a call to the facility. [The NP return call and/or family notification were excluded].
On 6/17/24 at 2:53pm, surveyor inquired if the Physician and/or Nurse Practitioner were made aware of R1's (6/9/24) change in condition and/ or request to go to the hospital, V6 (Assistant Director of Nursing) accessed R1's electronic medical records and stated It says that a call was placed to the on-call doctor and the NP would call back. I (V6) see they (staff) gave pain medicine; I do not see a follow-up call. Surveyor inquired about the facility policy for resident change in condition, V6 responded The protocol is that you should alert the Physician or Nurse Practitioner, let them know what's going on, see if they want to get some labs or diagnostic tests or whatever. We (Staff) follow through with that and document. Surveyor inquired if Physician, Nurse Practitioner and/or family notification was documented (6/9/24) in R1's medical record, V6 replied Unfortunately, I'm going to have to say no.
On 6/18/24 at 10:17am, surveyor inquired if the NP returned V5's (6/9/24) call regarding R1's change in condition, V5 stated He (NP) did call back I (V5) did not document that. Surveyor inquired about staff requirements for resident change in condition, V5 responded We call the family, alert the doctor, the DON (Director of Nursing) and we document it. Surveyor inquired if the alleged (6/9/24) NP notification was documented, V5 replied I got busy and I forgot to document that.
The change in resident's condition policy (reviewed 2/1/24) states Nursing will notify the resident's Physician or Nurse Practitioner when: there is a significant change in the resident's physical, mental or emotional status: It is deemed necessary or appropriate in the best interest of the resident. Once the Physician/NP has been notified and a plan developed, the Nursing or Social Service staff will alert the resident and family of the issue and any physician orders. The communication with the resident and their responsible party as well as the Physician/NP will be documented in the resident's medical record.
Jun 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviews, the facility failed to provide proper nursing care to one (R1) resident by failing to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviews, the facility failed to provide proper nursing care to one (R1) resident by failing to provide Indwelling Urinary Catheter care and Activities of Daily Living (ADL) Care in a sample of three reviewed.
Finding include:
R1's current face sheet documents R1 is a [AGE] year-old individual with medical diagnosis that include but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hydronephrosis with ureteropelvic junction obstruction, other obstructive and reflux uropathy, disorder of kidney and ureter, unspecified. R1's BIMS (Brief Interview for Mental Status) dated [DATE], is documented as 15/15, indicating R1 has intact cognition, and documents R1 has an External catheter. R1's MDS section GG dated 3/13/2024 documents R1 needs Substantial/maximal assist with toileting hygiene, shower/bathe self, eating, oral hygiene, R1 needs Setup or clean-up assistance, upper body dressing.
On 06/09/2024 at 09:47am, R1 was observed in his room lying in bed awake watching TV. R1 stated staff change him, and he has an indwelling urinary catheter which staff empty on a regular basis. R1's catheter was observed on the floor placed in a basin and was draining clear yellow urine and had 25 cc of clear yellow urine in it. R1's bed observed with a pillowcase which had black stains, R1 stated he does not know where the stains come from. R1 declined for surveyor to observe R1's urinary catheter insertion point. R1 stated he receives only one shower a week and he would like to get more frequent showers instead of getting bed baths. R1 stated he helps with dressing himself, but staff assist him. R1 stated he was in the hospital recently and had an appointment which was canceled after he got there, and R1 did not know why. R1 said he will go for surgery later this month.
On 06/09/2024 at 2:28pm, V1(Director of Nursing) stated any resident who comes to the facility with an indwelling catheter or has one inserted while in the facility should have physician orders stating the name and size of the catheter in place. V1 stated nurses follow physician orders regarding indwelling catheters and the catheters are changed as needed because some residents might need more frequent catheter changes than others. V1 stated improper ADL (Activities of Daily Care) can lead to UTIs (Urinary Tract Infections) for residents with indwelling urinary catheters. V1 further stated on 5/29/2024, she received a call from the hospital where R1 had gone for his procedure letting her know R1's procedure could not be performed because R1's Penis (R1 has indwelling urinary catheter) was caked and dirty. V1 stated she took disciplinary action on V7(Certified Nursing Assistant-CNA, Night Shift), suspended and wrote up V7 who was R1's night shift CNA on 5/29/2024, working 11pm to 7:00am for failure to provide proper ADL care to R1 before R1 went for his appointment for flexible cystoscopy.
On 6/9/2024 at 11:32am, V8 (Complainant) stated R1 come to his appointment looking dirty and his penis was caked and R1's procedure could not be done. Complainant stated she called the facility and spoke to V1 informing V1 that R1 went to the hospital for the appointment and R1 was looking dirty and R1's penis was caked and R1 could not have his procedure done (flexible cystoscopy).
On 06/09/2024 at 9:55am, V3(Licensed Practical Nurse-LPN) stated each resident gets showers two times a week and are given bed baths every day, and the showers are documented by the nurse because during shower time, the nurse does resident skin assessment and documents their findings in resident progress notes. V3 stated refusal of showers by residents are also documented in resident progress notes. V3 stated CNAs document resident showers in a shower book located by the nursing station, and each resident has specific days for showers.
V3 looked in the shower binder and stated there are no shower sheets documenting days R1 received/refused showers. V3 stated shower sheets communicate care given to residents between staff to make sure residents are receiving the ADL care the need/deserve V3 stated the last documented progress note on R1 shower/skin assessment was documented by V3 on 5/14/2024 and R1 had refused his shower on that day. V3 further stated residents need to be assisted with ADL care every day to make sure they are comfortable and fresh, and to prevent risk of infections.
V3 stated the CNAs (Certified Nursing Assistants) change the contents for indwelling catheters when they get full and they document input and output and if the CNAs notice something odd in the color of the urine such as blood, sediments of foul smell, they notify the nurse on duty who then follows up and notifies the physician.
V3 stated the nurses change the resident's catheter depending on physician orders and as needed to prevent urinary tract infections.
R1's progress notes dated 5/28/2024 documents R1 went to a nearby hospital for flexible cystoscopy but procedure was not completed due to resident having penile drainage, and crust noted to penile shaft, and further documents R1 received Cefuroxime 500 mg Q12h (every 12 hours) x (for) 7 days.
Physician Order Sheet (POS) dated 05/28/2024 documents:
-Cefuroxime Axetil Oral Tablet 500MG (Cefuroxime Axetil) Give 500mg by mouth every 12 hours for UTI Prophylactic for 7 Days Inventory in pharmacy pill bottle TOP OF CART.
Policy titled Urinary Catheter Care dated 11/23 documents:-Each resident with an indwelling catheter will receive perineal and catheter care with soap and water during routine care.
Policy titled Activities of Daily Living, dated 1/24 documents: -Activities of daily living is encouraged to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis
Hygiene: -Resident self-image is maintained. -Showers or baths will be scheduled per facility policy protocol while incorporating residents shower/bath preferences.
May 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to supervise and monitor two residents (R1 and R3) of 6 r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to supervise and monitor two residents (R1 and R3) of 6 residents reviewed for supervision. These failures resulted in R3 eloping from the facility without staff knowing that R3 eloped and R1 having a fall after being left in the shower room unattended and sustaining a forehead laceration which required sutures and sustaining a non-displaced linear fracture of the right distal radius.
Findings include:
According to face sheet, R1 is a [AGE] year-old resident admitted to the facility on [DATE]. R1's face sheet documents the following diagnoses including but not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, gastritis, unspecified, with bleeding, aphasia following cerebral infarction, essential (primary) hypertension, heart failure, unspecified, encounter for palliative care, dysphagia, oropharyngeal phase, acute respiratory failure with hypoxia.
MDS section GG (dated 03/12/2024) documents that R1 requires substantial/maximal assistance for showers and transfers. (Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.). MDS section C (dated 03/12/2024) documents that R1 has a BIMS score of 10, indicating that R1 has moderate cognitive impairment.
Care plan (dated 11/20/2023) documents that R1 has a self-care deficit (ADLs/Mobility) r/t hemiparesis/hemiplegia. The care plan documents that R1 is at risk for falls r/t weakness and impaired mobility and cognition.
R1's Fall Risk Assessment (dated 01/23/2024) documents that R1 is a high fall risk with the score of 12.
R1's Progress Note (dated 05/03/2024) documents, Upon arrival to 3 south, this writer was informed that the resident was on the floor by the housekeeper. This writer promptly responded. Resident observed on floor in 3-South, assisted bath-shower room. Head to toe assessment performed. Resident observed with laceration to right side of scalp, right shoulder bruise and right knee bruise. Resident transferred safely to wheelchair per 3 staff members due to space issue. Resident's vital signs- BP 150/98 P 101 R 20 O2 98% on room air, T 97.9. NP notified and orders to transfer resident to [community] Hospital ER obtained. Resident's daughter contacted and was notified. Director of Nursing made aware of incident & pending transfer. Resident exited via gurney per 911 paramedics.
R1's Progress Note (dated 05/03/2024) documents, The writer called [community] hospital to follow-up on resident. The resident will be discharged back to Facility. ER nurse will call back with ETA.
R1's Progress Note (dated 05/04/2024) documents, Resident returned from [community] hospital ER after been evaluated post fall yesterday morning. Brought back by two ambulance personnel and head to toe assessment was performed in which she has splint on her right-hand order of lidocaine patch was also brought back from the hospital. Quietly in bed sleeping.
R1's Hospital Diagnostic Imagining Report (dated 05/03/2024) states: There appears to be a non-displaced linear fracture through the right distal radius laterally which is best seen on the oblique view. There are no fractures or dislocations of the right hand. Discharge instructions for Laceration Repair of the scalp: Your scalp wound was cleansed and closed with stitches, staples, rubber bands, or adhesive strips.
Facility Final Incident Investigation Report (dated 05/10/2024) states: On 05/03/2024 at 9:10am, R1's assigned CNA. was assisting her with a shower. The CNA was assisting R1 with getting dressed after the shower was complete when R1 fell to the floor. The CNA immediately called for assistance. The nurse responded and assessed R1 injury noting a small cut to the right side of her head, bruising to her right shoulder, and bruising to her right knee. R1's NP was notified of the fall and post-fall assessment findings and the new orders were received to transfer R1 to the hospital for further evaluation and treatment. R1's daughter, was notified of R1's fall and transfer to the hospital. While in the hospital, R1 was diagnosed with a non-displaced linear fracture of the right distal radius. She returned from the hospital on [DATE] with a splint and a Lidoderm patch for pain.
On 05/21/2024 at 11:42am V12 (Licensed Practical Nurse) stated, R1 requires extensive care at times. For showers, R1 needs assistance. She can't do it by herself. R1 needs to be transferred into the shower chair and then transferred from the shower chair to her wheelchair. R1 needs to be dressed by staff and she needs help with everything. During the shower, you cannot leave R1 alone. We don't leave any resident alone during showers. For showers, R1 requires the assistance of 1 staff member.
On 05/21/2024 at 11:46am, surveyor observed R1 on the 3rd floor, secured memory care unit. R1 was being monitored by staff while R1 was sitting in the day room participating in resident activities. R1 was observed to be working on a puzzle. R1 nodded her head in response to surveyor, indicating that R1 is doing fine. R1 was observed to be comfortable and safe within her environment. Surveyor inspected R1's room and noted that R1's bed was in a low position, and a landing mat was present at the resident's bedside. R1 was observed to be wearing a helmet for safety.
On 05/22/2024 at 11:15am V20 (Housekeeper) stated, On 05/03/2024, I was cleaning a room and I heard a sound that sounded like boom. I went to the shower room to see where the sound came from. I opened up the door to the shower room and I saw R1 laying on the ground. I went to inform the nurse. R1 was in the shower room by herself. There was a shower chair in the shower room, and R1 fell from the shower chair. No staff where present in the shower room when I saw R1 on the floor. I went to inform the nurse and the nurse came to assess R1 immediately.
On 05/22/2024 at 11:44am V19 (Nurse) stated, On 05/03/2024, I arrived on the unit and V20 (Housekeeper) said to me that he heard a fall. V20 alerted me and another nurse. I immediately went to the shower room, and I saw R1 laying on the floor. I assessed R1 from head to toe. R1 had a laceration to the right scalp, a bruise to her right shoulder and a bruise to her right knee. R1 was crying and R1 was in pain. R1 is not able to verbalize readily. R1 can nod her head in response to a question, and make her needs known for the most part. R1 is on the memory care unit. I was told by the other nurse that the certified nursing assistant (V23) who was assigned to R1, left R1 in the shower room unattended. This incident took place somewhere between 7am and 8am. I called R1's Nurse Practitioner, the ambulance and I called R1's daughter. R1's daughter said that she was on her way to the facility. The ambulance arrived right away. R1's daughter arrived almost at the same time as the ambulance. R1 was transported to the hospital. I believe R1 returned back to the facility that same evening. R1 is a resident that requires a lot of supervision. It is not appropriate and not safe at all to leave R1 alone in the shower room.
Surveyor inquired about interviewing V23 (Certified Nursing Assistant assigned to R1 on 05/03/2024, at time the fall incident took place). On 05/22/2024 at 12:21pm V1 (Administrator) stated, V23 was terminated on 05/03/2024, the day of R1's fall incident.
On 05/22/2024 at 12:48pm, V24 (R1's Physician) stated, R1 is a high fall risk. R1 requires assistance from nurses and certified nursing assistants. R1 is not safe to be in the shower room by herself. R1's fall on 05/03/2024 could have been prevented, this was a preventable fall.
On 05/23/2024 at 11:37am V15 (Restorative Nurse) stated, R1 is a high fall risk due to having weakness and her health diagnosis. The fall prevention measures in place for R1 are floor mats at bed side for when R1 is in bed, a helmet, non-slip pad for R1's wheelchair, low bed and close monitoring. R1 needs to be up in a chair and R1 needs to be closely monitored when R1 is not in bed to prevent falls. R1 is not safe to be left alone in the shower room.
According to face sheet, R3 is a [AGE] year-old resident admitted to the facility on [DATE]. R3's face sheet documents the following diagnoses including but not limited to: Syncope and collapse, essential (primary) hypertension, type 2 diabetes mellitus without complications, cardiac arrest, cause unspecified, cerebrovascular disease, unspecified. According to a nursing progress note (dated 04/19/2024), R1 is ambulatory and alert and oriented x3. According to progress notes, R3 eloped from the facility on 04/26/2024.
R3's Care plan (dated 04/22/2024) documents that R3 is at risk for falls related to general weakness. The care plan documents that R3 has a self-care deficit (ADLs/Mobility) de-conditioning from recent hospitalization.
R3's Progress Note (dated 04/26/2024) documents, Resident not present upon doing rounds at facility. CNA staff stated that resident was possibly at appointment and had not returned on shift. Resident was reportedly not seen prior to lunch and did not eat lunch. No f/u information was given or received from 1st shift nurse during report. Unable to f/u due to lack of information about appt that resident may have been at. Oncoming nurse aware that client has not returned to facility from whereabouts.
R3's Progress Note (dated 04/27/2024) documents, Resident not received in report.
R3's Progress Note (dated 04/27/2024) documents, Resident not observed on unit during routine rounds. Manager on duty made aware. All staff on unit initiated a thorough search of the unit. DON made aware and code yellow paged overhead. All staff completed a thorough search of the facility grounds. Staff unable to locate the resident. Police department notified. Resident physician notified. Resident's listed cell phone contacted, and family member answered the phone. Family notified of resident not in facility. Calls placed to area hospitals, shelters, and senior centers with no success locating resident. Writer spoke with resident's roommate who indicated that resident called his family to pick him up in the side parking lot. Resident packed his personal belongings and left the facility AMA.
R3's Progress Note (dated 04/29/2024) documents, Resident remains absent from facility as of this time.
Facility Final Incident Investigation Report (dated 04/29/2024) states: On 04/26/2024, around noon, R3 was observed by his roommate, R9, talking to his family on the phone about wanting to leave the facility. According to R9, R3 had been talking to his family on the phone throughout the afternoon. R3 appeared upset with his family because he wanted to leave immediately, however, they couldn't pick him up until they got off of work later in the evening. Nurse V25 (Licensed Practical Nurse) was R3's assigned nurse for 3-11 and 11-7 shifts. She was late for work, arriving at 4pm. She did not receive nurse-to-nurse handoff because the prior shift nurse had already left for the day. She did not complete routine rounds. Between 4pm and 5pm, R3 packed up his belongings and left the facility with his family. R3 left through the front door. His family picked him up in the side parking lot. Staff contacted the VA (Veteran Affairs) regarding R3 leaving the facility. The VA caseworker indicated that this is a common behavior for R3, he frequently admits to skilled nursing facilities and leaves AMA abruptly. The VA caseworker indicates they have had contact with R3, and he is safe in the community.
On 05/21/2024 at 10:03am via telephone V4 (R3's friend) stated, R3 is fine. R3 did not like the facility and he left. R3 is fine and safe. I just talked to R3 a little while ago. R3 told them that he was going to get his mail and then he left the facility. R3 took all of his belongings when he left, and I picked him up from the side parking lot. R3 did not like the facility so he just left right out.
On 05/21/2024 at 10:14am V3 (Nurse Consultant) stated, We did have one elopement. The elopement was R3. R3 left on 04/26/2024. R3 was an alert and oriented resident. R3 was admitted to the facility on [DATE]. R3 was alert and oriented and R3 left. We were able to determine that R3 left somewhere between 4 and 5pm on 04/26/2024. R3 left and did not tell any staff that he was leaving. R3's roommate told us that R3 was on the phone with his family, or someone that sounded like his family. The roommate told us that the person picking R3 up was going to pick him up after work, which is after 4pm. R3 packed up all his personal items and was picked up in the side parking lot of the facility. We talked to the Veteran Affairs (VA), and they were able to locate him after R3 left. R3 was not answering his phone after he left from the facility. We did a whole house education on supervision and elopements. We hired a second front door monitor because we had a bad survey related to substance abuse, so we placed a second person there for monitoring and supervision. It is believed that R3 walked right out the front door without being stopped. R3 is safe after he eloped from the facility. On 04/26/2024 at 7:30, there is a progress note that says that the nurse did rounds and R3 was not there. This nurse put the note in after the fact. It was during her shift that we determined that the resident eloped. The timeline of the progress notes does not reflect the timeline of the actual occurrence of R3's elopement. The date and time are not properly reflected in the progress notes. V5 was the nurse who initiated the code Yellow, That's a code for a missing resident. A search was done on all units and R3 was not found.
On 05/21/2024 at 11:20am V5 (Licensed Practical Nurse) stated, I left here on 04/26/2024 at 3pm and R3 was still in the facility. R3 was still here when I left. On 04/27/2024 when I returned to work the next day, R3 was not here. R3 was not able to be located when I showed up to work the next day. R3 did not sign the Against Medical Advice (AMA) form with me. When I started my shift on 04/27/24, I noticed R3 was not here and I called a code Yellow, which means there is a missing resident. During the code, we were not able to find R3. R3's roommate stated that R3 packed his belongings and left with a family member. R3's roommate also left AMA, so the roommate is not at the facility anymore. I tried to reach out to the resident via cell phone and R3 did not answer. The police were called the same day when R3 was noted to be gone from the facility and a report was filed.
Elopement Policy (undated) states: The facility has a plan in case of an elopement of a resident from the facility. This enables the missing resident to be found as quickly as possible and to maintain the resident's safety, dignity, and privacy; If the resident is not located the facility supervisor will designate an employee to notify the resident representative, attending physician, policy department, surrounding area hospitals, surrounding shelters, surrounding area senior shelters.
Supervision and Safety Policy (undated) states: Our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility-wide priorities. Resident supervision is a core component to resident safety.
Apr 2024
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure that one resident's (R4's) pain was managed as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure that one resident's (R4's) pain was managed as per facility policy. This failure has affected one of four residents reviewed for pain management and caused R4 to endure pain consistently at a level of 8 out of 10 on the pain scale.
Findings include:
R4 is a [AGE] year old with diagnosis including but not limited to: Muscle wasting and atrophy, muscle weakness, fracture of orbit and traumatic subdural hemorrhage with loss of consciousness of unspecified duration.
R4 has a BIMS (Brief Interview for Mental Status) Score of 15, which indicates cognitively intact.
On 4/15/2024 during investigation, R4 was observed lying in bed with a frown on his (R4's) face.
On 04/15/2024 at 10:20 AM, V5 CNA (Certified Nurse Assistant) asked for permission and rolled R4 on his right side to check his back.
Surveyor observed a Lidocaine patch on R4's back with the date of 4/12/2023 written on it.
At that time, V5 CNA said, It looks like R4's pain patch was last changed on 4/12/2024.
04/15/2024 at 10:22 AM, R4 said, My pain level is about an 8 (on 1-10 pain scale). I don't recall getting my pain patch for a couple of days now.
At that time, V4 LPN (Licensed Practical Nurse/LPN) said, R4 complained to me of back pain of 8 out of 10 and I gave R4 oral pain medication. R4 said the oral medication doesn't work much. I (V4) wasn't aware that R4 did not have on his lidocaine patch because the lidocaine patch is scheduled for the night shift nurses. The night shift nurses put R4's pain patch on his back every morning at 6 AM and write the date in which the patch was applied on the patch. I will call the Doctor to request a stronger oral pain medication as needed.
04/15/2024 at 12:10 PM, V2 DON (Director of Nursing) said, R4's pain patch should absolutely be applied at the time and day that it is supposed to per order. If R4 hasn't had a pain patch since 4/12/2023, that is a medication error. If a patients' pain is not managed, it could spike the vitals and is unacceptable because the patient is uncomfortable when pain is not managed. Unmanaged pain could affect their daily activities such as even eating. A patient may not want to eat if they are in pain.
On 4/16/2024 at 11:23 AM, V13 (LPN) went with Surveyor to R4's room.
Upon checking, it was noted that there was no lidocaine patch on R4's back.
On 4/16/2024 at 11:23 AM, V13 (LPN) said, R4 doesn't have a patch on but I can help his nurse put on his patch.
On 4/16/2024 at 11:25 AM, V14 (LPN) said, R4 said that he (R4) was in pain earlier but that he did not want the acetaminophen because it did not work. R4's pain is at an 8. I was going to go back and offer R4 pain medicine again. The night nurse V15 (LPN) worked with R4 last night and coded the Lidocaine was a 9, which means that the lidocaine was not given. There is no progress note as to why V17 did not give the lidocaine, but the medication is available on the medication cart.
On 4/16/2024 at 11:35 AM, R4 said, no one offered me a pain patch this morning.
V15 (LPN) was unable to be reached during survey.
On 4/17/2024 at 12:20 PM V17 (LPN) said, I was R4's nurse on 4/13 and 4/14 overnight shifts. I am scheduled to give R4's lidocaine patch at 6 AM right before the end of my shift. R4 usually doesn't refuse his pain patch.
Surveyor asked if V17 administered R4's pain patch on the mornings of 4/14/2024 and 4/15/2024.
On 4/17/2024 at 12:25 PM V17 (LPN) said, I think that maybe I was moving too fast and forgot to put the lidocaine patch on R4's back. I did sign the medication out, but I don't remember giving the medication.
On 4/18/2024 at 4:11 PM, V20 (Nurse Practitioner) said, I was just informed that R4's pain is consistent. I have scheduled an oral medication for R4 to take daily. If the pain is not managed, it could cause frustration and worsened back pain.
R4's Physician Order Sheet documents, Lidocaine patch 5% apply to lower back topically in the morning for pain 3/10/2024 through 4/15/2024; Lidocaine patch 5% apply to lower back topically one time daily for pain 4/16/2024 through current.
R4's Medication Administration Record documents, No documentation of Lidocaine patch administered on 4/13/2024; V17 (LPN) documented that Lidocaine patch was administered on 4/14/2024 and 4/15/2024; V15 (LPN) documented '9' for Lidocaine patch on 4/16/2024.
R4's care plan documents, Focus: alteration in comfort secondary to pain. R4's pain related to lower back pain; Goal: R4 will be free of pain as evidenced by R4's subjective statement; R4 is at increased risk for alteration in pain/discomfort; Interventions: administer analgesic medication as ordered per plan of care.
R4's pain level summary documents, 4/13/2024 pain level of 10 on scale of 1-10; 4/15/2024 pain level of 8 on 1-10 scale; 4/16/2024 pain level of 8 on 1-10 scale.
R4's Pain Review dated 4/15/2024 documents, R4 has had pain in the last 5 days almost constantly; pain level of 8 on a 1-10 scale; current prescribed pain medication Lidocaine patch effective and decreases pain from an 8 to a 3 on a 1-10 pain scale.
Facility policy titled Pain Management and Assessment documents, residents will receive necessary comfort, exercise greater independence and enhance dignity through optimizing their ability to perform activities of daily living using a resident centered individualized approach to pain control.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review that facility failed to ensure that one bedbound resident (R5), (with current...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review that facility failed to ensure that one bedbound resident (R5), (with current deep tissue damage) had interventions in place to prevent further skin breakdown. This failure has affected one resident (R5) and has the potential to affect 14 other residents in the facility with pressure wounds.
Findings include:
R5 is a [AGE] year old with diagnosis including but not limited to: Pressure- Induced deep tissue damage, multiple sclerosis, unspecified protein-calorie malnutrition, difficulty in walking and anorexia.
On 4/16/2024 at 11:45 AM, R5 was observed lying in bed with V11 (R5's mother) at the bedside.
At that time, R5's heel protector/boot was observed soiled and lying in the bed, off of R5's foot.
Surveyor noted sign at head of R5's bed which documented, Do not remove heel protector, if soiled or need replaced, please see wound care.
On 4/16/2024 at 11:45 AM, V11 said, R5's wounds were acquired since he has been here. R5 did not have wounds when he first came here. R5's boot (heel protector) is often not on his foot when I come to see him, and he (R5) has an ulcer on his heel.
On 4/16/2024 at 11:52 PM, V14 (Wound Care Director) entered R5's room.
At that time, V11 asked to observe R5's heel wound.
R5's left leg was bent, and R5's left foot was positioned under his (R5's) body.
Surveyor observed the dressing/gauze on R5's left foot soiled and wet.
Surveyor inquired about the purpose of R5's heel protector.
On 4/16/2024 at 11:52 PM, V14 said, the DTI (deep tissue injury) on R5's heel could worsen without the heel protector on. This is why I have a sign by his (R5's) bed to remind the staff.
Surveyor asked V14 if R5's dressing was saturated with urine.
On 4/16/2024 at 11:52 PM, V14 (Wound Care Director) said, It's more than likely urine is on his (R5's) dressing. It smells like urine. We will change the dressing.
On 4/16/2024 at 12:00 PM V14 left R5's room to get supplies to change R5's left heel bandage.
On 4/16/2024 at 12:50 PM, V14 returned to R5's to change the heel bandage.
Surveyor inquired about the benefits of changing R5's wound bandage, especially when soiled.
On 4/16/2024 at 12:50 PM, V14 said, If the dressing is soiled or wet, it can make the wound worse.
Surveyor inquired about the expectations regarding R5's wound care.
On 04/17/2024 at 1:15 PM, V2 (Director of Nursing) said, R5 should have on his heel protector at all times to relieve the pressure. It is unacceptable that R5's heel protector was not on his foot. I expect for this intervention to be in R5's orders and care plan as well.
R5's Section M- Skin Conditions of MDS (Minimal Data Set) dated 3/22/2024 documents, R5 is at risk for developing pressure ulcers; R5 has one or more unhealed pressure ulcers; R5 requires a pressure reducing device for bed.
R5's progress note authored by V6 (Wound Nurse Practitioner) on 3/18/2024 documents, Wound assessment: Left foot is a Deep Tissue Pressure Injury persistent and has received a status of not healed; Additional orders: Offload heels per facility protocol.
R5's Physician order sheet excludes order for heel protector daily.
R5's Care plan excludes interventions regarding heel protector daily.
Facility document titled Physician Orders documents, Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders.
Facility document titled Pressure Ulcer Prevention documents, Purpose: to prevent and treat pressure sores; Equipment: (not limited to) Heel protectors; use positioning devices to relieve the pressure from heels, toes, knees, hips, ankles, etc. Prevent direct contact between bony prominences when applicable.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review that facility failed to ensure that one resident (R4), received scheduled me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review that facility failed to ensure that one resident (R4), received scheduled medication as prescribed by the doctor. This failure has affected one of four residents reviewed for medication.
Findings include:
R4 is a [AGE] year old with diagnosis including but not limited to: Muscle wasting and atrophy, muscle weakness, fracture of orbit and traumatic subdural hemorrhage with loss of consciousness of unspecified duration.
R4 has a BIMS (Brief Interview for Mental Status) Score of 15, which indicates cognitively intact.
On 4/15/2024 during investigation, V4 (Licensed Practical Nurse/LPN) was observed administering morning medication to R4.
04/15/2024 at 10:20 AM, V5 CNA (Certified Nurse Assistant) asked for permission and rolled R4 on his right side to check his back to observe a Lidocaine patch on R4's back with the date of 4/12/2023 written on it.
At that time, V4 LPN (Licensed Practical Nurse) said, I wasn't aware that R4 did not have on his lidocaine patch because the lidocaine patch is scheduled for the night shift nurses. The night shift nurses are scheduled to put R4's pain patch on his back every morning at 6 AM and write the date in which the patch was applied on the patch.
04/15/2024 at 10:22 AM, R4 said, I don't recall getting my pain patch in a couple of days now.
04/15/2024 at 12:10 PM, V2 DON (Director of Nursing) said, R4's pain patch should absolutely be applied at the time and day that it is supposed to per order. If R4's last pain patch was given on 4/12, that is a medication error.
On 4/16/2024 at 11:23 AM, V13 (LPN) went with Surveyor to R4's room.
Upon checking, it was noted that there was no lidocaine patch on R4's back.
On 4/16/2024 at 11:23 AM, V13 (LPN) said, R4 doesn't have a patch on but I can help his nurse put on his patch.
On 4/16/2024 at 11:25 AM, V14 (LPN) said, The night nurse V15 (LPN) worked with R4 last night and coded the Lidocaine was a 9, which means that the lidocaine was not given. There is no progress note as to why V17 did not give the lidocaine, but the medication is available on the medication cart.
V15 was not able to be reached during survey.
On 4/17/2024 at 12:20 PM V17 (LPN) said, I was R4's nurse on 4/13 and 4/14 overnight shifts. I am scheduled to give R4's lidocaine patch at 6 AM right before the end of my shift. R4 usually don't refuse his pain patch.
Surveyor asked if V17 administered R4's pain patch on the mornings of 4/14/2024 and 4/15/2024.
On 4/17/2024 at 12:20 PM V17 (LPN) said, I think that maybe I was moving too fast and forgot to put the lidocaine patch on R4's back. I did sign the medication out, but I don't remember giving the medication.
Surveyor asked if V17 usually wrote the date on R4's lidocaine patch to indicate when the patch was administered.
On 4/17/2024 at 12:20 PM V17 (LPN) said. Yes, when I place a new patch on any resident, I date it so that the next nurse will know how old the patch is.
On 4/17/2024 at 12:45 PM, V18 (LPN) said, I am the regular nurse on this unit. I take care of R4 often. The Lidocaine patch is supposed to be given on the overnight shift at 6am daily.
R4's Physician Order Sheet documents, Lidocaine patch 5% apply to lower back topically in the morning for pain 3/10/2024 through 4/15/2024; Lidocaine patch 5% apply to lower back topically one time daily for pain 4/16/2024 through current.
R4's Medication Administration Record documents, No documentation of Lidocaine patch administered on 4/13/2024; V17 (LPN) documented that Lidocaine patch was administered on 4/14/2024 and 4/15/2024; V15 (LPN) documented '9: Other' for Lidocaine patch on 4/16/2024.
V15's Progress Noted excluded any explanation as to why R4's lidocaine patch was not administered on 4/16/2024.
R4's Pain Review dated 4/15/2024 documents, R4 has had pain in the last 5 days almost constantly; pain level of 8 on a 1-10 scale; current prescribed pain medication Lidocaine patch effective and decreases pain from an 8 to a 3 on a 1-10 pain scale.
Facility policy titled Pain Management and Assessment documents, residents will receive necessary comfort, exercise greater independence and enhance dignity through optimizing their ability to perform activities of daily living using a resident centered individualized approach to pain control.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that one resident (R4), who requires hemodialysis three tim...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that one resident (R4), who requires hemodialysis three times per week, received his scheduled hemodialysis treatment on two different occasions. This failure has the potential to affect fifteen other residents who reside at the facility and receive dialysis.
Findings include:
R4 is [AGE] year old with diagnosis including but not limited to: End stage renal disease, chronic viral hepatitis C, unspecified kidney failure, anxiety disorder and essential hypertension.
R4 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates cognitively intact.
On 03/04/2024 during investigation, R4 was observed lying in his bed. Surveyor inquired about R4's dialysis treatment.
On 03/04/2024 at 11:20 AM R4 said, I've been here (the facility) since 02/09/2024 and I've missed dialysis a couple of times I think due to my insurance. I go to the dialysis center up the street in walking distance on Mondays, Wednesdays and Fridays. I'm not sure what type of service usually picks me up. I think that a taxi picks me up for dialysis.
Surveyor asked if R4 had ever refused dialysis treatment in the facility.
On 03/05/2024 at 12:45 PM, R4 said, I have never refused dialysis. There has been a couple of times that my ride just never shows up. I don't know who sets up my transportation here and I don't know who to call for my ride. I just let the front desk know that my ride didn't come.
On 03/04/2024 at 12:48 PM, V10 (R4's family) said, I complained because I have concerns with my son's health. Apparently, he (R4) is in the facility for a reason. He (R4) requires care and supervision. He (R4) should not be missing his dialysis treatment by any means.
On 03/05/2024 at 1:05 PM, V7 (LPN) said, R4 has missed dialysis twice that I am aware of. He complained to his mother about his ride not showing up and his mom then called me. At that time, it was too late for R4 to go to the dialysis center because they were closing. R4 never told me that his ride didn't come, so I thought he had gone to his appointment on both days 02/16/2024 and 02/21/2024. R4 didn't return to the unit to tell about his transportation issues.
On 03/03/2024 at 1:45 PM, V22 (Transportation Coordinator) said, I set up R4's transportation through his insurance. I believe that transportation calls R4 or the front desk once they arrive to the facility to pick R4 up, but I am not sure. I leave every day around 3 PM.
On 03/03/2024 at 1:50 PM, V1 (Administrator) said, I didn't know that R4 had any issues with being picked up for dialysis. Generally, if a resident's ride doesn't come, the front desk and security are notified, and they will assist with getting the ride for the resident.
On 03/05/2024 at 2:25 PM, V21 (Security) said, If a resident misses their transportation for an appointment, I immediately call and inform the nurse so that we can get the resident to their appointment. There have been times when a resident has walked back into the facility without letting me know that their ride never showed up. Sometimes the nurse will call downstairs to see if the patient has been picked up, but not all of the time,
On 03/05/2024 at 2:50 PM V20 (Dialysis center nurse) said, R4 has missed his dialysis treatment a couple of times to my knowledge. When he (R4) didn't show up for his appointment, I called the facility to see if he was still coming and was told that his ride didn't come. They would usually tell me that they are trying to schedule transportation for him. The dialysis center is three blocks away from the facility that R4 resides.
Surveyor inquired about possible outcomes when a person has missed dialysis treatment.
On 03/05/2024 at 2:50 PM V20 said, If a patient misses dialysis treatment, they are at risk for fluid overload, shortness of breath, electrolyte imbalance, chest pain, edema and cardiac arrhythmias due to not having the toxins pulled from their blood.
On 03/07/2024 at 12:50 PM, V2 (Director of Nursing) said, R4's dialysis order has been active since 02/09/2024. On 02/22/2024, there was a change in R4's chair time, which is why I entered another dialysis order with the new chair time of 2 PM. My expectations with dialysis is that every patient receives their dialysis when scheduled. Dialysis treatment is very important because the kidneys are not working properly. If dialysis is missed for whatever reason, I expect that the nurse try and get the patient a dialysis appointment for the next day if possible. Missed dialysis could lead to fluid overload. The heart pumps much harder and every other organ is also overworking. Follow-up is important. Medical treatment of any kind is of upmost importance.
Facility document titled Dialysis Residents lists sixteen residents, including R4.
R4's Order Listing Report documents an active order entered on 02/09/2024 for Dialysis on Mondays, Wednesdays and Fridays.
R4's Nursing Progress Note entered on 02/16/2024 by V7 (LPN) documents, R4 made nurse aware that his transportation to dialysis never arrived.
R4's Nursing Progress Note entered on 02/21/2024 by V7 (LPN) documents, nurse was made aware by R4's mother that he (R4) missed dialysis. V7 inquired with R4 and R4 confirmed stating that he (R4) missed dialysis due to his transportation never arriving.
Facility document titled Treatment Details Report, documents dialysis treatment for R4 for the following dates: 02/12/2024, 02/14/2024, 02/19/2024, 02/23/2024, 02/26/2024, 02/28/2024 and 03/01/2024.
No documentation of dialysis treatment was noted for R4 on 02/16/2024 or 02/21/2024.
Facility Policy titled Dialysis Care documents, Purpose: to adequately assess residents needs and provide care goals which achieve the highest practicable level of care to residents with end stage renal disease receiving hemodialysis or peritoneal dialysis.
Facility Policy titled Transportation for Residents documents, it is the policy of this facility to assist residents in obtaining transportation when necessary for services outside the facility; Designated personnel shall assist residents in obtaining transportation when it is necessary to obtain medical, dental, diagnostic, or other services outside the facility.
Facility Policy titled Physician Orders documents, Purpose: to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards.
Feb 2024
8 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that necessary treatment and services consistent with profess...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that necessary treatment and services consistent with professional standards of practice to prevent wound infection were implemented for 1 (R1) resident with a surgical wound due to left above the knee amputation. The facility failed to:
1.
Failed to sign TAR (treatment administration record) that treatment was provided.
2.
Failed to assess and monitor surgical wound upon admission and on weekly basis.
3.
Failed to complete nutritional consultation / assessment.
4.
Failed to complete Braden scale on a weekly basis.
These failures resulted to 1 (R1) resident admitted to the hospital with diagnosis of wound infection.
The findings include:
R1's health record documented an admission date on 1/8/24 with diagnoses not limited to Encounter for orthopedic aftercare following surgical amputation, Muscle wasting and atrophy, Dysphagia oropharyngeal phase, Type 2 diabetes mellitus with other circulatory complications, Acquired absence of left leg below knee, Peripheral vascular disease, Sepsis, Unspecified personality and behavioral disorder due to known physiological condition, Depression, Schizophrenia, Acquired absence of right leg below knee, Other polyosteoarthritis, Gastro-esophageal reflux disease without esophagitis, Anemia. R1's health record showed discharge date on 1/27/24.
On 2/14/24 at 10:48am V44 (Consultant Dietician) stated that if nutritional supplements were missed or not given it could put a resident at risk for weight loss, wounds could get worse, or it could delay wound healing. Reviewed R1's EHR (electronic health record) with V44 and he stated he tried to see R1 but there was no wound assessment at that time when he was in the facility, so R1 was not seen. V44 stated he was not able to find any nutritional assessment / evaluation documentation in R1's EHR.
At 12:58pm reviewed R1's EHR with V4 (Wound Care Director) and the EHR stated that he was admitted with a surgical wound related to Left Above Knee Amputation (AKA). She said that she saw wound documentation for R1 on 1/21/24 but there was no documentation regarding the surgical wound. No wound documentation upon admission on [DATE], 1/15/24 and 1/22/24. V4 said Braden scale was done on 1/8/24 only, no Braden scale done on 1/15/24 and 1/22/24. V4 Stated I don't know why Braden scale and wound assessment were not done as she was not doing wounds at that time. She said that she is trying to catch up with assessments. V4 said that skin assessment is done to document any skin breakdown or skin condition upon admission. V4 said that Braden scale is a risk assessment that would include shearing/friction, mobility, and moisture. V4 stated that wound care team sign electronic treatment administration record (ETAR) after providing the treatment to resident to make sure that it was done. She said that if ETAR was not signed it means that treatment was not provided. V4 said if treatment was not provided or missed, it could potentially lead to wound infection, delay wound healing or worsening of wound. V4 said that nutritional supplements are important to build protein that helps in wound healing.
At 2:42pm V36 (Assistant Director of Nursing/ADON, RN) said Braden scale is an assessment for friction, mobility, moisture, mobility to predict risk for skin breakdown so it will guide the staff how many times the resident needs to be changed or needing repositioning. She said wound assessment should be done on a weekly basis to assess progress of existing wound, if it is not done weekly, the facility is not able to evaluate if the treatment is effective or working or if needs to be changed or additional interventions should be implemented. V36 said nutritional supplements are very important in maintaining proper nutrients in repairing, rebuilding, and restoring skin tissues to aid or help in wound healing. V36 said TAR/MAR (Treatment Administration Record/Medication Administration Record) should be signed after providing treatment and after medication administration to prove that treatment was provided, and medications/nutritional supplements were given. V36 said if it was not signed or not documented, it was not done or was not given. She stated that if treatment is missed or not provided, this could lead to wound infection, worsening of the wound or delay wound healing. V36 said if nutritional supplements are not given, it could delay wound healing or worsen the wound.
R1's EHR reviewed with V36 and V36 stated that R1 was transferred to the hospital on 1/27/24 due to purulent drainage on left AKA (above the knee amputation) and was admitted to hospital with possible a wound infection.
At 4:49pm V39 (Wound Nurse Practitioner/NP) said that he was not familiar with R1 and R1 was not seen for wound evaluation. V39 stated that if there is a missed treatment or treatment is not done, it could potentially worsen the wound, delay wound healing or could lead to infection. V39 stated that nutritional supplements are very important for wound healing, help the body rejuvenate, repair damaged tissues and aid in healing process.
On 2/15/24 at 10:52am V40 (Nurse Practitioner/NP) was interviewed via phone and stated that she is familiar with R1. V40 said if wound treatment was missed or treatment was not done it could potentially delay wound healing, worsening of the wound or could lead to infection. V40 said nutritional supplements could play a part together with wound healing. She said that if nutritional supplements are not given as ordered, it could potentially delay wound healing or worsen the wound.
MDS (Minimum Data Set) dated 1/14/2024 showed R1's cognition was moderately impaired. R1 needed set-up/clean-up assistance with eating; Partial/moderate assistance with oral hygiene; Total assistance/Dependent with toileting and personal hygiene, shower/bathe self, lower body dressing, chair/bed transfer and Substantial/maximal assistance with upper body dressing. MDS showed R1 was always incontinent of bowel and bladder. R1 had 2 Stage III and 1 Unstageable pressure ulcers that were present upon admission. MDS also showed R1 had surgical wound.
R1's POS (Physician Order Sheet) showed the following orders but not limited to:
-
Skin prep staples to LT (left) AKA LOTA (leave open to air) one time a day AND as needed Apply dry dressing if drainage present.
-
Readycare 1.7 two times a day for low bmi (Body Mass Index) for age [AGE] ml.
-
Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals) Give 1 tablet by mouth one time a day for Wound care.
-
Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth one time a day for Wound care.
-
Critical Care Active Protein two times a day for Wound care give 30cc PO.
R1's MAR (Medication Administration Record) for the month of January 2024 showed:
-
Critical Care Active Protein and Readycare 1.7 were not signed that it was given on 1/15/24 and 1/20/24.
R1's TAR (Treatment Administration Record) for the month of January 2024 showed: Treatment to left AKA was not signed that it was done on 1/14/24 and 1/26/24. No wound or skin assessment found in R1's EHR upon admission on [DATE] and weekly thereafter on 1/15/24 and 1/22/24. Per V4, wound assessment should be done upon admission then weekly. No wound NP notes found in R1's EHR.
R1's Braden scale assessment dated [DATE] Scored 14 (moderate risk). No Braden scale assessment on 1/15/24 and 1/22/24 found on R1's EHR. Per V4, Braden scale is done weekly x 4 weeks.
R1's Care plan dated 1/10/24 documented in part: R1 has amputation of L AKA (left above the knee amputation). Care plan interventions included but not limited to: Monitor site for s/s infection. Dressing change per MD order.
Skin/Wound Note dated 1/27/2024 documented in part: R1 was observed with a left AKA with sutures purulent drainage, no odor, resident stated he has no pain, wound was cleaned with nss pat dry, covered with dry dressing.
R1's progress notes 1/28/2024 documented in part: R1 has been admitted with a diagnosis of possible wound infection.
R1's hospital records dated 2/13/24 documented in part:
-
R1 admission date: 1/27/24
-
R1 presented for stump wound drainage and erythema.
-
Diagnoses: Infection of amputation stump of left lower extremity, Surgical wound dehiscence of left amputation stump.
-
R1 had stump revision on left on 1/29/24 by ortho.
Facility's wound policy and procedures dated 1/1/24 documented in part:
-
To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown.
-
To promote healing of existing non pressure ulcer.
-
BRADEN scale should be completed for all residents upon admission/readmission for a total of four consecutive weeks, quarterly with each MDS assessment and when a significant change of condition occurs.
-
Upon identification of the development of a wound, the wound assessment will be documented.
-
Any skin impairments including surgical wound should be assessed and documented weekly by the wound nurse or designee. Documentation should cover all pertinent characteristics of existing pressure ulcers including location, size, depth, maceration, color of the ulcer and surrounding tissues and a description of any drainage, eschar, necrosis, odor, tunneling or undermining, if warranted.
-
A nutritional consultation should be completed for residents who are at risk for malnutrition.
-
Measurements are taken weekly.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement necessary treatment and services consistent ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement necessary treatment and services consistent with professional standards of practice to promote healing and prevent new ulcers from developing for a resident identified at risk. The facility failed to:
1.
Failed to initial or sign on the electronic treatment administration record (eTAR) after each treatment for 3 (R1, R4 and R5) residents with pressure ulcers.
2.
Failed to revise care plan to reflect alteration of skin integrity, approaches, and goals for care for 1 (R5) resident with multiple facility acquired pressure ulcers.
3.
Failed to do weekly wound assessment for 3 (R1, R4 and R5) residents with pressure ulcers.
4.
Failed to complete Braden scale assessment upon admission for a total of four consecutive weeks for 1 (R1) resident with multiple pressure ulcers.
5.
Failed to complete nutritional consultation or assessment for 1 (R1) resident with multiple pressure ulcers.
6.
Failed to ensure treatment orders for 1 (R5) resident with multiple facility acquired pressure wounds.
7.
Failed to monitor wound dressing to ensure it was intact and adhering for 1 (R4) resident with pressure ulcer.
These failures affected 3 (R1, R4 and R5) out of 3 residents reviewed for pressure ulcers. R1 with 2 stage 3 pressure ulcers to left elbow and coccyx, R4 with Stage IV pressure ulcer to sacrum, and R5 with multiple facility acquired Stage III pressure ulcers to left posterior thigh, right heel, right and left ischium.
The findings include:
R1's health record documented admission date on 1/8/24 with diagnoses not limited to Encounter for orthopedic aftercare following surgical amputation, Muscle wasting and atrophy, Dysphagia oropharyngeal phase, Type 2 diabetes mellitus with other circulatory complications, Acquired absence of left leg below knee, Peripheral vascular disease, Sepsis, Unspecified personality and behavioral disorder due to known physiological condition, Depression, Schizophrenia, Acquired absence of right leg below knee, Other polyosteoarthritis, Gastro-esophageal reflux disease without esophagitis, Anemia. R1's health record showed discharge date on 1/27/24.
R4's health record documented initial admission date on 2/11/22 with diagnoses not limited to Other chronic osteomyelitis, right ankle and foot, Methicillin resistant staphylococcus aureus infection, Local infection of the skin and subcutaneous tissue, Gangrene, Non-pressure chronic ulcer of other part of left foot with necrosis of bone, Pressure ulcer of sacral region stage 4, Peripheral vascular disease, Hypertensive heart disease with heart failure, Opioid use, Burn of third degree of left foot, Burn of third degree of right foot, Resistance to vancomycin vre of the wound, Insomnia, Cocaine use, Anemia, Major depressive disorder, recurrent, Heart failure, Schizophrenia, Sepsis, Cellulitis of left lower limb, Homelessness unspecified, Primary osteoarthritis.
R5's health record documented initial admission date on 11/07/14 with diagnoses not limited to Unspecified injury at unspecified level of cervical spinal cord, Paraplegia, Neuromuscular dysfunction of bladder, Type 2 diabetes mellitus with unspecified complications, Pressure ulcer of other site, stage 3 (left posterior thigh left ischial tuberosity right ischium), prostatic hyperplasia without lower urinary tract symptoms, Vitamin d deficiency, Methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere, Peripheral vascular disease, Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, Gout, Essential (primary) hypertension, Chronic kidney disease, Major depressive disorder, Gastro-esophageal reflux disease without esophagitis, Nutritional anemia, Other hereditary and idiopathic neuropathies, Extended spectrum beta lactamase (esbl) resistance.
On 2/14/24 at 10:04am observed R4 lying in bed, alert and verbally responsive, appears comfortable, with air mattress in place. Wound care observation conducted with V4 (Wound Care Director) assisted by V41 (Wound Care Nurse). Observed R4 open his incontinence brief, clean and dry. Observed open wound on sacral area with no dressing in place. V4 stated that maybe the CNA (Certified Nursing Assistant) had removed the dressing during care. V4 stated the sacral wound is classified as Stage IV acquired in the facility. Observed wound bed about 80% pinkish and 20% granulating tissue, no yellow slough noted. Observed V4 cleanse the wound with NSS (normal saline solution) then applied calcium alginate and covered with dry dressing.
At 10:19am observed R5 lying on bed, alert, and oriented x 3, verbally responsive, air mattress in placed. R5 refused wound care observation. He stated that wound care was already done by staff. R5 agreed wound to be seen by surveyor with V4. Observed V4 opened dressing on left posterior thigh, observed with open wound. V4 stated it is classified as Stage III. Observed wound bed 70% pinkish to reddish and about 30% yellow slough. R5 refused other wounds to be seen by surveyor.
At 10:24am V43 (Certified Nursing Assistant/CNA) said she is assigned to R4, and her shift started at 7:00am. She stated that R4 uses urinal, and she did not change R4 yet and is about to check for incontinence episode. V43 said she did not remove or touch R4's wound dressing on the buttocks.
At 10:48am V44 (Consultant Dietician) stated that residents with pressure wounds have metabolic stress in the body, the body is losing a lot of fluids and proteins, could have muscle wasting, dehydration, at risk for developing more pressure ulcers due to weight loss from the other wounds not healing so nutritional assessment or evaluation is needed. He said that caloric needs changed when there is an existing or non-healing wound. V44 said interventions with additional nutritional supplements or additional protein in the diet is important for wound healing. V44 stated that resident with a pressure ulcer is needing more calories and more protein to create / restore the tissue to promote wound healing. V44 stated that if nutritional supplements were missed or not given this could put resident at risk for weight loss, wound could get worst or could delay wound healing. Reviewed R1's EHR (electronic health record) with V44 and said he tried to see R1 but there was no wound assessment at the time when he was in the facility, so R1 was not seen. V44 stated not able to find any nutritional assessment / evaluation documentation in R1's EHR so it was not done.
At 12:58pm Reviewed EHR with V4 (Wound Care Director) for the following residents:
1.
R5 - V4 stated he has multiple acquired Stage 3 pressure wounds to right heel, right ischial, left posterior thigh and Left ischium that were not healed and no change in wound status. V4 stated that wound assessments should be done weekly and per EHR wound documentation was done on 12/25/23 then 1/21/24, it does not indicate that it was being done on a weekly basis.
2.
R4 - V4 stated that he has an acquired Stage IV pressure wound to sacrum, not healed, no change in wound status.
3.
R1 - V4 stated that he was admitted with 2 stage 3 pressure wounds to left elbow and coccyx and surgical wound related to Left AKA. V4 said that she saw wound documentation for R1 on 1/21/24 for coccyx, no wound documentation for left elbow and coccyx upon admission on [DATE] and 1/15/24. V4 said Braden scale assessment was done on 1/8/24, no Braden scale assessment done on 1/15/24 and 1/22/24. V4 Stated I don't know why Braden scale and wound assessment were not done as she was not doing wounds at that time. She said that she is trying to catch up with assessments. V4 said that skin assessment is done to document any skin breakdown or skin condition upon admission. V4 said that Braden scale is a risk assessment that would include shearing/friction, mobility, and moisture. V4 stated that the wound care team signs the electronic treatment administration record (ETAR) after providing the treatment to resident to make sure that it was done. She said that if ETAR was not signed it means that treatment was not provided. V4 said if treatment was not provided or missed, this could potentially lead to wound infection, delay wound healing or worsening of wound. V4 stated that the purpose of wound dressing is to keep the wound from being infected or contaminated. She said that if dressing fell off or was soiled and removed, there is PRN (as needed) order and treatment should be done by floor nurse. V4 said that nutritional supplements are important to build protein that helps in wound healing. V4 stated that wound treatment for R1, R4 and R5 wounds should have an order in the resident's EHR.
At 2:42pm V36 (Assistant Director of Nursing/ADON, RN) said wound dressing should be monitored and should be in place to keep the wound from debris, contamination that could possibly be at risk for infection and could worsen/damage/delay wound healing. V36 said Braden scale is an assessment for friction, mobility, moisture, mobility to predict risk for skin breakdown so it will guide the staff on how many times the resident needs to be changed or needing repositioning. V36 said wound assessment should be done on a weekly basis to assess progress of existing wound, if it is not done weekly, not able to evaluate if the treatment is effective or working or if needs to be changed or additional interventions should be implemented. V36 said nutritional supplements are very important in maintaining proper nutrients in repairing, rebuilding, and restoring skin tissues to aid or help in wound healing. She said TAR/MAR (Treatment Administration Record/Medication Administration Record) should be signed after providing treatment and after medication administration to prove that treatment was provided, and medications/nutritional supplements were given. V36 said if it was not signed or not documented, it was not done or was not given. V36 stated that if treatment is missed or not provided, this could lead to wound infection, worsening of the wound or delay wound healing. V36 said if nutritional supplements are not given, this could delay wound healing or worsen the wound. R1's EHR was reviewed with V36, V36 stated that R1 was transferred to hospital on 1/27/24 due to purulent drainage on left AKA (above the knee amputation) and was admitted to hospital with possible wound infection.
At 4:49pm V39 (Wound Nurse Practitioner/NP) stated that he is following R4 and R5 every other week and both residents are at risk for skin breakdown due to contributing factors which are immobility, incontinence, and multiple comorbidities. He said that he was not familiar with R1 and R1 was not seen for wound evaluation. V39 stated that if there is a missed treatment or treatment not done, this could potentially worsen the wound, delay wound healing or could lead to infection. He stated that wound dressing is important to be maintained to prevent wound contamination that could potentially delay wound healing or worsening of wound. V39 stated that nutritional supplements are very important for wound healing, help the body rejuvenate, repair damage tissues and aid in healing process.
On 2/15/24 at 10:52am V40 (Nurse Practitioner/NP) was interviewed via phone and stated that she is familiar with R1, R4 and R5. V40 said if wound treatments were missed or treatments were not done, this could potentially delay wound healing, worsening of the wound or could lead to infection. V40 said that wound dressing should be maintained to prevent contamination of the wound that could possibly lead to infection, delay wound healing if wound dressing is not maintained. V40 said nutritional supplements could play a part together with wound healing. She said that if nutritional supplements are not given as ordered could potentially delay wound healing or worsen the wound.
MDS (Minimum Data Set) dated 1/14/2024 showed R1's cognition was moderately impaired. R1 needed set-up/clean-up assistance with eating; Partial/moderate assistance with oral hygiene; Total assistance/Dependent with toileting and personal hygiene, shower/bathe self, lower body dressing, chair/bed transfer and Substantial/maximal assistance with upper body dressing. MDS showed R1 was always incontinent of bowel and bladder. R1 had 2 Stage III and 1 Unstageable pressure ulcers that were present upon admission. MDS also showed R1 had surgical wound.
R1'S POS (Physician Order Sheet) showed the following orders but not limited to:
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Clean LT (left) elbow with NSS, skin prep peri-wound apply foam dressing one time a day every Mon, Wed, Fri AND as needed if soiled or falls off.
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Clean Coccyx with wound cleanser, skin prep peri-wound apply Hydrocolloid one time a day every Mon, Wed, Fri AND as needed if soiled or falls off.
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Skin prep staples to LT (left) AKA LOTA (leave open to air) one time a day AND as needed Apply dry dressing if drainage present.
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Readycare 1.7 two times a day for low BMI(Body Mass Index) for age [AGE] ml.
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Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals) Give 1 tablet by mouth one time a day for Wound care.
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Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth one time a day for Wound care.
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Critical Care Active Protein two times a day for Wound care give 30cc PO.
R1'S MAR (Medication Administration Record) for the month of January 2024 showed:
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Critical Care Active Protein and Readycare 1.7 were not signed that it was given on 1/15/24 and 1/20/24.
R1's TAR (Treatment Administration Record) for the month of January 2024 showed: Treatment to Coccyx and Left elbow were not signed that treatments were provided on 1/26/24.
R1's wound assessment dated [DATE] documented in part: Stage III to Coccyx measuring 0.5 X 0.7 X 0.3cm. No wound assessment for left elbow on 1/21/24.
No wound or skin assessment found in R1's EHR upon admission on [DATE] and weekly thereafter on 1/15/24. Per V4, wound assessment should be done upon admission then weekly. No wound NP notes found in R1's EHR.
R1's Braden scale assessment dated [DATE] Scored 14 (moderate risk). No Braden scale assessment found on 1/15/24 and 1/22/24 found on R1's EHR. Per V4, Braden scale is done weekly x 4 weeks.
R1's care plan dated 1/10/24 documented in part: The resident has stage 3 pressure ulcer related to history of ulcers, Immobility, DM. Care plan interventions included but not limited to Administer treatments as ordered and monitor for effectiveness.
MDS dated [DATE] showed R4's cognition was intact. R4 needed set-up/clean-up assistance with eating; Substantial/maximal assistance with oral, personal and toileting hygiene and Total assistance/dependent to staff with shower/bathe self, lower body dressing and chair/bed transfer. MDS showed R4 was always incontinent of bowel and bladder. MDS also showed R4 had Stage IV pressure ulcer that was present upon admission.
R4's POS included the following orders but not limited to:
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Sacrum: Cleanse with wound cleanser skin prep peri-wound/Alginate silver/dry dressing one time a day.
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Critical Care Active Protein three times a day Give 30ml PO.
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Multi-Vitamin/Minerals Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth in the morning for Nutritional Supplement.
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Vitamin C Oral Tablet (Ascorbic Acid) Give 1 tablet by mouth one time a day for Wound care.
R4's MAR for the month of December 2023 and January 2024 showed: Critical Care Active Protein were not signed that it was given on 12/3/23, 12/19/23. 12/22/23, 12/23/23, 12/30/23, 12/31/23 and 1/13/24. MAR showed Multi-Vitamin/Minerals Tablet and Vitamin C Oral Tablet were not signed that medications were given on 1/13/24.
R4's TAR for the month of December 2023, January and February 2024 showed: Treatment to Sacrum were not signed that treatment was provided on 12/17/23, 12/20/23, 12/23/23, 12/24/23, 1/1/24, 1/14/24, 1/23/24, 1/24/24, 1/26/24, 1/30/24, 2/3/24, 2/5/24 and 2/11/24.
R4's wound assessment dated [DATE] documented pressure injury to sacrum measuring 2.0cm x 0.6cm x 0.2cm. Per wound nurse Sacrum was classified as Stage IV acquired in the facility.
R4's EHR reviewed with V4 and said it is indicated that there was no wound assessment documentation found on 12/7/23, 12/14/23, 12/21/23, 1/3/24, 1/10/24, 1/17/24 to Sacrum Stage IV pressure wound.
R4's wound NP notes dated 2/12/24 documented in part: Sacral is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2cm length x 0.6cm width x 0.2 cm depth.
R4's Initial Braden scale assessment dated [DATE] scored 13 (moderate risk) and latest assessment dated [DATE] showed 14 (moderate risk).
Care plan dated 1/2/24 documented in part: R4 has pressure ulcer on sacrum r/t Immobility. R4 Care plan interventions included but not limited to:
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Administer medications as ordered.
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Administer treatments as ordered and monitor for effectiveness.
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Monitor dressing to ensure it is intact and adhering. Report lose dressing to Treatment nurse.
MDS dated [DATE] showed R5 was cognitively intact. R5 needed set-up/clean up assistance with eating; Supervision/touching assistance; Total assistance/Dependent to staff with toileting hygiene, shower/bathe self, lower body dressing, chair/bed and toilet transfer and Substantial/maximal assistance with upper body dressing and personal hygiene. MDS showed he was frequently incontinent of bowel, with indwelling catheter. MDS showed 2 Stage III pressure ulcers that were not present upon admission.
Wound report provided by facility dated 2/5/24 to 2/9/24 showed R5 has the following wounds:
1.
Left posterior thigh - date identified on 4/14/21, facility acquired Stage 3 pressure ulcer. Last assessment date on 2/6/24 measured 3.0 x 4.0 x 0.2cm (Length x Width x Depth).
2.
Right ischium - date identified on 12/11/23, facility acquired Stage 3 pressure ulcer. Last assessment date on 2/6/24 measured 2.0 x 1.0 x 0.2cm.
3.
Left ischium - date identified on 1/8/24, facility acquired Stage 3 pressure ulcer. Last assessment date on 2/6/24 measured 1.0 x 1.0 x 0.2cm.
4.
Right heel - facility acquired Stage 3 pressure wound. Last assessment date on 2/6/24 measured 4.0 x 3.2 x 0.2cm. Per V4, could not determine when it started. V4 said per documentation, on May 16, 2019, it was already an existing wound.
R5's POS showed the following orders but not limited to:
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left posterior thigh cleanse with normal saline, pat dry skin prep peri wound apply moistened collagen then calcium cover with dry dressing one time a day for Wound care AND as needed Clean LT posterior thigh with NSS apply skin prep to peri-wound apply Ag+ alginate, cover with dry dressing.
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Cleanse Sacralcoxccygeal with Nss/skin prep/ pack with calcium alginate/boarder gauze one time a day.
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Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth in the morning for Wound care.
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Multivitamin Oral Tablet (Multiple Vitamin) Give 1 tablet by mouth in the morning for Nutritional Supplement.
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Critical Care Active Protein three times a day Give 30ml PO.
No treatment orders for the following wounds: Right and left ischium and Right heel.
R5's MAR for the month of December 2023 and January 2024 showed: Critical Care Active Protein were not signed that it was given on 12/22/23, 12/23/23, 12/31/23, 1/6/24, 1/14/24 and 1/17/24. MAR showed Multi-Vitamin/Minerals Tablet and Vitamin C Oral Tablet were not signed that medications were given on 1/17/24.
R5's TAR for the month of December 2023, January and February 2024 showed: Treatment to Left posterior thigh and Sacrococcygeal wounds were not signed that treatments were provided on 12/23/23, 12/29/23, 1/14/24, 1/23/24, 1/24/24, 1/26/24, 2/3/24, 2/4/24 and 2/11/24.
No treatment orders for the following wounds: Right and left ischium and Right heel.
No wound assessment documentation found for right heel wound on 12/1/23 and 12/8/23, 12/15/23 in R5's EHR. No wound assessment documentation found for Left thigh, right ischium, and right heel on 12/22/23, 12/29/23, 1/5/24. No wound assessment documentation for Left thigh, right ischium, and right heel on 1/12/24, 1/19/24 and 1/31/24.
Wound NP notes dated 2/5/24 showed R5 with multiple wounds documented in part:
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Right Ischial is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2cm length x 1cm width x 0.2 cm depth. There is no change noted in the wound progression.
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Left, Posterior Thigh is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3cm length x 4cm width x 0.2 cm depth. There is a Moderate amount of sero-sanguineous drainage noted which has no odor. There is no change noted in the wound progression.
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Right Heel is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 4cm length x 3.2cm width x 0.1 cm depth. There is a Moderate amount of sero-sanguineous drainage noted which has no odor.
R5's Initial Braden scale assessment dated [DATE] scored 11 (high risk) and latest assessment dated [DATE] showed 13 (moderate risk).
Care plan dated 1/3/24 documented in part: R5 has a pressure ulcer to coccyx and left posterior thigh. R5 Care plan interventions included but not limited to:
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Administer supplements to promote wound healing.
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Assess and document on wounds weekly and as needed.
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Administer treatments as ordered and monitor for effectiveness.
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Change dressing as ordered.
Facility's wound policy and procedures dated 1/1/24 documented in part:
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To identify factors that places the residents at risk for the development of pressure ulcers and to implement appropriate interventions to prevent the development of clinically avoidable wounds.
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To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown.
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To promote healing of existing pressure ulcers.
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BRADEN scale should be completed for all residents upon admission/readmission for a total of four consecutive weeks, quarterly with each MDS assessment and when a significant change of condition occurs.
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Identified risk factors should be addressed in the resident's care plan to assure appropriate interventions to manage the risk are implemented.
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Upon identification of the development of a wound, the wound assessment will be documented.
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Residents should be examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers. Findings from the weekly skin assessment should be documented/signed off by the licensed nurse.
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Any skin impairments including pressure ulcers should be assessed and documented weekly by the wound nurse or designee. Documentation should cover all pertinent characteristics of existing pressure ulcers including location, size, depth, maceration, color of the ulcer and surrounding tissues and a description of any drainage, eschar, necrosis, odor, tunneling or undermining, if warranted.
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A nutritional consultation should be completed for residents who are at risk for malnutrition.
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The goals of wound treatment are to: Protect the ulcer from contamination and promote healing.
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Measurements are taken weekly.
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 interviews and record reviews, the facility failed to protect R7, R8, and R10' s right to be free from abuse by a resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect R7, R8, and R10' s right to be free from abuse by a resident (R2). This failure resulted in R2 becoming physically aggressive by slapping and spitting on the face of R10, and R2 inappropriately touching R7 and R8.
Findings Include:
R2' s clinical records show R2 was initially admitted to the facility on [DATE] with listed diagnoses not limited to Schizophrenia and Alzheimer' s Disease. R2' s Minimum Data Set (MDS) dated [DATE] shows R2 had moderately impaired cognition and independent with walking. R2' s progress notes dated 1/26/24 at 3:18 PM documented by V5 (Restorative Nurse Manager) revealed that R2 was noted attacking other residents pulling (R2' s) own hair out, biting and scratching self. It also documents that emergency ambulance was called and transferred R2 to the acute hospital.
On 2/13/24 at 9:39 AM, a phone interview conducted with V3 (Insurance Case Manager). V3 stated that based on R2' s hospital records dated 1/30/24, R2 was hospitalized because R2 was fighting, scratching, biting staff, grabbing residents, and having combative behaviors. V3 stated that V3 suspected some peer-to-peer aggression and was unclear what went on in the facility. V3 stated that V3 tried to contact the facility but could not get a hold of anyone.
At 10:22 AM, V5 (Restorative Nurse Manager) stated that on 1/26/24, V5 was the nurse in charge for the afternoon shift and was coming in at around 2:30 PM when V5 witnessed R2 started screaming. V5 also stated witnessing R2 touching the private body parts of three male residents on the first floor. V5 stated, R2 grabbed the male private parts from the front and back. We were at the first floor nurses' station. One male resident was standing at the nursing station. Two other male residents were standing in the hall. [R2] came from the dining hall and started touching the male residents' private parts. V5 identified the two male residents as (R7) and (R8). V5 stated that V5 could not recall the third male resident' s name. V5 stated that these residents do not reside in the facility anymore since they were transferred to a different facility. V5 stated that R2 also attacked and spat on one resident that was sitting on a wheelchair. V5 thinks that the resident's name is (R10). V5 stated that V1 (Administrator) came after the incident. V5 stated that V1 was there before the emergency ambulance took R2 and was made aware of what happened.
At 12:54 PM, a phone interview conducted with V30 (Certified Nursing Assistant). V30 stated, I was there when it happened. It was around 1:30 PM when [R2] first started groping people. I heard it first happened in the dining room. I didn't' t see it there. But when [R2] was close to the nurses station, I saw [R2] started groping this one resident. I don' t remember the name. [R2] was grabbing the man from behind and touching his private part. I told [R2] she can' t be touching people like that. I re-directed [R2] back to [R2' s] room. V30 stated that V30 heard that there were other residents that R2 touched their private parts, but V30 did not witness.
At 1:14 PM, V1 (Administrator) stated that it is considered both sexual and physical abuse if a resident touched a private part of another resident.
At 2:23 PM, a phone interview was conducted with V31 (Licensed Practical Nurse). V31 stated that V31 was R2' s nurse in the morning of 1/26/24. V31 stated that when V31 came back from break, R2 was screaming, biting herself, pulling (R2' s) hair out, kicking and spitting at everybody. V31 stated V31 did not witness R2 touch the male residents private parts but heard other staff saying that R2 was grabbing the male residents private parts.
On 2/14/24 at 12:08 PM, a phone interview conducted with V28 (Certified Nursing Assistant). V28 stated that V28 walked past by the first floor on 1/26/24 but could not remember what time. V28 stated that V28 saw one female resident hit another resident on a wheelchair. V28 was unable to identify the names of the residents. V28 stated, I don' t know them. I work on different floors and those residents were just there for a short time from [other facility]. I don' t know those residents. I don' t know their names.
At 12:19 PM, R10 was sitting on a wheelchair, alert and able to verbalize needs. Interviewed R10 in R10' s room and R10 stated that R10 was transferred from the first floor. R10 stated that during R1' s stay on the first floor (R10 could not remember the date and time), there was a female resident that slapped and spat on R10' s face. R10 could not provide further details.
R7' s clinical records show an initial admission date of 7/24/23 and discharge on [DATE]. R7' s MDS dated [DATE] shows R7 was cognitively intact with no limitations with upper and lower extremities.
R8' s clinical records show an initial admission date of 1/17/24 and discharge on [DATE]. R8' s MDS dated [DATE] shows R8 was cognitively intact with no limitations with upper and lower extremities.
R10' s clinical records show an initial admission date of 1/17/24. R10' s MDS dated [DATE] shows R10 is cognitively intact with limitation of both lower extremities and uses a wheelchair for mobility.
The facility' s policy titled Abuse Prevention Program Facility Policy and Procedure dated 1/4/18 reads in part: This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation or resident property by establishing a resident sensitive and resident secure environment.
The facility ' s policy titled Resident Rights dated 5/22 shows that the facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their policy and procedure to report an abuse immediately ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their policy and procedure to report an abuse immediately and no later than two hours to the State Survey Agency (SA) for 3 (R7, R8, R10) out of 7 residents reviewed for abuse.
Findings Include:
R2's clinical records show R2 was initially admitted to the facility on [DATE] with listed diagnoses not limited to Schizophrenia and Alzheimer's Disease. R2's Minimum Data Set (MDS) dated [DATE] shows R2 had moderately impaired cognition and independent with walking. R2's progress notes dated 1/26/24 at 3:18 PM documented by V5 (Restorative Nurse Manager) shows that R2 was noted attacking other residents and pulling (R2's) own hair out, biting and scratching self. It also documents that an emergency ambulance was called and transferred R2 to the acute hospital.
At 10:22 AM, V5 (Restorative Nurse Manager) stated that on 1/26/24, V5 was the nurse in charge for the afternoon shift and was coming in at around 2:30 PM when V5 witnessed R2 started screaming. V5 also stated witnessing R2 touching the private body parts of three male residents on the first floor. V5 stated, R2 grabbed the male private parts from the front and back. We were at the first floor nurses' station. One male resident was standing at the nursing station. Two other male residents were standing in the hall. [R2] came from the dining hall and started touching the male residents' private parts. V5 identified the two male residents as (R7) and (R8). V5 stated that V5 could not recall the third male resident's name. V5 stated that these residents do not reside in the facility anymore since they were transferred to a different facility. V5 stated that R2 also attacked and spat on one resident that was sitting on a wheelchair. V5 thinks that the resident's name is (R10). V5 stated that V1 (Administrator) came after the incident. V5 stated that V1 was there before the emergency ambulance took R2 and was made aware of what happened.
At 12:54 PM, a phone interview was conducted with V30 (Certified Nursing Assistant). V30 stated, I was there when it happened. It was around 1:30 PM when [R2] first started groping people. I heard it first happened in the dining room. I didn't see it there. But when [R2] was close to the nurses' station, I saw [R2] started groping this one resident. I don't remember the name. [R2] was grabbing the man from behind and touching his private part. I told [R2] she can't be touching people like that. I re-directed [R2] back to [R2's] room. V30 stated that V30 heard that there were other residents that R2 touched their private parts, but V30 did not witness. V30 stated that V30 thinks V31 notified V1 of everything that happened because V1 was there on the first floor.
At 1:14 PM, V1 (Administrator) stated that if someone witnesses abuse, they must report it to V1 immediately and then V1 would file the reportable to the State Agency and complete an investigation. V1 stated that any type of abuse should be reported within 2 hours or less and as part of the initial report, the police should be contacted. V1 stated that V1 did not do an initial reporting regarding R2's behaviors that happened in 1/26/24. V1 stated that R2 was having behavior episodes trying to hurt herself. V1 stated that V1 was not told that R2 was touching other residents. V1 stated V1 did not witness R2 touch or hurt other residents. V1 stated that it's considered both sexual and physical abuse if a resident touched a private part of another resident and if that's the case it should have been reported to the State Agency immediately.
At 2:23 PM, a phone interview was conducted with V31 (Licensed Practical Nurse). V31 stated that V31 was R2's nurse in the morning of 1/26/24. V31 stated that when V31 came back from break, R2 was screaming, biting herself, pulling (R2's) hair out, kicking and spitting at everybody. V31 stated V31 did not witness R2 touch the male residents' private parts but heard other staff saying that R2 was grabbing the male residents' private parts. V31 stated that V1 and V2 (Director of Nursing) were there and knew what happened. V31 stated that V31 is not sure if V1 and V2 witnessed the whole incident.
On 2/14/24 at 12:08 PM, a phone interview was conducted with V28 (Certified Nursing Assistant). V28 stated that V28 walked past by the first floor on 1/26/24 but could not remember what time. V28 stated that V28 saw one female resident hit another resident on a wheelchair. V28 was unable to identify the names of the residents. V28 stated, I don't know them. I work on different floors and those residents were just there for a short time from [other facility]. I don't know those residents. I don't know their names. V28 stated V28 did not report the incident to anyone because V28 did not know the residents.
At 12:19 PM, R10 sitting on a wheelchair alert and able to verbalize needs. Interviewed R10 in R10's room and R10 stated that R10 was transferred from the first floor. R10 stated that during R10's stay on the first floor (R10 could not remember the date and time), there was a female resident that slapped and spat on R10's face. R10 could not provide further details.
On 2/15/24 at 3:29 PM, a phone interview conducted with V2 (Director of Nursing). V2 stated that V2 did not witness the occurrence that happen with R2. V2 stated V2 did not report or investigate the situation because V2 was busy handling so many things going on in the building that day.
R7's clinical records show an initial admission date of 7/24/23 and discharge on [DATE]. R7's MDS dated [DATE] shows R7 was cognitively intact with no limitations with upper and lower extremities.
R8's clinical records show an initial admission date of 1/17/24 and discharge on [DATE]. R8's MDS dated [DATE] shows R8 was cognitively intact with no limitations with upper and lower extremities.
R10's clinical records show an initial admission date of 1/17/24. R10's MDS dated [DATE] shows R10 is cognitively intact with limitation of both lower extremities and uses a wheelchair for mobility.
The facility's abuse reports and investigations in the last six months were provided. No documentation was found for R2's 1/26/24 incident of abuse to other residents.
The facility's policy titled; Abuse Prevention Program Facility Policy and Procedure dated 1/4/18 reads in part: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. Initial Reporting of Allegations - Then an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. This report shall be made immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or resulted in serious bodily injury; Five-day Final Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to thoroughly investigate an incident of abuse for 3 (R7, R8, R10) o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to thoroughly investigate an incident of abuse for 3 (R7, R8, R10) out of 7 residents reviewed for abuse.
Findings Include:
R2's clinical records show R2 was initially admitted to the facility on [DATE] with listed diagnoses not limited to Schizophrenia and Alzheimer's Disease. R2's Minimum Data Set (MDS) dated [DATE] shows R2 had moderately impaired cognition and is independent with walking. R2's progress notes dated 1/26/24 at 3:18 PM documented by V5 (Restorative Nurse Manager) shows that R2 was noted attacking other residents and pulling (R2's) own hair out, biting and scratching self. It also documents that an emergency ambulance was called and transferred R2 to the acute hospital.
At 10:22 AM, V5 (Restorative Nurse Manager) stated that on 1/26/24, V5 was the nurse in charge for the afternoon shift and was coming in at around 2:30 PM when V5 witnessed R2 started screaming. V5 also stated witnessing R2 touching the private body parts of three male residents on the first floor. V5 stated, R2 grabbed the male private parts from the front and back. We were at the first floor nurses' station. One male resident was standing at the nursing station. Two other male residents were standing in the hall. [R2] came from the dining hall and started touching the male residents' private parts. V5 identified the two male residents as (R7) and (R8). V5 stated that V5 could not recall the third male resident's name. V5 stated that these residents do not reside in the facility anymore since they were transferred to a different facility. V5 stated that R2 also attacked and spat on one resident that was sitting on a wheelchair. V5 thinks that the resident's name is (R10). V5 stated that V1 (Administrator) came after the incident. V5 stated that V1 was there before the emergency ambulance took R2 and was made aware of what happened.
At 12:54 PM, a phone interview conducted with V30 (Certified Nursing Assistant). V30 stated, I was there when it happened. It was around 1:30 PM when [R2] first started groping people. I heard it first happened in the dining room. I didn't see it there. But when [R2] was close to the nurses' station, I saw [R2] started groping this one resident. I don't remember the name. [R2] was grabbing the man from behind and touching his private part. I told [R2] she can't be touching people like that. I re-directed [R2] back to [R2's] room. V30 stated that V30 heard that there were other residents that R2 touched their private parts, but V30 did not witness. V30 stated that V30 thinks V31 notified V1 of everything that happened because V1 was there on the first floor.
At 1:14 PM, V1 (Administrator) stated that if someone witnesses abuse, they must report it to V1 immediately and then V1 would file the reportable to the State Agency and complete an investigation. V1 stated that V1 did not do an investigation regarding R2's behaviors that happened on 1/26/24. V1 stated that R2 was having behavior episodes trying to hurt herself. V1 stated that V1 was not told that R2 was touching other residents. V1 stated V1 did not witness R2 touch or hurt other residents. V1 stated that it's considered both sexual and physical abuse if a resident touched a private part of another resident and if that's the case it should have been reported to the State Agency immediately and should have been investigated.
At 2:23 PM, a phone interview was conducted with V31 (Licensed Practical Nurse). V31 stated that V31 was R2's nurse in the morning of 1/26/24. V31 stated that when V31 came back from break, R2 was screaming, biting herself, pulling (R2's) hair out, kicking and spitting at everybody. V31 stated V31 did not witness R2 touch the male residents' private parts but heard other staff saying that R2 was grabbing the male residents' private parts. V31 stated that V1 and V2 (Director of Nursing) were there and knew what happened. V31 stated that V31 is not sure if V1 and V2 witnessed the whole incident.
On 2/14/24 at 12:08 PM, a phone interview was conducted with V28 (Certified Nursing Assistant). V28 stated that V28 walked past by the first floor on 1/26/24 but could not remember what time. V28 stated that V28 saw one female resident hit another resident on a wheelchair. V28 was unable to identify the names of the residents. V28 stated, I don't know them. I work on different floors and those residents were just there for a short time from [other facility]. I don't know those residents. I don't know their names. V28 stated V28 did not report the incident to anyone because V28 did not know the residents.
At 12:19 PM, R10 sitting on a wheelchair alert and able to verbalize needs. Interviewed R10 in R10's room and R10 stated that R10 was transferred from the first floor. R10 stated that during R10's stay on the first floor (R10 could not remember the date and time), there was a female resident that slapped and spat on R10's face. R10 could not provide further details.
On 2/15/24 at 3:29 PM, a phone interview was conducted with V2 (Director of Nursing). V2 stated that V2 did not witness the occurrence that happen with R2. V2 stated V2 did not report or investigate the situation because V2 was busy handling so many things going on in the building that day.
R7's clinical records show an initial admission date of 7/24/23 and discharge on [DATE]. R7's MDS dated [DATE] shows R7 was cognitively intact with no limitations with upper and lower extremities.
R8's clinical records show an initial admission date of 1/17/24 and discharged on 2/6/24. R8's MDS dated [DATE] shows R8 was cognitively intact with no limitations with upper and lower extremities.
R10's clinical records show an initial admission date of 1/17/24. R10's MDS dated [DATE] shows R10 is cognitively intact with limitation of both lower extremities and uses a wheelchair for mobility.
The facility's abuse reports and investigations in the last six months were provided. No documentation was found for R2's 1/26/24 incident of abuse to other residents.
The facility's policy titled; Abuse Prevention Program Facility Policy and Procedure dated 1/4/18 reads in part: VII. Internal Investigation. 1. Incidents will be reviewed, investigated and documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Incidents or allegations involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be reviewed by administration and shall be investigated, as indicated and appropriate. VIII. External Reporting. 2. Five-day Final Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow their policies and procedures to administer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow their policies and procedures to administer a medication per physician's order for 1 (R6) out of 3 residents reviewed for pharmaceutical services with behavioral symptoms and who received an antipsychotic medication. R6's Medication Administration Record (MAR) was reviewed, it reflected that the medication had been unavailable for administration on multiple occasions.
Findings Include:
R6's Minimum Data Set, dated [DATE] shows R6 is cognitively intact. R6 Physician order Sheet (POS) with active orders as of 2/13/24 shows an order for Clonazepam 1 mg tablet, give 1 mg by mouth every 12 hours for anxiety related to anxiety disorder. Medication Administration Record (MAR) shows Clonazepam 1 mg tablet was not administered for ten days of admission.
Note text dated 2/13/24 by V20 (LPN) reads in part: rejection (from the pharmacy) was e-mailed to the facility on the 10th (2/10/24) regarding non-coverage.
On 2/13/24 V20 (License Practical Nurse) LPN stated R6 takes medications, but Clonazepam 1mg tablet twice a day had not been available since admission. V20 (LPN) faxed prescription to the doctor and pharmacy last Thursday 2/8/24. V20 was not sure if V20 spoke to V2 Director of Nursing (DON) about it.
On 2/13/24 at 12:10 PM, V4 (Wound Care Director) stated, V4 follows doctor's order, R6 has no wound, R6 was admitted with a healed wound, R6 has moderate swelling to Bilateral Lower Extremities, (BLEs) but no skin alteration and no wound treatment order.
On 2/13/24 at 11:47 am, R6 was up in wheelchair, appeared clean in personal clothes. R6 stated, I am not ready to speak to the surveyor at this moment.
On 2/13/24 at 12:43 pm, R6 is up in wheelchair propelling self on the first-floor day room. R6 stated R6 came to the facility on the night of 2/2/24 from (Local) Hospital. R6 cannot walk, R6 has edema/Lymphedema/Venous Stasis Dermatitis and dark scaly skin to bilateral leg, with healed wound. R6 stated the nurses did not give me all my medications, the nurses did not give me my Clonazepam since I came to this facility.
On 02/13/24 at 2:02 pm V2 (Director of Nursing/Registered Nurse) DON/RN stated it is V2's expectation that the nurses will administer medication according to the physician's order using the five rights. When a resident is admitted to the facility, the nurse should verify the list of the medications with the physician and fax it to the pharmacy. The pharmacy should deliver the medications the same day or latest the following day. If the medication is available in the Pyxis, the nurse should take it pending the pharmacy. If the Pharmacy did not deliver the medication, the nurse should inform V2, and V2 can reach out to the pharmacy or reach out to V21 (Nurse Consultant/RN). V2 is not aware of any resident without medication for a week and no resident stated that either. If V2 is aware, V2 would have called the physician for an alternative.
On 02/14/24 at 11:21 am, V35 (Infection Preventionist/LPN) stated, nurses should not wait for days before calling the pharmacy to find out why medication is not delivered. If the medication is not delivered due to insurance coverage, V35 will notify the doctor right away for another order and notify the DON/ADON, the family and document. V35 believed no resident should wait days for medication, V35 stated residents should receive medication as ordered by the physician, when medication is not administered as ordered it may affect the resident negatively. For example, if an antianxiety medication is not given, it may lead to increased anxiousness or behavioral problem, antihypertensive medication may result to high blood pressure, which can lead to medical emergency.
On 02/14/24 at 11:41 am, surveyor with R6 in room. R6 is up in wheelchair, dressed in clean clothes. R6 stated R6 got medication, but R6 was not sure if R6 got all the medications, R6 did not receive Clonazepam 1 mg tablet.
On 02/14/24 at 1:30 pm, surveyor asked V33 (LPN) for the bingo card of all the morning medications for R6, Clonazepam 1 mg tablet bingo card was missing, V33 stated it should be in the other medication cart being in use by V2 DON, but the bingo card was not in the medication cart, then V33 stated I took it from the Pyxis.
On 02/14/24 at 1:35 pm, surveyor observed that some licensed staff had documented that the medication was administered even though it was not available. Surveyor interviewed V2 (DON), V2 stated Clonazepam 1 mg tablet is still not available since admission.
On 02/15/24 at 12:00 pm, R6 is up in wheelchair in the day room, R6 stated I did not receive my medications this morning.
The facility policy for Administration of Medication, revision dated 1/1/2020 reads in part: Medications shall be administered in physician's written/verbal orders. MAC Rx Pharmacy Policies and Procedures Manual dated 10/25/14 reads in part; For emergency-controlled substance orders, the nurse will review the emergency kit list for available medications prior to contacting the prescriber.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure there were enough clean under pads and pillowc...
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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 there were enough clean under pads and pillowcases readily available for residents use. This failure has the potential to affect all 199 residents residing in the facility.
Findings Include:
On 2/13/24 at 12:07 PM, V9 (Certified Nursing Assistant) stated sometimes the staff does not get enough under pads for the residents.
At 12:54 PM, a phone interview conducted with V30 (Certified Nursing Assistant). V30 stated, They distribute linens to every floor each shift, but we don't get enough. We don't get any pillowcases for our residents. Some days they would only send two under pads and four bed sheets on our unit. We have around 50 residents on my unit. How am I supposed to take care of them and provide them clean linens if they only give us a few? What I do is I go downstairs to get my linens but most of the time they won't have any available.
On 2/14/24 at 9:47 AM, V14 (Laundry/Housekeeping Supervisor) stated that the facility is short of pillowcases. V14 stated, We don't have enough pillowcases in the building. Right now, we only have 60 clean pillowcases. V14 stated that V14 orders linens once a month and get's them delivered the first week of each month but there is still not enough. V14 stated that V14 already received the delivery for this month at the beginning of February and won't get any more delivery until the beginning of March.
At 9:56 AM, Surveyor asked V14's assistance to inspect all linen storage and linen carts in the entire building and the following were noted:
In the first-floor main linen storage room were found 18 flat sheets, no pillowcases, 6 fitted sheets, and no under pads.
At 10:04 AM, the linen storage room and linen carts in 2 North were found with 3 fitted sheets, 3 flat sheets, 1 under pad, and no pillowcase.
At 10:07 AM, the linen storage room and linen carts in 2 South were found with 3 under pads, 10 fitted sheets, 8 flat sheets, and 2 pillowcases.
At 10:16 AM, the linen storage room and linen carts in 3 North were found with 14 flat sheets, 6 fitted sheets, and 6 under pads, and 1 pillowcase.
At 10:19 AM, the linen storage room and linen carts in 3 South were found with 6 flat sheets, 1 pillowcase, 10 fitted sheets, and 6 under pads.
The facility's roster dated 2/13/24 documents 199 residents residing in the facility.
On 2/14/24 at 10:27 AM, V22 (Certified Nursing Assistant) stated that there are not enough clean pillowcases for the residents in the facility. V22 stated that V22 gets 4-5 under pads a day.
On 2/15/24 at 12:29 PM R6 stated that R6 does not get new bed sheets every day. R6 stated that the first time R6's bed sheets were changed was yesterday since R6 admitted in the facility. R6 stated R6 does not get any under pads. R6's Minimum Data Set (MDS) dated [DATE] shows R6 is cognitively intact. R6's face sheet shows an admission date of 2/2/24.
At 12:37 PM, R17 was sitting on the side of R17's bed eating lunch. R17 had one pillow with no pillowcase and the bed had no under pad. R17 stated that R17 does not get any under pad and pillowcase. R17 stated that staff changes R17's bed sheets every two weeks and R17 has not received a pillowcase. R17's MDS dated [DATE] shows R17 is cognitively intact.
At 12:44 PM, R18 was sitting on R18's wheelchair in R18's room. Surveyor noted R18's bed had no sheets with two pillows with only one pillowcase. R18 stated R18 is waiting for the staff to change R18's bed. R18 stated R18 has been in the facility for six to seven months. R18 stated the facility has never had enough linens especially pillowcases. R18 stated, Some days I don't have pillowcases for days. They don't change my bed sheets every day because sometimes they don't have sheets available. R18's MDS dated [DATE] shows R18 is cognitively intact.
The facility's Facility Assessment Tool documents in part: The facility central supply and nursing teams conduct visual inspections of the facility medical storage areas on a daily basis to ensure that established par levels are being maintained, and that requires equipment/supplies are readily available.
The facility's policy titled; LINEN HANDLING - NURSING no date reads in part: 13. Laundry personnel shall be responsible for assuring adequate amounts of clean linen and personal clothing are available on each nursing unit. 15. Clean linens shall be applied to each occupied health center bed at least twice each week or as needed.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure the kitchen floor was clean and equipment was in working order. These deficient practices have the potential to affect ...
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Based on observation, interview and record review, the facility failed to ensure the kitchen floor was clean and equipment was in working order. These deficient practices have the potential to affect all 197 residents receiving food prepared in the facility's kitchen.
Findings include:
On 02/13/24 at 2:00 PM, during kitchen tour observed V16 (Dietary Aide) and V17 (Dietary Aide) working in the dish room scraping uneaten food from dishes into garbage cans. Observed garbage disposal leaking a large amount of water onto the tiled floor with large pools of water collecting on the floor around the dish room including where the staff was working, under the counters, behind the dish machine and extending to the far corner of the room away from the dish machine. This standing water appeared dirty with particles of food and dirt mixed in it and with pieces of brown and black material floating in the water. Observed large cotton blanket on the floor underneath the counter which was saturated in water and had particles of food stuck on the blanket. Observed food containers and wrappers on the floor around garbage cans.
On 02/13/24 at 2:02 PM, V15 (Director of Dietary) stated there is a leak somewhere in the dish room which is where all the standing water is coming from. V15 stated there is also a leak under the 3-compartment sink which also needs to be fixed.
On 02/13/24 at 2:04 PM, V16 (Dietary Aide) stated the water is coming from the garbage disposal, and stated, see? You can see the water dripping on the floor right now. V16 stated it has been a problem for a while now and they put the blanket down because otherwise the water runs into the hallway. V16 stated we do our best to get up as much water as we can but there is still standing water left.
On 02/13/24 at 2:18 PM, V18 (Maintenance Director) stated he has been working at the facility for 2 weeks and that V18 has not been made aware of any leaking or broken equipment in the kitchen. V18 walked across the hallway with surveyor to the kitchen. V18 viewed garbage disposal actively leaking water, and water leaking from under the 3-compartment sink. V18 also viewed large amount of standing dirty water covering the wall in which the dish machine is along. V18 stated V18 was not told about this problem and should have been notified so V18 can address the problem. V18 stated the standing water could attract gnats and should not be there.
On 02/14/23 at 12:20 PM, V18 stated before seeing the problems in the kitchen yesterday, V18 did not know there were things that needed to be fixed and V18 cannot fix things unless V18 is told there is a problem. V18 stated there were puddles of standing water in the kitchen and it was dirty in there.
On 02/15/24 at 12:04 PM, V15 stated it would not be possible for the kitchen staff to get up all the water collecting on the kitchen floor because there is too much standing water even after the staff sweeps and mops the floor. V15 stated standing water attracts gnats and roaches because they love water and they like anything wet.
On 02/15/24 at 12:22 PM, during kitchen tour when dish machine was not in use, observed a large amount of standing water on the kitchen floor and the floor was dirty with black and dark brown material in the areas underneath and around the dishwasher and garbage disposal. Observed three unopened plastic containers of margarine and three empty margarine wrappers in the corner near the garbage disposal.
On 02/15/24 at 1:17 PM, V1 (Administrator) stated V1 was not made aware of the problem with kitchen equipment not working or leaking water. V1 stated there should not be standing water in the kitchen for a number of reasons including general cleanliness, safety issue for the staff, and pest control concerns.
On 02/16/24, V1 stated there are two residents who do not receive any meal trays from the kitchen because those two residents receive nothing by mouth (NPO).
Facility policy titled, Food Safety and Sanitation dated 09/22/23 documents the dietary manager will review cleaning schedules to evaluate the results and look for unsatisfactory areas. If unsatisfactory areas are found a plan of correction will be put in place to correct unsatisfactory areas.
Facility policy titled, Preventative Maintenance Program dated 11/2023 documents in part all facility areas are kept clean and in safe condition.
Facility provided Job Description titled Dietary Manager dated 03/23/17 which documents in part under essential duties and responsibilities ensure that dietary service work area are maintained in a clean and sanitary manner.
Jan 2024
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide individualized fall prevention interventions as indicated in a residents' care plan for a cognitively impaired residen...
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Based on observation, interview and record review, the facility failed to provide individualized fall prevention interventions as indicated in a residents' care plan for a cognitively impaired resident who had repeated falls; and failed to properly assess the fall risk of a resident. These failures affected two residents (R11 and R16) of three residents reviewed for falls. As a result, R11 fell, sustained a left hip fracture, and was sent to the hospital.
Findings include:
1. On 1/22/24 at 10am, V8 (Administrator) presented the facility's report of R11's fall dated 11/11/23, that was sent to the State Agency. This report states that R11 fell in the dining room while staff were passing trays and was sent to the hospital.
R11's Hospital Records written by V30 (Trauma Center/emergency room Physician), dated 11/12/23 documents: (R11) was a trauma level 2 patient that was transferred status post fall from wheelchair at the nursing home. Patient found to have left hip fracture. Assessment and Plan states that R11 had left hip fracture status post mechanical at the nursing home and sustained left comminuted intertrochanteric fracture.
On 1/22/24 at 12:34pm, R11 was observed in the dining room sitting in a recliner chair with the non-skid socks upside down on both feet. The smooth side was on the sole of the feet while the non-skid side was on top of the foot, for both right and left feet. V14(CNA) was asked if the socks were properly placed on R11's feet? The Surveyor asked about which side of the socks was supposed to touch the floor, and inquired if this fall prevention intervention was communicated to her(V14) and if she(V14) was aware of the reason for the non-skid socks? V14 then adjusted the socks on R11's feet.
On 1/23/24 at 12:40PM, V18(Nurse Consultant) presented the facility's incident reports of R11's fall events dated as follows:
8/10/23 - R11 observed on the floor in the dining room.
10/27/23 - R11 fell to the buttocks while being transferred into the shower room in wheelchair.
11/11/23 - R11 fell in the dining room and was sent to the hospital by ambulance.
On 1/22/24 at 11:30am, V27(Fall/Restorative Nurse/LPN/Licensed Practical Nurse) was interviewed about R11's fall prevention interventions. V27 stated that R11 is at high risk for falls. V27 added, We have interventions in the care plan.
R11's records reviewed include but are not limited to the following:
Face sheet shows that admission diagnoses include but are not limited to Dementia, Major Depressive Disorder, and Hypertension.
Fall Risk Review forms dated 8/12/23 and 10/27/23 both show that R11 is at risk for falls.
MDS (Minimum Data Set) section GG dated 11/16/23 shows that R11 requires moderate assistance for functional ability activities and transfers.
MDS section C dated 11/21/23 shows BIMS (Basic Interview for Mental Status) score of 7 out of 15(severe cognitive impairment).
Care plan Intervention dated 9/11/23 states in part: Ensure that R11 is wearing appropriate footwear (Specify and describe correct client footwear i.e., brown leather shoes, tartan bedroom slippers, black non-skid socks).
R11's records show the following as dated below:
On 8/10/23 at 8:00pm, V26(RN/Registered Nurse) documented in part: Resident found on floor in dining room, head to toe assessment done, neuro checks started, family made aware.
For the fall event of 8/10/23, Nursing Assessment record titled Predisposing Factors dated 8/10/23 states that R11's wheelchair was not locked, and no staff witnessed the fall.
On 10/27/23 at 9:20pm, V16(LPN) documented in part: Witnessed fall to buttock during transfer in w/c(wheelchair); Writer called in by CNA, head to toe observation performed. Noted red areas/scrapes to right lower side and back, no bleeding/drainage observed; area cleaned and skin protecting ointment applied. ROM (range of motion) observed as prior to fall without change.
On 11/11/23 at 3:26pm, V16(LPN) documented in part: Fall in the dining area; resident observed seated on floor with left leg bent and yelling from pain. Resident assisted by 3 staff into wheelchair to nurses' station. Appropriate staff made aware; PCP (Primary Care Physician) made aware, ordered to send to ER (Emergency Room) for evaluation; ambulance phoned for transport.
On 11/14/23 at 10:51pm: V16(LPN) documented in part that R11 was readmitted from Hospital; Diagnosis of left intertrochanteric femur fracture.
On 1/23/24 at 12:46pm, V16(LPN) was interviewed regarding how R11's falls happened on 2 out of the 3 incidents that V16 was the nurse. V16 stated that she(V16) was R11's nurse when the falls dated 10/27/23 and 11/11/23 happened. V16 explained that she does not remember if the fall of 8/10/23 was observed, but she(V16) was at the nursing station when the fall of 11/11/23 happened in the dining room, and she(V16) believes that there was staff in the dining room scheduled to monitor residents in the dining room. At this time, V16 showed the surveyor the dining room monitoring schedule for the day.
On 1/23/23 at 4:39pm, V21(NP/Nurse Practitioner) was interviewed regarding R11's frequent falls and why the nursing staff should follow the care plan for fall prevention, especially for a resident like R11 whose third fall resulted in a fracture. V21 stated that staff should follow the fall care plan to help reduce falls and injuries, and the interventions stated in the care plan should be followed, so the resident will not hurt themselves. The surveyor asked V21 about R11's fall risk and the importance of proper Fall Risk Assessment, high risk or low risk? V21 stated that R11 is definitely a high risk for falls because of weakness and because of history of falls.
R11's care plan dated 9/11/23 signed by V28(LPN) inaccurately stated that R11 is at Low Risk for falls, even though the fall report dated 8/10/23(a month earlier) written by V26(RN/Registered Nurse) stated that R11 is at high risk for falls due to impaired mobility requiring wheelchair use and due to impaired cognition.
2. On 1/22/23 at 12:39pm, another resident, R16, was observed in the wheelchair with a pair of regular white socks with smooth bottom. Inquired from V15(Activity Staff/CNA) if V15 was aware that R16's care plan states to wear proper footwear for safety and fall prevention. V15 stated The socks are smooth on the bottom; not non-skid socks.
On 1/22/24 at 1:55pm, V18(Nurse Consultant) stated that she(V18) is standing in for the Director of Nursing. V18 presented records that show that R16 had a fall on 6/17/2020 and another fall on 7/18/2019. No details of these falls were provided because the electronic health records system had some changes, according to V18.
On 1/23/24 at 11:32am in the third-floor dining room, R16 was observed in a wheelchair that was not locked. V29(CNA) was asked why the wheelchair was not locked since R16 is at risk for falls. V29 attempted to lock the wheelchair but was not successful. V29 stated This wheelchair is old, that's why it cannot lock. I will inform Restorative staff.
On 1/23/24 at 1:45pm, V18 stated that the wheelchair should be locked to reduce the risk of falling. Regarding the non-skid socks, V18 stated that the reason for the non-skid socks is to prevent falls by providing better traction on a smooth floor. V18 added that the correct way to wear the socks is to have the bottom treaded part at the sole of the foot and not on top of the foot.
R16's records reviewed show the following:
Face sheet that list diagnoses which include but are not limited to Epilepsy, Schizophrenia, Glaucoma, and Bipolar Disorder.
MDS section GG dated 11/21/23 shows that R16 requires moderate assistance for functional ability activities and transfers.
MDS section C dated 8/29/23 shows BIMS score of 4 out of 15(severe cognitive impairment).
Care plan Intervention dated 9/19/23 states that R16 should wear proper footwear for safety.
Facility's Fall Prevention and Management Policy dated 6/1/23 states: Initial Assessment: a). All residents will undergo a comprehensive fall risk assessment upon admission. b). Assessments will include factors such as medical history, mobility, medications, cognitive status, and previous fall history. 2. Individualized Care Plans: a). Individualized fall prevention care plans will be developed based on the resident's risk assessment. The Fall prevention care plan will be communicated to all staff members involved in the resident's care.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a cognitively impaired resident who was assessed to be...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a cognitively impaired resident who was assessed to be in pain receives pain management as stated in the pain assessment and care plan. This failure affected one resident(R19) of two residents reviewed for pain management.
Findings include:
R19's face sheet shows diagnoses which include but are not limited to Disorder of Bone Density and Structure, Muscle Wasting and Atrophy, Alzheimer's Disease, and Dependence on Renal Dialysis.
On 1/24/24 at 12:40pm, V22(R19's POA/Family) stated On that day, I went to see him(R19) at the nursing home, and he was across from the nursing station bent forward in a fetal position because of pain in his abdomen. We had to help him get in a wheelchair to take him back to his room, and the nurse did not give any pain medication.
On 1/23/24 at 1:28pm, V18(Nurse Consultant) stated The Director of Nursing just started work today and I will be standing in for her. V18 was interviewed about R19's pain management. V18 stated I looked through and I saw Tylenol administered for pain only once. At this time, V18 presented the Pain assessment records and care plan.
R19's records show the following:
MDS (Minimum Data Status) section C BIMS (Basic Interview for Mental Status) dated 5/17/2023 shows a score of 99(resident unable to complete interview).
Preadmission medication list from the hospital dated 1/25/23 shows that R19 was on Ultram 50mg(milligram) every 12 hours as needed for pain.
Care Plan dated 6/6/22 states R19 is at risk for alteration in comfort related to general aches and pains. Intervention says current pain medication management is not effective. Another intervention says administer medication as ordered and monitor for effectiveness of relief; Complete pain assessment; Educate resident and encourage to ask for pain medication before pain becomes too severe. Consider both pharmacological and non-pharmacological remedies.
Pain assessment dated [DATE] shows that R19 had abdominal pain level that says, Hurts a whole lot. Pain assessment dated [DATE] also shows that R19 had lower abdominal pain level that says, Hurts a whole lot.
On 12/17/22 at 6:48am, R19's progress note written by V20(Nurse) states in part: Resident complained of lower back pain, he described as burning pain and unable to sleep. Assessment was done. NP (Nurse Practitioner) was made aware, and he gave an order for X-ray of lumbar spine, Ibuprofen 600mg stat. However, MAR (Medication Administration Records) for December 2022 does not show that Ibuprofen 600mg(milligram) was administered to R19. Also, the POS (Physician Order Sheet) for December 2022 does not show that any pain medication was ordered for R19.
On 1217/22 at 2:58pm, V20(Nurse) documented in part: Writer assessed the patient and noted that he currently complains of lower abdominal pain. Patient unable to numerically rate pain.
Facility's Pain Management Program dated 6/2023 states under Purpose: To establish a program which can effectively manage pain in order to remove adverse physiologic and psychologic effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. It is the policy of the facility to facilitate resident's independence, promote resident comfort, preserve, and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program.
Dec 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of four residents (R5) reviewed for ADL care.
Findings include:
R5's medical record (Face Sheet) documents R5 is a [AGE] year-old admitted to the facility on 8.4.2020 with diagnoses including but not limited to: Unspecified Dementia, Type 2 Diabetes Mellitus, Metabolic Encephalopathy, and Unspecified Protein-Calorie Malnutrition. R5's MDS (Minimum Data Set, 9.12.2023) documents:
-BIMS (Brief Interview for Mental Status) of 3 (severe cognitive impairment)
-Bed Mobility/Transfer/Toilet Use: 3/2 (extensive assistance/One-person physical assist
-Bladder/Bowel: 3/3 (always incontinent)
Care plan (initiated 8.5.2020) documents in part, R5 is at risk for potential skin alteration related to comorbidities, impaired mobility, and incontinence. Keep linen clean, dry, and free from wrinkles. Keep skin, clean, dry, and moisturized.
12.6.2023 at 9:38 AM, R5 was observed awake, alert, lying on right side in bed. R5 said she did not know if she was soiled. Call light activated and answered by V19 (CNA-Certified Nursing Assistant). V19 said he is not resident's CNA but would check resident for incontinence. Soft brown feces was noted in R5's brief and on buttocks. R5's Incontinent pad was saturated with urine, a sheet, that had been placed between resident and incontinent pad, was also saturated with urine.
12.6.2023 at 9:43 AM, V14 (CNA-Certified Nursing Assistant) said she is R5's assigned CNA today. V14 said she checked resident around 8:30 AM this morning. V14 said resident was soiled at that time but she did not change resident because V14 had to get R5's roommate out of bed.
12.6.2023 at 10:17 AM, V15 (LPN-Licensed Practical Nurse) said residents should be checked every two hours and as needed (for incontinence). V15 said if a staff member knows a resident is soiled, staff should change the resident then, not wait. V15 said yes there is enough staff on the unit (to take care of residents). V15 said you should not find residents soiled, saturated with urine.
12.6.2023 at 3:34 PM, V2 (DON-Director of Nursing) said, our protocol is to check residents every two hours and as needed. If staff member finds a resident soiled, the staff member should change the resident.
V14's Employee Coaching/Counseling Form (12.6.2023) documents employee failed to provide incontinence care in a timely manner. Employee was educated on ensuring incontinence care is provided timely and requesting assistance when needed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required...
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Based on observation, interview, and record review, the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of three residents (R5) reviewed for ADL care.
Findings include:
On 12.6.2023 at 9:35 AM on 3 South, the census was 42, there were two nurses (V15-Licensed Practical Nurse and V23-Registered Nurse), and four Certified Nursing Assistants (V14, V19, V23, and V25).
12.6.2023 at 9:38 AM, R5 was observed awake, alert, lying on right side in bed. Call light activated by Surveyor; answered by V19 (CNA-Certified Nursing Assistant). V19 said he is not resident's CNA but would check resident for incontinence. Large soft BM was noted in brief and smeared on resident's buttocks. Incontinent pad was saturated with urine, a sheet, that had been placed between resident and incontinent pad, was saturated with urine as well.
12.6.2023 at 9:43 AM, V14 (CNA-Certified Nursing Assistant) said she is R5's assigned CNA today. V14 said she checked resident around 8:30 AM this morning. V14 said resident was soiled at that time but she did not change resident because V14 had to get R5's roommate out of bed.
12.6.2023 at 10:17 AM, V15 (LPN-Licensed Practical Nurse) said residents should be checked every two hours and as needed (for incontinence). V15 said if a staff member knows a resident is soiled, staff should change the resident then, not wait. V15 said yes there is enough staff on the unit (to take care of residents). V15 said you should not find residents soiled, saturated with urine.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours a day for five of eight days reviewed for October 2023 (10.8, 10.21, ...
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Based on interview and record review, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours a day for five of eight days reviewed for October 2023 (10.8, 10.21, 10.22, 10.28, 10.29) and two of eight days (11.5, 11.26) reviewed for November 2023.
Findings include:
12.5.2023 at 2:59 PM, V3 (former Staffing Coordinator) said there is always an RN in the building for eight hours a day, seven days a week.
12.7.2023 at 1:09 PM, V3 (Former Staffing Coordinator) went through all available staffing assignment sheets for 10.5.23-12.5.23; not all sheets available for each day/each shift. No RN staffing worked on the following days: 10.8.23, 10.21.23, 10.22,23, 10.29.23, 11.26.23, 12.2.23, and 12.3.23.
12.8.2023 at 10:51 AM, V1 (Administrator) said there should be an RN (Registered Nurse) for eight hours a day seven days a week.
Time Card Reports for October 2023 document there was no RN working in the facility on 10.8, 10.21, 10.22, 10.28, and 10.29. Time Card Reports for November 2023 document there was no RN working in the facility 11.5 and 11.26.
Nov 2023
12 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure one resident (R22) was free from severe phys...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure one resident (R22) was free from severe physical abuse and emotional trauma caused by three staff members. This failure resulted in R22 sustaining a right black eye, scratches under the eye and a scratch on top of R22's head after being repeatedly punched by staff members. The staff failed to recognize abusive behavior towards R22. Staff continued to work in the facility; facility staff failed to assess and monitor R22 for injuries.
This was identified as an immediate jeopardy which began on 10/12/23 when R22 was attacked by three facility staff members.
On 10/19/23 at 2:06 PM the Administrator and Nurse Consultant were notified and presented with the immediate jeopardy template. The immediate jeopardy began on 10/12/23.
The facility presented a removal plan on 10/20/23 at 10:16 AM that could not be accepted. The facility sent a revised plan on 10/20/23 at 3:00 PM. The facility's removal plan was accepted on 10/20/23 at 4:44 PM. However, the deficiency remains out of compliance at the second level of harm until the facility evaluates the effectiveness of the removal plan.
Findings include:
According to interviews with V1 (Administrator) and V55 (Laundry Aide), on 10/12/23 and 10/13/23, V21 (Licensed Practical Nurse), V56 (Licensed Practical Nurse), and V57 (Certified Nursing Assistant) physically attacked R22 by punching and hitting R22 multiple times while R22 was sitting in a wheelchair in the hallway. The attack was witnessed by V55 (Laundry Aide). Progress note dated 10/13/23, LATE ENTRY, created 10/16/23, reads in part: On 10/13/23 the Administrator received a report from housekeeping that the resident (R22) was involved in an incident where staff allegedly exhibited inappropriate behavior towards R22. On 10/13/23 at approximately 2:20pm, the writer observed bruising on R22's face.
According to facility daily staff schedules and attendance/timecard documents, all three staff members involved, continued to work their shifts on 10/12/23 (day of the incident). V56 worked a second shift on that day. All three staff returned to work on 10/13/23 and worked on R22's floor/unit. On 10/13/23 surveyor observed and interviewed V21 and V56 while on R22's floor/unit. There was no documentation in R22's electronic medical record on 10/12/23 detailing an incident involving abuse, or that R22 was sent out to the hospital, that the physician, law enforcement, or family were notified.
On 10/13/23 at 2:33 PM, R22 stated, I can walk a little but not that long. I can get in the wheelchair by myself. They took my wheelchair. The white girl at the desk took it. She took the chair to keep me from getting up and walking. I been in this bed two days. I don't know why she don't want me to walk. The white lady nurse poked me in the eye and back of my head with a writing pen. I don't know why, maybe I was getting smart with her.
On 10/13/23 at 2:33 PM, surveyor observed R22's right eye was black with a scratch underneath. Observed scratches on the top of R22's head, right side.
On 10/13/23 approximately 3:15 PM, R22 said she looked like you (surveyor), she poked me with a pen. V57 (Certified Nursing Assistant) told me not to talk to you.
Facility Incident Investigation final report, 10/19/23, reads in part: Right eye ecchymosis and right forehead bump all consistent with strike from fall. The facility is unable to substantiate abuse as there is no credible evidence that abuse occurred related to several conflicting descriptions of the events occurring on October 12. Two resident Witness Statements included with the final report say they witnessed staff hit R22.
R22 Order Listing Report/Physician Order Summary, printed 10/19/23, reads in part: Monitor discoloration to facial area, last order date 10/16/23. R22 Treatment Administration Record, 10/23, reads in part: Monitor discoloration to facial area one time a day, start date 10/17/2023.
R22 Order Listing Report/Physician Order Summary, printed 10/19/23, reads in part: Send out for CT (Computed Tomography) scan, last order date 10/13/23; STAT facial bone x-ray, last order date 10/13/23.
Hospital record, 10/13/23, physical exam of R22 reveals bilateral orbital ecchymosis. Diagnostic Imaging Report, 10/13/23, CT (Computed Tomography) scan of the brain without contrast, there is mild swelling and hematoma in the right frontal scalp.
On 10/13/23 at 3:22 PM, V1 (Administrator) stated V55 (Laundry Aide) reported to V1 that V55 heard three staff members beat up R22. V1 reports that V55 said V55 was on the floor (3 North) and saw part of it, V55 told me V55 was passing out laundry, R22 was in the medication line and tried to jump in front of R26. R22 stuck R22's leg out to trip R26. V57 (Certified Nursing Assistant) intervened to move R26 out of the line. R22 was swinging at V57 and hit V57's ear. Nurses, V21 and V56, came over to assist V57 because R22 was swinging on V57. V55 said she observed the nurse(V56) hit R22. V55(Laundry Aide) said it happened yesterday (10/12/2023). V55 said she attempted to report it yesterday but said I wasn't here in my office. V1 stated, I was here all day yesterday. V55 said there were other residents in the hallway when it happened. I interviewed residents on the unit. They said they saw R22 swinging at V57. V1 said, Nobody said they witnessed the staff fight/hit R22. V55 was not working today (10/13/2023). V55 came in, off-duty, to report. V55 came in between 12:50 PM to 1:10 PM. V1 said, No other staff reported this. I sent the reportable today at approximately 3 PM. V56 was suspended today pending investigation.
R22's 10/13/23 facesheet documents R22 is [AGE] years old. R22 has diagnoses not limited to dementia, mood disorder, difficulty in walking, unsteadiness on feet, bipolar disorder, osteoarthritis, seizures, major depressive disorder, Alzheimer's disease, acute systolic (congestive) heart failure, type 1 diabetes mellitus. MDS, 7/3/23, documents R22 has a BIMS (Brief Interview for Mental Status) of 06 suggesting R22 has severely impaired cognition, does not have hallucinations or delusions and R22 uses a wheelchair.
R22's care plan initiated 4/26/22 documents in part: Dementia. The resident has impaired cognitive function/dementia or impaired thought process related to dementia; with an intervention to communicate with the resident/family/caregivers regarding residents' capabilities and needs; R22's care plan initiated 4/5/23 documents in part: Resident may be at risk for potential abuse related to behavior problem; with an intervention assure resident that they are in a safe and secure environment with caring professionals; R22's care plan initiated 4/5/23 documents in part: Resident may be at risk for potential abuse related to mental/emotional challenges; with intervention report any unusual behavior or incident to supervisor; R22's care plan initiated 2/25/21 documents in part: The resident is/has potential to demonstrate physically aggressive behaviors related to anger, poor impulse control; with intervention when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later.
On 10/17/23 at 10:30 AM, V1 (Administrator) stated V56 (Licensed Practical Nurse), V21 (Licensed Practical Nurse), and V57 (Certified Nursing Assistant) were suspended for the abuse investigation. V1 stated the facility cameras do not work.
On 10/17/23 at 1:55 PM, V1 (Administrator) stated V1 is not sure if staff have CPI (Crisis Prevention & Intervention) training cards. All staff are trained on de-escalation. Residents are not supposed to be physically held down by staff. That would only happen if a physician gave an order for restraint. But we don't do that, we are a restraint free facility. If a resident is being held down that is a restraint, that is abuse. I am the Abuse Coordinator. If staff witness abuse, they are to report it to me. Staff are in-serviced on abuse at least quarterly. Abuse is a reportable incident it should be immediately reported to IDPH (Illinois Department of Public Health). We have two hours to submit a reportable. The three staff involved worked in the facility on 10/13/23 (the day after the abuse incident). I did not know about the incident on 10/12/23. I found out about the incident on 10/13/23.
On 10/17/23 at 3:05 PM, V2 (Director of Nursing) stated I was not told on Thursday, 10/12/23, about an incident involving abuse. I was made aware on Friday, 10/13/23. In the morning meeting, I was told by V1 (Administrator) that V55 (Laundry Aide) told V1 they witnessed abuse from the nursing staff. The alleged nurses said residents were in line for medications. R22 attempted to kick a resident and V57 (Certified Nursing Assistant) tried to stop R22. All three staff, V21 (Licensed Practical Nurse), V57, and V56 (Licensed Practical Nurse) stated no one physically touched R22 outside of trying to grab R22's hand to stop R22 from hitting another resident. V57 said V57 grabbed R22's hand to stop R22 from hitting a resident. We do not restrain here. It can be abuse if they cannot release themselves from the restraint. We call a code if a patient is hurting self and others. We remove them to keep them safe. We usually use verbal redirection. R22 is verbally aggressive, threatening, has attempted to hit people. R22 is usually re-directable. Yes, staff get behavior management and de-escalation training/CPI (Crisis Prevention & Intervention) training.
On 10/17/23 at 10:55 AM, V55 (Laundry Aide) stated I was on the floor, 3 North, on Thursday morning (10/12/23), maybe 10:30 AM to 11 AM. I know it was before 12 PM. I was delivering clothes. The residents were lined up for medication. I saw R22. R26 said Why you kick me. R22's leg is always extended out. There are no foot props on R22's wheelchair. R22 said I didn't kick you. V21 (Licensed Practical Nurse) asked who kicked you. V21 said I'm sick of R22. R22 got to go. V57 (Certified Nursing Assistant) moved R22 out of the line, moving toward R22's room. R22 was swinging back, saying Leave me alone. V57 took a pen out of V57's pocket and started stabbing R22 in the neck and head. V55 grabbed surveyors ink pen and demonstrated what V55 witnessed. V55 said and demonstrated that V57 clicked the pen to eject the ink cartridge as if to write and made stabbing motions. V55 said R22 was trying to block V57. V21 had R22's arm folded/pinned back. R22 was saying Let me go. V56 (Licensed Practical Nurse) started punching R22 in the face so hard. It was horrible. V55 stood up and demonstrated a fighting/boxing stance with both fists up. V55 said that is how V56 was fighting R22, like a boxer. Nobody came to stop it. They kept beating R22. They had no remorse that R22 was a helpless old man. V57 stabbed R22, had to be about 30 times. They did not investigate if the other resident was kicked. They don't like R22 for some reason. I don't know why. V57 said That's why your kids don't come see you, and don't answer the phone. V55 said Every time I close my eyes, I see this. I'm not sleeping, eating. I'm scared for R22. At the end, I told V21 to clean V21's face because there were some scratches. V57 said Aint (sic) sxxt wrong with me, I'm straight. R22 never touched V57 because V57 kept backing up. R22 was in the wheelchair the whole time. R22 has mobility issues. R22 can't get up right away. After, I saw V68 (Restorative Aide) and V69 (Restorative Aide). They told me to report what I saw. Later, I saw V68. V68 said she saw R22 and R22's head was bandaged, and eye was black and R22 was just lying in the bed. I told my coworker that they just beat R22 for no reason. My coworker told me to go tell the Administrator. The Administrator was not in the office. Just seeing that traumatized me. I couldn't work the rest of the day. What I witnessed was total abuse. I don't know who is the Abuse Coordinator. I don't see how this place is still open. I would never want nobody's parent to go through that. They always trying to cover up something. They did not try to talk to R22. V29 (Housekeeper) was on the floor at that time. I saw R25 on the floor at that time. Since I did not find the Administrator, I called my boss, V33 (Housekeeping Director), to report what I saw. I told V33 a resident was abused by two nurses and a CNA (Certified Nursing Assistant). I couldn't find the Administrator. I left that day around 1 PM to 1:30 PM. V55 said V55 has been at the facility since 2019. During the interview, V55 was observed crying/tearful and shaking.
On 10/17/23 at 11:40 AM, V33 (Housekeeping Director) stated I was off that day (10/12/23). V55 (Laundry Aide) called me at home crying. V55 said V55 seen something V55 thought V55 would never experience. V55 saw two nurses and a CNA brutally attack a resident. One was bending R22's hand back, one was restraining R22 in the chair and hitting R22 in the face, one was poking R22 with a pen. V55 said V1 (Administrator) was not in the office. I reached out to V1 to tell V1 what I was told. I text V1 that my Laundry Aide witnessed abuse of a resident. V1 text me back that V1 knew of an incident that R22 fell out of the bed. I notified V38 (Human Resource Director) on that Friday morning (10/13/23) around 8:30 AM. When I told V1 the story on Friday, V2 (Director of Nursing) was in the office and V2 was saying I don't believe that. V2 was trying to brush it off. I have been in-serviced on abuse, drug abuse, and abatement plan. The Administrator is the Abuse Coordinator. I've heard staff talking to residents recklessly saying things like That's why your family don't visit you. I've heard V57 say that to a resident. I have not witnessed staff cussing at residents.
On 10/17/23 at 11:55 AM, V38 (Human Resource Director) stated V33 (Housekeeping Director) said V33's staff member (V55) witnessed a resident being abused. We went to the morning meeting on Friday (10/13/23). I told V33 to tell V1 (Administrator). After V33 talked to V1, I saw V33 and V33 said they V1 and V2 (Director of Nursing) said the resident had a fall. Everybody has the abuse tag attached to their badge. I have not received reports of staff being under the influence of alcohol or drugs.
On 10/17/23 at 1:30 PM, V29 (Housekeeper) stated I am the housekeeper for 3 North. Friday (10/13/23) I was in R22's room sweeping. A nurse came into the room to change R22's head bandage. The nurse said to R22, You got your ass whooped. R22's head was wrapped in gauze and R22's right eye was black. I asked R22 who beat R22 up. R22 said The CNA, nurse, she on the clock now. [All three staff members named in the incident were working 10/13/23 the day after the abuse incident.] R22 is not cooperative, R22 is verbally aggressive when R22 don't get R22's way. R22 is in a wheelchair. R22's left leg don't really work. The left leg gets under the chair and slows R22 down. Nurses get impatient and push R22 out the way. I've seen V21 (Licensed Practical Nurse) deny R22 to use the phone when R22 has asked. I didn't report because it happened already. I have been in-serviced on abuse. The Administrator is the Abuse Coordinator. We report abuse to the Administrator. I have witnessed staff cussing at residents, especially V57 (Certified Nursing Assistant).
On 10/17/23 at 2:30 PM, V54 (Nurse Practitioner) stated it was reported that R22 had a fall on Thursday (10/12/23). They didn't see bruising or trauma on Thursday. Friday (10/13/23), according to staff, R22 had bruising on orbit around the eye, and I ordered to send R22 out. They thought bruising was from the fall. They notified me on Thursday of a fall but no notable trauma. Nothing to send out for on Thursday. They did not notify me of R22 being hit/abused. It is absolutely not okay for staff to hit a resident. R22 can be a little agitated at times, needs redirection. R22 was too aggressive on the dementia unit and was moved. R22 has cognitive impairment. Some dementia residents don't feel this is their normal and are aggressive. That is still no reason for staff to hit a resident. I don't condone for any resident to be hit, aggressive or not. Staff have not told me about behaviors from R22 lately that I would want to do urine testing. R22 uses a wheelchair, has an unsteady gait, is very tall. R22 can fall if R22 does not use the wheelchair. R22 is on blood thinners and can bruise easily. I noticed right orbit bruising. I did not order for head to be wrapped, there was no reason. R22 has one red area on top of the head, maybe a birthmark and has random scratches. R22 has low platelet count so bruises easier from any trauma, including being hit.
On 10/19/23 at 8:06 AM, V68 (Restorative Aide) stated I was informed about a resident being hit by V55 (Laundry Aide). V55 told us (myself and V69) V55 saw a staff member hit a resident. I told V55 to talk to the Administrator who is the Abuse Coordinator and the Director of Nursing.
On 10/19/23 at 8:10 AM, V69 (Restorative Aide) stated V55 (Laundry Aide) told me V55 saw a resident being hit by a staff member. V55 was distraught/emotional. V55 did not know what to do. We (I and V68) directed V55 to the Administration office.
On 10/19/23 at 8:40 AM, V19 (Wound Care Coordinator) stated I've been here as the treatment nurse for over ten years. R22 had a body assessment done on Monday (10/16/23). Monday was the first time I saw R22. Monday the nurse on the floor notified me that R22 needs a body check. I noticed discoloration (redness), yellowing, bruising around both eyes, minor abrasions to neck (right side) and head had abrasions back of the head, right side. They were new, fresh.
On 10/19/23 at 9:35 AM, V20 (Treatment Nurse) stated R22 doesn't have any wounds. I am familiar with R22 because I used to work the floor. R22 has no open wounds, no drainage. R22 has discoloration and yellowing of the right side of the face, eye and eyebrow area and forehead.
On 10/19/23 at 10:02 AM, V4 (Social Service Director) stated I am familiar with R22. V1 (Administrator) told me on Friday about the abuse allegation. R22 has a diagnosis of confusion. R22 states R22 has been attacked but cannot say by who or when. If you ask R22 again R22 will say that R22 fell.
On 10/19/23 at 10:21 AM, V33 (Housekeeping Director) stated I text V1 (Administrator) on 10/12/23 at 4:40 PM It was brought to my attention of abuse to a resident, R22 in room ###. R22 has a black eye. V1 replied on 10/12/23 at 5:06 PM Thank you for reporting R22 had a fall.
On 10/19/23 at 12:27 PM, R25 said R22 hit the staff. Staff hit R22 back. I was trying to stay out of it and walked the other way.
On 10/19/23 at 12:33 PM, R26 said R22 swung at me. V57 grabbed R22's wheelchair and pushed R22 toward R22's room. R22 swung back and hit V57. V56 and V21 grabbed R22's arms, one on each side. V57 was in front of R22. They pulled R22 into R22's room, that's the last I saw.
On 10/20/23 at 9:34 AM, V21 (Licensed Practical Nurse) stated V21 was in the process of setting up the medication cart. I heard a commotion in the hallway. As I was coming out of the nourishment room, R22 was kicking and flailing trying to hit staff [V57 (Certified Nursing Assistant) and V56 (Licensed Practical Nurse)]. I don't know why R22 was trying to hit them. I was told later, R22 had an altercation with another resident, R26, and they were trying to separate them. This happened in the hallway. There were other residents present. I tried to help get R22 to R22's room. The three of us (myself, V56 and V57) took R22 to R22's room. R22 was still flailing at us. R22 was in a high-back wheelchair at the time. R22 can take a few steps on R22's own, from what I've seen. I've seen R22 stand and get into R22's wheelchair or into the bed on R22's own. I walked out after getting R22 into the room. I went to the bathroom to gain my composure and wash my face. I don't know when the other two staff left R22's room. R22 is a psych patient and getting them into their own rooms is sometimes calming to the resident. R22 is very strong. I was trying to hold R22's left arm. I grabbed R22's left arm so R22 couldn't hit me. Because it was going so fast, I did not see the other two staff hold R22 anywhere. I'm not sure of all R22's diagnoses but I would not be surprised if R22 has dementia. R22 definitely is psych but I don't know 100% if R22 is a dementia patient. I did not hit R22, and I didn't witness the other two staff hit R22. I didn't see anyone punch R22 or stab R22 with an ink pen. I looked at R22 as I walked out of the room. I did not see any injuries on R22. R22 was not my resident. For the rest of the shift when I passed R22's room I did not notice anything out of the ordinary, but I did not go into the room. This happened on Thursday (10/12/23). I worked the next day, Friday (10/13/23), on R22's floor. R22 was not my resident. I can't recall seeing R22 on Friday. On Friday, you (surveyor) asked if I knew of an incident of staff being abusive to a resident and I said no. The Abuse Coordinator is the Administrator. Types of abuse are verbal, physical, sexual, financial, emotional. I don't remember the last in-service on abuse. I do remember that if I witness abuse, I report it to the Administrator.
On 10/20/23 at 10:11 AM, V56 (Licensed Practical Nurse) stated I was doing my medication pass. I heard loud voices, a verbal altercation. I saw R22 kicking and swinging at R26 and at V57 (Certified Nursing Assistant). I do not know why. I can't say if V57 tried to hold R22 down or if V57 hit R22. I was at my cart. I don't know what was going on over there. My cart was on the other side of the nursing station. They were away from me near the other side of the nursing station. I was on one side of the nursing station, and they were on the other. R22 can become aggressive and upset as R22's normal behavior. R22 was in R22's wheelchair. R26 was standing. R22 can walk slowly, unsteady, but majority R22 uses the wheelchair. I went over to assist in stopping R22 from harming self or others. I don't know if anyone was hit. I was pushing R22's chair forward to R22's room. Usually, when you get R22 away from what made R22 act out and into R22's room, R22 calms down. I don't recall if we pushed R22 into the room or just to the threshold of room and I left. From what I remember, myself and V21 (Licensed Practical Nurse) pushed R22 into R22's room. From what I remember, V57 did not help to wheel R22 into the room. I don't know where V57 was. I don't know if R22 was hit in the process. From the time the incident started to the time it ended, I didn't see any staff hit R22, punch R22 or stab R22 with an ink pen. I did not see any injuries on R22. I was not holding any extremity. I don't recall if V21 was holding an extremity. The Abuse Coordinator is the Administrator. If I witness or am involved in abuse, I am supposed to report it to the Administrator. I can't say when I was in-serviced on abuse. Types of abuse are isolation, if a resident doesn't feel safe, lack of care, resident struck by another resident or staff, verbal. On Friday, you (surveyor) asked if R22 reported anything to me and I told you no.
On 10/20/23 at 10:47 AM, V70 (Certified Nursing Assistant) stated when I arrived at work on 10/12/23, Thursday, at 8 AM, I did rounds. I saw red marks on R22's face. I went to the nurse. V56 (Licensed Practical Nurse), and V57 (Certified Nursing Assistant) said R22 had a fall overnight. When I asked R22 about R22's face, R22 said I'm cool, I'm fine. R22 was my resident that day.
On 10/20/23 at 4:26 PM, V68 (Restorative Aide) stated I saw R22 about an hour to two hours after I talked to V55 (Laundry Aide). I did not go all the way into R22's room. R22's head was wrapped up with a white gauze bandage. R22 was laying in the bed with back to me. I did not see R22's face. I asked R22 what was going on/what was wrong? R22 said R22 wasn't feeling good.
On 10/20/23 at 4:52 PM, V57 (Certified Nursing Assistant) stated we [me, V21 (Licensed Practical Nurse) and V56 (Licensed Practical Nurse)] heard a verbal altercation in the hallway. Went to see what was going on. R22 was swinging at R26. We intervened to hold R22's hand to stop R22 from swinging and to hold R22. We were telling R22 to stop swinging. R22 was swinging at us too. We sent both R26 and R22 to their rooms to separate them. We were blocking R22's swinging/hits. We did not hold R22 down. I did not punch or hit R22. I did not stab R22 with any object. I didn't see nobody hit R22. I didn't see anything happen after they went to their rooms. R22 was not my resident that day. The Administrator is the Abuse Coordinator. I don't recall the last in-service on abuse, but I know about abuse. Physical, mental, financial are types of abuse. If I witness abuse, then I'm supposed to report immediately to the Abuse Coordinator, the Administrator. No, I do not cuss at the residents. No, I do not use foul language at the residents. R22 was in the wheelchair. R22 could roll self to the room. R22 went to the room on R22's own.
Facility daily staff schedule dated 10/12/23, 7 AM-3 PM, indicates V56 (Licensed Practical Nurse), V21 (Licensed Practical Nurse) and V57 (Certified Nursing Assistant) were scheduled to work on 3 North.
Facility daily staff schedule dated 10/12/23, 3 PM-11 PM, indicates V56 (Licensed Practical Nurse), was scheduled to work on 3 North.
Facility daily staff schedule dated 10/13/23, 7 AM-3 PM, indicates V56 (Licensed Practical Nurse), V21 (Licensed Practical Nurse) and V57 (Certified Nursing Assistant) were scheduled to work on 3 North.
Attendance/Timecard document, printed 10/17/23, indicates that on 10/12/23, V56 (Licensed Practical Nurse) was clocked in for 15:00 hours, V21 (Licensed Practical Nurse) was clocked in for 9 hours, V57 (Certified Nursing Assistant) was clocked in for 7:30 hours.
Attendance/Timecard document, printed 10/17/23, indicates that on 10/13/23, V56 (Licensed Practical Nurse) was clocked in for 7:30 hours, V21 (Licensed Practical Nurse) was clocked in for 7:45 hours, V57 (Certified Nursing Assistant) was clocked in for 6:15 hours.
Corrective Action Notices, dated 10/13/23, indicate V56 (Licensed Practical Nurse), V21 (Licensed Practical Nurse) and V57 (Certified Nursing Assistant) were suspended pending investigation for alleged abuse toward a resident.
Facility Incident Investigation initial report, 10/13/23 (one day after the incident), alleges resident abuse.
Chicago Police Department report documents date of occurrence as 10/12/23. On 10/13/23 at approximately 5 PM, surveyor observed two police officers enter the facility. Surveyor asked V1 (Administrator) if the police officers were there for the incident surveyor was investigating and V1 said yes.
Facility Abuse Prevention Program Facility Policy and Procedure, 1/4/18, documents in part: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. During orientation of new employees, the facility will cover at least the following topics: what constitutes abuse, neglect, exploitation, mistreatment and misappropriation of resident property; staff obligations to prevent and report abuse, neglect, exploitation, mistreatment and misappropriation of resident property; dementia knowledge, awareness, management and prevention of abuse/mistreatment; how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff; how to recognize and deal with burnout, frustration, and stress that may lead to inappropriate responses or abusive reaction to residents; an employee's obligation under the law for reporting a suspected crime to the facility, the state survey agency and local law enforcement; the time frames for reporting; and managements obligation to prohibit retaliation against anyone who makes a report. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. Reports should be documented, and a record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act as administrator in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of suspicious bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation, and reporting to the administrator or the person designated to act on behalf of the administrator in the administrator's absence. If the resident complains of physical injuries or if resident harm is suspected, the resident's physician will be contacted for further instructions. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator. Incidents or allegations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be reviewed by administration and shall be investigated as indicated and appropriate. When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigated. This report shall be made immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or resulted in serious bodily injury; or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious bodily injury. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The facility shall also contact local law enforcement authorities in the following situations: Suspected physical abuse involving physical injury inflicted on a resident by a staff member or a visitor.
Facility Behavior Management for Agitated Behavior, 4/14, documents in part: Allow time to calm down with 1:1 explanation of why behavior is inappropriate and unacceptable in a calm, soft voice. Document all interventions attempted and administered and the resident's response to medical interventions.
According to the Facility Assessment, 5/16/2023, the facility offers mental health and behavior care. Manages the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities.
Abatement Plan Accepted by Regional Office on 10/20/23.
The surveyor conducted on site visit on 10/24/23:
What action(s) will be accomplished for the identified re[TRUNCATED]
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/3/23 during investigation, R9 was observed in her room. Surveyor inquired about R9's knowledge of residents consuming alco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/3/23 during investigation, R9 was observed in her room. Surveyor inquired about R9's knowledge of residents consuming alcoholic beverages in the facility.
On 10/3/23 at 10:45 AM, R9 said, I've seen residents getting drunk in the lobby quite frequently. When the nurses try to catch them, they (residents) hide the alcohol. A lot of the agency nurses may not even know what's going on with the drinking.
R9 is [AGE] year old with diagnosis including but not limited to: Hypertension, Gastro- Esophageal Reflux disease, Generalized Edema, Acquired absence of lung and Endocarditis.
R9's BIMS (Brief Interview for Mental Status) score is 15, which indicates cognitively intact.
R13 is [AGE] year old with diagnosis including but not limited to: Alcohol Abuse, Cocaine abuse, Heart failure, Hypertension and Atherosclerotic Heart Disease.
R13 ha a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.
R10 is [AGE] year old with diagnosis including but not limited to: Alcohol use, with intoxication, Hypertensive emergency, Opioid use, Acute Kidney failure, Acute Respiratory failure and Acute pulmonary edema.
R10 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.
During investigation (10/3/23- 10/5/23), Residents observed in the main dining area and the smoking patio unsupervised (with no staff member present).
On 10/4/2023 at 11:20 AM, V46 LPN/ Licensed Practical Nurse said, I have been working here for two weeks. On the 2nd floor I saw R10 drunk when he came to the unit.
On 10/4/23 at 11:45 AM, V21 (Licensed Practical Nurse) said, I have been here for 11 years. I just caught R13 with alcohol on 10/4/23. Resident's drink on the 1st floor (common area) all the time. A lot of them are still using drugs and drinking alcohol. We (Facility) are not sure how they (residents) get drugs or alcohol in the facility. On the 1st floor in the main dining area, I have smelled alcohol but can never pinpoint where the smell is coming from. This is when I will usually begin a search. I have searched and found liquor on residents in the past.
On 10/4/23 at 12:06 PM V4 (Social Service Director) said, R10 has drank alcohol in the main lobby. We have caught him intoxicated several times. The last time I saw R10 drinking was around 9/29/23.
Surveyor inquired about behavior contract, care plan and interventions for R10 and R13.
On 10/5/23 at 12:10 PM, V4 said, R10 or R13 don't have a specific Alcohol care plan. They have substance abuse care plan. That is basically the same thing, but I will put an alcohol care plan in. They (R10 and R13) should have an alcohol care plan. R10 is being involuntarily discharged because of the drinking. R13 is on a 30 day restriction now. She (R13) can't get a pass to go outside the facility for 30 days. Other residents drink in the facility too, but it is hard to pinpoint exactly who it is. This has been going on all year.
Surveyor inquired about security in the facility.
On 10/4/23 at 3:32 PM, V38 (Human Resource Director) said, We just hired security staff for the overnight shift. Security starts at 8 PM and the lobby doors lock at 8 PM. Curfew depends on resident's pass. Some residents may come in after 8 PM.
Surveyor requested R13's Nursing progress note regarding R13 drinking alcohol in the facility, authored by V21 on 10/2/23. R13's Nursing progress note was never received.
R10's Progress note dated 12/29/22 documents, it was reported that R10 was drinking alcohol in the main dining room area on the first floor.
R10's Nursing progress note dated 1/2023 documents, Social Services encouraged R10 to attend inpatient substance abuse treatment at Alcoholism and Substance Abuse center. R10 was educated on noncompliance with the treatment plan.
R10's Nursing progress noted dated 2/20/23 documents, Social Services met with R10 due to R10's noncompliance with Substance and Alcohol Abuse program.
R10's Care plan excluded Focus or Interventions pertaining to Alcohol Abuse/ Use in facility.
R13's Care plan excluded Focus or Interventions pertaining to Alcohol Abuse/ Use in facility.
Facility policy titled, Substance Use Procedure and Policy documents, it is the policy of Facility that the possession, sale, distribution and/or use of alcohol and/or other drugs is strictly prohibited in this facility.
Facility policy titled, Supervision and Safety documents, Resident supervision is a core component to resident safety.
Based on interviews and record reviews, the facility failed to provide supervision and interventions for two residents (R10 and R13) with substance abuse.
Findings include:
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
On 10/13/23 at 3:22 PM, V1 (Administrator) stated V55 (Laundry Aide) reported to V1 that V55 heard three staff members beat up R22. V55 said V55 was on the floor (3 North) and saw part of it. V55 told...
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On 10/13/23 at 3:22 PM, V1 (Administrator) stated V55 (Laundry Aide) reported to V1 that V55 heard three staff members beat up R22. V55 said V55 was on the floor (3 North) and saw part of it. V55 told me V55 was passing out laundry. R22 was in the medication line and tried to jump in front of R26. R22 stuck R22's leg out to trip R26. V57 (Certified Nursing Assistant) intervened to move R26 out of the line. R22 was swinging at V57 and hit V57's ear. Nurses, V21 and V56, came over to assist V57 because R22 was swinging on V57. V55 said V55 observed the nurse, V56, hit R22. V55 said it happened yesterday (10/12/2023). V55 said V55 attempted to report it yesterday but V55 said I wasn't here in my office. I was here all day yesterday. V55 said there were other residents in the hallway when it happened. I interviewed residents on the unit. They said they saw R22 swinging at V57. Nobody said they witnessed the staff fight/hit R22. V55 was not working today (10/13/2023). V55 came in, off-duty, to report. V55 came in approximately 12:50 PM to1:10 PM. No other staff reported this. I sent the reportable today at approximately 3 PM. V56 was suspended today pending investigation.
On 10/17/23 at 10:55 AM, V55 (Laundry Aide) stated I was on the floor, 3 North, on Thursday morning (10/12/23), maybe 10:30 AM to 11 AM. I know it was before 12 PM. I was delivering clothes. The residents were lined up for medication. I saw R22. R26 said Why you kick me. R22's leg is always extended out. There are no foot props on R22's wheelchair. R22 said I didn't kick you. V21 asked who kicked you. V21 said I'm sick of R22. R22 got to go. V57 moved R22 out of the line, moving toward R22's room. R22 was swinging back, saying Leave me alone. V57 took a pen out of V57's pocket and started stabbing R22 in the neck and head. V55 grabbed surveyors ink pen and demonstrated what V55 witnessed. V55 said and demonstrated that V57 clicked the pen to eject the ink cartridge as if to write and made stabbing motions. V55 said R22 was trying to block. V21 had R22's arm folded/pinned back. R22 was saying Let me go. V56 started punching R22 in the face so hard. It was horrible. V55 stood up and demonstrated a fighting/boxing stance with both fists up. V55 said that is how V56 was fighting R22, like a boxer. Nobody came to stop it. They kept beating R22. They had no remorse that R22 was a helpless old man. V57 stabbed R22, had to be about 30 times. They did not investigate if the other resident was kicked. They don't like R22 for some reason. I don't know why. V57 said That's why your kids don't come see you, don't answer the phone. V55 said Every time I close my eyes, I see this. I'm not sleeping, eating. I'm scared for R22. At the end, I told V21 to clean V21's face because there were some scratches. V57 said Aint (sic) sxxt wrong with me I'm straight. R22 never touched V57 because V57 kept backing up. R22 was in the wheelchair the whole time. R22 has mobility issues. R22 can't get up right away. After, I saw V68 and V69. They told me to report what I saw. Later, I saw V68. V68 said she saw R22 and R22's head was bandaged, and eye was black and R22 was just lying in the bed. I told my coworker that they just beat R22 for no reason. My coworker told me to go tell the Administrator. The Administrator was not in the office. Just seeing that traumatized me. I couldn't work the rest of the day. What I witnessed was total abuse. I don't know who is the Abuse Coordinator. I don't see how this place is still open. I would never want nobody's parent to go through that. They always trying to cover up something. They did not try to talk to R22. V29 (Housekeeper) was on the floor at that time. I saw R25 on the floor at that time. Since I did not find the Administrator, I called my boss, V33 (Housekeeping Director), to report what I saw. I told V33 a resident was abused by two nurses and a CNA (Certified Nursing Assistant). I couldn't find the Administrator. I left that day around 1 PM to 1:30 PM. V55 said V55 has been at the facility since 2019. During the interview, V55 was observed crying/tearful and shaking.
On 10/17/23 at 11:40 AM, V33 (Housekeeping Director) stated I was off that day (10/12/23). V55 called me at home crying. V55 said V55 seen something V55 thought V55 would never experience. V55 saw two nurses and a CNA brutally attack a resident. One was bending R22's hand back, one was restraining R22 in the chair and hitting R22 in the face, one was poking R22 with a pen. V55 said V1 (Administrator) was not in the office. I reached out to V1 to tell V1 what I was told. I text V1 that my Laundry Aide witnessed abuse of a resident. V1 text me back that V1 knew of an incident that R22 fell out the bed. I notified V38 (Human Resource Director) on that Friday morning (10/13/23) around 8:30 AM. When I told V1 the story on Friday, V2 (Director of Nursing) was in the office and V2 was saying I don't believe that. V2 was trying to brush it off. I have been in-serviced on abuse, drug abuse, and abatement plan. The Administrator is the Abuse Coordinator. I've heard staff talking to residents recklessly saying things like That's why your family don't visit you. I've heard V57 say that to a resident.
On 10/17/23 at 1:55 PM, V1 (Administrator) stated V1 is not sure if staff have CPI (Crisis Prevention & Intervention) training cards. All staff are trained on de-escalation. Residents are not supposed to be physically held down by staff. That would only happen if a physician gives an order for restraint. But we don't do that, we are a restraint free facility. If a resident is being held down that is a restraint that is abuse. I am the Abuse Coordinator. If staff witness abuse, they are to report it to me. Staff are in-serviced on abuse at least quarterly. Abuse is a reportable incident it should be immediately reported to IDPH (Illinois Department of Public Health). We have two hours to submit a reportable. The three staff involved worked in the facility on 10/13/23 (the day after the abuse incident). I did not know about the incident on 10/12/23. I found out about the incident on 10/13/23. All staff get background checks.
On 10/19/23 at 10:21 AM, V33 (Housekeeping Director) stated I text V1 (Administrator) on 10/12/23 at 4:40 PM It was brought to my attention of abuse to a resident, R22 in room ###. R22 has a black eye. V1 replied on 10/12/23 at 5:06 PM Thank you for reporting R22 had a fall.
Facility Abuse Prevention Program Facility Policy and Procedure, 1/4/18, documents in part: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. During orientation of new employees, the facility will cover at least the following topics: what constitutes abuse, neglect, exploitation, mistreatment and misappropriation of resident property; staff obligations to prevent and report abuse, neglect, exploitation, mistreatment and misappropriation of resident property; dementia knowledge, awareness, management and prevention of abuse/mistreatment; how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff; how to recognize and deal with burnout, frustration, and stress that may lead to inappropriate responses or abusive reaction to residents; an employee's obligation under the law for reporting a suspected crime to the facility, the state survey agency and local law enforcement; the time frames for reporting; and managements obligation to prohibit retaliation against anyone who makes a report. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. Reports should be documented, and a record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act as administrator in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of suspicious bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation, and reporting to the administrator or the person designated to act on behalf of the administrator in the administrator's absence. If the resident complains of physical injuries or if resident harm is suspected, the resident's physician will be contacted for further instructions. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator. Incidents or allegations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be reviewed by administration and shall be investigated as indicated and appropriate. When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigated. This report shall be made immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or resulted in serious bodily injury; or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious bodily injury. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The facility shall also contact local law enforcement authorities in the following situations: Suspected physical abuse involving physical injury inflicted on a resident by a staff member or a visitor.
Based on interview and record review the facility failed to report to IDPH (Illinois Department of Public Health) incidents of illicit drug overdose for one resident (R3) in the sample reviewed for opiates overdose; and failed to report to IDPH within the required regulation time an allegation of abuse of R22 by facility staff members.
Findings include:
On 09/27/23 at 10:15am, R3 had a change in condition. R3 was found unresponsive and was transferred to the local hospital. Assessment showed that R3 has altered mental status secondary to opiates overdose. Emergency care rendered to R3 includes but not limited to intubation (Mechanical Ventilation) for adequate airway protection and was admitted to ICU (Intensive Care Unit) for further management of Hypercapnic Respiratory failure secondary to opiate abuse.
R3's hospital record Encounter Summary showed reason for hospital visit includes Respiratory Distress, drug overdose.
EMS (Emergency Medical Services) report showed documentation that according to the nurse, who called 911 this morning, patient was not taking any narcotic based medications because patient's current medical conditions do not require any strong painkillers. Patient (R3) was found unresponsive approximately 20 to 30 minutes earlier. The nurse stated that patient is usually ambulatory at the scene (facility) and very active. ALS (Advance Life Services) Care was initiated at bed side including initial dose of Narcan 2 milligrams followed by EKG and vital signs monitoring supportive oxygen, and IV access. Patient removed from the scene and situated on ambulance stretcher in the treatment compartment of unit 76. The second dose of 2mg of Narcan was administered. Shortly later it was noticed that patient (R3) respiratory rate increased to about 24 and SPo2 reading increased from initial 66% on room air to 97%. At this point, patient was still completely unresponsive with GCS of three. On-route to (local hospital) ALS care continued. The third dose of 2 milligrams of Narcan IV was administered due to patient's altered mental status. Shortly after it was noticed that patient opened his eyes and started talking. Patient (R3) admitted snorting one line of heroin sometime earlier this morning.
R3's medical record showed documentation on the MDS (Minimum Data Set) that R3 BIMS score is 04, indicating that R3 is cognitively impaired and does not have an independent community pass without supervision due to BIMS score of 04 showing that R3 is cognitively impaired.
R3's medication list showed no order for narcotic medication.
On 10/11/23 at 11:02am, V1 (Administrator) stated that she (V1) did not report to IDPH because I (V1) did not think it should be reported.
On 11/02/23 at 5:01pm the facility reviewed diagnosis listed on the plan of care includes poisoning by heroin, accidental unintentional initial encounter.
The facility policy Incident / Accident reports dated 04/23 documented in part the incident / accident report is completed for all accidents, or incidents that includes where there is injury or potential for result in injury. Procedure listed includes but not limited to accidental / incidental unusual occurrences, all unexpected events that occur that cause actual or potential harm to a resident. The policy indicated that the Administrator, Director of Nursing, Assistant Director of Nursing, or Nursing Supervisor must notify the following if a serious injury occurs: the IDPH (Illinois Department of Public Health) as soon as possible within twenty-four (24) hours of occurrence. A narrative follow-up summary of incident is to be sent to the IDPH within five (5) working days. Incidents of unknown origin are to be investigated thoroughly to rule out abuse. These are to be reported to IDPH.
The policy indicated that results of investigations are analyzed, and findings discussed in safety meetings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R22's 10/13/23 facesheet documents R22 is [AGE] years old. R22 has diagnoses not limited to dementia, mood disorder, difficulty ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R22's 10/13/23 facesheet documents R22 is [AGE] years old. R22 has diagnoses not limited to dementia, mood disorder, difficulty in walking, unsteadiness on feet, bipolar disorder, osteoarthritis, seizures, major depressive disorder, Alzheimer's disease, acute systolic (congestive) heart failure, type 1 diabetes mellitus.
MDS, dated [DATE], documents R22 has a BIMS (Brief Interview for Mental Status) of 06 suggesting R22 has severely impaired cognition, does not have hallucinations or delusions and R22 uses a wheelchair.
According to interviews with V1 (Administrator) and V55 (Laundry Aide), on 10/12/23 and 10/13/23, V21 (Licensed Practical Nurse), V56 (Licensed Practical Nurse), and V57 (Certified Nursing Assistant) physically attacked R22 by punching and hitting R22 multiple times while R22 was sitting in a wheelchair in the hallway. The attack was witnessed by V55 (Laundry Aide). Progress note dated 10/13/23, LATE ENTRY, created 10/16/23, reads in part: On 10/13/23 the Administrator received a report from housekeeping that the resident (R22) was involved in an incident where staff allegedly exhibited inappropriate behavior towards R22. On 10/13/23 at approximately 2:20pm, the writer observed bruising on R22's face.
According to facility daily staff schedules and attendance/timecard documents, all three staff members involved, continued to work their shifts on 10/12/23 (day of the incident). V56 worked a second shift on that day. All three staff returned to work on 10/13/23 and worked on R22's floor/unit. On 10/13/23 surveyor observed and interviewed V21 and V56 while on R22's floor/unit. There was no documentation in R22's electronic medical record on 10/12/23 detailing an incident involving abuse, or that R22 was sent out to the hospital, that the physician, law enforcement, or family were notified.
On 10/13/23 at 2:33 PM, R22 stated R22 can walk a little but not that long. I can get in the wheelchair by myself. They took my wheelchair. The white girl at the desk took it. She took the chair to keep me from getting up and walking. I been in this bed two days. I don't know why she don't want me to walk. The white lady nurse poked me in the eye and back of my head with a writing pen. I don't know why, maybe I was getting smart with her.
On 10/13/23 at 2:33 PM, surveyor observed R22 right eye was black with a scratch underneath. Observed scratches on the top of R22's head, right side.
On 10/13/23 approximately 3:15 PM, R22 said she looked like you (surveyor), she poked me with a pen. V57 (Certified Nursing Assistant) told me not to talk to you.
On 10/17/23 at 10:55 AM, V55 (Laundry Aide) stated I was on the floor, 3 North, on Thursday morning (10/12/23), maybe 10:30 AM to 11 AM. I know it was before 12 PM. R26 said Why you kick me. R22's leg is always extended out. There are no foot props on R22's wheelchair. R22 said I didn't kick you. V21 asked who kicked you. V21 said I'm sick of R22. R22 got to go. V57 moved R22 out of the line, moving toward R22's room. R22 was swinging back, saying Leave me alone. V57 took a pen out of V57's pocket and started stabbing R22 in the neck and head. V55 grabbed surveyors ink pen and demonstrated what V55 witnessed. V55 said and demonstrated that V57 clicked the pen to eject the ink cartridge as if to write and made stabbing motions. V55 said R22 was trying to block V57. V21 had R22's arm folded/pinned back. R22 was saying Let me go. V56 started punching R22 in the face so hard. It was horrible. V55 stood up and demonstrated a fighting/boxing stance with both fists up. V55 said that is how V56 was fighting R22, like a boxer. Nobody came to stop it. They kept beating R22. They had no remorse that R22 was a helpless old man. V57 stabbed, had to be about 30 times. They did not investigate if the other resident was kicked. They don't like R22 for some reason. I don't know why. V57 said That's why your kids don't come see you, don't answer the phone. V55 said Every time I close my eyes, I see this. I'm not sleeping, eating. I'm scared for R22.
On 10/20/23 at 9:34 AM, V21 (Licensed Practical Nurse) stated I heard a commotion in the hallway. As I was coming out of the nourishment room, R22 was kicking and flailing trying to hit staff (V57 and V56). I tried to help get R22 to R22's room. The three of us (myself, V56 and V57) took R22 to R22's room. I was trying to hold R22's left arm. I grabbed R22's left arm so R22 couldn't hit me. For the rest of the shift when I passed R22's room I did not notice anything out of the ordinary, but I did not go into the room. This happened on Thursday (10/12/23). I worked the next day, Friday (10/13/23), on R22's floor. R22 was not my resident. I can't recall seeing R22 on Friday. On Friday, you (surveyor) asked if I knew of an incident of staff being abusive to a resident and I said no. The Abuse Coordinator is the Administrator. Types of abuse are verbal, physical, sexual, financial, emotional. I don't remember the last in-service on abuse. I do remember that if I witness abuse, I report it to the Administrator.
Facility daily staff schedule dated 10/12/23, 7 AM-3 PM, indicates V56 (Licensed Practical Nurse), V21 (Licensed Practical Nurse) and V57 (Certified Nursing Assistant) were scheduled to work on 3 North.
Facility daily staff schedule dated 10/12/23, 3 PM-11 PM, indicates V56 (Licensed Practical Nurse), was scheduled to work on 3 North.
Facility daily staff schedule dated 10/13/23, 7 AM-3 PM, indicates V56 (Licensed Practical Nurse), V21 (Licensed Practical Nurse) and V57 (Certified Nursing Assistant) were scheduled to work on 3 North.
Attendance/Timecard document, printed 10/17/23, indicates that on 10/12/23, V56 (Licensed Practical Nurse) was clocked in for 15:00 hours, V21 (Licensed Practical Nurse) was clocked in for 9 hours, V57 (Certified Nursing Assistant) was clocked in for 7:30 hours.
Attendance/Timecard document, printed 10/17/23, indicates that on 10/13/23, V56 (Licensed Practical Nurse) was clocked in for 7:30 hours, V21 (Licensed Practical Nurse) was clocked in for 7:45 hours, V57 (Certified Nursing Assistant) was clocked in for 6:15 hours.
Facility Abuse Prevention Program Facility Policy and Procedure, 1/4/18, documents in part: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. During orientation of new employees, the facility will cover at least the following topics: what constitutes abuse, neglect, exploitation, mistreatment and misappropriation of resident property; staff obligations to prevent and report abuse, neglect, exploitation, mistreatment and misappropriation of resident property; dementia knowledge, awareness, management and prevention of abuse/mistreatment; how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff; how to recognize and deal with burnout, frustration, and stress that may lead to inappropriate responses or abusive reaction to residents; an employee's obligation under the law for reporting a suspected crime to the facility, the state survey agency and local law enforcement; the time frames for reporting; and managements obligation to prohibit retaliation against anyone who makes a report. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. Reports should be documented, and a record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act as administrator in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of suspicious bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation, and reporting to the administrator or the person designated to act on behalf of the administrator in the administrator's absence. If the resident complains of physical injuries or if resident harm is suspected, the resident's physician will be contacted for further instructions. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator. Incidents or allegations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be reviewed by administration and shall be investigated as indicated and appropriate. When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigated. This report shall be made immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or resulted in serious bodily injury; or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious bodily injury. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The facility shall also contact local law enforcement authorities in the following situations: Suspected physical abuse involving physical injury inflicted on a resident by a staff member or a visitor.
Based on interview and record review the facility failed to conduct a thorough investigation for one resident (R3) reviewed for substance abuse and failed to immediately initiate an investigation into the physical abuse of one resident (R22). These failures resulted in the alleged perpetrators continuing to have access to R22 and exposing R22 to the potential of further abuse and R3 to additional substance abuse.
Findings include:
R3's is a [AGE] year-old male resident that was admitted to the facility initially on 08/30/23 with diagnosis information list that includes but not limited to Schizophrenia unspecified, Major Depressive Disorder, recurrent, unspecified, Hyperlipidemia unspecified, Essential (Primary) Hypertension, Chronic Atrial Fibrillation unspecified, Chronic Obstructive Pulmonary Disease unspecified.
R3's medical record Progress Note by V6 LPN (Licensed Practical Nurse) documented in part that at on 09/27/23 at 10:15am upon rounding, R3 was found unresponsive. Rapid Response (referring to code call to all present staff in the facility) notified and R3 was transferred to the local hospital. Showing no detailed emergency care rendered by staff before EMS was called.
EMS (Emergency medical Services) documentation showed that the facility informed the EMS staff that (R3) was found unresponsive approximately 20 to 30 minutes earlier. R3 was administered three doses of Narcan 2mg and was transferred to the local emergency room for further evaluation. R3 was intubated and admitted with diagnosis that include but not limited to Hypercapnic respiratory failure secondary to opiates overdose, altered mental status, secondary to opiate overdose, opiate abuse.
On 10/02/23 at 12:16pm, V4 SSD (Social Services Director) stated in part that (R3) went out to the hospital unresponsive. R3 did not have a community pass, R3 is only able to go out with family due to his BIMS 04. Due to the BIMS score R4 did not qualify for independent pass. R3 was not on the substance abuse list.
R3's MDS (Minimum Data Set) assessment tool dated showed that R3 has a BIMS (Brief Interview for Mental Status of 04 indicating that R3 is cognitively impaired.
R3's hospital record showed documentation that R3 arrived at the hospital in altered mental status and on 09/27/23 at 11:39am and that R3 was started on mechanical ventilation with high respiratory rate and will be admitted to ICU (Intensive Care Unit) for further management of hypercapnic respiratory failure likely secondary to opiate abuse.
R3's hospital record also showed assessment documentation dated 09/27/23 timed 8:30pm that documented in part that R3' laboratory and radiology result showed R3 was presented to the hospital with altered mental status found to be in hypercapnic respiratory failure requiring intubation, Hypercapnic respiratory failure secondary to opiates overdose, altered mental status, secondary to opiate overdose, opiate abuse, healthcare acquired pneumonia, AKI likely prerenal, COPD, chronic atrial fibrillation, schizophrenia, depression, hypertension, history of substance abuse, with plan to continue mechanical ventilation and started on Zosyn (Antibiotics).
On 10/02/23 at 12:16pm, V4 SSD (Social Services Director) stated in part that (R3) went out to the hospital unresponsive. R3 did not have community pass, R3 is only able to go out with family due to his BIMS 04. Due to the BIMS score R4 did not qualify for independent pass. R3 was not on the substance abuse list.
R3's MDS (Minimum Data Set) assessment tool dated showed that R3 has a BIMS (Brief Interview for Mental Status) of 04 indicating that R3 is cognitively impaired.
On 10/11/23 at 8:55am, V2 DON (Director of Nurse's) stated that when (R3) got back (facility) no investigation was done. V2 stated R3 denies use of drugs any way and test were negative, the paramedics just assumed that R3 was on drugs. There was no need for any investigation.
The facility was unable to present a police report about R3's overdosing on opiates; considering he had a cognitive impairment score BIMS 04 and was not eligible for independent community pass.
The facility was unable to present any plan of care addressing the use of illicit substance abuse whether as a suspicion or not. And no systemic investigation initiated to promote the safety of other residents.
The facility Incident/Accident Report policy dated 04/23 documented in part that incident/accident report is completed for all accidents or incidents where there is injury or potential to result in injury. Procedure listed includes accidents /incident unusual occurrences, all unexpected events that actual or potential harm to a resident. The Administrator, DON, ADON or Nursing supervisor must notify the IDPH (Illinois Department of Public Health) if a serious injury occurs within 24 hours of occurrence with a narrative summary of the incident to be sent to IDPH within (5) working days.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to revise and initiate a plan of care for one resident R3 reviewed fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to revise and initiate a plan of care for one resident R3 reviewed for opiate overdose. This failure affected R3 who was found unresponsive on 09/27/23. R3 was transferred to the local hospital and was admitted with a diagnosis that includes R3 was intubated and admitted with diagnosis that include but not limited to Hypercapnic respiratory failure secondary to opiates overdose, altered mental status, secondary to opiate overdose and opiate abuse.
Findings include:
R3's is a [AGE] year-old male resident that was admitted to the facility initially on 08/30/23 with diagnosis information list of Schizophrenia unspecified, Major Depressive Disorder, recurrent, unspecified, Hyperlipidemia unspecified, Essential (Primary) Hypertension, Chronic Atrial Fibrillation unspecified, Chronic Obstructive Pulmonary Disease unspecified.
R3's medical record Progress Note by V6 LPN (Licensed Practical Nurse) documented in part that on 09/27/23 at 10:15am upon rounding, R3 was found unresponsive. Rapid Response (referring to code call to all present staff in the facility) notified and R3 was transferred to the local hospital.
R3's EMS report documented that the EMS crew found [AGE] year-old male (R3) lying supine on the top of his bed. Initially patient (R3) was completely unresponsive. His eyes were pinpointed and not responding to the light. (R3) skin was cold and diaphoretic. The respiratory rate was severely decreased and inadequate. According to the nurse who called 911 this morning, patient was not taking any narcotic based medications because patient's current medical conditions do not require any strong painkillers. Patient (R3) was found unresponsive approximately 20 to 30 minutes earlier. The nurse stated that patient is usually ambulatory at the scene (facility) and very active. ALS (Advance Life Services) Care was initiated at bed side including initial dose of Narcan 2 milligrams followed by EKG and vital signs monitoring supportive oxygen, and IV access. Patient removed from the scene and situated on ambulance stretcher in the treatment compartment of unit 76. The second dose of 2mg of Narcan was administered. Shortly later it was noticed that patient (R3) respiratory rate increased to about 24 and SPo2 reading increased from initial 66% on room air to 97%. At this point, patient was still completely unresponsive with GCS of three. On-route to (local hospital) ALS care continued. The third dose of 2 milligrams of Narcan IV was administered due to patient's altered mental status. Shortly after it was noticed that the patient opened his eyes and started talking. Patient (R3) admitted snorting one line of heroin sometime earlier this morning. Patient stated he had been using heroin over the past 20 years.
R3's hospital record showed documentation on 09/27/23 at 11:39am that R3 was started on mechanical ventilation with a high respiratory rate and will be admitted to ICU (Intensive Care Unit) for further management of hypercapnic respiratory failure likely secondary to opiate abuse.
R3's hospital record also showed assessment dated [DATE] timed 8:30pm that documented in part that R3' laboratory and radiology result showed R3 was presented to the hospital with altered mental status found to be hypercapnic respiratory failure requiring intubation. Hypercapnic respiratory failure secondary to opiates overdose, altered mental status, secondary to opiate overdose and opiate abuse.
R3's medical record progress not showed documentation that R3 returned to the facility on [DATE], the facility did not revise R3's plan of care for substance abuse until 10/11/23 seven days after.
On 10/04/23 at 10:20am, V6 stated that she (V6) did not know anything about R3 being treated for any drug overdose (referring to opiate abuse). V1 (Administrator) and V2 DON (Director of Nurses) stated R3's care plan is not revised and there was no reason to assess and have a diagnosis to identify R3 for substance abuse because it was just a suspicion.
On 10/11/23 at 2:00pm, V1 (Administrator) presented R3's face sheet and plan of care that showed that R3's care plan has not been revised. V1 stated that there was no reason to assess and have a diagnosis to identify R3 for substance abuse because it was just a suspicion.
On 10/11/23 at 2:03pm, V2 (Director of Nurse's) stated we (referring to the facility) never believed that R3 overdosed on drugs. So R3's plan of care has not been revised or initiated for substance abuse.
As at 10/11/23 at 3:30pm, R3's plan of care has not been revised after the 09/27/23 incident and after readmission the facility did not address the issue of substance abuse even with the EMS and the hospital assessment.
On 10/17/23 at 2:49pm, V54 NP (Nurse Practitioner) stated that R3 should have a diagnosis added and should be care planned for substance abuse. V54 stated she did not add the diagnosis, but the MDS coordinator should.
On 10/17/23 at 3:00pm, V72 (Care Plan Coordinator) stated that he (V72) is in training at this time learning what to be done. V1 then stated that the other MDS coordinator will not be back to the facility for a month and cannot be reached by phone, but I try and get the phone number.
On 10/17/23 at 5:00pm, the facility was unable to present a revised plan of care for R3 focusing on the substance abuse or diagnosis that will alert the staff for monitoring R3.
The facility Care Plan policy dated 1/23 documented in part that all residents will have comprehensive assessments and an individualized plan developed to assist them in achieving and maintaining their optimal status. Procedure listed includes but not limited to care plans reviewed and discussed individually, all concerns, problems, needs.
The facility policy on admission of Resident dated 1/23 documented in part that the purpose of the policy includes but not limited to gathering information as a basis for planning individualized therapeutic care and to ensure adherence to facility policies. Procedure includes but not limited to using information obtained, contact the physician (attending) ensuring that admission orders cover all aspects of required care and treatment.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure that a treatment cart was locked when not in visual proximity of the nurse and not in use to prevent tampering. This fa...
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Based on observation, interview, and record review the facility failed to ensure that a treatment cart was locked when not in visual proximity of the nurse and not in use to prevent tampering. This failure has the potential to affect all residents residing on the 1st and 2nd floor of the facility.
Findings include:
On 10/02/23 at 10:25am on the 1st floor south wing the floor treatment cart was observed by the south elevator unattended and not locked. Treatment cart not visible to the nurse.
On 10/02/23 at 10:26am, V5 (Nurse) identified the cart as the treatment cart and stated in part that it (referring to the treatment cart) should be locked when not in use and not visible to the nurse because any of the residents can come and take medicated ointments (stored in the treatment cart).
On 10/02/23 at 10:39am a treatment cart was observed on the 2nd floor north wing unattended to and not in view of the nurse. When shown to V7 LPN (Licensed Practical Nurse) and V7 was asked about the facility policy on medication/treatment cart storage; V7 stated that the cart should be placed visible to the nurse when not in use and it should be locked because anyone can get into the cart without the nurse knowing it (referring to tampering). V7 stated that I'm not the nurse who left it here in the hallway they are all in the room doing the wound care, but I will lock it.
On 10/02/23 at 10:42am, V20 (Treatment Nurse / LPN (Licensed Practical Nurse) identify self as one of the treatment nurses. V20 stated I did not know the cart was left unlocked; it should be locked when not in use because somebody can get into it (referring to the treatment cart)
On 10/02/23 at 2:23pm, V2 DON (Director of Nurse's) stated in part that medication and treatment carts are to be kept at the nurse's station locked and if the nurses are away from the cart, it should also be locked. Medications should always be locked.
On 10/03/23 at 10:40am, interview conducted with V19 (Wound Care Coordinator) about securing the treatment cart to prevent tampering. V19 stated in part that the treatment cart is to be locked always when not in use to keep unauthorized person away and keep the resident safe.
On 10/17/23 at 5:19pm, on the 1st floor of the facility by the nursing station in the hallway the medication cart was observed left unattended, unlocked, and not in view of the nurse. V54 NP (Nurse Practitioner) was noted sitting in the nurse's station writing with their back turned towards the medication cart. V58 RN (Registered Nurse) who was noted inside the medication room came out and identified self as the 3pm to 11pm nurse in charge. V58 stated oh no when the medication cart was shown to V58 and they were asked about the facility protocol/ policy on medication and medication cart storage. V58 stated, it should be locked (referring to the medication cart), thank you.
The facility policy presented, and titled Administration Procedures for all Medications documented in part that the policy is to administer medications in a safe and effective manner. Listed procedures includes but not limited to securing all medication storage areas that includes (carts) are always locked unless in use and under the direct observation of the medication nurse/aide.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to follow current standards of infection control and prevention in storing soiled linen after residents' care. This failure has t...
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Based on observation, interview, and record review the facility failed to follow current standards of infection control and prevention in storing soiled linen after residents' care. This failure has the potential to affect all 45 residents residing on the 3rd floor.
Findings include:
On 10/02/23 at 10:57am, on the 3rd floor south wing hallway a yellow linen collection container was observed in the hallway with the lid unable to close due to over following soiled linens with the foul smell odor of urine in the hallway. V14 LPN (Licensed Practical Nurse) who was passing medication at the time of observation stated that the CNAs (Certified Nurse's Aides) know that it (referring to the soiled linen container) should not be this full and uncovered.
On 10/02/23 at 2:25pm V2 DON (Director of Nursing) stated in part that all soiled linen should be placed in the soiled linen container and closed, to contain the odor and not touching the floor for infection control prevention and control.
The facility nursing policy on Linen Handling dated 11/22 presented documented in part that the purpose of the policy is to ensure proper handling of soiled and clean linen and personal laundry in preventing the spread of microorganisms. Soiled linen hampers shall be transported to the laundry department or emptied on a regular schedule to prevent overflowing by assigned personnel.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that the facility was free from urine and fe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that the facility was free from urine and feces odor. The facility also failed to ensure that 2 elevators were in working condition. This failure has the ability to affect all 218 residents that reside in the facility.
Findings include:
On 10/3/23 during investigation, Surveyor observed 2 full barrels of laundry on unit 2N (2/ North) outside of room [ROOM NUMBER].
On 10/3/23 at 10:43 AM, Surveyor noted a strong odor on unit 2N.
On 10/03/23 at 10:55 AM, Surveyor noted a strong odor on the 2S unit (2/South) near the nurse's station. Two garbage containers were observed outside of a resident's room. One container containing soiled linen and one with garbage.
On 10/3/23 at 10:58 AM, V7 LPN (Licensed Practical Nurse) said, The unit usually smells like urine and feces when the CNAs (Certified Nurse Assistants) are doing patient care. When removing briefs and linen from the rooms, the smell travels. Sometimes the linen containers are kept in the hallways. That's where the odors come from. Once the soiled linen bins are full, laundry usually comes and grabs the laundry bins from the unit.
On 10/03/23 during floor rounds at 11:16 AM, Surveyor observed the elevator on unit 2S (2-South) open but stuck on the 2nd floor. At that time R11 was sitting near the elevator waiting.
R11 is [AGE] year old with diagnosis including but not limited to: Hypertension, Lack of coordination, Difficulty walking, Insomnia and Gout.
R11 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates cognitively intact.
On 10/03/23 at 11:16 AM, R11 said, That elevator isn't going nowhere. It's broke. That elevator is always broke.
On 10/5/23 at 10:48 V2 (Director of Nursing) said, There are a lot of problems in this building that are going to take some time to fix.
On 10/5/23 between 12:30 and 1:00 PM, Surveyor observed elevator #4 not working.
Surveyor and V27 (Maintenance Director) rode elevator #2 to the 2nd floor and noticed elevator #1 on the 2nd floor stuck with doors in open position.
On 10/5/23 at 12:45 PM, V27 said, This is where that elevator is usually stuck, here on the 2nd floor. Elevators #1 and #4 are the main ones that I have issues with. Out of the 4 elevators, there are still two that are working for the residents. Surveyor inquired about elevator servicing. V27 said, I don't know what is wrong with the elevators. It's always the same two elevators with the problems and we can't seem to figure out why.
Facility Elevator company work report documents the following: Service on 9/18/23 to elevators #1 and #2; Service on 9/5/23 to elevator #1, stuck on 2nd floor; Service on 8/28/23 to elevators numbers 1, 2 and 4; Service on 8/26/23 to elevators numbers 1 and 2.
Facility policy titled Job Description of Maintenance Supervisor documents, assure that the plant and equipment is properly maintained for resident comfort and convenience.
Facility policy titled Housekeeper documents, coordinate daily housekeeping services with nursing services when performing routine cleaning assignments in resident living and/ or residential areas.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that resident's rooms were free from peeling...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that resident's rooms were free from peeling drywall and leaking water from the ceiling or bathroom sink. This failure has affected 5 residents (R10, R15, R16, R17 and R18) of 21 reviewed for homelike environment.
Findings include:
R10 is [AGE] year old with diagnosis including but not limited to: Acute Respiratory failure, Hypertensive emergency, Acute Respiratory distress, Pneumonitis and Acute Pulmonary edema.
R15 is [AGE] year old with diagnosis including but not limited to: Difficulty walking, Lack of Coordination, Pulmonary embolism, Dyspnea, and Muscle wasting and Atrophy.
R16 is [AGE] year old with diagnosis including but not limited to: Chronic pain, Hypertension, Dyspnea, Shortness of Breath, Chest pain, Muscle wasting and Atrophy.
R17 is [AGE] year old with diagnosis including but not limited to: Chronic Obstructive Pulmonary Disease, Hypertension, Pressure ulcer of left ankle (stage 3), Insomnia, Dysphagia and Spinal Stenosis.
R18 is [AGE] year old with diagnosis including but not limited to: Chronic Osteomyelitis, Heart failure, Pain, Lack of coordination, and Idiopathic gout.
On 10/3/23 during facility tour with V27 (Maintenance Director), Surveyor entered R10's room.
R10's bathroom sink was leaking with a blanket on the floor around the base of the sink. The blanket was saturated with water.
The wall connected to the bathroom (inside of R10's room) had a hole with peeling baseboard, peeling drywall and peeling paint.
On 10/3/23 at 11:06 AM, V27 said, I have fixed the sink a couple of times but R10 constantly leans up on the sink from his wheelchair, putting all of his weight on the sink when he is drunk. That's why the sink keeps leaking. The drywall and baseboard is peeling because R10 runs into the wall with his wheelchair. I will fix the sink again.
On 10/4/23 at 3:23 PM during 2nd floor rounds, Surveyor observed leakage from the ceiling near the window in R15's room . The ceiling was observed with peeling paint, water stains, and drops of liquid coming from the ceiling.
On 10/4/23 at 3:25 PM, Surveyor observed leakage from the ceiling near the window in R16, R17 and R18's room. The ceiling was observed with peeling paint, water stains, and drops of liquid coming from the ceiling.
Surveyor inquired about how long there had been a leak in R15, R16, R17 and R18's rooms.
On 10/5/23 at 3:02 PM, V27 said, The leakage has been there since I've been here in 2019. The roof is a vinyl material. When it rains, that causes a leak in the roof. I had a company come out and give us a quote on renewing the roof. At that time the quote was like $28,000. I have gotten several quotes for corporate for a new roof over the years, but I am not the person to make the final decision. I can only do so much.
On 10/5/23 at 3:05 PM, Surveyor inquired about the possibility of mold growing in walls. V27 said, with the leakage, you never know what that outcome could be. We don't have mold, but the leaks can definitely lead to mold. V27 said, I didn't realize that the leak in R10's sink was as bad as it is. I had to order R10 a new sink, pedestal and water supply line today.
Facility work order for unit 2 North documents a work order entered on 9/12/23 for a leaking ceiling in R16, R17 and R18's room. R10 and R15's rooms were not included on the work order for unit 2 North.
Facility policy titled, Preventative Maintenance Program documents, to conduct regular environmental tours/ safety audits to identify areas of concern within the facility. Program will review during regular rounds: Paint is free from watermarks and peeling; Ceiling tiles are free from watermarks or spots; Wall coverings are intact and free of tears or loose seams.
Facility policy titled, Maintenance Director Job description documents, Inspect the facility on a regular basis, to ensure that the grounds, facility, and equipment are maintained in accordance with established policies and procedures and all hazardous areas are properly identified.
Based on observations, interviews and record reviews, the facility failed to ensure that there were enough laundry staff in the facility on each shift. This failure has the potential to affect 218 residents that reside in the facility and depend on laundry staff for clean linen, towels and or/ clothes.
Findings include:
On 10/03/23 during visit to the laundry room, Surveyor observed a pile of soiled linen in the entry way of the laundry room's back door. There were 4 barrels of linen and 1 barrel of resident's personal dirty clothes. Surveyor inquired about the pile of laundry in the laundry room.
On 10/03/23 at 3:10 PM, V36 (Laundry Aide/ Housekeeper) said, It's only me working from 1 PM -9 PM. It's hard to do everything by myself. I have to pull all of the laundry from the units and bring it to the laundry room, then I have to sort all of the clothes, wash them, and fold them. Sometimes there's a second laundry aide here to wash the personals clothes, while I focus on the linen, towels and gowns.
Surveyor received laundry staff schedule from V38 (Human Resource Director).
On 10/4/23 at 9:22 AM, V38 said, The letter 'L' on the laundry schedule stands for laundry and the numbers stands for shifts 1, 2, and 3.
On 10/4/23 at 1:20 PM, V40 (Laundry Aide) observed in laundry room folding linen and washing and folding linen. Surveyor observed 8 barrels of sorted dirty linen which included: 4 barrels of dirty linen, gowns, pads and towels; and 4 barrels of personal items. V40 said, I work 5AM- 1PM, but my schedule will change to 6AM- 2 PM. I worked by myself today but sometimes there is another laundry aide that handles the personal clothes. I had to do both today. It is a lot, but I have been here 14 years and I have a system. When I come, I go to all floors and pull all of the dirty laundry from the units (5 units), then I come back and sort the linen, wash and fold.
On 10/3/23 at 1:24 PM, V33 (Housekeeping Director) said, for the most part, there is one laundry aide per shift because of our budget. Surveyor inquired if one laundry aide per shift was sufficient for the needs of the facility?
On 10/3/23 at 1:25 PM, V33 said, No, one laundry aide is not enough for one shift. It's a lot for one person.
10/04/23 at 11:45 AM, V52 CNA (Certified Nurse Assistant) said, today I started with 5 wash cloths and 4 big towels. When I went down to laundry to get linen, the shelves were empty. I had called down to the laundry room around 9:00 AM for the dirty linen bins to be pulled from the unit, but no one could pick the dirty linen up until around 11 AM. The laundry staff have been responsible for taking down the linen.
Laundry staffing schedule for the period of 9/10/23- 10/7/23 indicates 1 laundry staff member worked alone on each shift (5 AM to 1 PM, 1 PM to 9 PM, and 9 PM to 5 AM).
Facility Census on 10/3/23 was 218.
Resident Council minutes from 6/22/2023 documents, Housekeeping/ laundry: Need more help in the laundry room, not getting clothes back on time.
Resident Council minutes from 7/19/2023 documents, Housekeeping/ laundry: Missing clothes, takes too long to get clothes back.
Resident Council minutes from 8/11/2023 documents, Housekeeping/ laundry: Clothes not being picked up on scheduled days.
Resident Council minutes from 9/28/2023 documents, Housekeeping/ laundry: Missing clothes.
Compliment/ Concern form from 8/28/23 documents, Resident's name: R21, Description of Compliment/ Concern: Missing clothes- laundry has had belongings for two weeks.
Policy titled Laundry Services documents; an adequate supply of clean linen will be maintained for resident care.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0675
(Tag F0675)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure that residents had clean linen available. 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 that residents had clean linen available. This deficiency has the potential to affect all 218 residents that reside in the facility.
Findings include:
R11 is [AGE] year old with diagnosis including but not limited to: Hypertension, Lack of coordination, Difficulty walking, Insomnia and Gout.
R11 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates cognitively intact.
R10 is a [AGE] year old with diagnosis including but not limited to: Alcohol use, with intoxication, Hypertensive emergency, Opioid use, Acute Kidney failure, Acute Respiratory failure and Acute pulmonary edema.
R10 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.
On 10/3/23 at 9:42 AM, Surveyor observed one linen cart on 2N unit empty (without linen) and another linen cart with 2 flat sheets (no towels) and on 2S (2/ South) Surveyor observed one linen cart without linen or towels.
On 10/03/23 at 11:16 AM, R11 said, This place never has face towels. When I want to wash my face in the morning, I can never get a face towel.
On 10/3/23 at 12:45 PM, R10 said, I can't never get clean towels or sheets around here. How am I supposed to clean myself with no towels?
On 10/3/23 at 11:22 AM, V33 (Housekeeping Director) said, This is my 2nd month here in this position. We have been short with towels and linen. I have made a couple of orders since I have been in this position. We have new owners and a different budget. I made a large order on Monday 10/2/23. We will be getting more linen soon.
On 10/3/23 at 2:30 PM, 39 LPN (Licensed Practical Nurse) said, Laundry and Housekeeping comes and empties the laundry bins quite a few times. The CNAs (Certified Nurse Assistants) can't do what they need to do because they don't have proper linen daily.
On 10/3/23 at 2:53 PM, V41 CNA said, The laundry is always backed up. Linen is like gold around here because it is hard to come by.
On 10/04/23 at 11:45 AM, V52 CNA (Certified Nurse Assistant) said, today I started with 5 wash cloths and 4 big towels. When I went down to laundry to get linen, the shelves were empty.
On 10/4/23 at 12:00 PM, two linen carts on 2N observed with no linen.
Policy titled Laundry Services documents; an adequate supply of clean linen will be maintained for resident care.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observations, interviews and record reviews, the facility failed to ensure that there were enough laundry staff in the facility on each shift. This failure has the potential to affect 218 res...
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Based on observations, interviews and record reviews, the facility failed to ensure that there were enough laundry staff in the facility on each shift. This failure has the potential to affect 218 residents that reside in the facility and depend on laundry staff for clean linen, towels and or/ clothes.
Findings include:
On 10/03/23 during visit to the laundry room, Surveyor observed a pile of soiled linen in the entry way of the laundry room's back door. There were 4 barrels of linen and 1 barrel of resident's personal dirty clothes. Surveyor inquired about the pile of laundry in the laundry room.
On 10/03/23 at 3:10 PM, V36 (Laundry Aide/ Housekeeper) said, It's only me working from 1 PM -9 PM. It's hard to do everything by myself. I have to pull all of the laundry from the units and bring it to the laundry room, then I have to sort all of the clothes, wash them, and fold them. Sometimes there's a second laundry aide here to wash the personals clothes, while I focus on the linen, towels and gowns.
Surveyor received laundry staff schedule from V38 (Human Resource Director).
On 10/4/23 at 9:22 AM, V38 said, The letter 'L' on the laundry schedule stands for laundry and the numbers stands for shifts 1, 2, and 3.
On 10/4/23 at 1:20 PM, V40 (Laundry Aide) observed in laundry room folding linen and washing and folding linen. Surveyor observed 8 barrels of sorted dirty linen which included: 4 barrels of dirty linen, gowns, pads and towels; and 4 barrels of personal items. V40 said, I work 5AM- 1PM, but my schedule will change to 6AM- 2 PM. I worked by myself today but sometimes there is another laundry aide that handles the personal clothes. I had to do both today. It is a lot, but I have been here 14 years and I have a system. When I come, I go to all floors and pull all of the dirty laundry from the units (5 units), then I come back and sort the linen, wash and fold.
On 10/3/23 at 1:24 PM, V33 (Housekeeping Director) said, for the most part, there is one laundry aide per shift because of our budget. Surveyor inquired if one laundry aide per shift was sufficient for the needs of the facility?
On 10/3/23 at 1:25 PM, V33 said, No, one laundry aide is not enough for one shift. It's a lot for one person.
10/04/23 at 11:45 AM, V52 CNA (Certified Nurse Assistant) said, today I started with 5 wash cloths and 4 big towels. When I went down to laundry to get linen, the shelves were empty. I had called down to the laundry room around 9:00 AM for the dirty linen bins to be pulled from the unit, but no one could pick the dirty linen up until around 11 AM. The laundry staff have been responsible for taking down the linen.
Laundry staffing schedule for the period of 9/10/23- 10/7/23 indicates 1 laundry staff member worked alone on each shift (5 AM to 1 PM, 1 PM to 9 PM, and 9 PM to 5 AM).
Facility Census on 10/3/23 was 218.
Resident Council minutes from 6/22/2023 documents, Housekeeping/ laundry: Need more help in the laundry room, not getting clothes back on time.
Resident Council minutes from 7/19/2023 documents, Housekeeping/ laundry: Missing clothes, takes too long to get clothes back.
Resident Council minutes from 8/11/2023 documents, Housekeeping/ laundry: Clothes not being picked up on scheduled days.
Resident Council minutes from 9/28/2023 documents, Housekeeping/ laundry: Missing clothes.
Compliment/ Concern form from 8/28/23 documents, Resident's name: R21, Description of Compliment/ Concern: Missing clothes- laundry has had belongings for two weeks.
Policy titled Laundry Services documents; an adequate supply of clean linen will be maintained for resident care.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interviews and record review, the facility failed to ensure that the kitchen was free from pests and failed to ensure that food was covered in a storage container. This failure h...
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Based on observation, interviews and record review, the facility failed to ensure that the kitchen was free from pests and failed to ensure that food was covered in a storage container. This failure has the potential to affect 217 residents that receive meals from the kitchen.
Findings include:
On 10/4/23 during investigation, Surveyor conducted a tour of the kitchen with V26 (Dietary Manager).
On 10/4/23 at 12:15 PM, Surveyor observed two black pests crawling on the wall by the dishwasher. Surveyor observed a brown pest crawling on the floor near the dishwasher. Flying pest where also observed in the kitchen.
On 10/4/23 at 12:15 PM, V44 (Dietary Aide) said, These are roaches crawling. V42 (Dietary Aide) said, Roaches are always near the dishwasher.
On 10/4/23 at 12:16 PM, Surveyor observed another brown pest crawling on the floor and pointed it out to V26 (Dietary Manager). V26 said, This is my 1st time seeing a roach here, the exterminators were just here the other day. Water was observed on the kitchen floor near the tray line and near the ice machine. A leakage was also observed underneath the dishwasher and a pan of brownish water sat on the floor underneath the dishwasher collecting the dripping water. A foul odor was noted in dishwashing area.
On 10/4/23 at 12:19 PM, V26 said, I smell the odor. I have been trying to find out what that foul odor is. There was a backup in the drain, but we have gotten it unclogged. The leakage coming from the dishwasher is from the garbage disposer I believe. The ice machine leaks all day. I am trying to get this kitchen together. I have only been here a couple of months as Dietary Manager. Surveyor and V26 walked into the dry storage area. Black flying pests were observed around a box of bananas and surrounding the oatmeal and sugar bins. The oatmeal and sugar bins were without lids. Thin Plastic partially covered the oatmeal and sugar bins.
On 10/4/23 at 12:21 PM, V26 said, We need new food bins. These bins have been missing lids for a while (referring to the oatmeal and sugar bins).
On 10/5/23 at 1:05 PM, Surveyor inquired about the importance of a sanitary kitchen? V26 said, It is important to make sure the kitchen is always sanitary, so the residents don't get sick.
Facility Census for 10/3/23 documents, 218 residents currently residing in facility.
Facility NPO (Nothing by mouth) list indicates that only 1 resident in the facility does not receive meals from the kitchen.
Facility policy documents, the facility will follow sanitary practices in food preparation and cooking to keep food safe. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby prevent foodborne illness.
Facility's pest control policy documents, Food will be covered and/or refrigerated, as applicable, to prevent pest invasion and spoiling.
Sept 2023
18 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the call light was within a resident's rea...
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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 the call light was within a resident's reach for use to call for staff assistance and failed to promptly respond to a resident's call light which affected one resident (R182) in the total sample of 74 residents reviewed for accommodation of needs.
Findings include:
R182's admission Record documents, in part, diagnoses of cerebral infarction, hypertension, type 2 diabetes mellitus, cognitive communication deficit, dysphagia, weakness, muscle wasting and atrophy, lack of coordination, hemiplegia affecting right dominant side and gastrostomy status.
R182's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R182 has severe cognitive impairment. R182's Functional Status for ADL Assistance for bed mobility for self-performance is coded as extensive assistance with a support of two + (plus) persons physical assist. R182's Bladder and Bowel Status for urinary and bowel continence is coded as always incontinent.
On 9/10/23 at 11:50 am, R182 observed lying in bed with R182's blanket covering R182 from shoulder to feet. R182's left bed side rail was up with the call light cord wrapped around the side rail and was hanging down touching the floor mat on the floor. When asked if R182 was able to reach the call light button, R182 shook R182's head side to side indicating no. When asked if R182 wears an incontinence brief, R182 nodded R182's head up and down indicating yes. This surveyor requested permission for an incontinence check by staff, and R182 granted permission. R182's call light was activated at 11:58 am.
On 9/10/23 at 12:11 pm, after 13 minutes, V18 (Certified Nursing Assistant, CNA) entered R182's room and answered R182's call light. This surveyor requested an incontinence check of R182 with R182's approval. V18 performed incontinence check for R182 which showed that R182 was incontinent of urine and stool. V18 stated, V18 works 7:00 am to 3:00 pm shift and when V18 answered R182's call light at 12:11 pm, V18 just returned from lunch break.
On 9/10/23 at 12:37 pm, V18 and V19 (CNA) completed performing R182's incontinence and activities of daily living (ADL) care.
On 9/10/23 at 12:57 pm, surveyor returned to R182's room (no staff present), and R182's call light remains in the same position of hanging from left side of the bed with the call light button on the floor mat on the floor.
R182's Care Plan, dated 5/31/23, documents, in part, R182 has an alteration in musculoskeletal status related to diagnoses of weakness, muscle wasting and atrophy, and lack of coordination with an intervention of Anticipate and meet needs. Be sure call light is within reach and promptly respond to all requests for assistance.
On 9/12/23 at 12:37 pm, V2 (Director of Nursing, DON) stated, V2's expectation of the nursing staff is that a resident's call light is to be answered as soon as it's on. V2 stated, staff are to answer the call light by going to the resident's room to see if the resident is okay. V2 stated, if the resident's need is not urgent, then staff can say that they are helping another resident and will come back to attend to that resident's need. V2 stated, despite a CNA being on a lunch break, the nurses and other CNAs on the floor will attend to those residents assigned to the CNA who is on a break. When asked the purpose of timely answering call lights, V2 stated, it's to ensure that the resident is safe and to address whatever needs they may have. Surveyor asked where the call light should be placed for residents. V2 stated, The call light is to be positioned within reach of the resident.
Facility policy dated 9/2019 and titled Call Light, documents, in part, Purpose: To respond to residents' requests and needs in a timely and courteous manner . Policy: All call lights will be answered by any staff within their scope of practice. Standards: All residents shall have the nurse call light system available and within easy accessibility to the resident at the bedside or other reasonable accessible location. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered . Procedure: 1. Answer light (signal) promptly.
Facility policy dated 9/2014 and titled Incontinency Care, documents, in part, Policy: Incontinent resident will be checked periodically every two hours and provided perineal and genital care after each episode . Procedure . 12. Place call light within reach and encourage use.
Facility job description titled Job Description for Nurse Aide and undated, documents, in part, . Responsibilities: . 2. Handling and serving residents to assure safety and comfort. 3. Observing instructions of nursing staff and performing in line with established routine. 4. Providing maximum resident care services to assure wellbeing of resident to the greatest degree. 5. Carrying out duties and responsibilities in conformance with established routine. Work Performed: Under supervision to perform duties assuring maximum care, security and treatment: 1. Assist with carrying out the Health Care Plan. 2. Assuring physical comfort and mental well-being of resident.
Facility job description titled Job Description for Charge Nurse and undated, documents, in part, . Responsibilities: . 4. Insures (Ensures) that the individual Health Care Plan is followed . 17. Is responsible for the well-being and nursing care of all residents assigned to his/her unit during tour of duty . Job Knowledge: . 3. Knowledgeable of facility's policies and procedures and how to carry these through.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
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 acknowledge and comply with one resident's (R40's) meal...
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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 acknowledge and comply with one resident's (R40's) meal preference. This failure has the potential to affect all residents in the sample of 74.
Findings include:
R40 has a diagnosis of but not limited Traumatic Subdural Hemorrhage, Bipolar Disorder, Dysphagia, Lack of Coordination, Type 2 Diabetes Mellitus, Hypertension, and Dysphagia. R40 has a Brief Interview of Mental Status score of 11 that indicates moderately impaired cognition.
Minimum Data Set, dated [DATE] documents that R40 needs supervision and a one person assist with eating.
Order Summary Report with active orders of 9/13/2023 documents that R40 has a General Diet Regular Texture, Regular thin liquids consistency, set up assistance and supervision.
Resident Council Minutes dated 6/22/2023 states, in part, not reading the sub paper.
On 9/10/2023 at 12:45pm surveyor observed R40 stating out loud and asking V17 (CNA) did he swap his lunch meal for a grill cheese. V17 did not respond to R40. R40 made the statement, loudly at least three times, letting staff know that he did not want the regular lunch and that he wanted a grill cheese sandwich, and no one responded to R40 until they brought R40's regular lunch tray and set it in front of him.
On 9/10/2023 at 1:03pm surveyor observed R40 with the regular lunch meal tray in his hand threatening to throw the tray if someone did not take it away because that was not what he requested.
On 9/10/2023 at 1:05pm R40 told surveyor that this (not giving him what he ordered) happens all the time with his meal requests for lunch and dinner and it makes him mad.
On 9/12/2023 at 11:30am V42 (LPN) stated, I would ask R40 what he wants and check to see if there is a substitute, and then I would call the kitchen and go get the substitute for the resident. V42 also stated No, it (the meal tray) should not be placed in front of the resident.
On 9/13/2023 at 10:46am V2 (DON) stated my expectation of the nursing state is to follow up with the resident's request.
Residents' Rights for People in Long Term Care Facilities with a revised date of 11/2018 documents, in part, your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life, and the facility must provide services to keep your physical and mental health, at their highest practical levels.
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 obtain an advance directive for two residents (R9, R105) in the res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an advance directive for two residents (R9, R105) in the resident's electronic medical record (EMR). This failure affected two residents (R9 and 105) in a sample of 74 residents reviewed for advance directives.
Findings include:
R105's face sheet shows that R105 has a diagnosis which includes but not limited to nontraumatic intracerebral hemorrhage in hemisphere subcortical, schizophrenia, open -angle glaucoma, benign prostatic hyperplasia without lower urinary tract symptoms, unspecified dementia, seizures, essential hypertension, non-traumatic subdural hemorrhage, repeated falls, encounter for surgical aftercare following surgery on nervous system, presence of cerebrospinal fluid drainage device. R105's Advance Directive on the admission Record (profile section) was blank.
R105's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 03 which indicates that R105 is cognitively impaired.
R105's Care Plan, dated 6/13/23, documents, in part, Focus: R105 has no advance directive documents at this time . Interventions: R105 is a FULL CODE
R105's Order Summary Report (POS), dated 09/12/23, which includes all active orders, no code status order is noted for R105.
On 09/11/23 at 1:25 pm, V13 (Social Service Director) stated, R105 does not have an advance directive code status order in R105's chart. V13 stated, V13 met with R105's family and R105's code status was discussed with nursing. V13 further explained, it is the responsibility of the nursing department to enter R105's code status orders on R105 Physician order sheet (POS) and R105's profile in R105's chart.
On 9/12/23 at 10:14 am, V2 (Director of Nursing, DON) stated, the nursing department and the social services department are both responsible for advanced directives being placed in the residents medical record. V2 explained, upon admission the nurse places the residents code status on the resident Physician Order Sheet (POS) and will create a banner on the residents profile banner indicating the residents code status. V2 stated, the nurse that completed R105's admission forgot to place R105's code status on R105's POS. V2 explained, the importance of a resident having a code status order on the profile and POS in a residents medical record is for the nurse is able to honor the residents wishes and the nurse will know how to treat a resident if a resident has an event.
R105's progress note dated 06/26/23 shows that R105's family would like to fill out advanced directives for R105 at a later date and R105 will remain a full code.
Facility's undated policy titled Advance Directives, documents, in part, Purpose: To establish guidelines to assure each resident is provided information on advanced directives . Standards: 3. The resident, the legal representative or the individual who has been authorized as the resident's health care representative will be asked if an advanced directive as recognized under the state law, has been executed. Documentation concerning this inquiry and the individual response shall include the date the entry was made and the individual making this inquiry. This information shall then be included in the residents medical record.
R9 has a diagnosis of but not limited to Atrial Fibrillation, Depression, Hypertension, and Systolic (Congestive) Heart Failure. R9's Brief Interview of Mental Status score is 13 that indicates cognitively intact.
R9's face sheet has no information listed for Advance Directive.
On 9/10/2023 at 5:15pm surveyor reviewed R9's code status and there was no code status listed on the profile screen on EMR (electronic medical record). Surveyor reviewed R9's Order Summary Report with active orders of 9/12/2023 that does not include a doctor's order for R9's code status.
On 9/12/2023 at 11:30am V42 (LPN) stated, a resident's code status is normally listed on the profile screen and R9's is not listed on the profile screen and R9 does not have an order either.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to ensure a care plan for advance directive is updated for one (R126) resident reviewed for care planning in the total sample...
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Based on observations, interviews, and record reviews, the facility failed to ensure a care plan for advance directive is updated for one (R126) resident reviewed for care planning in the total sample of 74 residents.
Findings include:
R126's (Active Order As Of: 09/12/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) muscle wasting, hypertension, and adult failure to thrive. Order Summary. Code Status: DNR (do-not-resuscitate). Active: 12/12/2022.
R126's (06/16/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating 126's mental status as cognitively intact.
The (9/5/23) Facility DNR (do-not-resuscitate) LIST documented that R126 was on the list.
The (9/5/23) Advanced Directives documented that R126's Code Status was DNR.
R126's (date initiated: 08/22/2022) Care Plan documented, in part Focus: (R126) has NO advance directive. Goal: will communicate the absence of advance directive. Intervention: Resident is a FULL CODE - if resident becomes unresponsive, CALL FOR HELP IMMEDIATELY and begin Basic Life Support sequence.
On 09/12/2023 at 11:54am, V13 (Social Service Director) stated, I do admission, quarterly and annually care plan for the advance directive. If a resident did not choose an advance directive, the resident is automatically full code. If there is an order for the DNR, Social service updates the POLST (Practitioner Order for Life-Sustaining Treatment) and have the doctor sign it.
On 09/12/2023 at 11:55am, V13 checked R126's POLST and stated, (R126) is DNR. V13 checked R126's care plan and stated, (R126) previous social services did not update (R126) advance directive care plan.
The (undated) Advance Directives documented, in part Purpose: To establish guidelines to assure each resident is provided information on advance directives. Responsibility: Social Service Director. Policy: It is the policy of this facility to allow the resident or authorized legal representative to make decisions regarding health care as well as refusal of service. Standards: 10. Advanced Directive(s) shall be addressed on the resident's plan of care, physician progress notes, and physician orders.
The (undated) Care Plan documented, in part A. Policy: All residents will have comprehensive assessments and an individualized plan of care developed to assist them in achieving and maintaining their optimal status. Procedure: 5. Care plan are reviewed and discussed individually. g. Notation is made on the care plan when a goal is changed. The goals may be changed for many reasons. A few examples are: resolved, unrealistic, deterioration in condition. 9.b. The Interdisciplinary Team is responsible for the implementation of resident care management. 10. All interdisciplinary Team department are responsible for charting that reflects the care plan concerns, problems, needs and/or strength, approaches or lack of progress with possible reasons for and any new problems.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide timely incontinence care for a dependent resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide timely incontinence care for a dependent resident which affected one resident (R182) in the total sample of 74 residents reviewed for activities of daily living (ADL) care.
Finding include:
R182's admission Record documents, in part, diagnoses of cerebral infarction, hypertension, type 2 diabetes mellitus, cognitive communication deficit, dysphagia, weakness, muscle wasting and atrophy, lack of coordination, hemiplegia affecting right dominant side and gastrostomy status.
R182's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R182 has severe cognitive impairment. R182's Functional Status for ADL Assistance for bed mobility for self-performance is coded as extensive assistance with a support of two + (plus) persons physical assist. R182's Bladder and Bowel Status for urinary and bowel continence is coded as always incontinent.
On 9/10/23 at 11:50 am, R182 observed lying in bed with R182's blanket covering R182 from shoulder to feet. Surveyor asked if R182 wears an incontinence brief. R182 nodded R182's head up and down indicating yes. This surveyor requested permission for an incontinence check by staff, and R182 granted permission.
On 9/10/23 at 12:11 pm, V18 (Certified Nursing Assistant, CNA) entered R182's room, and this surveyor requested an incontinence check of R182 with R182's approval. V18 pulled back R182's blanket with the smell of urine noted. V18 unsecured R182's incontinence brief in front and showed urine incontinence. V18 stated, V18 needed to step out of R182's room to retrieve linens to change R182. V18 stated, V18 is working the 7:00 am to 3:00 pm shift today and V18 just returned from lunch break. When asked when the last time is that R182 checked R182 for incontinence, V18 stated, V18 did resident rounds at 7:00 am and last checked and changed R182's incontinence brief at 8:00 am today. V18 stated, V18 then had to get my people up.
On 9/10/23 at 12:19 pm, V18 and V19 (CNA) entered R182's room with linens, pink wash basins, and soap. V18 proceeded to setup for incontinence and ADL care and started R182's facial and chest washing.
On 9/10/23 at 12:23 pm, V19 exited R182's room to retrieve towels and returned to R182's room at 12:26 pm.
On 9/10/23 at 12:32 pm, V18 cleansed R182's groin of incontinent urine. V18 and V19 then turned R182 to the right side which showed a medium amount of incontinent stool (soft, brown) and urine in the back of R182's incontinence brief. V18 and V19 continued and completed performing R182's incontinence and ADL care.
R182's Care Plan, dated 12/1/22, documents, in part, that R182 has an ADL self-care performance deficit with interventions of R182 requiring extensive staff participation for bed mobility, toilet use, and personal hygiene.
R182's Care Plan, dated 12/1/22, documents, in part, that R182 has a potential for skin integrity impairment with an intervention of Provide peri-care and barrier after incontinent episodes.
On 9/12/23 at 12:37 pm, V2 (Director of Nursing, DON) stated, nursing staff is expected to perform resident rounds every 2 hours and as needed. V2 stated, checking on residents every 2 hours ensures that staff are addressing resident needs or concerns. V2 stated, dependent residents are to be checked for incontinence every 2 hours and as needed to keep them dry and comfortable. V2 stated, for dependent residents, V2 expects nursing staff are actively looking in residents' incontinence briefs to see if they are incontinent especially if they cannot tell the staff. When asked if a CNA goes on a lunch break, what is V2's expectation of caring for the assigned residents of that CNA, and V2 stated, There are nurses and aides left on the unit and still address the resident's needs.
Facility policy dated 9/2014 and titled Incontinency Care, documents, in part, Policy: Incontinent resident will be checked periodically every two hours and provided perineal and genital care after each episode . Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity.
Facility policy dated 9/2020 and titled Activities of Daily Living (ADLS), documents, in part, Purpose: To preserve ADL function, promote independence, and increase self-esteem and dignity . Interventions may include . washing and drying the body . maintaining personal hygiene.
Facility job description titled Job Description for Nurse Aide and undated, documents, in part, . Responsibilities: . 2. Handling and serving residents to assure safety and comfort. 3. Observing instructions of nursing staff and performing in line with established routine. 4. Providing maximum resident care services to assure wellbeing of resident to the greatest degree. 5. Carrying out duties and responsibilities in conformance with established routine. Work Performed: Under supervision to perform duties assuring maximum care, security and treatment: 1. Assist with carrying out the Health Care Plan. 2. Assuring physical comfort and mental well-being of resident.
Facility document titled CNA Daily Assignment Sheet and dated 9/10/23, documents, in part, that V18 (CNA) is assigned to care for R182 for the 7:00 am to 3:00 pm shift.
Facility job description titled Job Description for Charge Nurse and undated, documents, in part, . Responsibilities: . 4. Insures (Ensures) that the individual Health Care Plan is followed . 17. Is responsible for the well-being and nursing care of all residents assigned to his/her unit during tour of duty . Job Knowledge: . 3. Knowledgeable of facility's policies and procedures and how to carry these through.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
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 maintain a resident's head of the bed elevated to at l...
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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 maintain a resident's head of the bed elevated to at least 30 degrees when the resident is receiving enteral feedings (tube feedings) via a gastrostomy tube (G-tube) which affected one resident (R182) in the total sample of 74 residents reviewed for tube feedings.
Findings include:
R182's admission Record documents, in part, diagnoses of gastrostomy status, cerebral infarction, dysphagia, hypertension, type 2 diabetes mellitus, cognitive communication deficit, weakness, muscle wasting and atrophy, lack of coordination, and hemiplegia affecting right dominant side.
R182's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R182 has severe cognitive impairment. R182's Nutritional Status for the Nutritional Approaches indicates a feeding tube.
On 9/10/23 at 11:50 am, R182 observed lying in bed with R182's head of the bed positioned at approximately 15 degrees with R182's tube feeding formula infusing via a pump at 50 milliliters/hour (ml/hr) into R182's G-tube.
On 9/10/23 at 12:11 pm, V18 (Certified Nursing Assistant, CNA) entered R182's room, and this surveyor requested an incontinence check of R182 with R182's approval. V18 applied gloves on hands, took R182's bed control and lowered R182's head of the bed to flat position while R182's tube feedings were infusing via pump into G-tube. V18 unsecured R182's incontinence brief in front and showed urine incontinence. V18 stated, V18 needed to step out of R182's room to retrieve linens to change R182 and left R182's head of bed flat with the tube feedings still infusing.
On 9/10/23 at 12:19 pm, V18 and V19 (CNA) entered R182's room with linens, pink wash basins, and soap. V18 proceeded to setup for ADL care and started R182's facial and chest washing.
On 9/10/23 at 12:23 pm, V19 exited R182's room to retrieve towels and returned to R182's room at 12:26 pm with towels. V18 is continuing to bath R182's body while the head of the bed is flat with R182's tube feedings infusing via G-tube.
On 9/10/23 at 12:29 pm, V19 (CNA) pressed the run/stop button to hold R182's tube feedings infusion. R182's tube feeding remains connected to R182's G-tube.
On 9/12/23 at 12:37 pm, when asked the body position of a resident who is in bed receiving tube feedings via pump into a G-tube, V2 (Director of Nursing, DON) stated, The head of the bed has to be elevated to the semi-Fowler or Fowler position. When asked why this elevated head position is needed, V2 stated, So that they (residents) don't aspirate. V2 confirmed, aspiration is when tube feedings can leave the stomach and enter into the lungs. When asked if a resident who is receiving tube feedings via pump into a G-tube and needs to have the head of the bed flat for ADL care, what should the nursing staff do, and V2 stated that the CNA will grab and get the nurse and let (the nurse) know so (the nurse) can put the tube feedings on hold. V2 stated that it's the nurse who does this because the nurse is responsible for the resident's tube feedings.
Online resource from The Nurse Page, dated 9/15/23, and titled Fowler's Position: A Comprehensive Guide for Nurses - 2023, documents, in part, that a semi-Fowler's position is when the head of the bed is raised at 30 to 45 degrees, and a fowler's position is when the head of the bed is raised at 45 to 60 degrees.
R182's Order Summary Report with active orders as of 9/11/23, documents, in part, R182's enteral - feed is for enteral feed order at 50 ml/hr times 20 hours, up at 6:00 am, down at 2:00 am.
R182's Care Plan, dated 12/29/22, documents, in part, that R182 has a nutritional problem with an intervention of Give g-tube feeding and water flushes as ordered.
R182's Care Plan, dated 5/31/23, documents, in part, that R182 has an alteration in gastro-intestinal status with an intervention of keeping the head of the bed elevated.
Facility policy dated June 2014 and titled Gastrostomy Feeding - Infusion Pump Method, documents, in part, Purpose: To provide nutrients, fluids and medications to residents requiring feeding through an artificial opening in the stomach . Procedure: . 5. Position resident on his/her back with head elevated to approximately 30 degrees.
Facility job description titled Job Description for Nurse Aide and undated, documents, in part, . Responsibilities: . 2. Handling and serving residents to assure safety and comfort. 3. Observing instructions of nursing staff and performing in line with established routine. 4. Providing maximum resident care services to assure wellbeing of resident to the greatest degree. 5. Carrying out duties and responsibilities in conformance with established routine. Work Performed: Under supervision to perform duties assuring maximum care, security and treatment: 1. Assist with carrying out the Health Care Plan. 2. Assuring physical comfort and mental well-being of resident . Job Knowledge: 1. Knowledge of procedures and techniques.
Facility job description titled Job Description for Charge Nurse and undated, documents, in part, . Responsibilities: . 4. Insures (Ensures) that the individual Health Care Plan is followed . 17. Is responsible for the well-being and nursing care of all residents assigned to his/her unit during tour of duty . Job Knowledge: . 3. Knowledgeable of facility's policies and procedures and how to carry these through.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to label and date oxygen tubing and a tracheostomy mask. This failure affected two residents (R143 and R151) reviewed for oxygen ...
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Based on observation, interview and record review, the facility failed to label and date oxygen tubing and a tracheostomy mask. This failure affected two residents (R143 and R151) reviewed for oxygen equipment, in a total sample of 74 residents.
Findings include:
R151's Face Sheet documents R151 has the following diagnosis that include, but are not limited to, chronic respiratory failure with hypoxia, anemia, unspecified, chronic obstructive pulmonary disease, unspecified, hypoxemia, unspecified injury of head, initial encounter, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, coronavirus infection, unspecified, morbid (severe) obesity due to excess calories, muscle weakness (generalized), other pulmonary embolism without acute cor pulmonale, long term (current) use of anticoagulants, pressure ulcer of sacral region, stage 3, unspecified lack of coordination, muscle wasting and atrophy, not elsewhere classified, multiple sites, dependence on supplemental oxygen, essential (primary) hypertension, functional quadriplegia.
R151's Brief Interview for Mental Status (BIMS) dated 07/21/23 documents that R151 has a BIMS score of 13, which indicates that R151's cognition is intact.
R151's MDS (Minimum Data Set) Section O. dated 07/21/2023 documents, in part, 00100.Special Treatments, Procedures, and Programs, Respiratory Treatments C. Oxygen Therapy 2. While a resident.
R151's Physician Order Summary Report dated 08/11/23 documents, in part, Oxygen(O2) at 2L(liters)/minute per n/c (nasal cannula). Maintain O2(oxygen) saturation at 92 or greater.
On 09/11/23 at 9:50am, surveyor observed R151 in bed awake and alert. R151 was observed with 2 liters oxygen via nasal cannula with tubing in place unlabeled and not dated. R151 was asked regarding R151's nasal cannula oxygen tubing. R151 stated, It was on Thursday or Friday when the nurse came in to change the oxygen tubing.
On 9/12/2023 at 10:54am V27 (RN/Registered Nurse/ 2nd Floor Unit Manager) stated, I do not see a label on the oxygen tubing indicating what date the tubing was changed. V27 stated, nurses are responsible for changing the oxygen tubing every week and placing a label with the date on the oxygen tubing indicating when the tubing was changed. V27 stated, tubing should be labeled with a date to let the next nurse know when the tubing should be changed and to reduce the possibility of an infection occurring in the resident.
On 09/12/2023 at 2:08pm V2 (DON/Director of Nursing) stated, nurses are responsible for changing the oxygen tubing. V2 stated the oxygen tubing should be changed weekly and as needed. V2 stated the nurses should label the oxygen tubing with a date on a label indicating when the oxygen tubing was changed, and this will also let the next nurse know when the tubing is due to be changed. V2 stated the oxygen tubing is labeled to reduce the possibility of infection.
R143's (Active Order As Of: 09/12/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) tracheostomy status, malignant neoplasm of head, face, and neck; malignant neoplasm of laryngeal cartilage; and chronic obstructive pulmonary disease. Order Summary: Oxygen at 4liters/minute per trach mask.
R143's (06/10/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. Section O. Special Treatments, Procedures, and Programs. O0100. Special Treatments, Procedures, and Programs. Respiratory Treatments. C. Oxygen Therapy: 2. While a resident. E. Tracheostomy Care: 2. while a resident.
R143's (06/28/2023) Care Plan documented, in part Focus: is receiving oxygen therapy related to respiratory insufficiency. Goal: will have no s/sx (signs and symptoms) of poor oxygen absorption. Interventions: Administer oxygen per physician orders.
On 09/10/23 at 12:10pm, R143's tracheostomy mask and tubing were not dated.
On 09/10/23 12:14 PM, these observations were pointed out to V9 (Licensed Practice Nurse). V9 stated, mask and the tubing are not labeled with date. These should be labeled with the date these were changed so people (staff) can know when these are changed and the rationale for changing the trache (tracheostomy) mask is for infection control.
On 09/11/2023 at 11:49am, V2 (Director of Nursing) stated, the night shift nurse and respiratory nurse are supposed to change the trache mask weekly and as needed. We are supposed to label it with the date it was change. Purpose of changing it weekly is to prevent infection. Making sure it is clean; infection control is a big thing.
On 09/12/2023 at 10:08am, V36 (Assistant Director of Nursing) provided this surveyor with Oxygen Equipment policy and procedure. This surveyor inquired if facility has specific policy for labeling and changing of tracheostomy mask. V36 stated, oxygen tubing's documented in the policy includes the tracheostomy mask.
The (8/14) Oxygen Equipment documented, in part Objective: To administer oxygen in conditions in which infection control is maintained. Procedure: 4. Oxygen tubing/nebulizer masks will be changed and dated weekly and prn (as needed).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rat...
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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 have a five percent (5%) or lower medication error rate. There were five medication errors out of 31 medication opportunities, resulting in a 16.13% medication error rate and affected six (R94 and R213) residents observed for medication pass.
Findings include:
On 09/11/23 at 8:33 am, V24 (Licensed Practical Nurse, LPN) was observed on the first-floor south medication cart. Surveyor observed V24 prepare and count 10 pills total that were administered to R94. Upon surveyor reconciling R94's medication for medications that were order for administration and medications that were observed as administered and documented by V24, the following medication error was identified:
1.)
Not given during observation: Ascorbic Acid Oral tablet 500 milligram (mg) 1 tablet by mouth three times a day for dietary supplement; prophylaxis.
2.)
Not given during observation: Cholecalciferol tablet 1000 unit (U) give 2 tablets by mouth one time a day for supplementation.
3.)
Omission error: Bactrim Oral tablet 400-80 mg give one tablet by mouth one time a day every Monday, Wednesday, Friday for immunocompromised/Prevention.
R94's Medication Administration Audit Report (MAAR) documents that Ascorbic Acid Oral tablet 500 milligram (mg) 1 tablet by mouth three times a day for dietary supplement; prophylaxis was administered at 10:23 am on 09/11/23; Cholecalciferol tablet 1000 unit (U) give 2 tablets by mouth one time a day for supplementation was administered at 10:24 am, on 09/10/23. However, the preparation or administration of these medication was not observed by the surveyor. R94's progress note authored by V24 on 09/11/23 at 10:24 am, documents that V24 was awaiting Cholecalciferol tablet 1000 unit (U) awaiting to be refilled.
V24 stated that R94's Bactrim was not available and was not in the pyxis. V24 stated, V24 would reorder R94's Bactrim medication. Upon review of R94's order summary report (POS), R94's Bactrim oral tablet 400-80 mg give one tablet by mouth one time a day every Monday, Wednesday, Friday for immunocompromised was observed discontinued by V24 on 09/11/23 and reordered to start on 09/12/23 after V24 did not have medication available for R94. R94 did not receive Bactrim oral tablet 400-80 mg on 09/11/23. V2 (Director of Nursing, DON) authored a progress note for V24 on 09/11/23 at 8:59 am, that documented that V2 spoke with pharmacy to send a 30-day supply of medication.
R94's Brief Interview for Mental Status (BIMS) dated 08/12/23 documents R94 with a score of 12 which indicates that R94 has some cognitive impairments.
R94's face sheet shows that R94 has a diagnosis which include but are not limited to multiple myeloma not having achieved remission, stem cell transplant status, and pancytopenia.
R94's Order Summary Report (POS) dated active orders as of 09/10/23 shows R94 receiving Bactrim oral tablet 400-80 mg give one tablet by mouth one time a day every Monday, Wednesday, Friday for immunocompromised.
On 09/11/23 at 8:33 am, V24 (Licensed Practical Nurse, LPN) was observed on the first-floor south medication cart. Surveyor observed V24 prepare and count 10 pills total that were administered to R213. Upon surveyor reconciling R213's medication for medications that were order for administration and medications that were observed as administered and documented by V24, the following medication error was identified:
1.)
Not given during observation: Sennoside-Docusate Sodium oral tablet 8.6-50 mg give Acidophilus 2 tablets by documents mouth two times a day for constipation.
2.)
Omission error: Gabapentin oral capsule 100 mg give 1 capsule three times for pain.
R213's Medication Administration Audit Report (MAAR) that: Sennoside-Docusate Sodium oral tablet 8.6-50 mg give Acidophilus 2 tablets by mouth two times a day for constipation was administered at 08:59 am on 09/11/23 and Gabapentin oral capsule 100 mg give 1 capsule three times for pain was administered at 12:32 pm on 09/11/23. However, this medication was scheduled to be administered at 9:00 am on 09/11/23.
R213's was admitted to the facility on [DATE] and does not have a Brief Interview for Mental Status (BIMS).
R213's face sheet shows that R213 has a diagnosis which include but are not limited to acute osteomyelitis left ankle and foot, end stage renal disease, and type 2 diabetes mellitus without complications.
On 09/12/23 at 10:14 am, V2 (Director of Nursing, DON) was interviewed regarding the facility's policy regarding medication administration and V2 stated, medications should be administered according to the physicians orders and the five rights of medication. V2 explained if a medication is not available to retrieve from the pyxis the nurse should call the pharmacy for a status of the medication as well as notify the physician. V2 stated, importance of administering medications as ordered by the physician is for the safety of resident and to ensure the residents plan of care is being followed.
The facility's policy dated 01/01/2020 and title Administering Medications document documents, in part: Purpose: To ensure safe and effective administration of medications in accordance with physician orders and state/federal regulations. Procedure: 6. Medications should be administered within one (1) hour of the prescribed times.
Facility's job description document titled Charge Nurse documents, in part: Responsibilities: 24. Ensure that all medications and treatments are charted after the fact by the person administering the medications or completing the treatment on his/her assigned shift.
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 ensure that an eye drop medication was labeled with an ...
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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 an eye drop medication was labeled with an open date and expiration date after opening the solution. This has the potential to affect one resident (R5) out of 74 residents in the sample.
Findings include:
On 09/11/23 at 10:21 am, Surveyor and V11 (Licensed Practical Nurse, LPN) inspected the 3-North Cart 2 and observed R5's Latanoprost solution 0.005% with no open date. V11 stated, eye drops expire 30 days after opening. V11 stated, eye drops are labeled with an open date in order to know when the eye drops expires.
On 09/12/23 at 10:17 am, V2 (Director of Nursing, DON) stated, eye drop medications should be labeled with an open date once open. V2 stated, it is important for eye drop medication to be labeled with an open date after the medication is open, in order for the nurse to know when to discard and reorder the medication. V2 explained, if a medication does not have an open date there is a potential to give ineffective medication and the nurse will not know if the medication is effective to the resident.
R5's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R5 is cognitively intact.
R5's face sheet shows that R5 has a diagnosis which includes but not limited to ocular hypertension unspecified eye.
R5's Order Summary Report (POS) dated 09/12/23 shows that R5 has an order for Latanoprost solution 0.005% instill 1 drop in both eyes at bedtime related to ocular hypertension, bilateral.
The facility's policy dated 05/01/18 and titled Mac Rx Pharmacy Policies and Procedure Manual Storage of Medications documents in part: Expiration and Dating: C. Certain medications or package types such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tables, blood sugar testing solutions and strips once open, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
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 check and document the temperatures of residents' pers...
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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 check and document the temperatures of residents' personal refrigerators daily and failed to maintain an appropriate refrigerator temperature inside a residents' personal refrigerator which affected R21 and R47 in the total sample of 74 residents reviewed.
Findings include:
R21's admission Record documents, in part, diagnoses of type 2 diabetes mellitus, end stage renal disease, dependence on renal dialysis, hypertension, heart failure, idiopathic gout, cachexia, and muscle wasting and atrophy.
R21's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 10 which indicates that R21 has moderate cognitive impairment.
On 9/10/23 at 12:43 pm, R21's personal refrigerator observed in room with a refrigerator temperature log posted on the front of R21's refrigerator with a date from June 2023. With R21's permission, this surveyor opened R21's refrigerator and observed the following items: mayonnaise jar, 2 sodas, liver cheese, 3 apple sauces, peach cup, gelatin cup, hot sauce bottle, supplement drinks, apple juice bottle, and a water bottle. R21 stated, facility staff hasn't come to check the temperatures recently of R21's personal refrigerator.
R21's Refrigerator Temperature Log dated June 2023, documents, in part, daily temperature readings in degrees Fahrenheit (F) with staff initials from 6/1/23 to 6/26/23. No further temperature readings or initials are noted 6/27/23 to 6/30/23.
R47's admission Record documents, in part, diagnoses of type 2 diabetes mellitus, hemiplegia, hypertension, heart failure, anemia, ataxia, and muscle wasting and atrophy.
R47's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R47 is cognitively intact.
On 9/10/23 at 12:47 pm, R47's personal refrigerator observed in room with no refrigerator temperature log noted on R47's refrigerator or in R47's room. With R47's permission, this surveyor opened R47's refrigerator and observed a thermometer with a reading of 50 degrees F. The following items observed in R47's refrigerator: 2 yogurts, yellow mustard, half of a left-over potato, a takeout food container, bar-b-que sauce and a water bottle. When asked if staff check R47's refrigerator for a temperature reading, R47 stated, it's not check every day.
On 9/10/23 at 12:53 pm, this surveyor asked V20 (Licensed Practical Nurse, LPN, Charge Nurse) to come into R47's room. When asked if there is a temperature log for R47's refrigerator, V20 stated, there are only thermometer logs for the medication room refrigerators. This surveyor pointed out to R21's refrigerator temperature log from June 2023 and requested a copy from V20.
On 9/11/23 at 10:03 am, this surveyor checked R47's personal refrigerator with an inside temperature on the thermometer reading as 50 degrees F.
On 9/12/23 at 9:49 pm, V39 (Housekeeping Director) stated, housekeepers are responsible for cleaning residents' personal refrigerators, and housekeepers will check these refrigerator temperatures daily. V39 stated, there is a temperature log where the housekeepers document the temperatures. V39 stated that the logs are kept on the personal refrigerators and that V39 keeps copies of the logs. When asked what the temperature of the inside of the refrigerator should be, V39 stated, 40 degrees (F) and under. When asked what V39 would expect of the housekeepers if the reading is above 40 degrees F, V39 stated, the housekeeping staff will notify V39. When asked if V39 has been notified of R47's refrigerator temperature being at 50 degrees on observations on 9/10/23 by this surveyor and V20 (Charge Nurse/LPN) and on 9/11/23 by this surveyor, V39 stated, No. This surveyor and V39 went to see R47's refrigerator. This surveyor asked V39 to read the thermometer inside R47's refrigerator, and V39 read the thermometer saying, It's over 40 degrees (F). V39 and this surveyor confirmed the thermometer reading at 45 degrees (F).
Facility policy dated October 2021 and titled Food at Bedside, documents, in part, General: Residents are allowed to keep food at the bedside . Guideline: 1. Food or beverages brought in by family or visitors may be stored in the resident's personal refrigerator . 4. Refrigerated foods that have been opened or left-over foods stored in the refrigerator with marked with use by date. The use by date is 6 days from the day the food was opened if there is no expiration date on the product. 5. When making rounds, staff will dispose of food that is expired.
Facility undated job description titled Job Description of Housekeeping Supervisor documents, in part, Purpose: The primary purpose of your job position is to direct the overall operation of the Housekeeping Department in accordance with current applicable federal, state, and local requirements, and as directed by the Administrator to assure that the highest degree of cleanliness and sanitation is maintained at all times . 4. Assure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained/operable to perform such duties/services. 5. Supervise/monitors work for department supervisor/personnel to ensure compliance of directives and established procedures . 15. Inspect the facility, on a daily basis, to ensure that cleanliness and sanitary standards are maintained at all times.
Facility job description dated 3/23/17 and titled Housekeeper, documents, in part, Summary: The primary purpose of the Housekeeper is perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, and/or the Director of Environmental Services, to assure that our facility is maintained in a clean, safe and comfortable manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that residents' call devices are functioning...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that residents' call devices are functioning to allow residents to call for staff assistance. This failure affected 2 residents (R126 and R165) reviewed for functioning resident call devices in a total sample of 74 residents.
Findings include:
On 09/10/23 at 12:39PM, R126's call device was located at the right side of R126's bed. R126 stated, it doesn't work for a month now. R126's pressed the call light. This surveyor checked the overhead call device indicator outside of R126 room. The indicator was not lit.
On 09/10/23 12:51 PM, V12 (Certified Nursing Assistant) stated, when the resident pressed the call light, the green light on the call light switch should be lit if it is working. It is not lit. (R126)'s call light is not working.
On 09/11/2023 at 11:42am, V2 (Director of Nursing) stated, residents should have a working call light so they can call for assistance, and so we can address their need.
On 09/11/2023 at 3:16pm, V21 (Maintenance Director) checked R126's call device. V21 stated, it is not working. It is a gateway failure.
On 09/11/2023 at 3:19pm, V21 showed this surveyor the master access point and power supply of all the call device throughout the building. V21 stated, it is managed and serviced by N***S. They are supposed to come here 2x a week or as needed. N***s is not coming here since the change of ownership and the new owner is still negotiating with N***S, still working on the contract.
On 09/11/2023 at 3:23pm, surveyor showed V21 the maintenance log sheet. V21 stated that is N***S issue. It means the issue of (R126)'s call light was noted on 08/02/2023 and the issue was not resolved up to this time.
R126's (Active Order As Of: 09/12/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) muscle wasting, hypertension, and adult failure to thrive.
R126's (06/16/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating 126's mental status as cognitively intact.
The (undated) 2 North Maintenance Log documented that R126 call device was noted not working on 8/2/23.
The (9/19) Call light policy and procedure documented, in part Purpose: To respond to residents' request and needs in a timely and courteous manner. Equipment: Functioning Nurse Call System.
R165's admission Record documents, in part, diagnoses of hemiplegia affecting the left dominant side, idiopathic peripheral autonomic neuropathy, hypertension, dysphagia, difficulty in walking, cognitive communication deficit, lack of coordination, contracture left knee and muscle wasting and atrophy.
R165's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 12 which indicates that R165 has moderate cognitive impairment.
R165's Care Plan, dated 5/30/23, documents, in part, that R165 has an alteration in musculoskeletal status related to diagnoses of muscle wasting and atrophy, left knee contracture, difficulty walking and lack of coordination with an intervention of Anticipate and meet needs. Be sure call light is within reach and promptly respond to all requests for assistance.
On 9/10/23 at 11:56 am, R165 stated, R165 cannot use R165's call light because it does not work. R165 stated, I told them (staff) about it. It don't work. R165 pressed the call light button, and no green button was activated on the call light panel in R165's room. This surveyor pressed R165's call light button, and no green light was activated on the call light panel in R165's room. This surveyor then looked outside of R165's room and did not see the call light bulb lighting up above R165's door in the hallway. This surveyor reentered R165's room. R165 stated, I been told them this (R165's call light not functioning). When asked how R165 gets help when in the bed in the room if R165 needs staff assistance, R165 stated, I call out because it (call light) don't work.
Facility document from the maintenance binder located at the nurse's station on R165's unit documents, in part, from 8/1/23 to 9/10/23, no entry for R165's call light not functioning properly.
On 9/10/23 at 12:41 pm, this surveyor requested to V8 (Licensed Practical Nurse, LPN) that V21 (Maintenance Director) be called to come to check R165's call light. V21 did not come to R165's floor.
On 9/10/23 at 1:56 pm, when asked about available maintenance staff being present in facility, V1 (Administrator) stated that V21 is out of the facility and will return later today.
On 9/11/23 at 12:22 pm, this surveyor and V21 (Maintenance Director) performed a brief environmental tour and went to R165's room. When asked about V21 being informed of R165's call light not working, V21 stated, the floor nurse notified V21 yesterday (9/10/23) and that it was the first time that V21 was made aware it. V21 said, the floor nurse switched out the call light cord and, then it worked. This surveyor informed V21 of R165's and this surveyor's attempts of pushing the call light button without it being activated outside the room for staff assistance on 9/10/23. V21 stated, With this particular call light button, it can malfunction with each drop to the floor, or the prongs can be pulled out at the wall. V21 stated that V21 gets notified of repairs need by word of mouth and can only handle what I can handle. This surveyor and V21 viewed the maintenance logbook at R165's nurse's station with the entry on 9/11/23 of call light system malfunction. When asked about this call light system malfunction entry, V21 stated, there is a gait way failure with the call light system, is an ongoing issue and that call light system company has been made aware. When asked how often he checks the floors' maintenance logbooks, V21 stated, When I can. V21 stated, It's a lot of work when I am by myself to cover all the floors maintenance needs.
Facility undated job description titled Job Description of Maintenance Supervisor, documents, in part, Purpose: The primary purpose of your job position is to direct the overall operation of the maintenance department in accordance with current applicable federal, state and local requirements, and as directed by the Administrator, to assure that a successful maintenance program is maintained at all times. Responsibilities: 1. Assist in the planning, developing, organizing, implementing, evaluation and directing of the maintenance department . 2. Assist in the development and implementation of departmental policies and procedures to assure that the maintenance of the premises, facility and equipment is current and all times. 3. Develop and maintain a good working rapport with inter- department personnel in other departments of the facility, to assure that maintenance programs can be properly planned and maintained to meet the needs of the facility. 4. Assure that the plant and equipment is properly maintained for resident comfort and convenience. 5. Supervises/monitors work department supervisors/personnel to ensure compliance of directives and established procedures . 15. Inspect the facility, on a regular basis, to ensure that the grounds, facility and equipment are maintained in accordance with established policies and procedures and all hazardous areas are properly identified.
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** On 9/11/2023 at 10:30am surveyor observed the pull string to the overhead light above R112's head of bed missing.
On 9/11/2023 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 9/11/2023 at 10:30am surveyor observed the pull string to the overhead light above R112's head of bed missing.
On 9/11/2023 at 10:32am R112 stated, I have made a request to maintenance to have the cord replaced, but maintenance is slow.
On 9/12/2023 at 10:43am V21(Maintenance Director) observed the light above the head of R112's bed with no pull string for R112 to turn the light on. V21 stated the pull strings are obsolete from the supply vendor. V21 stated the company is sending out the twist canopy switches now. V21 stated, R112 not having a cord to turn the light on above the head of the bed does not offer R112 a homelike environment.
On 09/10/23 at 11:07 am, Surveyor toured the facility's third floor south unit and observed R19, R31, R49 and R132's beds without a pillow or linen on the residents beds. Surveyor observed two linen carts on the third-floor south unit without linen. Surveyor inspected the third-floor linen room and observed two blankets, no pillows, no pillowcases, no flat sheets or fitted sheet in the linen closet.
On 09/10/23 at 12:52 pm, Surveyor brought this observation to V45 (Certified Nursing Assistant, CNA) and V45 stated, There is not enough linen in the building. We (referring to the CNA's) ran out of linen.
On 09/10/23 at 1:14 pm, Surveyor questioned V45 (CNA) regarding linen in the facility. V45 stated, I (V45) ran out of linen so I (V45) could not make the resident bed. V45 was asked how often does V45 not have linen to make residents beds. V45 stated, Every day. V45 stated, V45 went to the laundry room and the laundry room on 09/10/23 around 10:00 am and did not have linen for V45 to make all the residents beds on the third-floor south unit.
On 09/10/23 at 1:17 pm, Surveyor questioned V47 (CNA) regarding linen in the facility. V47 stated, I (V47) ran out of linen so I (V47) could not make all the residents bed. V47 was asked how often does V47 not have linen to make residents beds. V47 stated, Every day. V47 stated that the CNA's have a problem with receiving enough linen to make residents beds every day in the facility.
On 09/10/23 at 1:18 pm, Surveyor questioned V46 (CNA) regarding linen in the facility. V46 stated, There is no linen. We (referring to CNA's) ran out of linen. I (V46) went to the laundry room and there is no linen. I (V46) made the residents beds with what linen I (V46) had.
On 09/12/23 at 10:19 am, V2 (Director of Nursing, DON) stated, the CNA's are responsible for making the residents beds every day in the facility. V2 explained, if a resident does not have linen on the bed, it is not a homelike environment for the resident. V2 also explained, the housekeeping department is responsible for providing linen to the staff. V2 stated, the housekeeping department brings linens to units once a shift for staff. V2 was asked if there is enough linen for the residents beds. V2 stated, the staff complain regarding not having enough linen and V2 has taken this concern to V39 (Housekeeping Director).
On 09/12/23 at 11:31 am, V39 (Housekeeping Director) stated, V39 has worked at the facility for about two weeks. V39 was asked regarding linen for the facility. V39 stated, There is not enough linen in the facility to make all the residents beds. The company gives us what they think we deserve. The CNA's don't drop the linen so we can wash the linen. What is taken up to the floors we (referring to the housekeeping department) don't get back. V39 was asked regarding how often linen is taken to the units. V39 stated, linen is brought to the units once a shift. V39 also stated, CNA's at the facility complain about not having enough linen to make the residents beds daily. V39 was asked regarding the importance of the resident having linen for the residents beds. V39 stated, it is very important.
On 09/12/23 at 11:38 am, Surveyor, and V39 inspected the facility laundry room and observed 13 flat sheets, 10 fitted sheets, 3 pillowcases, and 9 bath blankets in the laundry room. V39 stated, This is all the linen we have right now until the Certified Nursing Assistants, (CNA's) drop more linen to be washed. V39 stated, the facility is challenged with linen on Monday, Wednesday, and Friday when the laundry department has to send 20 sheets and 20 blankets to the dialysis unit. V39 stated, V39 ordered linen for the facility one week ago and the linen that was received was not enough linen for the residents in the facility.
R19's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 14 which indicates that R19 is cognitively intact.
R19's face sheet show that R19 has a diagnosis which includes but not limited to cardiomegaly, Parkinson's, and schizophrenia.
R31's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 03 which indicates that R31 is cognitively impaired.
R31's face sheet show that R31 has a diagnosis which includes but not limited to lack of coordination, history of falling and diabetes 2 without complication.
R49's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 10 which indicates that R49 has a moderate cognitive impairment.
R49's face sheet show that R49 has a diagnosis which includes but not limited to essential hypertension, chronic kidney disease, and cerebellar ataxia.
R132's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 04 which indicates that R132 is cognitively impaired.
R132's face sheet show that R132 has a diagnosis which includes but not limited to cirrhosis of the liver, alcohol abuse and latent syphilis.
The facility's job description titled Job description of Housekeeping Supervisor documents, in part: Purpose: The primary purpose of your job position is to direct the overall operation of the Housekeeping Department in accordance with current applicable federal, state, and local requirements, and as directed by the Administrator to assure that the highest degree of cleanliness and sanitation is maintained at all times . 4. Assure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained/operable to perform such duties/services. 15. Inspect the facility, on a daily basis, to ensure that cleanliness and sanitary standards are maintained at all times . 19. Requisition, control and maintain adequate level of required housekeeping supplies and equipment.
On 09/12/2023 at 12:53pm, this surveyor and V37 (Wound Care Director/LPN) went inside R126's and 163's room to check on residents. Upon entry, R163 stated can you help change my sheets. I (R163) am wet. This surveyor inquired what happened. R163 stated, the ceiling is leaking, and my bed is wet. It bothers me. This surveyor and V37 looked up at R126's and R163's ceiling and observed water was dripping from the ceiling to R126's and R163's mattresses.
On 09/12/2023 at 12:54pm, R126 stated, my sheets are wet, and it bothers me too.
On 09/12/2023 at 12:56pm, V37 stated, I (V37) do not know what is going on. I (V37) think one of the residents on 3rd floor overflowed the sink or the toilet.
On 09/12/2023 at 1:11pm, V43 (Certified Nursing Assistant) stated, I (V43) already paged for (V21) to come here. I (V43) paged for him (V21) around 11am - 12pm. The water leak was on and off. I (V43) noticed it around the time I (V43) paged for maintenance.
On 09/12/2023 at 1:14pm, V27 (RN/Nurse Supervisor) stated, I (V27) already told maintenance about the leak. This (referring to the water dripping from the ceiling) should not happen because that is a discomfort to the residents.
On 09/12 at 1:16pm, surveyor pointed out to V21 (Maintenance Director) the water dripping from the ceiling. V21 stated, I (V21) don't know what is going on. I (V21) have to check what is wrong. There should be no leaking from the ceiling because it will not create a home like environment to residents.
R126's (Active Order As Of: 09/12/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) muscle wasting, hypertension, and adult failure to thrive.
R126's (06/16/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating 126's mental status as cognitively intact.
R163's (Active Order As Of: 09/12/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) heart failure, muscle wasting, and acute kidney failure.
R163's (08/03/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R163's mental status as cognitively intact.
The (09/12/2023) email correspondence with V1 (Administrator) documented the facility do not have a policy for homelike environment.
The (undated) Residents' Rights for people in Long-Term Care Facilities documented, in part Your facility must be safe, clean, comfortable and homelike.
R50 has a diagnosis of but not limited to Gout, Hypotension, Bradycardia, Muscle Wasting and Atrophy, Primary Osteoarthritis, Calcaneal Spur, Hypothyroidism, Type 1 Diabetes Mellitus, and Peripheral Vascular Disease. R50's Brief Interview of Mental Status score of 06 that indicates severely impaired.
R134 has a diagnosis of Cerebral Infarction, Mood Disorder, Anxiety Disorder, Thoracoabdominal Aortic Aneurysm, Hypocalcemia, Type 2 Diabetes Mellitus and Acute Kidney Failure. R134's Brief Interview of Mental Status score of 12 that cognitive intactness.
R180 has a diagnosis of Alcohol Liver Disease, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Pneumonia, Viral Hepatitis C, Hypertension, and Wrist Drop. R180's Brief Interview of Mental Status score of 15 that indicates cognitive intactness.
R181 has a diagnosis of but not limited to Unstable Angina, Bilateral Primary Osteoarthritis of Knee, Insomnia, Vitamin D Deficiency, Hypertension, Lack of Coordination and Muscle Wasting and Atrophy. R181's Brief Interview of Mental Status score of 14 that indicates cognitive intactness.
R197 has a diagnosis of but not limited to Hemiplegia and Hemiparesis, Epilepsy, Hyperlipidemia, Hypertension, Dysarthria and Dysphagia. R180's Brief Interview of Mental Status score of 13 that indicates cognitive intactness.
On 9/10/2023 at 11:45am surveyor observed R197's left closet door completely detached and standing up against the right side closet door. Surveyor further observed a large hole in the baseboard, corner guard was broken with sheet rock exposed, and the baseboard detached from the wall.
On 9/10/2023 at 12:05pm surveyor observed the bottom drawers of the clothing wardrobe without door covers on both sides of the clothing wardrobe for R50. R50 has no roommate at this time.
On 9/10/2023 at 12:06pm surveyor observed R134 and R197's wall corner guard hanging from the wall and a large hole in the wall.
On 9/10/2023 at 12:25pm surveyor observed the corner guard hanging off, a large hole in the baseboard and the baseboard not attached to wall by the sink in R180 and R181's room.
On 9/12/2023 at 11:03am V21 (Maintenance Director) stated, no, it is not a homelike environment with closet doors off, missing drawers covers, holes in the walls, baseboards hanging off and missing corner guards. V21 also stated, the detached door could fall and strike the resident, or the door could be used as a weapon.
Work order sheet for 3 North (6/01/2023-9/10/2023) does not list any issues with R50, R134, R180, R181 and R197 rooms.
Updated Job Description of Maintenance Supervisor documents, in part, assure that plant and equipment is properly maintained for resident comfort and convenience, ensure that resident's rights to privacy, property are well established and followed by all department personnel and inspect the facility, on a regular basis, to ensure that the grounds and equipment are maintained in accordance with established policies and procedures.
Based on observation, interview and record review, the facility failed to provide a homelike environment by providing linens or pillows for resident beds; by ensuring that water was not leaking from the ceiling onto resident beds in room; by maintaining integrity of resident room walls, closet doors, baseboards, drawer covers, overhead lights, and wall air conditioner units; and by repairing or replacing damaged furniture. These failures affected R19, R31, R49, R50, R112, R126, R132, R134, R163, R165, R180, R181, R182 and R197 and has the potential to affect all 215 residents in the facility.
Findings include:
On 9/10/23 at 11:42 am, in the 2 South dining, this surveyor observed a chair with a light brown, plastic seat cushion that had 9 gaping tears in the plastic covering exposing the foam cushion underneath. The exposed foam cushion was discolored with black and brown stains. The edges of the plastic seating from the tears were frayed and elevated.
On 9/11/23 at 10:07 am, in the 2 South dining, this surveyor observed the same chair with the torn and discolored seat cushion.
On 9/11/23 at 12:22 pm, this surveyor and V21 (Maintenance Director) performed a brief environmental tour and walked into the 2 South dining room. This surveyor and V21 observed the same chair with the torn and discolored seat cushion. V21 stated, it's an old chair. When asked if V21 is viewing facility furniture for condition integrity, V21 stated, V21 tries to do (V21's) best and staff will put a towel on the seat cushion to cover the holes, but that it could become saturated with incontinence. When asked if this chair is considered part of a homelike environment for residents, V21 stated, No. It's not homelike. V21 stated, this is the first time V21's been made aware of the condition of this chair. When asked how V21 is notified of furniture needing to be repaired, V21 stated, the staff will text or call V21. V21 stated, when V21 comes into the building in the morning, V21 is flooded with things from residents and staff. V21 stated, if residents or staff are complaining of repairs needed, then V21 will look at it and puts it on list for V44 (Maintenance) to do daily. This surveyor and V21 continue the environmental tour and enter R165 and R182's room. This surveyor and V21 observed the room's wall air conditioner unit. V21 stated, I (V21) see the facing (cover) is missing. V21 stated, this is not a home like environment having this exposed air conditioning unit with no front cover. When asked how often V21 is checking the status of the room air conditioners, V21 stated, it is per request and V21 has not been informed of this missing air conditioner front cover. V21 stated, V21 does not have any alternative facing to cover the front of the wall air conditioner.
Facility undated job description titled Job Description of Maintenance Supervisor, documents, in part, Purpose: The primary purpose of your job position is to direct the overall operation of the maintenance department in accordance with current applicable federal, state and local requirements, and as directed by the Administrator, to assure that a successful maintenance program is maintained at all times. Responsibilities: 1. Assist in the planning, developing, organizing, implementing, evaluation and directing of the maintenance department . 2. Assist in the development and implementation of departmental policies and procedures to assure that the maintenance of the premises, facility and equipment is current and all times. 3. Develop and maintain a good working rapport with inter-department personnel in other departments of the facility, to assure that maintenance programs can be properly planned and maintained to meet the needs of the facility. 4. Assure that the plant and equipment is properly maintained for resident comfort and convenience. 5. Supervises/monitors work department supervisors/personnel to ensure compliance of directives and established procedures . 15. Inspect the facility, on a regular basis, to ensure that the grounds, facility and equipment are maintained in accordance with established policies and procedures and all hazardous areas are properly identified . 17. Establish an effective preventative maintenance program for cleaning, painting, maintaining facility equipment, etc. (and other things), as necessary/approved.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
On 9/11/2023 at 10:05am surveyor observed an electrical plate covering hanging off the wall behind R64's head of bed.
On 9/11/2023 at 10:30am surveyor observed the electrical outlet plate cover missi...
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On 9/11/2023 at 10:05am surveyor observed an electrical plate covering hanging off the wall behind R64's head of bed.
On 9/11/2023 at 10:30am surveyor observed the electrical outlet plate cover missing from the wall behind R112's head of bed.
On 9/12/2023 at 10:41am V21(Maintenance Director) observed the electrical plate detached from the wall behind the head of R64's bed. V21 stated, maintenance is responsible for replacing the plates. V21 stated, I have not received a work order for this.
On 9/12/2023 at 10:43am V21(Maintenance Director) observed the missing electrical outlet plate on the wall behind the head of R112's bed. V21 stated, having the outlet plate cover off the electrical outlet does pose a safety risk for the residents and staff.
R9 has a diagnosis of but not limited to Atrial Fibrillation, Depression, Hypertension, and Systolic (Congestive) Heart Failure. R9's Brief Interview of Mental Status score is 13 that indicates cognitive intactness.
On 9/10/2023 at 12:30am surveyor observed the electrical outlet just above R9's bed missing an outlet cover. R9 stated, this is dangerous and it has been that way since he moved into this room.
On 9/11/2023 at 10:55am surveyor observed that R9's electrical outlet had a cover now.
On 9/11/2023 at 11:03 V21 (Maintenance Director) stated, a missing outlet cover is not safe and it is not homelike.
On 9/13/2023 at 10:46am via email V2 (DON) stated, the nurse is to first assess the safety of the resident and remove them, if necessary and notify maintenance verbally as well as complete a work order and notify administration.
Undated Job Description of Maintenance Supervisor documents, in part, the primary purpose of your job position is to assure that a successful maintenance program is maintained at all times, inspect the facility, on a regular basis, to ensure that the grounds, facility and equipment are maintained in accordance with established policies and procedures and all hazardous areas are properly identified.
Environmental Services Schedule (undated) documents, in part, to report all fire and electrical hazards, (i.e. exposed wires, broken receptacles, etc).
Based on observation, interview and record review, the facility failed to maintain a safe environment by correcting hazards from damaged furniture with an exposed nail and electrical outlets not covered. These failures affected R9, R64 and R112 and has the potential to affect the 47 residents residing on 2 South.
Findings include:
On 9/10/23 at 11:42 am, in the 2 South dining, this surveyor observed a brown wooden chair with a maroon and green flowered cloth seat cover with the left chair arm detached from the frame of the back of the chair. The chair arm is hanging down towards the floor exposing a gray screw approximately one inch with the sharp end of the exposed screw pointing outwards.
On 9/11/23 at 10:07 am, in the 2 South dining, this surveyor observed the same chair with the chair arm hanging down exposing a gray screw approximately one inch with the sharp end of the exposed screw pointing outwards.
On 9/11/23 at 12:22 pm, this surveyor and V21 (Maintenance Director) performed a brief environmental tour and walked into the 2 South dining room. This surveyor and V21 observed the same chair with the chair arm hanging down exposing a gray screw approximately one inch with the sharp end of the exposed screw pointing outwards. V21 stated, Oh, I (V21) will get rid of this (the chair). V21 stated that staff will tell V21 when furniture is broken and that V21 will get rid of this chair. When asked if V21 was made aware by staff of this broken chair with the exposed nail, V21 stated, No. When asked if this chair in the 2 South dining room is a hazard for residents on 2 South floor, V21 stated, Yes. That screw. There's a risk of injury from the screw.
On 9/12/23 at 12:37 pm, V2 (Director of Nursing, DON) stated, if nursing staff would see a broken chair in the dining room with a one inch nail sticking out of the chair, what should they do, and V2 stated, the staff should remove the chair immediately from the resident area. When asked why, V2 stated, Because it could cause injury.
Facility policy dated March 2015 and titled Supervision and Safety, documents, in part, Policy: Our Policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility-wide priorities . 2. Safety risks and environmental hazards are identified on an ongoing basis . 9. Staff to decrease safety risk factors as much as possible.
Facility undated job description titled Job Description of Maintenance Supervisor, documents, in part, Purpose: The primary purpose of your job position is to direct the overall operation of the maintenance department in accordance with current applicable federal, state and local requirements, and as directed by the Administrator, to assure that a successful maintenance program is maintained at all times. Responsibilities: 1. Assist in the planning, developing, organizing, implementing, evaluation and directing of the maintenance department . 2. Assist in the development and implementation of departmental policies and procedures to assure that the maintenance of the premises, facility and equipment is current and all times. 3. Develop and maintain a good working rapport with inter- department personnel in other departments of the facility, to assure that maintenance programs can be properly planned and maintained to meet the needs of the facility. 4. Assure that the plant and equipment is properly maintained for resident comfort and convenience. 5. Supervises/monitors work department supervisors/personnel to ensure compliance of directives and established procedures . 15. Inspect the facility, on a regular basis, to ensure that the grounds, facility and equipment are maintained in accordance with established policies and procedures and all hazardous areas are properly identified . 17. Establish an effective preventative maintenance program for cleaning, painting, maintaining facility equipment, etc. (and other things), as necessary/approved.
Facility policy dated November 2018 and titled Residents' Rights for People in Long-Term Care Facilities, documents, in part, . Your facility must be safe, clean, comfortable and homelike.
Facility document dated 9/10/23 and titled Daily Census documents, in part, that 47 residents reside on the 2 South floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete the controlled drug count sheet which is util...
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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 complete the controlled drug count sheet which is utilized to count controlled substances for two residents (R67 and 216); and failed to complete a controlled drug receipt/record disposition form for three residents (R112, R149 and R204). This has the potential to affect all 47 residents on the 2-south unit and all 60 residents on the 2-north unit.
Findings include:
On 09/10/2023 V1 (Administrator) presented facility census report that documented the residents census of 47 residents on the 2-south unit and all 60 residents on the 2-north unit.
On 09/11/23 at 9:12 am, Surveyor and V8 (Licensed Practical Nurse, LPN) performed a controlled substance audit of the 2-south team 2 medication cart. Surveyor did not observe a controlled drug receipt/record/disposition form for the following residents:
R204 without a controlled drug receipt/record/disposition form for methadone 100 mg tablet.
R149 without a controlled drug receipt/record/disposition form for R149's Methadone HCI (Hydrochloride) concentrate 10 milligrams (mg)/ milliliter (ml).
On 09/11/23 at 9:15 am, V8 stated, R204 and R149 do not need a controlled drug receipt/record/disposition form for R204's and R149's scheduled II narcotic medications. V8 was asked regarding the purpose and importance of having a controlled drug receipt/record/disposition form for controlled drug medications. V8 stated, the purpose and the importance of having a controlled drug receipt/record/disposition form for controlled drug medications was to keep an accurate count of the residents narcotic medications.
On 09/11/23 at 9:55 am, Surveyor and V25 (Licensed Practical Nurse, LPN) performed a controlled substance audit of the 2-south team 1 medication cart. Surveyor observed the controlled substance binder containing the controlled drug receipt/record/disposition form that V25 did not sign for the following residents:
R216's Hydrocodone/Acetaminophen tablet 5-325 mg take 1 tablet by mouth every 6 hours as needed for pain. Surveyor observed R216's medication card with 4 pills and R216's-controlled drug receipt/record/disposition form observed with 5 pills indicated for dispense.
R67's Clonazepam 0.5 mg take 1 tablet by mouth every morning and at bedtime. Surveyor observed R67's medication card with 7 pills and R67's-controlled drug receipt/record/disposition form observed with 8 pills indicated for dispense.
On 09/11/23 at 9:59 am, V25 (LPN) stated, I (V25) gave the medication, but I (V25) did not sign it yet. V25 stated, the purpose and the importance of signing the controlled drug receipt/record/disposition form for controlled drug medications was to keep an accurate count of the residents narcotic medications.
On 09/11/23 at 11:12 pm, Surveyor and V28 (Licensed Practical Nurse, LPN) performed a controlled substance audit of the 2-north team 1 medication cart. Surveyor did not observe a controlled drug receipt/record/disposition form for the following residents:
R112's without a controlled drug receipt/record/disposition form for R112's Lorazepam Oral concentrate 2 mg/ ml.
On 09/11/23 at 11:15 am, V28 stated, V28 did not know why R112 did not have a controlled drug receipt/record/disposition form for R112's Lorazepam Oral concentrate 2 mg/ ml. V8 was asked regarding the importance of having a controlled drug receipt/record/disposition form for controlled drug medications. V28 stated, To make sure that all the narcotics are there (referring to the narcotics box).
On 09/12/22 at 10:18 am, V2 (Director of Nursing, DON) was interviewed regarding the facility's policy for controlled narcotics and V2 stated, every controlled substance medication should have a controlled drug receipt/record disposition form. V2 explained, upon change of shift and switching of medication keys the nurses should count before and after and sign off on the accountability sheet as well as the nurse should sign the controlled drug receipt/record disposition form after the resident medication is dispensed to the resident. V8 explained the importance of having a controlled drug receipt/record disposition form and signing out narcotic medications on the controlled drug receipt/record disposition form is for accountability of the medication and to follow the control substance guidelines. V8 also stated, it is important to have accurate controlled drug receipt/record disposition forms so that the nurse knows the medication count is correct and the nurse can see what was given to the resident.
R204's face sheet shows that R204 has a diagnosis which includes but not limited to end stage renal disease, syphilis, otitis medical left ear, anemia, essential primary hypertension, and dependence on renal dialysis.
R204's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) does not indicate a score for R204 which indicates that R204 is cognitively impaired.
R204's Order Summary Report (POS) dated 09/12/23 shows that R204 is receiving Methadone 100 mg tablet daily by mouth.
R149's face sheet shows that R149 has a diagnosis which includes but not limited to opioid use, alcohol use, acute respiratory failure, hypertensive emergency, major depression, and acute pulmonary edema.
R149's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) indicates a score of 15 which indicates that R149 is cognitively intact.
R149's Order Summary Report (POS) dated 09/12/23 shows that R149 is receiving Methadone HCI oral concentrate 10 mg/ml 80 mg tablet daily by mouth.
R67's face sheet shows that R67 has a diagnosis which includes but not limited to bipolar disorder, low back pain, muscle wasting, urinary tract infection, difficulty walking, muscle weakness and essential hypertension.
R67's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) indicates a score of 14 which indicates that R67 is cognitively intact.
R67's Order Summary Report (POS) dated 09/12/23 shows that R67 is receiving Klonopin (Clonazepam) give 1 tablet by mouth in the morning related to bipolar disorder.
R67's Controlled Drug/Receipt/Record/Disposition Form dated dispensed 08/11/23 shows that R67 has 8 Clonazepam 0.5 mg tablets for dispense.
R216's face sheet shows that R216 was admitted to the facility on [DATE] and does not have a Minimum Data Set (MDS), Brief Interview of Mental Status (BIMS) at this time. R216 face shows that R216 has a diagnosis which includes but not limited to unspecified trochanteric fracture of left femur, hemiplegia, human immunodeficiency virus, alcohol abuse, and tobacco use.
R216's Order Summary Report (POS) dated 09/12/23 shows that R216 is receiving Hydrocodone/Acetaminophen tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain.
R216's Controlled Drug/Receipt/Record/Disposition Form dated dispensed 09/07/23 shows that R216 has 5 Hydrocodone/Acetaminophen tablet 5-325 mg tablets for dispense.
R112's face sheet shows that R112 has a diagnosis which includes but not limited to insomnia, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, malignant neoplasm of pharynx, cyst of pancreas, schizophrenia, and asthma.
R112's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) indicates a score of 15 which indicates that R112 is cognitively intact.
R112's Order Summary Report (POS) dated 09/12/23 shows that R112 is receiving Lorazepam oral concentrate 2 mg/ml give 0.25 ml by mouth every 6 hours as needed for anxiety and/or restlessness.
The facility's job description document titled Charge Nurse documents, in part: Responsibilities: 24. Ensure that all medications and treatments are charted after the fact by the person administering the medications or completing the treatment on his/her assigned shift . 27. Ensure that drugs covered by the Controlled Substances Act are verified by inventory.
The facility's document dated 10/25/2014 and titled Controlled Substance Storage documents, in part: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures:
D. A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, II, IV, and V medications . E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses or one QMA (Quality Medication Aide) in the states who have approved such staffing positions.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the facility policy to conduct resident criminal history bac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the facility policy to conduct resident criminal history background checks within 24 hours after admission of a new resident which affected R213, R216, R222, R223 and R225 in the total sample of 74 residents and has the potential to affect all 215 residents in the facility.
Findings include:
Facility document dated 9/10/23 and titled MDS (Minimum Data Set) Resident Matrix, documents, in part, that R213, R216, R222, R223 and R225 were new admissions to the facility.
On 9/11/23, this surveyor requested criminal history background checks from V1 (Administrator) for R213, R216, R222, R223 and R225 along with their census reports and received the following:
R213: Census report documents, in part, that R213 was admitted to the facility on [DATE] and is an active resident in the facility. R213's criminal history background check was performed on 9/11/23 with document reading: Registry search done on 9/11/23.
R216: Census report documents, in part, that R216 was admitted to the facility on [DATE] and is an active resident in the facility. R216's criminal history background check was performed on 9/11/23 with document reading: Registry search done on 9/11/23.
R222: Census report documents, in part, that R222 was admitted to the facility on [DATE] and is an active resident in the facility. R222's criminal history background check was performed on 9/11/23 with document reading: Registry search done on 9/11/23.
R223: Census report documents, in part, that R223 was admitted to the facility on [DATE] and is an active resident in the facility. R223's criminal history background check was performed on 9/11/23 with document reading: Registry search done on 9/11/23.
R225: Census report documents, in part, that R225 was admitted to the facility on [DATE] and is an active resident in the facility. R225's criminal history background check was performed on 9/11/23 with document reading: Registry search done on 9/11/23.
On 9/12/23 at 11:07 am, V40 (Admissions Director) stated, V40's responsibility is to perform the resident criminal background checks for new admissions to the facility. When asked when does V40 perform the criminal background checks for residents who are new admissions, V40 stated, When they get here. V40 stated, when the newly admitted residents arrives, V40 will puts their information for criminal background checks into the electronic verification system which checks for history of sex offenders and criminal activity with the state department of correction. V40 stated, I (V40) try to do it within a week of the resident's arrival. This surveyor showed V40 the criminal background checks for R213, R216, R222, R223 and R225 who were new admissions and that their criminal background checks were done on 9/11/23 despite being admitted 4 days or greater. V40 stated, I (V40) didn't pull them right away. V40 was asked the purpose of performing criminal background checks for residents within 24 hours of admission. V40 stated, to make sure that the resident is not a sex offender, and if so, the facility would make an adjustment and send to another facility.
On 9/12/23 at 1:04 pm, V1 (Administrator) stated, as the abuse coordinator, criminal background checks are expected to be done by V40 for all residents with expectations to do it consistently, do it timely, and do it accurately. When asked what the time frame is for V40 performing the resident criminal background checks, V1 stated, 72 hours is the longest we can go. V1 stated, it's 24 to 72 hours to perform the resident criminal background checks, but V1 will have to double check. When asked why the facility performs resident background criminal checks, V1 stated, We need to know who's in the building. We need to maintain safety and keep the residents and staff safe; and to adequately deny someone who doesn't belong here.
On 9/11/23 at 11:12 am, V50 (MDS Coordinator) confirmed that the facility census of active residents on 9/10/23 at 9:10 am is 215 residents.
Facility undated job description titled Admissions Coordinator, documents, in part, Summary: The Admissions Coordination is responsible for reviewing and preparing for new admissions in accordance with established policies and procedures . Essential Duties and Responsibilities: . Admit and prepare identification records for residents in accordance with our established policies and procedures . Assume the administrative authority, responsibility, and accountability of performing the assigned administrative duties.
Facility policy dated 1/4/2018 and titled Abuse Prevention Program: Facility Policy and Procedure, documents, in part, Introduction: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . Facility Policy and Procedure: . II. Pre-admission Screening of Potential Residents: This facility shall check and review of the criminal history background for any resident seeking admission to the facility in order to identify previous criminal convictions. The facility will: Request a Criminal History Background Check within 24 hours after admission of a new resident.
Facility policy dated November 2018 and titled Residents' Rights for People in Long-Term Care Facilities, documents, in part, . Your rights to safety: You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually.
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 posted in a prominent place readily accessible to residents and visitors and failed to ens...
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Based on observation, interview and record review, the facility failed to ensure the Daily Nurse Staffing was posted in a prominent place readily accessible to residents and visitors and failed to ensure the Daily Nurse Staffing was complete with the required information. This failure affected all 215 residents residing in the facility.
Findings include:
On 9/10/23 at 9:10 am, this surveyor entered the facility and did not observe the Daily Nurse Staffing posted in the lobby/reception area of the facility.
On 9/11/23 at 9:00 am, this surveyor entered the facility and did not observe the Daily Nurse Staffing posted in the lobby/reception area of the facility.
On 9/12/23 at 9:15 am, this surveyor entered the facility and did not observe the Daily Nurse Staffing posted in the lobby/reception area of the facility.
On 9/12/23 at 9:34 am, V38 (Staffing Coordinator) stated, V38 is responsible for posting the nurse and CNA (Certified Nursing Assistant) schedule and posts it for employees to see in a locked bulletin board by the employee time clock in the back hallway. When asked if V38 posts the facility's Daily Nurse Staffing anywhere else for residents or visitors to see with the census and number of Registered Nurses (RN), Licensed Practical Nurses (LPN) and CNAs, V38 stated, V38 posts it also in the facility lobby in a slot on the wall. This surveyor asked to go with V38 to see the posting, and V38 stated, I (V38) haven't put it up yet. V38 then printed the nurse and CNA staff schedule from V38's computer and showed this surveyor the document that V38 states, V38 posts as the Daily Nurse Staffing. This schedule, dated 9/12/23, shows the first initial and last names of staff on each floor, with no titles, for the day shift. V38 stated, each shift, V38 changes up the nurse and CNA schedule. This surveyor and V38 then walk to facility lobby, and V38 points to the empty plastic holder on the wall near the receptionist desk in the lobby. When asked if V38 posted the Daily Nurse Staffing yesterday (9/11/23), V38 stated, Yes. When asked if V38 posted the Daily Nurse Staffing on 9/10/23, V38 stated, V38 doesn't work on the weekends and that sometimes the supervisor will post it in the lobby. This surveyor informed V38 this surveyor and the survey team did not view the Daily Nurse Staffing posted on 9/10/23, 9/11/23 and 9/12/23 with the holder being empty.
Facility document titled 1st Week Tuesday: 9/12/23 documents, in part, the day shift nurse and CNA schedule for the 5 units with the first initial and last names of all staff and does not include titles of nursing staff or the census.
On 9/11/23 at 11:12 am, V50 (MDS {Minimum Data Set} Coordinator) confirmed that the facility census of active residents on 9/10/23 at 9:10 am is 215 residents.
Facility undated policy title Staffing, documents, in part, Purpose: 1. To have appropriate amount of nursing staff on a daily basis.
Facility undated job description titled Scheduler/Central Supply, documents, in part, Summary: The Scheduler/Central Supply position is responsible for ensuring appropriate staffing for our facility while maintaining staffing regulations.
The (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) State Operations Manual documents, in part, the following:
§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.
§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.
GUIDANCE §483.35(g)
The facility's staffing data document may be a form or spreadsheet, as long as all the required information is displayed clearly and in a visible place.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to ensure proper labeling and dating of food items in the refrigerator and freezer and maintain sanitary conditions in the food pr...
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Based on observation, interview and record review the facility failed to ensure proper labeling and dating of food items in the refrigerator and freezer and maintain sanitary conditions in the food preparation areas. This failure has the potential to affect all residents receiving oral nutrition.
On 9/10/2023 at 9:40am surveyor observed in the refrigerator ½ loaf of yellow cheese with no label or date, 1/2 bag of shredded cheese with a sticker with no name of product name or dates, a long steel pan of Alfredo, written on the foil, that was not dated or covered properly. Surveyor further observed in the refrigerator a medium size steel container with 8 boiled eggs in it with no label or date, a medium size steel pan of peanut butter and jelly mixed with a date of 9/08/2023 and a medium sized steel pan of turkey slices with a date of 9/03/2023.
On 9/10/2023 at 9:45am V3 (Cook) stated, food items should be labeled and have an in and use by date and the pan with the boiled eggs should have a use by date on it too.
On 9/10/2023 at 9:49am surveyor observed 2 large round roasted turkeys wrapped in foil with no label or date, and flour Tortillas with no label or date in the freezer.
On 9/10/2023 at 9:50am surveyor observed a wet bath blanket on the floor in front of the ice machine. V7 stated, the ice machine makes ice very slowly, but it is leaking or something.
On 9/10/2023 at 9:55am surveyor observed, in the dry storage room, two large clear bags flour and breadcrumbs, in their original packaging with no label or dates on it sitting on the shelve.
On 9/11/2023 at 10:04am surveyor observed 4 bath blankets covering the floor drains in the food preparation area that were completely soaked with a water and water pooling in the area.
On 9/11/2023 at 10:05am V33 (Dietary Aide) stated, the water backs up in the drains and spills out onto the floor and that when the sinks are turned on the water backs up in the drains and backs up into the kitchen.
On 9/11/2023 at 11:41am V6 (Dietary Manager) stated, the drains have been leaking for over a month and management has been made aware and nothing has been done about it yet.
On 9/12/2023 at 2:25pm V34 (Dietary Aide/Cook) stated, the water backing up in the drains has been a problem for the last two years.
On 9/12/2023 at 2:30pm V6 stated food items in the refrigerator and or freezer should be labeled with an in and expiration date and the name of the food product. V7 also stated, the water coming up from the drains is definitely a hazard and safety issue.
On 9/13/2023 at 10:43am via email V21 (Maintenance Director) stated, water pooling in the kitchen increases the chances of staff slipping (Safety) and the presence of airborne insects.
Undated policy titled Food Storage documents, in part, protect food from contamination, to ensure wholesomeness, and to prevent the spread of infections and communicable disease, all stored food products will be covered, identified and dated. Dating of potentially hazardous foods shall indicate the last day the item can be consumed, and ingredient bins and bulk food containers will be properly labeled to identify the food products stored.
Undated Job Description of Maintenance Supervisor documents, in part, the primary purpose of your job position is to assure that a successful maintenance program is maintained at all times, inspect the facility, on a regular basis, to ensure that the grounds, facility and equipment are maintained in accordance with established policies and procedures and all hazardous areas are properly identified.
Undated Environmental Services Schedule documents, in part, report any leaking drains.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to secure the lid on the outside garbage dumpster in an effort to prevent pest and rodents from entering into the facility. This f...
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Based on observation, interview and record review the facility failed to secure the lid on the outside garbage dumpster in an effort to prevent pest and rodents from entering into the facility. This failure has the potential to affect all residents residing in the facility.
On 9/10/2023 at 8:31am surveyor observed the lid to one of the garbage dumpsters open from overflowing garbage bags.
On 9/10/2023 at about 9:30am surveyor observed the lid to one of the garbage dumpsters open from overflowing garbage bags.
On 9/13/2023 at 10:43am via email V21 (Maintenance Director) stated, dumpster lids should be closed when not in use to prevent and deter rodent activity. Housekeeping is responsible for ensuring the dumpster lids are closed after use.
Policy titled Waste Management with a date of 5/14 documents, in part, to prevent the spread of infection, dumpster lid kept closed and maintenance and housekeeping personnel shall assure the dumpster area is kept clean and all trash bags are inside the dumpster, and dumpster lids closed.
Sept 2023
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to provide adequate and sufficient care for one resident (R1) of 3 re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to provide adequate and sufficient care for one resident (R1) of 3 reviewed for two person-assist for bed mobility. This failure resulted in R1 falling out of bed and sustaining a subdural hematoma.
Findings include:
R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Chronic Myeloid Leukemia, BCR/ABL-Positive, Not Having Achieved Remission, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Site, Other Specified Symptoms and Signs Involving the Digestive System And Abdomen, Pain in the Right Knee.
Facility Incident Investigation Report (dated 08/23/2023) regarding R1 documents in part: Resident has impaired mobility and cognition requiring total staff assistance with mobility and transfers. Resident is able to move in bed but requires staff assistance for safety. MD notified of fall and injury with orders to send resident to the hospital for further evaluation. Resident was admitted to the hospital with a diagnosis of Subdural Hemorrhage.
Minimum Data Set Section G (MDS) (dated 05/31/2023) scored R1 as (3) requiring 2-to-3-person physical assistance for bed mobility. MDS section C (dated 05/15/2023) scores R1 as having a BIMS score of 4, indicating that R1's cognition is impaired.
R1's Fall Care plan (dated 01/17/2023) documents that R1 is at risk for falls r/t poor safety awareness, poor balance, unsteady gait. R1's fall care plan documents that R1 exhibits impaired bed mobility r/t CVA and R1 is not able to position/ reposition self when in bed or sitting.
Fall Risk Assessment (dated 05/26/2023) prior to fall incident on 08/20/2023 scored R1 as (14) a moderate risk for falls.
Fall Prevention Program (dated 02/28/2014) states: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.
On 08/29/2023 at 12:38pm V4 CNA (Certified Nursing Assistant) stated, On 08/20/2023 I was going to change R1, and all her care items were gathered at her bedside table. R1 was in the bed with R1's top half of her body centered in bed, and R1's legs were more near the edge. I was on R1's left side of the bed. I turned to grab the items that were needed to provide the care for the resident. I had to step away to be able to reach them, and that's when R1 fell out of the bed. R1 requires a two-person assistance for ADL care, and at the time R1 fell, I did not have any other staff member in the room with me. I did not reposition R1 before I stepped away to grab the care items. That day, there were several CNAs scheduled to work on that unit, however, there were multiple call offs. I was the only CNA who was working the 3-south unit and there was not enough staff to help me. For the 3rd floor/3 south unit, there should have been 4 certified nursing assistants, but it was only me and the restorative aide. R1 requires the assistance of 2 staff members, and we were short that day, so I had to change R1 by myself. R1 requires 2 CNAs because R1 moves a lot and it is unsafe, but I was the only on the floor, so I had to change the resident by myself.
On 08/29/2023 at 1:01pm V3 RN (Registered Nurse) stated, On 08/20/203, the last time I saw R1 was when I administered R1 her morning medications. The CNA on duty came to inform me that R1 fell. I was at the nurse's station when V4 came to inform me of the fall. We were working short that day because we had multiple call offs from CNAs who were scheduled to work on the 3-south unit. V4 and a restorative aide were the only ones who were working on the unit, so it was really hard for the two of them to care for all these residents. V4 was the only CNA at the bedside doing R1's care because there was no other CNA to assist V4 with changing R1. R1 requires the assistance of 2 CNAs for ADL care. R1 slid out of the bed and after the fall, I saw that R1 had a knot on her forehead. I notified R1's physician and family and I sent the resident out to the hospital, after initiating neuro-checks. R1 sustained a subdural hematoma from the fall.
On 08/30/2023 at 11:37am, V5 (Staffing Coordinator) stated, On 08/20/2023, for the unit of 3 south, there were 5 certified nursing assistants scheduled and we had 4 call offs. On that shift there was only a total of 1 CNA working the 3-south unit during the 7am-3pm shift. A restorative aide was pulled to work the 3-south unit. We are not utilizing a staffing agency. The new company that owns the building does not want to utilize a staffing agency. Sometimes a staffing agency is needed during times where there are a lot of call offs. The facility is attempting to hire more staff, both nurses and CNAs.
On 08/30/2023 at 12:10pm, V7 (Restorative Director) stated, R1 does not walk. R1 is chair bound and requires total staff assistance of 2 people for transfers. R1 requires a 2 person assist for bed mobility. R1 requires the assistance of 2 CNAs when being changed.
On 08/31/2023 at 9:54am V2 (Director of Nursing) stated, The facility has an issue with employee call offs. There are a lot of call offs. The staffing coordinator will have the schedule filled appropriately and all of a sudden, we will have many call offs. The facility does not use a staffing agency because the corporate office decided not to use the agency. We do a good job covering the shifts by offering bonuses and the corporate office feels like a staffing agency is not needed.
On 09/05/2023 at 2:33pm V15 (Nurse Practitioner) stated, I am aware that R1 had a fall on 08/20/2023. R1's fall could have been avoided. R1 moves and scoots all over in bed. I know the resident really well. R1 has leukemia. R1 scoots all over the bed and R1 does not walk. If there were 2 staff members the fall could have been avoided potentially because when R1 is changed, she definitely needs the assistance of two CNAs. R1 shifts her weight a lot. It is not safe for one CNA to provide ADL care. R1 is not appropriate for one staff member for ADL care and changing the resident. One CNA can wash the resident's face or provide assistance with feeding the resident, however, when R1 is being changed, the resident requires the assistance of 2 CNAs.
R1's Progress Note (dated 08/20/2023) documents, Nurse alerted to residents' room, resident laying on her back on floor. CNA stated, Resident rolled from bed during ADL care, head to toe observation done and resident alert per usual mental status, large hematoma to left side of forehead with no bleeding, cold compress applied, pain level evaluated, denies pain and discomfort, ROM preformed, resident able to move all extremities, resident sent to ER. Family and MD made aware.
Progress Note (dated 08/20/2023) documents, Call placed to ER to get updated status on resident, was made aware that resident was transferred to Community ER. Call placed to Community ER x3 to get updated status; each attempt was unsuccessful, due to no one answering the ER phone. Endorsed to oncoming nurse to follow up with status.
Progress Note (dated 08/20/2023) documents, Report from Community ER stated that the Resident has been admitted after evaluation. DX subdural hematoma.
Review of the schedule 3 south 7am-3pm (dated 08/20/2023) indicated that there was only one certified nursing assistant working and one restorative aide.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate staffing for the 3-south unit of the f...
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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 adequate staffing for the 3-south unit of the facility on 08/20/2023. This failure resulted in R1 falling of the bed and sustaining a subdural hematoma as a result of the facility not having adequate staffing to provide resident care.
Findings include:
Review of the schedule 3 south 7am-3pm (dated 08/20/2023) indicated that there was only one certified nursing assistant working and one restorative aide.
On 08/30/2023 at 11:37am, V5 (Staffing Coordinator) stated, On 08/20/2023, for the unit of 3 south, there were 5 Certified Nursing Assistants (CNAs) scheduled and we had 4 call offs. On that shift there was only a total of 1 CNA working the 3-south unit during the 7am-3pm shift. A restorative aide was pulled to work the 3-south unit. We are not utilizing a staffing agency. The new company that owns the building does not want to utilize a staffing agency. Sometimes a staffing agency is needed during times where there are a lot of call offs. The facility is attempting to hire more staff, both nurses and CNAs.
On 08/30/2023 at 12:10pm, V7 (Restorative Director) stated, R1 does not walk. R1 is chair bound and requires total staff assistance of 2 people for transfers. R1 requires a 2 person assist for bed mobility. R1 requires the assistance of 2 CNAs when being changed.
On 08/31/2023 at 9:54am V2 (Director of Nursing) stated, The facility has an issue with employee call offs. There are a lot of call offs. The staffing coordinator will have the schedule filled appropriately and all of a sudden, we will have many call offs. The facility does not use a staffing agency because the corporate office decided not to use the agency. We do a good job covering the shifts by offering bonuses and the corporate office feels like a staffing agency is not needed.
Minimum Data Set Section G (MDS) (dated 05/31/2023) scored R1 as (3) requiring 2-to-3-person physical assistance for bed mobility.
MDS section C (dated 05/15/2023) scores R1 as having a BIMS score of 4, indicating that R1's cognition is impaired.
R1's Fall Care plan (dated 01/17/2023) documents that R1 is at risk for falls r/t poor safety awareness, poor balance, unsteady gait. R1's fall care plan documents that R1 exhibits impaired bed mobility r/t CVA and R1 is not able to position/ reposition self when in bed or sitting.
Fall Risk Assessment (dated 05/26/2023) prior to fall incident on 08/20/2023 scored R1 as (14) a moderate risk for falls.
R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Chronic Myeloid Leukemia, BCR/ABL-Positive, Not Having Achieved Remission, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Site, Other Specified Symptoms and Signs Involving the Digestive System And Abdomen, Pain in the Right Knee.
Facility Incident Investigation Report (dated 08/23/2023) regarding R1 documents in part: Resident has impaired mobility and cognition requiring total staff assistance with mobility and transfers. Resident is able to move in bed but requires staff assistance for safety. MD notified of fall and injury with orders to send resident to the hospital for further evaluation. Resident was admitted to the hospital with a diagnosis of Subdural Hemorrhage.
On 09/05/2023 at 2:33pm V15 (NursePpractitioner) stated, I am aware that R1 had a fall on 08/20/2023. R1's fall could have been avoided. R1 moves and scoots all over in bed. I know the resident really well. R1 has leukemia. R1 scoots all over the bed and R1 does not walk. If there were 2 staff members the fall could have been avoided potentially because when R1 is changed, she definitely needs the assistance of two CNAs. R1 shifts her weight a lot. It is not safe for one CNA to provide ADL care. R1 is not appropriate for one staff member for ADL care and changing the resident. One CNA can wash the resident's face or provide assistance with feeding the resident, however, when R1 is being changed, the resident requires the assistance of 2 CNAs.
R1's Progress Note (dated 08/20/2023) documents, Nurse alerted to residents' room, resident laying on her back on floor. CNA stated, Resident rolled from bed during ADL care, head to toe observation done and resident alert per usual mental status, large hematoma to left side of forehead with no bleeding, cold compress applied, pain level evaluated, denies pain and discomfort, ROM preformed, resident able to move all extremities, resident sent to ER family and MD made aware.
Review of the schedule 3 south 7am-3pm (dated 08/20/2023) indicated that there was only one certified nursing assistant working and one restorative aide.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a comfortable home like environment. This fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a comfortable home like environment. This failure has the potential to affect all 215 residents in the facility.
Findings Include:
On 08/29/2023 at 9:50 am, R6 stated, The drawer from my dresser is missing and it has always been this way. Nothing was done about it. The paint in my room is old and chipped and the trim from the base boards is gone. It is like that in the entire facility. This place needs to be renovated.
On 08/29/2023 at 10:01am, R8 stated, The facility is old looking and it really needs a lot of work. The residents feel depressed living in an old run-down building.
On 08/30/2023 at 11:06pm, R9 stated, This place looks terrible. This place is so run down that it is depressing.
On 08/31/2023 at 10:40am, R4 stated, The facility is very run down. It's a shame that we have to live like that. The entire facility is a dump. The sink in my room is loose and it needs to be replaced. The Maintenance Director said he will fix it. Maintenance fixed it before and he will fix it again, but the sink is old and a new one should be put in. The entire facility needs work because the resident rooms have chipped paint everywhere and the trim is missing from the base boards in many rooms in the facility. The facility needs work, and it looks bad. It is horrible to live in a building so run down like this. It makes us feel like the owners don't care about the residents who live in the facility. The Maintenance Director wants to fix everything, but he can't do any work unless the owners approve it.
On 08/31/2023 at 1:20pm, V2 (Director of Nursing) stated, I have received many resident and family complaints pertaining to the environment. A lot of family and residents have been complaining that the facility is run down and needs updates.
On 09/05/2023 at 10:06am V12 (Social Service Director) stated, I do the grievance log and I have received many resident complaints pertaining to the facility being old and run down and needing a lot of work. A lot of residents have complained about their furniture being old and broken. I have received resident complaints pertaining to missing drawers from the dressers. Some of the furniture is old and they are replacing that furniture. I have residents complaining about the paint in their rooms being chipped or that their sink is not working.
On 09/05/2023 at 11:04am V13 (Maintenance Director) stated, I have received resident complaints pertaining to drawers missing from the dressers. We are getting new furniture. I have received complaints from the residents pertaining to leaking toilettes and we have been correcting those. A lot of residents are complaining about the overall appearance of their rooms and the facility does need a lot of work. The residents are not happy that the building is old and run down and a lot of work needs to be done.
On 09/05/2023 at 1:01pm, R5 stated, My room needs work. The entire building is run down, and it is depressing to live like this. The inside of the building is old and needs a lot of work. The floors are old and missing tiles. The rooms have old, chipped paint. The base boards are missing, and the dry wall needs to be repaired. The sink in my bathroom is moving and it needs to be replaced. The Maintenance Director has fixed it several times, but the thing is old and needs to be replaced. It is depressing to live like this.
During facility observations (08/29/2023 to 09/07/2023) surveyor observed that the facility is in deplorable condition and does not resemble a homelike environment. Surveyor observed residents missing drawers out of their dressers in room [ROOM NUMBER], 323, 343, 345 and room [ROOM NUMBER].Surveyor observed resident rooms to have chipping paint and no trim noted around baseboards in room [ROOM NUMBER], 323 and room [ROOM NUMBER]. Surveyor observed resident room numbers to have missing numbers outside their door in room [ROOM NUMBER] and 340. Surveyor noted the sink in room [ROOM NUMBER] and room [ROOM NUMBER] to be loose and moving. The facility floors were observed to be in deplorable condition.
Jun 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
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
Based on interview and records review, the facility failed to provide medical records in a timely manner for one (R2) of three residents reviewed. This deficiency has a potential of delaying R2's medi...
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Based on interview and records review, the facility failed to provide medical records in a timely manner for one (R2) of three residents reviewed. This deficiency has a potential of delaying R2's medical care.
Findings include:
On 6/3/2023 at 11:29am, V1(Administrator) said R2's family member called facility around May 12th, 2023 and spoke to V1regarding getting/requesting R2's medical records. V1said she had R1's family member fill out the medical records request form, and V1 took a copy of R2's family member ID and POA (Power of Attorney) forms, then V1 said she told R2's family member that the person who deals with medical records(V3-Health Information Management) was not in on that day and that V1 would ask V3 to put in the request for R2's medical records when V3 comes back to the office on Monday. V1 said R2's family member called on a Friday. V1 said after R3's family member provided the documents required to process medical records, she(V1), put the request in V3's mailbox for V3 to follow up and reminded V3 on Monday when V3 came back to work that there was a request for medical records for R2.
V1 said V3 replied Ok. V1 said life went on, and then this week, (week of May 29th,) V3 told V1 that she, V1 might get a phone call from an upset family member (R2's family member) who did not get medical records requested earlier, over two weeks ago, and had not heard back from the facility. V1 said V3 dropped the ball. Medical records request is supposed to be processed within 24-48 hours, and the family member or resident should be notified that the facility received the request, and they should be told of the charges the medical records requested will cost. V1 said it is important for medical records to be processed in a timely manner because a physician, an attorney or other health care professionals could be asking or needing the medical records for residents' continuation of care, and it is also a resident's right to be provided their medical records when they request them.
Policy titled: Medical Records Request, dated 7/14 documents:
-Once a medical record review is complete and the requesting party has been determined to have authority to obtain a copy, the facility will notify the requesting party of the cost of copies.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to document wound care treatments for one resident (R2) of 2 residents reviewed for wound care.
Findings include:
On 6/3/23 at 1:...
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Based on observation, interview and record review, the facility failed to document wound care treatments for one resident (R2) of 2 residents reviewed for wound care.
Findings include:
On 6/3/23 at 1:14 PM, V4 (Wound Nurse-LPN) stated R2 has arterial wounds to the left heel, left toes, left lateral foot, and has a wound on the left side of the head. The left head wound is being treated with hydrogel gauze and a dry dressing daily. All the wounds on the left foot are treated with betadine, ABD pad and wrapped with Kerlex 3 times a week and as needed. V4 stated treatments are documented on the TAR (treatment Administration Record), they are not documented in another place. V4 stated if treatments are not documented it was not done, according to nursing standards. V4 stated there is a wound nurse for weekdays. V4 is the wound nurse every other weekend. V4 stated if the resident is not receiving the services they should be, then the wound will decline. V4 stated R2 left lateral foot wound has improved. V4 stated it cannot be assumed that treatment is provided just because the wound is getting better. Doctors' orders need to be followed.
On 6/3/23 at 10:00 AM, Observed V4 (Wound Nurse-LPN) treat R2's head wound.
On 6/3/23 at 10:20 AM, Observed V4 (Wound Nurse-LPN) treat R4's right leg stump wound.
R2's Physician Order Summary, 6/3/2023, documents in part: paint left lateral foot with betadine cover with foam dressing wrap with roll gauze one time a day every Monday, Wednesday Friday, start date 2/21/2023
Reviewed R2's TAR (Treatment Administration Record) for 5/23 and 4/23. There is no documentation for left lateral foot. Both indicate no treatment was done on R2 left lateral foot.
Reviewed Wound Assessment Details Report, 4/26/2023, documents in part: Wound: left lateral foot; Area 12.00 cm2. Reviewed Wound Assessment Details Report, 5/31/2023, documents in part: Wound: left lateral foot; Area 6.90 cm2.
Facility policy Physician's Orders, 8/2021, documents in part: MAR/TAR: Medication Administration Record/Treatment Administration Record - the legal medical record for recording medication and treatments.
Apr 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to uphold one resident's (R2) right to keep living in the facility by attempting to improperly discharge R2.
Findings include:
On 4/3/23 at 10...
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Based on interview and record review, the facility failed to uphold one resident's (R2) right to keep living in the facility by attempting to improperly discharge R2.
Findings include:
On 4/3/23 at 10:34 AM, R2 stated that V3 (RN/Registered Nurse) was the nurse that discharged him (R2) on 2/27/23 on the allegation of possession of illegal substances, but when she (V3) found out the truth, she (V3) sent V23 (LPN/Licensed Practical Nurse/Former CNA/Certified Nursing Assistant) to tell R2 to come back upstairs since he (R2) was already in the lobby. R2 stated that he (R2) overheard V3 on the phone talking to social services saying, I (V3) refuse to discharge him (R2). I (V3) didn't know you guys didn't find nothing on him (R2). You're asking me to discharge him (R2) on hearsay because someone else reported on him (R2). R2 added, She (V3) definitely stood up for me. When the surveyor inquired how the incident made him (R2) feel, R2 replied, Oh terrible, because I (R2) really didn't have anywhere to go. I (R2) wasn't really sure if the shelter would have accepted me. I (R2) was basically going out on the streets. R2 denied that he (R2) wanted to leave AMA (Against Medical Advice). R2 stated that he (R2) signed a discharge paper, but he (R2) threw it out the next day. The surveyor inquired if the form he (R2) signed was an AMA form. R2 answered, It was a different form. R2 added that he (R2) had to go back to the unit to retrieve all his (R2) medications. R2 stated, That's how I (R2) knew I (R2) was really leaving. The surveyor inquired if R2 was given a 30-day notice prior to discharge. R2 replied, Oh no. The same day they came up with these accusations was the day they wanted to discharge me. R2 added that V7 (LPN/Licensed Practical Nurse), who works on the first floor, instructed him (R2) to call in a complaint to the state agency about the situation.
R2's 1/16/23 BIMS (Brief Interview for Mental Status) determined a score of 15, indicating R2's cognition is intact.
R2's admission Record documents diagnoses including but not limited to opioid abuse, asthma and major depressive disorder.
On 04/03/23 at 10:27 AM, surveyor inquired if on 2/27/23, R2 was leaving AMA or if it was a facility-initiated discharge. V3 replied, I don't quite remember which one it was. I'm not sure if he (R2) was physically being discharged or if he (R2) asked. I (V3) do remember that I (V3) myself encouraged him (R2) not to leave. At 10:30 AM, the surveyor inquired if V3 could look into the electronic medical record to see if there was a discharge order. V3 stated, I don't see an order. At 10:53 AM, the surveyor inquired if V3 provided R2 with his (R2) medications when he (R2) was leaving. V3 stated, I don't recall if he (R2) was given his (R2) medication or not. The surveyor then inquired if V3 ever spoke with social work about R2 being wrongfully discharged . V3 replied, I (V3) am not sure. I've had many phone calls talking to different nurses. I (V3) am an advocate for my patients. I (V3) don't really recall that conversation per say. The surveyor inquired if the facility could discharge a resident for alleged drug possession. V3 stated, Absolutely not.
On 04/03/23 at 2:15 PM, V7 (LPN/Licensed Practical Nurse) stated that R2 asked him (V7) what he would do if he was being accused of doing something wrong, but he wasn't doing anything wrong. V7 acknowledged that he (V7) showed R2 where the flyers were on the wall for the Ombudsman and state agency hotline. V7 added, I (V7) did tell him (R2) he can call if he (R2) has a legitimate concern.
On 04/04/23 at 10:39 AM, V7 stated, I (V7) can't recall the exact circumstances of the situation, but I (V7) know security was with him, and another staff was with him, and they escorted him (R2) out to the lobby. V7 was unable to recall who the other staff member was. V7 added, He (R2) wasn't clear on the reason why he (R2) was being asked to leave. That was the day we started having the conversations.
On 04/04/23 at 10:16 AM, R9 (R2's roommate) stated, They was trying to discharge him (R2). When the surveyor inquired why staff was trying to discharge R2, R9 answered, I think it had a lot to do about the drugs. R9 added that staff was alleging that R2 was selling drugs in the facility, however after conducting a room search, they didn't find anything.
R9's 1/23/23 BIMS determined a score of 15, indicating R9's cognition is intact.
On 04/04/23 at 11:31 AM, the surveyor inquired if a resident can be discharged from the facility for allegedly selling drugs. V1 (Administrator) stated, We can do an IVD (Involuntary Discharge) for that because that would be considered not following facility policies and rules. V1 added that R2 has never been issued an IVD.
On 04/04/23 at 12:25 PM, V13 (Social Services Director) stated that on 2/27/23, she (V13) was educating R2 on the new 4-hour Pass policy when R2 became agitated and threatened to leave. The surveyor inquired if R2 signed an AMA form. V13 answered, I don't believe he (R2) signed an AMA. I (V13) know he (R2) was in the lobby for like an hour. He (R2) never left. V13 added, If he (R2) signed an AMA or if he (R2) refused to sign, we'd put that in the documentation.
On 04/04/23 at 3:37 PM, V16 (Security) stated, They were pretty much trying to discharge him (R2). V16 stated that he (V16) overheard that R2 was accused of selling drugs to another resident, but they never found anything on him (R2). V16 added, He (R2) was in the lobby pretty much the whole time. He (R2) definitely didn't want to leave. He (R2) was calling sheltered home facilities because he (R2) pretty much had nowhere else to go. V16 added that if security was escorting someone out of the facility due to being unruly, they wouldn't be allowed to sit in the lobby.
On 04/05/23 at 10:24 AM, V23 (LPN/Former CNA) confirmed that she (V23) was instructed by the nurse on the unit at the time to go to the lobby to tell R2 to come back to the unit. When the surveyor inquired if R2 was being discharged or leaving AMA, V23 stated, I'm not sure. I (V23) know I was just told to have him (R2) return with his belongings.
On 04/05/23 at 11:14 AM, V24 (DON/Director of Nursing) stated that she (V24) was on vacation at the time of the alleged incident involving R2, so she (V24) is unaware of the circumstances that occurred that day. The surveyor inquired if a resident can be discharged from the facility for an allegation of selling drugs. V24 (DON/Director of Nursing) stated, Not for an accusation that is not founded.
On 04/05/23 at 11:53 AM, the surveyor inquired if residents are allowed to take their medications if they are leaving AMA. V2 (ADON/Assistant Director of Nursing) stated that they can if the physician allows it. V2 stated, I actually tell the nurses to put in an order AMA may leave with medications. V2 added that there should also be a progress note saying that the resident is requesting to leave with medications and that the physician was notified.
During review of R2's physician Order Summary Report, the surveyor did not see any physician-initiated discharge orders. Additionally, there were no orders indicating that R2 was leaving AMA with his (R2) medications.
Review of R2's progress notes revealed no documentation related to an AMA discharge or R2's refusal to sign an AMA form.
During review of R2's electronic medical record, a completed Discharge Instructions form was noted documented on 2/27/23 and signed by V3 (RN). In Section H. Medication Education, a box was noted checked next to 1. Verbal and 2. Written provided by 5. Nurse (V3).
On 04/05/23 at 12:37 PM, the surveyor inquired if discharge instructions are provided to a resident who is leaving AMA. V24 (DON) answered, Discharge instructions don't go to AMA, but again I (V24) was not here. Maybe they convinced him (R2) to stay and then they did a planned discharge, but I (V24) don't know. V24 exited the room and returned shortly after stating that she (V24) spoke with V3 (RN). V24 stated, She was trying to prevent him (R2) from leaving AMA and had a conversation with him (R2) and convinced him (R2) to stay. This information contradicts the surveyor's interview with V3 on 04/03/23 at 10:27 AM, in which V3 stated that she (V3) did not remember whether R2 was being discharged or leaving AMA. V24 added that V3 stated that the reason why she (V3) filled out the discharge instructions form was because she (V3) tried to get prepared in the event that he (R2) decided to discharge the correct way.
R2's 1/9/23 signed Duet Program admission Contract documents, in part, .6. Resident was informed about compliance with the Duet Program and mandatory group attendance. Resident acknowledges that he/she will receive a 30-day notice if non-compliant with the program.
The facility provided the surveyor the revised 11/18 Illinois Long-Term Care Ombudsman Program Booklet titled Resident's Rights for People in Long-Term Care, which documents, in part, Your rights to stay in your facility: You have the right to keep living in your facility. You must be given written notice if your facility wants you to move from the facility. The reasons for asking you to leave must only be for the following reasons: you are a danger to yourself or others; your needs cannot be met by the facility; your health has improved, and you no longer need the services of a long-term care facility; you have not paid your bill after reasonable notice; your facility closes.
The revised 12/17 Discharges policy documents, in part, General: To establish a plan of how to discharge a resident from the facility to home, another facility, or the hospital. Guideline: Discharge to Home: . 2. When the IDT (Interdisciplinary Team) in conjunction with the resident and resident's representative determine that a resident is ready to be discharged , the physician is contacted for an order. 3. Social services with meet with the resident and/or resident's representative to set up outside services and equipment. 4. A discharge form is completed by all involved members of the IDT that explains the resident care needs at home. 5. If medication is to be sent with the resident, a physician order is necessary. 6. Teaching will be done with the resident/representative on any discharge plan of care needs. This will be documented in the medical record. 7. On the day of discharge, the nurse will review the discharge form as well as the medications with the resident and/or resident representative. 8. The resident and/or resident's representative will sign the discharge sheet. A copy of the signed sheet is given to the resident and/or resident's representative and one is kept in the chart. 9. All the resident's personal belongings should be taken on the day of discharge.
The revised 11/17 Involuntary Discharge policy documents, in part, General: To provide proper notification to all parties regarding a resident who is being involuntarily discharged .Guideline: 1. The facility will provide notification of an involuntary discharge or transfer according to guidelines established by Federal and State agencies .3. The resident, responsible party (if appropriate) and agencies are notified in writing of the discharge 30 days prior to the discharge date . This done via a notice of Involuntary Discharge form with an opportunity for hearing .7. The resident cannot be involuntarily discharged from the facility until the process is completed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure that fall prevention interventions were in place as per individual care plan for 2 residents (R1 and R8) out of 4 resid...
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Based on observation, interview and record review, the facility failed to ensure that fall prevention interventions were in place as per individual care plan for 2 residents (R1 and R8) out of 4 residents reviewed for fall prevention interventions.
Findings include:
On 04/03/23 at 2:25 PM, R1 was observed sitting in his (R1) wheelchair wearing regular socks. R1 stated, My shoes are being washed right now. The surveyor inquired if R1 has any non-skid socks. R1 replied, No, they don't apply none. Didn't even ask us about none. The hospital gave me some, not them. R1 stated that he (R1) has fallen before coming out of the bathroom when he (R1) did not have his shoes on. R1 stated, They waxed the floor. I don't think that is any good because that wax makes you fall. A sign was observed on R1's bathroom door reading, Tips to prevent a fall: 1. When getting up with help use *slipper/shoes *nonskid slipper socks.
On 04/03/23 at 3:00 PM, this observation was brought to the attention of V3 (RN/Registered Nurse). The surveyor inquired if the facility has non-skid socks. V3 replied, Absolutely. The surveyor inquired if R1 should be wearing them. V3 replied, Absolutely. I'll get some on him right now.
On 04/05/23 at 8:57 AM, R11 (R1's roommate) confirmed that R1 has fallen coming out of the bathroom before. R1 added that R1 usually sits in his (R1) wheelchair, but he (R1) will try to get up on his (R1) own.
R1's admission Record documents diagnoses including but not limited to repeated falls, non-traumatic intracerebral hemorrhage, traumatic subdural hemorrhage, muscle wasting and atrophy, and lack of coordination.
R1's 3/4/23 BIMS (Brief Interview for Mental Status) determined a score of 11, indicating R1's cognition is moderately impaired.
R1's 2/27/23 Fall Risk Screen documents a score of 22, determining that R1 is a High Risk for falls.
R1's 9/4/21 care plan documents, in part, Focus: (R1) is at risk for falls r/t (related to) weakness. Interventions include but are not limited to Encourage and assist as needed to wear non-slip footwear.
On 04/04/23 at 9:30 AM, R8 was observed lying in bed with no floor mat observed on the floor. At 2:35 PM, the surveyor again observed R8 in bed with no floor mat in place. This observation was brought to the attention of V18 (CNA/Certified Nursing Assistant). The surveyor inquired if R8 has any floor mats in place. V18 stated, No. She's not a fall risk.
R8's admission Record documents diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, difficulty in walking, muscle wasting and atrophy, and lack of coordination.
R8's 1/9/23 BIMS determined a score of 15, indicating R8's cognition is intact.
R8's 4/6/23 Fall Risk Screen documents a score of 13, indicating R8 is a moderate risk for falls.
R8's 4/12/21 care plan documents, in part, Focus: (R8) is at risk for falls r/t (related to) weakness. Interventions include but are not limited to (R8) has a low bed with floor mat for safety.
On 04/05/23 at 11:14 AM, V24 (DON/Director of Nursing) stated that the expectation with fall prevention interventions is, That we assess residents upon admission and quarterly, and that we have the appropriate fall interventions in place to prevent fall or injury. V24 added that all staff is responsible for making rounds and ensuring that the fall prevention interventions are in place.
On 04/06/23 at 12:45 PM, the surveyor inquired what the purpose of a floor mat and non-skid footwear is. V24 (DON) answered respectively, To prevent injuries. To prevent fall. The surveyor inquired if a resident is care planned for non-slip footwear, if it is expected that the resident being wearing it. V24 replied, Yes.
The revised 7/14 Falls Management guideline documents, in part, General: This facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed .2. Residents at risk for falls will have Fall Risk identified on the interim plan of Care with interventions implemented to minimize fall risk.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure that fall prevention interventions were in place as per individual care plan for two residents (R1 and R3) out of three...
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Based on observation, interview and record review, the facility failed to ensure that fall prevention interventions were in place as per individual care plan for two residents (R1 and R3) out of three residents reviewed for fall prevention interventions.
Findings include:
On 03/06/23 at 10:46 AM, the surveyor observed R1 lying in bed on a low air loss mattress with boasters in place. No floor mat was observed on R1's left side of the bed.
On 03/06/23 at 2:09 PM, R1 was still observed with no floor mat in place. This observation was brought to the attention of V7 (CNA/Certified Nursing Assistant) who stated, No, she (R1) don't. She's supposed to. There's a restorative binder at the nurse's station. It tells you who's at risk for falls and what they supposed to have.
On 03/06/23 at 2:13 PM, the surveyor was reviewing the restorative binder when V7 came back to nurse's station to tell surveyor, I (V7) just saw she (R1) had some by the window, so I (V7) just put them on the side of the tube feeding.
The 2 South Floor Fall Intervention list documents that R1 should have floor mats and air mattress with boasters.
R1's admission Record documents diagnoses including but not limited to cerebral infarction due to unspecified occlusion or stenosis of left cerebral artery, hemiplegia affecting right dominant side, dysphagia (oropharyngeal phase), type 2 diabetes mellitus, weakness and cognitive communication deficit.
R1's 12/09/22 MDS (Minimum Data Set) section C for Cognitive Patterns determined that a BIMS (Brief Interview for Mental Status) could not be completed as R2 was coded a 0. No (resident is rarely/never understood). R1 also coded a 1. Memory Problem for both short-term and long-term memory.
R1's 12/31/22 care plan documents, in part, Focus: Actual fall, with actual fall on 12/30/22. Interventions include but are not limited to, Floor mats to be put at bedside when resident in bed. Remove when resident is out of bed to avoid tripping hazard.
On 03/06/23 at 1:59 PM, R3 was observed lying in bed with R3's bed up against the wall on R3's right side. No floor mat was observed on R3's left side of the bed.
On 03/06/23 at 2:18 PM, the surveyor inquired who makes sure the fall interventions are in place? V8 (LPN/Licensed Practical Nurse) replied, We do. The nursing staff and the restorative staff. The surveyor inquired if R3 had a floor mat in place. V8 replied, No he does not. The surveyor inquired if R3 should have a mat in place. V8 replied, According to the list, yes. The surveyor inquired why the floor mat is important. V8 answered, To prevent dangerous falls. Just in case he does fall, it's less of an injury.
The 2 South Floor Fall Intervention list documents that R3 should have floor mat.
R3's admission Record documents diagnoses including but not limited to tracheostomy, gastrostomy, seizures, essential hypertension, atrial fibrillation, anxiety disorder, bipolar disorder, chronic respiratory failure with hypoxia, and pain in left ankle and joints of left foot.
R3's 2/8/23 BIMS determined a score of 13, indicating R3's cognition is intact.
R3's care plan initiated on 8/18/21 documents, in part, Focus: (R3) is at risk for falls r/t (related to) weakness, poor balance, poor safety awareness/impulsiveness. Interventions include but are not limited to, (R3) has a floor mat and low bed for safety.
On 03/08/23 at 11:25 AM, V14 (Restorative Director/Falls Nurse) stated that if a resident is care planned for floor mats, she (V14) expects them to be in place. V14 added, When they go in to do care, they move the floor mat and put it behind the door, but you gotta remember to put it back in place.
On 03/08/23 at 12:55 PM, the surveyor inquired what the expectation is of nursing staff regarding fall precautions. V2 (DON/Director of Nursing) stated, Making sure that the interventions are in place. Once the fall screen is completed, and we determine what their (resident's) needs are, I expect them (staff) to follow the plan of care. V2 added that the responsibility of ensuring that fall interventions are in place is not limited to just one person, but rather everyone should be responsible. The surveyor inquired what the risk is of not having fall interventions in place. V2 replied, Head injuries, bruises, fractures, a wide range of injuries.
The revised 2/23 Falls Management guideline documents, in part, General: This facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed .2. Residents at risk for falls will have Fall Risk identified on the interim plan of Care with interventions implemented to minimize fall risk.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to follow their abuse policy for four residents (R1, R2, R6, R7) out of six residents reviewed abuse. This failure resulted in staff members no...
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Based on record review and interview the facility failed to follow their abuse policy for four residents (R1, R2, R6, R7) out of six residents reviewed abuse. This failure resulted in staff members not immediately intervening on two separate occasions before residents became physically aggressive towards their peers. R1 and R2 had a verbal argument that resulted in a physical altercation where R1 and R2 grabbed each other aggressively. R6 and R7 had a verbal disagreement in their room resulting in R6 causing an injury to R7's finger.
The Finding Include:
Facility abuse report denotes on 2-10-2023, R1 and R2 were involved in a physical altercation. Both residents were immediately separated. Both residents received head to toe assessments. No abnormalities noted.
R1's 2/10/2023, 21:10, Health Status/Progress Note Text reads: Resident was noted being physically aggressive toward roommate. Writer immediately separated the residents. Writer performed head to toe assessment with no abnormalities noted. MD made aware. Family made aware.
R1's 2/11/2023, 14:08, Social Service Note Text reads: SSA met with the resident due to the resident displaying physical aggression towards his roommate. The resident is alert and oriented. The resident stated his roommate was upset due to family issues and his roommate expressed and took his anger out on him, so he defended himself. The resident was educated and encouraged to seek staff immediately when/if a conflict arises and to use effective and positive impulse controls. The resident was receptive to education and encouragement given. The resident was presented with a contract and signed it. The resident's pass has been restricted for 7 days. The care plan is updated. SS will continue to follow up as needed.
R2's 2/10/2023, 21:20, Health Status/Progress Note Text reads: Resident was noted being physically aggressive with roommate in hallway. Writer immediately separated the residents. Writer performed head to toe assessment with no abnormalities noted. MD made aware. Family made aware.
R2's 2/11/2023, 14:23, Social Service Note Text reads: SSA met with the resident due to the resident exhibiting physical aggression towards his roommate on 2/10/2023. The resident stated he does not know why he and his roommate had a conflict. The resident was educated and encouraged on seeking staff immediately when/if a conflict arises. The resident is receptive to education and encouragement. The resident was presented with a bx contract. The care plan is updated. SS will continue to follow up as needed.
V11 (Administrator) stated on 2/23/23 at 4:50 PM that all abuse report should be sent to IDPH within 24 hours according to the facility abuse protocol. V11 stated any allegation of abuse is filled out on the incident form, the preliminary 24-hour abuse form then faxed to IDPH within 24 hours. V11 stated she got report from staff that R1 and R2 got into a minor altercation and were immediately separated and neither sustained any injuries.
V1 (Social Worker) stated on 2/23/23 at 5:00 PM that R1 has been oaky and not had any behavior problems in the past. V1 stated R2 has been okay and also had been a good resident for the most part. V1 stated neither R1 and R2 have a history of fighting with others and got along as roommates. V1 stated it seemed that when they had a recent altercation, it was because they got on each other nerves somehow.
V2 (Certified Nurse Aide) stated on 2/23/23 at 5:15 PM she'd been working at the facility for a year and is familiar with R1 and R2. V2 stated R1 is outgoing and a cool resident that plays his music. V2 stated she has not seen or heard of R1 attacking or abusing any of the other residents. V2 stated R2 is good guy that comes up and down to smoke and interacts well usually with his peers. V2 stated one day as she was passing trays, she saw R1 and R2 in the hall arguing then the nurse separated them immediately. V2 stated, they did not see R1 or R2 swing, throw punches or hit the other.
V3 (Registered Nurse) stated on 2/23/23 at 5:25 PM she heard a loud commotion coming from R1 and R2's bedroom. V3 stated when she went inside, she saw them grabbing each other while both of them were in their wheelchairs. V3 stated she ran into the room and separated R1 and R2. V3 stated she asked them what happened, and they both blamed each other for making the other one upset. V3 stated before that incident R1 and R2 got along well and were just watching a game on the television. V3 stated after both were separated, assessed them and noted with no injuries but she still notified doctor, administrator, and family members.
On 2/23/23 at 5:45 PM R1 stated he was in his room when R2 came in mumbling something under his breathe. R1 stated he told R2 to calm down when suddenly R2 hit him, so he hit him back. R1 stated him and R2 are no longer roommates and has no fear of R2 or anyone.
On 2/23/23 at 5:50 PM R2 stated that nothing happen between him and R1 and he is okay. R2 stated he feels safe in the facility.
Facility abuse report denotes on 1/4/2023 the nurse heard the resident R7 calling for help and saying that her roommate bit her finger. The roommate R6 was immediately removed from the room. Nurse assessed R7 and provided care. NP notified and gave orders to have R7 sent out for a medical evaluation. Both residents' families and physicians have been notified.
R6 has a BIMS assessment of 3/15 indicating severe mental impairment due to medical diagnosis of dementia.
R6's 1/4/2023, 06:23, Behavior Note Text reads: The resident attacked her roommate. An attempt to ask the resident what happened was unsuccessful. However, the residents roommate reported that she was attacked, bitten on her right index finger, and jumped on by the resident. The Resident was removed to the dining for monitoring.
R6's 1/4/2023, 10:41, Health Status/Progress Note Text reads: NP notified of altercation that took place this morning involving another resident. NP gave orders for CMP, CBC, CXR, U/A C&S. Orders carried out. Resident to be monitored for behaviors for the next 72 hours, . made aware of occurrence and new orders with no concerns at this time. Will continue with care and monitor for the duration of this shift.
R6's 1/5/2023, 17:54, Health Status/Progress Note Text reads: No aggression and or agitation noted this shift, resident does require redirection and can be resistant, however no physical aggression noted this shift.
R7's 1/4/2023, 07:02, Health Status/Progress Note Text reads: Resident yelled out for help that she had been bitten by her roommate. Resident was observed on the floor in her room by the bedside. Mild bleeding was observed on resident right index finger. Finger was assessed and cleaned. Roommate was moved out of the room to the dining room. On call provider was notified, new order given to transfer resident to hospital for evaluation. Resident case worker notified via voice message. Vital signs stable, A&O x 3. Documentation completed will endorse to incoming nurse.
R7 1/4/2023, 05:25, SBAR Note Text reads: REASON FOR REPORT: Pain in the right index finger and upper ear due to been attacked by roommate.
R7 1/4/2023, 20:30, Health Status/Progress Note Text reads: Resident returned from hospital visit. Resident is alert upon return, skin assessment done, resident has band aid on right second finger, slight swell to right ear, no active bleeding. Resident returned with new orders for Augmentin. Tylenol PRN for pain.
V7 (Dementia Manager) stated 3/1/23 at 4:50 PM, R6 she has been in the facility for a while but R7 had only been in the facility a few days. V7 stated R6 is quiet, ambulates and is a hoarder. V7 stated R7 had only been there a little while and used a wheelchair plus oxygen. V7 stated it was reported by the nurse that R7 was bitten by R6. V7 stated no one witnessed the incident but the nurse claimed to have seen bite marks on R7 finger. V7 stated at time of the incident R6 and R7 were roommates but since then have been assigned new roommates.
V10 (Registered Nurse) stated on 3/1/23 at 5:05 PM he was at the nurses station and heard noise coming from R6 and R7's room. V10 stated he went to the room they shared and R7 told him that R6 jumped on her and hurt her finger. V10 stated he called the physician/Nurse Practitioner who ordered that R7 go to the hospital for an evaluation.
V8 (Certified Nurse Aide) stated on 3/1/23 at 5:15 PM she was sitting in the hall and heard R7 ask for help. V8 stated she ran to the room and saw R6 was by the bathroom door and R7 standing up holding onto the foot board looking upset. V8 stated when she asked them what happen and called the nurse. V8 stated R7 told her that she did not know why R6 was acting mean and her finger was hurting. V8 stated the nurse came immediately and assessed them. V8 stated R6 is usually not combative and can be redirected. V8 stated R6 had roommates before and had no issues of not getting along with her roommates in the past.
V18 (Nurse Practitioner) stated on 3/1/23 at 5:25 PM she was surprised that R6 and R7 had an altercation. V18 stated there were no pictures or proof that R7 finger was bit however for precaution the hospital ordered the antibiotics. V18 stated R7 was not harmed and from time to time residents have little squabbles.
V1 (Social Worker) she stated on 3/1/23 at 5:45 PM R6 and R7 both have Dementia but are usually quiet. V1 stated she was not aware of them having behaviors prior to the incident of one biting the other. V1 stated after the incident they were separated and are no longer roommates.
V11 (Administrator) she stated on 2/23/23 at 4:50 PM all abuse report should be sent to IDPH within 24 hours according to the facility abuse protocol. V11 stated any allegation of abuse is filled out on the incident form but the preliminary 24-hour abuse form then faxed to IDPH within 24 hours. V11 stated she got report from staff that R6 and R7 got into a minor altercation and were immediately separated and neither sustained any significant injuries.
Facility's abuse policy denotes this facility prohibits mistreatment, neglect, or abuse of its residents and attempted to establish a resident sensitive and resident secure environment. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers and staff from other agencies providing services. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility.
Dec 2022
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
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 their indoor temperature was at a comfortable le...
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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 their indoor temperature was at a comfortable level for 7 (R1, R2, R3, R5, R6, R7, R8) of 7 residents reviewed for safe physical environment. These cold temperatures had the potential to affect all 228 residents residing in the facility.
Findings Include:
On 12/27/22 at 09:56 AM V5 (R5 Family member) stated on 11/18/22 I was in the facility from 11 AM - 2 PM and it was cold in the facility. They gave R5 a few extra blankets.
AccuWeather for the facility location on 12/22/22 through 12/28/22 indicated the following:
12/22/22 high of 34 degrees Fahrenheit and a low of -6 degrees Fahrenheit.
12/23/22 high of -1 degrees Fahrenheit and a low of -9 degrees Fahrenheit.
12/24/22 high of 13 degrees Fahrenheit and a low of -1 degrees Fahrenheit.
12/25/22 high of 14 degrees Fahrenheit and a low of 2 degrees Fahrenheit.
12/26/22 high of 22 degrees Fahrenheit and a low of 12 degrees Fahrenheit.
12/27/22 high of 26 degrees Fahrenheit and a low of 8 degrees Fahrenheit.
12/28/22 high of 45 degrees Fahrenheit and a low of 25 degrees Fahrenheit.
Observation of temperatures taken in the facility by V3 (Maintenance Director) on 12/27/22 from 11:45 AM through 12:10 PM indicated the following:
On 12/27/22 at 11:25 AM V3 (Maintenance Director) stated we have been having complaints from residents about the temperature in the building. The heat was turned on 10/15/22. We have been having complaints from residents about the temperature in the building and issues with some residents needing more plastic to the A/C (Air Conditioning) units and windows. We have been providing more blankets to make sure the residents are comfortable. R4 has been calling about the room temperature. If I am not here when there is a complaint, I put plastic on the window the next day or as soon as we get here. The temperatures are taken twice a day when it is really cold. I leave the facility at 04:00 PM and my assistant leaves at 05:30 PM. There is a vinyl roof on the third floor, and it gets cold when the snow sticks. Each resident has a floor heater in their room that automatically comes on when we change over to heat. We had a complaint about the temperature maybe once in November, but we put plastic up. The main heat handler is on the first floor and pushes air up to the second floor. I got temperatures for November and December, but I do not have any temperatures for October. The temperatures are taken when it starts getting cold.
On 12/27/22 at 11:45 AM V3 (Maintenance Director) stated the projected temperature is 77 degrees F (Fahrenheit). 1st floor dining room [ROOM NUMBER] degrees (F) at floor, 71 degrees (F) at ceiling and 71.6 degrees (F) on the back wall. One south hallway corner wall 63.5 degrees (F), floor 60 degrees(F), ceiling 64.9 degrees (F), wall 64.4 degrees(F). A 1st floor room has plastic to the window, ceiling 61 degrees(F), wall 62 degrees (F), floor heater 101 degrees (F). Floor heaters were observed at the base of the wall beneath the windows in the residents' rooms. One of the room's floor heater appeared to have been taken apart. V3 (Maintenance Director) stated the floor heater has to be put back together; it looks like it's been destroyed. R7 stated it's been cold in here. It's cold in here and worst at night. I have 2 extra blankets.
On 12/27/22 at 11:50 AM V3 (Maintenance Director) stated 2nd floor North hallway ceiling 70.5 degrees, floor 68.7 degrees(F), wall 69.4 degrees (F), wall 69.4 degrees(F). One of the room's floor temp 64.6 degrees (F), wall 66.2 (F), floor heater 106.3 degrees (F). 2 north dining room [ROOM NUMBER].5 degrees (F), wall 70.0 degrees (F), ceiling 68.9 degrees (F). room [ROOM NUMBER] floor 61 degrees (F), wall 65 degrees (F). 2 south hallway floor 64 degrees (F), ceiling 65.5 degrees (F), east wall 62 degrees (F) and west wall 64 degrees (F). Another 2nd floor room [ROOM NUMBER].5 degrees (F), north wall 67 degrees (F), south wall 68.2 degrees (F) and floor heater 98 degrees (F). 2 south dining room floor 48 degrees (F), ceiling 52 degrees (F) and east wall 52 degrees (F). There was plastic observed on the windows in the 2 south dining room.
On 12/27/22 at 12:00 PM V3 (Maintenance Director) stated the 3-north thermostat on wall has a target temperature of 75.0 degrees and is at 73.0 degrees. 3-north hallway floor 70.0 degrees (F), west wall 69.6 degrees (F) and ceiling 71.4 degrees (F). One ot the room's north wall 64.0 degrees (F), ceiling 60 degrees (F), floor heater 98 degrees (F). Third floor dining room has a dual A/C (Air Conditioning) and heat unit set at 80 degrees. Floor temperature 65 degrees (F), ceiling 64.8 degrees (F), wall 64 degrees (F). One of the room's floor temperature 67.5 degrees (F), wall 67.1 degrees (F), ceiling 67.1 degrees (F) and floor heater 67.1 degrees (F). Plastic was observed on the windows. R6 stated there is a draft from the window at night.
On 12/27/22 at 12:10 PM V3 (Maintenance Director) stated 3 south hallway ceiling 74 degrees (F), floor 71 degrees (F), east wall 72 degrees (F) and west wall 71 degrees (F). The thermostat located on the wall in the hallway set at 75 degrees. One of the room's floor 63.9 degrees (F), ceiling 62 degrees (F), north wall 65 degrees (F) and floor heater 96.1 degrees (F). The unit that we have on the roof warm the hall and in the rooms the heat is from the floor heaters. R6 was observed sitting on the bed in the room with a jacket on. R6 stated at night there is a cold draft that come in through the window. During the facility tour staff and residents were observed with hats on and residents were observed in the hallways and resident rooms with jackets and coats on.
On 12/27/22 at 01:58 PM V1 (Administrator) stated in October and November I ordered an excess of blankets. R2 has called the ombudsman, fire, police, salvation army, city, and state. Every time R2 call's, someone comes out and goes up to R2's room to take the temperature.
On 12/27/22 at 03:28 PM V10 (2 South Nurse Manager) stated If a resident complains about being cold, we try to get extra blankets and call maintenance to see if they can adjust the thermostat.
Observation of temperatures taken in the facility by V4 (Maintenance Assistant) on 12/27/22 at 04:39 PM indicated the following:
On 12/27/22 at 04:39 PM V4 (Maintenance Assistant) stated the second-floor south hallway 68.5 degrees (F). room [ROOM NUMBER] 66.9 degrees (F). One of the room's was observed with no plastic on the window. V4 (Maintenance Assistant) stated we do the extras to make the residents comfortable. Everyone is going to say they are cold. We are trying to keep the cold out of the building. Dining room on the second floor is cool and many of the residents have on hats. Another room [ROOM NUMBER].6 degrees (F). 3 north dining room [ROOM NUMBER] degrees (F).
Observation of temperatures taken in the facility by V3 (Maintenance Director) on 12/28/22 at 09:11 AM - 09:30 AM indicated the following:
On 12/28/22 at 09:11 AM V3 (Maintenance Director) stated the room temperature is an estimate of the wall, ceiling and floor temperatures. We use a thermo gun and the temperature is plus or minus 3 degrees as the real feel. A 1st floor room [ROOM NUMBER].8 degrees (F), ceiling 66.2 degrees (F)north wall 66.2 degrees (F), south wall 66.0 degrees (F) and outer wall 63 degrees (F). R7 stated I thought they were going to put plastic up to the window yesterday. It was cold over the weekend and yesterday. Another room's window was observed without plastic. V3 (Maintenance Director) stated one south hallway floor 63.0 degrees (F), wall 65 degrees (F) and ceiling 66 degrees (F). The estimated real feel is 67 degrees. A room on the 2nd floor 67 degrees (F), ceiling 74 degrees (F). Another on the 2nd floor 71 degrees (F) and ceiling 65 degrees (F). V3 stated the real feel is 69 - 70 degrees. R5 was observed in bed and stated, it is still cold in here the window has to be retaped. V3 (Maintenance Director) stated a 3rd floor room [ROOM NUMBER] degrees (F), wall 68 degrees (F) and ceiling 68.7 degrees (F). Another 3rd floor room [ROOM NUMBER] degrees (F), ceiling 68 degrees (F), south wall 66 degrees (F) and north wall 65 degrees (F). A 2nd floor room [ROOM NUMBER] 65 degrees (F), ceiling 68 degrees (F), south wall 66 degrees (F) and north wall 65degrees (F).
On 12/28/22 at 09:32 AM R8 was observed with a hat on sitting on the bed eating breakfast. R8 stated it is cold in here. They gave me a few sheets and one blanket. They put plastic on the windows to stop the wind but that's not going to stop the wind, but it just is not working. It was cold in the room where I felt uncomfortable. I put the hat on top of my head and wear a jacket in the building because it is cold in here.
On 12/28/22 at 09:51 AM R2 was observed sitting on the bed in the room with a hat on. R2 stated it was freezing in here on 12/23/22 so I called my sister to come get me and I stayed with her on 12/24/22 - 12/25/22. They put plastic to the window and gave extra blankets, but it only helped a little.
On 12/28/22 at 10:02 AM R1 was observed in bed covered with a blanket. R1 stated everyone complained that it has been cold since 12/23/22. We told the facility to turn up the heat and they said they are going to bring up heaters. They gave me an extra blanket, but you see how thin this blanket is. They just put plastic on the other window in this room yesterday and the plastic on this window by me needed to be retaped because air still comes in.
On 12/28/22 at 10:06 AM R3 was observed lying in bed with a coat on. R3 stated it is cold in here all day. I have to keep my coat on every day. I have one blanket. They need to turn the heat up. People come here to get well, not sick.
R5 was readmitted to the facility on [DATE] with diagnosis not limited to Fusion of Spine, Cervical Region, Anemia, Paraplegia, Complete, Age-Related Physical Debility, Immobility Syndrome, Neuromuscular Dysfunction of Bladder and Lack of Coordination. R5 MDS (Minimum Data Set) Section C Cognitive Pattern BIMS (Brief Interview for Mental Status) is 15 indicating intact cognition.
On 12/28/22 at 10:15 AM R5 was observed lying in bed with a jacket on and covered with a blanket. R5 stated my sister called and reported that the facility was cold on 11/18/22 when the temperature got down to 20 degrees it was really cold in here. I told maintenance and anyone that would listen. They brought me more blankets, but I have a problem moving my limbs and having all that cover makes it more difficult to do anything. I was in the hospital, and it has been cold in here since I came back to the facility on [DATE]. There is a draft that comes in the window and there is no plastic on the window. When I am cold that makes me uncomfortable.
On 12/28/22 at 10:27 AM V11 (Licensed Practical Nurse) stated On Saturday, Sunday and Monday it was cold here in the facility. The residents complained that it was cold. I gave extra blankets and tried to get maintenance to put plastic on their windows. Some rooms were warm, and some were cold. The resident rooms are colder than the hallway.
On 12/28/22 at 11:49 AM V1 (Administrator) stated, if the residents complain of heat V3 (Maintenance Director) will check the room and see what the cause of it being cold and start putting up plastic covers on wall air conditioning units. They take temperatures daily, but they do not do individual rooms. They will go in there if a problem is reported. The floor heaters are the only thing that is heating the resident rooms. This is the worst complaints that I have ever had, and I have been here for 4 years. I do know the windows are drafty. I ordered more blankets and waiting on the delivery.
On 12/28/22 at 12:16 PM V12 (Licensed Practical Nurse) stated On 12/24/22 R5 complained of being cold. I put more blankets on R5. I worked Saturday 12/24/22 and it was cold in the facility. Some of the rooms are warmer than the hall and all of the residents were saying it was cold. I worked on 2 South and tried to put as much cover on the residents and offered hot coffee. Maintenance was made aware but if he came in, I did not see him.
On 12/28/22 at 02:43 PM V7 (Certified Nurse Assistant) stated at the beginning of the week it was cold. I work 3-11 and had a hoody on.
On 12/29/22 at 8:59 AM V2 (Director of Nursing) stated If there is a complaint of residents being cold, we assess the situation, make sure covers are on the air conditioning unit, put plastic to the windows for drafts, take temperature of rooms and address from there.
On 12/29/22 at 09:54 AM V3 (Maintenance Director) stated the heat was turned on 10/15/22 but we did not start doing temperature checks at that time. The first temperature check was done 11/21/22 to make sure all of our units were operating properly. I don't recall if R5 complained about it being cold. If the resident complains of it being cold, I would check the temperature at that time and make sure the floor heater is on. We just check hallway and dining room temperatures, that is where our main units are. When we were checking the room temperatures, I noticed there is a difference in the room and hallway temperatures. The temperature checks are checked once a day under cold conditions with resident complaints temperatures are checked twice a day.
The facility provided a Packing List dated 11/22/22 for 24 Blanket spread which have not been received.
Facility provided a Temperature Log dated 11/21/22, 11/22/22, 11/23/22, 11/24/22, 11/25/22, 11/26/22, 11/30/22, 12/01/22, 12/02/22, 12/03/22, 12/04/22, 12/05/22, 12/09/22, 12/15/22, 12/16/222, 12/17/22, 12/18/22, 12/19/22, 12/21/22, 12/22/22, 12/23/22, 12/24/22 09:00 & 04:30 PM, 12/25/22 09:00 & 04:30 PM and 12/26/22 09:00 & 10:00 AM with no documented resident room temperatures.
Facility census obtained from Resident Census and Conditions of Residents.
Policy:
Titled Resident Rights dated 05/22 document in part: 2 Residents are entitled to exercise their rights and privileges to the fullest extent possible.
Titled Cold Related Emergencies undated document in part: This policy is written with intent and efficient response to a cold related emergency due to equipment failure. The facility maintains the heating and ventilation system on a preventive maintenance program. Procedure: 1. Should the heating system malfunction during cold weather, maintenance shall monitor indoor temperatures in all areas occupied by residents.
Nov 2022
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a functioning call light system and failed to m...
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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 a functioning call light system and failed to monitor its call light system. This failure affected 52 residents residing on the 3rd floor of the facility.
Findings include:
Record review documents that room [ROOM NUMBER] is occupied by two residents who are unable to use the call lights system.
Facility census dated 11/12/2022 documents that a total of 52 residents reside on the 3 South unit on the 3rd floor of the facility. Facility document dated 10/2021, titled Call light answering documents in part 6. Report all defective call lights to nurse supervisor or maintenance director promptly. 7. Answer the patient or resident's call as soon as possible.
On 11/12/2022 at 8:47am, surveyor located on the 3 South unit on 3rd floor of the facility at the nurse's station. Surveyor observed a blinking purple light on the call light system at the nurse's station, no audible sound heard while purple light was blinking. Surveyor also observed a purple light blinking outside of room [ROOM NUMBER], no audible sound heard from the blinking purple light outside of room [ROOM NUMBER].
On 11/12/2022 at 9:00am, surveyor located on the 1st floor of the facility. R2 stated I no longer wear incontinence briefs and I now go to the bathroom on my own. There were times when I waited a long time for my call light to be answered. When I was wearing incontinence briefs and needed assistance with toileting, I had to wait 1 hour to 2 hours to get my call light answered. When the nurses bring me my medication, I take each medication out of the cup and ask the nurses what it is. The nurse tells me then I take my medication in front of the nurse.
On 11/12/2022 at 9:50am, surveyor located on the 2nd floor of the facility. V9 (CNA) stated We are able to hear the call light alarm and the phone rings at the nurse's station to let the staff know that a resident activated their call light.
On 11/12/2022 at 10:56am, surveyor located on the 3 South unit on 3rd floor of the facility at the nurse's station. Surveyor observed a blinking purple light on the call light system at the nurse's station, no audible sound heard while purple light was blinking. Surveyor also observed a purple light blinking outside of room [ROOM NUMBER], no audible sound heard from the blinking purple light outside of room [ROOM NUMBER].
On 11/12/2022 at 10:56am, V8 (3rd Floor LPN) stated I am not sure what the purple light is and why it is blinking, I'll have to look at the manual book to see. I can also call maintenance to see if they know what the purple light means.
On 11/12/2022 at 11:00am, V10 (Maintenance) located on the 3 South unit on the 3rd floor of the facility and states This is a new call system that we just recently had installed about 4 months ago. With this system, you can hear the call light when a resident rings their call button. The new call light system is connected to a speaker inside of the resident's room and connects to the nurse's station whenever the resident activates their call light button. V10 enters room [ROOM NUMBER], no residents were observed inside. V10 observes the blinking purple light and tries to activate the call light system in room [ROOM NUMBER] without success. V10 also tries to use the call light speaker in room [ROOM NUMBER] to communicate with the nurse's station without success. V10 then states The purple light means there is some sort of malfunction with the call light system, so I have to try and repair it myself or put in a work order for it to be fixed.
On 11/12/2022 at 11:34am, surveyor located on the 3 South unit on the 3rd floor of the facility and asks V7 (3rd Floor RN) how does staff know when a resident has activated their call light and need their call light answered. V7 states There is a phone here at the nurses station. When the resident push their call light button, the phone displays the resident's room number who needs assistance, and the phone allows the nurses to communicate with the residents. V7 walks over to the call light system phone to demonstrate how the system works and surveyor observed that the call light phone was not plugged in. V7 states That's crazy, the phone is not hooked up. The call light phone is usually not unplugged like this. V7 then grabs the phone cord and plugs the cord into the call light phone. Surveyor then hears an audible alarm along with the blinking purple light. Surveyor also observes a message across the call light phone which stated room [ROOM NUMBER] cord out V7 stated I have been here since 7am and I did not notice that the call lights could not be heard and wasn't turned on. I did not unplug the phone and I hope that no one thinks that I unplugged the call light phone.
On 11/12/2022 at 3:20pm, V2 (DON) stated We've had a new call light system for a couple of months now. When residents pull the call light, it alarms and alerts the staff at the nurse's station. The light above the resident room also illuminates and stays on until the call light is addressed. There is a phone at the nurse's station that rings, but I don't know how it works since the system is fairly new. Everyone working should be able to answer the call lights. I think we should answer a call light right away. I would expect a call light to be answered within a few minutes to 10 minutes. We were never in-serviced on the different color coding of the call light system, so I am not aware of what the different colors mean.
On 11/12/20222 at 3:41pm, surveyor and V2 located at the 1st floor nurses station and V2 observed testing the call light system to figure out the color coding system. V2 located inside of R2s' room across from the nurse's station and pushes the call light button. Surveyor observes a blue light illuminate above R2s' room and hears an audible alarm. V3 (1st Floor RN) stated That blue light means that the resident pushed their call light. V3 then picks up the call light system phone and speaks into the phone demonstrating how the call light is answered. V3s' voice can be heard through the speaker located inside of R2s' room. V3 then states We can answer the call light through this phone and once we address the call light, we can turn the call light off from this phone. V3 then presses a button on the phone and R2s' call light and audible alarm turns off. V2 located inside of the resident bathroom across from the 1st floor nurses station and pushes the call light button. Surveyor observes a red light illuminate above the bathroom door and hears an audible alarm. V3 also turns the bathroom call light off from the nurse's station call light system phone located at the 1st floor nurses station. V2 then states Now I understand a little better how the call light system works but I have never seen a purple light or know what it means.
Aug 2022
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the call light was within a dependent resi...
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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 the call light was within a dependent resident's reach which affected one (R51) of 104 residents reviewed for accommodation of needs.
Findings Include:
R51's admission Record, documents, in part, that R51's diagnoses include schizophrenia, depression, muscle wasting and atrophy, idiopathic gout, osteoarthritis and cellulitis of left lower limb.
R51's Minimum Data Set (MDS), dated [DATE], documents, in part, Section C. Brief Interview for Mental Status (BIMS) score: 15. which indicates that R51 is cognitively intact. Section G. Functional Status: self-performance for personal hygiene, and toilet use is coded as requiring extensive assistance, and support is coded as one-person physical assist.
On 8/1/22 at 10:35 am R51's call light was observed not within R51's reach and was on the floor under R51's bed.
On 8/2/22 at 10:05 am R51's call light was observed not within R51's reach and was on the floor under R51's bed.
On 8/2/22 at 10:30 am V28 (Unit Manager) stated that the call lights should be in all resident's reach.
On 8/3/22 at 1:30 pm V2 (Director of Nursing, DON) stated that during rounds the staff should make sure all call lights are able to be reached by the resident in case the resident needs something.
R51's Care Plan, dated 2/14/22, documents, in part, that a focus of Potential for falls, Resident at risk for injury from falls r/t (related to) weakness, unsteady gait with an intervention of call light within resident's reach when in room.
Facility Policy dated October 2021 and titled Call Light Answering, documents, in part, General: To provide the staff with guidance on responding to resident's request and needs. Responsible Party: IDT (Interdisciplinary team) Procedure: . 5. When the patient or resident is in bed or confined to bed or chair, provide the call light within easy reach of the patient or resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure that a resident's low air loss mattress was placed at the recommended setting. This failure affected one resident (R39)...
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Based on observation, interview and record review, the facility failed to ensure that a resident's low air loss mattress was placed at the recommended setting. This failure affected one resident (R39) of the four residents reviewed for pressure ulcer prevention interventions in a total sample of 104 residents.
Findings include:
On 08/01/2022 at 10:20am on the second floor, R39 was observed in the bed, laying on a low air loss mattress with a pink and white pad underneath R39. The reading observed on R39's control panel for the low air loss mattress was set at 175 lbs(pounds).
On 08/01/2022 at 10:30am V13(LPN/Licensed Practical Nurse) stated, I'm(V13) not sure what the setting is for R39's low air loss mattress is supposed to be. V13 stated the machine is set at 175 lbs(pounds) now.
On 08/01/2022 at 10:35am R39 stated the machine is supposed to be on 210 lbs(pounds).
On 08/01/2022 at 10:40am V12(Wound Care Nurse/LPN (Licensed Practical Nurse) stated the setting on the control panel for R39's low air loss mattress is on 175 lbs(pounds) now, it should be on 210 lbs.(pounds).
On 08/01/2022 at 10:45am V12(Wound Care Nurse/LPN) observed by surveyor changing the setting on the low air mattress of R39 to 210 lbs.(pounds).
On 08/01/2022 at 10:45am V12(Wound Care Nurse/LPN) stated the purpose of the low air loss mattress is to reduce pressure for residents who have pressure ulcers.
On 08/02/2022 at 10:45am V12(Wound Care Nurse/LPN) stated the entire wound care department is responsible for making sure the low air loss mattresses are on the proper settings. V12 stated the low air loss mattress settings are checked every morning by the wound care staff.
On 08/03/2022 at 1:36pm V2 (DON/Director of Nursing) stated the purpose of the low air loss mattress is to assist with wound prevention and wound healing. V2 stated the wound care nurse is responsible for checking the settings on the control panel of the low air loss mattress to make sure it is on the correct setting for that resident.
On 8/3/2022 R39's Brief Interview for Mental Status (BIMS) score, dated 04/13/2022, is 15, indicating R39's cognition is moderately intact.
On 8/3/2022 R39's MDS Section G, Functional Status, documents, in part, A. Bed Mobility 3/3 Extensive assistance/two+ persons physical assist.
On 8/3/2022 R39's Care Plan dated 02/14/22 documents in part, the focus, R39 has a pressure ulcer to the coccyx, left posterior thigh, left ischium, right ischium, and right buttocks. At risk for further pressure ulcer development related to comorbidities, impaired mobility, and incontinence. DX: anemia, neurogenic bladder, diabetes mellitus type 2, paraplegia, personal history of COVID 19. Interventions include, but are not limited to, Apply low air loss mattress to bed.
On 8/3/2022 R39's Physician Order Summary Report dated 08/03/2022 documents, May apply Air Mattress/Heel-Lift Boots.
On 8/3/2022 R39's Braden Scale for Predicting Pressure Score Risk dated 8/3/2022 is scored at 13 with the score of 13-14 indicating R39 is Moderate Risk for developing a pressure sore.
The facility policy titled Skin Management: Specialty Mattress revised 12/19 documents, in part, underneath Procedure 3. Settings will be observed every shift to ensure mattress is functioning properly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to provide a specialized adaptive drinking cup for a re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to provide a specialized adaptive drinking cup for a resident (R98); failed to follow a physician order for a specialized adaptive drinking cup for a resident (R98); and failed to follow a physician order for specific feeding guidelines related to swallowing (R98). These failures have the potential to affect 1 (R98) of 6 residents reviewed for adaptive equipment usage in a total sample of 104.
Findings include:
On 8/1/22 at 11:32 AM, surveyor observed R98 feeding self in 3rd floor dining room. R98 was sitting at a table toward the back of the dining room and was facing the back wall of the dining room. This location was farthest away from the staff distributing meal trays. Surveyor did not observe any specialized cup on R98's lunch tray. Surveyor observed R98 drinking juice from regular plastic cup. This plastic cup was the same cup that the other residents in the dining room received. Surveyor observed 1-2 coughs noted while R98 drank juice. Surveyor did not observe staff within close proximity to R98 while R98 was feeding self. Surveyor did not observe staff provide any type of verbal cueing or monitoring.
On 8/2/22 at 9:13 AM, surveyor observed R98 feeding self and drinking juice and milk out of a standard plastic cup. Surveyor did not observe any specialized cup on R98's breakfast tray. Surveyor observed R98 cough 2-3 times while drinking liquids. R98 consumed 75% milk and 100% juice. Surveyor did not observe staff provide any type of verbal cueing and did not see any staff sitting at the table with R98 or sitting within close proximity to R98 during meal service.
On 8/2/22 at 12:00 PM, V30 (Food Service Director) stated that the kitchen has not been asked to provide adaptive feeding equipment to any of the current resident trays and that the kitchen does not give out any type of adaptive feeding equipment, those items are provided on the unit.
On 8/2/22 at 12:05 PM, an interview was conducted with V31 (Speech Language Pathologist). V31 stated that R98 had a video swallow assessment which recommended the use of a specialized drinking cup with thin liquids and other specific feeding guidelines to prevent choking and aspiration. V31 stated that R98 is at a higher risk for aspiration due to his (R98) impulsivity and cognitive function. V31 stated that she (V31) provided the specialized cup labeled with R98's name on it and educated the nursing staff on the use of the cup and notified dietary so they could clean the cup after every meal. V31 stated she (V31) would define close supervision as being within sitting distance to a staff member and within direct eye contact. V31 stated R98 can feed himself however close supervision is needed to follow the feeding guidelines recommended from the video swallow.
On 8/2/22 at 12:42PM, V32 (Certified Nursing Assistant) stated that R98 used to have a special cup but that he (R98) does not use it anymore. V32 stated that sometimes she sees R98 coughing when R98 drinks or eats too fast. V32 stated that if R98 was still on a special cup, it would come up on his meal tray and then get sent back to the kitchen to be cleaned.
R98 was admitted to the facility on [DATE] with diagnosis which included but not limited to: Dysphagia, Oropharyngeal Phase, Type 2 Diabetes Mellitus, Adult Failure to Thrive, Alzheimer's Disease, Aphasia following Cerebral Infarction. R98's MDS (Minimum Data Set) from 5/13/22 BIMS (Brief Interview For Mental Status) score is 00 indicating severe cognitive impairment.
Physician order dated 4/25/22 document in part close supervision with meals, set up assistance upright 90 degrees for all intake, monitor rate and bolus size; small bites and sips, alternates liquids and solids, monitor for pocketing; ensure mouth clear between bites, d/c meal if patient having repeated coughing.
Modified Barium Swallow Study completed 4/28/22 document in part recommendations for swallow precautions including small bites, small sips, alternate solid/liquid, upright 90, aspiration precaution, monitor rate, thin liquids via (adaptive drinking cup).
Physician order dated 05/10/22 document in part: use (adaptive drinking cup) with liquids.
V31's progress note dated 5/10/22 documents Patient received (adaptive drinking) cup on this date. The (adaptive drinking) cup administers 5cc thin liquids at a time to decrease risk of penetration and aspiration. Nursing staff educated on use; dietary staff made aware that it needs to be washed before every meal. Cup and lid labeled with Pt's name and room number.
Certified Nursing Assistant task instructions for R98's eating provided to surveyor on 8/3/22 document in part 1:1 assist with all meals and to use (adaptive drinking) cup to drink out of.
R98's meal ticket provided to the surveyor on 8/2/22 document in part the following close supervision with meals, intake monitor rate and bolus size, small bites and sips, alternates liquids and solids, monitor for pocketing, ensure mouth clear between bites, d/c meal if having repeated coughing, use (adaptive drinking) cup with liquids.
Policy Titled Self-Help Devices (Adaptive Equipment) from Dietary Department dated 2016 document in part, self-help feeding devices will be provided on the tray to clients who require them.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the residents were treated with respect and dign...
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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 residents were treated with respect and dignity by not passing out meals to all residents sitting at a table at the same time. These failures affected 8 residents (R45, R54, R56, R73, R76, R95, R163, R215) reviewed during dining in a total sample of 104 residents.
Findings include:
On 8/1/22 at 1:17 PM, observed lunch cart delivered at 3rd floor dining room. Surveyor observed R45, R56, R76 sitting at the same table. At 1:19 PM, R76 was served lunch tray and began to eat. Surveyor observed R45 and R56 watching R76 eat. At 1:29 PM, R45's lunch tray was delivered. At 1:34 PM, R56 received her (R56)'s tray.
On 8/3/22 at 12:50 PM, observed R56, R76, R95 sitting at the same table in 3rd floor dining room while R76 was eating lunch. R56 and R95 did not have a lunch tray in front of them. Surveyor heard R76 ask R56 are you hungry? At 1:02 PM, R56 received her (R56) lunch tray. At 1:04 PM, R95's lunch tray was delivered.
On 8/3/22 at 12:50 PM, observed R73, R109, R215 sitting at the same table in the 3rd floor dining room while R109 was eating lunch. R73 and R215 did not have a lunch tray in front of them. At 1:00PM, R215 received a lunch tray. At 1:01 PM, R73 received a lunch meal.
On 8/3/22 at 12:59 PM, V36 (Licensed Practicing Nurse, Unit 3rd Floor Manager) stated that the meal trays do not come up in any order and that the staff pass out the trays as they arrive on the food charts. V36 stated that residents sitting at the same table should be served meals at the same time because it is a dignity issue.
On 8/3/22 at 1:09 PM, V8 (Licensed Practicing Nurse, Restorative Coordinator) stated that she (V8) does not know if there is a seating chart but there should be one. V8 then stated that the unit manager has a seating chart.
On 8/3/22 at 1:12 PM, V30 (Food Service Director) stated that before COVID there was a seating chart the kitchen followed but now there is not a seating chart anyone has given him (V30) to use.
On 8/3/22 at 1:20 PM, V36 (Licensed Practicing Nurse, Unit 3rd Floor Manager) stated that she (V36) does not have a current seating chart for residents who eat in the 3rd floor dining room.
Policy titled, Resident Rights document in part the resident is always treated with respect, kindness, and dignity.
Policy titled, The Dining Experience from Food and Nutrition Services 2021 [NAME] document in part meals are served at approximately the same time to all the clients sitting at a table.
On 08/01/22 at 1:10 PM, R54 received her (R54) lunch tray at 1:10 pm. R54 was sitting at the table with R163 who didn't receive his (R163) tray until 1:18 pm. When the surveyor asked V18 (CNA/Certified Nursing Aide) if residents sitting at the same table should be served at the same time, V18 stated, I'm new here. I would have to ask. V19 (CNA/Certified Nursing Aide) stated, We just go in order, referring to passing out the tray in the order they arrive on the cart. Regarding serving all residents seated together at the same time, V19 agreed, You don't want one person to eat when the other is hungry.
On 08/02/22 at 10:27 AM, regarding being served his (R163) lunch tray later than R54, R163 stated, That's how it is all the time.
R163's 06/08/22 BIMS (Brief Interview for Mental Status) determined a score of 15, indicating R163's cognition is intact.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure a clean and homelike environment by having loose or missing baseboards, walls damaged and not intact, broken or missing ...
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Based on observation, interview and record review the facility failed to ensure a clean and homelike environment by having loose or missing baseboards, walls damaged and not intact, broken or missing cabinets, window curtain not attached to curtain rod, and torn window screen. These failures affected residents (R5, R11, R21, R22, R25, R53, R56, R65, R74, R95, R104, R105, R122, R131, R157, R158, R162, R167, R186, R201, R210, R305) when reviewed for environment in the sample of 104 residents.
Findings include:
On 8/1/22 at 10:22 AM, observed R56, R158, R162's baseboards not attached to the wall behind R162's bed and on the opposite wall. Observed corner of wall near bathroom exposed to metal corner support approximately two feet from the floor extending up the wall. Surveyor observed brown rust-like color along the metal corner support and baseboard pulling away from the wall near the bathroom. Observed missing lower cabinet near the left side of closet.
On 8/1/22 at 10:28 AM, observed R21, R95, R201's baseboards pulling away from the wall, exposing crumbling white wall with small particle pieces on the floor approximately three feet in length. Observed missing lower cabinet near right side of closet.
On 8/1/22 at 10:30 AM, observed R25, R74, R122's corner wall near bathroom exposed crumbling wall with baseboard separating from wall. Brown, rust-like material observed attached to wall.
On 8/1/22 at 10:32 AM, observed R104, R131, R167's wall to the right of the air conditioner, under the window to be very soft and squishy. Observed paint buckling in this area. Surveyor able to move the wall back and forth in two areas estimated to be 1.5 x 1 and 6x 6. Observed area behind R167's bed had missing baseboard estimated to be approximately four feet in length.
On 8/2/22 at 9:34 AM, R104 stated that the baseboards missing in his (R104) room makes him feel creepy when he (R104) looks at the crumbling wall.
On 8/2/22 at 9:39 AM, V36 (Licensed Practical Nurse, Unit Manager) observed condition of walls in R104, R131, R167's room and stated that it looks like the wall is crumbling, and there should be a plastic baseboard covering it. V36 stated that aesthetically the wall does not look nice and that since this is the resident's home it should look just as nice as ours.
On 8/2/22 at 9:47 AM, conducted walking tour with V7 (Maintenance Director) to R21, R25, R56, R74, R95, R104, R122, R131, R158, R162, R167, R201's rooms. V7 stated that the problem with missing baseboards and crumbling walls is that it creates an open area for insects and does not look nice for the residents. V7 stated the soft wall in R104, R131, R167's room is likely due to water in the wall from rain since it's under the window. V7 stated that staff fills out work orders when items need to be fixed. V7 stated that he did not know if any work orders had been submitted to address the areas discussed. V7 stated that cabinet doors can only be replaced five at a time due to the cost of the cabinets and that maintenance removes nails to prevent a safety issue.
On 8/3/22 at 10:25 AM, V7 stated that the maintenance staff conducts rounds daily and that he does not have any work orders for R21, R25, R56, R74, R95, R104, R122, R131, R158, R162, R167, R201's rooms for the past eight months since he (V7) has been employed at the facility.
Policy titled, Preventative Maintenance & Inspections document in part to provide a safe environment for residents and those inspections verify if all equipment and furnishings are in working order and free from safety hazards.
Facility's document dated 2003 titled Director of Maintenance Job Description documents, in part: Purpose of Your Job Position: The primary purpose of your position is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner.
On 08/01/22 at 10:30 AM, R305's window was observed open with a hole, approximately a foot long in length and 5 inches wide, in the window screen. R305 stated that the hole causes flies to get in. This observation was brought to the attention of V7 (Maintenance Director) who stated, We can replace the screen.
On 08/03/22 at 10:31 AM, the surveyor inquired if the maintenance daily walk-through includes checking the window screens. V7 stated, Lately, we've just been checking to see if the windows are secure and making sure that are closed, not open. The surveyor inquired why a window screen is necessary. V7 replied, To keep out insects.
The undated Preventative Maintenance & Inspections documents, in part, Policy Guidelines: In order to provide a safe environment for residents, employees, and visitors, a preventative maintenance program has been implemented to promote the maintenance of equipment in a state of good repair and condition .C. Inspections: 4. Building inspections include the following: resident/patient rooms, exterior of facility.
The 2003 Director of Maintenance job description documents, in part, The primary purpose of your job position is to plan, organize, develop and direct the overall operation of the Maintenance Department in accordance with current federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner.
On 8/1/22 at 10:50 AM observed window curtain not being attached to the curtain rod in R65 and R5's room close to R65's bed.
On 8/1/22 at 11:10 AM observed window curtain not being attached to the curtain rod in R210's room.
On 8/2/22 at 12:45 PM observed window curtain not being attached to the curtain rod in R65 and R5's room close to R65's bed.
On 8/2/22 at 12:50 PM observed window curtain not being attached to the curtain rod in R210's room.
8/3/22 at 10:20 AM V7 (Maintenance Director) stated that the curtains in the resident's room is maintenance's responsibility. V7 stated that V7 has noticed the window curtains not being attached to the curtain rod in the resident's rooms. V7 stated that the curtains not being attached to the curtain rod in the resident's room would not be a comfortable homelike environment for the residents. V7 stated that V7 has not received a work order for the window curtains not being attached to the curtain rod in the resident's rooms.
On 8/3/22 at 1:30 PM V2 (Director of Nursing) stated that if the facility doesn't address the window curtains not being attached to the curtain rod in the resident's rooms, then it would not be a comfortable homelike environment for the residents. V2 stated that the staff is to report window curtains not being attached to the curtain rod and put in a work order for maintenance to repair.
On 08/04/22 at 10:18 am, Surveyor toured the facility's 3 south unit and observed the following observations in the residents rooms in need of repair:
In R11 and R105's bathroom a large hole in the wall near the floor behind the bottom of the toilet area. R11 and R105's room with baseboard hanging loose from the wall with white pieces of wall plaster on the floor and the wall with peeling paint.
In R22 and R157's room loose baseboards hanging behind the sink area with pieces of white wall plaster on the floor and wall in need of paint.
In R53 and R186's room a loose wall bracket hanging down pulled from the wall with visible holes in the wall with wall in need of paint. R53 and R186's closet door broken and hanging to the ground.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure that assistive devices were properly maintained for two residents (R121 and R306) in the sample of 104 residents and fa...
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Based on observation, interview and record review, the facility failed to ensure that assistive devices were properly maintained for two residents (R121 and R306) in the sample of 104 residents and failed to remove clutter from a restorative storage closet and ensure that the storage closet was locked, which has the potential to affect all 57 residents on the 3 North unit.
Findings include:
On 08/01/22 at 10:25 AM, R306 showed the surveyor the toilet safety rail in R306's bathroom. R306 grabbed the handle and demonstrated how the safety rail was loose and sliding off the toilet. The steel bracket securing the safety rail to the toilet was observed to be loose and not properly secured to the toilet seat. R306 stated that she (R306) has to steady herself (R306) with her (R306) hand on the toilet seat because it makes her (R306) feel like she's (R306) going to fall off the toilet when sitting down.
On 08/01/2 at 12:00 PM, this observation was brought to the attention of V16 (RN/Registered Nurse) who stated that the loose toilet safety rail can be a Risk for injury or fall. V16 stated that she (V16) will let maintenance know to tighten the safety rail.
On 08/03/22 at 10:04 AM, V8 (Restorative Coordinator, LPN/Licensed Practical Nurse) stated that the purpose of the toilet safety rail is, To be able to transfer herself and place herself safely on the toilet.
R306's admission Record documents diagnoses of weakness, history of falling, and dizziness.
R306's 07/28/22 BIMS (Brief Interview for Mental Status) determined a score of 15, indicating R306's cognition is intact.
On 08/01/22 at 10:50 AM, R121's wheelchair was noted to be missing the pad on the left armrest. When the surveyor asked if it was bothering R121, he (R121) stated, A little bit. R121 stated that he (R121) would like to get it fixed. This observation was brought to the attention of V5 (LPN/Licensed Practical Nurse). When the surveyor asked if there's a risk for skin breakdown due to no padding, V5 stated, Yeah, something could happen.
On 08/03/22 at 10:05 AM, V8 stated that the restorative department is responsible for providing wheelchairs for residents. V8 stated that if a wheelchair is missing the padding on the armrest, I have little cushions (trough) that can be attached so it wouldn't be rubbing or anything. V8 added her (V8) staff does weekly walk-throughs to make sure equipment is working right or not missing anything, but ultimately the nurses, the aides, everyone should be responsible for maintaining the equipment. If you see something, say something about it.
R121's 05/27/22 BIMS (Brief Interview for Mental Status) determined a score of 15, indicating R121's cognition is intact.
R121's face sheet documents diagnoses including but not limited to quadriplegia C5-C7, incomplete and muscle wasting and atrophy.
R121's 5/19/22 care plan documents, in part, Focus: Has potential for skin integrity impairment .(R121) has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Quadriplegia C5-C7. Interventions: (R121) use wheelchair to get around facility with limited assistance at times.
On 08/01/22 at 10:53 AM, the storage room on 3 North was observed unlocked with a wheelchair in the doorway. When the surveyor looked inside, the room was noted to be cluttered with equipment stacked on top of each other with no way to get inside. At the end of the room, the equipment was stacked approximately two feet from the ceiling.
On 08/01/22 at 11:00 AM, V8 (Restorative LPN/Licensed Practical Nurse) stated that the door shouldn't have been left open. It should be locked. The surveyor inquired if there is a potential for harm if a resident were to walk in and try to grab a piece of equipment from the pile which could cause other equipment to topple over, V8 responded, I can't say that because it's usually locked. V8 acknowledged that the door was currently unlocked.
On 08/02/22 at 12:40 PM, V1 (Administrator) stated that the restorative department is responsible for the restorative storage closet. The surveyor inquired whether equipment should be stacked on top of the other to the point of being unable to enter the room? V1 replied, No it shouldn't. V1 added that the door should be closed and locked at all times. When asked if V1 would consider that a hazard, V1 replied, I would.
The 2003 facility Restorative Care Nurse job description documents, in part, The Purpose of Your Job Position: The primary purpose of your job position is to perform restorative nursing procedures that maximize the resident's existing abilities, emphasize independence instead of dependence, and minimize the negative effects of disability with an attitude of realistic optimism under the supervision of a restorative nurse .Duties and Responsibilities (Safety and Sanitation): . assuring that necessary equipment and supplies are maintained to perform such duties/services .develop, implement, and maintain a procedure for reporting hazardous conditions or equipment.
The undated Preventative Maintenance & Inspections documents, in part, Policy Guidelines: In order to provide a safe environment for residents, employees, and visitors, a preventative maintenance program has been implemented to promote the maintenance of equipment in a state of good repair and condition .C. Inspections: 1. Inspections verify that all equipment and furnishings are in working order and free from safety hazards .4. Building inspections include the following: resident/patient rooms, storage areas.
The 2003 Director of Maintenance job description documents, in part, Duties and Responsibilities (Equipment and Supply Functions): Make periodic rounds to check and to assure that necessary equipment is available and working properly.
The 7/14 Falls Management Policy documents, in part, General: This facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to provide oral supplements as recommended. This failur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to provide oral supplements as recommended. This failure has the potential to affect 4 residents (R91, R95, R98, R162) reviewed for nutrition status in a total sample of 104.
Findings include:
On 8/1/22 at 1:40PM, observed R98 consuming lunch tray in 3rd floor dining room. R98 received mechanical soft meat, mashed potatoes, mixed vegetables, pineapple tidbits, and juice. There were no nutritional supplements on tray. Meal ticket documented nutritional treat with meals.
On 8/1/22 at 1:46 PM, observed R91 consuming lunch tray in 3rd floor dining room. R91 received pureed meat, pureed vegetables, mashed potatoes, pureed bread and pureed pineapple. There were no nutritional supplements on tray. Meal ticket documented nutritional treat with meals.
On 8/1/22 at 1:50 PM, observed R95 consuming lunch tray in 3rd floor dining room. R95 received meat, potatoes, mixed vegetables, bread, pineapple tidbits. There were no nutritional supplements on tray. Meal ticket documented nutritional treat and listed to provide at lunch and dinner.
On 8/2/22 at 9:13 AM, observed R98 consuming breakfast tray in 3rd floor dining room. R98's received biscuit covered in sausage gravy, hot cereal, milk, and juice. The tray did not contain any type of nutritional supplement. Meal ticket documented nutritional treat with meals.
On 8/3/22 at 9:44 AM, observed R162 being fed breakfast by staff in 3rd floor dining room. R162 received pureed bread, pureed sausage gravy, hot cereal in individual serving bowls in addition to juice and milk. The tray did not contain any type of nutritional supplement. Meal ticket documented nutritional treat with meals.
R91 was admitted to the facility on [DATE] with diagnosis which included but not limited to: Unspecified Dementia, Peripheral Vascular Disease, Anemia, Type 2 Diabetes Mellitus. R91's MDS (Minimum Data Set) from 5/9/22 BIMS (Brief Interview For Mental Status) score is 01 indicating severe cognitive impairment.
Registered Dietitian assessments completed 1/27/22, 2/23/22, 3/20/22, 4/25/22, 5/26/22, 6/27/22 for R91 documents in part risk factors which include recent unplanned weight loss, BMI of 20.8 or less, non-pressure skin condition and malnutrition and supplement to be provided nutritional treat three times per day.
R95 was admitted to the facility on [DATE] with diagnosis which included but not limited to: Unspecified Dementia, Schizophrenia. R95's MDS (Minimum Data Set) from 5/11/22 BIMS (Brief Interview For Mental Status) score is 05 indicating severe cognitive impairment.
Registered Dietitian assessment completed 9/19/19 for R95 documents in part weight loss may be related to progressive dementia and multiple supplements ordered including but not limited to frozen treats w/meals. Diet Tech dietary profile completed 2/4/22 documents in part current nutritional supplement as nutritional treat.
R95's physician order dated 9/19/19 documents in part to provide frozen treat with all meals.
R98 was admitted to the facility on [DATE] with diagnosis which included but not limited to: Dysphagia, Oropharyngeal Phase, Type 2 Diabetes Mellitus, Adult Failure to Thrive, Alzheimer's Disease, Aphasia following Cerebral Infarction. R98's MDS (Minimum Data Set) from 5/13/22 BIMS (Brief Interview For Mental Status) score is 00 indicating severe cognitive impairment.
R98's physician order dated 10/28/20 documents in part to provide nutritional treat with all meals.
R162 was admitted to the facility on [DATE] with diagnosis which included but not limited to Unspecified Dementia, Dysphagia, Psychosis, Retarded Development following protein-calorie malnutrition.
R162's MDS (Minimum Data Set) from 6/7/22 BIMS (Brief Interview For Mental Status) score is 03 indicating severe cognitive impairment.
R162's physician order dated 5/27/21 documents in part to provide nutritional treat with all meals.
R162's nutrition care plan documents interventions dated 9/2/21 in part nutritional treat.
Registered Dietitian assessments completed 2/22/22, 3/31/22, 4/25/22, 7/22/22 for R162 documents in part risk factors which include recent BMI of 20.8 or less, malnutrition, recent unplanned weight gain and supplement to be provided nutritional treat three times per day.
On 8/2/22 at 11:45 PM, V30 (Food Service Director) stated that nutritional treats are a frozen product that is delivered to the unit from the kitchen. V30 stated that the nutritional treats are used to help resident's gain weight or get more nutrients like protein if they have a wound. V30 stated that the risk if a resident had an order for a supplement and did not receive the nutritional treat would be weight loss, and not enough nutrients for wound healing.
On 8/2/22 at 4:10 PM, interviewed V37 (Registered Dietitian) over the phone. V37 stated that nutritional supplements are used as an intervention due to weight loss, poor appetite, skin impairment, increased nutritional needs. V37 stated the nutritional treats is a general term used to describe frozen fortified ice cream. V37 stated that nutritional treats listed on the meal ticket should be provided with the meal from the kitchen.
From Food and Nutrition Services policy dated 2021 titled, Supplements documents in part nutritional supplements will be provided as ordered to clients whose nutrient needs may be increased, nutritional supplements may include special commercial products which have increased nutrient density and fortified food items may be served with meals.
From facility dated 8/1/21 titled, Physician's Orders documents in part that it is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. The safety of residents is of primary importance. The provider will write the order in the medical record and the nurse is responsible for executing the order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
On 8/01/2022 at 10:31am surveyor observed R179's oxygen tubing was not dated.
On 08/03/2022 at 11:28am V28(Unit Manager-2nd Floor/RN (Registered Nurse) stated the nurse is responsible for changing th...
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On 8/01/2022 at 10:31am surveyor observed R179's oxygen tubing was not dated.
On 08/03/2022 at 11:28am V28(Unit Manager-2nd Floor/RN (Registered Nurse) stated the nurse is responsible for changing the oxygen tubing and the humidifier bottles, every week, once a week. V28 stated the date it was changed should be on the humidifier bottle and the oxygen tubing. V28 stated, No, there is no date on R179's oxygen tubing.
On 08/03/2022 at 1:36pm V2(DON/Director of Nursing) stated the nursing staff is responsible for changing the oxygen tubing. V2 stated the tubing should be changed weekly and as needed. V2 stated the oxygen tubing and humidifier bottle should be dated with the date the equipment was changed.
On 8/3/2022 R179's Physician Order Summary Report dated 08/03/2022 documents, O2(Oxygen) at 2L via nasal cannula every shift for SOB (Shortness of Breath).
Policy (presented by the facility) titled Integra Respiratory Therapy Procedure Oxygen therapy (undated) does not document that oxygen tubing should be dated.
Based on observation, interview and record review, the facility failed to ensure that staff donned the appropriate PPE (personal protective equipment) for PUI (persons under investigation) residents on contact and droplet isolation and failed to label and date oxygen equipment to prevent the spread of microorganisms including COVID-19 which affected R179, R205, R207, R211, R213, R558, R559, and R560 and had the potential to affect the 17 residents on the 1st floor of the facility.
Findings include:
Facility document, titled 1 S (South) 10 Day Quarantine and dated 8/1/22, documents, in part, that R205, R207, R211, R213, R558, R559 and R560 are documented as PUI for persons under investigation for COVID-19.
On 8/1/22 at 10:22 am, a contact and droplet isolation sign was visibly observed posted on R559's room door. V14 (Certified Nursing Assistant, CNA) was observed entering R559's room with no gown or gloves on.
Facility isolation sign (blue in color with a picture of a stop sign) documents, in part, Droplet/Contact Precautions: Health Care Workers Must Wear: N95 Respirator . Gloves, Gown, Protective Eyewear (you must wear goggles or a face shield).
On 8/1/22 at 10:30 am, a contact and droplet isolation sign was visibly observed posted on R558's room door. R558 stated to this surveyor that the nurses and CNA's wear the blue/teal uniforms and will wear gloves when coming in R558's room but don't ever wear gowns. R558 stated, I (R558) see their uniforms. They aren't wearing gowns in my room.
On 8/1/22 at 10:37 am, a contact and droplet isolation sign was visibly observed posted on R205's room door. V15 (Activities Aide) was observed wearing a blue surgical face mask and entered R205's room with no gown or gloves on.
On 8/1/22 at 10:39 am, R205's call light was observed lit up. V11 (CNA) was observed entering R205's room with no gown on.
On 8/1/22 at 10:42 am, V14 entered R205's contact and droplet isolation room with no gown.
On 8/1/22 at 10:43 am, this surveyor asked V15 about the surgical face mask that V15 was wearing, and V15 stated that V15 was given the surgical face mask by the facility staff sitting (V25 Bed Maker, CNA in Training)) in the front (where you enter the facility).
On 8/1/22 at 10:52 am, a contact and droplet isolation sign was visibly observed posted on R207's room door. V22 (Floor Tech/Housekeeping) entered R207's room with no gown on and stated that R207 is there to clean the room. V22 then brought out the small garbage bucket from inside R207's room into the hallway and then placed one liner in bucket then another liner inside the first liner.
On 8/1/22 at 10:54 am, V22 walked back into R207's room with broom to sweep without wearing a gown. V22 then walked out of R207's room at 10:55 am. On 8/1/22 at 10:56 am, V22 walked back into R207's room with no gown on with a mop and mopped the floor. On 8/1/22 at 10:57 am, V22 walked out of R207's room.
On 8/1/22 at 12:31 pm, a contact and droplet isolation sign was visibly observed posted on R207's room door. V14 entered R207's room holding the lunch tray and wearing no gloves or gown.
On 8/1/22 at 12:33 pm, a contact and droplet isolation sign was visibly observed posted on R211's room door. V11 entered R211's room holding the lunch tray and wearing no gloves or gown.
On 8/1/22 at 12:33 pm, a contact and droplet isolation sign was visibly observed posted on R560's room door. V14 entered R560's room holding the lunch tray and wearing no gloves or gown.
On 8/1/22 at 12:34 pm, a contact and droplet isolation sign was visibly observed posted on R558's room door. V11 entered R558's room holding the lunch tray and wearing no gloves or gown.
On 8/1/22 at 12:35 pm, a contact and droplet isolation sign was visibly observed posted on R559's room door. V14 entered R559's room holding the lunch tray and wearing no gloves or gown.
On 8/1/22 at 12:37 pm, a contact and droplet isolation sign was visibly observed posted on R205's room door. V14 entered R205's room holding the lunch tray and wearing no gloves or gown.
On 8/1/22 at 12:38 pm, a contact and droplet isolation sign was visibly observed posted on R213's room door. V11 entered R213's room holding the lunch tray and wearing no gloves or gown. A contact and droplet isolation sign was visibly observed posted on R207's room door. V14 entered R207's room holding the lunch tray and wearing no gloves or gown.
On 8/1/22 at 12:39 pm, a contact and droplet isolation sign was visibly observed posted on R211's room door. V14 entered R211's room wearing no gown.
On 8/2/22 at 9:54 am, a contact and droplet isolation sign was visibly observed posted on R211's room door. V24 (Bed Maker, CNA in Training) entered into R211's room with no gown on.
On 8/2/22 at 10:13 am, V25 (Bed Maker, CNA in Training) was sitting in front entrance of the facility as screener with two boxes of face masks. V25 showed this surveyor one box labeled as an N95 respirator mask, and V25 opened the box to show that the N95 masks were green and white striped in color. V25 showed this surveyor the other box labeled as a procedural (surgical) mask, and V25 showed this surveyor that the surgical masks were blue in color.
On 8/2/22 at 10:33 am, V4 (Infection Preventionist) stated that residents are isolated as a PUI for 10 days. V4 stated that if a resident is not fully vaccinated with a booster and is a new admission, then the resident will be under PUI observation. V4 was observed wearing eye goggles and a blue surgical mask, like the surgical mask that V15 (Activity Aid) was observed wearing. When asked about which mask V4 is wearing, V4 stated just a surgical mask. V4 stated that staff are to wear the N95 (green and white striped) face masks when working on the 1 South (PUI/COVID floor). V4 stated, Staff on 1st floor have to have the N95 mask on all the time.
R205's COVID-19 Vaccination card documents that R205 has received one dose of the multistep 2 series COVID-19 vaccine.
R207's document, dated 7/28/22 and signed by R207, documents, in part, that R207 has declined the COVID-19 vaccine.
R211's Immunization record documents, in part, that R211 has received the 2 step COVID-19 vaccine but is not boosted for COVID-19.
R213's Immunization record documents, in part, that R213 is not eligible for the COVID-19 vaccine.
R558's document, provided by the facility from the state automated registry exchange, documents, in part, that R558's valid shots are for the 2 step COVID-19 vaccine but is not boosted for COVID-19.
R559's document, dated 7/30/22 and signed by R559, documents, in part, that R559 has declined the COVID-19 vaccine.
R560's document, dated 7/30/22 and signed by R560, documents, in part, that R560 has declined the COVID-19 vaccine.
On 8/2/22 at 12:04 pm, V4 (Infection Preventionist) stated that PUI residents are on contact and droplet isolation. V4 stated that when a resident is a new admission to the facility and is not fully vaccinated with the primary and booster vaccines for COVID-19, then the resident is placed on contact and droplet precautions for 10 days. V4 stated that staff will wear an N95 face mask, gloves, gowns and a face shield or eye goggles. V4 stated that staff must don these four PPE items prior to entering the PUI isolation room. V4 stated that staff wear this PPE because they (staff) are exposed to the organism in the environment. COVID can transfer through droplets. PUI is a person under investigation (for COVID-19). If resident is not vaccinated fully, we (staff) don't know who they (residents) came in contact with so if they (residents) test negative one day, they (residents) may test positive tomorrow. We (staff) keep on PUI for safety of our community in the building. When asked about the contact precautions by donning gloves and a gown, V4 stated, COVID lives on environment surfaces, and staff come in contact with their (residents) environment.
On 8/3/22 at 1:30 pm, V2 (Director of Nursing) stated that the difference between an N95 mask and a surgical mask is that the N95 mask is a respirator and will filter more of the respiratory droplets. V2 stated that the staff must wear an N95 mask for PUI and COVID-19 positive residents.
Facility document, titled Daily Census with a printed date and time as 8/1/22 at 9:07 am, documents, in part that 17 residents are residing on the 1 South floor in the facility.
V11's COVID-19 Vaccination Record Card documents that V11 has received the 2 step multidose and booster vaccination for COVID-19.
V14's COVID-19 Vaccination Record Card documents that V11 has received the single step dose vaccination for COVID-19.
V15's COVID-19 Vaccination Record Card documents that V15 has received the 2 step multidose vaccination for COVID-19.
V22's COVID-19 Vaccination Record Card documents that V22 has received the 2 step multidose and booster vaccination for COVID-19.
V23's COVID-19 Vaccination Record Card documents that V23 has received the 2 step multidose vaccination for COVID-19.
Facility document, titled COVID Data Tracker from Centers for Disease Control and Prevention (CDC) and provided to survey team on 8/1/22 during the entrance conference with V1 (Administrator), documents, in part, that the facility's county area is in a high community level from 7/20/22 to 7/26/22.
Facility policy, titled Infection Prevention and Control Program and dated 2/14/22, documents, in part, Intent: Facility is responsible for protecting and promoting quality of life and health for all their patients and residents by developing and implementing Infection Prevention and Control Programs and systems that provide information and education, effective regulation and oversight, quality services, and surveillance of diseases and conditions . 8. Transmission Based Precautions: a. The facility has policies and procedures of transmission-based precautions (TBP) (i.e., Contact Precautions, Droplet Precautions .) to be followed to prevent spread of infections, which included selection and use of PPE . b. Residents with known or suspected infections, or with evidence that represent an increased risk of transmission, are placed on the appropriate TBP.
Facility policy, titled Transmission Based Precautions and titled April 2021, documents, in part, General: To prevent the spread of infections from residents known to be infected or colonized with pathogens that can be transmitted by contact, droplet or airborne transmission.
Facility job description, titled Charge Nurse and dated 2003, documents, in part, Purpose of Your Job Position: The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times . Duties and Responsibilities: . Personnel Functions: . Ensure that all nurse aide trainees are under the direct supervision of a licensed nurse . Ensure that department personnel . follow the department's established policies and procedures at all times . Nursing Care Functions: . Implement and maintain established nursing objectives and standards.
Facility job description, titled Certified Nursing Assistant and dated 2003, documents, in part, Purpose of Your Job Position: The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessments and care plan, and as may be directed by your supervisors . Personnel Functions: Perform all assigned tasks in accordance with our established policies and procedures . Safety and Sanitation: . Follow established safety precautions in the performance of all duties.
Facility job description, titled Nurse Aide Trainee and dated 2003, documents, in part, Purpose of Your Job Position: The primary purpose of your job position as a full time staff member is to acquire the knowledge, skills, and certification as a Certified Nursing Assistant by participation in the facility's planned educational program consisting of classroom instructions, clinical practice, and on-the-job, supervised training, and to perform certain services for which you have been trained and found to be competent during the training period . Personnel Functions: Perform all assigned tasks in accordance with our established policies and procedures.
Facility job description, titled Activity Assistant and dated 2003, documents, in part, . Duties and Responsibilities: . Safety and Sanitation: . Use protective clothing devices.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure food items were properly labeled, dated and stored; failed to practice safe hand washing and use of gloves; failed to c...
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Based on observation, interview and record review, the facility failed to ensure food items were properly labeled, dated and stored; failed to practice safe hand washing and use of gloves; failed to clean kitchen equipment and failed to ensure that cook/service ware are sanitized. These deficient food sanitation practices have the potential to affect all 216 residents receiving food prepared in the facility's kitchen.
Findings include:
On 8/1/22 at 9:08 AM, during initial kitchen tour breakfast tray line was in progress. Surveyor observed V33 (Diet Aide) carrying 6-8 slices of toasted bread from the toaster with bare hands and put the toast into a large metal container on the tray line. Surveyor then observed V33 wash his (V33)'s hands for less than 5 seconds and put on gloves. Surveyor observed V34 (Diet Aide) using gloved hand to grab toast out of large metal container on tray line and place toast on individual resident trays. V34 observed alternating between touching different scoops to portion out food and touching toast directly with gloved hand. Surveyor did not observe any tongs in use, or handwashing.
On 8/1/22 at 9:18 AM, observed the following items opened in the walk-in refrigerator.
Mayonnaise delivered 7/22/22, no open or expiration date
Ranch Dressing delivered 5/31/22, no open or expiration date
Italian Dressing delivered 7/5/22, no open or expiration date
V30 (Food Service Director) stated that if the staff does not date the item when opened there is no way to know how long an item has been in the refrigerator or when it will expire.
On 8/1/22 at 9:24 AM, walk-in refrigerator observed to have gray dust covering the fan screen and the ceiling close to the fans. V30 stated that the substance could fall from the ceiling on to the food items stored in the refrigerator.
On 8/1/22 at 9:27 AM, observed large amount of black substance on the outside and within the folds of the walk-in refrigerator door gaskets. V30 stated that the substance looked like mold and dirt.
On 8/1/22 at 9:30 AM, observed 4 packages of taco shells in a milk carton on the floor in the back corner of the freezer. V30 removed the milk carton from the floor and stated that no food should be stored on the floor.
On 8/1/22 at 9:33 AM, observed 50 pound bag of Panko breadcrumbs opened in dry storage room not labeled with an open date or in a container or sealed closed. V30 stated that the bag of breadcrumbs should be in a container or plastic bag so we don't get rodents or bugs.
On 8/1/22 at 9:49 AM, observed thick layer of dark brown grime around the inside of the can opener holder and food particles on, above and below the puncture site of the can opener. V30 stated that cleaning the can opener is on the cleaning schedule.
On 8/2/22 at 10:04 AM, observed V35 (Cook) take a whisk soaking in a pitcher filled with light brown water, rinse it off with water in the cold preparation sink and then put the whisk into the pureed corn V35 was preparing. V35 then used a large scoop from the thickener bin to add thickener to the pureed corn and used the whisk to mix the thickener into the pureed corn. Surveyor observed V35 place the large scoop used to add thickener directly on top of the metal counter. Surveyor observed the counter to have visible red food stains, and other food debris. V35 observed picking up the thickener scoop again and resubmerging it into the thickener bin to collect more thickener to add to the pureed corn. Observed V35 add thickener to the pureed corn and then put the thickener scoop back on top of the metal counter. Observed V35 take the whisk from the container of pureed corn and place it into the bottom of the cold preparation sink. R35 then used the blender to puree the corn.
On 8/2/22 at 10:15 AM, observed the blender to be covered in left over pureed corn. Observed V35 rinsing out the blender container, blade and lid in the cold preparation sink with water. V35 then reassembled the blender and proceeded to puree the meatballs using the same blender.
On 8/2/22 at 10:21 AM, observed V35 take the same whisk laying on the bottom of the cold preparation sink and use it to stir the pureed meatballs. V35 then observed placing the whisk back into the cold preparation sink, laying on the bottom of the sink. At 10:22 AM, observed V35 take the thickener scoop from the counter and submerge it into the thickener bin to obtain more thickener. V35 adds this thickener to the pureed meatballs, and then places the scoop back on top of the counter V35 observed picking up the whisk from the cold preparation sink and used it to blend the thickener into the pureed meatballs. V35 was not observed washing hands before or during pureed food preparation.
On 8/2/22 at 10:45 AM, V30 (Food Service Manager) stated that whisk and blender should have been sanitized between each use due to infection control. V30 stated, residents can get sick from cross contamination.
Policy titled Hand Washing from the Dietary Department 2016 Manual document in part employees will practice safe food handling to prevent foodborne illness, and wash hands before engaging in food preparation, before putting on new gloves and after handling soiled equipment and utensils.
Policy titled Preparation/Cooking from the Dietary Department 2016 Manual document in part avoid bare hand contact with ready-to-eat food, and to clean and sanitize utensils, counter tops and equipment.
Policy titled Labeling and Dating Foods from the Dietary Department 2016 Manual document in part if opened, the cold food items is labeled with the date opened and the date by which to discard or use by.
Policy titled, Storage of Refrigerated Foods from the Dietary Department 2016 Manual document in part food in the refrigerator is covered, labeled and dated with a use by date.
Policy titled, Storage of Frozen Foods from the Dietary Department 2016 Manual document in part food is stored six inches above the floor.
Policy titled, Storage of Dry Good/Foods from the Dietary Department 2016 Manual document in part that open products are labeled, dated with the use by date and tightly covered to protect against contamination including from insects and rodents.
Policy titled, Cleaning Procedure for Equipment and Utensils from the Dietary Department 2010 Manual document in part for blender to be washed, rinsed, sanitize and then air dry.
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?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), 12 harm violation(s), $437,799 in fines, Payment denial on record. Review inspection reports carefully.
- • 107 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $437,799 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 Morgan Park Healthcare's CMS Rating?
CMS assigns MORGAN PARK HEALTHCARE 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 Morgan Park Healthcare Staffed?
CMS rates MORGAN PARK HEALTHCARE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 58%, which is 12 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 73%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Morgan Park Healthcare?
State health inspectors documented 107 deficiencies at MORGAN PARK HEALTHCARE during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 12 that caused actual resident harm, and 93 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 Morgan Park Healthcare?
MORGAN PARK HEALTHCARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by SABA HEALTHCARE, a chain that manages multiple nursing homes. With 294 certified beds and approximately 207 residents (about 70% occupancy), it is a large facility located in CHICAGO, Illinois.
How Does Morgan Park Healthcare Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, MORGAN PARK HEALTHCARE's overall rating (1 stars) is below the state average of 2.5, staff turnover (58%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Morgan Park Healthcare?
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?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Morgan Park Healthcare Safe?
Based on CMS inspection data, MORGAN PARK HEALTHCARE 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 2 Immediate Jeopardy citations (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 Morgan Park Healthcare Stick Around?
Staff turnover at MORGAN PARK HEALTHCARE is high. At 58%, the facility is 12 percentage points above the Illinois average of 46%. Registered Nurse turnover is particularly concerning at 73%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Morgan Park Healthcare Ever Fined?
MORGAN PARK HEALTHCARE has been fined $437,799 across 7 penalty actions. This is 11.7x the Illinois average of $37,457. 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 Morgan Park Healthcare on Any Federal Watch List?
MORGAN PARK HEALTHCARE 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.