How many inspection deficiencies does GOLDWATER CARE CLINTON have?

GOLDWATER CARE CLINTON has 86 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at GOLDWATER CARE CLINTON?

GOLDWATER CARE CLINTON has a one-star staffing rating from CMS with 0.35 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is GOLDWATER CARE CLINTON located?

GOLDWATER CARE CLINTON is located in CLINTON, IL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does GOLDWATER CARE CLINTON have?

GOLDWATER CARE CLINTON has 134 certified beds.

Who owns GOLDWATER CARE CLINTON?

GOLDWATER CARE CLINTON is a non profit - corporation facility and is part of the GOLDWATER CARE chain.

What questions should families ask when visiting GOLDWATER CARE CLINTON?

Families visiting GOLDWATER CARE CLINTON should ask about staff retention and training programs, what corrective actions were taken after fines. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does GOLDWATER CARE CLINTON compare to other nursing homes?

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

GOLDWATER CARE CLINTON

Name: GOLDWATER CARE CLINTON
Address: 1 PARK LANE WEST, CLINTON, IL, 61727, US
Telephone: (217) 935-8500
Rating: 1.0

1 PARK LANE WEST, CLINTON, IL 61727 · (217) 935-8500

Non profit - Corporation 134 Beds GOLDWATER CARE Data: November 2025

Trust Grade

0/100

#530 of 665 in IL

Share this report:

GOLDWATER CARE CLINTON nursing home in CLINTON, IL - Photo 1 of 5

GOLDWATER CARE CLINTON nursing home in CLINTON, IL - Photo 2 of 5

Photo by Goldwater Care Clinton

GOLDWATER CARE CLINTON nursing home in CLINTON, IL - Photo 3 of 5

Photo by Goldwater Care Clinton

GOLDWATER CARE CLINTON nursing home in CLINTON, IL - Photo 4 of 5

Photo by Goldwater Care Clinton

GOLDWATER CARE CLINTON nursing home in CLINTON, IL - Photo 5 of 5

1 / 5 photos

Last Inspection: December 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Goldwater Care Clinton has received a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #530 out of 665 nursing homes in Illinois, placing them in the bottom half of facilities statewide, but are the top option out of two in De Witt County. While the facility is showing an improving trend, with issues decreasing from 52 in 2024 to 14 in 2025, they still face serious challenges, such as a concerning 76% staff turnover rate and less RN coverage than 92% of facilities in the state. Specific incidents include a resident who sustained a fall requiring emergency treatment after the facility failed to implement proper fall interventions, and another resident who was not protected from physical abuse by a fellow resident, resulting in bruising and fear. Overall, while there are some improvements, families should weigh these serious weaknesses against the potential for better care in the future.

Trust Score: F
In Illinois: #530/665
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 76% turnover. Very high, 28 points above average. Constant new faces learning your loved one's needs.
Penalties: $72,309 in fines. Higher than 82% of Illinois facilities, suggesting repeated compliance issues.
Skilled Nurses: Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 86 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 52 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: 76%

30pts above Illinois avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $72,309

Well above median ($33,413)

Moderate penalties - review what triggered them

Chain: GOLDWATER CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is very high (76%)

28 points above Illinois average of 48%

The Ugly 86 deficiencies on record

6 actual harm

Sept 2025 6 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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right (R3) to be free of physical abuse from (R2) for two of six residents reviewed for abuse in the sample list of 19.Findings include:R2's Abuse/Neglect Screening form dated 5/1/25, documents R2 has a history of mistreating others by physical and verbal abuse, psychiatric mental health issues which include psychotic symptoms, and documents R2 cries a lot and them becomes angry with other residents.R2's undated diagnoses list documents the following diagnoses: other specified Anxiety Disorder, and Alzheimer's Disease, unspecified. R2's Progress Note/Psychotropic dated 8/21/25, documents R2's diagnoses as: Major Depressive Disorder, Dementia in other diseases classified elsewhere, severe, with Agitation, and Anxiety with somatic features.R2's Minimum Data Set (MDS) dated [DATE], documents R2 is not cognitively intact.R2's Care Plan dated 8/27/25, documents R2 has a problematic manner characterized by ineffective coping, verbal/physical aggression related to cognitive impairment.The facility's abuse report dated 8/21/25, documents R3 was in R2's room where R3 was lying in R2's bed. R2 made physical contact with R3's upper thigh.On 9/10/25 at 2:03 PM, V3 Certified Nursing Assistant (CNA) stated R2 is very verbal, tries to reach for other residents, takes their arms and grabs them often. V3 stated staff has to call R2's daughter V13, to have V13 sit with R2 to calm R2 down. On 9/16/25 at 12:22 PM, V1 Administrator stated R2 is a resident who has been physical with residents.On 9/17/25 at 10:35 AM, V2 Director of Nursing (DON) stated R2 did hit R3 on 9/11/25.The facility's Abuse Prevention and Reporting Policy dated Revisions 10/24/22, documents the facility affirms the right of the residents to be free from abuse and therefore prohibits abuse.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a fall investigation, develop a root cause, and implement relevant fall interventions for one resident (R4) of three residents reviewed for falls in the sample list 19. This past non-compliance occurred from 8/9/25 to 8/19/25.Findings include:R4's undated diagnoses list documents R4's diagnoses as: Cellulitis of Right Lower Limb, other Chronic Pain, other Lack of Coordination, and need for assistance with Personal Care.R4's Minimum Data Set (MDS) dated [DATE], documents R4 requires supervision or touching assistance with walking. R4's Psychiatric Notes dated 8/5/25, documents R4 has thought blocking process and poor insight.R4's Minimum Data Set (MDS) dated [DATE], documents R4 in not cognitively intact.R4's Care Plan dated 7/14/25, documents R4 has Impaired Cognitive Function or Impaired thought Processes related to Dementia with interventions to cue, reorient, and supervise as needed. This same Care Plan documents R4 is at high risk for falls.On 9/16/25 at 12:22 PM, V1 Administrator stated R4's fall was not reported in a timely manner and stated it is when we got a coroner's request from the hospital that we then realized it and then completed and submitted the documents. V1 stated V5 Assistant Director of Nursing (ADON) had the on-call phone the day R4 fell but falls with injuries should be reported to V2 Director of Nursing (DON) but at the time we did not know there was an injury. V1 stated V2 DON should have reported the fall to the Regional Clinical Coordinator and then the paperwork should have been completed and sent in. V1 stated they had communication with the hospital. The hospital said R4 was having surgery and then R4 wasn't going to have surgery and then it was reported that R4 was put on hospice and then we got word R4 passed, so once we got the coroner's inquest, we realized we did not do this correctly. On 9/16/25 at 2:06 PM, V2 DON stated V2 is pretty sure V2 got a call from V5 ADON and V2 told V5 about R4's fall. V2 stated V2 did not inform anyone because V2 was not the on-call person V5 was. V2 stated V2 thought V2 was just being kept in the loop. V2 stated V2 can't remember if V2 talked to V1 Administrator about it (R4 fall) or not. V2 stated this incident was reported late when we realized after the fact so V1 was notified, and an investigation was started. V2 stated V2 had another abuse allegation that took V2s focus. V2 stated V2 completely forgot about R4's fall. The facility's Incident and Accidents Policy dated 4/7/2019, documents an incident/accident report is completed for all accidents or incidents where there is injury or the potential to result in injury. This policy also documents an incident/accident report is to be completed by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) and is to include the date and time of accident/incident, full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, and treatment rendered. This policy also documents all incidents/accidents reports or reviewed, signed, and investigated by the Administrator and the Director of Nursing.Prior to survey date of 9/19/25, the facility had taken the following actions to correct the non-compliance which include these education components : Quarterly Quality Assurance meeting on 8/22/25 with managers/department heads in attendance regarding follow-up from incident occurring on 8/9/25, failing to report fall with injury for R4; Resident Rounds in-service on 8/22/25, 8/23/25, 8/24/25, 8/25/25, 8/26/25 with all staff; Behavioral Health Services in-service for all staff regarding behavioral health services; Incidents and Accidents in-service on 8/22/25, 8/23/25, 8/24/25, 8/26/25, with all staff; Pain Assessment in-service on 8/22/25, 8/23/25, 8/24/25, 8/25/25, 8/26//25, for all staff; Baseline Care Plan in-service on 8/22/25, 8/23/25, 8/24/25, 8/25/25, 8/26/25 for all staff; Abuse Prevention and Reporting in-service on 8/22/25, 8/23/25, 8/24/25, 8/25/25, 8/26//25 for all staff; Fall Prevention Program in-service on 8/22/25, 8/23/25, 8/24/25, 8/25/25, 8/26//25, for all staff; Comprehensive Care Plans in-service on 8/22/25 for all nurses; and Incident Correction and IDT Completion Plan in-service on 8/22/25, for all nurses.

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

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure resident records were accurately documented and maintained for five residents (R12, R13, R14, R15, R16) of five residents reviewed for documentation in the sample list of 19.Findings include:The facility's Employee Disciplinary Form dated 7/22/25, documents V12 Certified Nursing Assistant (CNA), received a final warning regarding incomplete documentation. This report documents five residents (R12, R13, R14, R15, R16) were audited with 10 Activities of Daily Living (ADL) examples, totaling 40 occurrences of mis-documentation occurring in the past 30 days. This form documents R12 having 6 occurrences, R13 having 16 occurrences, R14 having 6 occurrences, R15 having 10 occurrences, and R16 having two occurrences of mis-documentation. On 9/17/25 at 10:13 AM, V1 Administrator, stated V12 CNA had been terminated on 9/15/25, due to false charting previously for documenting giving baths but did not do the baths.

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide multiple scheduled showers for dependent residents. This failure affected three of three residents (R6, R8, R9) reviewed for showers on the sample list of 19. Findings Include: Facilities Bathing - Shower and Tub Bath Policy dated January 2018 documents: Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub bath or bed/sponge bath will be offered according to resident's preference, two times per week or according to the resident's preferred frequency and as needed or requested. Staff are to document bathing task and assistance provided in the electronic record, including pertinent observations. 1. R6's Medical Diagnoses list dated September 2025 documents R6 is diagnosed with Unspecified Dementia, Generalized Anxiety, Parkinson's Disease, Insomnia, Pressure Ulcer of the Sacral Region, Overactive Bladder, Congestive Heart Failure, and Abnormalities of the Gait and Mobility. R6's Minimum Data Set (MDS) dated [DATE] documents R6 is Dependent on staff assistance for Shower/Bathing. R6's Shower/Bathe Task for the last 30 days documents R6 is scheduled to receive showers on Tuesday and Fridays from 6:00 PM - 6:00 AM. This same record documents R6 received a shower on 8/20/25, 8/23/25, 9/3/25, 9/6/25 and 9/17/25, there are no other documented showers, baths or refusals in R6's electronic medical record. 2. R8's Medical Diagnoses list dated September 2025 documents R8 is diagnosed with Chronic Kidney Disease Stage 3, Muscle Wasting and Atrophy, Sepsis, Gangrene and Diabetes Type II. R8's Minimum Data Set (MDS) dated [DATE] documents R8 requires partial/moderate assistance for Shower/Bathing. The facility's Shower List dated 8/1/25 documents R8 is supposed to have showers on Tuesday and Friday from 6:00 PM - 6:00 AM. R8's Shower/Bathe Task for the last 30 days documents R8 received a shower on 8/26/25, 9/2/25 and 9/12/25 and refused showers on 9/3/25 and 9/5/25. There are no other documented showers, baths or refusals in R8's electronic medical record. 3. R9's Medical Diagnoses list dated September 2025 documents R9 is diagnosed with Dementia, Delusional Disorder, Depression, Need for Assistance with Personal Care. R9's Minimum Data Set (MDS) dated [DATE] documents R9 requires partial/moderate assistance for Shower/Bathing. The facility's Shower List dated 8/1/25 documents R9 is supposed to have showers on Tuesday and Friday from 6:00 AM - 6:00 PM. R9's Shower/Bathe Task for the last 30 days documents R9 received a shower on 8/26/25 and 9/9/25 and refused showers on 8/22/25 and 9/12/25. There are no other documented showers, baths or refusals in R9's electronic medical record. On 9/18/25 at 2:30 PM V1 Administrator confirmed the facility provides two showers per week to residents and staff should document when showers are given or refused. On 9/18/25 at 2:45 PM V2 Director of Nurses confirmed the facility provides two showers per week for residents and staff should document the showers in the resident's electronic medical record under Task section under the bathing task. V2 confirmed staff should be documenting if a shower is given or refused and if refused staff should be notifying the nurse who should reapproach the resident and address any barriers.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete multiple wound dressing treatments and failed to address a residents repeated refusals for wound treatment. This failure affected one of three residents (R9) reviewed for wounds on the sample list of 19. Findings Include: The facility's Pressure Injury and Skin Condition assessment dated [DATE] documents the purpose of the policy is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown and assuring interventions are implemented. Dressing should be changed in accordance with physician orders and documented in the Treatment Administration Record (TAR). Physician ordered treatments shall be initialed by the staff on the electronic TAR after each administration. R9's Medical Diagnoses list dated September 2025 documents R9 is diagnosed with Dementia, Delusional Disorder, Depression, Need for Assistance with Personal Care, and Malignant Neoplasm of unspecified Site of Right Female Breast. R9's Physician Order Sheet dated September 2025 documents an order for a wound treatment to her Right Breast to be completed daily.R9's Care Plan dated 4/14/25 documents R9 has a cancer ulcer under her right breast and staff are to perform treatments per physician order. R9's September 2025 Treatment Administration Record (TAR) documents three wound treatments not completed and eight refused wound treatments between 9/1/25 and 9/17/25. R9's August 2025 Treatment Administration Record (TAR) documents five wound treatments not completed and three refused wound treatments.R9's July 2025 Treatment Administration Record (TAR) documents one wound treatment not completed and four refused wound treatments. On 9/18/25 at 2:45 PM, V2 Director of Nurses confirmed staff should be completing wound orders according to physician order. If they are not completed or if the resident has repeated refusals, the staff should notify the physician and document in the resident's electronic medical record.

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 F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a per day. This failure has the potential to affect all 104 residents in the facility. Findings Include: Facility Nursing Hall Assignment Sheets reviewed from 8/27/25 through 9/15/25 documented nine days (8/27, 8/28, 9/2, 9/3, 9/4, 9/9, 9/11, 9/13, 9/14) that the facility failed to use the services of a Registered Nurse for at least eight consecutive hours. On 9/18/25 at 2:30 PM V1 Administrator confirmed there were days with no RN staffing available. V1 also confirmed the facility's average daily census was around its current census of 104 residents. The Bed Management sheet dated 9/10/25 documents a current census of 104 residents.

Jun 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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide consistent quality care for five of eight residents (R1, R2, R5, R6, R7) reviewed for nursing care on the sample list of eight. Findings Include: The Facility assessment dated [DATE] documents all medical and non-medical supplies needed and ordered by the physician will be provided to the resident in a timely manner. If equipment is not in the facility, it will be ordered and provided, borrowed from a sister facility or rented to endure the needs of the residents are met. Staffing is adjusted based on resident census and acuity. Resident preferences and suggestions are elicited during resident council meetings and will be taken into consideration. Concerns will be addressed as appropriate and the need for additional staff will be considered to meet the needs of the residents in the facility. The facility's March 2025 Grievance Log and Resident Council Minutes document resident concerns with not getting scheduled showers. The summary of findings, documents showers were indeed not being completed due to use of agency staff not completing assigned tasks. The facility's April 2025 Grievance Log and Resident Council Minutes document resident concerns with call light response times, not enough staff on resident units, staff being on their phones while on the clock, ice water not being passed, staff being loud in the hallways at night, and scheduled showers not being provided. The summary of findings, documents showers were indeed not being completed due to increased use of agency staff who are not completing assigned tasks/cares. The facility's May 2025 Grievance Log and Resident Council Minutes document resident concerns with staff being on their phones while on the clock, ice water not being passed, staff being loud in the hallways at night, and two-hour checks not being done. 1. R1's Medical Diagnoses List dated June 2025 documents R1 is diagnosed with Hemiplegia and Hemiparesis post Stroke, Chronic Obstructive Pulmonary Disease, Muscle Atrophy, Dysphagia, and Reduced Mobility. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact and requires max assist for activities of daily living and is dependent on staff for transfers. R1 requires the use of a motorized wheelchair for mobility. On 5/27/25 at 12:30 PM V4 R1's Daughter stated on 5/17/25 R1 called her about 7:30 PM to tell her she could not find any staff to help her get ready for bed. V4 stated she came to the facility and assisted R1 to bed and then walked through the facility to find staff. V4 stated she walked through the entire facility two times and did not see any staff. V4 stated she finally found one male staff member (unknown) sleeping in a dark area at the end of one hall and then found another staff member, V3 Licensed Practical Nurse (LPN), who attempted to help her find others. V3 and V4 walked around the facility two more times without finding any other staff members. V4 stated she asked V3 LPN to call V2 Director of Nurses (DON) and let him know that staff were not available to meet the needs of the residents. V4 stated as she and V3 walked around the facility they observed many resident call lights on and some residents asleep in their wheelchairs in the common areas. V4 stated when she spoke with V2 DON the next day he told her they have had issues with some of the agency Certified Nursing Assistants (CNAs) they have had working in the building. On 5/27/25 at 2:35 PM V3 LPN confirmed that V4 approached her looking for staff on the night of 5/17/25. Both V3 and V4 searched the building twice and could not find anyone else. V3 confirmed V4 was very upset and worried that there was no one there to care for her mother (R1). V3 stated she reassured V4 that she would be calling V2 DON and letting him know about the situation. V3 stated after V4 left the building V3 found out that R1's assigned aide (unknown) had gone to lunch without telling V3. V3 stated she has had many issues with the agency staff who come to work at the facility. V3 stated the aides will tell charge nurses what they will and won't do and they often have attitudes and don't do the work they are supposed to be doing. V3 stated staff have just left for break and not come back or they don't show up for their shift at all. V3 stated she knows family members of residents see the decline in care and are upset about it and she is frustrated that she is unable to do anything about it. On 6/3/25 at 3:30 PM R1 stated she regularly has issues getting her call light answered in a timely manner. Staff will come in and turn off the call light and say they will be back but then never come back. R1 stated on 5/17/25 when she called her daughter, it was because she was unable to find anyone to help her get ready for bed. 2. R2's Medical Diagnoses List dated June 2025 documents R2 is diagnosed with Diabetes, Anxiety, Major Depression, Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, Irritable Bowl Syndrome, Repeated Falls, and Lack of Coordination. R2's Minimum Data Set, dated [DATE] documents R2 has a mild cognitive impairment and requires partial assist for activities of daily living and is independent for most transfers. R2 requires the use of a manual wheelchair for mobility. On 5/30/25 at 3:19 PM R2 stated she has issues getting her call light answered in a timely manner. R2 feels the facility needs more staff especially at night in order to provide better care for the residents. R2 stated she feels the quality of care she receives has gone down in the few months. 3. R5's Medical Diagnoses List dated June 2025 documents R5 is diagnosed with Diabetes, Down Syndrome, Depression, Congestive Heart Failure, Prosthetic Heart Valve, Long Term Anticoagulant Use, and Lack of Coordination. R5's Minimum Data Set, dated documents R5 is 5/1/25 documents R5 is cognitively intact and requires supervision or touching assist for most activities of daily living and transfers. R5 requires the use of a manual wheelchair for mobility. R5's Progress Note dated 5/21/25 documents R5's PT/INR (Prothrombin Time/International Normalized Ratio) results and a physician order to take ten milligrams of Coumadin and recheck PT/INR the following Monday (5/26/25). R5's Progress Note dated 5/29/25 documents R5's PT/INR lab work would be taken on 5/30/25 by outside laboratory. R5's Progress Note dated 5/30/25 documents R5's PT/INR lab work was completed and resulted with a PT of 27.3 and INR of 3.9. Orders were received to hold R5's Coumadin dose for two days and recheck PT/INR on 6/1/25. On 6/3/25 at 3:20 PM R5 stated the facility could use more staff especially at night and the staff often take a long time to answer call lights. Sometimes she waits longer than 30 minutes. R5 confirmed she takes a blood thinner and get blood work done regularly due to her blood thinning medication. R5 confirmed her blood work was delayed last week. 4. R6's Medical Diagnoses List dated June 2025 documents R6 is diagnosed with Congestive Heart Failure, Anxiety, Diabetes, Lack of Coordination, and Atrial Fibrillation. R6's Minimum Data Set, dated [DATE] documents R6 is cognitively intact and requires partial or moderate assist for most activities of daily living and supervision or touching assist for transfers. R6 requires the use of a manual wheelchair for mobility. R6's Progress Note dated 5/21/25 documents R6's PT/INR (Prothrombin Time/International Normalized Ratio) results and a physician order to hold R6's Coumadin dose for one night and recheck PT/INR in one week (5/28/25). R6's Progress Note dated 5/29/25 documents R6's PT/INR lab work would be taken on 5/30/25 by outside laboratory. R6's Progress Note dated 5/30/25 documents R6's PT/INR lab work was completed and resulted with a critical INR of 5.82. Orders were received to hold R6's Coumadin dose, give five milligrams of Vitamin K, and recheck PT/INR on 5/31/25. On 6/3/25 at 3:23 PM R6 stated the facility could use more staff especially at night and the staff often take a long time to answer call lights. Sometimes she waits longer than 30 minutes. R6 stated the week prior (5/28/25) she was told her blood work couldn't be done on time because the facility did not have the testing strips they needed. R6 stated she had to wait two extra days (5/30/25) for the blood test. 5. R7's Medical Diagnoses List dated June 2025 documents R7 is diagnosed with Diabetes, Vascular Dementia, Anxiety, Insomnia, Dysphagia, Difficulty Walking, and Communication Deficit. R7's Minimum Data Set, dated [DATE] documents R7 is cognitively intact and requires moderate or maximal assist for most activities of daily living transfers. R6 requires the use of a manual wheelchair for mobility. On 5/30/25 at 2:50 PM R7 stated the facility could use more staff and she often waits a long time for her call light to be answered. R7 feels the quality of care has gone down. On 5/30/25 at 4:15 PM V2 Director of Nurses confirmed the facility has had to use more agency staff, especially CNAs. V3 confirmed they have had issues with the bad attitudes of agency staff and because they can just go work anywhere it is hard to keep those staff accountable for their actions or lack of actions. V2 acknowledged that this creates a risk for poor quality of resident care. On 6/3/25 at 10:30 AM V7 Registered Nurse stated she has seen an issue with long call light wait times and believes staffing is an issue not because they are short staffed but because the agency staff they have on the schedule usually aren't the best workers and don't do their jobs well. On 6/3/25 at 3:56 PM V2 DON confirmed the facility did not have the PT/INR testing strips they needed to complete physician ordered PT/INR tests. V2 confirmed the staff delayed the tests which were completed 2-3 days after originally ordered. V2 confirmed R6's lab result came back a critical result on 5/30/25. V2 confirmed the facility still does not have the Pt/INR test strips in house but instead are now drawing resident's blood and sending it to the lab in order to complete the PT/INR tests timely. V2 also confirmed the facility has had complaints in Resident Council, with Grievances, and from residents and families concerning ice water not being passed, call lights not answered timely, showers not being done per schedule, and two-hour checks not being completed. V2 confirmed they have had some issues with the quality of work from the agency CNAs that have picked up shifts with the facility.

May 2025 5 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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the dignity of one (R1) of three residents reviewed for dignity from a total sample list of seven residents. Findings include: The facility provided Dignity Policy dated 4/23/18 documents that the facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and a respect in full recognition of his or her individuality. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. R1's undated diagnosis sheet documents R1's diagnoses include: Epilepsy, Primary Hypertension, and Venous Thrombosis with Embolism. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. On 4/30/25 at 11:33AM, R1 stated there have been several times when she doesn't receive her medications and that it is usually from an agency nurse who she doesn't know. R1's physician order dated 2/3/25 documents Keppra (anti-seizure) 1000 milligram (MG), twice daily. R1's physician order dated 2/18/25 documents Oxcarbazepine ((anti-seizure) 150MG, twice daily. On 4/30/25 at 11:33AM, R1 stated, Sunday evening I am supposed to get my medicines between 4-8. I didn't get them until 1:00AM. When I asked the nurse about getting my seizure medications, she said, Well, I guess you will just have to have a seizure. On 5/5/25 at 1:20PM, V14 Licensed Practical Nurse (LPN) stated that she was incredibly overwhelmed that Sunday night and that she had been told in report that R1 had asked for her medications all day. I was very curt to R1 because I was overwhelmed and was trying not to make a medication error. Her medications were late. On 5/5/25 at 1:00PM, V2 Director of Nursing stated that he expected staff to treat residents professionally at all times and that it was unacceptable and rather harsh to tell someone that they would just have to go ahead and have a seizure. On 5/5/25 at 12:45PM, R1 stated that when (V14 LPN) told her that she would just have to have a seizure because she hadn't had her medications, I thought it was very disrespectful and unprofessional and it made me feel uncared for and undignified.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer medications according to physician orders for two of three residents (R1, R2) reviewed for medication administration in the sample list of seven. Findings include 1.) The facility provided Medication Preparation and General Guidelines Policy dated December 2019 documents that it is the policy of the facility to administer medications as prescribed. Medications are administered within 60 minutes of scheduled times. Current medications are listed on the Medication Administration Record (MAR) and the MAR is initialed by the person administering the medication, in the space provided under the date. If a scheduled medication is not given, an explanation is documented. R1's April/May 2025 medication administration record documents orders for Amiloride (potassium sparing medication) 10 Milligrams (MG) daily, Celexa (antidepressant) 20 MG daily, Cranberry tablets (urinary health) 400MG daily, Fiber-Lax (constipation preventative) 625MG daily, and Famotidine (acid reducer) 20 MG twice daily. R1's April medication administration record documents the following medications were not administered as ordered on the following dates: Amiloride 5MG on 4/22/25, Celexa on 4/22/25, Cranberry 400MG on 4/22/25 & 4/23/25, Fiber-Lax 625MG on 4/22/25, 4/28/25 and 4/29/25, Famotidine 20MG 4/22/25 AM, 4/23/25 AM and PM, and 4/26/25 AM. R1's Minimum Data Set, dated [DATE] documents R1 as cognitively intact. On 4/30/25 at 11:33AM, R1 stated that there have been several times when she hasn't received her medications, usually in the evening and usually from an agency nurse with whom she is not familiar. 2.) R2's April/May 2025 medication administration record documents orders for Aspirin 81MG, 75MG, CoQ-10 (enzyme) 100MG, Daily Multivitamin, Fenofibrate (decreases cholesterol) 160MG, 100MG daily, Miralax (constipation preventative) 17 Grams, Myrbetriq (bladder activity) 25 MG daily and Rosuvastatin (decreases cholesterol) 40MG all daily. R2's April/May 2025 medication administration record documents the following medications were not administered as ordered on the following dates: Aspirin 81MG on 4/25/25 and 5/4/25 daily, CoQ10 on 4/25/25 and 5/4/25 daily, Multivitamin on 4/25/25 and 5/4/25 daily, Fenofibrate 160MG on 4/25/25 and 5/4/25 daily, Rosuvastatin 40MG on 4/24/25 daily, Myrbetriq 25MG on 4/25/25 and 5/4/25 daily. On 4/30/25 at 12:00PM, V2 Director of Nursing stated that he did not know why R1 and R2's medications were not given as ordered. On 5/5/25 at 11:36AM, V2 Director of Nursing stated that he would expect medications to be given as ordered, if they weren't documented, they weren't given, and the failure to give medications as ordered can be harmful to a resident.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) The facility's Resident Council Meeting Minutes dated 4/9/25 document a new concern regarding if there are enough linens and an ongoing concern regarding the use of wipes. R7's Minimum Data Set, dated [DATE] documents R7 is cognitively intact. On 5/5/25 at 10:14 AM R7 stated the facility has run out of washcloths since the facility stopped using incontinence wipes, and currently R7's hallway (100 hall) does not have any washcloths. On 5/5/25 at 10:28 AM V11 Certified Nursing Assistant (CNA) stated since the change in ownership the facility no longer provides wipes, and they have run out of washcloths for the last two to three weeks. V11 stated V11 thinks staff are throwing the wash clothes away instead of using the hopper to rinse prior to laundering. V11 stated this has been an ongoing issue that has been brought to laundry's attention. V11 stated V11 does not currently have any washcloths on the 100 hallway and V11 uses bath towels when washcloths are unavailable. The linen carts on the 100 hall/shower room and clean linen closet were viewed with V11, and V11 confirmed these carts/rooms did not contain a supply of washcloths. On 5/5/25 at 10:34 AM V10 CNA stated V10 only had a few wash clothes this morning on the 200 hallway, and the supply was used up. The clean linen room on the 200 hall was viewed with V10, who confirmed there was no supply of washcloths. On 5/5/25 at 10:36 AM V12 CNA stated there are frequently not enough washcloths for resident use. There were four washcloths on the 300 hall, confirmed with V12. On 5/5/25 at 10:37 AM The laundry room was viewed with V9 Laundry Aide. There were no washcloths readily available in the laundry room. V9 stated there have been times that the CNAs come to laundry because they have run out of washcloths, and the CNAs get upset when they don't have any washcloths to give them. V9 stated there are washcloths currently in the washer, but none readily available at this time. On 5/5/25 at 10:42 AM the clean linen carts on the 400 hall were viewed with V13 CNA, who confirmed there were seven washcloths. V13 stated the facility frequently runs out of washcloths since changing from wipes to washcloths. Based on observation, interview, and record review the facility failed to have linens and incontinence briefs for three of seven residents (R5, R6, R7) reviewed for resident preferences from a total sample list of seven residents. Findings include: 1.) On 5/5/25 at 9:37 AM R5 stated the facility ran out of her size briefs the weekend of April 26-27, 2025. R5 stated that they gave her a smaller size to use which was uncomfortable. R5's Minimum Data Set, dated [DATE] documents R5 is cognitively intact. On 5/5/25 at 9:40 AM R6 stated about a week or so ago they ran out of several sizes of briefs. They gave her a smaller size and she wasn't able to fasten them. R6's Minimum Data Set, dated [DATE] documents R6 is moderately cognitively intact. The facility provided purchase order dated 4/25/25 documents a rush order submitted at 9:20AM for extra large briefs, large briefs, ultra size briefs, and medium size briefs. On 4/30/25 at 9:35AM V4 Certified Nursing Assistant (CNA) stated that she worked on Friday (4/25/25) and she knew they ran out of briefs from Saturday until Sunday. On 4/30/25 at 1:00PM, V7 CNA stated, I worked this weekend and we ran out of bariatric briefs, double extra large and extra large briefs. On 4/30/25 at 10:00AM, V2 Director of Nursing ( DON) stated that he knew that they were low on brief supplies, but he didn't know that they had run out. On Friday 4/25/25, (V2) tried to use the corporate credit card but that it had a negative balance so he could not go to (store name) or anywhere else for the supplies. The DON stated that he was ordering the supplies because the regular supply person was off. V1 Administrator confirmed that they had tried to use the credit card unsuccessfully and that they worked together to try to get a rush order to go through because the big order could not be approved. When asked if there was a system or mechanism for obtaining supplies in a situation such as this, V1 Administrator stated that a system needed to be developed for supply management.

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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 provide ordered dressing changes and failed to accurately document worsening pressure wound staging for three (R2, R3, and R4) of four residents reviewed for pressure wounds from a total sample list of seven residents. Findings include: The facility provided Pressure Injury and Skin Condition assessment dated [DATE] documents the facility policy is to assess, monitor, and document the presence of skin breakdown, pressure injuries, and other ulcers and to insure that interventions are implemented. Pressure and other ulcers will be assessed and measured at least every seven days and documented in the resident's clinical record. Physician ordered treatments shall be initialed by the staff on the treatment administration record after each administration. 1.) R4's wound report dated 2/1/25-4/30/25 documents R4 has a facility acquired skin tear on the right outer ankle, identified on 4/10/25. On 4/30/25 at 1:20PM, V3 Wound Nurse stated that the wound began as a skin tear and that is how it is being treated. R4's physician wound evaluation and treatment dated 4/17/25 documents that after debridement, R4's wound was documented as a stage three wound. R4's physician order dated 4/16/25 documents to cleanse the right ankle and above the ankle with wound wash, cover with a single layer of Xeroform, apply an abdominal dressing and secure it daily. R4's treatment administration record dated 4/22/25 documents the dressing change was not completed. On 4/30/25 at 1:15PM, V3 Wound Nurse performed R4's wound dressing on her right ankle. The wound is the size of a dime and oval in shape. No slough or infection is noted. On 5/5/25 at 1:15PM, V3 Wound Nurse stated that she did not realize that V8 Wound Physician had identified R4's wound as a stage three wound and that changes would be made to ensure that she was aware of the development and plan for wounds based on the wound physician's rounds. 2.) R2's wound report dated 1/30/25-4/30/25 documents R2 was admitted to the facility on [DATE] with a right heel pressure wound. R2's physician order dated 4/16/25 documents the treatment for the right medial heel includes cleaning the area with wound wash, applying a thick coat of Santyl, apply Dakin soaked gauze, cover with a gauze dressing, wrap with gauze wrap and then securing, daily. R2's April 2025 treatment administration record documents that the dressing was not completed on 4/25/25, 4/26/25 and 4/27/25. 3) R3's March physician order dated 2/28/25-3/7/25 documents an order to cleanse the left hip with normal saline, pack loosely with Iodoform gauze and cover with an abdominal pad twice daily. R3's March physician order dated 3/7/25-3/28/25 documents an order to cleanse the left hip with normal saline and then pack with one single long strand of gauze, covering with an abdominal pad twice daily. R3's March 2025 treatment administration record dated: 3/2/25 PM, 3/17/25 PM, 3/18/25 PM, 3/19/25PM, 3/20/25PM, 3/21/25PM, 3/23/25PM, 3/24/25PM, 3/25/25PM and 3/26/25 PM document that R2 did not receive her evening (PM) wound dressing change. On 4/30/25 at 1:30PM, V3 Wound Nurse stated that if a dressing change isn't documented, it wasn't done.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer medications as ordered resulting in repeated significant medication errors for two (R1, R2) of three residents reviewed for significant medication errors from a total sample list of seven. Findings include: The facility provided Medication Preparation and General Guidelines Policy dated December 2019 documents that it is the policy of the facility to administer medications as prescribed. Medications are administered within 60 minutes of scheduled times. Current medications are listed on the Medication Administration Record (MAR) and the MAR is initialed by the person administering the medication, in the space provided under the date. If a scheduled medication is not given, an explanation is documented. R1's undated diagnosis sheet documents R1's diagnoses include: Epilepsy, Primary Hypertension, and Venous Thrombosis with Embolism. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. On 4/30/25 at 11:33AM, R1 stated there have been several times when she doesn't receive her medications and that it is usually from an agency nurse who she doesn't know. R1's physician order dated 2/3/25 documents Keppra (anti-seizure) 1000 milligram (MG), twice daily. R1's physician order dated 2/18/25 documents Oxcarbazepine (anti-seizure) 150MG, twice daily. R1's physician order dated 11/28/24 documents Chlorthalidone (diuretic) 12.5MG daily. R1's physician order dated 3/29/24 documents Eliquis (platelet inhibitor) 5MG twice daily. R1's physician order dated 4/17/25 documents Amlodipine (blood pressure) 5MG daily. R1's April/May 2025 medication administration record documents that Keppra 1000MG was not given on 4/22/25 for the AM dose and on 4/23/25 for the PM dose. Chlorthalidone 25MG was not given on 4/22/25 or 4/26/28 daily doses. Eliquis 5MG was not given on 4/22/25 AM dose, 4/23/25 AM dose and 4/23/25 PM dose. Amlodipine 5MG was not given on 4/19/21 and 4/21/25 daily doses. R2's undated diagnosis sheet documents the following diagnoses include: Diabetes, Ocular Hypertension, Primary Hypertension, Peripheral Vascular Disease, and Heart Disease. R2's April/May 2025 medication administration record documents physician orders for Clopidogrel (antiplatelet) 75MG, Glimepiride (anti-diabetic) 1MG, Hydrochlorothiazide (blood pressure) 12.5MG, Lisinopril (blood pressure) 20MG, Metoprolol Succinate (blood pressure) 100MG daily, Metformin Extended Release (anti-diabetic) 750 MG twice daily, Cephalexin (antibiotic) 500 MG three times daily, and Pregabaline (anti-seizure) 25MG daily. R2's April/May 2025 medication administration record documents the following medications were not administered as ordered on the following dates: Clopidogrel 75MG on 4/25/25 and 5/4/25 daily, Glimepiride 1MG on 4/25/25 and 5/4/25 daily, Hydrochlorothiazide 12.5MG on 4/25/25 and 5/4/25 daily, Pregabaline 25MG on 4/23/25 daily, Lisinopril 20MG on 4/25/25, 5/4/25 daily, Metoprolol Succinate 100MG on 4/25/25 and 5/4/25 daily, Metformin 750MG on 4/25/25 and 5/4/25 both the AM doses, and Cephalexin 500MG on 4/19/25 at the 4:00PM dose. On 4/30/25 at 12:00PM, V2 Director of Nursing stated that he did not know why R1 and R2's medications were not given as ordered. On 5/5/25 at 11:36AM, V2 Director of Nursing stated that he would expect medications to be given as ordered and the failure to do so can be harmful to a resident.

Feb 2025 1 deficiency

MINOR (C) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Deficiency F0680 (Tag F0680)

Minor procedural issue · This affected most or all residents

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to provide the services of a clinically qualified Director of Activities. This failure has the potential to affect all 77 residents residing in the facility. Findings include: On 02/18/25 at 10:52 AM V5 states V5 is the Director of Activities and is required to manage all aspects of the activity department. This includes completing and implementing the facility activity calendar as well as scheduling staff. V5 states V5 is not certified and must enroll to begin the certification course. V5 states V5 is unsure when that will occur. On 02/18/25 at 11:00 AM V5, Activity Director, was actively managing activity personnel and directing the activity staff and coordination of the activities. On 02/19/25 at 10:58 AM V1 states V5 is the Activity Director and is not certified. The resident census report indicates 77 residents reside in the facility.

Jan 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 F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

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 provide and implement activities to meet the interests and needs of the residents. This failure affects five (R1, R2, R3, R4, and R5) of five residents reviewed for activities on the sample list of five. Findings Include: On 1/28/25 intermittent observations were done between 10:05am and 2:20pm. R1 through R5 were observed between 10:05am and 10:20am sitting at tables in the dining/activity area participating in various activities (reading, puzzles, coloring, and folding). At 2:15pm, R2, R3, and R5 were observed sitting at the same tables they had been observed at 10:05am and 12:26pm in the dining/activity area with their empty lunch dishes still on the table. Residents were not observed in any group activities during these observations and no other individual activities observed while on the unit. There is no documentation in the Memory Care Unit Activity Binder for R1, R2, R3, R4, or R5 for the month of January 2025. This binder contains a resident specific Enrichment Information Sheet Memory Lane-Fitness for the Mind: which lists goals, key interests, focus of programming and participation barriers. This binder also contains Daily Enrichment Program Documentation Form containing Activities List and Participation Level. This form is for staff to document what activities each individual resident participated in daily. There is no activity calendar posted or available on the unit. 1. R1's Face Sheet documents R1 has diagnoses including Dementia and Anxiety. R1's Comprehensive assessment dated [DATE] documents R1 is moderately cognitively impaired. Further documents the following related to activities: How important is it to you to do your favorite activities-Very Important. This same record documents the following as activities as very important/important to R1: do your favorite activities; get outside to fresh air when the weather is good; participate in religious services or practices; having books, newspapers, and magazines to read; and listen to music you like. R1's Care Plan dated 1/22/24 documents the following: R1 has recently been admitted to the Memory Lane Fitness for the Mind Program. R1 will participate in three group activities daily. Encourage R1 to attend participation in exercise group, trivia, church services and outdoor activities when weather permits. R1's Progress Notes dated 1/13/25, 1/14/25 and 1/23/25 documents R1 having behaviors towards R4 (R1's spouse). R1's Progress Notes dated 1/24/25 documents R1 wandering around the unit. A Grievance Report dated 1/15/25 and signed by V7 Social Services Director (SSD) documents the following: R1's family concerns related to Certified Nursing Assistant (CNA) activity routine brought up during care plan meeting. Findings/Conclusions: Identify specific activities for programming for residents in department. Staff not following through with activity planning. The facility substantiated the grievance. Corrective action: educate Memory Care staff. On 1/28/25 at 2:20pm, V8 R1 and R4's Representative stated V8 brought up concerns regarding lack of mental stimulation, an activity calendar, and activities being routinely provided. V8 stated V8 was advised by V7 SSD that these activities were not being done. V8 stated R1 is having frequent behaviors due to not being mentally stimulated. 2. R2's Face Sheet documents R2 has diagnoses including Dementia and Cognitive Communication Deficit. R2's Quarterly assessment dated [DATE] documents R2 is severely cognitively impaired and no activity preferences noted. R2's Care Plan dated 12/19/24 documents the following: R1 has been admitted to the Memory Lane Fitness for the Mind Program. R2 will actively participate in four enrichment programs daily. R2 enjoys reading, word searches, arts and crafts, cooking, watching movies and listening to music, current events, social groups, and table games. 3. R3's Face Sheet documents R3 has diagnoses including Dementia with behavioral disturbances and Anxiety. R3's Comprehensive assessment dated [DATE] documents R3 is severely cognitively impaired. Further documents the following related to activities: How important is it to you to do your favorite activities-Very Important. This same record documents the following as activities as very important/important to R3: having books, newspapers, and magazines to read; listen to music you like; be around animals/pets; go outside to get fresh air when the weather is good; do things with groups of people and participate in religious services or practices. R3's Care Plan dated 1/16/25 documents the following: R3 has recently been admitted to the Memory Lane Fitness for the Mind Program. R3 will actively participate in four enrichment programs daily. R3 enjoys activities such as reading and word/number games. Encourage R3 to participate in small group activities. Encourage participation in Mindful Moments programing, focusing on wiping tables, folding, doing dishes. 4. R4's Face Sheet documents R4 has diagnoses including Dementia and Anxiety. R4's Comprehensive assessment dated [DATE] documents R4 is moderately cognitively impaired. Further documents the following related to activities: How important is it to you to do your favorite activities-Important. This same record documents the following activities as very important/important to R4: go outside to get fresh air when the weather is good; participate in religious services or practices; having books, newspapers, and magazines to read and listen to music you like. On 1/28/25 at 2:33pm, R4 stated, not much to do down here. 5. R5's Face Sheet documents R5 has the following diagnoses including Dementia with agitation. R5's Quarterly assessment dated [DATE] documents R5 is severely cognitively impaired and no activity preferences noted. R5's Care Plan dated 11/7/24 documents the following: R5 has recently been admitted to the Memory Lane Fitness for the Mind Program. R5 will actively participate in four enrichment programs daily. Encourage R5 to attend and participate in exercise activities, group physical activities, church services, outdoor activities, bible study, and group activities. Encourage participation in Mindful Moments programming focusing on bingo, cooking club, sewing, and card games. On 1/28/25 at 12:15pm, V1 stated the Memory Care Unit is an activities based unit and at a certain census point the activity aide is utilized in the rest of the facility. V1 stated this is due to the fact that the Memory Care Specialists (CNA's) work a dual role down on that unit and are able to provide those activities to the residents. V1 stated the activity aides are all CNA's also. On 1/28/25 at 12:44pm, V4 Memory Care Specialist (MCS) stated the Memory Care Unit has not had a dedicated activity person since sometime in December. V4 stated staff set residents up to do various activities but we are unable to do bingo or many group activities due to staffing/acuity. V4 stated the activity person filled the resident daily activity sheets out in the binder. V4 stated, we don't have time to do it plus our regular resident cares duties also and I'm not charting if I didn't do it. V4 stated based on resident acuity and staff breaks, this leaves one staff member to attempt to run group activities and provide individual activities on the unit while doing all their usual CNA duties. On 1/28/25 at 12:50pm, V5 Memory Care Specialist stated there are only two of them (MCS) and a nurse on the unit during a shift for 19 residents. V5 stated at least three residents are always two staff assist and another four residents are two staff assist depending on their mood/behaviors on any particular day. On 1/28/24 at 3:20pm, V10 Regional Administrator stated staff on that unit (Memory Care) should be doing group activities, providing individual activities, and documenting those activities. On 1/28/24 at 3:28pm, V9 Enrichment Specialist stated V9 was hired to do activities on the Memory Care unit. V9 stated the unit is an activities based unit and the activities are based on the needs of the residents. V9 stated V9 would find activities to fit their needs such as morning workouts, weather, news, and crafts. V9 stated V9 was moved off of the Memory Care unit before Christmas and moved to main activities department of the facility. V9 stated there are six activity aides in the main facility currently and none on an activity based unit. V9 stated V9 completed the activity binder for the residents on the Memory Care unit when V9 was working on the unit. V9 stated V9 is not a CNA.

Dec 2024 20 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to complete a thorough investigation and implement/develop post fall interventions for three of three residents (R26, R16, R15) reviewed for falls in the sample list of 43. These failures resulted in R26 sustaining a fall requiring sutures and/or staples. Findings Include: 1.) R26's electronic Progress Notes documents the following: 9/8/24 at 5:56 AM, R26 had an unwitnessed fall in his room and was found on the floor with a laceration above the left eye. R26 was sent to emergency room where they glued the laceration and applied adhesive strips to the laceration. 9/18/24 at 7:15 PM, R26 had an unwitnessed fall in his room and was found on the floor laying on his left side. This note by V26 Licensed Practical Nurse documents R26 stated he hit his head and had complaints of left shoulder and hip pain. R26 was sent to emergency room for evaluation and returned with bruising above the left eye and a skin tear above the right eye. 10/13/24 at 3:01 PM, documents R26 was found lying on the floor next to his wheelchair. R26 had a laceration to the top of his head measuring five centimeters in length and was sent to the hospital for evaluation. Progress Note on 10/13/24 at 8:26 PM, document R26 returned to facility with seven sutures and five staples to his forehead. R26's current care plan last revised on 9/17/2024 does not contain any new fall interventions for R26's falls on 9/18/24 or 10/13/24. On 12/4/24 at 1:59 PM, V2 Director of Nursing stated the floor nurse updates care plans after a fall with fall interventions and V2 audits care plans to ensure the interventions are there. V2 confirms no fall interventions were initiated after R26's falls on 9/18/24 and 10/13/24. 3.) On 12/2/24 at 10:00 AM, R15 states he had a fall with aide involvement mid-September causing refracture to R15's left femur head at surgical site. R15 states he was impatient waiting for help with transferring and the aide and himself tumbled about 1 week prior to his surgery. R15 states he returned to hospital on 9/23/24 but surgery was delayed 2 days related to facility not holding blood thinner as ordered, then R15 found to have UTI delaying surgery longer. R15 progress note dated 8/15/2024 at 09:08 PM documents R15 self-propelled into room and placed call light on. R15 was notified that the CNA (certified nurse assistant) was with another patient, and it wouldn't be long. R15 heard resident yelling for help. R15 was found kneeling with upper torso on bed, in a praying type of position. MD (medical doctor) and POA (power of attorney) notified. R15's fall assessment dated [DATE] documents R15 care plan was reviewed, and all fall interventions were in place, but does not document new interventions post fall. R15's medical record does not document post fall assessments, fall risk assessments, neurological assessments, or frequent vital signs. R15's hospital records dated 9/23/24 document R15's orthopedic surgeon's physical as follows [AGE] year-old male who is non-ambulatory who had a [NAME]-cervical neck fracture and was doing well post-operatively until an aide fell on top of him. Since that time, he reports increased pain in the operative hip area and severe at times with transfers. He is non-ambulatory baseline. He is seen in the pre-op holding area this morning and his surgery has been canceled due to ongoing UTI along with his Eliquis being continued until Saturday. Past surgical history that includes Hip Fracture Surgery (Left, 6/13/2024). R15's hospital records dated 9/25/24 documents physician notes as follows: recent history of left femoral neck fracture status post closed reduction of intramedullary fixation of the left hip 06/13/2024. Complicated by traumatic displacement of the intramedullary nail. Hip x-ray from 09/20/2024 showed interval loosening/osseous fracture around the femoral head screw with inferior displacement of the femoral head. On 12/03/24 at 1:30 PM V6 RN states that R15 had to have revision surgery from hardware malfunction due to wrong hardware originally placed in R15 hip. Denies any incident where resident and staff member fell prior to revision. V6 does confirm R15 had a fall on 8/15/24 because R15 is impulse and inpatient. Facility failed to provide an investigation from 8/15/24 fall, on 12/3/24 at 2:15PM, V1 administrator, offered a nursing progress note dated 8/15/24. V1 denies knowledge of fall after 8/15/24 for R15 that included staff. 2.) R16's Continuity of Care Document printed 12/5/24 includes the following diagnoses: Difficulty Walking, Unsteadiness on Feet, Muscle Wasting/Atrophy. R16's Progress Note dated 11/22/2024 at 10:00AM documents (R16) observed in supine position on floor in hallway. (R16) reports that she lost her balance and fell forwards onto her right knee before positioning herself back onto her buttocks, then to supine position. (R16) denies hitting her head. Neurological signs Within Normal Limits. Range of Motion Within Normal Limits. x3 staff assist and full mechanical lift used to assist resident into bed. Resident voices complaints of pain to Right knee. 5cm x 2cm (centimeter laceration noted to right knee related to fall. Laceration cleansed and pressure applied. Resident sent to (hospital) related to right knee laceration. R16's Progress Note dated 11/22/2024 at 1:20PM documents (R16) returned to facility at this time via Emergency Medical Services transport. Seven intact sutures noted to Right knee. Band-Aid noted to L arm r/t (related to) tdap (tetanus) injection. (R16) denies pain. New orders received for Keflex 500 mg (milligrams) BID (twice a day) x 10 days. New order received for Nurse to remove seven sutures in 10-14 days. R16's Care Plan updated 11/1/24 does not document any new interventions to address the 11/22/24 fall with injury. The facility did not provide documentation a thorough fall investigation was completed nor a root cause of the fall was identified for R16's fall on 11/22/24. On 12/4/24 at 2:15 PM, V2 Director of Nursing stated the floor nurse updates care plans after a fall with fall interventions and V2 audits care plans to ensure the interventions are there. V2 confirms no new fall interventions were initiated after R16's fall on 11/22/24. On 12/4 24 at 2:30PM V1, Administrator confirmed that a root cause analysis was not completed following (R16's) fall 11/22/24.

CONCERN (D)

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

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review the facility failed to submit the Minimum Data Set (MDS ) in a timely manner for one resident (R74) of 18 residents reviewed for MDS in a sample list of 43. Findings Include: The facility's Final Validation Report printed 12/4/24 at 8:52AM documents R74's MDS target Date 5/2/24 Care Plan Late. Care Areas Assessment (CAA) is more than 13 days after entry date. R74's MDS target Date 7/24/24 Assessment completed Late. Care Areas Assessment (CAA) is more than 14 days after assessment reference date. On 12/04/24 at 8:56 AM V16 Care Plan Coordinator and V17, Corporate Care Plan Consultant verified Assessment/Care Plan for R74 dated 5/2/24 and 7/24/24 were late. The facility's Care Plan Policy revised 11/28/19 states The comprehensive Care Plan will be developed within seven days after the completion of the comprehensive MDS assessment as outlined in the resident assessment (RAI) guidelines.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete resident comprehensive assessments. This failure affects one resident (R14) of 3 residents reviewed for accuracy of assessments on the sample list of 43. Findings include: R14's Minimum Data Set (MDS) dated [DATE] Section N0415 documents R14 as taking an anticoagulant. R14's Clinical Physician Orders do not document an order for an anticoagulant in the medical record. On 12/3/24 at 2:15 PM V16 stated R14 was not on an anticoagulant and the MDS was coded wrongly. V16 stated V16 would need to modify and submit a correct MDS.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview, and record review, the facility failed to refer residents with newly diagnosed serious mental disorders for a level II PASARR (Pre-admission Screening and Resident Review) resident review upon a significant change in status assessment for two of two residents (R6, R14) reviewed for level II screening in the sample list of 43. Findings include: R6's Continuity of Care Document dated 12/04/2024 at 12:59 PM documents an admission date of 08/03/2020. R6's Interagency Certification of Screening Results dated 8/13/2020 does not document there is a reasonable basis to suspect a mental illness for R6. R6's Continuity of Care Document dated 12/04/2024 at 12:59 PM documents a diagnosis of Unspecified psychosis not due to a substance or known physiological condition was added for R6 on 04/04/2024. R6's Continuity of Care Document dated 12/04/2024 at 12:59 PM documents a physician order for the antipsychotic medication Seroquel (quetiapine) 25 mg tablet at bedtime. R14's Continuity of Care Document dated 12/04/2024 at 1:00 PM documents an admission date of 05/27/2020. R14's Interagency Certification of Screening Results dated 5/13/2020 does not document there is a reasonable basis to suspect a mental illness for R14. R14's Clinical Physician Order dated 09/15/2022 at 04:36 PM documents a diagnosis of Paranoid schizophrenia. R14's Clinical Physician Order dated 09/15/2022 at 04:36 PM documents a physician order for the antipsychotic medication Seroquel (quetiapine) tablet; 100 mg; twice daily. On 12/3/24 at 11:27 AM V2 Director of Nurses stated any resident with a mental illness should have a level II screening. On 12/3/24 at 12:45 PM V1 Administrator stated the social service director is responsible for screenings. V1 stated the two residents (R6, R14) do not have a level II screening in the medical record.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

3.) R26's electronic medical chart documents R26 sustained unwitnessed falls with injury on 9/8/24, 9/18/24, and 10/13/24. R26's Progress Notes dated 9/8/24 at 5:56 AM, document R26 was found on the floor in R26's room bleeding from a laceration above the left eyebrow and bruising to the left eye. The Notes document R26 stated he dropped his toothbrush in the bathroom and was attempting to pick it up when he fell forward in the wheelchair and hit his head on the floor. The Notes document R26 was sent to the local emergency room where glue and adhesive strips were applied to a laceration above the left eye. R26's Progress Notes dated 9/18/24 at 7:15 PM, document R26 yelled for help and was found on the floor laying on his left side in between the recliner and the nightstand. The Notes document R26 stated he hit his head and R26 was sent to the local emergency room with left shoulder pain. R26's Progress Notes dated 10/13/24 at 3:25 PM, document R26 was found in his room lying beside R26's wheelchair with the wheelchair cushion on the ground. The Notes document R26 stated I don't know what happened. The Notes document R26 had one laceration on the top of his head measuring five centimeters in length, one laceration to the forehead measuring five centimeters in length, and a laceration to the right pinky finger measuring 0.5 centimeters in length. The Notes document R26 was sent to the local emergency room where five staples and seven sutures were applied to the lacerations on R26's head. R26's current care plan last revised on 9/17/2024 does not contain any fall interventions for R26's falls on 9/8/24, 9/18/24, and 10/13/24. On 12/04/24 at 09:52 AM, V20 Family Member stated R26 has had several falls. V20 stated it seems like R26 has fallen a lot and the staff say R26 is usually picking stuff up off the floor. V20 further stated V20 has been to care plan meetings at the facility but the facility has never discussed R26's falls or what they were going to do to prevent falls. On 12/4/24 at 1:59 PM, V2 Director of Nursing stated the floor nurse updates care plans after a fall with fall interventions and V2 audits care plans to ensure the interventions are there. V2 confirmed no fall interventions were initiated after R26's falls. 2.) On 12/3/24 at 11:04 AM, R15 stated he fell mid-September after he fell in August, causing refracture to R15's left femur head at the surgical site. R15 stated he returned to the hospital on 9/23/24 for left hip revision (surgery). R15 stated he returned to the facility October 4th, 2024. On 12/3/24 at 11:04 AM R15 was in bed without sheets and lying directly on the mattress. Dressings were present to R15's right shin and Left foot great toe and heel. R15's hospital discharge orders dated 10/4/24 documents orders for pressure ulcer treatment and post operative precautions. R15's current care plan with admission date of 6/18/24 does not include documentation on falls or fall interventions. This care plan does not document revision surgery, or precautions needed post operatively. R15's care plan shows no documentation on pressure ulcers or preventative measures. Based on observation, interview and record review, the facility failed to revise care plans following falls with injury and new pressure ulcers for three of four residents (R26, R15, R181) reviewed for care plans in of a sample of 43. Findings Include: The facility's Care Plan Policy revised 6/1/22 states It is the policy of this facility to develop and implement a Base Line Care Plan, a comprehensive person-centered care plan and conduct care plan meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental, and psychological needs that are identified in the resident's comprehensive assessment. 1. R181's Treatment Administration Record (TAR) for December 2024 includes a treatment order for Coccyx wound -apply calcium alginate and silicone bordered foam dressing daily. R181's Initial Wound Evaluation and Management Summary dated 11/27/24 documents (R181) has a stage II Pressure Ulcer on the coccyx measuring 1.2 x 0.7 x 0.1 Centimeters of greater that one days duration. R181's Care Plan reviewed 10/29/24 documents R181 is at risk for pressure ulcers but was not updated to include the current pressure ulcer. On 12/2/24 R181 was observed in bed. V34, R181's family member was visiting. R181 seemed confused and was oriented to person, but was disoriented to time and place. V34 stated R181 had a pressure ulcer on his coccyx for which he is now getting treatment. V34 stated (R181) has been confused since he came here after breaking his hip. R181 was not observed to be on a pressure relieving mattress. V34 stated (R181) is in bed a lot now. (R181) doesn't want to get up much.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review the facility failed to administer insulin per manufacturer's directions and according to standards of practice for three residents (R25,R45, R47) of four residents reviewed for insulin administration in a sample list of 43 residents. Findings Include: 1. R25's Medication Administration Record (MAR) for December 2024 includes an active physician's order for Novolog (insulin) Flexpen U100. Subcutaneously per sliding scale before meals. The manufacturer's package insert for Novolog Flexpen U-100 documents Novolog starts acting fast. Eat a meal within 5 to 10 minutes after taking it. On 12/4/24 at 11:00AM V30 Licensed Practical Nurse (LPN) stated I have given all my insulin for 100 hall for lunch today. When asked when lunch would be served V30 stated about 12:00 Noon. R25's Medication Administration Record for December 2024 documents R25's insulin was administered at 11:04AM on 12/4/24. 2. R45's Medication Administration Record (MAR) for December 2024 includes an active physician's order for Admelog SoloStar U-100 Insulin (insulin lispro) insulin pen; 100 unit/ml Amount to Administer: 16 units; subcutaneous with meals R45's Medication Administration Record for December 2024 documents R45's insulin was administered at 11:02AM on 12/4/24. 3. R47's Medication Administration Record (MAR) for December 2024 includes an active physician's order for Admelog SoloStar U-100 Insulin (insulin lispro) 100 unit/ml Administer per sliding scale before meals and at bedtime. R47's Medication Administration Record for December 2024 documents R47's insulin was administered at 11:02AM on 12/4/24. The manufacturer's package insert for Lispro insulin documents Administer Insulin Lispro by subcutaneous injection into the abdominal wall, thigh, upper arm, or buttocks within 15 minutes before a meal or immediately after a meal. On 12/4/24 at 12:10 PM V30 verified that lunch had not been served to R25, R45, R47 and R25, R45, R47 had not been given any nourishment between receiving insulin and being served lunch. On 12/5/24 at 9:00AM V1, Administrator verified lunch was served between 12:00PM and 12:05PM on 100 Hall on 12/4/24.

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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 provide an effective communication program for one resident (R40) of 18 residents reviewed for communication in a sample list of 43. Findings Include: R40's Continuity of Care Document printed 12/5/24 includes the following diagnoses: Amyotropic Lateral Sclerosis, Dysphasia, and Anxiety Disorder. On 12/02/24 at 2:18 PM R40 was in his room in a custom fitted wheelchair. R40 spoke very softly and deliberately but given time could be understood. R40 stated They don't take time to listen to me. They assume I can't talk to them, but I can. I have Amyotropic Lateral Sclerosis (Lou GehrigsDisease). I am 44 and I would like to be talked to. Sometimes I feel like I am not here. R40's Minimum Data Set (MDS) dated [DATE] documents R40 is cognitively intact and sometimes understood. On 12/3/24 at 9:00AM V10, Licensed Practical Nurse (LPN) stated I am agency, but I come to this facility a lot. (R40) is alert and oriented and can speak, but not very loudly and it takes time to listen to (R40). V10 verified there is no plan she is aware of to address R40's communication needs. R40's Care Plan updated 10/11/24 does not address R40's issue with effective communication. The facility's Care Plan Policy revised 6/1/22 states It is the policy of this facility to develop and implement a Base Line Care Plan, a comprehensive person-centered care plan and conduct care plan meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental, and psychological needs that are identified in the resident's comprehensive assessment.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

B. Based on interview and record review the facility failed to complete neurological checks after unwitnessed falls with head injury for one of three residents (R26) reviewed for falls out of a sample list of 43. Findings include: The facilities Emergency Care Procedure policy revised 4/3/18 documents if a fall is unwitnessed, notify the physician and initiate neurological checks at least every 4 hours for twenty-four hours, or until stable, or as ordered by Medical Doctor. R26's Electronic Progress Notes document on 9/8/24 at 5:56 AM, R26 had an unwitnessed fall in his room and was found on the floor with a laceration above the left eye. R26 was sent to the emergency room where they glued the laceration and applied adhesive strips to the laceration. R26's Electronic Progress Notes document on 9/18/24 at 7:15 PM, R26 had an unwitnessed fall in his room and was found on the floor laying on his left side. V26 Licensed Practical Nurse documents R26 stated he hit his head and had complaints of left shoulder and hip pain. R26 was sent to emergency room for evaluation and returned with bruising above the left eye and a skin tear above the right eye. R26's Electronic Progress Notes on 10/13/24 at 3:01 PM, document R26 was found lying on the floor next to his wheelchair. R26 had a laceration to the top of his head measuring five centimeters in length. V27 Licensed Practical Nurse documents R26 was sent to emergency room for evaluation. On 10/13/24 at 8:26 PM, notes by V28 Licensed Practical Nurse document, R26 returned to the facility with seven sutures and five staples to the forehead. Progress Notes and events from 9/8/24, 9/18/24 and 10/13/24 document no evidence of neurological checks were completed for R26. R26's Observation Assessments on 9/8/24, 9/18/24, and 10/13/24 do not contain documentation of neurological assessments. On 12/3/24 at 11:00 AM, V2 Director of Nursing stated the facility does not have documentation of neurological checks for any of R26's falls. On 12/03/24 12:23 PM, V6 Registered Nurse stated after a resident sustains an unwitnessed fall and hits their head, An Observation Assessment with neurological checks should be completed every four hours for twenty four hours. On 12/4/24 at 10:30 AM, V1 Administrator stated if a resident sustains a fall and hits their head neurological checks should be initiated and completed every four hours for twenty-four hours. V1 further stated the Director of Nursing should be auditing electronic medical records after an incident happens to ensure all documentation and assessments are being completed. Failures at this level require more than one deficient practice statement. A. Based on interview and record review, the facility failed to transcribe and implement physician orders to start a medication for one of one resident (R72) reviewed for medication orders on the sample list of 41. This failure resulted in a delay of medication administration for R72. Findings include: R72 's Progress Note dated 11/14/2024 at 02:10 PM written by V41 Registered Nurse documents the primary care physician was at the facility. The Note documents a new order for Colace QD (Daily) for chronic constipation. On 12/5/24 at 10:43 AM, R72's Clinical Physician Orders do not contain the physician order to administer Colace (Laxative) daily. On 12/5/24 at 10:46 AM, R72's November 2024 Medication Administration Record does not document the administration of Colace. On 12/5/24 at 10:44 AM R72's December 2024 Medication Administration Record does not document the administration of Colace. As of 12/5/24 R72 has missed 21 doses of the medication. On 12/4/24 at 11:27 AM V2 Director of Nurses stated all nurses are to transcribe the physician orders as soon as the nurse's receive the order from the physician. V2 continued stating that V41 should have processed/transcribed the physician order and contacted the pharmacy as soon as the order was transcribed, and that R72's Clinical Physician Orders do not contain the ordered medication from the 11/14/24 progress note.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 12/3/24 at 11:04 AM R15 observed in bed without sheets and resident lying directly on mattress. Dressing to right shin noted, undated, with black colored drainage in quarter size area on dressing. R15's left foot great toe and heel were wrapped in an undated dressings. R15's exposed feet were very dry and flaky white scales were noted on feet and mattress. Air mattress with bumpers noted. Error light flashing on air mattress however air mattress is inflated currently. R15 states he has pain in his left heel. R15's feet were in foam boots without socks noted. R15 states he has not gotten out of bed yet and wants to stay in bed now until family arrives at 2:00 PM. At 2:15 PM on 12/03/24, R15 remained in bed in same position on right side as observed at 11:04 AM. At 3:25 PM R15 remained in same position, at this time R15 states he hasn't moved all day. R15's face sheet dated 12/04/24 documents medical diagnosis including fracture of unspecified part of neck of left femur with subsequent encounter for closed fracture and pressure ulcer of unspecified buttock stage 2. R15's hospital discharge orders dated 10/4/24 documents orders for pressure ulcer treatments for left heel wound, coccyx stage 2-3 pressure ulcer and left hip incision. R15's physician wound notes dated 10/23, 10/31, 11/6, 11/13, and 11/20/24 document unstageable, stage 4 and stage 3 pressure ulcerations. R15's facility treatment record dated 11/05/24-12/02/24 documents 13 missing treatment administrations. R15's current care plan with admission date of 6/18/24 includes documentation on risk for skin breakdown but does not document any current pressure ulcers or current interventions. Based on observation, Interview, and record review the facility failed to assess, implement interventions and physician ordered treatments to prevent the development/worsening of pressure ulcers for two (R181, R15) of three residents reviewed for pressure ulcers in a sample list of 43 residents Findings Include: 1.) R181's Minimum Data Set (MDS) dated [DATE] documents R181 was cognitively intact and not at risk for pressure ulcers had any pressure ulcers. R181's Continuity of Care Document dated 12/5/24 includes the following diagnoses: Displaced Fracture Right Femur (10/30/24), Generalized Anxiety Disorder, Muscle Wasting/Atrophy, Parkinson's Disease, and Chronic Congestive Heart Failure. R181's Initial Wound Evaluation and Management Summary dated 11/27/24 documents (R181) has a stage II Pressure Ulcer on the coccyx measuring 1.2x0.7x0.1 Centimeters of greater that one days duration. R181's Treatment Administration Record (TAR) for December 2024 includes a treatment order for Coccyx wound -apply calcium alginate and silicone bordered foam dressing daily. On 12/2/24 R181 was observed in bed. V42, R181's family member was visiting. V42 stated R181 has a pressure ulcer on his coccyx for which he is now getting treatment. V42 stated (R181) has been confused since he came here after breaking his hip. R181 was not observed to be on a pressure relieving mattress. V42 stated (R181) is in bed a lot now. (R181) doesn't want to get up. much. The facility's policy Pressure Injury/Pressure Ulcer Prevention and Treatment revised 10/24/22 states: All high and moderate (Skin) risk residents will be assessed for the needs of the items below. If the intervention is needed it will be added to the Care Plan A. Special Mattress and Wheelchair Cushions. R181's Care Plan dated 10/29/24 documents R181 is at risk for pressure ulcers but was not updated to include the current pressure ulcer(11/27/24). There were no assessments for special need items nor changes in R181's skin risk status noted.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

3.) R231's face sheet dated 12/04/24 documents medical diagnosis including heart failure and Chronic obstructive pulmonary disease with (acute) exacerbation. On 12/02/24 at 11:00 AM R231 resting in bed with nasal cannula in nose attached to oxygen tank on 3 liters concentrated oxygen per minute. Humidification bottle not bubbling, no date seen on humidification bottle. Oxygen tubing attached to patient does not have date visible. Portable oxygen tank with undated tubing attached to walker next to R231's bedside. On 12/04/24 at 10:45 AM R231 walking in hallway with therapy staff. Nasal cannula in nose attached to portable oxygen tank. No date noted on tubing. Based on observation, interview and record review the facility failed to properly date, label humidifier bottles and oxygen tubing when changed for three of three residents (R11, R20, R231) reviewed for respiratory services in the sample list of 43. Findings include: The facility's Oxygen Policy and Procedure with a revision date of 03/16/17 documents, Oxygen set-up (cannula/mask, tubing) must be exchanged every 7days. Documentation: Date, time, flow rate, frequency, and results of oxygen therapy Medical Record. 1.) R20's Medication Administration Record dated 12/1/2024 - 12/2/2024 documents O2 at 2 liters per nasal cannula continuous for SOB (Shortness of Breath). This Medication Administration Record dated 12/1/2024 - 12/2/2024 documents to Change O2 (oxygen( nebulizer tubing Q (every) week. This Medication Administration Record dated 12/1/2024 - 12/2/2024 documents V40 changed the tubing and humidifier bottle on 12/1/24. On 12/2/24 at 11:18 AM, R20's oxygen concentrator was running via a nasal cannula. There is no date of the humidifier bottle or tubing to indicate when it was changed and they are not stored in anything to protect from contamination. The humidifier bottle was empty. On 12/3/24 at 10:30 AM, R20 was in her room, eating breakfast wearing the nasal cannula from the oxygen concentrator. The nasal cannula and humidifier bottle remain undated. The humidifier bottle remains empty at this time. 2.) R11's Clinical Physician Orders dated 12/3/24 documents O2 at 4 liters per nasal cannula PRN (as needed) for SOB (Shortness of Breath). The same Physician Orders document Change O2 (oxygen) tubing Q (every) week on Sunday night. On 12/2/24 at 10:08 AM, R11's oxygen concentrator was running via a nasal cannula. There is no date on tubing to indicate when it was changed and they are not stored in anything to protect from contamination. There was no humidifier bottle attached to the concentrator at this time. On 12/3/24 at 10:30 AM, R11 was not in her room, nasal cannula from the oxygen concentrator was laying on the bed. The nasal cannula undated. The continues to be no humidifier bottle attached to the oxygen concentrator at this time. On 12/3/24 at 11:27 V2 stated the nurses should be following the oxygen policy and that all nasal cannula tubing and humidifier bottles should be changed and dated weekly as ordered by the physician and the policy states.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review the facility failed to monitor one resident (R38) receiving opioid medication for bowel function for one resident reviewed for opioid medication in a sample list of 43. Finding include: R38's Medication Administration Record (MAR) for December 2024 documents R38 has a current order for hydrocodone-acetaminophen tablet; 5-325 mg; amt: 1tablet; oral Every 8 Hours - PRN (as needed). It is documented on this MAR R38 received this as needed medication four times between 11/29/24 and 12/4/24. There is no documentation to support R38's bowel function is being monitored. R38's Care Plan reviewed 10/8/24 does not include interventions to monitor bowel movements for use of an opioid medication. R38's Progress Note dated 10/9/24 at 8:14 Am documents R38 reported (R38) had not had a bowel movement in three days On12/4/24 at 2:00PM V2, Director of Nursing verified the facility has no system in place for monitoring of bowel function in residents who use narcotic medications but if a resident doesn't have a bowel movement is a few days it would be charted in the Progress Notes. On 12/4/24 at 2:05PM V1, Administrator verified the facility does not have a policy specific to narcotic medication monitoring.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

2.) On 12/3/24 at 1:15 PM V6 registered nurse (RN) states there is no specific behavior tracking and that if resident has behavior out of the norm, then there would be a progress note. V6 states R15 has angsty periods where he just cannot be redirected out of mood. R15 will often call POA (power of attorney) and that helps calm him down. V6 states they are attempting behavior modification with R15 but most times they go through the steps of redirection with R15, and it fails. V6 states the reasoning for the scheduled anti-anxiety medications is because POA wants R15 to be consistent with medications and behaviors even though resident is sleepier and more withdrawn. R15's point of care (POC) task tracking sheet dated 11/01/24 - 12/03/24 documents that certified nursing assistants (CNA's) only documented no behavior seen but does not document any specific behaviors, there were 27 entries out of the possible 99 documented. No behavior assessments documented in R15's medical record. R15's hospital discharge records dated 10/4/24 document mediation orders for duloxetine (anti-depressant) 60 milligrams (mg) daily, and mirtazapine (anti-depressant) 15mg at bedtime. R15's care plan with admission date of 6/18/24 does not document anti-depressant and anti-anxiety medication use nor interventions for nursing care. There was no gradual dose reduction (GDR) attempted for R15's anti-depressants or anti-anxiety medications documented. On 12/04/24 at 10:15 AM, current lorazepam 1mg BID (twice a day) order consent requested from V2 and V2 provided old consent dated 7/25/24 for lorazepam 1mg prn (as needed) order. V2 states this is only consent on file. Based on interview and record review the facility failed to obtain consent, assess/monitor residents receiving psychotropic medications and failed to document attempts to utilize nonpharmalogical interventions for two residents (R15, R38) reviewed for psychotropic medication in a sample list of 43. Findings include: The facility's Pharmacological Drug Usage Procedure revised 10/18/17 states Purpose: 1. To provide appropriate assessment and monitoring of residents receiving these (psychotropic) medications. 2. To ensure residents receive gradual dosage reductions and behavioral interventions in an effort to discontinue these medications and minimize adverse consequences. Procedure: 2. Psychopharmacological medication usage must be reassessed at least every 90 days and include rationale for continuation the medication. 1.) R38's active physician's orders printed 12/5/24 include the following orders for psychotropic medications Clonazepam (antianxiety) 1 mg (milligrams) TID (three times daily) Trazadone (Antidepressant) 50 mg daily, Paxil (Antidepressant) 20 mg daily and Melatonin (Sleep Aide) 5mg at bedtime daily. R38's electronic medical record does not include assessments for these Psychotropic medication. There is no documentation to support nonpharmacological interventions were attempted. There are no targeted resident specific behaviors identified or tracked for R38. On 12/4/24 at 2:30PM V2, Director of Nursing verified there are no psychotropic medication assessments, behavior tracking, or nonpharmacological interventions identified or tracked for R38. V2 also verified R38 is receiving the above list of psychotropic medications.

CONCERN (D)

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the timeliness of laboratory services were completed as ordered by a physician for one (R28) of one resident reviewed for laboratory services on the sample list of 43. Findings include: R28's undated face sheet documents a diagnosis of type two diabetes mellitus. R28's December 2024 Physician Orders documents and order for R28 to have an A1C (blood test to check ongoing sugar levels) was to be drawn on 2/3/24 and 8/3/24. R28's laboratory results dated [DATE] document results for an A1C level for 9/13/2023 and 10/16/24. R28's medical record did not contain any results for an A1C level on 2/3/24 and 8/3/24. On 12/4/24 at 1:00 PM, V31 Director of Therapy stated R28's A1C level has only been drawn once this year which was on 10/16/24. V31 stated they were unable to find labs for February 2024 and August 2024. On 12/4/24 at 1:30 PM, V2 Director of Nursing stated the floor nurses ensure the labs are being completed as ordered. V2 stated the only A1C level she can find for R28 this year was drawn on 10/16/24. V2 confirmed the labs were not obtained as ordered.

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to implement accurate complete care plans to include fall prevention, pressure ulcer prevention, oxygen treatment, communication methods and medications for four of four residents (R15, R40, R54, R231) reviewed for care plans in a sample list of 43. Findings Include: 1.) R15's face sheet dated 12/04/24 documents medical diagnoses including Left Femur Fracture, Acute Kidney Failure, Pressure Ulcer of Buttock Stage 2, Major Depressive Disorder, and Anxiety. R15's Physician Wound Notes dated 10/23/24, 10/31/24, 11/6/24, 11/13/24, and 11/20/24 document unstageable, stage 4 and stage 3 pressure ulcers for R15. On 12/3/24 at 11:04 AM R15 had dressings to the right shin, left heel, and left great toe. R15's current Care Plan with admission date of 6/18/24 does not document any pressure ulcers or current interventions. R15's Progress Note dated 8/15/2024 at 09:08PM documents R15 self-propelled into R15's room and placed the call light on and R15 was notified that the CNA (certified nurse assistant) was with another patient, and it wouldn't be long. The Progress Note documents R15 was heard yelling for help and R15 was found kneeling with R15's upper torso on the bed, in a praying type of position. R15's current Care Plan with admission date of 6/18/24 does not include documentation on falls or fall interventions. R15's Hospital Discharge Records dated 10/4/24 document medication orders for Duloxetine (anti-depressant) 60 milligrams (mg) daily, Mirtazapine (anti-depressant/antianxiety) 15mg at bedtime, and Apixaban (anti-coagulant) 2.5mg daily. R15's Care Plan with admission date of 6/18/24 does not document anti-coagulant or anti-depressant and anti-anxiety medication use nor interventions for nursing care. On 12/3/24 at 12:20 PM, V6 Registered Nurse (RN), stated R15 takes anti-coagulant and anti-depressant and anti-anxiety medications. V6 stated R15 does have multiple pressure ulcers and is unclear why his care plan does not reflect this. V6 stated R15 had fall on 8/15/24 and that R15 is impulsive and inpatient which is why he fell. 2.) R231's face sheet dated 12/04/24 documents medical diagnoses including Heart Failure and Chronic Obstructive Pulmonary Disease with (acute) Exacerbation. On 12/02/24 at 11:00 AM R231 was resting in bed with oxygen running at three liters per minute via a nasal cannula and a portable oxygen tank was attached to a walker next to R231's bed. R231's current Care Plan dated with admission date of 10/11/24 does not include an oxygen therapy plan of care. 3.) R54's face sheet dated 12/04/24 documents an admission date of 10/12/24 for Vascular Disorder of the Intestine. On 12/02/24 at 10:00 AM, R54 stated she is in the facility for rehabilitation following something happening in her stomach. R54 stated she experiences a great deal of pain from this. R54 stated she had been at the facility in the past about three years prior for therapy after a knee replacement. R54's Care Plan dated with admission date of 10/02/24 documents R54 was admitted to the skilled nursing facility following recent hospitalization for left knee replacement. R54's Care Plan does not document any vascular disorder of intestine. 4. On 12/02/24 at 2:18 PM R40 was in his room in a custom fitted wheelchair. R40 spoke very softly and deliberately but given time could be understood. R40 stated They don't take time to listen to me. They assume I can't talk to them, but I can. I have Amyotropic Lateral Sclerosis (Lou GehrigsDisease). I am 44 and I would like to be talked to. Sometimes I feel like I am not here. On 12/3/24 at 9:00AM V10, Licensed Practical Nurse (LPN) stated I am agency, but I come to this facility a lot. (R40) is alert and oriented and can speak, but not very loudly and it takes time to listen to (R40). R40's Care Plan updated 10/11/24 does not address R40's issue with effective communication. The facility's Care Plan Policy revised 6/1/22 states It is the policy of this facility to develop and implement a Base Line Care Plan, a comprehensive person-centered care plan and conduct care plan meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment.

CONCERN (E)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record reviews, the facility failed to assess the residents for eligibility, and ensure residents were offered and administered the pneumococcal and influenza vaccines. This failure affects four (R14, R43, R26, R54) of five residents reviewed for immunization in the sample list of 43. Findings include: 1. R14 Continuity of Care Document dated 12/04/2024 at 1:00 PM documents an admission date of 05/27/2020. R14 medical record review does not include an Influenza Education and consent/declination form for the Influenza vaccine. R14 medical record contains an undated Pneumococcal Education and consent/declination form for the Pneumococcal vaccine. R14 face sheet dated 12/05/2024 at 10:02 AM documents administration of the Influenza Vaccine on 11/7/2023. R14 Medication Administration Record (MAR) dated 12/05/2024 at 10:03 AM for 10/1/24 thru 10/31/24 does not document the administration of the influenza/pneumococcal vaccines. 2. R43 Face Sheet dated 12/04/2024 at 01:07 PM documents an admission date of 02/25/2020. R43 medical record review contains an Influenza Education and consent/declination form for the Influenza vaccine that is completely filled out and dated 8/19/24 requesting the administration of the influenza vaccine. R43 medical record contains an undated Pneumococcal Education and consent/declination form for the Pneumococcal vaccine that is not filled out completely. The consent requests the administration of the Pneumococcal vaccine. R43 medical record contains an undated Covid-19 Education and consent/declination for the Covid-19 vaccine. R43 Face Sheet dated 12/04/2024 at 01:07 PM documents administration of the Influenza Vaccine on 11/8/2023, Pneumovax Date: declined 3/17/2020, and COVID-19 Vaccine: complete 1/5/21 & 1/28/21. R43 Medication Administration Record (MAR) dated 12/05/2024 at 10:09 AM for 10/1/24 thru 10/31/24 does not document the administration of the influenza/pneumococcal vaccines. 3. R26 Face Sheet dated 12/04/2024 at 01:05 PM documents an admission date of 07/24/2022. R26 medical record review contains an Influenza Education and consent/declination form for the Influenza vaccine that is completely filled out and dated 9/12/24 requesting the administration of the influenza vaccine. R26 medical record contains an undated Pneumococcal Education and consent/declination form for the Pneumococcal vaccine that is not filled out completely. The consent requests the administration of the Pneumococcal vaccine. R26 Face Sheet dated 12/04/2024 at 01:07 PM documents administration of the Influenza Vaccine on 11/10/2023 and a Pneumovax Date: **REF (Refused) 11/12/14. R26 Medication Administration Record (MAR) dated 12/05/2024 at 10:18 AM for 10/1/24 thru 10/31/24 does not document the administration of the influenza/pneumococcal vaccines. 4. R54 Face Sheet dated 12/04/2024 at 01:01 PM documents an admission date of 10/02/2024. R54 medical record review contains an Influenza Education and consent/declination form for the Influenza vaccine that is not completely filled out and dated 9/12/24 requesting the administration of the influenza vaccine. R54 medical record does not contain a Pneumococcal Education and consent/declination form for the Pneumococcal vaccine. R54 Face Sheet dated 12/04/2024 at 01:01 PM documents an administration of the Influenza Vaccine on 11/06/2023, and Pneumovax Date: 09/27/2016. R54 Medication Administration Record (MAR) dated 12/05/2024 at 10:26 AM for 10/1/24 thru 10/31/24 does not document the administration of the influenza/pneumococcal vaccines. On 12/3/24 at 11:35 AM V1 states if the consents are undated they are not valid, and there is no documentation of the vaccines being completed the vaccines have not been done.

CONCERN (F)

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

Grievances (Tag F0585)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review the facility failed to ensure Resident Council grievances were resolved in a timely manner. This failure had the potential to affect all 90 residents who reside in facility. Findings include: The facilities Grievance Policy revised 6/1/2022 documents residents have the right to voice grievances to the facility and grievances shall be addressed by the facility in a timely manner. Resident Council Minutes dated 1/8/24 document under old business concerns with cell phone and ear bud usage, call lights not being answered timely, and certified nursing assistants (CNAs) are loud in hallways. Resident Council Minutes for 3/11/24 document under new business concerns with second shift CNAs on phones during meals and rude attitudes when answering call lights with what do you want. Resident Council Minutes dated 4/1/24 document phone usage during resident cares is still a concern. Resident Council Minutes dated 6/3/24 document CNAs are always on their phones. Resident Council Minutes dated 7/8/24 document CNAs are on their phones once managers leave. Resident Council Minutes dated 8/5/24 document concerns with CNAs being on cell phones and in evening they gather in the dining room and get on phones as soon as management leaves. Resident Council Minutes dated 9/9/24 document CNAs gathering in dining rooms on cell phones or electronic device. Resident Council Minutes dated 10/14/24 document CNAs are still on phones during cares. Resident Council Minutes dated 11/4/24 document residents are still having issues with nurse/ CNA on cell phones. On 12/03/24 at 10:25 AM, R16 stated we have been complaining about certified nursing assistants (CNA) at resident council meetings for months. R16 stated CNAs are talking on their phones and have ear buds in ears while providing care for residents. R16 further stated she does not feel the facility is addressing the problem. On 12/3/24 at 10:35 AM, R63 stated the CNAs are always on their phones once management leave the building. R63 stated they bring it up all the time, but it's not getting better. On 12/3/24 at 1:00 PM, V1 Administrator stated she is aware of the cell phone issues in the facility and the facility plans to implement management staying later in evening to monitor cell phone usage by staff. The facilities roster dated 12/2/24 documents 90 residents reside in facility.

CONCERN (F)

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

Deficiency F0729 (Tag F0729)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview, and record review, the facility failed to document receiving registry verification that the employee has met eligibility requirements to work in the facility prior to start date. This failure has the potential to affect all 90 residents residing in the facility. Findings include: The facility census sheet dated 12/2/24 documents there are 90 residents who reside at the facility. On 12/3/24 at 10:00 AM employee V32 Certified Nursing Assistant (CNA), V33 CNA, V34 CNA, V35 CNA, V36 Cook, V37 Resident Aide employee files were reviewed for documented evidence of Illinois Health Care Worker registry eligibility to work in a healthcare facility. None was obtained from the employee files. Timecard reprint dated 12/3/24 at 11:47 AM documents V34 first day of employment was 11/20/23. Illinois Healthcare Worker Registry added to the employee file documents it was checked on 12/3/24. Timecard reprint dated 12/3/24 at 11:53 AM documents V33 first day of employment was 11/20/23. Illinois Healthcare Worker Registry added to the employee file documents it was checked on 12/3/24. Timecard reprint dated 12/3/24 at 12:24 PM documents V36 first day of employment was 11/21/23. Illinois Healthcare Worker Registry added to the employee file documents it was checked on 12/3/24. Timecard reprint dated 12/3/24 at 12:28 PM documents V32 first day of employment was 11/21/23. Illinois Healthcare Worker Registry added to the employee file documents it was checked on 12/3/24. Timecard reprint dated 12/3/24 at 12:29 PM documents V35 first day of employment was 11/20/23. Illinois Healthcare Worker Registry added to the employee file documents it was checked on 12/3/24. On 12/3/24 at 11:00 AM V13, Human Resource Manager, stated V13 was new to the human resources position. V13 stated V13 is unable to locate any documented evidence of registry verification for eligibility to work in the nursing facility for the new employees. On 12/3/24 at 11:12 AM V1 stated the human resource manager and staff are unable to locate documented evidence of registry verification for eligibility to work in the nursing facility for the new employees.

CONCERN (F)

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

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to conduct and document an accurate facility assessment. This failure has the potential to affect all 90 residents who reside at the facility. Finding Include: The facility census sheet dated 12/2/24 documents there are 90 residents who reside at the facility. 1. The facility assessment dated [DATE] Section A.1 states This facility has the following equipment to meet to meet the medical needs of the resident: Sit to stand or sling type mechanical lifts are not listed in this section. On 12/4/24 at 2:00PM V3, Assistant Director of Nursing provided a list of 18 residents who currently use mechanical lifts for mobility. V3 verified all of these residents use mechanical lifts for mobility. V3 verified it is possible that all residents who live at the facility could have to utilize a mechanical lift in the event of a fall. 2. The facility assessment dated [DATE] Section B. Medications does not list Narcotic medications or opioids. R38's Medication Administration Record (MAR) for December 2024 documents R38 has a current order for hydrocodone-acetaminophen tablet; 5-325 mg (milligrams); amount: one tablet; oral Every 8 Hours - PRN (as needed). On 12/4/24 at 2:00PM V3 stated We do have orders for Narcotic pain medications for multiple residents at any given time. On 12/4/24 at 2:15 PM V1, Administrator verified the facility does utilize mechanical lifts and narcotic medication and these items are not included on the Facility Assessment.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Failures at this level require more than one deficient practice statement. A. Based on observation, record review and interview, the facility failed to maintain infection prevention procedures to provide a sanitary laundry service. This failure has the potential to affect all 90 residents residing in the facility. Findings include: On 12/02/24 at 02:18 PM V9 identifies self as dayshift laundry aide. V9 entered the soiled linen holding room, applied gloves to the hands, no gown or other PPE (Personal Protective Equipment) was applied and sorted the soiled laundry into containers for personal linens, facility white linens, slings and facility incontinence linens. V9 removed the soiled linen from the collection barrels. Soiled linen included personal linen, soiled incontinence bed pads, soiled towels and washcloths, and soiled bed linen. V9 was observed leaning over soiled linen carts, V9's personal clothing was touching soiled linen collection barrels and the soiled linen including soiled bed pads, bed linens and soiled personal clothing. V9 states V9 sorts the laundry 3-4 times daily, is responsible for sorting, washing, drying and folding all laundry. On 12/02/24 at 02:25 PM V9 states she collects all soiled linen from the hallway collection barrels, sorts the soiled linen, then starts the soiled linen in the washing machines, transfers the clean linen from the washer to the dryer, removes clean linen from dryer to clean cart and fold the clean linen. On 12/02/24 at 02:28 PM V9 leans over the clean linen cart with the uniform touching the cart and moves the cart to the dryer and V9 then begins removing the clean linen from the dryer by reaching into the clothing dryer and placing the clean linen into the cart. Several pieces of clean linen, towels, sheets and wash cloths, touching V9 uniform as V9 pulled them from the clothing dryer closer to V9 for transfer to the clean linen cart. V9 states the clean towels, washcloths, and sheets are for use throughout the facility. On 12/02/24 02:32 PM V9 initiated a load of clothing protectors in the washer without washing V9's hands at this time. Inservice training record dated 5/14/24 provided by V8 document that V9 was trained on Job duties, dwell times, PPE (personal protective equipment) use, isolation and handwashing. V9 printed and signed the inservice training attendance sheet and confirms it is her signature. On 12/3/24 at 12:45 PM V1 stated that staff are expected to follow in-service training and all policies while working at the facility. V1 stated that V9 should have donned the proper PPE including a gown before sorting the soiled linen, doffed the PPE after completing the sorting of the linen and washed her hands. The facility census sheet dated 12/2/24 documents there are 90 residents who reside at the facility. B. Based on observation, interview, and record review the facility failed to notify visitors timely of a facility outbreak, failed to wear the appropriate personal protective equipment, and failed to prevent possible cross contamination for five (R54, R9, R70, R72, and R73) of five residents reviewed for infection control on the sample list of 43. Findings include: On 12/04/24 upon entering facility at 8:45 AM, observed V24 desk receptionist, V1 administrator, and V25 maintenance staff, wearing procedure masks. Facility entrance doors did not have any signage alerting to outbreak status or personal protective equipment needed to enter facility. V24 stated she was unclear if the facility had a Covid 19 outbreak stating, she was instructed to wear a mask. At 9:00 AM on 12/4/24, V1 stated there are 2 positive residents in facility on the 200 wing with Covid that were identified the evening prior on 12/3/24. V1 stated she had posted signage at entrance at 9:15 AM on 12/4/24. At 9:30 on 12/4/24, the following observations were made on the 200 wing: R54 has droplet and contact signage outside of room and PPE bin with N95 masks, gowns, and gloves available. Used N95 mask laying on top of PPE bin. Resident breakfast tray sitting on bedside table. R73 has signage of droplet and contact posted outside room with PPE bin including N95 masks. Breakfast tray noted on bedside table. V22, housekeeper, cleaning room with gown, gloves, and procedure mask, no eye protection on. V22 mopped floor and red bag removed from bin. V22 removed her gloves and gown outside of isolation room. V22's soiled gloves were used to close resident door, V22 then touched the dustpan on housekeeping cart. On 12/4/24 at 9:50 AM V23, dietary, states all isolation trays should be double bagged and then washed twice. At 9:54AM on 12/4/24, V15, Infection prevention licensed practical nurse, stated We are in outbreak status for two covid positive residents. All staff who enter the rooms should use N-95, gown, gloves, and hand hygiene. We are initiating contact tracing and testing. We will test all residents and staff. The Social Service Director is positive, but we have determined there was no contact with residents or staff. We are planning to reach out to local public health for guidance on testing in the future. Facility document titled Alert Media dated 12/4/24 documents text message sent to unknown staff at 3:51 PM on 12/3/24. Message states We have had a resident test positive for COVID. Going forward all staff will have to wear surgical masks until further notice. Proper PPE will be used when entering the affected residents room. Resident testing will start tomorrow. Staff testing information will follow shortly. Does not document who message was sent to or if message was received and understood. R73's progress note dated 12/4/24 at 3:04 PM documents covid positive test. R70's progress note dated 12/3/24 at 2:59 PM documents covid positive test. R9's progress note dated 12/4/24 at 4:25 PM documents R9's readmission from hospital. This note documents on 12/1/24 at 12:26 PM when R9 was admitted to hospital, R9 tested positive for RSV. On 12/05/24 at 8:45 AM, three more residents identified with positive Covid tests. Immediate observation conducted on all facility wings. R9, R70 and R72 have droplet precaution signs on their room doors. R9 and R72 have isolation carts available, R70 did not have isolation cart. Observations were conducted on 12/4/24 between the hours of 9:30am to 3:30pm and 9:00am-11:00am on 12/5/24. During this time, facility staff were observed wearing standard procedure (surgical) masks throughout facility and in patient care areas. Direct care staff seen entering isolation rooms did not wear N-95 or equivalent masks and no eye protection was observed at any time. As of 12/5/24 the facility had no yet notified the local health department of facility outbreak.

CONCERN (F)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview, and record review, the facility failed to document education, offering the COVID-19 Vaccine, and the consent and/or declination of COVID-19 vaccines for staff. This failure has the potential to affect all 90 residents residing in the facility. Findings include: The facility census sheet dated 12/2/24 documents there are 90 residents who reside at the facility. On 12/3/24 at 10:00 AM employee V30 Licensed Practical Nurse (LPN), V32 Certified Nursing Assistant (CNA), V33 CNA, V34 CNA, V35 CNA, V36 CNA, V37 Resident Aide, V38 LPN, V40 LPN files were reviewed for documented evidence of education, offering of the COVID-19 Vaccine to staff, and the consent and/or declination of COVID-19 vaccines. None was obtained from the files. On 12/3/24 at 11:00 AM V13, Human Resource Manager, stated V13 was new to the human resources position. V13 stated V13 is unable to locate any documented evidence of education, offering of the COVID-19 Vaccine to staff, and the consent and/or declination of COVID-19 vaccines for staff. On 12/3/24 at 11:12 AM V1 stated the staff is unable to locate documented evidence of education, offering of the COVID-19 Vaccine to staff, and the consent and/or declination of COVID-19 vaccines for staff.

Nov 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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 report bed bugs and room change to a resident representative for one (R1) of five residents reviewed for bed bugs in the sample list of five. Findings include: The facility's Transfer of a Resident policy dated 1/11/23 documents Upon need for a room transfer within the facility, staff shall meet and discuss the reasons for transfer. The Social Service Director shall discuss the potential room change with the resident and resident's representative. Form NH-#341 Room/Roommate Change Notification shall be utilized should either party request notification in writing. Transfer of the resident and belongings shall be completed as soon as possible and documented by Social Services. The facility's Change in a Resident's Condition dated December 2002 documents the resident's representative will be notified when there are changes in the resident's physical, mental, or psychosocial status. The (Pest Control Company) Proof of Service dated 11/10/24 documents (R1's former room) was treated for bed bugs with an insecticide. R1's Minimum Data Set, dated [DATE] documents R1 has severe cognitive impairment. R1's undated Face Sheet documents V13 as R1's Family and Emergency Contact. R1's Census documents R1 changed rooms on 11/12/24. There is no documentation in R1's medical record as to why this room change occurred or that bed bugs were found in R1's room. On 11/18/24 at 9:46 AM there were no residents residing in R1's former room. At 9:58 AM R1's current room was observed. On 11/18/24 at 11:16 AM V13 confirmed V13 was not aware that bed bugs were found in R1's room on 11/10/24 and V13 was not aware that R1 changed rooms. On 11/18/24 at 11:45 AM V2 Director of Nursing stated bed bugs were found in R1's room on 11/10/24, and this was the only room affected. V2 stated V2 instructed the staff to move R1 into another room. V2 stated resident families of those affected should have been notified of the bed bugs and room change, and this should be documented in a progress note. V2 confirmed there is no documentation in R1's nursing notes that V13 was notified of the bed bugs and room change. At 1:42 PM V2 confirmed R1's electronic medical record does not contain a Room/Roommate Change Notification form for R1's transfer on 11/10/24. On 11/18/24 at 12:55 PM V14 Licensed Practical Nurse confirmed V14 was R1's assigned nurse on 11/10/24, and confirmed V14 did not report bed bugs and room change to V13.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure medical records were complete and accurate for two (R1, R2) of five residents reviewed for bed bugs. Findings include: The (Pest Control Company) Proof of Service dated 11/10/24 documents (R1's/R2's former room) was treated for bed bugs with an insecticide. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment. R1's ongoing Census documents R1 changed rooms on 11/12/24. There is no documentation in R1's medical record that bed bugs were found in R1's room. R2's MDS dated [DATE] documents R2 as cognitively intact. R2's ongoing Census documents R2 changed rooms on 11/12/24. There is no documentation in R2's medical record that bed bugs were found in R2's room. On 11/18/24 at 9:46 AM there were no residents residing in R1's/R2's former room. At 9:58 AM R1's current room was observed. On 11/28/24 at 10:38 AM R2 was in R2's room. R2 stated R2 recently moved rooms because the facility told R2 that bugs were found on former roommate's bed (R1's). On 11/18/24 at 10:10 AM V3 Maintenance Supervisor stated V3 received a call on 11/10/24 reporting that R1's/R2's room had bed bugs. V3 stated V3 came to the facility that day and contacted (Pest Control Company), R1 and R2 were transferred out of the room, and all of their clothing and linens were bagged and sent to laundry. At 10:50 AM V3 stated V3 observed the bed bugs on R1's mattress seams, and there were no bed bugs found on R2's bed. On 11/18/24 at 11:33 AM V12 Service Manager of (Pest Control Company) stated a service technician went to the facility on [DATE], a positive bed bug specimen was found, and an insecticide was used to treat the room (R1's/R2's former room). On 11/18/24 at 11:45 AM V2 Director of Nursing stated bed bugs were found in R1's/R2's room on 11/10/24, and this was the only room affected. V2 instructed the staff to move R1 and R2 into another room. V2 confirmed bed bugs being found should have been documented in R1's/R2's nursing notes. At 1:33 PM V2 stated the facility does not have a policy regarding medical records. On 11/18/24 at 12:55 PM V14 Licensed Practical Nurse stated on 11/10/24 two unidentified Certified Nursing Assistants reported there was a lot of blood on R1's bed linens. V14 stated V14 went to R1's room and stated there was blood on R1's bed linens and bugs along the crevices of R1's mattress. V14 stated R1's and R2's clothing was changed and they were removed from the room. .

Oct 2024 7 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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 protect a resident's (R2) right to be free from physical abuse by another resident (R1). This failure resulted in R2 experiencing psychosocial harm and fear of R1, and a bruise on R2's arm. This failure affected two of two residents (R1, R2) reviewed for abuse on the sample list of 10. Findings include: The facility's Abuse Prohibition and Reporting policy with a revised date of 11/28/19 documents the purpose of this policy is to protect residents from any kind of abuse. This policy documents, Special attention will be given to identifying behavior that increases the residents potential for abusing self or others or being the victim of abuse. These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as; entering other residents rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and/or are totally dependent on staff. Appropriate interventions to address identified behaviors will be included on resident care plans, and reviewed as/when change occurs. These interactions will be communicated to the direct care staff. If the incident involves alleged abuse and substantiated evidence indicates that another resident of the facility is the perpetrator of the abuse, then the Administrator shall take all the steps necessary to protect all residents in the facility from abuse until the alleged perpetrator can be evaluated. The facility's initial report dated 9/29/24 at 7:03 PM documents the facility is reporting a possible resident to resident incident the final report will follow. R1's Nurses Notes dated 9/29/24 at 1:07 AM by V8 Licensed Practical Nurse (LPN) documents R1 had been up all night pressing the call light but becoming agitated when staff enter the room. V8 attempted to administer R1's Risperdal (antipsychotic) and R1 grabbed the medication cup and threw it on the floor. V8 documents when she attempted to pick up the medication R1 became aggressive and hostile. R1's Nurses Notes dated 9/29/24 at 4:33 AM by V8 documents V8 was at the nurse's station and heard someone yell help me. V8 documents that she went to R2's room and saw R1 standing over her as R2 was laying on the floor. R1 became aggressive when V8 asked him to leave the room. V8 documents that Emergency Medical Services (EMS) and the police were called. On 10/1/24 at 9:30 AM, R2 stated that she remembers R1 coming into her room and grabbed her arm and pulled hard on it and pulled her onto the floor. R2 stated that R1 has come into her room before. R2 stated that when he comes in her room he gets real loud and the last time he came into her room he sat on her legs in her bed. R2 stated she doesn't want him in her room and stated that she is scared of him. On 10/1/24 at 10:32 AM, V8 stated on 9/29/24 that R1 was restless most of the evening and kept turning on his call light. V8 stated after about the third time of going into his room she offered R1 Risperdal and he grabbed the medication cup out of her hand and threw it on the floor. V8 stated when she tried to pick up the medication cup he came at her. V8 stated he was verbally aggressive and agitated so she left the room. V8 stated around 1:30 AM she heard a female resident yell for help and V8 went to R2's room. V8 stated that V14 Certified Nursing Assistant followed her into R1's room. When she entered R2's room she saw R2 on the floor and R1 was standing over her. V8 asked R1 to leave but he would not leave. V14 went around the back of R1 and over R2's bed to get to R1 and stayed between R1 and R2. V8 stated when V14 got on the floor with R2, R1 lunged at V14. V8 stated that when he went to try to hit V14, V8 wrapped her arms around R1 to try to stop him. V8 stated that more staff came into the room to help. V8 went to call V1 because V8 stated it was an abuse situation and needed to be reported. V8 stated then she called the EMS. V8 when she went back to the room R1 had the other nurse that came to help pinned in the closet doorway. V8 stated that the EMS and the police came shortly after and it took the EMS about 20 minutes to get R1 on the gurney to take him to the hospital for an evaluation. V8 stated that R2 told her R1 came into her room and told her to get up that they had s**t to do and grabbed her arm and pulled her out of bed onto the floor. V8 stated that R2 had bruising to her left arm and said that her left hip was hurting. V8 stated that R2 looked frightened. On 10/1/24 at 11:12 AM, R2 stated that she did feel abused by R1. She said that he sat on her in her bed and then he threw her on the floor. R2 stated that she feels sorry for him (R1) but says she is afraid he (R1) is going to hurt someone. R2 stated that he (R1) should not be here. On 10/1/24 at 2:39 PM, V14 Certified Nursing Assistant (CNA) stated on 9/29/24 they heard someone yelling help and went into R2's room, where the yelling was coming from, and R1 was standing over R2. V14 stated that she made her way behind R1 and around R2's bed and climbed over R2's bed to get onto the floor with R2. V14 stated that R1 came at her and grabbed her arm and tried to choke her. V14 stated that he shoved the nurse into the wall a couple of times also. V14 stated that R2 told her that R1 came into her room and threw her covers off and told her that they had stuff to do and grabbed her arm and pulled her out of bed onto the floor. V14 stated that R2 was shaking and scared and asked if R1 was going to come back into her room. On 9/30/24 at 12:45 PM, R1 was very agitated with staff. R1 yelled at staff, kicked at them, swung his arms at them and pushed V17 Licensed Practical Nurse backwards. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and he had physical and verbal behaviors directed towards others. R2's MDS dated [DATE] documents R2 is cognitively impaired. R2 repeatedly recalled the event the same each time she was interviewed.

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

Read full inspector narrative →

Based on interview and record review the facility failed to timely report an allegation of resident to resident abuse to the state survey agency for two of four residents (R1, R2) reviewed for abuse in the sample list of 10. Findings include: The facility's Abuse Prohibition and Reporting policy with a revised date of 11/28/19 documents that employees should immediately report alleged abuse to the Administrator. If the matter involves alleged abuse, the Administrator or designee shall provide the Illinois Department of Public Health with initial notice of the alleged abuse as soon as possible, but not more than 2 hours after the matter becomes known. R1's Nurse's Note dated 9/29/24 at 4:33 AM by V8 Licensed Practical Nurse documents V8 was at the nurse's station and heard someone yell help me. V8 documents that she went to R2's room and saw R1 standing over her as R2 was laying on the floor. R1 became aggressive when V8 asked him to leave the room. V8 documents that Emergency Medical Services (EMS) and the police were called. V8 documented that the police arrived at 1:48 AM and EMS arrived at 1:53 AM. On 10/1/24 at 12:46 PM, V1 Administrator stated that she got the call from V8 LPN at 2:00 AM on 9/29/24 and V1 did not come into the facility to send in the report to the stated until 6:30 PM on 9/29/24. V1 stated she thought she had 24 hours. The facility's facsimile reporting the possible resident to resident incident documents it was sent in on 9/29/24 at 7:02 PM to the state survey agency.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for one of ten (R5) residents reviewed for comprehensive care plan out of a sample list of ten. Findings include: The facilities Care Plan Policy dated 6/1/22 documents the facility will develop a baseline care plan within 48 hours of a resident's admission. R5's electronic face sheet dated 10/1/24 documents R5 was admitted to facility on 9/23/24. On 9/30/24 at 2:40 PM, V1 (Administrator) stated she was unable to find a baseline care plan. Electronic care plan record does not document a comprehensive care plan on 9/30/24. On 9/30/24 at 2:30 PM, V7 (Certified Nursing Assistant) stated R5 is NPO (nothing by mouth) and an one assist for transfers. V7 stated R5 will often get up alone without asking for assistance or pressing call light. V7 stated R5 likes to take his clothes off often and pulls at gastrostomy tube (G-Tube). V7 stated R5 prefers to sleep in wheelchair or recliner chair. R5 is on contact isolation for Extended Spectrum Beta-Lactamases (ESBL) in 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 F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

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 document/monitor/track resident behaviors and failed to develop/implement non pharmacological behavioral interventions for one of four residents (R1) reviewed for abuse in the sample list of 10. Findings include: The facility's Behavior Emergencies policy with a revised date of 6/1/22 documents the purpose of the policy is to ensure the safety of al resident by evaluating resident on admission and when behavior emergencies occur. This policy also documents that the nursing staff will put into action intervention techniques agreed upon after consulting with physician's. The policy documents that an evaluation by a psychiatrist (if ordered by a physician) will be completed and nursing staff will record a detailed report of behaviors. This policy documents the inter-disciplinary care plan team will meet to discuss the resident involved and review and modify the care plan as appropriate. R1's undated Care Plan documents R1 was admitted to the facility to the facility on 6/28/24 with diagnoses including Parkinson's Disease, Unspecified Dementia with Agitation, Major Depressive Disorder, Unspecified Encephalopathy and Urinary Tract Infection. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and has physical and verbal behaviors directed at others. R1's Care Plan problem dated 7/2/24 documents R1 displayed physical and verbal behaviors directed towards staff with interventions to approach slowly and explain tasks prior to initiating them. R1's medical record had no behavior tracking information prior to 9/23/24. R1's Mood and Behavior assessment dated [DATE] documents that R1 called another resident a [NAME] and called her stupid. There are no areas on this assessment that were completed. All of the questions are blank. R1's Mood and Behavior assessment dated [DATE] documents inaccurate diagnoses of Anxiety and Schizophrenia which are not documented anywhere in R1's medical record. It lists Depression also which is one of his documented diagnosis. The behaviors identified are rejection of care and wandering with Delusions. This assessment documents these behaviors occurred on third shift and he had multiple episodes. This assessment documents that the identified behaviors put R1 and others at significant risk for physical illness or injury and at risk of emotional harm. There is no further documentation of what was done to treat or address these issues. There was nothing added to the care plan or any interventions developed. R1's Nurse's Notes document verbal aggression towards staff and exit seeking behaviors starting on 6/30/24. R1's Nurse's Notes document on 7/30/24 that R1 started going into other resident's rooms in addition to the verbal aggression. R1's Nurse's Note dated 8/26/24 at 5:56 PM documents R1 continues to get into female resident's faces and when informed they are not who he thought they were he became hostile and aggressive towards staff. On 9/8/24 at 6:21 AM R1's Nurse's Note documents he continued to get into female resident's faces thinking they were his wife. He got aggressive with staff and slammed his hand down on the table. Nurse's Note dated 9/10/24 at 5:44 AM documents R1 needed a lot of redirection from entering female resident's rooms and became physical and verbal with staff. The facility's incident investigation dated 9/11/24 documents at approximately 3:48 PM, V1 Administrator was called to the Dementia Unit and was informed that R1 attempted to assist R6 from R6's wheelchair and R6 had to be lowered to the floor by a staff member. This report documents that R1 attempted to move R6 by the collar part of her sweater. This report documents that R1 was sent to the emergency room for evaluation and R1 was moved off of the Dementia unit to a different hall due to R6's family being worried about her safety. R1 was diagnosed with a Urinary Tract Infection and the only intervention developed was to move him to a different hallway. R1's Nurse's Notes dated 9/12/24 at 1:51 AM documents R1 was walking up and down the hallway going into other residents rooms and turning on their lights and waking them up. Verbal aggression towards staff with redirection. At 9:15 AM R1 was wandering up and down the halls and went through the double doors at the end of the hall, when redirected by staff to not go through the doors he lunged at the CNA, pointing his finger in her face and yelling No. R1's Nurse's Notes continue to document wandering, exit seeking and verbal aggression. On 9/19/24 R1 was setting off door alarms and when approached by staff he began swinging at them and grabbing them. R1 was sent out to the emergency room again and no new behavioral interventions were developed or implemented for R1. R1's Nurse's Notes document that R1 returned to the facility on 9/20/24 and on 9/21/24 continued to try to go into other resident's rooms. Continued documentation of aggression towards staff. On 9/22/24 at 9:40 PM, R1 Nurse's Notes document R1 was uncooperative and refusing care, R1 kept exiting the unit he was on. This note documents R1 chased a CNA (certified nursing assistant) down the hall and the CNA locked herself in the bathroom because she was scared of R1. R1 then chased another CNA into the shower room and began pounding on the shower room door. Physician was notified and an order to increase medication was obtain and unsuccessful so they sent him out to the emergency room again. R1's Nurse's Notes dated 9/25/24 at 4:03 AM documents R1 was pacing the halls and was being very combative with staff and exit seeking. Medication adjustments were made. On 9/26/24 at 10:55 PM, R1 was found in R2's room sitting on R2's bed and became combative when redirected and began to chase staff. Again (R1) was sent to the emergency room and no new interventions were developed. R1's Nurse's Notes dated 9/27/24 at 4:28 AM documents R1 continued to go into other residents rooms, he hit a CNA and a Nurse in the face and tried to spit on them. On 9/29/24 R1 pulled R2 out of her bed onto the floor and became very aggressive with staff. R1 was sent to the emergency room again. On 9/30/24 more episode of aggression are documented. On 9/30/24 at 11:30 AM, V1 Administrator stated that they just put R1 on one to one's this past weekend. They had previously just been monitoring him. On 9/30/24 at 11:38 AM, V2 Director of Nursing stated confirmed that R1's Care Plan was not updated with new behavior interventions. On 10/1/24 at 12:35 PM, V1 confirmed there was no behavior tracking being done prior to 9/23/24. V1 confirmed there were no individualized behavior plans developed or put into place for R1. On 9/30/24 at 12:45 PM, R1 was being combative with staff. He was swinging and kicking at them and pushed a nurse backwards. R1 was sent out to the emergency room again.

CONCERN (D) 📢 Someone Reported This

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

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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 obtain a stop date for a PRN (as needed) antipsychotic medication, failed to complete initial and quarterly psychotropic medication assessments, failed to document behaviors to warrant the use of an antipsychotic medication, failed to develop care plan with non-pharmacological interventions and failed to obtain psychotropic medication consents for two of three residents (R1, R9) reviewed for psychotropic medications in the sample list of 10. Findings include: The facilities policy Psychopharmacological Drug usage procedure dated 10/18/17 documents Residents will not receive Psychotropic drugs unless the medication is necessary to treat a diagnosed specific condition. PRN orders for psych drugs are limited to 14 days unless the MD extends another 14 days. Rationale needs documented in Residents medical record for PRN order. AIMS testing must be done on all residents receiving anti-psychotic drugs at start of therapy and at least every 6 months after while on therapy. Consent for use of psychopharmacological medications must be given in writing by the resident or residents representative. Documentation of behaviors and conditions requiring the use of a Psychotropic medication must be done on a routine basis as well as documentation to medication response. 1.) On 10/1/24 at 2:05 PM, R9 was ambulating independently with no assistive devices in memory unit. R9 had a spoon, butter knife and fork in her pocket that she picked up from dining room table. R9 was carrying toilet paper that she had torn off a toilet paper roll in bathroom. R9 required frequent redirection from staff during observations. R9's Minimum Data Set, dated [DATE] documents R9 is severely cognitively impaired. R9's Physician order sheet documents an order dated 9/16/24 for Seroquel 25 mg (milligrams) daily PRN (as needed) for anxiety. There is no stop date to this order and no written consent on file. The same physician order sheet documents an order dated 9/28/24 for Xanax 0.5 mg to be given one hour before showers for anxiety. There is no written consent for this medication on file. R9's care plan dated 10/1/24 does not document revisions to care plan for changes in Seroquel dosage, PRN use of Seroquel or the addition of Xanax for anxiety. R9's care plan was last revised July 2024. R9's electronic record documents an AIMS (Abnormal Involuntary Movement Scale) dated 12/15/23. V1 (Administrator) stated this is the most recent AIMS assessment on file. R9's electronic record dated 10/2/24 does not contain psychotropic medication assessments. V2 confirms there are no psychotropic medication assessments. R9s Behavior Intervention Tracking Form Dated 9/1/24-9/29/24 documents R9s behaviors as mild. R9's behavior tracking sheets do not document what behaviors are being tracked or any non-pharmacological interventions in place. On 10/2/24 at 12:00 PM, V2 (Director of Nursing) stated, I think it's my job to be monitoring Psychotropic medications, but to be honest it hasn't been done since I started in June 2024. 2.) R1's undated Care Plan documents R1 was admitted on [DATE] with diagnoses including Parkinson's Disease, Urinary Tract Infection, Unspecified Dementia with Agitation, Major Depressive Disorder and Encephalopathy. R1's Medication Administration Record (MAR) dated 9/1/24-10/1/24 documents orders for Abilify (antipsychotic) 2 mg (milligrams) one tablet by mouth for diagnosis of Dementia with Agitation with a start date of 9/26/24, Lorazepam (antianxiety) 0.5 mg three times a day for Major Depressive Disorder with a start date of 7/2/24 and an end date of 9/23/24 then an increase to Lorazepam 1 mg three times a day with a start date of 9/23/24, and Risperdal (antipsychotic) 1 mg every 8 hours as needed for Unspecified Dementia with Agitation with a start date of 9/25/24 and an end dated of 9/26/24 then a new order for Risperdal 1 mg every 8 hours as needed for Unspecified Dementia with Agitation with a start date of 9/26/24 and no stop date. R1's medical record does not contain any signed consents for any of the psychotropic medications that R1 has been given. R1's medical record does not contain any psychotropic medication assessments for any of the psychotropic medication that R1 has been given. On 10/2/24 at 11:41 AM, V1 Administrator confirmed there are no consents for R1's psychotropic medications and no assessments for those medications either.

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

Read full inspector narrative →

Based on interview and record review the facility failed to ensure insulin was administered as ordered and failed to monitor blood glucose levels as ordered resulting in a significant medication error for one of three residents (R8) reviewed for medications in the sample list of 10. Findings include: The facility's Medication Administration policy with a revised date of February 2004 documents the objective is to provide medications deemed necessary for a diagnosed condition. This policy also documents, All medications must be administered to the resident in the manner and method prescribed by the physician. R8's undated diagnosis list includes diagnoses of Acute Kidney Failure, Type 2 Diabetes Mellitus and Chronic Kidney Disease Stage 3. R8's Medication Administration Record (MAR) dated 7/1/24-7/30/24 documents orders for Insulin Lispro 100 units/ml (milliliters) per sliding scale after meals for Type 2 Diabetes Mellitus with a start date of 6/18/24. During July R8 received anywhere from 2 units to 8 units of insulin per meal. R8's MAR dated 7/1/24-7/30/24 documents an order for Insulin Lispro 100 units/ml per sliding scale at bedtime with a start date of 6/18/24. During July R8 received anywhere from 2 units to 5 units before bed. R8 MAR dated 7/1/24-7/30/24 has no blood glucose monitoring or insulin administration documented for supper and bedtime on 7/18/24 and no blood glucose monitoring or insulin administration of 7/19/24 at breakfast, lunch, supper and bedtime for a total six doses of insulin potentially missed. On 9/30/24 at 1:44 PM, V1 Administrator stated that their computers were down on July 18 and July 19 due to the Microsoft issues that were happening. V1 confirmed they did not have any paper copies of Physician's Orders to be able to tell what medications and treatments residents required. V1 confirmed some residents did miss medications. V1 stated that they got the pharmacy to send over paper copies of orders so they could administer medications. On 10/1/24 at 2:06 PM, V1 confirmed there is no documentation that R8 had any blood glucose monitoring completed and no documentation that R8 received insulin as ordered on the evening and night of July 18th, 2024 and all of July 19th, 2024.

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 F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review that facility failed to revise comprehensive care plans appropriately for five of ten residents (R1, R3, R4, R5, R9) reviewed for care plan revision out of a sample list of ten. Findings include: The facilities policy Care Plan Policy dated 6/1/22 documents, the facility will revise comprehensive care plan when there is a change in resident goals, or physical, mental, or psychosocial functioning, which was not otherwise identified in the baseline care plan. 1.) R1's Care Plan documents that R1 was admitted to the facility on [DATE] and documents a problem start date of 7/2/24 regarding R1 displaying physical and verbal behaviors directed towards staff. The only interventions for this problem were to approach R1 slowly and explain tasks prior to initiating. R1's Nurse's Notes dated 9/11/24 at 8:23 PM documents that R1 tried to transfer another resident from her wheelchair to another chair. That resident had to be lowered to the floor and R1 was sent out to the hospital for an evaluation. This behavior of resident contact was never added to the care plan and no interventions were developed. R1's Nurse's Notes document multiple trips to the emergency room for behaviors and R1's Care Plan was never updated with the behaviors or hospital trips. On 9/30/24 at 11:38 AM, V2 Director of Nursing confirmed that R1's Care Plan was not updated. 2.).R3's electronic medical record documents R3 had an unwitnessed fall in Dining room on 9/7/24. R3's Progress notes dated 9/7/24 documents R3 sustained a laceration to left side of head which required transfer to emergency room and 8 stitches to left forehead. R3's care plan dated 9/30/24 does not documen at fall on 9/7/24 or any new fall interventions. On 9/30/24 at 11:10 AM, R3 was sitting at dining room table with a bucket of farm animals in front of him. R3 is alert to self only. R3 required walking assistance using front wheeled walker and staff member using a gait belt. R3 was wearing gripper socks. 3.).R4's electronic medical record documents R4 sustained an unwitnessed fall in room on 8/21/24. R4 was sent to emergency room for pain and was admitted to hospital for a left hip fracture. R4 returned to facility on 8/25/24 with a new order for R4 to be non weight bearing until evaluated by therapy. R4 returned with an abductor cushion from hospital. R4's care plan dated 10/1/24 does not document new fall interventions on comprehensive care plan or changes in functional status after fall which resulted in fracture on 8/21/24. On 9/30/24 at 12:00 PM, R4 was sitting at Dining room table in a high back wheelchair with an abductor cushion between legs. R4 is dependent on staff for feeding assistance. R4 had nonsensical garbled speech. 4.).R5's electronic medical record documents R5 sustained an unwitnessed fall on 8/27/24 in room. Progress note dated 8/27/24 documents R5 was observed to have no gripper socks on, no adult brief and the floor was wet with urine. R5 was pushing bedside table to get to bathroom and slipped on the wet floor. R5 was sent to emergency room where R5 sustained a frontal lobe bleed. R5's care plan dated 9/30/24 does not include any care plan revisions after unwitnessed fall on 8/27/24. On 9/30/24 at 2:30 PM, R5 sitting in recliner chair in room with call light fastened to shirt. R5 is alert and pleasant but confused. R5 was unable to recall falling. 5.).R9's Physicians order sheet documents an order dated 9/16/24 for Seroquel 25 milligrams daily PRN (as needed) for anxiety. The same Physician order sheet documents an order on 9/28/24 for Xanax 0.5 milligrams on Tuesday and Fridays one hour before showers for anxiety. R9's care plan does not document any Psychotropic medication changes or non-pharmacological interventions after 7/24. On 10/1/24 at 2:05 PM, R9 was ambulating independently with no assistive devices in memory unit. R9 had a spoon, butter knife and fork in her pocket that she picked up from a dining room table. R9 also was carrying toilet paper that she had torn off a toilet paper roll in bathroom. R9 appeared very anxious and needed lots of redirection from staff. R9 is severely cognitively impaired. R9 moves frequently across unit grabbing new items. On 10/1/24 at 2:25 PM, V2 (Director of Nursing) stated that the facility nurses are supposed to modify care plans with any changes and V2 audits care plans to ensure changes have been made. V2 stated that due to staffing changes V2 has not been able to audit care plans.

Jun 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 6/25/24 at 11:05 AM R2 was lying in bed sleeping with call light in reach. On 6/25/24 at 10:55 AM V15 (R2's Family) stated R2 was complaining to family R2 doesn't get attention from nurses like R2 should. V15 stated V15 feels the issue is the facility is short staffed and uses a lot of agency staff. V15 stated V15 feels the agency staff just do whatever they want and there is no accountability. R2's Grievance Report dated 5/9/2024 documents R2's family requested a room move as they voiced concerns that R2 was not receiving enough care. R2 was moved to a different hallway. On 6/26/24 at 10:30 AM V6 stated that R2 uses her call light when she needs pain medications or becomes confused. R2's MDS dated [DATE] documents R2 has severe cognitive impairment and is dependant on staff assistance for toileting. 3.) On 6/25/24 at 9:40 AM R3 was in R3's room with call light in reach. On 6/25/24 at 9:50 AM R3 stated regular staff answer the call lights quickly, but when agency staff are working it takes forever. R3 stated second shift has been bad lately, agency staff will come in and turn the call light off and leave the room. R3's call light report dated 6/25/24 documents on 6/23/24 R3's call light was turned on at 4:36 PM and was shut off at 5:05 PM (29 minutes). R3's MDS dated [DATE] documents R3 is cognitively intact and requires substantial/maximal staff assistance with dressing, bathing, toileting, and hygiene; and partial/moderate assistance with transfers. R3's care plan dated 5/1/24 documents R3 requires assistance of one staff member for transfers. 4.) On 6/25/24 at 9:35 am R8's call light was on. There were four unidentified CNAs standing in the Clean Utility room located on R8's hallway. V7 CNA walked past R8's room and did not respond to the call light. At 9:45 AM R8's call light remained on. V3 (Registered Nurse) opened the Clean Utility door and instructed the CNAs to leave the room and answer call lights. On 6/26/24 at 9:55 AM R8 stated the facility does not have enough staff. R8 stated sometimes it takes a long time for staff to answer R8's call light. R8's MDS dated [DATE] documents R8 requires substantial staff assistance with toileting, partial/moderate assistance for transfers, and partial-maximal assistance with dressing. R8's MDS dated [DATE] documents R8 is cognitively intact. Based on observation, interview, and record review the facility failed to answer call lights and care requests timely for four (R1, R2, R3, R8) of eight residents reviewed for call lights in the sample list of eight. Findings include: The facility's Call Light policy dated January 2004 documents to answer call lights promptly, respond to resident's request, and promptly return to the room if you need to obtain assistance or supplies. The facility's Resident Council Meeting Minutes dated 4/1/24 documents residents voiced concerns that second shift Certified Nursing Assistants (CNAs) have rude attitudes when answering the call light, call lights are turned off and staff say they'll return, and CNAs are telling the residents they are short staffed and need to be patient. These minutes document that on third shift residents wait over 20 minutes for call light response. The facility's Resident Council Meeting Minutes dated 5/6/24 document residents voiced concerns that agency CNAs turn call lights off and walk out of the room without providing assistance, and CNAs are telling the residents they are short staffed and need to be patient. The facility's Resident Council Meeting Minutes dated 6/3/24 document residents voiced concerns with agency CNAs and CNAs are always on their personal cellular phones. 1.) On 9/25/24 at 9:40 AM R1 stated approximately two weeks ago, on the evening of an unidentified date, R1 was transferred onto the toilet and the two unidentified CNAs left R1's room and never came back. R1 stated R1 was left on the toilet for 30-60 minutes with R1's call light on, and had to yell and bang on the wall in order to get staff response. R1 stated usually the evening shift has a problem with answering R1's call light timely. R1 was sitting in an electric wheelchair and R1's right hand was contracted. On 6/26/24 at 9:15 AM R1 stated R1 wanted to clarify the incident occurred in the morning, and not the evening as R1 previously stated. R1 stated R1 has to wait at least 30 minutes for R1's call light to be answered in the evenings. R1's Face Sheet dated 6/25/24 documents R1 admitted to the facility on [DATE] and has diagnoses of Cerebrovascular Disease with right sided Hemiparesis/Hemiplegia. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R1's Grievance dated 6/14/24 documents R1 reported that R1 had to wait for staff assistance while sitting on the toilet for a long period of time. The facility's call light report dated 6/25/24 documents R1's call light was activated on 6/21/24 at 5:32 PM and cleared at 5:39 PM, and turned on again at 5:48 PM and cleared at 6:08 PM. This report documents R1's call light was activated on 6/24/24 at 7:14 PM and cleared at 7:34 PM. On 6/25/24 at 11:26 AM V3 Registered Nurse confirmed R1's accuracy and that R1 is cognitively intact. On 6/25/24 at 11:48 AM V11 CNA stated V11 usually works second shift and the workload is doable with the number of CNAs scheduled. V11 stated there are a few CNAs, mostly agency, who sit on their personal cellular phones and frequently leave the hall, which affects call light response times.

May 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0603 (Tag F0603)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the use of a departure alert system was being used in the treatment of medical symptoms and not for staff convenience. This failure affects one (R1) of three reviewed for supervision on the sample list of six. Findings include: R1's Face Sheet (current) documents R1 was admitted to the facility on [DATE] with diagnoses including: Transient Cerebral Ischemic Attack, Difficulty in Walking, and Muscle Wasting/Atrophy. R1's Comprehensive Assessment (MDS) dated [DATE] documents R1 is severely cognitively impaired. On 5/14/24 at 10:22am, V12 (Activity aide) stated V3 (Activity aide) got a text that R1 was across the street. V12 stated V12 and V3 ran across the street and R1 was across the road by the fence walking towards the water tower. V12 stated R1 told her she was doing a lap around when we found her. V12 stated, I have seen her walk down to the end of sidewalk and walk back up while I was outside. I was told on 5/10/24 after the incident by (V13(Social Service Director)) and (V1) that residents are not allowed to go outside by themselves. I was called Friday asked if I knew how (R1) got outside.( V13) told me on Friday after the incident that residents cannot walk sidewalk unattended. I was not aware of this until after the fact. Residents just normally go outside by themselves other than residents with wander guards. I was never told different until Friday. I was told its activities staff responsibility as of today (5/15/24) that activities staff has to go outside with them. (R1) walks around facility often and will come sit up front. (R1) normally would go outside by herself and come back in when she wanted. I don't feel she needs a departure alert system on. On 5/14/24 at 10:30am, R1 observed laying in bed with a departure alert system around right ankle. R1 stated, they put it there because I went for a walk and didn't tell anyone R1 stated, I feel like I'm in prison. On 5/14/24 at 10:45am, V3 Activity stated V3 was busy with an activity with residents when this happened. V3 stated V3 received a text message on 5/10/24 at 3:17pm from an off duty staff member (V11 Dietary Aide) telling V3 that R1 was down the road by the buses and water tower. V3 stated V3 ran out of the facility to this location and V3 reported it was really busy as school was letting out and there were lots of cars coming. V3 stated, When I found her, she was standing by a fence where they lock the buses up at the school bus garage. I asked her what she was doing and (R1) stated , 'I went for a walk.' V3 stated V1 arrived in V1's car at that time and they assisted R1 in car and back to facility. On 5/15/24 9:10 am, V14 Certified Occupational Therapy Assistant stated as of 5/6/24 R1 was independent with ambulation/transfers and uses a four wheeled walker for ambulation and she has always used a walker since being here. On 5/15/24 at 11:55 am, V9 R1's Representative stated V9 was notified of R1 crossing the street on 5/10/24 by V1. V9 stated R1 loves to walk and realized she had gone too far. V9 stated R1 told V9 it was upsetting when staff came running towards R1 and picked R1 up in a car. V9 stated the plan is for R1 to transition into assisted living after completing therapy. V9 stated V9 comes to the facility most evenings and takes R1 for a drive or walk. V9 stated the departure alert system on R1 is really upsetting to her and feels like she's in prison. On 5/15/24 at 1:34 pm, V1 Administrator in Training stated R1's departure alert system was placed on 5/10/24 after R1 left the facility property as a precautionary measure. V1 stated this was due to less management/supervision going into the weekend in case [R1] decided to go for another lap (walk) again. On 5/15/24 at 1:55 pm, V7 Certified Dietary Manager stated V7 has been completing assessments including elopement and portions of the MDS on residents. V7 stated V7 has been cross trained by V13 (Social Service Director) and V15 Corporate RN. V7 stated V7 was instructed by V1 to place the departure alert system on R1 on 5/10/24 as a precautionary measure. V7 stated, it's not appropriate. I don't feel she's trying to leave. She's not packing belongings or exit seeking. V7 stated R1 is a former smoker. V7 stated R1 was upset on Friday (5/10/24) when V7 placed the departure alert system on R1. R1's Elopement Risk Assessments completed on 4/25/24 and 5/13/24 both indicate R1 is not an elopement risk. R1's Care Plan (5/1/24) does not have R1 as an elopement risk or a departure alert system documented. The facility Restraint Policy dated 11/28/17 documents the following: It is the policy of the facility to strictly limit the use of restraints in the facility and to promote the least restrictive environment for the resident. No physical restraints with locks shall be used. Neither physical nor chemical restraints shall be used on a resident for the purpose of discipline, convenience, or to unnecessarily inhibit a resident's freedom of movement or activity and that are not required to treat the resident's medical symptoms. Definition: Convenience- the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care, and is not in the resident's best interest.

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

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 accurately complete R1's comprehensive assessment. This failure affects one (R1) of three residents reviewed for accuracy of assessments on the sample list of 6. Findings include: R1 was observed intermittently throughout the survey on 5/14/24 and 5/15/24 utilizing a four-wheeled walker for ambulation. R1's Face Sheet (current) documents R1 was admitted to the facility on [DATE] with diagnoses including: Transient Cerebral Ischemic Attack, Difficulty in Walking, and Muscle Wasting/Atrophy. R1's Care Plan dated 5/1/24 documents the following entries dated 5/8/24: uses a walker with one assist. R1's Comprehensive Assessment (MDS) dated [DATE], Section GG Functional Abilities and Goals, documents R1 uses a motorized wheelchair and/or scooter. On 5/14/24 at 10:30am, V5 Regional Nurse Consultant stated the facility does not currently have an MDS Coordinator. On 5/15/24 at 9:10am, V14 Certified Occupational Therapist Assistant stated R1 uses a four-wheeled walker for ambulation. On 5/15/24 at 11:55am, V9 R1's Representative stated R1 uses a walker for ambulation. On 5/15/24 at 1:55pm, V7 Certified Dietary Manager stated V7 has been cross-trained on completing resident MDS's. V7 stated V7 did not complete the section related to functional abilities/goals on R1's 5/1/24 MDS. V7 stated V7 does not complete that section on any resident. V7 stated that section was completed by V13 Corporate Registered Nurse. V7 confirmed R1 uses a four-wheeled walker for ambulation and not a motorized wheelchair and/or scooter. V7 stated R1 has used a walker since admission to the facility. The facility MDS Completion Policy dated 6/1/22 documents the following: The facility will designate a MDS Coordinator to facilitate the completion of the required assessments. Each discipline is responsible for completing their assigned sections of the MDS. MDS Coordinator: Section GG.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to develop and implement a person centered comprehensive care plan for elopement (R2 and R3) for two of three residents reviewed for elopement in the sample list of 6. Findings include: The facility Risk for Elopement list dated 5/13/24, documents R2 and R3 as elopement risks. R2's Care Plan dated 5/1/24 does not include elopement. R3's Care Plan dated 5/1/24 does not include elopement. On 5/14/24 at 10:30 am V5 Regional Nurse Consultant states that care plans are not being updated because they don't have a Care Plan Coordinator or MDS Coordinator. V5 confirms that R2 and R3 do not have an Elopement Risk care plan and the departure alert system is not documented on R1's comprehensive care plan. The Missing Resident Policy dated 2/25/19 Residents at risk for wandering shall be assessed and addressed on the care plan. The facility Care Plan Policy revised on 6/1/22 states: It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Mar 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to notify a resident's (R1) Health Care Power of Attorney of the delayed collection and results of an ordered urinalysis with subsequent bacteria growth, resulting in antibiotic treatment. R1 is one of three residents reviewed for family notifications of treatments and changes in conditions on the sample of eight. Findings include: R1's Physician Order Sheet dated February includes an order dated 2/27/24 for a UA/C&S (Urinalysis with Culture and Sensitivity). R1's Progress Notes dated on 3/2/24 and on 3/4/24 document urine was collected for the above order. The 3/2/24 urine sample was not sent and the sample of 3/4/24 was sent to the laboratory for testing (6 days after the order to collect one). R1's Laboratory report dated 3/4/24 documents R1's urine as being positive and a culture and sensitivity was completed. On 3/6/24 per Laboratory reports, R1's urine grew the bacterium of Escherichia coli with greater than 100,000 colony forming units per milliliter of urine in the sample. On 3/7/24 an order for Cefdinir (antibiotic) 300 mg (milligrams) twice a day for 7 days is documented in R1's Medical Record. There is no documentation in R1's Medical Record that R1's family or Health Care Power of Attorney (V6) was notified of the results or treatment of R1's Urinary Tract Infections. On 3/22/24 at 1:00 pm, V6 stated the facility never notified V6 of their failure to get the ordered urine collection when they were supposed to. Nor did the facility notify V6 of the results and subsequent treatment. On 3/26/24 at 11:05 am, V1 Administrator confirmed that V1 had a conversation with V6 about the facility's failure of notifying V6 of R1's urinalysis/culture results and subsequent 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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a routine bath and/or shower to one (R1) of three residents reviewed for bathing in the sample of eight. Findings include: R1's Minimum Data Set, dated [DATE] documents the following: R1 is moderately cognitively impaired, incontinent of both urine and bowel and needs substantial assist with activities of daily living. R1's Care Plan (current) directs staff to assist with showers on Wednesday and Saturdays. R1's Shower data sheet documents R1 receiving a shower on 3/9/24 and not getting another shower until 3/17/24 (8 days later). There were no hospitalizations during this time per the Facility Census Sheet. On 3/26/24 at 10:00 am, R1 stated he doesn't remember when R1's showers are given, but R1's family have told R1 that R1 smells at times. On 3/26/24 at 11:00 am, V2 Director of Nursing confirmed the facility did not have documentation that R1 received a shower after 3/9/24 until a shower was given on 3/17/24.

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

Read full inspector narrative →

Based on interview and record review, the facility failed to collect and send an ordered urine sample for a resident (R1) with a known history of Urinary Tract Infections in a timely manner. Thus, delaying treatment for a positive urinalysis and culture. R1 is one of three residents reviewed for Urinary Tract Infections and treatment in the sample of eight. Findings include: R1's Face Sheet dated January 2024 (on admit) includes the following diagnoses: Benign Prostatic Hypertrophy, Urinary Tract Infection, Difficulty Walking, Muscle Wasting and Chronic Kidney Disease. R1's Physician Order Sheet dated February includes an order dated 2/27/24 for a UA/C&S (Urinalysis with Culture and Sensitivity). R1's Progress Notes document the following: 02/27/2024 at 12:55 pm - Communication faxed to (V9 Primary Care Physician) notifying of resident (R1's) noticeable decline over the last couple of days. Awaiting new orders. 02/27/2024 at 5:16 pm - (V9) faxed back the following orders: obtain CBC (Complete Blood Count), CMP (Comprehensive Metabolic Profile), TSH (Thyroid Stimulating Hormone), UA (Urinalysis). 02/28/2024 at 12:27 pm - Spoke with residents (R1) POA (V6 Power of Attorney) regarding (V6's) concerns this am. Lab has been drawn UA needs to be collected. 03/02/2024 at 5:52 pm - Urine specimen collected. In 300 hall fridge (3 days after the order). 03/04/24 at 4:52 pm - Writer obtained UA. UA sent to lab (2nd Urine specimen collected 5 days after the initial order). R1's Laboratory report dated 3/4/24 documents the following positive results on R1's UA: Urine Nitrites = Positive, normal range is Negative/trace. Urine Albumin = 1+ normal is documented as Negative Urine Blood = 2+ normal range is documented as 0-.5 blood cells per high powered field (HPF) of urine sediment. Urine [NAME] Blood Cells = greater than 100, normal range is documented as 0-2 /HPF of urine sediment. Urine Red Blood Cells = 3-5, normal range is documented as 0-2/HPF of urine sediment. Urine Bacteria = 4+ normal range is documented as Negative A Culture and Sensitivity was completed due to R1's urinalysis being positive and is documented as follows: R1's Laboratory report dated 3/6/24 documents that R1's urine grew the bacterium of Escherichia coli of greater than 100,000 colony forming units per milliliter of urine in the sample. On 3/7/24 an order for Cefdinir (antibiotic) 300 mg (milligrams) twice a day for 7 days is documented in R1's Medical Record. R1 received the first dose on 3/8/24 per R1's Medication Administration Records. R1's antibiotic was later changed to a different antibiotic of Cipro 250 mg every 12 hours on 3/14/24. On 3/26/24 at 11:00 am V2 Director of Nursing confirmed that R1's urine collected on 3/2/24 (three days after order was received) had sat out too long or was not sent to the lab when it should have. V2 confirmed V2 found out about it on 3/4/24 and the urine was then collected and sent (5 days after urinalysis was ordered). V2 also confirmed that R1 received R1's first dose of an antibiotic (Cefdinir) on 3/8/24 (10 days after staff reported a noticeable decline in R1 on 2/27/24).

Feb 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to administer significant medications (which can jeopardize resident's health and safety) for one of four residents (R8) reviewed for significant medications in the sample list of four. Findings include: R8's undated Face Sheet documents R8's diagnoses as: Cerebral Infarction, unspecified and Chronic Atrial Fibrillation, unspecified. R8's MAR dated 1/1/24 - 1/31/24, documents Amiodarone (chronic atrial fibrillation) 200 mg once a day, not administered on 1/28/24 or 1/29/24 documenting drug unavailable on both days. This same POS documents Lasix (heart failure) 20 mg once a day, not administered on 1/15/24, 1/16/24, 1/17/24, 1/28/24, and 1/29/24, documenting drug unavailable for all five days. On 2/1/24 at 10:30 AM, V1 Administrator stated V1 was unaware of medications being given late and medications not being available in the convenience box. On 2/1/24 at 3:16 PM, V7 Corporate Nurse, stated if medications have not been taken in a few days the doctor should notified. The facility's Medication Errors and Drug Reactions Policy dated Revised 02/04, documents the objective is to safeguard the resident. The facility's Pharmaceutical Procedures Policy dated Revised 01/05/23, documents medication errors should be reported to the resident's physician as soon as possible.

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

Read full inspector narrative →

Based on interview and record review, the facility failed to accurately document medication distribution times for three residents (R4, R6, R7) of four residents reviewed for accurate medication administration documentation in the sample list of four. Findings include: R4's Medication Administration Record (MAR) dated 1/1/24 to 1/31/24, documents on 1/29/24, R4 received 7:00 AM-10:00 AM medications at 3:54 PM. These medications include: Cholecalciferol, Lasix, Lisinopril, Lorazepam, Zoloft, and Seroquel. R6's MAR dated 1/2/24 to 1/31/24, documents on 1/29/24, R6 received 7:00 AM-10:00 AM medications at various times. These medications include: Aspirin 3:50 PM; Cholecalciferol 3:50 PM; Diclofenac Sodium, 2 doses at 2:39 PM; Folic Acid 3:50 PM; Furosemide (twice a day) 3:50 PM; Leflunomide 3:50 PM; Metoprolol Succinate 3:50 PM; Potassium Chloride (twice a day) 3:50 PM; and Prilosec 3:50 PM. R7's MAR dated 1/2/24 to 1/31/24, documents on 1/29/24, R7 received 7:00 AM-10:00 AM medications at 4:01 PM and/or given two doses at one time. These medications include: Amlodipine; Aspirin; Dicyclomine (three times a day), two at 4:01 PM; Ferrous Sulfate (three times a day), two given at 4:01 PM; Folic Acid; Lasix; Metoprolol (twice a day), given first dose at 4:01 PM; Omeprazole; Paxil; Plaquenil (twice a day); and Seroquel (twice a day), given first dose at 4:01 PM. R4, R6, R7's MARs were documented as charted late instead of given late on 1/29/24 by V3 Licensed Practical Nurse (LPN). On 1/31/24 at 2:00 PM, V16 LPN stated medications are charted on when given. On 1/31/24 at 3:11 PM, V4 LPN stated medications are to be signed off when given. On 2/1/24 at 10:30 AM, V7 Regional Nurse Consultant stated medications should be charted when given and if given late then that's what should be documented instead of charted late. On 2/2/24 at 11:55 AM, V3 LPN stated V3 should have documented given late instead of charted late when giving the 7:00 AM-10:00 AM medications in the afternoon on 1/29/24. The facility's Pharmaceutical Procedures Policy dated Revised 1/5/23, documents charting of administration of medications shall be done immediately after administration.

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 F0659 (Tag F0659)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to follow medical doctor's medication administration orders for four residents (R5, R6, R7, R8) of four residents reviewed for medication administration/distribution in the sample list of four. Findings include: R5's undated Face Sheet documents R5's diagnoses as: Major Depressive Disorder, Pain, unspecified, unspecified Dementia, and Diabetes Mellitus with unspecified complications. R5's Physician Orders dated 1/1/24 to 1/31/24, document orders for Cymbalta (Antidepressant/Nerve Pain) 60 milligrams (mg) by mouth twice a day, Gabapentin (Antidepressant/Nerve Pain) 600 mg 0.5 tablet by mouth twice a day, Memantine (Dementia/Memory Loss) 10 mg by mouth twice a day, Metformin (Antidiabetic) 500 mg by mouth twice a day, and Naproxen (Anti-inflammatory/Pain) delayed release/enteric coated 500 mg by mouth twice a day. R5's Medication Administration Record (MAR) dated 1/29/24, documents the 7:00 AM - 10:00 AM doses of all the medications as missed/not given. R6's undated Face Sheet documents R6's diagnoses as: Essential (primary) Hypertension. R6's Physician's Orders dated 1/1/24 to 1/31/24, document an order for Hydralazine (Hypertension) 10 mg two tablets three times a day. R6's MAR dated 1/29/23, documents the 8:00 AM dose as drug not available. R7's undated Face Sheet documents R7's diagnoses as: Anemia and Iron Deficiency. R7's January 2024 MAR documents instructions for R7 to have Ferrous Sulfate (Anemia) 325 mg by mouth three times a day. R7's MAR dated 1/29/24, documents two doses given at 4:01 PM and no morning dose administered. R8's undated Face Sheet documents R8's diagnosis as: Chronic Atrial Fibrillation. R8's MAR dated 1/28/24 and 1/29/24, documents Amiodarone (Chronic Atrial Fibrillation) 200 mg by mouth once a day drug not available; and Lasix (Heart Failure) 20 mg by mouth once a day drug not available on 1/15/24, 1/16/24, 1/17/24, 1/28/24, and 1/29/24. On 1/31/24 at 2:47 PM, V3 Licensed Practical Nurse (LPN) stated if there is no medication (to give when due), we can get into the safe box (convenience box) and fax the information to the pharmacy so it will come that night and if it's a really important medication, we can fax to the doctor, but usually really important medications are in the safe box (convenience box). On 2/1/24 at 10:30 AM, V7 Regional Nurse Consultant stated if a medication is not available, the nurses should check the convenience box. V7 stated we do have back up pharmacies in town and a last ditch effort would be get an order from the doctor to hold the medication until delivery or get an alternative medication. The facility's Pharmaceutical Procedures Policy dated Revised 1/5/23, documents all medications shall be given as prescribed by the physician and at the designated time. This policy also documents a convenience box may be kept at the facility in a locked cabinet or a locked medication room and is to be used for starter or first doses and normal ordering procedures should follow to ensure residents receive a full supply of the ordered medication.

Jan 2024 13 deficiencies

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to obtain Level 2 PASARR (Pre-admission Screening and Record Review) for residents receiving a mental illness diagnosis during their residency at the facility. This failure affects three residents (R14, R35, R43) out of six reviewed for PASARR on the sample list of 31. Findings include: 1. R14's current Face Sheet dated 1/10/24 documents R14 was originally admitted to the facility 8/11/21. R14's original OBRA (Omnibus Reconciliation Act) Pre-admission Screen dated 7/28/21 documents there was no reasonable basis to suspect mental illness or developmental disability for R14. R14's current Face Sheet dated 1/10/24 documents R14 received a mental illness diagnosis 'Psychotic Disorder with Delusions Due to a Known Physiological Condition' on 10/7/21. R14's current Physician Order Sheet dated 1/10/24 documents R14 receives the anti-psychotic medication Quetiapine 150 milligrams (mg) each bedtime and 100 mg each morning, prescribed for R14's mental illness diagnosis of Psychotic Disorder with Delusions Due to a Known Physiological Condition. R14's Electronic Medical Record (EMR) did not contain a Level 2 PASARR, nor any mental health screening, to determine if R14 required any specialized services related to the mental illness diagnosis. 2. R35's current Face Sheet dated 1/9/24 documents R35 was originally admitted to the facility 1/23/15. R35's original OBRA Pre-admission Screening dated 1/21/15 documents there was no reasonable basis to suspect mental illness or developmental disability for R35. R35's current Face Sheet dated 1/9/24 documents R35 received a mental illness diagnosis of 'bipolar disorder' on 11/17/18, and a mental illness diagnosis of 'Unspecified Psychosis Not Due to a Substance or a Known Physiological Condition' on 3/8/08. R35's current Physician Order Sheet dated 1/9/24 documents R35 receives an off-label prescription for Depakote 250 mg twice daily for the diagnosis bipolar disorder, and the anti-psychotic medication Seroquel (quetiapine) 100 mg each evening and 50 mg each morning for the diagnosis Unspecified Psychosis Not Due to a Substance or a Known Physiological Condition. R35's EMR did not contain a Level 2 PASARR, nor any mental health screening, to determine if R35 required any specialized services related to the mental illness diagnoses. 3. R43's current Face Sheet dated 1/10/24 documents R43 was originally admitted to the facility 1/10/22. R43's original OBRA Pre-admission Screen dated 12/3/21 documents there was no reasonable basis to suspect mental illness or developmental disability for R43. R43's current Face Sheet dated 1/10/24 documents R43 received a mental illness diagnosis 'schizoaffective disorder' on 3/7/22. R43's current Physician Order Sheet dated 1/10/24 documents R43 receives the anti-psychotic medication Seroquel (quetiapine) 25 mg each bedtime for the mental illness diagnosis schizoaffective disorder. On 1/10/24 at 2:12 PM, V6 (Social Services Director) stated, I have nothing else for those three residents (R14, R35, and R43). V6 then referred to the Regional Nurse (V2) to clarify if these residents should have had a Level 2 Screening after receiving the mental illness diagnoses, and V2 nodded her head in the affirmative. V6 then stated, I will get those three referred into the system so they will be cued up for screening.

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline Care Plan within 48 hours of resident's admission for one resident (R376) of one resident reviewed for Care Plans in the sample list of 31. Findings include: R376's undated Face Sheet documents R376's medical diagnoses as: Diabetes Mellitus Due to Underlying Condition without Complications, Pain in Unspecified Hip, Essential (primary) Hypertension, Chronic Obstructive Pulmonary Disease, Chronic Atrial Fibrillation, Pulmonary Hypertension, Calculus of Kidney, Low Back Pain, and Constipation. This same Face Sheet documents R376 was admitted to the facility on [DATE] at 1:30 PM. There was no baseline care plan in R376's medical record. On 1/10/24 at 2:50 PM, V2 (Regional Nurse) confirmed there was not a baseline care plan for R376 and V2 just did it. The facility's Care Plan Policy dated Revised 6/1/22, documents the baseline Care Plan will be completed within 48 hours of a resident's admission by gathering information from the admission body assessment, hospital transfer information, physician's orders, and discussion with the resident and resident representative. This policy also documents to include the minimum healthcare information necessary to properly care for a resident including but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and Preadmission Screening and Resident review (PASARR) recommendations.

CONCERN (D)

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

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a discharge summary for one resident (R73) who was discharged to another nursing facility. R73 is one of one resident reviewed for discharge in a sample list of 31. R73's closed Electronic Medical Record documents R73 initiated a discharge to another nursing facility. R73's historical Physician Order Sheet dated October 2023 documents the facility had received an order for R73 to be transferred to another nursing facility on 10/25/23. R73's care plan dated 9/7/23 does not contain any information concerning preparation for R73 and the impending discharge. The family of R73 came to the facility on [DATE] to transfer R73 to her new facility and the family was not given discharge information for R73 including a medication list or required levels of assistance. R73's closed Electronic Medical Record did not have any discharge summary or recapitulation of stay. Information stated in R73's progress notes was an order was received on 10/25/23 and R73 was discharged to another facility on 10/27/23. V1 (Administrator) and V2 (Corporate Regional Nurse) both stated on 1/11/24 at 10:35 am there is no discharge summary for (R73).

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

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 provide showers to residents according to their plans of care, physician orders, and preferences. This failure affects two residents (R10, R26) out of four reviewed for activities of daily living on the sample list of 31. Findings include: 1. On 1/10/24 at 12:57 PM, at the resident group interview, R10 stated, The showers are not getting done, the staff say they are too busy, or they are short staffed. R10's Minimum Data Set (MDS) dated [DATE] documents R10 received a score of 15 out of a possible 15 for a Brief Interview for Mental Status (BIMS), rating R10 as cognitively intact. This same MDS documents R10 requires partial to moderate assistance for transfers from chair to shower, and for showering. R10's current Physician Order Sheet and Care Plan, both dated 1/10/24 document R10 is scheduled to receive showers twice weekly on Mondays and Thursdays. R10's documented Shower Sheets dated 11/2/23 through 1/8/24 document R10's showers were given as scheduled with one exception on 11/16/23 when R10 had a doctor appointment, and two exceptions on 12/4/23 and 12/11/23 which were documented as refused. On 1/11/24 at 02:18 PM, R10 stated, My scheduled shower days are Mondays and Thursdays. I get them regularly on the Thursdays, but Mondays I do not get them regularly at all, Mondays seem to be a bad day. R10 further stated, I have never ever refused a shower. R10 then stated, If they are marking on the sheets that I am getting them on Mondays, or marking that I am refusing, I don't want to say they are lying but they are trying to make it look like they are doing their jobs and make it look good. R10 continued, They usually say they are too busy or short of help. R10 concluded by stating, Once a week shower is not what I am used to, I am used to taking one every day and after the second day you start to feel bad about yourself and after a week you get really smelly. 2. On 1/9/24 at 10:20 AM, R26 was seated in a wheelchair in R26's own room. R26 had a remarkable oily smell around her seemingly emanating from the head area, like unwashed hair. On 1/9/24 at 10:20 AM, R26 stated, I haven't been getting my showers right. I went almost two weeks without one. R26 further stated, They say they are too busy. R26 continued, I am supposed to get showers on Saturday and Wednesday evenings. I did get one this past Saturday evening (1/6/24) and I should be scheduled for one tomorrow evening. R26's MDS dated [DATE] documents R26 received a score of 14 out of a possible 15 for a BIMS, rating R26 as cognitively intact. This same MDS documents R26 requires partial to moderate assistance for chair to shower transfers, and for showering. R26's Physician Order Sheet and Care Plan, both dated 1/11/24, document R26 is scheduled for showers each Saturday and Wednesday. R26's Nurses Notes dated 11/15/23 through 1/11/24 document R26 was admitted to the facility on [DATE]. R26's documented Shower Sheets dated 11/15/23 through 1/6/24 document the first documented shower received by R26 was 11/25/23 (10 days after admission). These same shower sheets document R26 only received a hair wash on 12/2/23 and 12/9/23. These same shower sheets document R26 refused a shower four times on 12/13/23, 12/16/23, 12/23/23, and 1/6/23 (which R26 stated she had received). On 1/11/24 at 02:33 PM, R26 stated, Yes I remember not getting showers, it was a real close estimate to say it was about 2 weeks after I got here before I got a shower. R26 then stated, I have refused a shower only one time because it was offered to me late at night and I had visitors, and I was already cold, so I told them let's just wait until the next day. R26 then stated, There was one time I asked them not to wash my hair because I wasn't feeling good and I was coughing, so the aid said, 'we better not wash your hair' because she didn't want me to get sicker with wet hair. R26 then reiterated, I am positive I got my shower this past Saturday (1/6/24).

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

Read full inspector narrative →

Based on interview and record review, the facility failed to complete skin risk assessments, wound management daily reports, document weekly wound descriptions/measurements, and complete weekly skin checks for one resident (R67) of two residents reviewed for pressure ulcers in the sample list of 31. Findings include: R67's undated Face Sheet documents R67's diagnoses as: Cerebral Infarction, Muscle Wasting and Atrophy, Need for Assistance with Personal Care, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. R67's Physician orders dated 1/2024, document for staff to conduct weekly skin checks on Wednesdays 7:00 AM - 3:00 PM shift. R67's Treatment Administration Record (TAR) dated 7/1/23-7/31/23, the documentation of R67's weekly skin checks were not documented as being completed on Wednesday 7/5/23, Wednesday 7/12/23, Wednesday 7/19/23; TAR dated 8/1/23-8/31/23, the documentation of R67's weekly skin checks were not documented as being completed on Wednesday 8/16/23, Wednesday 8/23/23, Wednesday 8/30/23; TAR dated 9/1/23-9/30/23, the documentation of R67's weekly skin checks were not documented as being completed on Wednesday 9/6/23, Wednesday 9/13/23; TAR dated 12/1/23-12/31/23, the documentation of R67's weekly skin checks were not documented as being completed on Wednesday 12/13/23. R67's Observation Reports were completed on 7/21/23, 8/7/23, 9/14/23, and not again until 12/20/23, and no other reports completed through 1/12/24. R67's Wound Management Detail Report was only completed on one day, 10/16/23 in which on this date R67 was documented as having a wound. On 1/11/24 at 12:42 PM, V2 (Regional Nurse/Interim Director of Nursing), stated we do not have the first four weeks of skin risk assessments for R67, and they should have been done, we do not have Pressure Ulcer Assessments being done weekly and they should have been, we do not have consistent weekly skin checks being done and we should have. The facility's Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol dated Revised 10/24/22, document a skin risk assessment is completed on all residents when admitting to the facility and weekly for the first four weeks after admission, then quarterly; assess a pressure injury for location, size, wound bed, drainage, odor, tunneling, undermining or sinus tract, wound edges/surrounding tissue, pain, and determine the injury's current stage of development.

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

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to maintain humidification of supplemental oxygen, failed to change oxygen tubing, and failed to document physician orders for oxygen administration. These failures affect one resident (R26) out of one reviewed for oxygen on the sample list of 31. Findings include: On 1/9/24 (Tuesday) at 10:14 AM, R26 was seated in her own room in a wheelchair. R26 was receiving supplemental oxygen from a concentrator at two liters by a nasal cannula. R26's undated oxygen humidifier bottle was completely empty and dry, and the oxygen cannula tubing was not dated. On 1/9/24 at 10:14 AM, R26 stated, I am having trouble breathing this morning. I am all stopped up. I had covid last month and this is day 20 of my breathing troubles. On 1/9/24 at 12:12 PM, V4 (Registered Nurse/RN), stated, We change the humidifier bottles and tubing once a week. On 1/9/24 at 12:12 PM, V5 (RN), stated, We change them once a week on Monday nights. The changes are marked on the MARs (Medication Administration Records). On 1/9/24 at 3:30 PM, R26 was seated in her own room receiving oxygen from the concentrator. The humidifier bottle remained undated and completely dry, and the oxygen cannula tubing remained undated. On 1/9/24 at 3:35 PM, V19 (Licensed Practical Nurse), stated, I have been working this hall (hall where R26 was residing) since 6:00 AM. V19 then stated, I am new, so I am not sure what the facility policy says for changing oxygen tubing and water bottles. If the water bottle is dry, then it definitely would need to be changed. On 1/9/24 at 3:35 PM, V2 (Regional Nurse) stated, The bottles and tubing should be changed weekly, and my preference is for them to be dated when they are changed. V2 continued, If the bottle is empty then it needs to be replaced. R26's Medication Administration Record dated for January 2024, and current and historical Physician Order Sheet, both dated 1/11/24 documents there was not a physician order nor a medication administration record entry for R26's oxygen administration nor for oxygen tubing and humidifier bottle changes until 1/9/24. R26's Nurse Notes dated 12/20/23 documents R26 had been using oxygen at the facility since 12/20/23. The facility's policy 'Oxygen Therapy and Safety' dated 4/9/20 documents, Humidifier bottle attached to tank flow meter and filled to appropriate level with sterile distilled water.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to obtain physician responses, and failed to implement physician responses, for consultant pharmacist recommendations. This failure affects three residents (R14, R34, and R43) out of five reviewed for unnecessary medications on the sample list of 31. Findings include: 1. R14's Medication Regimen Reviews (MRRs) dated 4/20/23, 5/8/23, 6/19/23, 7/18/23, 8/14/23, 9/25/23, and 10/25/23, all documented the same recommendation from V14 (Registered Consultant Pharmacist), This resident has an order for the following inhaled corticosteroid: Trelegy Ellipta. To prevent candidiasis (thrush) caused by the inhaled corticosteroid, ensure the resident rinses their mouth with water (swish and spit) after each inhalation. Please consider adding this to the order on the MAR (Medication Administration Record). None of the 7 monthly Medication Regimen Reviews documented any follow-up with R14's physician, any response from R14's physician, nor any consideration by the facility's nursing staff to implement or decline to implement V14's recommendations. 2. a. R34's MRR dated 5/1/23 documents Consultant Pharmacist (V15) recommendations to change the diabetic medication Ozempic from once monthly to once weekly because this medication was designed to be injected weekly in order to maintain proper blood sugar levels; to separate the thyroid medication Levothyroxine from the mineral supplement Magnesium by at least 4 hours to ensure proper absorption of the Levothyroxine. There was a documented Physician response okay. R34's current Physician Order Sheet dated 1/10/24 documents R34 continues to receive the diabetic medication Ozempic once monthly on the first Monday of each month since 4/25/23. This same Physician Order Sheet documents R34 continues to receive the thyroid medication Levothyroxine as scheduled daily between 3 AM and 6 AM, while the mineral supplement Magnesium is administered at 8:00 AM, Noon, and 4:00 PM, also since 4/25/23, leaving the potential for the two medications to be administered to R34 with only a one hour difference as 8:00 AM dose of Magnesium can be administered one hour earlier or one hour later than the scheduled time. On 1/11/24 at 1:21 PM, V2 (Regional Nurse) acknowledged the Pharmacist medication recommendations should have had some follow-up and should have been implemented by nursing staff. V2 concurred the Magnesium could be scheduled at Noon, 4:00 PM, and 8:00 PM. 2. b. R34's MRR dated 7/2/23 documents a consultant Pharmacist (V15) recommendation This resident is currently receiving more than one ophthalmic preparation. The eye drop must make full contact with the eye, and it must have sufficient contact time before the next drop is administered. A minimum of 3 - 5 minutes is suggested for the majority of ophthalmic preparations. Please consider adding the wait time to the order itself. This form has no documentation that the recommendation was communicated to R34's physician, and no documented follow-up that nursing staff had considered implementing, or declined to implement, the Pharmacist recommendation. R34's MRR dated 12/14/23 documents a consultant Pharmacist (V16) recommendation This resident is currently receiving more than one ophthalmic preparation: Pataday, Refresh Optive, and Carboxymethylcellulose (Artificial Tears). The eye drop must make full contact with the eye, and it must have sufficient contact time before the next drop is administered. A minimum of 3 - 5 minutes is suggested for the majority of ophthalmic preparations. Please consider adding the wait time to the order itself. R34's current Physician Order Sheet dated 1/10/24 documents R34 had been receiving the multiple eye drops without the recommended administration instructions from 4/25/23 through 12/15/23. 3. a. R43's MRR dated 2/14/23 documents a consultant Pharmacist (V16) recommendation for a dosage reduction of the antipsychotic medication Quetiapine, from 12.5 mg each bedtime to 12.5 mg each bedtime Monday through Saturday and 6.25 mg at bedtime each Sunday. This MRR documents dosage reduction attempts are required by the Centers for Medicare and Medicaid Services (CMS). This same MRR has no documented physician response to accept nor decline the recommendation. R43's current and historical Physician Order Sheets dated 1/10/24 documents R43 continued to receive Quetiapine 12.5 mg each bedtime through 9/8/23 when the medication was increased to 25 mg each bedtime. 3. b. R43's MRR dated 4/20/23 documents a consultant Pharmacist (V16) recommendation for a dosage reduction of the antidepressant medication Escitalopram, from 10 mg daily to 10 mg Monday through Saturday and 5 mg on Sundays. This MRR documents dosage reduction attempts are required by CMS. This MRR has no documented physician response to accept nor decline the recommendation. R43's current and historical Physician Order Sheets document R43 has received the antidepressant Escitalopram 10 mg daily continuously through 1/10/24. On 1/11/24 at 1:09 PM, V2 (Regional Nurse) stated, The normal process for these MRR's is supposed to be, when the Pharmacist sends the recommendations, the Director of Nursing is supposed to review them, then send them to the physician and the physician signs them either to accept or decline the recommendation. If the physician declines, he is supposed to document why. On 1/11/24 at 1:21 PM, V1 (Administrator) and V2 concurred that All of these MRR's should have been addressed but were not.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based observation, interview, and record review, the facility failed to follow basic infection control procedures during indwelling catheter care for one resident (R67) of one resident in the sample list of 31. Findings include: R67's undated Face Sheet documents R67's diagnoses as: Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Urinary Tract Infection, and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. R67's Physician Order Sheet dated 1/1/24 through 1/10/24, documents indwelling catheter care every shift. R67's Care Plan dated 12/15/23, documents R67 will have indwelling catheter care managed appropriately as evidenced by not exhibiting signs of infection. On 01/10/24 at 1:50 PM, observed indwelling catheter care for R67 by V12 (Certified Nursing Assistant/CNA). V12 wore the same gloves from beginning of indwelling catheter to end of indwelling catheter care without ever changing V12's gloves. On 1/10/24 at 2:10 PM, V11 (Licensed Practical Nurse/Infection Preventionist) stated V12 should have changed gloves any time going from dirty to clean and using hand sanitizer or washing hands if hands are visibly soiled. The facility's Infection Control Policy dated Revised 12/17/19, documents Standard Precautions are based on the principle that all body fluids may contain transmissible infectious agents and Standard Precautions should be applied to the care of all residents. This same policy also documents Standard Precautions include hand hygiene.

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R67's Face Sheet documents medical diagnoses including Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Urinary Tract Infection. R67's Physician Order Sheet (POS) dated 1/2024, documents 16 French 10 milliliters (mm) indwelling catheter, and indwelling catheter care every shift. On 01/10/24 at 1:50 PM, V12 (CNA) during indwelling catheter care, held onto R67's penis and did not secure the catheter when washing, rinsing, and drying R67's penis for catheter care. On 1/10/24 at 2:10 PM, V11 (Licensed Practical Nurse) stated V12 should have held onto the resident's indwelling catheter tubing near the meatus during washing, rinsing, and drying during catheter care to secure the tubing so not pulling on the tubing. The facility's Catheter Care Policy dated Revised 06/05, documents the objective is to prevent infection and odors. Based on observation, interview, and record review, the facility failed to respond to residents' requests for toileting assistance in a timely manner, resulting in residents experiencing episodes of incontinence, and failed to properly perform urinary catheter care. These failures affect four residents (R10, R11, R26, R67) out of four reviewed for incontinence and urinary catheter on the sample list of 31. Findings include: 1. On 1/10/24 at 12:57 PM, at the resident group interview, R10 stated, I have had to wait to go to the bathroom, the CNAs (Certified Nursing Assistants) say they are too busy because they are short staffed. I also used to need two people to help me but now I can go with only one, but I don't think that has been communicated very well and I think they don't want to come help me because they still think I need two people. R10 further stated, I have had some incontinence because of having to wait so long. R10's Minimum Data Set (MDS) dated [DATE] documents R10 received a score of 15 out of a possible 15 for a Brief Interview for Mental Status (BIMS), rating R10 as cognitively intact. This same MDS documents R10 requires partial to moderate assistance for transfers from chair to toilet and for toileting. 2. On 1/10/24 at 12:57 PM, at the resident group interview, R11 stated, I could go to the bathroom by myself if the staff would leave my wheelchair in reach. I think the communication is nil because they are constantly putting it out of my reach, then I have to wait for someone to answer my call light and that takes a long time. R11 then stated, There have been times I waited an hour or an hour and a half and then I am incontinent. It happens a lot. R11's MDS dated [DATE] documents R11 received a score of 14 out of 15 for a BIMS, indicating R11 is cognitively intact. 3. On 1/9/24 at 10:20 AM, R26 stated, When I was on the two corridor (200 hall) I had a couple of accidents in my (incontinent brief) because they didn't come quick enough to help me to the bathroom. They say they are too busy, and they are short of help. R26's MDS dated [DATE] documents R26 received a score of 14 out of a possible 15 for a BIMS, rating R26 as cognitively intact. This same MDS documents R26 requires partial to moderate assistance for chair to toilet transfers. On 1/9/24 at 2:13 PM, V17 (Family Member of R26) stated, (R26) is my great-grandmother and I am a nurse. (R26) is [AGE] years old but she isn't forgetful, and never had urinary accidents until going into the nursing home. The facility's Resident Council Meeting Minutes dated 11/6/23, 12/4/23, and 1/8/23, each document in old and new business, resident complaints of staff not answering call lights in a timely manner, staff walking past call lights without answering, staff standing in the hallways visiting and not answering call lights, low levels of CNA (Certified Nursing Assistant) staffing and leaving call lights out of residents' reach.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure their medication error rate was less than 5% during medication pass on 1/10/24. There were 26 opportunities, and total medication errors were 4. This gives the facility a 15.38% medication error rate. This failure affects four residents (R5, R26, R60, R229) out of 14 on the sample list of 31. Findings include: 1. On 1/10/24 at 3:13 PM, V5 (Registered Nurse) administered R26 Metoprolol Tartrate 25 milligram, 0.25 tablet (1/4 tablet) to equal 6.25 milligrams. R26's Physician Order Sheet (POS) documents Metoprolol Tartrate 25 mg 1 tablet BID. 2. On 1/10/24 at 3:47 PM V11 (Licensed Practical Nurse/LPN) passed medications to R5 and did not give the medication ordered for Pataday eye drops 1 drop to both eyes. V11 stated at 3:47 PM We do not have this drug in our cart to give R5. No alternative medication was given to R5. 3. V11 passed medications to R229 and failed to serve the medication with food as directed on the medication card and the physician's orders. On 1/10/24 at 3:49 PM R229 received the following medication Creon Delayed Release 24,000-76,000 units capsule with meals. The medication was taken by R229, and no food was offered, and the mealtime would of been about 1 hour away. 4. V11 at 3:56 PM passed medication to R60. The physician order documented to give Voltaran Arthritis Pain gel 1% administer 4 grams. The medication V11 placed on R60 was Biofreeze 4 grams. The facility policy titled Medication Administration Using Electronic Medication Administration Record. Revision date 11/2011 documents, the objective of the policy is To provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident. Procedure states: 1. No medication will be given to any resident without an order from the resident's physician. V2 (Regional Nurse) confirmed on 1/11/24 at 9:30 am the medications were not given correctly and understands the medication error rate was over the 5%.

CONCERN (F)

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to have Registered Nurse coverage for at least 8 consecutive hours a day, 7 days a week for a total of 3 days in the 14 days reviewed. This failure has the potential to affect all 76 residents residing in the facility. Findings include: Reviewing the facility's nurse's assignment sheet from December 24, 2023 through January 6, 2024. The facility had 3 days during this schedule which did not document RN time of 8 hours per day. The following days of 12/25/23, 12/26/23 and 12/31/23 were the days the facility did not provide the 8 hours of RN coverage. Licensed Practical Nurses worked the 3 days the RNs were not present. V2 (Regional Corporate Nurse) confirmed on 1/10/24 at 10:30 AM Yes those 3 days we did not have an RN scheduled to work. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 1/9/24 documents 76 residents reside in the facility.

CONCERN (F)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to develop a thorough and complete Quality Assessment & Assurance (QAA) of Policies and Procedures and a Quality Assurance Performance Improvement (QAPI) Program. The facility also failed to implement the QAA and QAPI Programs by failing to identify quality deficiencies, develop and implement appropriate plans of action to correct such deficiencies, and conduct distinct Performance Improvement Projects (PIPS). This failure has the potential to affect all 76 residents in the facility. Findings include: On 1/10/24 at 9:59am, V1 (Administrator) stated the facility does not have a more comprehensive QAPI policy. V1 confirmed the QAA Committee has not been implementing the QAA Policies and Procedures and has not been implementing a complete QAPI Program. The Quality Assurance Performance Improvement Policy dated 6/1/22 documents the facility shall implement an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. A QAPI plan shall be developed through the use of web-based assessment and reporting tool. Opportunities for improvement are to be identified and addressed through the development of Performance Improvement Projects. The Long-Term Care Facility Application for Medicare and Medicaid report dated 1/9/24 documents 76 residents reside in the facility.

CONCERN (F)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure required personnel attended the Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 76 residents in the facility. Findings include: On 1/10/24 at 9:59am, V1 (Administrator) provided QAA meeting attendance signature sheets for the previous year's QAA meetings dated 1/26/23, 4/27/23, 7/27/23 and 10/26/23. On 1/10/24 at 10:18am, V2 (Regional Nurse) confirmed there were no identifiers noting the Director of Nursing or Infection Preventionist on the QAA meeting attendance signature sheets for 1/26/23, 4/27/23, and 7/27/23. V1 and V2 were unable to identify the Director of Nursing and Infection Preventionist as V1 began employment at the facility on 9/5/23 and V2 was unsure who held those positions during those times. The January 2023 QAA meeting attendance signature sheet does not document the facility Director of Nursing was present for the meeting. The April 2023 QAA meeting attendance signature sheet does not document the Infection Preventionist and V9 Medical Director were present for the meeting. The July 2023 QAA meeting attendance signature sheet does not document the Infection Preventionist was present for the meeting. On 1/10/24 at 10:27am, V6 (Social Services Director) confirmed V6's signature was on the 2023 QAA meeting attendance signature sheets. V6 confirmed the January 2023 QAA meeting attendance signature sheet does not document the facility Director of Nursing was present for the meeting; the April 2023 QAA meeting attendance signature sheet does not document the Infection Preventionist and V9 (Medical Director) were present for the meeting; and the July 2023 QAA meeting attendance signature sheet does not document the Infection Preventionist was present for the meeting. The Quality Assurance Performance Improvement Policy dated 6/1/22 documents the following: Staff Involved: Administrator (Executive Leader representing Governing Body), Director of Nursing, Activity Director, Admissions/Social Services Director, Director of Memory Care (when applicable), Food Service Supervisor, Housekeeping/Laundry Supervisor, Human Resources Manager, CNA (Certified Nursing Assistant) representative, Medical Director, Pharmacist, and Infection Preventionist. A QAA committee shall be developed and meet on a quarterly basis. Members shall include, but are not limited to, those listed above. The Long-Term Care Facility Application for Medicare and Medicaid report dated 1/9/24 documents 76 residents reside in the facility.

Oct 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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 protect the resident's right to be free from physical abuse by another resident for two of four residents (R4, R5) reviewed for abuse in a sample list of 7. Findings include: The October 2023 Physician Order Sheet documents R4's diagnoses are Unspecified Dementia, Unspecified Severity, with Other Behavioral Disturbance, Chronic Obstructive Pulmonary Disease and Diabetes Mellitus. R4's Minimum Data Set (MDS) dated [DATE] states R4 is severely cognitively impaired and R4 is able to walk independently with supervision of one staff. R4's care plan dated 9/7/23 documents R4 gets herself up and will start walking down the hall and will go in and out of other resident's room. On October 24, 2023 at 10 AM, R4 got up from sitting in her room and entered another resident's room without supervision. R4 then turned around and came out of the room. The October 2023 Physician's Order Sheet documents R5's diagnoses are Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Chronic Diastolic Heart Failure and Shortness of Breath. The Minimum Data Set, dated [DATE] documents R5 is severely cognitively impaired. The MDS also documents R5 needs assistance of one for ADL's (activities of daily living) and uses a wheelchair for transportation. Facility incident report dated 10/11/2023 documents on 10/11/2023 at approximately 7:15 AM R4 was up walking in the hallway and Staff were in the dining room assisting the residents with breakfast and V11 (Certified Nursing Assistant/CNA) heard R5 yelling get out of my room. The report documents V11 went to R5's room and witnessed R4 sitting in R5's lounge chair. V11 stated she saw R5 hit R4 on the left side of the head twice. The report documents V11 immediately separated the two residents and called for assistance. The report documents V12 (Licensed Practical Nurse/LPN) assessed both residents immediately and no injuries were noted, and neurological assessment was started on R4. The report documents the Doctor and Power of the Attorney (POA) of both parties were notified of the incidents and the incident was reported immediately to V1 (Administrator). V11 (CNA) stated on 10/24/23 at 10:53 AM As I entered (R5's) room (R5) was hitting (R4) on the left side of (R4's) head and telling (R4) to get out of her recliner and room. I called for assistance and the charge nurse (V12) came down and assessed both residents. (R4) was laughing the entire time like nothing ever happened. (R4) got up from (R5's) chair and walked out the door when (V12) was done assessing her. On 10/24/23 at 11:02 AM V12 (LPN) stated per phone conversation, Yes, I heard (V11) call for assistance and I went down to (R5's) room. (V11) had separated (R5) from (R4). (R4) was sitting in the lounge chair and laughing. I assessed both residents and (R4) took off out the door when I completed her assessment, and I started assessing (R5). There were no injuries, I then went and notified the Administrator, Doctors and POAs. The facility's policy titled Abuse Prohibition and Reporting (Elder Justice Act) revised 11/28/19 states The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation and use of any physical or chemical restraint not required to treat resident's symptoms.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete quarterly assessments for the risk of skin breakdown for two of three residents (R1, R2) reviewed for pressure sores in total sample of seven residents. Findings include: 1. The Physicians Order Sheet (POS) dated October 2023 lists the following diagnoses for R1: Dementia with Behaviors, Unspecified Displaced Fracture of Surgical Neck of Right Humerus, initial encounter for Open Fracture, and Pressure Ulcer Stage Four. The same POS also documents R1 was placed on hospice. The Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and R1 requires assistance of two staff in all areas of activities of daily living. The quarterly pressure risk assessment for R1 was completed on 2/1/23 and 5/3/23. Both assessments rated R1 as Moderate Risk for pressure ulcers. R1's next quarterly pressure ulcer risk assessment should have been completed 8/3/23. The assessment was not found in R1's medical record. Hospital records document R1 was sent to the hospital on [DATE] with an infected buttocks pressure sore. 2. The Physician's Order Sheet (POS) for R2 dated October 2023 lists the following diagnoses: Pressure Ulcer of Right Hip, Stage Two 07/14/23 and Pressure Ulcer of Right Ankle, Stage Four developed 05/31/23. The POS dated October 2023 documents an order for R2 to be admitted to hospice on 6/1/2023. The Minimum Data Set, dated [DATE] documents R2 is severely cognitively impaired and R2 requires assistance of two staff for all activities of daily living. The quarterly pressure risk assessment for R2 was completed on 2/21/23 and 6/7/23. The 2/21/23 assessment rated R2 as at Risk for pressure ulcers. The 6/7/23 assessment for R2 rated R2 at moderate risk for skin breakdown. The next quarterly pressure ulcer risk assessment should have been completed 8/3/23. The assessment was not found in R1's medical record. V2 (Corporate Regional Nurse) and V3 (Wound Nurse) both confirmed on 10/26/23 at 3:30 pm, R1 and R2 should have another skin risk pressure ulcer assessment completed because their policy is to have them completed every quarter. Both R1 and R2 only had 2 assessments completed. The Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol revised 10/24/22 states A skin risk assessment is completed on all residents upon admission and weekly for the first four weeks after admission, quarterly, and whenever there is a change in the resident's condition.

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review the facility failed to ensure R3 was free of physical abuse by R2. This failure affects two of three residents (R2 and R3) reviewed for abuse on the total sample list of five. Findings include: The facility's investigation file documents on 5/1/23 at approximately 11:45 AM, a resident-to-resident altercation between (R2 and R3). (R2 and R3) were watching a movie in the television area next to the nurse's station. V4 LPN overheard (R2) raising her voice towards (R3), V4 went to intervene but (R2) made contact with (R3's) right forearm before nurse was able to separate the two residents. (R3) was noted to have a superficial scratch (3 inches) to right forearm. On 5/23/23 at 3:05 PM V4 (Licensed Practical Nurse/LPN) stated, I was sitting at the nurses station and I heard 'bickering' coming from the television area, beside the nurses station, I popped up and looked over, both residents were sitting and I saw (R2's) arms 'helicoptering' (moving in circles) and I ran around the desk to (R2 and R3), while going towards the area I saw (R2) open handedly hit (R3) on the right forearm. (R3) had a small scratch on her arm. R2's medical record documents, at 11:40 AM on 05/01/23 by V4 (LPN), this resident and another were in the TV/dining room area watching a movie, heard (R2) start yelling at other resident (R3), and seen (R2) hit other resident with both hands with what appeared to be open handed, on (R3's) right arm, immediately separated the two residents. R3's medical record documents on 11:40 AM on 05/01/23 by V4 (LPN), this resident and another resident were in the TV/dining room area, watching a movie. heard (R2) start yelling, stood up and (R2) hit (R3) with both hands with what appeared to be open handed, on (R3's) right arm, (R3) has a 3-inch superficial scratch on her right forearm. The facility's policy, with a revision date of 11/28/2019, titled Abuse Prohibition and Reporting documents, Policy: The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation of any physical or chemical restraint not required to treat the resident's symptoms. 7- Special attention will be given to identifying behavior that increases the resident's potential for abusing self or others or being the victim of abuse. These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as: entering other residents' rooms, residents with self-injurious behaviors, residents with communication disorders and those who require heavy nursing care and/or are totally dependent on staff.

Jan 2023 4 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

Notification of Changes (Tag F0580)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to promptly notify a resident's family of a change in condition. This failure affects one of three residents (R1) reviewed for falls on the sample of six. Findings include: R1's Progress Notes dated 11/23/2022 1:29 PM document R1's pain assessment was completed and R1 stated R1's left hip is hurting (R1) and it's a dull pain. There is no documentation V25 (R1's Family) was notified of R1's complaints of left hip pain on 11/23/22. On 1/5/23 at 11:20am, V25 stated V25 was unaware of R1's complaints of left hip pain that began on 11/23/22 until 11/24/22. V25 stated V25 was upset that V25 had not been notified promptly of R1's change in condition. V25 stated the facility is fully aware V25 is to be notified immediately. The facility's Change in a Resident's Condition policy dated 12/2002 documents the facility shall promptly notify the resident and or resident's representative of changes in the resident's condition and/or status. This policy documents the nurse will notify the residence representative when there is a significant change in the residence physical, mental, or psychosocial status.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document thorough post fall investigations. The facility also failed to implement post-fall, fall prevention interventions. These failures affect two of three residents (R1, R2) reviewed for falls on the sample of six. These failures resulted in R1 having three falls during the month of November 2022. R1 was found to have a mildly comminuted fracture of the medial aspect of the superior left pubic ramus with mild displacement and angulation and a non-displaced fracture of the medial aspect of the inferior left pubic ramus. Findings include: 1.) a.) R1's Care Plans dated 4/19/22 document R1 is at risk for falls due to generalized weakness and history of falls. These care plans document R1 may have poor safety awareness related to a diagnosis of Dementia. These care plans include fall prevention interventions including to provide toileting assistance routinely and as needed. R1's Fall Risk assessment dated [DATE] documents R1 is a high risk for falling. R1's Fall Investigation dated 11/13/22 documents R1 has moderate impaired cognition. This investigation documents on 11/13/22 at approximately 11:45am, R1 was witnessed standing in R1's room between the two beds straightening the blankets on R1's bed and before V19 (Certified Nursing Assistant/CNA) could intervene, R1 lost R1's balance and fell. R1 was noted to be incontinent at the time of the fall. R1 was seen in the emergency room with no findings and came back to the facility with orders for Physical and Occupational Therapy for weakness and that these orders were already active. This investigation documents R1 has several considerations that increase R1's risk for falls including a past medical history of Non-traumatic Chronic Subdural Hemorrhage, Muscle Wasting and Atrophy, Dementia, Unspecified Lack of Coordination, Unsteadiness on Feet, Need for assistance with personal care, abnormal posture, pain, muscle weakness, and age-related osteoporosis as well as vitamin B12 deficiency anemia, insomnia, and vitamin D deficiency all of which increase R1's risk for falls and injury related to falls. This investigation documents the probable root cause of the fall was the resident standing to straighten (R1's) bedcovers. This investigation documents staff are to ensure bed is made if R1 is not in bed and to encourage R1 to call for assistance when straightening up R1's bed. R1's fall event report for this fall documents R1 stood up and fell back toward the bed, however R1's progress notes located within this fall event report document R1 leaned forward and fell down. R1 progress notes dated 11/13/2022 document at 1:03 PM the facility received a call from V25 (R1's family) voicing concerns related to R1's fall and V25 had noticed times of increased confusion with R1. This investigation does not document when R1 was last toileted. This investigation also documents R1's bed was already made at the time of this fall. This investigation documents a handwritten witness statement by V19 (CNA) documenting R1 was last seen at 10:00am, sitting in R1's wheelchair with reason of breakfast. This statement documents V19 was the only staff member on the unit at the time of R1's fall. There is no documentation of when R1 was last toileted prior to this fall. There is no documentation of an interview with R4, R1's roommate regarding this fall. On 1/10/22, the facility provided documentation of therapy service dates (evaluation dates and dates of therapy discharge) for R1 which include as follows: Physical Therapy - Evaluation date 4/19/2022 - discharge date [DATE] Evaluation date 10/2/2022 - discharge date [DATE] Occupational Therapy - Evaluation date 4/20/2022 - discharge date [DATE] Evaluation date 10/3/2022 - discharge date [DATE] Speech Language Pathology - Evaluation date 4/21/2022 - discharge date [DATE] Evaluation date 6/9/2022 - discharge date [DATE] There is no documentation R1's orders from R1's emergency room visit due to R1's fall on 11/13/22 for Physical and Occupational Therapy for weakness were active as the facility's investigation documents were. There is no documentation R1 received PT/OT as ordered by the emergency room. On 1/4/23 at 1:05pm, V19 (CNA) stated on 11/13/22 R1 had a fall and was found between resident beds, near the foot of the bed. V19 stated R1 likes to grab at everything including bed sheets and items that are on the floor such as ant bait stations. V19 stated on 11/13/22, R1's bed was made prior to the fall in hopes R1 would not try to fix the sheets. V19 stated V19 could not recall if R1's room call light was on but R4, R1's roommate would alert staff to R1 doing things R1 is not supposed to do and may have turned the light on. V19 stated V19 did not see the fall occur, V19 just found R1 on the floor. V19 stated R1 was incontinent at the time of this fall and that R1 had been toileted some time before breakfast. V19 stated he did not recall taking R1 to the toilet, but R1 had been provided with incontinence care. V19 stated V19 was unable to identify additional staff who were working on the unit at the time of R1's fall but since R1 did not document additional names on R1's written witness statement, the staff were probably agency staff. V19 stated V19 thought maybe R1 was trying to adjust bed sheets because of R1 was located near R1's bed, however V19 was unsure. b.) R1's Fall Investigation documents R1 had a fall on 11/16/22 at 7:30am. This investigation documents R1's cognition as moderately impaired. The investigation documents at approximately 7:30am, R1 was observed sitting on the floor on R1's buttocks in front of R1's wheelchair in the hallway. R1 reported mild left-hand pain with normal range of motion. There was a small bruise noted to the posterior left hand related to a blood draw on 11/13/22. This investigation documents prior to the fall, R1 had last been observed sitting in the hallway and R1 had been dressed and toileted 20 minutes prior to falling. R1 was incontinent of bladder at the time of the fall. R1 stated R1 just stood up and fell. This investigation documents immediate interventions including analgesics, alternate call and increased frequency of visual checks. R1's Investigation Report documents the root cause of R1's fall on 11/16/22 as self-transferring with interventions including staff to assist to the dining room upon rising in the morning and offer snack/beverage as R1 allows and orthostatic vital signs. There is no documentation as to an investigation in to why R1 was attempting to self-transfer. There is no documentation as to investigation in to R1's incontinence at the time of the fall. This investigation documents V19 and V31 (CNAs) were working on the unit at the time of R1's fall. V19's written witness statement dated 11/16/22 documents V19 thinks the fall occurred because (R1) was soaked and tried to stand up and that V19 last observed R1 at 7:00am to get dressed but does not document if R1 was toileted at that time or provided incontinence care. There is no documentation of a witness statement from V31. R1's progress notes dated 11/16/22 at 8:21 AM document Orthostatic vital signs were obtained with a lying blood pressure and pulse and two blood pressures and pulses while sitting. There is no documentation of a blood pressure or pulse while R1 was standing. R1's care plans dated 11/16/22 document R1's risk for falls and that R1 may have poor safety awareness related to Dementia with interventions including Orthostatic Vitals but does not include how often to complete the orthostatic vital signs. On 1/4/23 at 1:05pm, V19 stated V19 was working on the unit R1 resides on 11/16/22 when R1 was found on the floor. V19 stated staff were in the middle of getting residents up. V19 stated V19 was in a room and had come out of the room and found R1 sitting in front of the doorway. R1 was in the hall prior to the fall because the facility tries not to leave R1 alone in the wheelchair in R1's room due to wandering. V19 stated V19 could not recall if V19 got R1 ready that morning. V19 stated R1 is more of a brief change and that R1 was not offered/attempted to be taken to the bathroom for R1 to attempt to use the toilet. V19 stated if R1 was taken to toilet, it was R1 telling staff R1 wanted to be taken to the bathroom to use the toilet. V19 stated, if we took (R1) to the toilet we would have to stay with (R1) because (R1) would get up on R1's own. V19 stated R1 was pretty wet/soaked with urine at the time of this fall. c.) R1's fall investigation documents R1 had a fall on 11/24/22 at 8:43am. This investigation documents R1 is a high risk for falls. This investigation documents on November 24th, 2022, at 8:45 AM R1 was observed on the floor near the sink in R1's room. R1 was complaining of pain to R1's posterior head and R1's left hip. This investigation documents R1's range of motion was within normal limits and all extremities. Due to the use of anti-platelet medication combined with R1's head pain in addition to R1's hip pain the facility was concerned about R1's condition and felt R1 needed to be further evaluated. During R1's emergency room visit and X-ray of R1's hip with pelvis results document a non-displaced fracture of inferior pubic ramus on the right side. This investigation also documents, additionally, the resident has experienced significant weight loss over the past month from 108 pounds on November 8th, 2022, to 102 pounds on November 28th, 2022. This shows a general decline in the resident's condition. This investigation also documents R1 first complained of left hip pain on November 23rd, 2022, and R1's primary care physician was notified and a left hip X-ray was requested via fax. Later that same day the facility followed up with the office on the request for a left hip X-ray with no response to the request for an X-ray being received prior to the fall the following day. This investigation documents on the day of the fall R1 was assisted from bed and provided with morning cares including bruising R1's teeth and continence cares hair care and her face and hands were washed at approximately 7:30 AM. Prior to the incident R1 was last seen at 8:25 AM in her wheelchair in the hall. The wheels to R1's wheelchair were noted to be unlocked and R1 stated R1 was trying to get to the sink when R1 fell. This investigation documents based on the investigation the probable root cause of the fall was R1 self-transferring and standing unassisted to use R1's sink with post fall interventions of providing assistance for R1 to and from meals as R1 allows and to assist R1 to activities after breakfast and cares as R1 allows. R1's Event Report for this fall documents R1 complained of left hip pain following the fall with rotation/deformity of upper left extremity marked as present. Three written witness statements by V31, V32 and V33 (CNA) document R1 was last seen by staff at 8:25 AM that morning in the hallway. Two statements, V32 and V33 (CNA) document R1 was incontinent at the time of the fall. There is no documentation in the investigation that R1 had been taken to/provided assistance to use the toilet, only that R1's brief was clean and had incontinence cares provided. There is no documentation in the investigation related to rotation/deformity of left upper extremity marked as being present on the event for R1's fall on 11/24/22. This investigation documents R1's Hospital History and Physical dated 11/30/22 documents R1 is in distress and ill-appearing. This H&P documents R1 presented to the emergency room with recurrent falls, a right hip fracture as per V25 (R1's Family) which was non-operable. R1 presented to the emergency room and ended up being admitted with poor oral intake, severe dehydration, and dysphagia with right hip pain plus recurrent falls. Additional diagnoses include hypernatremia secondary to dehydration, recurrent falls at the facility. R1's X-ray results of the pelvis and right and left hip dated 12/1/22 document a mildly comminuted fracture of the medial aspect of the superior left pubic ramus with mild displacement and angulation. There is a non-displaced fracture of the medial aspect of the inferior left pubic ramus. These results do not document any right pelvic fractures. On 1/5/22 at 3:00pm, V2 (Director of Nursing/DON) stated V2 thought the fall investigations were being completed thoroughly but there is no documentation of some of the details in the investigations. V2 stated the facility usually just reviews the handwritten witness statements while completing investigations unless there are questions about what is written on the statements, the investigation does not include calling or interviewing witnesses. 2.) a.)R2's Care Plans dated 12/28/22 document R2 has potential for injury from falls related to generalized weakness and a history of falls. R2 may have poor safety awareness due to Dementia and has diagnoses including Parkinson's Disease, Bipolar, and Arthritis. These care plans document the goal is to reduce the risk for major injury related to falls with fall prevention interventions including to encourage and remind R2 to call for assist prior to toileting and for staff to provide toileting assistance routinely and as needed. R2's Fall assessment dated [DATE] documents R2 is a High risk for falls. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact. R2's Fall event form documents R2 had a fall on 12/13/22 at 11:20am. This form documents R2 was self-ambulating from R2's bathroom to R2's bed and lost balance and fell. This form documents R2's call light was on, and an unidentified Certified Nursing Assistant (CNA) was walking to R2's room and heard a crash and found R2 on the floor. R2 complained of pain and had an abrasion to the left shoulder. This form documents immediate measures and interventions taken including to complete neurological checks and observe R2. R2's Progress Notes dated 12/13/22 at 11:20am document R2 was observed sitting on the floor beside the bed. R2's back was resting on the side of bed with legs extended in front of R2. R2 stated R2 was walking from the bathroom with the walker and lost R2's balance and fell. R2 was reminded R2 requires assistance with ambulation. R2 was upset and stated it was the facility staff's fault for not helping R2. There is no documentation regarding the investigation of how long the call light was on. There is no documentation regarding the investigation of if R2 was going to or coming from the bathroom. R2's fall investigation summary for R2's fall on 12/13/22 documents the root cause of this fall as self-transferring with a post fall intervention to place non-skid strips to the right side of R2's bed. This summary does not document why R2 was self-ambulating/transferring. This summary documents, (R2) was planning to self-ambulate to the bathroom although there is no documentation of this statement in the investigation other than the final summary of the investigation. There is no documentation in this investigation as to when R2 had last been assisted or offered to be assisted to the toilet. There is only one witness statement by V31 in R2's investigation although this witness statement documents multiple additional staff members including V19, V31, V34 (CNAs) were working on the unit at the time of R2's fall on 12/13/22. b.) R2's Fall Investigation documents R2 sustained a fall on December 26th, 2022, at 4:40 PM in R2's room. This investigation documents R2's past medical history of a right femur fracture, Parkinson's, unspecified Dementia with Behaviors, syncope and collapse, muscle wasting and atrophy, muscle weakness, difficulty in walking, a history of falling, heart failure, and abnormalities of gait and mobility as well as lack of coordination. At the time of the fall R2 was on aspirin 81 milligrams daily. This investigation documents R2's cognition as cognitively intact with a root cause of R2 slipping out of R2's wheelchair. R2's care plan was updated with post fall interventions including physical therapy to screen for wheelchair position and safety, a cushion secured with (brand name adhesive) to the wheelchair, and that R2's wheelchair was replaced. There is no documentation in this investigation of an assessment of the wheelchair R2 was using at the time of the fall. This investigation documents R2 was last seen by staff sitting in the wheelchair in R2's room. This investigation documents at the time of the fall there was significant bleeding from R2's right forehead. R2 was transferred to the local emergency room and found to have a Subdural Hematoma. R2 was deemed to not be a good candidate for neurosurgical intervention and was transported back to the facility from the local emergency department. When R2 was asked what happened, R2 stated, something is wrong with my wheelchair. (R2) slid out R2 guesses. This investigation documents the probable root cause of the fall was R2 slipping from the wheelchair but does not document why R2 slipped from the wheelchair. This investigation documents R2 was having right sided head pain. This investigation documents hospital discharge instructions with diagnosis including fall, traumatic hematoma of forehead, acute Subdural hematoma, hand laceration, and skin tear. This investigation documents one witness statement from V21 (CNA.) There are no additional witness statements from staff working on the unit R2 resides on at the time of this fall. There is no documentation the state survey agency was notified of the major injury R2 sustained of an acute Subdural hematoma from R2's fall on 12/26/22. R2's Progress Notes dated December 26th at 5:22 PM document V22 (Licensed Practical Nurse/LPN) heard HELP ME being called out while passing pills in the hallway. R2 was found on the floor lying on the right side holding R2's head with R2's left arm. R2 stated R2 thinks something is wrong with his chair and that R2 guesses R2 just slipped out of R2's chair. The emergency room records document a Computed Tomography of the Head exam results dated 12/26/22 that document R2's exam revealed an acute Subdural hematoma along the right temporal and right frontal convexity measuring up to 0.4cm (centimeters) in diameter. Additional emergency room documentation dated 12/26/22 documents R2 sustained a scalp hematoma abrasion that was closed with adhesive closure, a scalp hematoma measuring 5cm by 6cm in diameter, two dorsal superficial skin tears that were closed with adhesive closure and a 2cm laceration to the right ring finger. R2's Investigation for R2's fall on 12/26/22 documents a hospital emergency room report dated 12/29/22 documents R2 returned to the emergency department on December 29th, 2022, with chief complaint of decreasing responsiveness. The emergency department trauma service felt in light of R2's do not resuscitate status there was nothing additional they could offer then continued do not resuscitate and comfort measures. R2's hospital notes document R2 was observed to have extensive facial bruising. These notes document R2 was discharged back to the facility on [DATE] in critical condition. On 1/5/22 at 3:00pm, V2 (Director of Nursing) stated V2 did not report R2's major injury of an Acute Subdural Hematoma with use of Aspirin (Antiplatelet) medication because R2 only went to the emergency department and did not receive further intervention like a drain or sutures. V2 stated V2 just usually reports broken bones or if a resident requires sutures. The facility's Accident and Incident Report policy dated 4/2/2019 documents the objective of the policy is to document all accidents and incidents occurring to resident's, visitors, and employees. This policy documents if the State Survey Agency notification is required, it is the responsibility of the Director of Nursing or Administrator to do so. This policy documents in all cases, there must be an exact description of the accident/incident including witnesses and statements. The Resident Accident & Incident Reports form dated March 2002 documents a blank spreadsheet the facility uses to document the residents incidents and accidents including the possible cause and that the cause was investigated and notifications were made, including a notification to the State Survey Agency. The facility's Emergencies policy dated 4/3/18 documents immediate care of a resident after a fall including to check the residents ability to explain what happened and evaluate the residents condition before the fall. Determine if possible where, how and when the accident occurred. If a head injury has occurred notify the physician immediately for orders to transfer the resident to the emergency room.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to implement a resident's (R1) physician's orders for physical, occupational and speech therapy. The facility also failed to implement a resident's (R5) physician's orders for speech therapy timely. This failure affects two of six residents (R1, R5) reviewed for physician's orders on the sample of six. Findings include: 1. R1's Face Sheet dated 1/9/23 documents R1's diagnoses including Dementia, Oropharyngeal Dysphagia and history of Non-traumatic Chronic Subdural Hemorrhage. R1's Speech Therapy (ST) Treatment Encounter Notes dated 10/29/22 document the speech therapy department was waiting on R1's Modified Barium Swallow Study to determine if R1 was safe for oral intake, but R1 was not taken to the appointment. These notes document, secondary to no updated swallow study and current tolerance of diet level, ST is discharging (R1) on current diet level. R1's Progress Notes dated 10/07/2022 10:52 AM document a New recommendation received from ST for modified Barium swallow at this time for diet upgrade. R1's Progress Notes dated 11/4/22 at 1:02pm document R1 received new Physical Therapy/Occupational Therapy/Speech Therapy (PT/OT/ST) orders from V16 (R1's Primary Care Physician's office.) R1's Electronic Physician's Orders do not document R1's order on 11/4/22 for PT/OT/ST. There is no documentation therapy completed evaluations or treatments for R1 with PT/OT or ST after orders were received on 11/4/22. On 1/4/22 at 10:20am, V18 (Director of Rehabilitation/DOR) stated the facility had a problem with Speech Therapists working as scheduled so the facility borrowed speech therapists from other facilities. V18 stated the facility was able to contact other Speech Therapists from other facilities as needed. V18 stated V28 (ST) was at the facility on 11/11/22, 11/15/22, 11/28/22, 11/30/22 but was unsure why V28 did not evaluate R1. V18 stated the facility's nursing department should communicate with us when orders for speech therapy are received. V18 stated speech therapy discharged R1 because R1 was safe with diet R1 was on. V18 stated V25 (R1's family) requested further testing to evaluate R1's swallow and V18 thinks R1 had completed the swallow testing but was unsure of the results of the testing. V18 stated V18 doesn't recall any of the speech therapists talking to V18 about issues with R1's swallowing or choking. V18 stated V18 was unaware of R1's orders for PT/OT/ST on 11/4/22. 2. R5's Face Sheet dated 1/9/23 documents R5's diagnoses including Dementia, Major Depressive Disorder and Oropharyngeal Dysphagia. R5's Progress Notes dated as follows document: 11/15/2022 7:00 PM R5 was overheard coughing in the dining room. R5 was choking on food. 11/16/2022 5:11 PM V2 (Director of Nursing/DON) said V2 was working on getting speech therapy orders for R5. 11/16/2022 5:17 PM Orders for Speech Therapy evaluation were received. 11/23/2022 1:02 PM No further coughing noted at mealtimes. New orders were received to downgrade R5's liquid consistency to honey thick. R5's Physician's Orders dated 11/16/22 document an order for speech therapy to evaluate and treat. R5's Physician's orders also document an order dated 11/23/22, one week after R5's choking episode, of a diet order change including honey thickened liquids. R5's Speech Therapy (ST) evaluation and plan of therapy dated 11/28/22 documents R5 was evaluated by ST on 11/28/22, twelve days after the order was received. On 1/9/23 at 4:20pm, V1 (Administrator) stated if there is no documentation of a speech therapy screen in R5's records, then it was not completed. V1 stated therapy evaluation and treatment orders should be entered into the resident's electronic physician's orders and implemented/followed as soon as possible.

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 F0659 (Tag F0659)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to implement physician's orders for weekly weights for one of three residents (R1) reviewed for nutrition/weights on the sample of six. Findings include: R1's Order History documents an order dated 6/29/22 that R1 is to have weekly weights obtained on Fridays and timed to occur between 7:30am to 1:00pm, due to lack of dentures. R1's Electronic Medical Record (EMR) documents the facility obtained two weights in October on 10/7/22 and 10/14/22. There is no documentation of additional weights obtained in October for R1. R1's Progress Notes dated 11/29/22 at 4:01pm document R1's weight on 11/8/22 was 108 lbs (pounds) and R1's weight on 11/28/22 was 102 lbs. There are no additional weights documented for November 2022 for R1. On 1/9/23 at 4:20pm, V2 (Director of Nursing) stated V2 was unable to find documentation of additional weights for R1 in R1's medical record. On 1/9/22 at 2:15pm, V1 (Administrator) stated the facility does not have a policy on physician's orders. V1 stated the facility just uses standard practice when the facility receives an order. V1 stated physician's orders that are given by a physician are entered in the electronic medical record and followed/implemented.

Dec 2022 4 deficiencies

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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 assist with feeding a dependent resident. This failure affected one (R55) of two residents reviewed for activities of daily living on the sample list 30. Findings include: R55's Physician Order Report Sheet (POS) dated 11/30/22 documents the following diagnoses: Alcohol Dependence with Alcohol-induced Persisting Dementia, Hypertension secondary to other Renal Disorders, Depression, History of Abnormal Weight Loss, and Dysphagia, Oropharyngeal Phase. The same POS documents the following diet order dated 11/26/22: Puree Diet, Nectar Thick Liquids, High Calorie /High Protein Supplementation Continues. R55's Minimum Data Set, dated [DATE] documents R55's Brief Interview of Mental status score of 14 out of a possible 15, indicating no cognitive impairment. R55's Care Plan documents the following: Problem Start Date: 11/14/2022.Category: Nutritional Status (R55) has difficulty chewing and swallowing. This puts (R55) at risk for chewing, choking and swallowing difficulty. (R55) also is at risk for weight loss dt (due to) poor po (by mouth) intakes. Short Term Goal Target Date: 02/14/2023 (R55) will have no s/s (signs or symptoms) of chewing, choking or swallowing difficulties. (R55) will have no further weight loss through next review. Offer assistance during meals. On 11/30/22 at 9:19 am R55 was lying in bed. R55 had a breakfast tray of pureed food items on bedside dresser. R55 meal items were out of R55 reach. R55's entire meal was untouched. R55 stated R55 is hungry, and staff have not come in to assist him. On 11/30/22 at 9:25 am V22 (Certified Nursing Assistant/CNA) stated I am an agency CNA. I was going to feed (R55) after I took care of (R2). I was getting (R2) cleaned up, so (R2) can eat on (R2's) own. (R55) does need assistance eating. I took care of (R55) previously, on another hall. I know (R55) needs assistance. I brought (R55's) tray (breakfast) down (to room) about 8:15 am. There is a microwave down here on this hall. I normally feed my people (residents) that need assistance right away. I don't have to provide any other residents with feeding (assistance). I took two residents (unidentified) down to the dining room and past (delivered) everybody's (residents), five all together, here on the hall. I noticed (R2) needed assistance. I changed (provided incontinence care) (R2). I know (R55) has to be monitored while I feed (R55), so (R55) doesn't choked. I was just busy and didn't get back to (R55). I know it's been awhile (one hour and 10 minutes from the time R55's tray was delivered to room). I was just busy that's all. On 11/30/22 at 1:45 pm V2 (Director of Nursing/DON) stated (R55) is Hospice. We no longer record his food intake. That being said, (R55) still requires staff to feed him. He (R55) was not eating well, went to the hospital for pneumonia and returned to us without the desire to eat. Meals still have to be provided. He (R55) is alert and can make his own decisions. Dietary is tracking his weights and supplements have been added. The (V23 Registered Dietician) Dietician was here yesterday. V2 also stated Our expectation is that every meal is served hot and (R55) is to be fed every meal. If he declines, it should be reported to the nurse and documented. All my staff will be educated. It (failure to assist with feeding) should have never happened. The facility policy Feeding Assistance dated Revised February 2004 documents the following: Objective: 1. To serve attractive, well-balanced meals.2. To provide nutrients for the wellbeing of the resident.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure R146's room was free of a tripping hazard. R146 is one of five residents reviewed for falls/accidents on the sample list of 30. Findings include R146's Physician Order Report sheet dated 11/02/22-12/02/22 documents R146's admission date is 11/3/22. R146's same Physician Order Report sheet documents the following diagnoses: Unspecified, Atrial Fibrillation, Malignant Neoplasm of Upper Lobe Left Bronchus or Lung, Essential Hypertension, Generalized Anxiety Disorder, Other Chronic Pain, Unspecified Systolic Congestive Heart Failure and Difficulty in Walking, Not Elsewhere Classified. R146's Minimum Data Set (MDS) dated [DATE] documents R146's Brief Interview of Mental status score of 13, out of a possible 15, indicating R146 has no cognitive impairment. The same MDS documents R146 is not steady, only able to stabilize with staff assistance for all transitions for transfer. R146's Fall Risk assessment dated [DATE] documents R146's fall risk score as 19. R146's same Fall Risk Assessment indicates R146's score is greater than 15, therefore at High Risk for falls. On 11/30/22 at 10:01 am, R146 was lying bed with a front wheeled walker at the right-side foot area of R146's bed. R146 had supplemental oxygen being delivered from a bedside concentrator at the right-side head of the bed, at three liters per minute via a nasal cannula. The nasal cannula oxygen tubing extended to the oxygen concentrator with multiple feet of excess oxygen tubing. The excessive oxygen tubing was coiled in three-foot layered circle pattern. The coiled tubing laid directly next to R146's bed and extended to R146's front wheeled walker. The excessive oxygen tubing blocked R146's path to get out of R146's bed. R146 stated I walk by myself and have to be very careful. I don't know why it (oxygen tubing) is left that way instead of in that bag (pointed to the oxygen concentrator at the head of the bed) on the oxygen machine. On 11/30/22 V8 (Certified Nursing Assistant) confirmed R146's oxygen tubing was on the floor and stated R146's oxygen tubing should not be on the floor. On 11/30/22 at 2:35 pm, R146 was lying in bed with oxygen being delivered at three liters per nasal cannula. R146's oxygen tubing from the nasal cannula dropped two feet down to the floor, and again had coiled excessive oxygen tubing that extended to R146's oxygen concentrator, blocking R146's exit from the bed. V2 (Director of Nursing/DON) entered R146's room. V2 stated R146's oxygen tubing length was 25 feet. V2 also stated the 25-foot oxygen tubing is the only extended tubing the facility uses when the routine 7-foot tubing is not enough. V2 also stated The oxygen tubing should be wrapped loosely and placed in this plastic bag, (V2 removed the clear plastic storage bag from the oxygen concentrator), that is what it is here for. V2 stated to R146, I will re-educate staff, that this tubing (oxygen) is not to be left in your way on the floor. It is not sanitary and is a tripping hazard. The undated facility policy Accident/Incident Prevention documents the following: When a resident has been identified as a high risk for accidents/incidents, interventions will be put into place per the individual resident assessment and care plan. The interventions may include, but not limited to the following: (fifth bullet) Keep residents' room free of obstruction and clutter.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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 prevent cross contamination during incontinence care, failed to change gloves and perform hand hygiene during incontinence care and failed to maintain oxygen tubing in a clean sanitary manner off the floor for residents. These failures affected two of two residents (R69, R146) reviewed for infection control in the sample list of 30 . Findings include: 1.) The facility's Incontinence Care policy with a revised date of February/2004 documents, Objective: 1. To keep skin clean, dry, free of irritation and odor. Procedure: 2. Wash your hands and put on gloves. This policy does not direct when to change gloves. R69's Face Sheet documents diagnoses including Nontraumatic Chronic Subdural Hemorrhage, Muscle Wasting and Atrophy, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety and History of Urinary Tract Infections. R69's Care Plan dated 6/17/22 documents R69's has the potential for urinary tract infections related to history of Urinary Tract Infections with interventions of perineal care after incontinent episodes. R69's Minimum Data Set, dated [DATE] documents R69 is always incontinent of bowel and bladder. On 11/29/22 at 12:01 PM V6 and V8 (Certified Nursing Assistants) donned gloves to perform incontinence care for R69. V6 took some toilet paper rolled together and sprayed it with perineal wash and wiped R69's perineal area from back to front. V6 used the same area of the toilet paper and wiped other areas of the perineum. V6 and V8 rolled R69 to R69's side and with the same pair of gloves. V6 removed R69's wet incontinence brief and with the same pair of gloves, washed the back side of R69. With the same pair of gloves, V6 slid a clean brief underneath R69 and fastened the brief. With the same pair of gloves, V6 pulled up R69's slacks and placed the mechanical lift sling underneath R69 and handled the control to the lift and transferred R69 to the wheelchair. With the same pair of gloves, V6 straightened R69's feet on the wheelchair foot pedals and then straightened the incontinence pad on R69's bed. V6 removed V6's gloves then combed R69's hair. On 11/29/22 V2 (Director of Nursing) stated that the Certified Nursing Assistants should change their gloves as needed and should not wipe from back to front during perineal care and should only use an area of the cloth/tissue one time then rotate areas. 2.) R146 Physician Order Report (POS) sheet dated 11/02/22-12/02/22 documents R146's admission date is 11/3/22. R146's same Physician Order Report sheet documents the following diagnoses: Unspecified Atrial Fibrillation, Malignant Neoplasm of Upper Lobe Left Bronchus or Lung, Essential Hypertension, Generalized Anxiety Disorder, and Unspecified Systolic Congestive Heart Failure. R146's same POS documents the following: O2 (oxygen) at 3 (three) L (liters)/ (per) nasal cannula continuous for SOB (Shortness of Breath), Continuous. On 11/30/22 at 10:01 am, R146 was lying in bed. R146 had oxygen being delivered from a bedside concentrator at the right-side head of the bed, at three liters per minute via a nasal cannula. The nasal cannula oxygen tubing extended to the oxygen concentrator with multiple feet of excess oxygen tubing. The excessive oxygen tubing was coiled in three-foot layered circle pattern. The coiled tubing laid directly next to R146's bed, on the floor. R146 stated I walk by myself and have to be very careful. I don't know why it (oxygen tubing) is left that way instead of in that bag (pointed to the oxygen concentrator at the head of the bed) on the oxygen machine. On 11/30/22 V8 (Certified Nursing Assistant/CNA) confirmed R146's oxygen tubing was on the floor and stated R146's oxygen tubing should not be on the floor. On 11/30/22 at 2:35 pm R146 was lying in bed with oxygen being delivered at 3 liters per nasal cannula. R146's oxygen tubing from the nasal cannula dropped 2 feet down to the floor, and again had coiled excessive oxygen tubing that extended to R146's oxygen concentrator. V2 (Director of Nursing/DON) entered R146's room. V2 stated R146's oxygen tubing length was 25 feet. V2 also stated the 25-foot oxygen tubing is the only extended tubing the facility uses when the routine 7-foot tubing is not enough. V14 (Housekeeper) was sweeping under R146's bed. V14 moved the broom under R146's bed, dragging an accumulation of cellophane wrappers and visible dust clusters out and directly into R164's excess oxygen tubing laying on the floor. V14 moved the broom over the top of the accumulated debris which was entangled in R146's oxygen tubing. V2 stated to R146, I will re-educate staff that this tubing is not to be left in your way on the floor. It is not sanitary and is a tripping hazard. The facility policy Oxygen Therapy dated revised May 2012 documents the following: Objective: 1. To provide a source of oxygen to persons experiencing an insufficient supply of same. The same policy documents: Safety Factors: 7. Be sure to prevent contamination of the oxygen equipment due to its presence in locations such as : Dining Room; (and) Bathroom.

CONCERN (E)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected multiple residents

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 assess and obtain a physician order for a resident to self-administration of gastrostomy feedings (g-tube), flushes and dressing changes to gastrostomy access site. The facility failed to document that a resident was self-administrating gastrostomy feedings, flushes, and dressing changes. The facility also failed to accurately transcribe g-tube medication route of medication administration. This failure affects one(R49) resident reviewed for g-tubes on the sample list of 30. Findings include: R49's Minimum Data Set, dated [DATE] documents R49's Brief Interview of Mental Status score of 13 out of 15 indicating R49 has no cognitive impairment. R49's Physician Order Report Sheet (POS)dated 11/02/22-12/02/22 documents the following Diagnoses: Wernicke's encephalopathy (Primary, Admission), Encounter for immunization, Dysphagia, unspecified, Nausea, Gastrostomy (G-tube) Status, Malignant Neoplasm of Mouth, Unspecified, Malignant Neoplasm of Mandible, Secondary and Unspecified Malignant Neoplasm of Lymph Nodes of Multiple Regions (History of). R49's POS dated 11/02/22-12/02/22 documents, High Calorie/High Protein Supplement Continuous (Does not document the route or amount of the supplement). The same POS documents: Weight Loss: Offer nutritional snacks between meals, Three Times A Day - PRN. Chocolate (nutritional supplement) TID (three times a day) between meals DX: Abnormal weight loss] Three Times A Day; 10:00 AM, 02:00 PM, 08:00 PM. R49's same POS documents: Route of administration is oral unless otherwise noted (R49 interview below documents R49 takes nothing by mouth. R49's POS dated 11/02/22-12/02/22 documents, Give 200cc (cubic centimeter) water flush each shift. Special Instructions: Water flush equal to 200cc twice a day; 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM, [DX: Gastrostomy status]. Check for residual before each feeding and document amount. Four Times A Day; 06:00 AM, 12:00 PM, 06:00 PM, 12:00 AM. (brand name of feeding) 1.5 (calorie). [DX: Gastrostomy status] Special Instructions: Give 50cc water flush before and after each intermittent bolus feeding; Document actual feeding and water flush amounts. Notify MD of refusals. Total within 24hrs- 2,000ml (milliliter), 3,000 Kcal (calories), 136g (grams) protein, 2, 328ml/24hs. [DX: Gastrostomy status] Four Times A Day; 06:00 AM, 12:00 PM, 06:00 PM, 12:00 AM General 08/25/2022 - Open Ended. R49's POS dated 11/02/22-12/02/22 documents, a dressing change order as follows: Cleanse g-tube site with NS (normal saline), apply gauze dressing daily and PRN (as needed), notify MD of any changes. [DX: Gastrostomy status] Once A Day; 06:00 PM - 06:00 AM. The same POS documents as of 09/24/2022 - Open Ended Flush gastrostomy tube before and after every use with 10 ml. of warm water. Do not use any Gel Caps in any port of tube. Keep wound clean and dry with soap and water. May place 2x2 or 4 x 4 gauze under the tube if desired. Do not attempt to remove or pull 3 button anchors around the tube; they will fall off on their own in 4 to 6 weeks, continuous. R49's same POS documents the following medications were ordered orally: Buspirone tablet; 10 mg, Cholecalciferol (vitamin D3) capsule; 5,000 unit; amt: 1 capsule, Claritin (loratadine) tablet; 10 mg; amt: 1 tablet, Dilantin-125 (phenytoin) suspension; 125 mg/5 mL; amt: 4ml, Famotidine tablet; 20 mg; amt: 1 tablet, Finasteride tablet; 5 mg; amt: 1 tablet, Magnesium tablet; 250 mg; amt: 1 tablet, Sennosides-docusate sodium tablet; 8.6-50 mg; amt: 2 tablets, Topamax (topiramate) tablet; 100 mg; amt: 1 tablet, Valproic Acid (as sodium salt) solution; 250 mg/5 mL; amt: 15 ml. R49's correlating Medication Administration Record documents multiple unidentified nurses signed off that R49 was administered the above medications orally instead of per g-tube, the same nurses administered R49's g-tube feedings and dressing changes. There was no documentation prior to 12/2/22 indicating the intended route for medication administration was via g-tube. R49's resident progress notes document medications administered via g-tube on 11/27/22 5:03 AM and 11/30/22 11:30 PM. R49's POS dated 11/02/22-12/02/22 does not document R49 self-administration of g-tube feedings. R49's care plan dated 10/20/22 documents feedings and flushes per gastric tube and stoma care Discipline: nursing. On 11/30/22 at 11:05 AM, R49 stated he does administer R49's own g-tube feedings, administers his own g-tube flushes, and does his own dressing changes around the g-tube access site. On 11/30/22 at 11:20 AM V12 (RN) stated R49 does his own g-tube feedings. On 12/2/22 at 12:05 PM R49 went to R49's room, obtained water to flush R49's g-tube and prepared R49's liquid feeding formula to be self-administered. R49 put a towel on himself, put some water mixed with formula into a cup, and poured the mixture of water and formula into the g-tube feeding syringe, which R49 had attached to the G-tube. R49 stated R49 does not eat food and takes all his medication by g-tube. R49 stated he does all his own flushes and g-tube feedings, three times a day. R49 stated R49's g-tube gets clogged a lot. R49 stated R49 just got back from going out to the emergency room to get R49's g-tube unclogged this morning. R49 also stated R49's g-tube clogged a few days ago and several times before that. On 12/2/22 at 12:19 PM, V27 (Licensed Practical Nurse/LPN) stated R49 does R49's own g-tube feedings. V27 also stated that R49's g-tube was clogged this morning and R49 was sent out for it. V27 also stated there should be an order for R49 to do the g-tube feedings himself and there isn't one. On 12/2/22 at 12:28 PM V2 (Director of Nursing/DON) stated the nurses do R49's g-tube feedings and flushes. V2 stated V2 was not aware R49 was doing the flushes and the feeding himself. V2 also stated there would not be anything in R49's CP about R49 doing the flushes and feedings himself because as far as V2 knew, R49 doesn't do it himself. V2 was informed there is no order in R49's medical record that states R49 can administer his own g-tube feeding and flushes. V2 was also informed there is no order in R49's medical record that indicate R49 takes medication per g-tube, the orders R49 takes are ordered as by mouth. V2 stated V2 was unaware of this information. The facility policy NG (Nasal Gastric)/ G-Tube (Gastrostomy) (Placement of) dated March 2004, documents the following: Purpose: 1. To provide a source of nourishment when oral feedings are neither possible nor desired due to a resident's condition. Objective: 1. To maintain an open route for passage of nourishment fluids and medication. The facility policy Medication Administration revised February 2004 documents the following: Objective: 1. To provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident. Procedure: 1. No medication will be given to any resident without an order from the resident's physician. 2. The Physician's Order must include: Name of medication, dosage, frequency, and route of administration. Start date and stop date of short-term medications must be included (antibiotics, surgery prep meds, etc.). 3. The Physician must provide a diagnosis for each medication to support the need for the medication. 4. All Physician's Orders must be given to the pharmacy, exactly as stated by the physician. 5. All Physician's Orders must be accurately transcribed to the MAR. 6. All medications must be administered to the resident in the manner and method prescribed by the physician.

Nov 2022 6 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

Notification of Changes (Tag F0580)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

Based on interview and record review the facility failed to notify R11's Physician of newly observed bruising for one of three residents (R11) reviewed for notification of change in condition in the sample list of 17. Findings include: The facility's Emergencies policy with a revised date of 4/3/18 documents, Nurse is charge of resident will evaluate resident's condition. If help is needed and there is more than one nurse available, the nurse assigned to resident will stay with resident and will send a nurses aide to go call the other nurse. Second nurse will notify DON (Director of Nursing), resident's physician, and follow his/her orders. R11's Order Summary dated 11/20/22 documents diagnoses including Dementia, Generalized Anxiety Disorder, Urinary Tract Infection, Muscle Wasting and Atrophy, Difficulty in Walking and Dysphagia. R11's Care Plan dated 6/28/22 documents R11 has generalized weakness and decline in R11's functional status related to history of cervical fracture. R11 requires extensive assistance of one staff with ambulation and dressing. R11's Nurse's Notes dated 11/4/22 at 9:15 AM documents R11 was found on the floor by staff. R11 had fallen and hit R11's head. Physician was notified by facsimile. R11's next Nurse's Note documented as a late entry on 11/4/22 at 5:01 PM documents Writer (V11 Licensed Practical Nurse) noticed left eye starting to swell and bruise. Staff applied ice pack to eye area. There is no documentation that the Physician was notified at this time of the newly identified swelling and bruising. R11's next Nurse's Note dated 11/4/22 at 9:53 AM documents the POA (Power of Attorney) is at the facility and wants R11 sent to the hospital. R11's Nurse's Notes documents V11 sent R11 to the hospital. There is no documentation in the Nurse's Note that the Physician was notified of sending R11 to the hospital. On 11/20/22 at 1:54 PM, V2 (Director of Nursing) confirmed that the Physician should have been notified of the newly identified bruising and swelling on R11's face when the nurse first saw it. V2 confirmed there is no documentation that the Physician was notified at that time.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review the facility failed to prevent misappropriation of resident's property for two of eight residents (R14, R15) reviewed for medication administration in the sample list of 17. Findings include: The facility's Medication Administration policy with a revised date of February 2004 documents, Objective: 1. To provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident. Procedure: 1. No medication will be given to any resident without an order from the resident's physician. R15's Face Sheet documents a diagnosis of Diabetes Mellitus without complications. R15's Order Sheet documents an order for Insulin Lispro Solution 100 units/ml (milliliter) per sliding scale before meals and at bedtime with a start date of 6/3/22. R14's Face Sheet documents a diagnosis of Type 2 Diabetes Mellitus without complications. R14's Order Sheet documents an order for Humalog U-100 (Insulin Lispro) 100 units/ml per sliding scale with a start date of 10/19/22. On 11/17/22 at 12:31 PM, V9 (Licensed Practical Nurse agency nurse) removed a vial of Insulin Lispro from the medication cart. The label of this Insulin Lispro vial documented R15's name and orders on it. V9 drew up two units of Insulin Lispro from R15's vial. V9 proceeded to the dining room and removed R14 from the dining room and took R14 around the corner and injected R15's Insulin Lispro into R14's stomach and returned R14 to the dining room. On 11/17/22 at 12:40 PM, V9 confirmed that V9 used R15's insulin for R14's injection. V9 stated there was none of R14's insulin in the medication cart and V9 did not know if the facility had a backup supply of insulin. V9 stated that V9 was not trained. On 11/17/22 at 1:00 PM, V2 (Director of Nursing) confirmed there is a backup supply of insulin in the medication room and V2 stated V2 does not know why R14 did not have any of R14's insulin in the medication cart. V2 stated V9 should not have used R15's insulin for R14, V9 should have asked another staff member where the backup supply was located.

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

Read full inspector narrative →

Based on interview and record review the facility failed to develop a new fall intervention following a fall for one of three residents (R2) reviewed for falls in the sample list of 17. Findings include: On 11/15/22 at 4:30 PM, V1 (Administrator) stated that the facility does not have a Fall Prevention policy. R2's Care Plan dated 10/27/22 documents diagnoses including Nontraumatic Chronic Subdural Hemorrhage, Muscle Wasting and Atrophy, Unspecified Dementia, Unspecified Lack of Coordination and Unsteadiness on Feet. The facility's Accident/Incident Log documents R2 had a fall on 10/20/22 and another fall on 11/13/22. R2's Fall Investigation for 10/20/22 fall documents that R2 was found on the floor in the dining room with no injuries indicated. The intervention for this fall was for therapy to screen for weakness and safe transfers. There is no other intervention developed. R2's Therapy Screen dated 10/11/22 completed by V21 (Certified Occupational Therapy Assistant) documents Staff notes no changes. No therapy initiated. On 11/20/22 at 1:11 PM, V16 (Physical Therapy Assistant/Director of Rehab) stated that they completed a therapy screen for R2, and they did not feel that there was any decline therefore no reason for therapy. V16 stated for the therapy screen they do not do any hands on. V16 stated it is just a quick look over of the resident and talk to staff. On 11/21/22 at 3:10 PM, V2 (Director of Nursing) stated that there was no intervention developed other than for therapy to screen R2. V2 stated that the interventions that were in place were still current, so they did not change anything. V2 confirmed R2 had another fall on 11/13/22.

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review the facility failed to properly clean equipment and failed to prevent cross contamination during a wound treatment for two of three residents (R16, R9) reviewed for infection control in the sample list of 17. Findings include: 1.) R16's Face Sheet documents diagnoses including Diabetes Mellitus, History of Poliomyelitis, Iron Deficiency Anemia and Abnormal Weight Loss. R16's Physician's Orders documents and order to apply skin prep to wound on left posterior heel daily, heel protectors to be worn at all times till healed, once a day, dated 10/27/2022. On 11/21/22 at 2:31 PM, V7 (Licensed Practical Nurse/Wound Nurse) used a pair of bandage scissors, without cleaning them first, to cut the old bandage off of R16's foot. R16's wound on R16's heel was open and covered the entire bottom of R16's heel. V7 stated that the open wound was new. V7 stated that the last V7 knew the wound was covered with eschar. V7 stated V7 needed to contact the doctor before finishing the treatment. V7 rinsed V7's bandage scissors with water in the sink and wrapped them in a paper towel. On 11/21/22 at 3:02 PM, V7 stated that V7 used normal saline to clean V7's bandage scissors before using them. V7 stated that V7 could not find any bleach wipes on the treatment cart. 2.) R9's Care Plan documents a Stage 2 open blister to the right heel dated 10/9/22 with an intervention to complete treatment according to Physician's orders dated 10/10/22. R9's Physician's Orders dated 11/20/22 documents an order for the Right heel to monitor open area, cleanse right heel with wound wash, pat dry, apply (Petroleum gauze) to wound bed, cover with abdominal dressing, and wrap with rolled gauze, secure with tape daily. On 11/21/22 at 2:39 PM, V7 (Wound Nurse) removed the old dressing from R9's leg and saturated a dry gauze pad with normal saline and wiped over R9's wound repeatedly over the same area of the wound with the same area of the moistened gauze cross contaminating the wound. V7 then took a dry piece of gauze and dabbed the wound several times over the same area repeatedly cross contaminating the wound. On 11/21/22 at 3:02 PM, V7 stated that V7 did not realize that V7 cross contaminated R9's wound while cleaning and drying it.

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 F0659 (Tag F0659)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review the facility failed to follow Physician's Orders for pain medication administration for one of eight residents (R7) reviewed for medication administration in the sample list of 17. Findings include: The facility's Medication Administration policy with a revised date of February 2004 documents, Objective: 1. To provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident. Procedure: 1. No medication will be given to any resident without an order from the resident's physician. 6. All medications must be administered to the resident in the manner and method prescribed by the physician. R7's Face Sheet documents diagnoses including Malignant Neoplasm of Upper Lobe, Left Bronchus or Lung, Generalized Anxiety Disorder and Other Chronic Pain. R7's Order Sheet documents an order for Tramadol (narcotic pain reliever) tablet 50 mg (milligrams) one tablet oral every six hours prn (as needed) with a start date of 11/3/22 and a stop date of 11/9/22. There are no other orders for Tramadol on R7's Order Sheet. On 11/17/22 at 8:51 AM, V3 (Registered Nurse) stated R7 requested medication for pain and anxiety. V3 stated that there was a refill for Tylenol 3 requested yesterday but they do not have it yet. R7 stated that R7 is supposed to get Tramadol. R7 stated that R7 has been taking it for the last two weeks. V3 confirmed there is no active order for Tramadol at this time. V3 stated the Tramadol order ended on 11/9/22. R7's Controlled Substance Record dated 11/4/22 documents 30 tablets were received on 11/4/22. This Record documents R7's Tramadol was removed from the medication card twelve times from 11/10/22 to 11/16/22 without an active Physician's Order. R7's Medication Administration Record dated 11/1/22 through 11/17/22 does not document any Tramadol administration after 11/9/22 since the order was stopped on 11/9/22. R7's Tramadol medication card had seven Tramadol tablets remaining on 11/17/22. On 11/17/22 at 3:07 PM, V2 (Director of Nursing) stated that there has to be a Physician's Order to give a medication and the nurses should not have been giving R7 Tramadol without an active order. On 11/17/22 at 4:40 PM, R7 stated that R7 has been getting the Tramadol several times a day every day for the last couple of weeks.

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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 prevent a pressure ulcer from developing, failed to complete treatments as ordered, failed to implement pressure ulcer interventions, and failed to document pressure ulcer measurements in the medical record for three of three residents reviewed (R5, R9, R16) for pressure ulcers in the sample list of 17. Findings include: The facility's Pressure Injury Prevention and Treatment Protocol policy with a revised date of October 2015 documents, Objective and Purpose: To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of any pressure injury that might develop. 4. Staff will be trained on pressure injury prevention and safety measures to be taken, including identifying redness that remains when pressure is relieved and proper positioning procedures. 5. Incontinent resident will be taken to the bathroom at least every two hours if able or according to their individualized toileting plan. If residents are incontinent, perineal care will be given and the resident will be dried. F. Protein supplement will be put in place. H. Weekly individual treatment report will be done and put on clinical chart. J. For those residents that cannot reposition themselves, transfer self out of bed or cannot turn and position themselves in bed, staff will be responsible for. K. Special devices will be used to relieve pressure. Predisposing Factors may include: 1. Bedridden/decreased mobility 2. Spinal condition injury 3. Past hip fracture 4. Post CVA (Cerebrovascular Accident) 5. Nutritionally depleted 6. Contractures 7. Comatose 8. Obese 9. The critically ill 10. Incontinence 11. Previous pressure injury 12. Diabetes. 1.) R5's Face Sheet documents R5 was admitted on [DATE] with diagnoses including Displaced Intertrochanteric Fracture of Left Femur, Restless Leg Syndrome, Age Related Osteoporosis, Muscle Wasting and Atrophy, Nutritional Anemia, Urinary Incontinence, Cognitive Communication Deficit, Other Irritable Bowel Syndrome and Vitamin Deficiency. R5's Care Plan dated 10/28/2022 documents R5 has the potential for skin breakdown related to generalized weakness and decline in mobility. 10/28/22 R5 was admitted with an incision to the left hip. 10/28/22 R5 admitted with a bruise to the right inner arm. 10/28/22 R5 admitted with an abrasion to the left outer calf. 11/3/2022 R5 has a Stage 1 pressure area to the coccyx and left buttock. Interventions documented on the care plan dated 10/28/22 are to assist with turning and repositioning routinely and PRN (as needed), keep clean and dry as possible, minimize skin exposure to moisture, pressure relieving mattress on bed, pressure relieving mattress to seat of w/c (wheelchair), provide incontinence care after each incontinent episode, moisture barrier product as needed. R5's Minimum Data Set (MDS) dated [DATE] documents R5 requires extensive assistance of two staff for transfers and one staff for bed mobility, toileting, dressing and personal hygiene. This MDS documents R5 has developed two stage 1 pressure ulcers. R5's Nurse's Notes dated 11/04/2022 at 11:40 AM documents, WC (wheelchair) cushion placed in chair and care plan reviewed and updated documented by V2 (Director of Nursing). There is no Nurse's Note documented regarding a pressure ulcer. There is a Registered Dietician progress note documented 11/15/22 that documents R5 has two stage 1 pressure ulcers according to the wound report. R5's Physician Order Report dated 10/20/22 through 11/20/22 does not document a treatment order for the pressure ulcer on the coccyx and left buttock. This order summary documents an order for barrier cream with (perineal) care for diagnosis of Unspecified urinary Incontinence dated 11/1/22. This order does not instruct where to apply the barrier cream or that there are pressure ulcers to be treated. The facility's Weekly Wound Report dated 10/29/22 through 11/4/22 documents R5 has an area on the coccyx measuring 1.8 cm (centimeters) x (by) 2 cm and an area on the left buttock measuring 2 cm x 2 cm and documents the date of the first treatment as 11/3/22 and the current treatment is barrier cream. R5's medical record does not document any measurements or assessments of these pressure ulcers. On 11/17/22 R5 was in R5's wheelchair at 8:38 AM, 9:58 AM, 11:07 AM, 11:22 AM, 12:23 PM and 2:30 PM. On 11/17/22 at 2:30 PM, V6 (Certified Nursing Assistant/CNA) confirmed V6 is R5's CNA today and confirmed that V6 has not done anything with R5 since R5 got out of bed this morning. V6 stated that R5 doesn't want to lay down or go to the bathroom. On 11/17/22 at 2:34 PM, V6 and V5 (CNA) assisted R5 into bed to lay down. V5 and V6 did not take R5 to the toilet and did not check R5 for incontinence at this time. On 11/20/22 at 11:47 AM, R5 was assisted to transfer to bed by V6 and V15 (CNA). V6 lowered R5's incontinent brief and there were two pressure ulcers on R5's bottom. One on the right and one on the left buttock. Both areas are red and appear to either have been open or about to open. There are two areas on the left side approximately 1/2 and 1 cm around that the skin appears to be thinner. V6 stated that V6 thinks there is barrier cream on R5's bottom. 2.) R9's Care Plan dated 10/13/22 documents diagnoses including Fracture of Unspecified Part of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing(Primary), Chronic Diastolic (congestive) Heart Failure, Difficulty in Walking, Muscle Weakness (generalized), Need for Assistance with Personal Care, Spinal Stenosis, Lumbar Region with Neurogenic Claudication, Retention of Urine, Pressure Ulcer of Right Heel, Repeated Falls, Pain and Edema. This Care Plan documents a Stage 2 open blister to the right heel dated 10/9/22 with an intervention to provide diet and supplements per Physician's orders dated 10/18/22. R9's Physician's Orders dated 11/20/22 document an order for the Right heel to monitor open area, cleanse right heel with wound wash, pat dry, apply (Petroleum gauze) to wound bed, cover with abdominal dressing and wrap with rolled gauze, secure with tape daily. Monitor for (signs and symptoms) of infection. Notify (Physician) if needed. Once A Day from 07:00 PM - 04:00 AM dated 10/10/2022. These Physician's Orders document an order for a Regular HC/HP (High Calorie/High Protein) supplementation, Continuous, dated 10/17/2022. R9's Diet Order Change Request dated 10/14/22 completed by V22 (Registered Dietician) documents a recommendation for a High Calorie/High Protein supplementation and a Multivitamin with minerals and this request is signed by V23 (R9's Physician) on 10/17/22. R9's Medication Administration Record does not document the high calorie/high protein supplement. On 11/21/22 at 12:40 PM, R9 was in the dining room eating lunch. R9 had roast pork, stuffing, carrots, cake with frosting and juice. There was no high calorie/high protein supplement at R9's place setting during lunch. R9's meal ticket documents a Regular diet, Regular texture and HCHP (High Calorie/High Protein). On 11/21/22 at 12:55 PM, V18 (CNA) stated that a nurse gives that HCHP, dietary does not give it anymore. At this time V19 (Dietary Aide) stated V19 was not aware of what that HCHP was and did not give it to the residents. On 11/21/22 at 12:56 PM, V17 (agency Licensed Practical Nurse/LPN) stated V17 was not aware of what HCHP was and does not do anything with it. On 11/21/22 at 1:35 PM, V7 (LPN/Wound Nurse) stated V7 does not know what the HCHP is exactly. On 11/21/22 at 1:40 PM, V2 (Director of Nursing) stated that HCHP comes from dietary. On 11/21/22 at 1:45 PM, V20 (Dietary Manager) stated that the HCHP would either be in super cereal oatmeal or fortified pudding or yogurt. V20 stated that it would come from dietary in individual servings for the resident. V20 confirmed if the dietary aide did not know what it was then it was not provided to R9 as ordered. On 11/21/22 at 2:39 PM, V7 prepared to complete the dressing change for R9. V7 removed the dressing that was on R9's right foot, which was actually around R9's ankle loosely, and not over the wound. V7 confirmed the dressing was dated 11/18/22. V7 confirmed that the dressing is supposed to be changed daily and it was not. V7 confirmed it had not been changed for three days according to the dated dressing. 3.) R16's Face Sheet documents diagnoses including Diabetes Mellitus, History of Poliomyelitis, Iron Deficiency Anemia and Abnormal Weight Loss. R16's Physician's Orders documents and order to apply skin prep to wound on left posterior heel daily, heel protectors to be worn at all times till healed, once a day, 7:00 PM - 04:00 AM dated 10/27/2022. These Physician's Orders also document an order for heel protective boots BL (bilateral) boots should be worn at all times, Twice A Day, 6:00 AM - 6:00 PM, 6:00 PM - 6:00 AM dated 10/27/2022. On 11/21/22 at 9:35 AM, R16 was not in R16's room but there was one heel protector boot laying on the bed. On 11/21/22 at 11:32 AM, R16 was in R16's room in R16's wheelchair. R16 had a heel protector boot on the left foot but not on the right foot. On 11/21/22 at 12:24 PM, R16 was in R16's wheelchair in the dining room and R16 had a heel protector boot on the left foot but none on the right foot. R16's Care Plan dated 10/13/22 documents R16 has a stage 2 pressure area to the left heel with an intervention of heel protectors dated 10/14/22. On 11/21/22 at 2:31 PM, V7 confirmed R16 should have bilateral heel protectors on both feet. R16's medical record does not document any measurements or assessments of the pressure ulcer on R16's left heel.

Nov 2022 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

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to ensure proper body alignment during turning and positioning for one (R1) of three residents reviewed for accidents on the sample list of ten. This failure resulted in R1 sustaining a left Humerus fracture. Findings include: On 11/2/22 at 9:34 AM, R1 was lying in bed in a hospital gown. R1 had an arm sling around the left arm. The Nurse's Note dated 10/28/2022 at 5:37 AM, written by V6 (Licensed Practical Nurse) documents, (V5 Certified Nurse's Assistant/CNA) asked writer to come help roll (R1) in bed to get dressed in morning. Upon rolling resident (left) arm got under (R1) and a pop noise was heard. (R1) complained of pain going down (left) arm. Upon assessment resident (left) arm appeared to be swollen at the top of the shoulder. Hand grasp strong bilaterally. Unable to fully assess length of arm due to (R1) refusing to extend arm. R1's Hospital Transfer Report dated 10/28/22 at 11:27 AM, documents, (R1) arrived per (Emergency Medical Services) from (facility) where staff reports (R1) was lying on (left) arm when placed in bed and pop was heard. (R1) was complaining of pain this am. (R1) confused and unable to answer questions at this time. This report documents R1 was diagnosed with a Left Humerus Fracture. On 11/3/22 at 10:51 AM, V6 (Licensed Practical Nurse) stated, (V5 CNA) asked for help turning R1 in bed. V6 stated when turning R1 they tried to cross (R1's) arms, but R1's arm kept dropping to the side. V6 stated R1 has difficulty following directions and we kept crossing R1's arms so R1 wouldn't roll on top of it. V6 stated after we had (R1) halfway over (R1's) arm fell back down and then went under her side and R1 rolled on top of R1's shoulder and we heard a pop noise. R1 complained of pain. R1 was sent to the emergency room and was diagnosed with a left Humerus fracture. V6 stated we should have had three staff to assist her to ensure that R1's arms remained crossed. R1 is an extensive assistance with bed mobility. The facility's undated Turning and Positioning Protocol provided by V2 Director of Nursing documents, 5. Be sure the resident is in good body alignment.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to develop interventions and a plan of care after a resident (R2) was found smoking unsupervised while using oxygen. This failure has the potential to affect one (R2) of three residents reviewed for accidents on the sample list of ten. Findings include: R2's hospital history and physical dated 10/5/22 documents, She endorses persistent tobacco use but denies shortness of breath or chest discomfort at this current time. R2's Nurse's Note dated 10/15/2022 at 3:35 AM documents, (R2) was caught smoking cigarette in room while on oxygen. (Unknown Certified Nurse's Assistant) stated that (R2) was emptying cup in trash and seen ashes in cup. I went to observe situation (R2) stated that (R2) have in fact been smoking in room. Educated (R2) that this a smoke free facility and that (R2) could of put self at high risk for lighting fire while on oxygen. (R2) then stated to me that (R2) did smoke a cigarette that (R2) kept in purple wallet. This note also documents that R2 had a pack of cigarettes. On 11/2/22 at 12:59 PM, R2 was sitting in her room. R2 was receiving oxygen via a nasal cannula. R2 stated her cigarettes are at home. R2 stated she wishes she could go outside and smoke. R2's plan of care dated 10/11/2022 documents R2 has potential for respiratory distress related to a diagnosis of Chronic Obstructive Pulmonary Disease and requires the use of oxygen. R2's plan of care does not document interventions or a plan of care for the risk of smoking while using oxygen. On 11/2/22 at 2:30 PM, V2 (Director of Nursing) stated she got a phone call from the nurse the night R2 was found smoking in the room. V2 stated a care plan with interventions should have been developed and implemented after R2 was found smoking in the room.

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

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 provide nail care, oral care, and shaving for three (R1, R3, and R8) of four residents reviewed for hygiene on the sample list of 10. Findings include: 1. On 11/2/22 at 9:34 AM, R1 was lying in bed in a hospital gown. R1's fingernails were long, jagged, and had accumulated black dirt and debris underneath them. R1's teeth had food build up on the front of them. R1's care plan dated 5/6/16 documents R1 requires extensive assistance with grooming. 2. On 11/2/22 at 9:39 AM, R3's chin had multiple whiskers on it. R3's fingernails were long and had black accumulated debris under them. R3's teeth had food caked on the surface. R3's Annual Minimum Data Set assessment data 8/10/2022 documents R3 requires extensive assistance with grooming. 3. On 11/3/22 at 10:00 AM, R8 was lying in bed with head of bed elevated and right arm elevated on top of pillow, R8 had multiple white hairs covering the entire chin area. R8's MDS assessment dated [DATE] documents R8 requires extensive assistance of one staff member for personal hygiene. On 11/3/22 at 12:22 PM, V2 (Director of Nursing) stated R1, R3, and R8 require assistance with grooming and would expect staff to assist them as needed.

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 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, 6 harm violation(s), $72,309 in fines. Review inspection reports carefully.
• 86 deficiencies on record, including 6 serious (caused harm) violations. Ask about corrective actions taken.
• $72,309 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.

Email me this report

About This Facility

What is Goldwater Care Clinton's CMS Rating?

CMS assigns GOLDWATER CARE CLINTON 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 Goldwater Care Clinton Staffed?

CMS rates GOLDWATER CARE CLINTON's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 76%, which is 30 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 80%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Goldwater Care Clinton?

State health inspectors documented 86 deficiencies at GOLDWATER CARE CLINTON during 2022 to 2025. These included: 6 that caused actual resident harm, 79 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Goldwater Care Clinton?

GOLDWATER CARE CLINTON is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by GOLDWATER CARE, a chain that manages multiple nursing homes. With 134 certified beds and approximately 88 residents (about 66% occupancy), it is a mid-sized facility located in CLINTON, Illinois.

How Does Goldwater Care Clinton Compare to Other Illinois Nursing Homes?

Compared to the 100 nursing homes in Illinois, GOLDWATER CARE CLINTON's overall rating (1 stars) is below the state average of 2.5, staff turnover (76%) 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 Goldwater Care Clinton?

Based on this facility's data, families visiting should ask: "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?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.

Is Goldwater Care Clinton Safe?

Based on CMS inspection data, GOLDWATER CARE CLINTON has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). 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 Goldwater Care Clinton Stick Around?

Staff turnover at GOLDWATER CARE CLINTON is high. At 76%, the facility is 30 percentage points above the Illinois average of 46%. Registered Nurse turnover is particularly concerning at 80%. 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 Goldwater Care Clinton Ever Fined?

GOLDWATER CARE CLINTON has been fined $72,309 across 2 penalty actions. This is above the Illinois average of $33,802. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Goldwater Care Clinton on Any Federal Watch List?

GOLDWATER CARE CLINTON 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.

Facility Details

Beds: 134
Avg. Residents: 88
Occupancy: 66.2%
Ownership: Non profit - Corporation
Chain: GOLDWATER CARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -10
6 Actual Harm citations: -30
86 Deficiencies: -10
Fines ($72,309): -10
Abuse Finding: -15
Final Score: 0/100

Nearby Alternatives

THE HAVEN OF FARMER CITY 1-star

View all in CLINTON →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 146076