LA BELLA OF DANVILLE
For profit - Corporation
200 Beds
Independent
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#561 of 665 in IL
Photo by La Bella of Danville
Photo by Jeremy Laird
Photo by La Bella of Danville
1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
La Bella of Danville has received a Trust Grade of F, indicating significant concerns and a poor overall quality of care. It ranks #561 out of 665 facilities in Illinois, placing it in the bottom half of state options and #5 out of 5 in Vermilion County, meaning there are no better local alternatives. Although the facility has shown improvement over time, dropping from 42 issues in 2024 to 17 in 2025, it still faces serious challenges, including a concerning 60% staff turnover rate, which is higher than the state average, and $439,062 in fines, indicating persistent compliance issues. Specific incidents raised by inspectors include a failure to supervise a cognitively impaired resident who eloped from the facility and a delay in addressing a resident's significant weight gain that led to hospitalization for congestive heart failure. The staffing situation is also troubling, with less RN coverage than 83% of Illinois facilities, which affects the quality of care residents receive.
- Trust Score
- F
- In Illinois
- #561/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $439,062 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 114 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 16%
Review needed
42 → 17 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 42 issues
2025: 17 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: 60%
14pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $439,062
Well above median ($33,413)
Significant penalties indicating serious issues
Staff turnover is elevated (60%)
12 points above Illinois average of 48%
The Ugly 114 deficiencies on record
3 life-threatening 9 actual harm
May 2025
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to effectively supervise R3 to prevent falls. This failure resulted in R3 falling from R3's wheelchair to the floor in R3's room. This failure...
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Based on interview and record review, the facility failed to effectively supervise R3 to prevent falls. This failure resulted in R3 falling from R3's wheelchair to the floor in R3's room. This failure affects one resident (R3) of three reviewed for accidents in the sample of eight.
Findings Include:
R3's diagnosis list (printed 5/7/2025) documents R3's diagnoses include: Cerebral Infarction (stroke), Personal History of Transient Ischemic Attack (temporary disruption of blood flow to the brain causing stroke-like symptoms), and Alzheimer's Disease.
R3's admission Assessment (3/13/2025) documents R3 has severe cognitive impairment, uses a wheelchair, and is dependent on staff for mobility and transfers from the wheelchair to other surfaces.
The facility fall log (April, 2025) documents R3 experienced falls in the facility on 4/1/2025, 4/12/2025, and 4/13/2025.
R3's Care Plan (printed 5/7/2025) documents R3 is at risk for falls and a new intervention starting on 4/1/2025 for staff to place R3 in bed after meals.
The facility Post Fall Huddle (4/1/2025) documents R3 experienced an unwitnessed fall in R3's room on 4/1/2025 when R3 attempted to get up from R3's wheelchair to walk. The same record documents interventions to prevent further reoccurrence/falls including frequent checks and education for staff to keep R3 in a common area or monitored when in R3 is in R3's wheelchair.
R3's medical progress notes (4/2/2025) document R3 experienced a fall on 4/1/2025, is at high risk for falls, and staff should place R3 in bed after all meals.
R3's Progress Notes (4/12/2025) document R3 experienced a subsequent fall in R3's room on 4/12/2025 at 3:05PM. The same report alleges R3 was transferred by two staff members from the floor to the bed after the fall and documents, educate staff to lay (R3) down after all meals.
On 5/7/2025 at 12:32PM, V2 (Director of Nursing) reported R3's 4/12/2025 fall was witnessed by V6 (Certified Nurse Aide).
On 5/8/2025 at 2:37PM, V6 denied being present in the facility on 4/12/2205 when R3 experienced a fall from the wheelchair to the floor. V6 reported being away from the facility on scheduled vacation on 4/12/2025.
On 5/8/2025 at 2:50PM, V2 (Director of Nursing) then reported V6 was not the facility staff member who witnessed R3's fall on 4/12/25 but the staff member was V10 (Certified Nurse Aide).
On 5/8/2025 at 3:03PM, V10 denied ever witnessing any of R3's falls and denied witnessing R3's fall occurring on 4/12/2025.
On 5/9/2025 at 10:48AM, V2 (Director of Nursing) then alleged the facility staff member taking care of R3 on 4/12/2025 who observed R3 fall from the wheelchair was V11 (Minimum Data Set Coordinator).
On 5/9/2025 at 2:17PM, V11 reported allegedly being present when R3 fell to the ground on 4/12/2025 from R3's wheelchair and reported V12 (Certified Nurse Aide) was the staff member who helped V11 move R3 off the floor after the fall. V11 denied knowing if staff had placed R3 into bed following lunch on 4/12/2025 prior to the fall occurring at 3:05PM.
On 5/9/2025 at 2:32PM, V12 (Certified Nurse Aide) denied ever witnessing any of R3's falls and denied helping V11 move R3 off the floor after R3's fall on 4/12/2025.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect resident's rights to be free from verbal and physical abuse ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect resident's rights to be free from verbal and physical abuse from another resident. This failure affected three of five residents (R4, R5, R8) reviewed for abuse in the sample of eight.
Findings Include:
The facility's Abuse Prevention and Reporting- Illinois policy dated August 2023 documents the facility affirms the right of its residents to be free from abuse. The policy defines Abuse as the willful infliction of injury. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse as the infliction of injury on a resident. Physical abuse includes hitting, slapping, and other similar behaviors. The policy defines Mental Abuse as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal Abuse is defined as the use of oral, written, or gestured communication to residents within hearing distance regardless of age, ability to comprehend, or disability. Verbal abuse can include harassing, mocking, insulting, or ridiculing a resident. Resident-to-resident altercations that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations.
1. The Serious Injury and Communicable Disease Report dated 4/22/25 documents R4 and R5 were involved in an altercation. At approximately 7:45 PM on 4/22/25, R4 attempted to touch the watch on R5's arm. R5 responded by grabbing R4's wrist which created a skin tear to R4's right wrist.
R4's Medical Diagnoses List dated May 2025 documents R4 is diagnosed with Dementia with Psychotic Features, Mental Disorder, Anxiety, Bipolar Disease, Psychotic Disorder with Delusions, Violent Behavior, and Altered Mental Status.
R4's Minimum Data Set, dated [DATE] documents R4 is severely cognitively impaired.
R4's Care Plan dated 2/12/25 documents R4 wanders and is at moderate risk for abuse.
R5's Medical Diagnoses List dated May 2025 documents R5 is diagnosed with Dementia with Agitation, Generalized Anxiety Disorder, and Insomnia.
R5's Minimum Data Set, dated [DATE] documents R5 is severely cognitively impaired.
R5's Care Plan dated 3/2/25 documents R5 had a behavior problem of cursing and hitting staff and has mood swings. R5 is also physically aggressive and strikes out and scratches. R5 is also a moderate risk for abuse.
R5's Abuse Neglect Screening dated 3/2/25 documents R5 has behaviors that may provoke a reaction by residents or others which include but are not limited to: verbal aggression, insults to race or ethnicity, physical aggression, inappropriate touching or grabbing, and wandering.
On 5/13/25 at 11:46 AM V18 Licensed Practical Nurse (LPN) stated on 4/22/25, he witnessed R4 reach for and grab R5's wristwatch. V18 stated R5 does not like to be touched or grabbed like that. V18 confirmed R5 quickly grabbed R4's arm in retaliation and made a skin tear. R4 yelled out.
2. The Serious Injury and Communicable Disease Report dated 5/5/25 documents on 5/5/25 at approximately 1:00 PM R5 and R8 were involved in an altercation.
R8's Medical Diagnoses List dated May 2025 documents R8 is diagnosed with Dementia, Alzheimer's Disease, and Mild Cognitive Impairment.
R8's Minimum Data Set, dated [DATE] documents R8 is severely cognitively impaired.
R8's Care Plan dated 8/21/23 documents R8 has the potential for aggressive behaviors and is at high risk for abuse.
R8's Abuse Neglect Screening dated 2/25/25 documents R8 has a history of mistreating others with verbal/physical/sexual abuse.
On 5/8/25 at 4:15 PM V9 Certified Nurse Assistant (CNA) stated she was at the nurses' station and witnessed R5 sitting in her wheelchair in the middle of the hallway. R8 was attempting to push R5's wheelchair out of the way. R5 got upset and started swinging her arms in R8's direction. V9 is unsure if R5 was able to hit and make contact with R8, however R8 became upset and hit R5 across her face right beside her cheek and eye area. V9 stated R8 hit R5 hard and R5 was holding her face and then preceded to call R8 a N***** (racial slur).
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
Based on interview and record review, the facility failed to administer five consecutive doses of ordered intravenous antibiotic medication. This failure affects one resident (R3) of one reviewed for ...
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Based on interview and record review, the facility failed to administer five consecutive doses of ordered intravenous antibiotic medication. This failure affects one resident (R3) of one reviewed for medication administration in the sample of eight.
Findings Include:
R3's diagnosis list (printed 5/7/2025) documents diagnoses including: Cutaneous Abscess of Buttock and Encounter for Change or Removal of Non-surgical Wound Dressing.
R3's Care Plan (printed 5/7/2025) documents R3 has a history of wound infection requiring antibiotic treatment.
R3's wound treatment timeline (undated) documents R3 was to start antibiotic treatment for a wound infection on the morning of 4/19/2025.
R3's Order Entry (4/18/2025 at 6:44PM) documents a medical order for R3 to begin antibiotic treatment with Unasyn, 1.5 grams, intravenously every eight hours.
R3's medication administration record (April, 2025) documents R3 did not receive the first dose of the above ordered antibiotic until 4:00PM on 4/20/2025.
V13's handwritten note (5/7/2025) documents facility staff did not notify V5 (R3's wound care medical provider) of the above missed antibiotic doses.
On 5/9/2025 at 2:50PM, V3 (Assistant Administrator) reported an expectation for facility staff to reach out to a prescribing medical provider within a day's time if they are unable to provide a medication ordered for a resident.
Apr 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of abuse involving two (R9, R10) residents out ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of abuse involving two (R9, R10) residents out of four residents reviewed for abuse in a sample list of 11 residents.
Findings include:
The facility policy titled Abuse, Neglect, Exploitation and Misappropriation Program -Reporting and Investigating reviewed September 2024 documents residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This same documents if the Administrator cannot immediately refute the allegation relating to resident to resident abuse, neglect, exploitation, and/or misappropriation, the Administrator initiates a thorough investigation, completes and submits initial reports to the required agencies, and notifies local authorities.
R10's Minimum Data Set (MDS) dated [DATE] documents R10 as severely cognitively impaired. This same MDS documents R10 requires supervision with eating, dependent on staff for toileting, dressing, personal hygiene, bed mobility and transfers.
R9's Minimum Data Set (MDS) dated [DATE] documents R9 as cognitively intact. R9's Electronic Medical Record (EMR) documents R9 can self-propel in his wheelchair about the facility.
R9, R10's abuse summary report documents facility staff reported to V1 Administrator that R9 was allegedly touching and kissing R10. This same report documents there were no observations of inappropriate contact observed by other staff present in the dining room (on 4/7/25).
On 4/17/25 at 2:40 PM V1 Administrator stated V18 Certified Nurse Aide (CNA) reported to V1 that R9 had put his hand on R10's inner thighs and that R9 had kissed R10 on the side of her neck. V1 stated V18 CNA reported that V18 had removed R10 from the area immediately. V1 Administrator stated V1 did review the camera footage and interview staff and other residents who were present. V1 stated he did not report this allegation of sexual assault to the State Agency. V1 Administrator stated the facility Abuse Policy does state any allegation of abuse must be reported unless it can immediately be refuted. V1 Administrator stated he started an investigation on 4/7/25 but did not report anything to the State 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
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow physician orders in arranging a referral for an outside resou...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow physician orders in arranging a referral for an outside resource for one (R1) resident out of three residents reviewed for physician orders in a sample list of 11 residents.
Findings include:
R1's undated Face Sheet documents R1 admitted to the facility on [DATE] with a pre-existing Left Above the Knee (AKA) amputation.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and bed mobility.
R1's Physician Order Sheet (POS) dated April 2025 documents a physician order starting 12/26/25 for Carbohydrate Controlled Diet (CCD)/Renal, regular texture with regular/thin liquids consistency. This same POS documents a physician order dated 3/27/25 to refer R1 to a Prosthetic clinic.
R1's Nurse Progress Note dated 3/27/25 at 11:28 AM documents R1 is to be referred to a prosthetic clinic. R1's Nurse Progress Notes do not document any other information regarding an appointment being made to a prosthetic clinic.
On 4/15/25 at 3:40 PM V6 Social Service Director (SSD) stated she was aware of R1's referral to the prosthetic clinic and let the Interdisciplinary Team (IDT) know. V6 SSD stated the IDT team told her that they were going to work on getting the referral, but no one ever followed up on R1's referral.
On 4/16/25 at 3:15 PM V14 Physical Therapy Assistant (PTA) stated she worked with R1 who was non-compliant at times and cognitively intact. V14 PTA stated therapy does not set up appointments for residents V14 stated the nursing department is in charge of setting up outside services for residents.
On 4/17/25 at 9:35 AM V15 Nurse Practitioner stated V15 NP wrote a progress note documenting the need for a referral for R1 to the prosthetic clinic. V15 NP stated she wrote the physician order herself on 3/27/25. V15 NP stated she expects the facility to follow and carry out all the physician orders.
On 4/17/25 at 1:25 PM V20 Transportation Director stated V20 is responsible for arranging appointments for residents and transporting the residents back and forth to appointments. V20 stated he was aware of R1's referral to a prosthetic clinic but was told by V6 Social Service Director (SSD) to not make the appointment.
On 4/17/25 at 3:45 PM V1 Administrator stated the facility does not have a policy instructing employees to follow a physician order. V1 Administrator stated it is the expectation that when a provider such as a Physician or Nurse Practitioner writes a referral for services and writes a physician order to obtain a referral the staff are expected to follow the provider's order. V1 Administrator V1 stated if the staff had obtained an appointment for R1's referral for a prosthetic device, the staff could have informed R1 of this before he left and he could have at least had the appointment made for him.
Apr 2025
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to honor the resident rights for one (R100) resident out o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to honor the resident rights for one (R100) resident out of one resident reviewed for resident rights in a sample list of 47 residents.
Findings include:
R100's undated Face Sheet documents medical diagnoses as Muscle Wasting and Atrophy, Morbid Obesity, Acute Kidney Failure, Weakness, Contracture of Muscle, Difficulty in Walking, End Stage Renal Disease, Lymphedema and Moderate Protein Calorie Malnutrition.
R100's Minimum Data Set (MDS) dated [DATE] documents R100 as cognitively intact. This same MDS documents R100 as being dependent on staff for toileting, dressing, bathing, transfers and requires maximum assistance for personal hygiene.
R100's Care plan intervention dated 10/12/2022 instructs staff to provide resident with opportunities for choice during care provision.
On 4/8/25 at 11:00 AM R100 was laying in his bed on his back. R100 stated, I want to get up. They (staff) told me I have to stay in bed until the (V39) Wound Physician sees me. That might be four or five o'clock. I want to get up and they make me wait for hours. R100 was teary eyed as is asking to get out of bed. R100 stated he can't get up by himself or he might fall, and the staff will not help him get up.
On 4/8/25 at 11:05 AM V5 Licensed Practical Nurse (LPN) stated R100 was told by V7 Wound Nurse/Registered Nurse (RN) that he had to stay in bed until the V39 Wound Physician saw him. V5 LPN stated V39 Wound Physician has not arrived yet and does not know what time V39 will be at the facility.
On 4/8/25 at 12:10 PM V6 Certified Nurse Aide (CNA) stated R100 has been crying all morning because he wants to get out of bed, but V7 Wound Nurse/RN won't let us (staff) get R100 out of bed until he is seen by V39 Wound Physician. V6 CNA stated R100 loves to get up in his wheelchair so he can roam around the facility and wave to everybody.
On 4/10/25 at 8:10 AM V7 Wound Nurse/RN stated R100 refused to have his dressing changed this morning because he wanted to get out of bed. V7 stated V7 told R100 that he needed to stay in bed until his dressings could be changed. V7 stated R100 refused because he did not want to stay in bed.
On 4/10/25 at 8:30 AM R100 stated, I am fine with having my dressings changed. I am not fine with the staff making me stay in bed all day. I should be able to get up when I want to. If I lay down, then they (staff) won't let me get back up. They always make me stay in bed for hours and hours.
On 4/10/25 at 9:05 AM V2 Director of Nurses (DON) stated R100 should not be asked to stay in bed for long periods of time to wait for wound care to be provided. V2 stated R100 is alert and oriented. V2 DON stated making R100 stay in bed for hours is a violation of R100's rights. V2 DON stated if R100 had to wait a few minutes, that would be ok but waiting for hours is not acceptable and R100 should be able to get up when he wants to.
On 4/10/25 at 9:20 AM V7 Wound Nurse/Registered Nurse (RN) stated she asked R100 to stay in bed on 4/8/25 so that he could be seen by V39 Wound Physician. V7 Wound Nurse stated V39 arrived in the facility at 1:00 PM. V7 Wound Nurse stated V7 does offer R100 incentives to lay down. V7 RN/ Wound Nurse stated R100 can get up anytime he wants to, but V39 Wound Physician likes to see R100 when he is laying in his bed. V7 stated R100 refuses to lay back down after he is up and would possibly miss wound care if the staff allowed him to get out of bed before V39 sees him. V7 Wound Nurse/RN stated on other days, R100 can get up at his preferred time but on days that V39 Wound Physician comes, it works out better if (R100) stays in bed.
The facility policy titled Resident Rights reviewed January 2025 documents federal and state laws guarantee certain basic rights to all residents of this facility. These rights include resident's right to have a dignified existence and be treated with respect, kindness and dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to notify a resident and their representative in writing about a hospital transfer and failed to provide a bed hold notice for one of two resi...
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Based on interview and record review, the facility failed to notify a resident and their representative in writing about a hospital transfer and failed to provide a bed hold notice for one of two residents (R82) reviewed for hospitalizations on the sample list of 38.
Findings Include:
On 04/8/25 at 11:00am, R82 stated R82 went to the hospital 2 times in the last 2 weeks. R82 stated the facility did not talk with R82 about a Bed Hold Policy nor was R82 provided a Bed Hold Policy upon going to the hospital.
On 4/9/25 at 12:21 pm, V35 [NAME] President of Clinical Operations stated Bed Holds are to be filled out by the nurses when a resident is sent to the hospital; a copy should be sent with the resident, and the facility keeps a copy. V35 confirmed that R82 was sent to the hospital on 3/25/25 and 3/28/25 and a Bed Hold Policy was not given to R82.
R82's Progress Notes documents R82 was sent to the hospital on 3/25/25 and 3/28/25.
R82's Medical Record does not contain a copy of the facility bed hold policy, or documentation that R82 or R82's representative was provided a copy of the facilities bed hold policy.
Facilities Bed-Hold and Returns Policy dated October 2022 documents: Policy Statement: Residents and/or representatives (on writing) of the facility and state (if applicable) bed-hold policies. Policy Interpretation and Implementation: 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice. a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete a residents comprehensive assessment. This fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete a residents comprehensive assessment. This failure affects one (R119) of two residents reviewed for accuracy of assessments in the sample list of 47.
Findings include:
R119's Comprehensive assessment dated [DATE] documents R119 has been taking an antibiotic.
R119's February 2025 Order Summary Report does not document R119 having any antibiotic orders.
R119's Electronic Medical Record does not document R119 taking any antibiotics during the assessment period.
On 4/11/25 at 12:53pm, V38 MDS Coordinator stated V38 completed the medication section of R119's 2/23/25 comprehensive assessment and marked R119 as taking an antibiotic. V38 confirmed R119 was not prescribed and/or administered any antibiotics during February 2025 (assessment look back period).
The facility Resident Assessments Policy (revised March 2022) documents all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.
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
Based on observation, interview and record review the facility failed to enter in new wound dressing change orders and failed to provide wound care in accordance with professional standards. This fail...
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Based on observation, interview and record review the facility failed to enter in new wound dressing change orders and failed to provide wound care in accordance with professional standards. This failure affected one of three residents (R138) reviewed for wounds on the sample list of 47.
Findings Include:
The facility's Wound Care policy dated October 2010 documents staff should always verify the physician order and use the no-touch technique when cleaning a wound and if touching a wound is necessary, use sterile gloves.
R138's Medical Diagnoses List dated April 2025 documents R138 is diagnosed with Idiopathic Aseptic Necrosis of the Right and Left foot and Peripheral Vascular Disease.
On 4/11/25 at 10:25 AM V7 Wound Nurse performed R138's wound dressing changes. V7 sanitized her hands, placed new clean gloves on her hands, then preceded to cleanse R138's right lateral foot wound with gauze soaked in Betadine. V7 then picked the new clean dressing that covered both of R138's right foot wounds and placed it on R138's right foot with the same gloves she had worn to clean the wound. V7 dressed R138's right foot and secured the dressing in place then removed her dirty gloves and sanitized her hands.
On 4/11/25 at 10:30 AM V7 Wound Nurse confirmed that she should have removed her dirty gloves after cleaning R138's right lateral foot wound, before she picked up and placed the new clean dressing on R138's right foot.
R138's Physician Order Sheet dated 4/11/25 documents R138's right lateral foot wound is to be cleansed with wound cleanser, apply medical honey to the wound bed, place calcium alginate, cover with abdominal pad, wrap with a stretch gauze dressing and secure with an ace wrap.
R138's Wound Evaluation and Management Summary dated 4/8/25 documents R138's right lateral wound should be treated with gauze soaked in Betadine solution then covered with an abdominal pad, wrap with a stretch gauze dressing and secure with an ace wrap.
R138's Wound Evaluation and Management Summary dated 4/8/25 documents R138's right lateral wound should be treated with gauze soaked in Betadine solution then covered with an abdominal pad, wrap with a stretch gauze dressing and secure with an ace wrap.
On 4/11/25 at 10:40 AM V7 Wound Nurse confirmed V39 Wound Doctor saw R138 on 4/8/25 and changed R138's wound dressing orders. V7 confirmed she did not enter the new wound dressing orders in the computer yet. The previous orders were twice per day and included deferent wound treatments than the most recent orders. V7 confirmed R138's wound dressing changes have been documented under the old order and have been done twice per day despite the order changing on 4/8/25. V7 confirmed she should have changed the order in the computer the same day that she received the new orders from V39 Wound Doctor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent cross contamination during catheter care for on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent cross contamination during catheter care for one (R5) resident out of one resident reviewed for catheter care in a sample list of 47 residents.
Findings include:
R5's undated Face Sheet documents medical diagnoses as Hereditary Spastic Paraplegia, Morbid Obesity, Dependence on Wheelchair, Epilepsy, Cerebral Palsy, Neuromuscular Dysfunction of Bladder, Acquired Absence of Right and Left Above the Knee Amputations, Presence of Urogenital Implants, Scoliosis, Syringomyelia and Syringobulbia.
R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. This same MDS documents R5 as being dependent on staff for toileting and maximum assistance with bathing.
R5's Physician Order Sheet (POS) dated April 2025 documents a physician order to cleanse Suprapubic catheter site with wound cleanser apply T-Drain dressing to site twice daily.
On 4/9/25 at 2:05 PM V13 Licensed Practical Nurse (LPN) completed catheter care for R5's Supra Pubic Indwelling Urinary Catheter. V13 LPN removed R5's split gauze from R5's Supra Pubic catheter insertion site which was contaminated with yellow/pink drainage. V13 LPN cleansed yellow/pink drainage from R5's Supra Pubic catheter insertion site by wiping the gauze back and forth multiple times over the same area. V13 LPN used the same contaminated gloves to place a new split gauze over R5's Supra Pubic Catheter insertion site without changing gloves or using hand hygiene. R5's Supra Pubic catheter insertion site was reddened and in an abdominal fold.
On 4/9/25 at 2:25 PM R5 stated the staff never clean his Supra Pubic catheter insertion site. R5 stated the staff do change his catheter monthly and will clean the site then but 'never' clean it daily.
On 4/9/25 at 2:30 PM V13 Licensed Practical Nurse (LPN) stated she contaminated R5's Supra Pubic catheter insertion site by wiping contaminated gauze back and forth and by not changing her gloves between cleaning the drainage from his wound and applying a new gauze.
On 4/9/25 at 3:15 PM V2 Director of Nurses (DON) stated contaminating an open wound such as R5's Supra Pubic catheter insertion site could lead to an infection.
The facility policy revised October 2010 instructs facility staff to discard disposable items into designated containers after cleansing around the catheter site. Remove gloves and discard in designated container. Perform hand hygiene. Inspect the stoma site and skin around the stoma for any redness or skin breakdown.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to accurately transcribe a physician order which resulted in a resident receiving nine inaccurate doses of a psychotropic medication (antidepre...
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Based on interview and record review the facility failed to accurately transcribe a physician order which resulted in a resident receiving nine inaccurate doses of a psychotropic medication (antidepressant). This failure affected one of five residents (R79) reviewed for Unnecessary Medications on the sample list of 47.
Findings Include:
The facility's Adverse Consequences and Medication Errors dated February 2023 documents a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medications errors include administering the wrong dose of a medication.
R79's Medical Diagnoses List dated Major Depression Disorder, Vascular Dementia, Post Traumatic Stress Disorder, Insomnia, and General Anxiety.
R79's Nurses Note dated 4/1/25 at 2:09 PM documents R138 returned from a Veteran's Administration appointment with written orders to increase his Sertraline (Antidepressant) to 100 mg and the order was entered.
R79's Physician Order Sheet dated April 2025 documents R79 is prescribed Sertraline (Antidepressant) 50 milligrams, two tabs by mouth at bedtime for mood disorder and 25 milligrams (mg) at bedtime- given with the 50 mg tab for a total dose of 75 mg.
R79's Medication Administration Record documents R79 received both the Sertraline 100 mg dose and the Sertraline 25 mg dose on 4/1, 4/2, 4/3, 4/4, 4/6, 4/7, and 4/8/25. R79 was out of the facility on 4/9/25.
On 4/10/25 at 2:05 PM V35 Regional Clinical Nurse confirmed the order to increase the Sertraline to 100 mg per night conflicted with R79's current orders. V35 stated, V9 Assistant Director of Nurses entered the dosage increase for R79's Sertraline medication on 4/1/25 which changed it from 75 mg to 100 mg per night. V9 did not realize there were two separate orders for Sertraline on R79's Physician Orders and subsequently increased the Sertraline 50 mg tablet order to 100 mg but did not discontinue the Sertraline 25 mg tablet order. V35 confirmed this error meant that R79 had been receiving 125 mg of Sertraline at bedtime since 4/1/25 instead of the accurate dosage of Sertraline 100 mg at bedtime. V35 stated a medication error report will be completed for this error.
R79's Medication Error Report dated 4/10/25 documents a medication error was discovered by a state surveyor and reported to the facility. R79's Sertraline was being given at the wrong dose.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer, administer and/or obtain consent or declination of Influenza ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer, administer and/or obtain consent or declination of Influenza and Pneumococcal vaccinations for two (R57, R128) residents out of five residents reviewed for immunizations in a sample list of 47 residents.
Findings include:
1. R57's undated Face Sheet documents R57 admitted to the facility on [DATE].
R57's Minimum Data Set (MDS) dated [DATE] documents R57 as severely cognitively impaired.
R57's Electronic Medical Record (EMR) does not document consent, administration nor refusal of an Influenza vaccination and Pneumococcal vaccinations since admission to facility.
2. R128's undated Face Sheet documents R128 admitted to the facility on [DATE].
R128's Minimum Data Set (MDS) dated [DATE] documents R128 as severely cognitively impaired.
R128's Electronic Medical Record (EMR) does not document a consent nor administration/refusal of an Influenza vaccination since admission.
On 4/11/25 at 12:40 PM V41 Registered Nurse (RN)/Infection Preventionist (IP) stated the facility is not able to provide any documentation that R57 was offered, administered and/or refused an Influenza nor Pneumococcal vaccination and that R128 was not offered, administered and/or refused an Influenza vaccination. V41 RN/IP stated she did obtain consent on 4/2/25 and the immunization clinic is coming to the facility on 4/17/25 to administer resident vaccinations for R57 and R128. V41 stated immunizations should be offered at the time a resident admits to the facility.
The facility policy titled Influenza Vaccine revised March 2022 documents between October 1 and March 31 each year, the influenza vaccine shall be offered to residents unless the vaccine is medically contraindicated, or the resident has already been immunized. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record.
The facility policy titled Pneumococcal Vaccine revised March 2022 documents all residents are offered Pneumococcal vaccines to aid in preventing pneumonia/Pneumococcal infections. Assessments of Pneumococcal vaccination status is conducted within five (5) working days of the resident's admission if not conducted prior to admission. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the Pneumococcal vaccination.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0923
(Tag F0923)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to maintain a functional bathroom ventilation fan. This failure affects one resident (R128) of one two reviewed for environment on the sample li...
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Based on observation and interview, the facility failed to maintain a functional bathroom ventilation fan. This failure affects one resident (R128) of one two reviewed for environment on the sample list of 47.
Findings include:
On 4/8/2025 at 12:55PM, R128 reported R128's bathroom ventilation fan was inoperable and had not worked since R128 admitted to the facility in June of 2024. R128 reported wanting the fan to operate. When the ventilation fan switch was turned to the on position, the fan blades did not move.
On 4/11/2025 at 11:16AM, the ventilation fan remained inoperable as above. R128 was present and reported previously asking several staff members (unidentified) over time to repair the fan, but nobody has done anything about it.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 146 resid...
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Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 146 residents in the facility.
Findings include:
On 4/9/2025 at 2:25PM, V10 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V10 reported being the full-time manager of the facility food service (person in charge) and reported not being a clinically qualified Certified Dietary Manager (also known as Certified Food Protection Professional) or having equivalent training. V10 denied meeting the State of Illinois standards to be a food service manager or dietary manager (required in states that have their own established standards to be a food service manager or dietary manager (483.60(a) (2) ii). V10 reported only completing a one-day course on food service sanitation (ServSafe) which did not include any instruction on clinical nutrition. V10's ServSafe certification (8/25/2022) documents V10 is a Certified Food Protection Manager. The same record does not document V10 is a Certified Dietary Manager (Certified Food Protection Professional) and does not document V10 has any qualifications in clinical nutrition. V10 reported the facility dietician does not work in the facility full-time but works one day per week.
V10 denied:
-being a dietician;
-being a certified dietary manager;
-having an associate's or higher degree in food service management or in hospitality;
-being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition;
-being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician;
-or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course.
On 4/11/2025 at 1:47PM, V10 reported the food prepared in the kitchen is available for all residents in the facility to eat.
Throughout the duration of the survey from 4/8/2025-4/11/2025 on first and second shifts, the facility failed to maintain sanitary dishwashing areas and failed to exclude and prevent flying insects in the facility food service areas resulting in direct cross-contamination of resident dishes.
The facility Long-Term Care Facility Application for Medicare and Medicaid (4/9/2025) documents 146 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by failing to exclude and prevent flying insects in the facility food service area...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by failing to exclude and prevent flying insects in the facility food service areas resulting in direct cross-contamination of resident dishes. This failure has the potential to affect all 146 residents in the facility.
Findings include:
On 4/8/2025 at 11:15AM, accumulations of decomposed food covered the underneath side of the facility kitchen dishwasher drainboards and surrounding wall, floor, and plumbing surfaces. The mechanical dishwasher drain pipe discharged into a floor-level receiving trough that was soiled with accumulations of food debris. A fetid odor was present in the area. A clear ten liter plastic container was positioned beneath the dishwasher drain screen and was half-full of yellow colored liquid and food debris. A second container was located beneath the drain pipe of an adjacent three-basin sink and partially full of opaque water. Three or more winged insects resembling fruit flies were present resting on and flying around the dishwasher areas.
On 4/9/2025 at 2:3PM, the dishwasher area conditions remained as above. The three-basin sink drain pipe was actively dripping into the collection container positioned below the pipe. The drainboard attached to the dishwasher contained an integral disposal basin where staff scrape dishes prior to washing them in the mechanical dishwasher. The basin is designed to empty directly into an attached food grinder/disposal which was no longer present at the time of the survey. The basin drain pipe was directly plumbed to discharge into a metal pan resting inside of the floor trough and contained cloudy water and chunks of food debris. Accumulations of food debris were present inside of the basin. Twelve or more flies were flying around and resting on the drain opening where the food grinder was previously located as well as the nearby drain trough and sewage pipe leading to the main sewer. Several flies were flying between the trough and sewage pipe and landing on the food contact surfaces of clean resident dishes located on a nearby storage rack a few feet away from the drain trough and sewer pipe. A fetid odor remained in the area.
Facility pest control reports document the following notes related to the kitchen:
-3/31/2025: fly issues in the kitchen and Open Actions from Previous Service (3/3/2025): potential harborage with the recommendation to clean area.
-3/17/2025: baited coffee machine in South kitchen; Today's Observations: German cockroaches and spiders.
-3/3/2025: build-up in the North building by the dishwasher area; Today's Observations: potential harborage in kitchen area and the recommendation to clean area.
On 4/11/2025 at 1:47PM, V10 reported the food prepared in the kitchen is available for all residents in the facility to eat.
The facility Long-Term Care Facility Application for Medicare and Medicaid (4/9/2025) documents 146 residents reside in the facility.
Mar 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the safety of one (R1) resident by not implement...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the safety of one (R1) resident by not implementing resident centered fall interventions and failed to thoroughly investigate one (R1) resident fall with injury out of four residents reviewed for falls in a sample list of four residents. R1 experienced pain and bleeding after her fall thus was transported to and evaluated at the emergency room, where she received three sutures to her forehead because of the fall.
Findings include:
R1's Electronic Medical Record (EMR) documents medical diagnoses of Intracapsular Fracture of Left Femur, Left Artificial Hip Joint, Forehead Laceration, Protein Calorie Malnutrition, Diabetes Mellitus Type II, Morbid Obesity, Cerebral Infarction, Trans Ischemic Attack (TIA), History of Falling, Abnormalities of Gait and Mobility and Dementia.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 requires supervision with toileting, bathing, dressing, personal hygiene, bed mobility and transfers.
R1's Fall Risk assessment dated [DATE] documents R1 as a fall risk.
R1's Care plan intervention dated 10/10/2024 documents R1 is to wear non-skid socks while in bed. This same care plan documents an intervention dated 5/16/24 which instructs staff to ensure R1's Activities of Daily Living (ADL) are met and to provide a safe and secure environment.
R1's Change of Condition Evaluation dated 1/18/25 documents R1's bed was in low position prior to her fall.
R1's SBAR dated 1/19/25 documents R1 had an injury to her forehead with sutures in place.
R1's Nurse Progress Note dated:
-1/18/25 at 1:20 AM documents, Observed (R1) in a pool of blood in a sitting position on the floor facing the door with her Left foot under her bottom. Evidence suggest (R1) may have hit her head on the nightstand. Cleaned blood off wound bed with Normal Saline and sterile gauze. Applied cold compress. Called 911 due to the amount of blood (R1) had lost.
- 1/18/25 at 10:42 AM documents, (R1) came back to the facility from hospital at approximately 8:55 AM. (R1) has a stitch to forehead laceration, area has dried blood. (R1) has no complaints of pain to other parts of the body.
-1/18/25 at 10:49 PM documents, Hematoma on (R1's) forehead with a one inch laceration. Pain scale 10 out of 10. Sutures intact.
-1/19/25 at 12:03 AM documents R1's emergency room nurse reported to the facility that R1 has three stitches and needs them removed in 5-7 days and needs to be seen by Physician in the next seven days.
-1/20/25 at 1:22 PM documents the facility interdisciplinary team reviewed R1's fall from 1/18/25. This same note documents, Staff observed (R1) seated on floor of room by bed, facing door. Right leg extended; Left leg bent with Left foot under buttocks. Blood noted on floor. Laceration noted to (R1's) forehead. Bleeding controlled with clean dry dressing. No other injuries noted. Pain reported at laceration, no other complaints of pain/discomfort. (R1) reported that she rolled out of bed which is likely as prior to fall event resident was noted to be in bed. (R1) transported to emergency room. (R1) returned with three staples to forehead. Root Cause Analysis: (R1) rolled while sleeping and fell off the bed. IDT intervention: (R1's) bed to be in low position while she is in bed.
R1's Hospital Record dated 1/18/25 documents R1's chief complaint as Laceration, Head Injury and Fall. This same report documents R1 had a fall from her bed resulting in a forehead laceration.
R1's Final Report to the State Agency dated 1/22/25 documents R1 fell from her bed on 1/18/25 at 1:20 AM resulting in a 1.5 centimeter (cm) laceration that required treatment in the emergency room where three sutures were placed. This same report documents R1's care plan was updated with a new intervention of ensuring R1's bed is to be in low position.
On 3/1/25 at 9:30 AM, 1:15 PM and 3:20 PM R1 was lying in her bed. R1's bed was positioned up against the wall with the window approximately four feet from the ground. R1 had five pillows surrounding her head and torso on the wall side of her (her Left side). R1 was positioned on the right side of the bed closest to the room door. R1 did not have call light in reach. R1 was not wearing no skid socks.
On 3/2/25 at 10:00 AM R1 was lying in her bed with her call light laying over her bedside dresser, not within R1's reach or visual field.
On 3/1/25 at 9:40 AM V4 Agency Licensed Practical Nurse (LPN) stated V4 is R1's nurse. V4 Agency LPN stated she is unaware of how to find a resident care plan or how to find a residents fall interventions. V4 LPN stated she does not have any residents on her hallway that are considered being at risk for falls. V4 Agency LPN stated, I just walk down the hall and if a resident has a floor mat in front of their bed, then I know that resident might have fallen before. If they (facility) don't put the mat down, that resident is not considered a fall risk.
On 3/1/25 at 9:55 AM V8 Certified Nurse Aide (CNA) stated she is R1's CNA. V8 CNA stated R1 is not considered a fall risk. V8 CNA stated the facility has a binder that tells you all the basic information including fall risk and interventions.
On 3/2/25 at 9:20 AM V21 Assistant Director of Nursing (ADON)/Registered Nurse (RN) stated he is the manager of the North building where R1 resided when she fell on 1/18/25. V21 ADON/RN stated R1 has fallen out of bed prior to 1/18/25. V21 ADON stated R1's sleeping patterns should have been included on her care plan. V21 ADON stated, All of those pillows would have crowded (R1) out of her bed. It forced (R1) to sleep close to the edge of bed which wasn't safe. The staff should have answered (R1's) call light as soon as it was activated and not waited until they (staff) got to (R1) during rounds. (R1) has Dementia. (R1) didn't know what she was doing. That is why we (staff) are here is to help these residents. We (staff) all knew how she slept. I don't know why it wasn't on (R1's) care plan but it should have been. Then the agency staff would know to not put so many pillows in her bed.
On 3/2/25 at 3:30 PM V17 Certified Nurse Aide (CNA) stated she was the CNA on duty on 1/18/25 when R1 fell obtaining a forehead laceration. V17 CNA stated R1 was known to be a 'wild sleeper' who tosses and turns all night. V17 CNA stated R1 is incontinent but also was able to use the bathroom. V17 CNA stated when she started her shift, she checks on all her residents and saw R1 lying in bed with her bed positioned up against the wall with the window. V17 stated R1 had five large pillows surrounding her head and torso on the wall side of her (her Left side). V17 stated R1 was positioned on the Right side of the bed closest to the room door. V17 CNA stated she was doing her rounds and heard R1 screaming. V17 CNA stated when she went to check on R1, R1 was laying on her stomach on the floor in between the bedside dresser and bed with her head facing the door. V17 CNA stated R1 was looking at me when I walked into her room with a very scared, panicked look on her face. V17 stated she could tell that R1 was scared. V17 CNA stated there was no one around, so she had to leave R1 to get V18 Agency Licensed Practical Nurse (LPN). V17 stated when they (V17, V18) both returned to R1's room, she was sitting on the floor with her back leaning against her bed. V17 stated R1 was wearing one sock, and the other foot was bare. V17 CNA stated R1's bed was already in low position. V17 CNA stated the staff on the previous shift had placed R1's five pillows on her bed. V17 CNA stated she was aware of R1's position in bed and decided to wait until time for rounds to reposition R1. V17 stated, I should have taken those pillows out. I knew better. But really, that should have been on (R1's) care plan so the agency staff will know better. We (staff) that work here all know that. It is the agency staff that put them there. I just should have taken them out as soon as I saw them. That was an awful night for (R1) and all of us (staff).
On 3/2/25 at 3:50 PM V18 Agency Licensed Practical Nurse (LPN) stated R1 was a 'wild sleeper'. V18 LPN stated she was notified by V17 CNA that R1 had fallen. V18 LPN stated when V18 arrived at R1's room, R1 was sitting on the floor with her right leg extended and her left leg bent as R1 was sitting her Left foot. V18 LPN stated R1's sheets were still on her bed, but her facility blanket, and her personal comforter were blood soaked and twisted up in her legs. V18 LPN stated R1 had a large pool of blood on the floor next to her and her head was bleeding profusely. V18 LPN stated she provided first aid and called emergency services. V18 LPN stated R1 was complaining of pain to her forehead. V18 LPN stated R1 had one sock on, and the other foot was bare. V18 LPN stated she believes R1 was trying to get up to use the bathroom when she got tangled in the blankets and fell. V18 LPN stated R1's call light had been activated. V18 LPN stated R1 would not have had a safe position in her bed due to all the pillows. V18 LPN stated, I work agency, so I really do not know these residents that well. I rely on the facility staff. I have worked with (R1) before and know she should not have had all those pillows and also the staff should have answered her call light so she wouldn't have tried to get up on her own.
On 3/2/25 at 2:40 PM V16 Nurse Practitioner (NP) stated R1's fall on 1/18/25 resulted in a trip to the emergency room for assessment and treatment of her forehead laceration which required three sutures. V16 NP stated R1's fall could have been prevented if the fall interventions were in place. V16 NP stated the staff should know where to find fall interventions for all residents, know who is at risk for falls and be able to follow the fall care plan interventions to prevent falls with major injury like R1's 1/18/25 fall. V16 NP stated R1 could have sustained neurological deficits from her head injury she sustained at the facility. V16 stated residents who are assessed to be a fall risk should have care plan interventions initiated and in place that are consistent with each residents patterns, behaviors and capabilities. V16 NP stated the staff should assess every resident at risk for falls to create individual care plans that are centered around the individual's needs. V16 NP stated R1's fall could have been prevented if the facility would have created an accurate care plan and followed fall interventions that were specific to R1.
The facility policy titled Falls Clinical Protocol revised March 2018 documents the staff and Physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable.
Jan 2025
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision for a cognitively impaire...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision for a cognitively impaired resident, known to exit seek, and with a prior elopement history, to prevent an elopement. The facility also failed to complete a full body post-elopement assessment to determine injury, failed to develop an elopement care plan with interventions in a timely manner, and failed to ensure functional exit door alarms. These failures resulted in R1, a severely cognitively impaired resident at risk of falls and receiving anticoagulation therapy, exiting the facility without staff knowledge or supervision, walking approximately 0.4 miles in extreme cold weather down a busy street. R1's likely path included steep ditches and large rocks. These failures affect one of three residents (R1) reviewed for elopement on the sample list of 14.
The Immediate Jeopardy began on 01/01/25 at approximately 4:30 PM, when R1 exited the facility by a deactivated alarmed exit door. Staff were unaware R1 was missing for approximately one-half to one hour. During this time R1 walked in the street during rush hour traffic, in below freezing temperature, without a coat until a passerby alerted the facility staff of R1's location. Staff confirmed R1 was not assessed for possible injury, or hypothermia after being brought back to the facility. V1 Administrator was notified of the Immediate Jeopardy on 1/16/25 at 3:00 pm.
The surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 01/23/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
Findings include:
R1's Census record documents R1's initial admission to the facility was on 12/27/24.
R1's Diagnoses sheet dated 12/27/24 documents the following: Dementia in Other Diseases Classified Elsewhere, Severe, With Mood Disturbance, Delirium Due to Known Physiological Condition, Restlessness and Agitation, Hypertension, Paroxysmal Atrial Fibrillation, Muscle Weakness (Generalized), Unspecified Abnormalities of Gait and Mobility, and Other Lack of Coordination.
R1's Physician Order Sheet (POS) dated 12/27/24 - 1/9/25 documents the following: Eliquis (anticoagulant) Oral Tablet 5 (five) milligram (mg), Give 5 mg by mouth two times a day for Atrial Fibrillation, Metoprolol Succinate ER, Oral Tablet Extended Release 24 Hour, 50 MG every day for Hypertension and Spironolactone Tablet 25 MG, Give 1 tablet by mouth one time a day for Hypertension.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and R1 has a history of falls before and after admitting to the facility.
R1's admission Assessment (Baseline Care Plan) dated 12/27/24 documents R1 has had falls prior to admission, R1 has an unsteady gait and sitting balance, and R1 is at high risk of falls.
R1's Elopement Evaluation dated 12/30/24 documents R1 that has the ability to leave the building, R1 is not considered independent for outside pass privileges, and R1 has been noted at exit doors or wandering. R1's Care Plan was not updated to include a concern for elopement until 1/1/24.
R1's Nurse's Note dated 12/30/2024 at 04:13 am documents, Resident still up and not staying seated. Resident wandering and exit seeking. Resident pushing on exit doors. Redirected but continues.
R1's 72 hour Charting Follow-Up Late Entry Note dated 1/1/25 at 10:42 AM (fall 12/30/25) documents (R1) Follow-up assessment post-fall. Resident is alert and disoriented per usual baseline. No new injuries noted on assessment. No pain. No changes noted in ROM (range of motion). Bed in lowest position. Monitoring for behaviors. Call light in reach. Non-skid socks/ footwear in place, increase monitoring, (departure alert device), and 1:1 (one on one). No skin issues noted. No bruising noted. No s/s (signs or symptoms) of infection noted to site. No swelling noted. Fall Follow up assessment post-fall.
R1's Nurses Notes dated 12/30/24 at 11:40 pm document, Resident alert but confuse(d) and disoriented. Respiration even and non-labored. Speech clear. Appetite good and drink fluids well. Needs assist with ADLs (Activities of Daily Living). Can be combative when agitated. Uses wheelchair for mobility. No complaints made from fall. Continue(s) to get out of bed or chair by himself and at times cannot be dissuade. Very unstable when on his feet. High risk for falls. Concern for a need for one on one monitoring made known to DON (V2, Director of Nursing) and Administrator (V1).
R1's Behavior Note dated 12/31/2024 at 12:21 am documents, Resident noted to be combative and aggressive with CNA (unidentified Certified Nursing Assistant) when attempting to assist resident. Resident grabbed CNA in collar while she was attempting to help resident back in his wheelchair. Shortly after resident attempted to elope via south hall exit. Resident was able to open the door and step outside before the nurse (unidentified) on duty was able to catch him. Resident began to resist staff attempting to re-direct him from the exit. Resident ask this writer if she had called the police for him, he was being held against his will and needed the police to rescue him. Resident was informed he was placed in the facility for assistance with his care by his family and he was not being held hostage but receiving health care. Resident was assisted back to the nursing station where he is currently sitting.
R1's admission assessment dated [DATE], signed by V3, Nurse Practitioner documents R1 has a baseline altered mental status and is non decisional and R1 had a fall over the weekend without any noted injury. V3's Assessment documents, (R1) has a history of impulsivity since admission [DATE]) to the facility, crawling in his room, and requiring frequent observation with fall mats at bedside. He has also been wandering and exit-seeking, with potential placement on a (departure alert device bracelet) per (V2, Director of Nursing) DON and clinical staff. The same assessment directs staff to provide Frequent observation.
R1's COMMUNICATION- with Family/NOK/POA (Power of Attorney) dated 12/31/2024 at 1:48 am, signed by V3, Licensed Practical Nurse (LPN), documents, Resident sent to ER (emergency room) for evaluation and treatment as needed due to resident falling, hit his head against wall resulting in him biting his tongue. Resident tongue purple in color. Resident states his tongue is painful 10/10 (on a scale of one to ten equals extreme pain). (V6, Assistant Director of Nursing) ADON was made aware of resident incident and state(d) send resident to ER due to being on anticoagulant (blood thinner). MD (V7, Medical Director) made aware of incident at 1:07 am. Call attempted to POA (V13, R1's Family Member) 01:13 am at (private number), voicemail not set up unable to leave message. Nurse to nurse report given to (V4, Registered Nurse) at (local Hospital). Emergency service contacted at 1:20 am, arrived at 01:30 am. Resident noted to be confused in regard to the details of the incident. Nurse (unidentified) on duty, who was at the nursing station where the incident took place, states the resident was standing up adjusting his jacket and fell back hitting his head against the wall. This writer (V30, LPN) had just walked off from the resident assisting him back into his chair.
R1's Nurse's Note dated 12/31/24 at 3:35 pm documents, Resident POA (V13, Power of Attorney) here, and made aware of resident being sent to (local hospital). Resident has been anxious this shift. Resident has been up ambulating this shift. Resident (V13, Family Member) here most of shift. Resident reminded most of shift to sit in w/c (wheelchair). Resident became agitated with writer after (V13, Family Member) left. Resident has been confused. Resident took all meds (medications) whole without difficulty.
R1's Incident Note dated 01/01/25 at 5:30 pm, signed by V8, Registered Nurse (RN), documents Resident was observed ambulating outside the facility. CNA (V15, Certified Nursing Assistant) went to get resident to come back inside the building. No distress noted. No injury noted. POA (V13, Family Member), MD (V7, Medical Director), DON (V2, Director of Nursing) and Administrator (V1) notified. Resident placed on one on one monitoring (alarm bracelet) placed to left ankle. Will continue to monitor.
R1's one on one supervision sheet is dated as initiated 01/01/25 at 5:30 pm.
On 1/9/25 at 7:15 am V8, Registered Nurse (RN) stated, The evening (R1) got out and walked down (Street Name) Avenue, I think it was the 01/01/25. A passerby called the facility and said we had a confused resident walking in the middle of the street, over by the apartments. The passerby said he (R1) did not have on a coat. It was pretty cold day. I can't remember if it snowed yet, but I think it may have. There was snow when I left my shift. (Street Name) Avenue traffic gets very busy during evening rush hour. The CNA (V15, Certified Nursing Assistant) went right away to go find him (R1). (R1) was always trying to go somewhere. He was consistently exit-seeking. He would shake the exit doors whenever I worked. He had never gotten far out of the building when I had him (was R1's nurse). I had not seen (R1) for a quite a while that evening. I am not sure how long he was gone. Nobody had seen him for about an hour. I asked everyone. I figured it was probably (R1) the passerby saw. None of us working heard an alarm go off. We had no idea how he got out of the building, or how long he had been gone. I ended up telling (V12, Maintenance Director) to look at the cameras to find out which door (R1) went out because nothing triggered an alarm when he (R1) left. I admitted (12/27/24) him (R1) and did not know he was an elopement risk at time. He was admitted with A-Fib (abnormal fast heartbeat) and had a history of falls. It was evident within a day or two of admission he was an elopement risk. He was not a one-on-one until 1/1/25 after he was found outside walking in the street. We put a (departure alert device) on him at time too. When (V15, CNA) brought him (R1) back to the facility, he (V15, CNA) said he did not see any injuries. (V15, CNA) said (R1) was very cold and warmed up in (V15, CNA's) car. V8, RN stated I did not complete a full body assessment, vital signs or neurological assessment when (R1) returned to the building. I did not complete an accident report, or risk management report. The incident note you have is all I had time to do. I was working a hall and a half (of residents) and training a new nurse. Now I think about it, he (R1) had several falls in the facility. He came to us with a history of falls. He could have had a fall outside when he eloped evening (1/1/25). He used a wheelchair, and we were constantly reminding him not to stand up. He had a very unstable gait. I should have completed a thorough assessment, just like we do when a resident has an unwitnessed fall.
On 1/9/25 at 8:55 am V13, R1's Family Member stated, (The facility) has called me (V13) four times about (R1) exiting the building. Three times, I was told he was just outside the doors. Once he walked right out the front door. The other times he went out the side doors. One time they reported he was found walking down (Street Name) Avenue. I was not thrilled about. It was 20 degrees (Fahrenheit) outside. I did not understand how could happen if he was adequately supervised. He can't walk steady and is in a wheelchair. How could he get all the way to (Street Name) Avenue and have been walking. He has had a couple falls before and after being at (the facility) trying to walk.
On 01/9/25 at 4:45 pm R6 stated R6's room and R1's room, share a bathroom. R6 stated R1 was confused and repeatedly came in to R6's room and yelled for R6 to get out of R1's house. Staff were supposed to be watching him. Half the time the staff were visiting with each other down the hall, nowhere near his (R1) room. I saw with my own eyes several times. They did nothing to keep him out of my room. I finally put a chair against the bathroom door so he would stop coming in. He was supposed to have a sitter with him all the time. They obviously were not keeping a good eye on him.
On 1/9/25 at 1:35 pm V12, Maintenance Director stated he had reviewed the cameras to determine which doors R1 left from on each elopement attempt. V12 stated, The first time he went out on 1/1/25, he went out the west door. He had a heavy coat and shoes on. He left his wheelchair at the door. A CNA (unidentified) saw (R1's) chair (wheelchair) at the exit. The CNA was talking to (V8, Registered Nurse). They (unidentified CNA and V8, RN) saw out the window, as (R1) was walking past the window. They both ran out the west hall door and brought him back. The second time, the same day (1/1/25), he had sweat pants and a tee shirt on, and no coat. (R1) went out the smoking door and pushed open the emergency gate off the patio (this fall R1 walked down (Street Name) Avenue). On 1/6/25 he went out the west wing exit door. (V8, RN) and a CNA (unidentified) went out immediately and brought him back in. His next elopement on 1/7/24, he could be seen fighting with staff at the west door. Five staff exited the building and stayed with him until the police came. I will give you a timeline from the cameras.
On 1/9/25 at 3:10 pm V12, Maintenance Director provide the timeline of R1's four elopements from the facility, which confirmed V12's interview account of the elopement incidents noted above.
On 1/1/25 R1 was dressed in heavy coat, blue jeans, and shoes at 8:58 am when R1 exited the facility via the west wing door, leaving his wheelchair at the exit.
* At 8:59 R1 could be seen on the facility camera walking northbound on the sidewalk.
* At 9:02 am R14 sees R1's wheelchair and looks at the exit door.
* At 9:03 am (unidentified receptionist) shuts off the alarm.
* At 9:04 am R14 alerts staff (unidentified) to the wheelchair.
* At 9:05 am R14 talks to V8, Registered Nurse (RN).
* At 9:06 am R1 walks south, past the windows. (unidentified CNA) and V8, RN rush out [NAME] door.
* At 9:07 am (unidentified CNA) brings R1 back into the facility. V27, CNA moves a spare hospice bed in the hallway, over to the entrance, for R1 to sit down on while the unidentified CNA goes to get R1's wheelchair. R1 taken to his room.
On the same day 1/1/25 R1 had a second elopement timeline documents:
* At 4:35 pm R1 was in the west wing dining area.
* At 4:42 pm R1 went out the smokers door, to the patio and rolls to the north gate.
* At 4:44 pm R1 pushed the emergency north side gate open. R1 went out of the gate wearing sweatpants and tee-shirt.
* At 4:47 pm Unidentified male CNA possibly shut alarm off. V12 stated the male CNA walked in the direction of the key pad to shut off the alarm but could not actually be seen entering the code.
* At 4:50 pm (eight minutes after R1 exited the building, by this timeline) V53, Receptionist takes a phone call and alerts an unidentified staff member.
* At 4:59 pm V15, CNA grabs his own coat.
* At 5:02 pm V15 and V38, CNAs go out the front door.
* At 5:06 pm R1 is brought back via front door by V15 and V38.
* At 5:08 pm V15, CNA and V8, RN were trying to determine R1's exit door location.
V6 Assistant Director confirmed there is no progress note or assessment documentation of R1's elopement in R1's medical record correlate to the first elopement 1/1/25 on above time line.
On 1/9/25 at 4:05 pm V15, Certified Nursing Assistant stated, I was the person went to get (R1), I think it was on the first (January 1, 2025). Supper trays had not been delivered yet. A woman (unidentified) called the facility. The woman said she saw a guy walking in the middle of the street, on (Street Name) Avenue. She said the guy was down by the (Name) apartments. The (Name) apartments are about a half mile down the road. (Street Name) is a busy street. It happened during rush hour traffic too. I could have guessed it was (R1), but we didn't know for sure, yet. I had not seen him for a while because he goes all over the place in his wheelchair. It was around 4:30 pm the last time I saw him. He was notorious for shaking the exit doors and trying to leave. He was an exit seeker for sure before. Everybody knew it. I should say, I knew it. I can't speak for what other people knew. They should have known it, is what I will say. He would rush the door and say he needed to leave. He has done since he was admitted (12/27/24). We usually hear the door alarms sound and get to him before he gets too far out the door. That evening, no door alarm sounded. We had no idea what door he went out, or how long he was gone. I left (the facility) and drove down (Street Name). Traffic was heavy. I got down by the apartments. He (R1) was walking down the north bound lane. He was not in the center of the street. He was in the center of the north bound lanes. He was about four feet from the curb when I saw him. Traffic was going around him. I stopped in the street, so all the traffic went around my car, instead of him (R1). I got out of my car and went to get him. I don't know what the temperature was, but I was cold just getting out of my car. (R1's) arms were red and he (R1) said his hands were getting numb they were so cold. He was just in a short sleeved tee-shirt and had no coat on. He was really, cold. The lady that called was parked in the apartment drive. She said she talked to him, and noticed he seemed very confused that it was why she called. She thought it could be a resident from (the facility). I had my heat turned up as high as it could go. (R1) thanked me for picking him up and wanted me to take him to some address in Danville. I worked with him a lot and know he has dementia. I told him I would like him to come with me and warm up first. He did not have any behaviors for me, then or ever. I have heard he has been aggressive with other staff. Never for me. I have a lot of experience working with dementia residents. Most often they can be distracted with an activity or food. I found both worked for (R1). We got back to the facility and sat in the car for a couple more minutes, so he was good and warm. He (R1) was cooperative when I turned him over to (R8, Registered Nurse/RN). (V8, RN) asked if he was hurt. I told her (V8, RN), he (R1) was cold, but I didn't notice if he had any injuries. (R8, RN) took it (assumed R1's care) from there. I don't know if she did vitals or anything. I went on to get supper trays served. It was close to 5:30 pm which is normal time for supper trays to come up. V15, CNA stated, I later heard (R1) went out the smoking area doors. That door alarm has not worked right for a while. You just push on the bar for a couple of seconds, and it opens without the alarm sounding. Somebody is usually at the nurse's station and can see door if people go out to smoke. After this elopement they put a (departure alert bracelet) on (R1's) ankle and made him (provided R1) a one on one (constantly supervised by one staff). I was his one on one several times since, and never had a problem distracting him if he started exit seeking. V15, CNA agreed to show this surveyor the area R1 would have likely traveled, to where V15, CNA found R1 in the street 1/1/25.
On 1/9/25 at 4:14 pm V1, Administrator confirmed R1 exited the building through the smoking area doors.
On 1/9/25 at 4:18 pm V15, CNA and this surveyor went to the interior and exterior doors that exit the facility to the patio and courtyard smoking area, at the back of the building, north side of the building. The first, interior door does not alarm. The exterior door has a horizontal push bar lever across the center of the door. V15 directed the surveyor to push the bar for a few seconds and it will open. The door did not open. There is a green button to the left of the door. When pushed, the door opens and the alarm sounds. V1 was just inside the interior door and responded to the alarm. V15 stated, They must have already fixed it. This door alarm has not functioned properly for a long time. Once V15, CNA and this surveyor were out on a smoking patio, at the back of the south building, there were two gates. One single-wide gate was to the left, down a sidewalk off the patio approximately 50 feet. A double-wide second gate was straight ahead off the patio, approximately 50 feet. V15 stated the single-wide gate was likely not the gate R1 used, because it opens inward and would be difficult to maneuver R1's wheelchair. V15, CNA and this surveyor walked the approximately 50 feet forward to a double-wide gate, which opens outward. The patio gate has an emergency exit required pushing the button and holding it. No alarm sounded. Together V15 and this surveyor walked approximately 150 feet around the fenced patio to winding sidewalk. The sidewalk sloped downward past two wings of the facility building, as we headed towards the front of the building on the south side. V15, CNA stopped at the edge of the building outside the therapy room. V15, CNA stated, This is where (R1's) left his wheelchair that night. V15 stated, In order for (R1) to get to (Street Name) Avenue he would have had to walk from his wheelchair across all this grass and head north again to where I found him. V15, CNA and this surveyor walked down a 50-foot uneven hill, from the sidewalk where R1's wheelchair had been found. At the base of the uneven hill, we continued to walk through the grass another approximately 150 feet straight towards (Street Name) Avenue. The ground was rough with divots throughout. V15, CNA and this surveyor were approximately 10 feet from the street. There were approximately over one hundred, extra-large scattered rocks stacked haphazardly from the ground. The large rocks extended up an eight-foot steep incline. At the ground level the extra-large rocks spanned six feet wide at the base and extended upward to a three-foot-wide easement at the street. V15, CNA stated each rock weighed approximately 20 or 25 pounds. The street curb, on each side of the three-foot-wide easement, was eight inches tall. As this surveyor and V15, CNA decided we could not safely balance ourselves on the rocks, we turned to walk in the uneven grass, at the bottom of the eight-foot steep incline. V15 stated, (R1) may have climbed the rocks, but most likely walked in the grass. He (R1) had a very unstable gait. That is why he used a wheelchair. He had a couple falls in the facility from trying to stand up from his wheelchair. He was not safe to walk on his own. I can't imagine how (R1) was able to walk this area. You (surveyor) and I (V15, CNA) are having a hard time maintaining our balance. As we continued to walk, this surveyor and V15, CNA had on coats. V15 stated, It was about this cold when I found (R1) (Confirmed on Accu-Weather website, temperature was 23 degrees Fahrenheit, at this time). There was some wind, but no snow. As we continued to walk on the uneven grass next to the steep incline, which was running parallel to the street, the incline gradually level out with the street eight inch curb. We walked past both the North and South facility buildings. We walked across one parking lot entrance road to the facility. The parking lot entrance to the North building junction with the street was crowded with a steady flow of vehicles. The speed limit posted was 35 miles per hour. V15 stated this steady flow of traffic is the normal for rush hour traffic on the and is about the same time R1 would have been out walking in the traffic. After crossing the parking lot entrance, there was a grassy area approximately 200 feet, next to an apartment complex. Before reaching the apartment parking lot entrance road off the street, there was an approximately 15 feet by 20 feet concrete slab in the grassy area. There was an electrical site warning sign. There were four steel electrical utility transformer boxes on the concrete slab. One of the electrical utility transformer boxes was four foot wide by approximately eight foot long and eight-foot tall. The other three steel electrical utility transformer boxes were approximately three foot tall, by three foot wide and two foot long. The electrical boxes had multiple access doors with pad lock. At the opposite end of the same 200-foot grassy area there was a gas line warning sign. The gas line warning sign was outside of four concrete, two and a half feet tall pillars. The four pillars sat in a square pattern approximately eight feet apart. Inside the four concrete pillars there were multiple metal gas pipes. The gas pipes varied in sizes of approximately two- and three-inch diameters. The metal pipes looked like a play structure for children. The metal gas pipes crossed each other in jungle gym fashion at different heights. The metal gas pipes structure stood approximately eight feet high at its tallest. The gas pipe structure was approximately six feet wide and four feet long at the base. The metal pipes had locks on several of the bar junctions. V15 pointed to the area V15 found R1 on the. R1 was found across the grassy area from the gas pipe structure, in front of the drive to the apartment complex parking lane entrance, in the middle of the north bound lane.
This surveyor measured the mileage by car. R1 traveled on foot on 1/1/25. The distance one way by car, from the facility to where R1 was found, measured four tenths of a mile. This does not include the facility sidewalk distances from the back of the south building to the front of the south building, where R1 had left his wheelchair.
The National Oceanic and Atmospheric Administration ([NAME]) website documents on 01/01/25 at 4:35 pm, in this city it was 30 degrees Fahrenheit with 10 mile per hour winds, equal to real feel temperature on the skin of 21 degrees Fahrenheit.
On 1/15/25 at 7:20 am V7, Medical Director stated he was informed of several of R1's elopements. None of R1's elopements or attempts reported to V7 by the facility included (R1) that exited the building and was walking down street unassisted. V7 stated V7 did not know R1 was off the facility grounds. V7, stated R1 has Dementia, has been sent to the emergency room post-falls because he is on a blood thinner and had hit his head. V7 stated is his standard protocol to have a resident on blood thinners evaluated at the hospital post unwitnessed falls and witnessed to have hit their head during a fall. V7 stated, I had not heard a door alarm malfunctioned either. Alarms in the ER (Emergency Room) go off all the time. I even had a patient go hypoxic. No one initially responded to the alarm. It is the same in nursing homes. I think the staff are immune to the sounds of the alarms. They hear them often. (R1) should have been closely supervised to prevent this from happening. His (R1's) Dementia alone put him at risk of elopement. Having had falls, the short time he was in the facility, also put him at risk serious of injury. To hear he was out walking in the street, in cold temperatures, adds to the potential for serious harm. Knowing he had not been assessed by the nurse when he returned to the facility, is even more concerning. A full assessment should have been completed immediately, to have gotten a full picture of any harm after the incident. Adequate supervision may have changed all. Yes, he was at great risk of serious injury.
On 1/22/25 at 1:30 pm V38, CNA stated no one had seen (R1) for about an hour. V38 stated V8, Registered Nurse asked everyone night after the facility got a call that R1 was outside the facility.
R1's Care Plan dated 12/31/24 does not document an elopement care area until 01/01/25. R1's care Plan documents the following: (R1) is an elopement risk/wanderer related to restlessness and agitation. (R1) cut off his (departure alert) bracelet. Date Initiated: 01/01/2025.
He will not leave facility unattended through the review date. Date Initiated: 01/01/2025.
His safety will be maintained through the review date. Date Initiated: 01/01/2025.
Assess for fall risk Date Initiated: 01/01/2025, Enhanced supervision: 1:1 (one on one) within line of sight. Date Initiated: 01/01/2025 (Departure Alert Device) in place on left ankle. Monitor device is functioning properly, daily.
The facility presented an abatement plan to remove the immediacy on 1/16/25. The survey team reviewed the abatement plan and accepted the abatement plan on 1/21/25.
The Immediate Jeopardy began on 1/01/25 was removed on 1//23/24 when the facility took the following actions to remove the immediacy:
1. Confirmed the facility identified residents affected or likely to be affected by completing resident elopement assessments and reassessments and updating care plans. Completed by V1, Administrator V2, DON, V6, ADON/ QA Nurse, V10 Social Service Director (SSD) South, V11, SSD North, V28, ADON Evening shift on 1/2/2025.
2. Confirmed elopement binder was updated and at the nurses' stations, and the reception desk. Completed by V10 on 1/2/25.
3. Confirmed Accidents and Incidents- Investigating and Reporting Policies including documentation of the condition of the affected person, including vital signs was revised and updated. Completed by V9, [NAME] president of Clinical Services on 1/2/25.
4. Staff training was initiated and is ongoing as of 1/23/25. In-service training on elopement protocol and retention quiz were not provide prior to start of shift for several staff. The surveyor confirmed a sample of staff not in-serviced, which included: V36, Housekeeper, V40 Housekeeper, V41, CNA, V43, LPN, V45 CNA, and V50 Laundry, and Agency staff included: V34, CNA, V44, LPN, V47 LPN, V48, LPN, and V49, CNA. All staff identified stated they have been working in the facility throughout the month of January. V1, Administrator acknowledged all staff have not been educated as planned, as of this exit date 1/23/25.
5. Confirmed V1, V2 and V28 Assistant Director of Nurses initiated education relating to immediate head to toe assessments following unusual occurrences. Completed on 1/2/2025.
6. Confirmed V12, Maintenance Director assessed all doors, exit alarms, and the departure alert system to ensure proper working order and observed during survey. Ad-Hoc QAPI (Quality Assurance Performance Improvement) meeting was completed on 1/2/2025 discussing event and evaluating the current elopement program including conducting daily assessments of exits, and routinely scheduled elopement drills to be ongoing. One mock drill was completed during survey. Completed 1/2/25 and ongoing.
7. Confirmed V1, provided training to the IDT (Interdisciplinary team) regarding development of care plans to address residents who are newly identified with exit-seeking /wandering behaviors and elopement risk. Completed 1/2/25 and is ongoing.
8. Confirmed Ad-Hoc QAPI meeting, including the Medical Director by phone, to discuss the incident and the corrective actions to prevent similar events. Completed 1/2/25 and ongoing.
9. Confirmed in interviews, Daily IDT meetings were conducted to discuss new or worsening wandering/exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring appropriate clinical interventions are implemented to prevent an incident of elopement. 1/2/25 and ongoing.
10. Confirmed QAPI team will review results of the audits, posttests, door and window checks. The QAPI team will determine if additional monitoring or corrective actions are necessary based on the review of monitoring activities. Completed 1/2/25 and ongoing.
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to file a grievance for a known resident complaint for two (R1 and R3) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to file a grievance for a known resident complaint for two (R1 and R3) of three residents reviewed for administration from a total sample list of 18 residents.
Findings include:
On 11/4/24 at 12:21PM, R1 was eating in his room. R1 stated that he doesn't like to eat in the dining room with R2 because R2 hacks and spits up mucous, causing him to lose his appetite. Additionally, R2 throws the tissues that she spits into, onto the floor. R1 said, It is just disgusting and hard to avoid seeing it or stepping in it. I won't even go to BINGO anymore because I just can't stand to see and hear her spit mucous everywhere. R1 stated that he has complained about this to all of the staff, including V5 Assistant Administrator, but they haven't done anything about it.
On 11/4/24 at 7:20PM, R3 stated that he doesn't like it when R2 hacks and spits up mucous in the dining room and that he has seen her throw her tissues onto the floor. R3 stated that the staff know about this and haven't done anything to address the situation.
On 11/6/24 at 10:00AM, V1 provided three months' worth of grievances that did not include any information about R2's behaviors.
On 11/6/24 at 12:30PM, V5 stated she was aware that R2's behaviors are not appreciated by many of the residents and that R2 continues to cough, [NAME], spit and throw her tissues on the floor every day. V5 stated she has not filled out a grievance about this because she thought it was R2's behavior.
The facility Grievances/Complaints, Filing Policy dated April 2017 documents that residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and or their representative and all grievances will be investigated with a written response to the complainant within five working days.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a clean and comfortable environment for four (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a clean and comfortable environment for four (R1, R3, R10 and R11) of five residents reviewed for a safe, clean, comfortable, and home-like environment from a total sample list of 18 residents.
Findings include:
On 11/6/24 at 12:20 PM, R2 was sitting at a dining room table covered with napkins, tissues, condiments, and bags of personal items on the table. On top of these items laid mucous filled tissues.
On 11/4/24 at 12:21 PM, R1 was eating in his room. When asked why he wasn't eating in the dining room, R1 stated that he doesn't like to eat with R2. R1 stated that (R2) is nice enough, but that her hacking and spitting up mucous causes him to lose his appetite. Additionally, R2 throws the tissues that she spits into, onto the floor. R1 said, It is just disgusting and hard to avoid seeing it or stepping in it. I won't even go to BINGO anymore because I just can't stand to see and hear her spit mucous everywhere. R1 stated that he has complained about this to all of the staff, but they haven't done anything about it and that R2's hacking and spitting makes me sick to my stomach.
On 11/4/24 at 7:20 PM, R3 stated that he doesn't like it when R2 hacks and spits up mucous in the dining room and that he has seen her throw her tissues onto the floor.
On 11/4/24 at 12:15, R10 and R11 were sitting at a table in the dining room eating lunch, next to R2. Both stated that they didn't like R2's spitting up mucous in the dining room.
On 11/6/24 at 12:30PM, V5 Administrative Assistant stated that she was aware that R2's behaviors are not appreciated by many of the residents and that R2 continues to cough, [NAME], spit and throw her tissues on the floor every day.
R2's care plan dated 8/25/23 documents that R2 has a behavior that includes throat clearing during meal times and that R2 is supposed to be supervised by staff and reminded not to continue with this behavior.
Oct 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to administer medications as ordered for three (R4, R7, R5) of seven residents reviewed for medication administration in the samp...
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Based on observation, interview, and record review the facility failed to administer medications as ordered for three (R4, R7, R5) of seven residents reviewed for medication administration in the sample list of 12. This failure resulted in three medication errors out of 25 opportunities, a 12 % medication error rate.
Findings include:
1. R7's October 2024 Medication Administration Record (MAR) documents to administer Ferrous Sulfate 325 milligrams (mg) one tablet by mouth once daily scheduled as Lib B (Liberalized Breakfast).
On 10/24/24 at 9:46 AM V9 Licensed Practical Nurse administered R7's morning medications Aspirin 81 milligrams (mg), Folic Acid 1 mg, Calcium Carbonate 600 mg, Vitamin D 1000 units. V9 had to locate a bottle of Thiamine 100 mg and administered one tablet at 10:10 AM. V9 did not administer Ferrous Sulfate 325 mg. At this time V9 confirmed R9's morning/breakfast medication administration was complete. At 10:13 AM V9 confirmed V9 had not administered R7's Ferrous Sulfate 325 mg.
The facility's Med (Medication) Pass Times documents Liberalized Breakfast is scheduled to be given between 6:00 AM and 11:00 AM.
2.) R4's October 2024 MAR documents to administer Combivent Respimat inhaler 20-100 mcg/act (micrograms per actuation) one puff three times daily and administer Breo Ellipta inhaler 100-25 mcg/act one puff once daily, swish and spit after each inhalation.
The Breo Ellipta Highlights of Prescribing Information dated January 2019 documents to rinse your mouth after inhalation administration.
On 10/24/24 at 9:56 AM V9 obtained Breo Ellipta 200-25 mcg/act (per actuation), which was labeled with R12's first name. V9 also obtained Combivent Respimat inhaler 20-100 mcg/act labeled with R12's full name. Both inhalers were stored in the original packaging container that was labeled with R4's name. V9 handed the Breo Ellipta to R4, and R4 self-administered one puff. R4 did not rinse his mouth after administration. V9 left the room and did not instruct R4 to rinse his mouth after administration.
On 10/24/24 at 10:19 AM V9 confirmed the Breo Ellipta and Combivent inhalers labeled with R12's name was in R4's original packaging for R4's inhalers. V9 confirmed R12's Breo Ellipta dosage is not the same dose as R4's, and the incorrect dose of medication was given. V9 stated V9 did not understand why R12's medications were in the same medication cart as R4's since they don't reside on the same hall of the facility. V9 confirmed V9 did not instruct R4 to rinse and spit after R4's inhaler administration. V9 stated R4 usually does that himself.
R12's Physician Order dated 6/29/24 documents to administer one puff Breo Ellipta 200-25 mcg/act once daily.
On 10/24/24 at 12:44 PM V2 Director of Nursing stated V2 was just made aware that R12's inhalers were stored in R4's inhaler container. V2 stated inhalers should be stored in the correct resident's medication packaging container. V2 stated V2 thinks a nurse was working two different medication carts and may have put R12's inhaler in the wrong cart by mistake.
3.) R5's October 2024 MAR documents to give Aripiprazole (antipsychotic) 2 mg by mouth daily.
On 10/24/24 at 10:02 AM V9 administered R5's morning medications. V9 was unable to locate R5's Aripiprazole and therefor did not administer this medication. At 11:55AM V9 stated V9 was unable to locate this medication and there was none in the facility's backup supply box. V9 stated V9 will have to reorder the medication from the pharmacy. V9 looked in R5's electronic medical record and submitted a reorder to the pharmacy for this medication. V9 stated the system shows this medication was last reordered on 9/26/24.
R5's Nursing Note dated 10/24/2024 at 11:58 AM documents Aripiprazole was not administered due to the medication being unavailable. There is no documentation this medication was given on 10/24/24 or that the physician was notified of the missed dose.
The facility's Administering Medications policy dated April 2019 documents medications are to be administered according to physician orders, and check to verify the right resident, right medication, right dosage, right time, and right method prior to administering the medication.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were available to be given as order...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were available to be given as ordered resulting in multiple missed doses of medications for three (R5, R6, R7) of six residents reviewed for medications in the sample list of 12.
Findings include:
1.) On 10/24/24 at 12:13 PM R6 stated the facility has run out of R6's medications but was unable to state which medications.
R6's Minimum Data Set (MDS) dated [DATE] documents R6 is cognitively intact.
R6's August, September and October 2024 Medication Administration Records (MARs) document to give Duloxetine Hydrochloride (antidepressant) Delayed Release 60 milligrams (mg) by mouth one daily and Lorazepam (antianxiety) 0.5 mg twice daily. Duloxetine was not administered on 8/28/24, 9/12/24, 9/27/24, and 10/21/24. Lorazepam was not administered as ordered on 9/21/24, 9/23/24-10/3/24.
R6's Nursing Notes document the following:
On 8/28/2024 at 5:49 PM Duloxetine was unavailable.
On 9/12/2024 at 4:36 PM Duloxetine was on order and awaiting pharmacy delivery.
On 9/21/24 at 9:24 AM Lorazepam was on order.
On 9/23/2024 at 10:50 AM the Nurse Practitioner said R6 is now seen by (Psychiatry Services), who should oversee ordering of Lorazepam.
On 9/26/24 at 8:53 PM Lorazepam was on order.
On 9/27/24 at 4:29 PM Duloxetine was on order.
On 9/27/24 at 8:57 PM waiting for pharmacy to deliver Lorazepam.
On 9/29/2024 at 8:57 AM and 10:33 PM unable to obtain new Lorazepam script.
On 9/30/2024 at 9:28 AM Lorazepam was not available.
On 10/1/2024 at 7:45 PM Lorazepam was not available.
On 10/1/2024 at 8:04 AM Lorazepam was on order.
On 10/2/2024 at 10:40 AM getting new Lorazepam order from doctor.
On 10/21/2024 at 3:46 PM R6's Duloxetine was on order.
There is no documentation in R6's medical record that R6's physician was notified of the missed doses of medications.
The facility's backup medication box Inventory Replenishment Report dated 3/21/23 includes Lorazepam 0.5 mg.
2.) On 10/24/24 at 10:55 AM R7 stated the facility ran out of R7's bone medication for several weeks.
R7's MDS dated [DATE] documents R7 as cognitively intact.
R7's September and October 2024 MAR documents Alendronate-Cholecalciferol 70-2800 mg give one tablet by mouth once weekly on Fridays for Osteoporosis ordered 5/3/24-10/17/24, and this medication was not given as scheduled between 9/1/24 and 10/17/24. The order was changed on 10/18/24 to Alendronate Sodium 70 mg weekly on Fridays.
R7's Nursing Notes document the following:
On 8/30/24 at 5:18 AM Alendronate-Cholecalciferol was on order.
On 8/30/2024 at 11:14 AM Alendronate was not refilled due to a billing issue and the billing department was notified.
On 8/31/24 at 2:18 AM Alendronate was not refilled due to a billing issue, the billing department was notified and awaiting a prior authorization for refill. Will follow up with the provider in the morning.
On 9/13/24 at 5:57 AM Alendronate was not available.
On 9/13/2024 at 7:11 AM called the pharmacy regarding Alendronate refill, but unable to reach a representative.
On 9/27/24 at 4:36 AM Alendronate on order.
On 9/30/2024 at 6:46 AM the pharmacy was called regarding Alendronate, unable to reach a representative. The on-call nurse was notified.
On 10/6/24 at 6:06 AM prior authorization is the documented reason why Alendronate was not given.
On 10/11/24 at 4:52 AM Alendronate was on order.
On 10/16/2024 at 6:18 PM pharmacy was contacted to reorder Alendronate; medication was transferred to billing department due to being a non-covered medication.
There is no documentation in R7's medical record that R7's physician was notified of the missed doses and non-coverage of Alendronate prior to 10/18/24.
3.) R5's October 2024 MAR documents to give Aripiprazole (antipsychotic) 2 milligrams (mg) by mouth daily.
On 10/24/24 at 10:02 AM V9 Licensed Practical Nurse administered R5's morning medications. V9 was unable to locate R5's Aripiprazole 2 mg tablets and therefor did not administer this medication. At 11:55 AM V9 stated V9 was unable to locate this medication and there was none in the facility's backup supply box. V9 stated V9 will have to reorder the medication from the pharmacy. V9 looked in R5's electronic medical record and submitted a reorder to the pharmacy for this medication. V9 stated the system shows this medication was last reordered on 9/26/24.
R5's Nursing Note dated 10/24/2024 at 11:58 AM documents Aripiprazole was not administered due to the medication being unavailable. There is no documentation of any follow up with pharmacy or the physician regarding this medication being unavailable.
On 10/24/24 at 12:44 PM V2 Director of Nursing stated if medications are not available to be given then it is documented on the MAR and a progress note should document the pharmacy was notified or if an insurance issue. V2 confirmed a checkmark on the MAR indicates the medication was given. V2 stated if a medication is not given the nurse should document the reason. At 12:50 PM V2 stated the physician was contacted on 10/17/24 and gave orders to change Alendronate to an alternate covered medication. V2 confirmed R7's missed doses of this medication due to an insurance non-coverage issue. At 2:08 PM V2 stated the pharmacies sends an electronic facsimile notification to the facility for insurance non-coverage issues, we are to follow up with the physician to notify of the non-coverage and obtain orders. V2 stated V2 was not aware of R7's Alendronate non-coverage until September. V2 completed the required form and submitted the form to the pharmacy. V2 stated if a medication is not available and doses are missed, the physician should be notified to obtain a hold order. V2 stated if the medication is not available in the backup medication supply box, then our pharmacy works with a local pharmacy to deliver medications that are needed prior to the scheduled daily delivery. V2 confirmed the nurses must contact the facility's pharmacy to initiate this process if needed.
The facility's pharmacy policy Unavailable Medications dated 10/25/14 documents medications may be unavailable from the pharmacy due to drug recalls, temporary shortage, or permanent drug recalls. This policy documents the pharmacy suggests alternative/comparable drugs and dosages, and the nursing staff are responsible for notifying the physician or the facility's medical director to explain the situation and obtain new orders.
The facility's pharmacy policy Emergency Pharmacy Service and Emergency Kits dated 7/18/18 documents the emergency pharmacy is available 24 hours per day and emergency needs are met by using the facility's emergency medication box or by special order through the pharmacy. This policy documents when a medication is not readily available the nurse should contact the physician to determine if it can be delayed until the scheduled pharmacy delivery. The nurse should then check the backup supply box and if the medication is unavailable the nurse should contact the after-hours emergency pharmacy number. This policy documents if the medication is a controlled medication, the nurse will contact the pharmacist to receive a one-time access code to access the controlled substances stored in the emergency box. Emergency medication administration is documented on the resident's MAR.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer insulin timely resulting in repeated significant medicati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer insulin timely resulting in repeated significant medication errors for one (R6) of six residents reviewed for medications in the sample of 12.
Findings include:
On 10/24/24 at 12:13 PM R6 stated R6 has not been getting her medications on time, and some medications that are scheduled to be given at noon are not given until later in the afternoon. R6 stated this includes insulin and R6's blood sugars have dropped because of it.
R6's Minimum Data Set, dated [DATE] documents R6 is cognitively intact.
R6's October 2024 Medication Administration Record (MAR) documents to administer Lispro (insulin) 36 units and additional dosing per blood glucose based sliding scale before meals three times daily at 7:30 AM, 11:00 AM, and 4:00 PM.
R6's October 2024 Medication Administration Audit Report documents the following:
Lispro scheduled at 7:30 AM was given on 10/6/24 at 1:30 PM, 10/9/24 at 9:23 AM, 10/16/24 at 9:01 AM, and 10/20/24 at 10:04 AM.
Lispro scheduled at 11:00 AM was given on 10/3/24 at 1:56 PM, 10/6/24 at 1:30 PM, 10/11/24 at 4:17 PM, and 10/15/24 at 2:18 PM.
Lispro scheduled at 4:00 PM was given on 10/3/24 at 5:35 PM, 10/4/24 at 5:45 PM, 10/7/24 at 5:36 PM, 10/11/24 at 5:50 PM, 10/12/23 at 5:52 PM, 10/16/24 at 7:39 PM, 10/18/24 at 6:06 PM, 10/20/24 at 6:56 PM, and 10/22/24 at 5:39 PM.
On 10/24/24 at 1:40 PM V2 Director of Nursing confirmed the nurses document medication administration times at the time the medications are given, and the recorded times should be accurate. At 2:08 PM V2 stated if the medication has a scheduled time (not liberalized range), then the medication should be given within an hour window before or after the scheduled time.
The facility's Administering Medications policy dated April 2019 documents medications should be administered according to physician's orders and within one hour of the prescribed time, unless otherwise specified.
Aug 2024
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to complete wound dressing changes as ordered by the wound...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to complete wound dressing changes as ordered by the wound care physician. This failure affects one resident (R1) out of three residents reviewed for wound care on a sample list of nine. This failure resulted in R1's wounds becoming repetitively infested with parasitic fly larvae (maggots) requiring sanitation, causing pain and causing the wound to deteriorate.
Findings include:
R1's medical record documents admission to the facility on 2/13/23 with diagnoses of Acute Kidney Failure, Type II Diabetes Mellitus, Morbid Obesity, Benign Prostatic Hypertrophy, Lymphedema, Dementia, Falls, Wounds, Weakness, Malaise, and Anxiety.
R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact.
R1's Wound Evaluation and Management Summary dated 8/7/24 by V16 Wound Physician documents wounds of the right, anterior, medial leg size 8 centimeters by 5 centimeters by 0.1 centimeter (cm); the right lateral leg size 17 cm by 6cm by 0.01cm; the left calf size 18cm by 10cm by 0.05cm and the left anterior leg size 20cm by 16cm by 0.05cm. The wound care order includes the application of 0.1% Triamcinolone cream to both legs with 4-layer compression wraps from ankle to knee, twice a week.
On 8/19/24 at 12:18PM, V10 Wound Nurse said on the evening of 8/12/24, V14 Licensed Practical Nurse notified her she found maggots in R1's leg dressing and in his wheel chair. V10 Wound Nurse said she notified V16 Wound Physician and he ordered R1's legs to be washed with Betadine (antiseptic), and an abdominal dressing pad with gauze wrap followed by a pressure wrap every other day for 30 days.
R1's Wound Evaluation and Management Summary dated 8/13/24 by V16 Wound Physician documents the right, anterior, medial leg wound measured 16cm by 14cm by 0.1cm and has declined. The wound evaluation completed on 8/20/24 documents the wound has continued to decline. The evaluation documents the right, lateral leg wound measured 18cm by 10cm by 0.01cm and a new wound was evaluated on the right lateral foot measuring 4cm by 6cm by 0.1cm. V16 Wound Physician documented on 8/20/24 R1's right leg wounds continue to decline.
On 8/15/24, V10 Wound Nurse documented she completed the prescribed dressing changes on R1's wounds. However, no documentation of the appearance, size, drainage or condition of the wounds was found in R1's medical record on date.
On 8/17/24, V22 Registered Nurse (RN) documented she completed the prescribed dressing changes on R1's wounds. However, no documentation of the appearance, size, drainage or condition of the wounds was found in R1's medical record on date.
On 8/19/24 at 9:00AM, R1 was sitting near the nurse's station in a wheel chair with R1's legs wrapped. R1 said he had terrible pain in his legs and feet and behind his eye. R1 said the pain in his legs had been worse recently, but he didn't know why, and he needed someone to address it.
On 8/19/24 at 9:25AM, R1's resident room, consisting of four residents, smelled strongly of urine and had two fly strips hanging in the room. One fly strip had six flies on it.
On 8/19/24 at 9:30AM, R1's bilateral leg and foot dressings were saturated with thick yellow drainage and with urine. V2 Director of Nursing (DON) removed R1's right lateral and medial leg wound dressings and the dressing pulled away from the wound contained 7 adult size (length of a diameter of a dime) live maggots. At this time, V2 DON said this is the second time R1 has gotten maggots in the facility, as he was notified R1 had maggots in his wounds last Monday. V2 DON said this is unacceptable care. R1 was complaining of pain as the dressing was removed and asking V2 DON to please re-wrap his legs.
On 8/19/24 at 4:00PM, V22 RN confirmed she did not perform a dressing change on 8/17/24 and R1 did not refuse, but rather we only had three Certified Nursing Assistants (CNAs) and the nurses were having to help pass trays and feed and I just got busy and forgot to do it after I charted it.
On 8/19/24 at 10:10AM, V13 Nurse Practitioner (NP) stated, This has to be dealt with immediately. It could have been prevented and it could certainly have made the wound worse causing infection. This is unacceptable care.
On 8/19/24 at 2:48PM, V16 Wound Physician said based on the size of the maggot, he questioned whether the dressings were being changed as ordered. V16 said maggots cause concern for infection, and he told the staff to move the resident to a private room and deep clean the room.
On 8/20/24 at 9:30AM, V1 Administrator confirmed had the dressing changes been completed as ordered, maggot infestation could have potentially been prevented or at least caught sooner.
On 8/20/24 at 11:00AM, V10 Wound Nurse stated she had suggested alternative pain control to V13 NP because of R1's pain with dressing changes, including Gabapentin and R1's wounds weren't getting better.
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 F0800
(Tag F0800)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a diet as ordered for five (R1, R3, R6, R8 and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a diet as ordered for five (R1, R3, R6, R8 and R9) of five residents with diabetes reviewed for diabetic diet orders from a total sample list of nine residents reviewed.
Findings include:
The facility Physician Order Policy dated 11/2023 documents that after an order is received and confirmed, it will be completed as directed by the prescriber.
The facility provided menu dated 8/20/24 documents one option for all residents for breakfast meal, lunch meal and dinner meal.
The facility provided diet order report documents that R1, R3, R6, R8 and R9 all have orders for a low concentrated sweets diet.
The facility provided undated menu cards document orders for a carbohydrate controlled diet/low concentrated sweet diet for R1, R3, R6, R8 and R9.
On 8/20/24 at 8:45AM, ravioli and sauce was being made for lunch for the residents. V18 [NAME] confirmed that this was the only entree available for lunch.
1. R1's undated diagnoses list includes: Acute Kidney Failure, Type II Diabetes Mellitus, Morbid Obesity, Benign Prostatic Hypertrophy, Lymphedema, Dementia, Falls, Wounds, Weakness, Malaise, and Anxiety.
R1's physician order dated 10/30/22 documents an order for a low concentrated sweet / no added salt diet.
R1's physician order dated 10/5/23 documents to give 23 units of Novolog (Aspart) Insulin before meals.
R1's physician order dated 12/15/22 documents to give 45 units of Basaglar Insulin daily.
2. R3's undated diagnoses list includes: Cerebral Vascular Incident, Type II Diabetes Mellitus, Pseudobulbar Affect Disorder, Dysphasia, Dementia, Left Above Knee Amputation, Anxiety, Alzheimer's, Weakness, Stage Four Pressure Ulcer, Depression, and Malaise.
R3's quarterly nutritional assessment dated [DATE] documents a dietary order for low concentrated sweets.
R3's physician order dated 6/19/23 documents an order for Glargine Insulin to give 40 units twice daily.
3. R6's undated diagnoses list includes: Type II Diabetes Mellitus, Morbid Obesity, Uterine Cancer, Peripheral Vascular Disease, Gastroesophageal Reflux Disease, Panic Disorder, Anxiety, Difficulty Walking, and Hydronephrosis.
R6's quarterly nutritional assessment dated [DATE] documents a low concentrated sweets diet order.
4. R8's undated diagnoses list includes: Surgical Amputation, Sepsis, Type II Diabetes Mellitus, Cognitive Communication Deficit, Mood Disorder, Cerebral Atherosclerosis, Chronic Kidney Disease Stage 3, Absence of right toes in 2018 and 2019, Schizophrenia, Autism, Mild Intellectual Disability, and Heart failure.
R8's quarterly nutritional assessment dated [DATE] documents a dietary order for low concentrated sweets.
R8's physician orders dated 8/6/24 document Aspart Insulin 7 units to be given before meals, Glargine Insulin 14 units to be given daily and Novolog Insulin per sliding scale to be given based on blood sugar.
5. R9's undated diagnosis list includes: Diabetes Mellitus Type I with Hypoglycemia, Hyperglycemia, and Other Diabetic and Neurological Conditions; Depression, Weakness, Falls, Malnutrition, Congestive Heart Failure, Cardiomyopathy, Anxiety, Insomnia, and Atherosclerosis.
R9's quarterly nutritional assessment dated [DATE] documents a dietary order for low concentrated sweets.
R9's physician orders dated 3/22/24 document Glargine Insulin to give 10 units in the evening and 17 units in the morning.
R9's physician orders dated 5/25/24 document Lispro Insulin to give 2 units three times a day before meals and as needed per sliding scale before meals and before bed.
On 8/20/24 at 8:45AM, V18 [NAME] confirmed the breakfast served to all residents was a biscuit, sausage gravy, and a banana. V18 [NAME] stated there are no different menus for residents with diabetes.
On 8/20/24 at 8:49AM, V19 Dietary Assistant Manager stated they always provide everyone with the same meal, there are no differences in portions size or the food or carbohydrates for diabetics.
On 8/20/24 at 8:55AM, V2 Director of Nursing said he was unaware that the diabetic residents were not getting a diabetic (low concentrated sweet) diet and that giving them a regular diet could cause their blood sugar to elevate causing health problems.
On 8/20/24 at 9:50AM, V21 Registered Dietician said she was unaware the staff were not serving a low concentrated sweets diet to the diabetics. V21 said this failure could cause residents to have weight gain, uncontrolled blood sugars, could lead to poor circulation and wound healing. This could have caused resident harm.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to have an effective pest management program in place allowing flies to proliferate in the facility. This failure has the potentia...
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Based on observation, interview and record review the facility failed to have an effective pest management program in place allowing flies to proliferate in the facility. This failure has the potential to affect all 141 residents who reside in the facility.
Findings include:
The Resident List Report dated 8/19/24 documents 141 residents reside in the facility.
The facility Pest Control Policy dated 3/2024 documents the Environmental Services Director will be responsible for coordinating the facility pest control program. The pest control program will be conducted on a regular and as needed basis. Outside openings shall be protected against the entrance of insects by tight-fitting, self-closing doors, closed windows, screening, controlled air current or other means. All buildings will be tight-fitting and free of breaks.
The facility contracted pest control program service reports from April 2024 to August 2024 do not document flies as an area of concern or attention.
On 8/19/24 at 8:55AM, V3 Staffing Coordinator said there were usually a lot of flies near the front of the building.
On 8/19/24 at 9:10AM, R5's room had a hanging fly strip in her window. R5 said she had to have one because the flies were so bad over the past 2-3 months. R5 said she didn't think it was ok for flies to be in the facility, I can't do anything about them.
On 8/19/24 at 9:12AM, R4's room had a hanging fly strip over his bed. More than 50 flies were attached to it. R4 said he must have a fly strip due to all of the flies in the facility. They are really bad.
On 8/19/24 at 9:17AM, V7 LPN stated, Too many of my residents have to use fly strips to keep the flies off of them. It's ridiculous.
On 8/19/24 at 9:25AM, R1's resident room had two fly strips hanging in the room. One had six flies on it and the other had one.
On 8/19/24 at 9:25AM, the fly light by the courtyard door was completely covered with flies. V11 Maintenance Director said the company didn't leave any spare filters to change it out.
On 8/19/24 at 9:30AM, V2 Director of Nursing confirmed a resident currently residing in the facility had maggots found in his wounds on two separate occasions in the past week.
On 8/20/24 at 8:40AM, two flies were observed in V1 Administrator's office.
On 8/20/24 at 2:30PM, fly strips were observed with flies on them in four additional resident rooms.
On 8/19/24 at 3:10PM, V17 Contracted Pest Control Representative (CPCR) assessed the fly strip in a resident room and counted 10 flies which V17 confirmed as house flies.
On 8/19/24 at 3:15PM, V17 Contracted Pest Control Representative said they had not been notified until today there was an issue with flies. V17 stated, There is always something can be done to control pests and I recommend fly lights. The fly strips in the rooms are not ours, so neither I, nor my crew knew the extent to which they were in the buildings.
On 8/19/24 at 3:30PM, V17 CPCR said he did an inspection of the building and has located areas where flies are entering the facility. V17 said the flies were able to enter through the air conditioning units and there was standing water provided a breeding site for flies just outside of the building. V17 said he shared this information with V11 Maintenance Director.
On 8/19/24 at 9:20AM, V11 Maintenance Director stated, Flies aren't pests! We do have fly traps on all the halls, and I ordered fly lights, but they aren't here yet. I have a whole box of fly strips, we supply them. We have a light at the door out to the courtyard (provided by our Pest Control Company).
Jun 2024
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
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident was free from physical abuse for two of three residents (R1, R2) reviewed for abuse on the sample list of nine. This fail...
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Based on interview and record review, the facility failed to ensure a resident was free from physical abuse for two of three residents (R1, R2) reviewed for abuse on the sample list of nine. This failure resulted in R2 experiencing discomfort and swelling to the face as well as being fearful of R1 after R1 hit R2.
Findings Include:
The facility's undated Preliminary 24 Hour Abuse Investigation Report documents on 6/3/24 at approximately 11:45 pm, V1 Administrator received an allegation that R1 struck R2 on the side of the face.
R1 and R2's Physical Abuse Investigation Folder contained the following staff witness statements:
V9 CNA's (Certified Nursing Assistant) statement documents R1 became very aggressive on Monday night (6/3/24). It started when R1 came back to the facility and just progressed. A little after 11:00 pm, another CNA came and got V9 stating that R1 had hit R2, R1's roommate, in the face and they needed separated. V4 Agency LPN (Licensed Practical Nurse) reported that the police were called to diffuse the situation and for V9 and the other staff to wait on the police. Before the police officer arrived, R1 came out of the room and started cursing the staff out. When the police officer arrived, R1 was still yelling at everyone while we were trying to calm him down. R1 said that since staff didn't see R1 hit R2, it didn't happen. After the police officer left the facility, staff asked R1 to switch rooms and R1 cursed staff out again and accused staff of being racist against R1 so R2 agreed to switch rooms instead.
V10 CNA's statement documents, at the beginning of V10's shift (3rd shift) on 6/3/24, R1 was yelling out profanity. As V10 started walking to R1's room, R1 came out into the hallway and started yelling at the nursing staff. Upon arrival to R1's room, R2 was telling the nurse that R1 hit R2 in the side of the head with R1's fist. R1 returned to the room still yelling at the staff and R2. The police were called, and the officer suggested we separate the residents for the night. R2 was moved into a different room.
V11 CNA's statement documents on 6/3/24 during 3rd shift, R1 and R2's call light was on and upon entry to the room, R2 yelled out that R1 needed to get out of the room because R1 came over to R2's side of the room and hit R2 in the face. V11 asked them both to stay quiet until I (V11) got back with a nurse. Once the nurse arrived, the situation further escalated. R1 was saying racial and rude remarks to the staff. R2 was moved to a different room.
R2's Other Skin Condition Report dated 6/4/24 at 12:06 am by V4 Agency LPN (Licensed Practical Nurse) documents R2 has slight swelling to the left side of the face, near the eye.
On 6/10/24 at 11:00 am, R2 stated R2 had loaned R1, former roommate, some money. R2 stated R1 never paid R2 back so R2 asked R1 for the money and R1 hauled off and hit me (R2) in the face. R2 stated the police were called and R2 was moved into a different room. R2 explained R2 was happy to move because R2 was fearful of what R1 would do to R2 since R2 reported R1 to the police. R2 also stated that after being hit in the face, R2's face was initially sore and swollen.
On 6/11/24 at 8:15 am, V5 SSD (Social Service Director) confirmed R1 hit R2.
The facility's Abuse Prevention and Reporting Police dated October 2022 documents this facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse is defined as any physical or mental injury inflicted upon a resident other than by accidental means.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the safety of residents by failing to accurately screen and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the safety of residents by failing to accurately screen and assess a new resident upon admission and implement necessary safety interventions for two of three residents (R1, R2) reviewed for abuse on the sample of nine. This failure resulted in a newly admitted resident (R1) residing in a room with R2 and R1 being physically aggressive with R2, hitting R2 in the face with a closed fist. As a result of the physical abuse, R2 experienced facial discomfort and swelling along with psychosocial harm.
Findings Include:
The facility's Identified Offender-admission Guidelines Policy dated May 2024 documents, Criminal History Record Information will be requested, the facility must review screenings and all supporting documentation to determine if the placement is appropriate, the facility must develop a plan of care appropriate to the needs of the offender. Upon admission of an identified offender, the facility, in consultation with the medical doctor and law enforcement, must specifically address the resident's needs in an individualized plan of care that reflects the risk assessment of the individual. In conducting a risk assessment of an identified offender and developing a plan of care, the facility shall consider the following: the care and supervision needs, if any, specific to the individual's criminal offense, the results of the screening conducted pursuant to the act, the amount of supervision required by the individual to ensure the safety of all residents, staff, and visitors in the facility. The physical and mental abilities of the individual, the current medical assessments of the individual, approaches to resident care that are proactive and are appropriate and effective in dealing with any behaviors specific to the identified offense, and the number and qualifications of staff needed to meet the needs of the individual and the required level of supervision at all times. The care planning of identified offenders shall include a description of the security measures necessary to protect facility residents from the identified offender, including whether the identified offender should be segregated from other residents, if the facility's risk assessment determines that an identified offender must have his or her own room.
R1's admission Referral Pack dated 5/10/24 contained a plan of care dated 2/6/24 that documents R1 has been identified as an Offender of a felony offense as listed in Section 25 of Healthcare Worker Background Check Act and has been assessed as a Moderate Risk towards other residents, staff or visitors. The nature of resident's offense was criminal trespass, burglary, false alarm complaints, DUI, retail theft, criminal damage to state property, resisting a peace officer, aggravated battery. He has a criminal history of being incarcerated most of his life from 1983-2021.
R1's ongoing Census documents R1 was admitted to the facility on [DATE].
R1's Medical Record contained two different Illinois State Police Background Checks for R1, each with a different date of birth . The first one dated 5/10/24 documents, no record on file. The second one dated 5/22/24 documents, multiple hits and documents the following arrests and convictions: criminal trespass to land, false alarm/complaint to 911, burglary, DUI (Driving Under the Influence)/Alcohol, retail theft, criminal damage to state property, resisting a peace officer, possession of cannabis, attempted theft, and aggravated battery.
R1's MDS (Minimum Data Set) dated 5/17/24 documents R1 is alert and oriented, has verbal behaviors, and requires supervision with ambulation and transfers.
R1's Care Plan dated 5/31/24 does not document any Identified Offender Information.
R1's Progress Notes dated 6/4/24 at 12:00 am by V4 Agency LPN (Licensed Practical Nurse) documents R1 was placed on 15 minute checks and R2 (R1's roommate) was removed from the room due to R2's allegations of R1 striking R2 in the face.
R2's Progress Note dated 6/4/24 does not document the allegation of R1 hitting R2 however it does document a new skin concern of slight swelling on left cheek near the eye with no bruising at this time.
On 6/10/24 at 11:00 am, R2 confirmed that R2 was struck in the face by R1. R2 stated R2 chose not to pressure charges on R1 but did report R1 to the police and was fearful of what R1 would do to R2 because of that, so R2 was happy that the facility moved R2 into a different room. R2 also stated that after being hit in the face, R2's face was initially sore and swollen.
R1's Medical Record did not contain an Abuse Risk Assessment until 6/4/24 {25 days after admission to the facility and the day of the incident}. This assessment documents R1 is at high risk.
On 6/11/24 at 8:15 am, V5 SSD (Social Service Director) stated the Corporate Office completes background checks, prior to admission, for all new admissions and if it comes back with a hit, then they give it to V5 to schedule finger prints. V5 stated V5 noticed the original background check had the wrong birthday input into the system so a new background was completed and that is when R1's hits showed up. V5 reviewed R1's ongoing census that documents upon admission [DATE]), R1 was admitted into a four bed ward then was moved into a private room on 5/12/24, but V5 is unsure what happened to cause that room move. V5 explained that R1 remained in the private room until 5/22/24 when R1 was moved into a semi-private room with R2, due to another resident needing the private room R1 was in. V5 explained that after R1 hit R2 on 6/4/24, R2 was moved into a different room because R1 refused to move rooms. When asked about any safety precautions that were in place due to R1's background report, V5 stated V5 was aware of R1's background information however R1 was not displaying any behaviors until R1 was placed with a roommate, therefore no safety precautions were in place or care planned. V5 also stated, It has surprised us all because when (R1) was first admitted , (R1) was very pleasant but something happened and (R1) just turned left. V5 explained, R1 has not been physical with anyone since the incident with R2 however R1 continues to harass and torment, to the point where the staff are fearful of R1. V5 stated the next day when V5 checked on R2, R2 was still talking about the incident and wanted the police called again. The police came back out but R2 again did not press charges.
On 6/11/24 at 10:12 am, V15 Freedom of Information Officer with the Danville Police Department confirmed that on 6/3/24 a couple minutes before midnight, the Danville Police Department received a call regarding R1 hitting R2, then was called back the following day regarding the same incident.
On 6/11/24 at 10:42 am, V13 Regional Director of Operations, with V1 Administrator present, stated R1's background was run prior to R1's admission and as soon as the facility figured out it was run with the wrong date of birth , another background check was run. When asked about interventions to keep facility residents safe from R1 based off R1's background check, V13 did not provide any and stated V13 was not aware that R1 had an aggravated battery conviction on R1's record.
On 6/11/24 at 10:50 am, R1 stated when R1 was admitted to the facility and placed into a room with other residents, a four bed ward, that R1 told both V1 Administrator and V5 SSD that the other two facilities R1 had been at in the past had R1 in a private room due to R1's background check and recommendations from the police but that this facility told R1 they could not do that. R1 explained after being in the four bed ward, another resident complained about R1, so the facility moved R1, then moved R1 in with just one other resident. R1 stated R1 thought R1 could handle it with just one other resident but I (R1) couldn't. (R2) accused me (R1) of hitting (R2) so now I (R1) have to defend myself. Had they {facility} had me (R1) in a room by myself to start like I (R1) told them {V1 and V5} I (R1) needed; this never would have happened.
On 6/11/24 at 11:07 am, V1 stated R1 never told V1 that R1 needed to be in a private room based on R1's background check however R1 did ask V1 about being in a private room but the facility couldn't accommodate that.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan for one of three residents (R1) r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan for one of three residents (R1) reviewed for abuse on the sample list of nine.
Findings Include:
The facility's Identified Offender - admission Guidelines Policy dated May 2024 documents upon admission of an identified offender to a facility or a decision to retain an identified offender in the facility, the facility, in consultation with the medical doctor and law enforcement, must specifically address the resident's needs in an individualized plan of care that reflects the risk assessment of the individual. The care planning of identified offenders shall include a description of the security measures necessary to protect facility residents from the identified offender, including whether the identified offender should be segregated from other residents if the facility's risk assessment determines that an identified offender must have his or her own room, then all of the criteria below must be met: the room must be in direct view of the nursing station, the room must be separated from rooms of residents who are at risk, and the resident must not share his or her bathroom with any other resident.
R1's ongoing Census documents R1 was admitted to the facility on [DATE].
R1's Criminal History Report dated 5/22/24 documents several arrests and convictions including one for aggravated battery.
R1's admission referral packet dated 5/10/24 contained a plan of care dated 2/6/24 from the referring facility that documents R1 has been identified as an Offender of a felony offense as listed in Section 25 of Healthcare Worker Background Check Act and has been assessed as a Moderate Risk towards other residents, staff or visitors. The nature of resident's offense was criminal trespass, burglary, false alarm complaints, DUI, retail theft, criminal damage to state property, resisting a peace officer, aggravated battery. He has a criminal history of being incarcerated most of his life from 1983-2021.
R1's Comprehensive Care Plan dated 5/31/24 does not document that R1 is an Identified Offender, what R1's risk level is or any interventions that are in place.
On 6/11/24 at 8:15 am, V5 SSD (Social Service Director) confirmed R1's Identified Offender Status and Risk Level is not care planned and should be.
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 F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to honor R4's breakfast meal preferences. This failure affects one of (R4) three residents reviewed for meal preferences in the sample list of ni...
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Based on observation and interview the facility failed to honor R4's breakfast meal preferences. This failure affects one of (R4) three residents reviewed for meal preferences in the sample list of nine.
On 6/11/24 at 7:28 AM R4 showed the surveyor a picture of R4's 6/9/24 breakfast tray, which showed one fried egg only on the plate. R4 stated that is what R4 was served on 6/9/24 and 6/10/24. R4 explained R4 prefers fried eggs and about one month ago, talked with V16 Dietary Manager and requested two fried eggs, two pieces of toast and two sausages every day for breakfast and that the facility did it a couple of days but since then, R4 is only getting one slice of toast and then the past two days, didn't even get that, R4 only got one fried egg.
On 6/11/24 at 7:28AM R4's breakfast tray consisted of two fried eggs, one slice of toast, oatmeal and a four ounce drink.
On 6/11/24 at 2:00 PM V16 confirmed R4 spoke with V16 awhile back and requested to receive two fried eggs and two pieces of toast for every breakfast so that is what R4 should be served. V16 stated V16 is not aware of R4 only getting one fried egg on 6/9/24 and 6/10/24.
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from verbal abuse by staff. Thi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from verbal abuse by staff. This failure affects one (R9) of three residents reviewed for verbal abuse on the sample list of nine residents.
Findings include:
The facility abuse policy dated 8/2023 documents the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure the facility is doing all is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents has attempted to establish a resident sensitive and resident secure environment.
R9's Minimum Data Set, dated [DATE] documents R9 as cognitively intact.
R9's care plan dated 5/8/23 documents R9 has occasional incontinence requires assistance with grooming and toileting/cleaning.
On 5/23/24 at 2:56PM, R9 said he woke up with loose stools this morning and couldn't make it to the bathroom in time. R9 said he pushed the call light and V11 Certified Nursing Assistant (CNA) answered the call light. V11 CNA handed R9 wipes so he could reach himself to wipe and when R9 demonstrated to V11 CNA he could not reach himself to wipe, V11 CNA said, If you weren't so fat, you'd be able to reach. R9 said this made him feel ashamed and embarrassed, especially when he relayed this information to V12 Activity Director. R9 stated after sharing his experience with V12 Activity Director; V1 Administrator, V2 Director of Nursing and a local police officer interviewed him.
On 5/23/24 at 3:20PM, V1 Administrator said V11 CNA was suspended pending the abuse investigation and based on the information she had gathered, she would consider this verbal 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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to facilitate interdisciplinary care plan meetings including residents for one (R2) of three residents reviewed for care plan meetings from a t...
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Based on interview and record review the facility failed to facilitate interdisciplinary care plan meetings including residents for one (R2) of three residents reviewed for care plan meetings from a total sample list of nine residents.
Findings include:
The facility Care Plan Meeting Procedure dated 3/2024 documents invitations will be extended to the resident or their representative, to participate in the resident's quarterly care plan meeting. Social Services, Nursing, Dietary, Activities, Restorative or Rehabilitation services will also be included to discuss any issues at the care plan meeting.
R2's quarterly care plan dated 5/16/24 documents V8 Care Plan Coordinator was the only person in attendance for R2's care plan meeting. No documentation was recorded regarding falls, injuries or fall interventions. No documentation regarding behaviors, cares or weight loss was recorded.
On 5/23/24 at 11:00AM, V8 Care Plan Coordinator said she did not know if R2's guardian had received her invitation to the care plan meetings and she held it on her own, without any other members of the team or the resident.
On 5/23/24 at 11:08AM, V2 Director of Nursing said the resident, the family, a nurse, social services and dietary at a minimum should be present and participating in care plan meetings. V2 said, I wasn't aware they weren't participating.
On 5/23/24 at 2:30PM, V3 Regional Nurse Consultant stated, We have to change the way we are communicating with the guardian for (R2) when it comes to care conferences. It isn't happening right now, and we don't even know if they are getting our requests for meetings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide bathing, shaving and nail care for one (R2) of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide bathing, shaving and nail care for one (R2) of three residents reviewed for dependent activities of daily living from a total sample list of nine residents.
Findings include:
The facility Bathing policy dated 3/2024 documents ensuring a resident's cleanliness is done to maintain proper hygiene and dignity. The facility Nail Care policy dated 3/2024 documents nails should be assessed during bathing and addressed for cleanliness, length and uneven edges. The facility Certified Nursing Assistant (CNA) policy dated 7/2023 documents essential duties of the CNA include bathing, dressing, grooming, shaving, and feeding residents.
R2's Minimum Data Set, dated [DATE] documents R2 is dependent for all care.
R2's Minimum Data Set, dated [DATE] documents R2 is severely cognitively impaired.
No documentation could be provided by the facility indicating when R2's last shower, shave or nail trim was most recently done.
On 5/22/24 at 2:30PM, R2 was sitting on his bed in the dark, rocking, the bed sheet was soiled and R2 was wearing hospital gown and sweatpants. R2's gown and sweatpants were visibly soiled, R2's toenails were 1/2 inch long past the end of the toe and R2 was unshaven with hair 1 and 1/2 inches long.
On 5/23/24 at 9:00AM, V1 Administrator and V2 Director of Nursing said they saw R2 the day before and recognized R2 needed attention. V1 Administrator said R2 needed a shower, a bed change, needed to be shaved and to have his toenails clipped. V2 Director of Nursing said R2 had been in state for a while and he did not know why the CNAs nor the Podiatrist had not addressed his care needs and it wasn't dignified.
Apr 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**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 (R206) right to be free from sexu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect a resident's (R206) right to be free from sexual abuse and failed to protect a resident's (R208) right to be free from physical abuse from another resident. R206 and R208 are two of four residents reviewed for abuse in the sample list of 36.
Findings include:
1. R206's Diagnosis Sheet (current) includes the following diagnoses: Alzheimer's Disease, Difficulty in Walking and Fracture of the Left Femur.
R206's Minimum Data Set (MDS) dated [DATE] documents R206 as being Severely Cognitively Impaired and uses a wheelchair for mobility.
A facility report titled, Final Abuse Investigation, dated 4/5/24, documents an incident of alleged sexual abuse on 4/1/24 involving R206 with R205 as the alleged perpetrator. The Abuse Investigation Report documents that on 4/1/24 R205 and R206 were in the dining room eating. R205 self-propelled R205's wheelchair over to R206 and touched (R206's) chest over the top of (R206's) clothes. There was no physical injury to (R206).
A witness (V21 Dietary Aide) statement for the above Abuse Investigation Report is included in the investigation and is documented as follows: Around 6:37 pm, (R205) was grabbing (R206's) chest area and didn't let go. (R206) pulled away from (R205) and (R205) still refused to let (R206) go.
R205's MDS dated [DATE] documents R205 as being moderately cognitively impaired and uses a wheelchair for mobility.
R205's Psychiatric Notes dated 3/26/24 includes the following diagnoses: schizoaffective disorder - Bipolar type, Generalized Anxiety, and Inappropriate Sexual Behavior.
On 4/10/26 at 10:25, R206 was sitting in R206's wheelchair involved in an activity. R206 appeared calm, engaged, and happy.
On 4/10/24 at 1:30 pm, R205 was sitting in R205's room. R205, without prompting, blurted out I won't do it again. R205 reiterated, I grabbed a lady's breast, I won't do it again. R205 confirmed that R205 knew grabbing R206's breast was wrong and stated, I just got the urge to do it.
On 4/10/24 at 3:10 pm, V21 confirmed that V21 had witnessed the actual sexual abuse of R206 by R205. V21 stated V21 was coming out of the kitchen and V21 saw R205 grab R206's breast. V21 told R205 to let go but R205 wouldn't. V21 confirmed that R206 tried to pull away from R205 and R205 still wouldn't let go of R206's breast.
On 4/12/24 at 10:07 am, video of the above sexual abuse was observed. The video recording visibly shows R205 intentionally self-propel over to R206, cupping R205's hand and placing it on R206's left breast. V21 is present in the video.
2. R208's Diagnoses Sheet (current) includes the following diagnoses: Dementia, Difficulty in Walking and Alzheimer's Disease.
R208's MDS dated [DATE] documents R208 as being moderately cognitively impaired.
A facility report titled, Final Abuse Investigation Report, dated 4/11/24, documents an allegation of physical abuse on 4/4/24 involving R208 with R209 as the alleged perpetrator. The report documents on 4/4/24 that R209 was walking down the hall of the facility yelling that R208 had stolen R209's jacket. R208 was standing in the doorway of R208's room and R209 made contact with (R208). Both residents lost their balance during the contact and fell to the floor.
The above report includes two witness statements by N14 Nurse Practitioner and V35 Certified Nurse Assistant.
V14's statement dated 4/4/24 documents the following: I was in the hallway walking towards a resident's room when I realized (R209) was behind me. (R208) was standing by (R208's) room's door. (R209) walked toward (R208's) room, stood in front of (R208) and yelled at (R208) and said, 'You stole my garbage can.' (R208) said 'No, I didn't.' (R209) continued yelling at (R208). (R209) was out of control, and I was not able to pull (R209) back away from (R208). (R209) yelled at (R208) and finally they grappled. While grappling, (R209) walked backward, and they both fell against the hallway wall at which moment staff arrived and separated them.
V35's statement dated 4/4/24 documents the following: It was at approximately 1:00 pm, I was standing at the nurses station. Resident (R209) started yelling and following the NP (V14 Nurse Practitioner) as (V14) was walking down the hall. (R209) was yelling '(R208) stole my leather coat and sold it for drug money.' (R209) stopped at the doorway of resident room (R208). (R209) became physical and both ended up on the floor. (R209) kept saying 'you stole my stuff.' (R209) struck (R208) with a closed fist, then they tussled to the floor and was rolling around. We immediately separated them and placed (R209) on a 1 on 1 supervision.
R209's Diagnosis Sheet (current) includes the following diagnoses: Dementia with Behaviors and Psychosis.
R209's MDS dated [DATE] documents R209 as being severely cognitively impaired. R209's Care Plan (current) documents R209 with potential aggressive behaviors.
On 4/12/24, R208 and R209 refused to be interviewed.
On 4/12/24 at 11:40 am, V14 confirmed R209 had followed V14 down the hall and was yelling and when arriving at R208's door, R209 hit R208, and they fought and fell to the ground. V14 stated, I could not get them apart.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to do complete a thorough investigation of an allegation of sexual abuse between two residents (R205) and (R206). R205 and R208 are two of fou...
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Based on interview and record review, the facility failed to do complete a thorough investigation of an allegation of sexual abuse between two residents (R205) and (R206). R205 and R208 are two of four residents reviewed for abuse in the sample list of 36.
Findings include:
A facility report titled, Final Abuse Investigation, dated 4/5/24, documents an incident of alleged sexual abuse on 4/1/24 involving R206 with R205 as the alleged perpetrator. The Abuse Investigation Report documents that on 4/1/24 R205 and R206 were in the dining room eating. R205 self-propelled R205's wheelchair over to R206 and touched (R206's) chest over the top of (R206's) clothes.
The above investigation in its entirety documents two statements from staff, V21 Dietary Aide as a witness that documents V21 seeing R205 grab R206's chest area and another staff member, Certified Nurse Assistant (V34) who was called for assistance to retrieve R205 and take R205 to a separate area. This investigation also documents V1 Administrator asked the (unidentified) Interdisciplinary Team if they had knowledge of R205's sexual inappropriate behaviors before and V1 documents they had not. There are no documented interviews from any of the Interdisciplinary Team (IDT). There are no other interviews in the above investigation of other staff or residents who may have experienced R205's inappropriate sexual behavior.
On 4/11/24 at 10:30 am V1, Administrator confirmed there were no other residents in the dining room when the alleged sexual abuse happened. V1 also confirmed V1 did not interview other facility residents that could have potential knowledge of, or experienced sexual abuse themselves and not reported. V1 confirmed the IDT discussed the incident, and they knew nothing about R205 being sexually inappropriate, but did not document these interviews and or statements from the IDT.
Mar 2024
23 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) On 3/03/24 at 11:20AM, V45, R97's family member said R97 has lost weight since being at this facility.
On 3/3/24 at 11:21 A...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) On 3/03/24 at 11:20AM, V45, R97's family member said R97 has lost weight since being at this facility.
On 3/3/24 at 11:21 AM, R97's continuous tube feeding was running onto the floor as it was disconnected from port. On 3/5/24 at 11:30AM, R97's continuous tube feeding was turned off.
R97's 12/18/23 dietician note documents a weight review and tube feeding review for R97 indicating that R97 is underweight.
R97's weight sheet documents that on 12/20/23, R97's weight is 149.4 pounds. R97's weight sheet documents that on 12/27/23, R97's weight is 135.6 pounds, a ten percent weight loss in one week. R97's medical record does not document notification of the physician for this significant weight loss.
R97's physician orders dated 12/18/23 document that R97 is to be weighted weekly. R97's medical record does not document that R97 received weekly weights from 12/18/23 through March 6, 2024.
On 3/6/24 at 11:47 AM, V2 Director of Nursing confirmed that the Physician should be notified of any significant weight loss in residents.
Based on observation, interview, and record review the facility failed to identify significant weight loss, timely report significant weight loss to the dietitian and physician, ensure weight loss was assessed/evaluated by a physician, notify the resident representative of weight loss, implement nutritional recommendations, and obtain weekly weights for five (R70, R39, R62, R60, R97) of nine residents reviewed for nutrition in the sample list of 54. These failures resulted in R70 experiencing a significant one month weight loss of 5.52% after experiencing a 10.77% weight loss the month prior, and a total weight loss of 24.25% in six months.
Findings include:
The facility's Significant Weight Gain or Loss Policy revised February 2024 documents: 1. Dietary/Nursing team will obtain weights from nursing. a. After review a request for reweighs will be determined. 2. Dietician/Nursing will determine significant weight changes 1. Gain or loss of 5% in the last month b. Gain or loss of 7.5% in the last three months c. Gain or loss of 10% in the last six months 3. Dietician will review these clients and document the change 4. If recommendations are indicated will be communicated to nursing to notify the provider of the significant weight changes and recommendation. If weight loss noted: family and resident will be notified in addition to physician. IDT (Interdisciplinary Team) will review monthly to assure appropriate plan of care and interventions for those with significant weight gain or loss.
1.) R70's undated weight log documents the following weights: 158 pounds (lbs.) on 5/22/23. 159.3 on 6/7/23. 154.2 on 8/1/23. 137.6 (10.77% loss in one month) on 9/4/23. 130 (5.52 % loss in one month) on 1/0/1/23. 136.8 on 11/1/23. 136.2 on 12/12/23. 136 on 1/8/24. 120.8 on 2/1/24. 116.8 (24.25% loss in six months) on 2/19/24. 119.8 on 2/19/24. 115.2 on 3/4/24. There are no documented weights after 10/1/23 until 11/1/23 or between 2/19/24 and 3/4/24 to verify the accuracy of the weights.
R70's Minimum Data Set (MDS) dated [DATE] documents R70 has cognitive impairment and R70 weighs 136 lbs. This MDS incorrectly documents R70 has not had a significant weight loss within the last six months. R70's Care Plan dated 9/21/23 documents R70 has unplanned and unexpected weight loss and includes interventions to notify the physician and dietitian immediately if weight decline persists. This care plan does not document any new interventions to address R70's weight loss after 1/12/24.
R70's Diet Order dated 2/27/24 documents double portions at breakfast, lunch and supper. R70's Physician Order dated 12/20/23 documents give nutritional supplement 120 milliliters (ml) twice daily. There are no other documented nutritional supplements in R70's medical record. R70's March 2024 Medication Administration Record (MAR) documents administration of the nutritional supplement but does not document how much of the supplement is consumed.
There is no documentation in R70's medical record that R70's September 2023 significant weight loss was reported and evaluated by a dietitian and physician, or that R70's February 2024 significant weight loss was reported to or evaluated by a physician prior to 2/20/24 and reported/evaluated by the dietitian prior to 2/26/24. There is no documentation that V40 (R70's Family) was notified of R70's significant weight loss in September 2023 or continued weight loss noted in February and March 2024.
R70's Dietary Note dated 2/26/24 at 6:32 PM and recorded by V19 Dietitian documents R70's diagnoses include Alzheimer's Disease, Type 1 Diabetes Mellitus, Protein Calorie Malnutrition, Hypertension, Dysphagia, Iron Deficiency Anemia, Anxiety, Muscle Weakness and Encephalopathy. This note documents R70 is 68 inches tall, 119.8 lbs., and Body Mass Index is 18.2, underweight. R70's diet includes double portions at breakfast and dinner, and a nutritional supplement twice daily. This note documents significant weight loss for one, three, and six months, weight is down 16 lbs. from last month, R70 eats well, and unclear etiology of this weight loss. V19 recommended to increase double portions for all meals to prevent further weight loss.
On 3/3/24 at 12:10 PM V39 Certified Nursing Assistant (CNA) fed R70 the noon meal that consisted of puree barbecue sandwich, vegetables, mashed potatoes, chocolate nutritional shake, and lemonade. R70's meal ticket did not document double portions. At 12:30 PM R70 ate all the noon meal. V39 stated R70 eats well and ate all the noon meal today. On 3/4/24 at 11:44 AM R70's meal ticket did not document double portions for the noon meal. At 12:18 PM R70 ate all R70's noon meal. On 3/5/24 at 8:42 AM R70 ate all R70's breakfast and R70's meal ticket documents double portions for the breakfast meal.
On 3/4/24 at 4:11 PM V40 (R70's Family) stated V40 was not sure if R70 has had any weight loss, nobody has told V40 what R70 currently weighs, and V40 had planned to ask the facility about that.
On 3/4/24 at 11:20 AM V38 Memory Care Director stated the nurses would know if a resident had a weight loss and V38 assists the CNAs in obtaining weights. V38 stated V38 reports weight loss to V41 Care Plan Coordinator and V5 MDS Coordinator during the weekly weight meetings. V38 stated V38 attends the meetings if the dementia unit (where R70 resides) has residents with weight loss. V38 last attended a weight meeting about a month ago. V38 stated R113 is the only resident on this unit with weight loss.
On 3/4/24 at 12:53 PM V18 Licensed Practical Nurse (LPN) stated V18 gave R70's morning nutritional supplement and R70 only drank about 60 of the 120 ml given. V18 stated usually V18 tries to give R70 the remaining amount later, but V18 did not do that today.
On 3/5/24 at 8:38 AM V25 Dietary Aide/Cook stated dietary staff look at the meal tickets to determine which residents should have double portions at meals. V25 stated double portions is listed on R70's dinner meal ticket, but not on R70's noon meal ticket.
On 3/5/24 at 10:14 AM V21 Assistant Administrator stated weights are only documented in the resident's electronic medical record. V21 stated the Assistant Director of Nursing (ADON) is responsible for notifying the resident's family of weight loss, but we didn't have an ADON recently until a few weeks ago. V21 stated the ADON is also responsible for leading the weight program and V21 was unsure who was leading the weight program in the ADON's absence. V21 stated the dietitian's assessments are documented in the progress notes and V21 did not see a dietitian note/assessment for R70 in September. V21 stated double portions should be on the resident's meal tickets.
On 3/5/24 at 11:51 AM V8 stated R70 had atelectasis found on R70's chest x-ray in September 2023, and V40 did not want any follow up x-rays, appointments, or anything invasive done. V8 stated V8 evaluated R70 today and the staff report R70 eats well. V8 stated V8 was unsure of the direct cause of R70's weight loss since V40 refused invasive testing. V8 stated V8 does not evaluate for weight loss and refers to the dietitian to address weight loss. V8 stated this is a large building, there is a lot of weight loss. V8 relies on the facility to report significant weight loss. V8 does not have time to evaluate each resident for weight loss, and V8 records the resident's weight in V8's Progress Notes. V8 stated the staff should absolutely follow the dietitian's recommendations and if those recommendations are not followed it can contribute to weight loss. V8 stated on 2/20/24 V8 noted in V8's notes that R70 had a slight weight gain. V8 reviewed R70's weights, and stated V8 believes R70's weight of 119.8 on 2/19/24 was inaccurate as it was obtained by a mechanical lift and the other weights were in a wheelchair.
On 3/5/24 at 12:16 PM V20, Interim [NAME] President of Clinical Operations, stated V20 requested that V8 evaluate R70 today, and confirmed V40 was not notified of R70's significant weight loss in February. At this time documentation was requested that the physician was notified and evaluated R70's weight loss in September and February. The facility failed to provide this requested documentation.
On 3/5/24 at 12:55 PM V19 Dietitian stated V19 conducts V19's nutritional assessments off site and runs a weight report during the first week of each month to identify significant weight loss. V19 stated V19 then places those identified residents on the Nutrition at Risk form, gives recommendations and the form to the facility, and if the facility identifies weight loss or nutrition concerns then they contact V19 by electronic mail. V19 stated it is difficult to stay up on the weights and nutritional assessments due to this being a large facility. V19's contract is for 36 hours per month at the facility, and it is difficult to complete all of it in that time frame. V19 stated V19 would have identified R70's significant weight loss during the first week of February when V19 ran the weight report, and V19 requested a reweigh on 2/16/24 to verify the accuracy of the 2/1/24 weight. V19 believes the weight was accurate based on R70's following weights. V19 stated the facility should implement V19's recommendations within a week and confirmed that waiting a week could also result in additional weight loss during that time. V19 stated V19 determines if residents are consuming supplements by communicating through electronic mail to the facility and reviewing progress notes. V19 stated if the resident isn't consuming the supplements, then V19 would try adding additional dietary supplementation such as fortified cereal, nutritional shakes, double portions, and whole milk with meals. V19 stated V19 did not give any nutritional recommendations for R70 in February until 2/26/24 when V19 recommended adding double portions to all meals, and V19 would have given that recommendation sooner once R70's weight loss was verified. V19 stated ideally the facility should reweigh to verify weights and should be completed by the 10th of each month. V19 stated V19 did not see any documentation that R70's significant weight loss and nutrition was evaluated in September by a dietitian, and double portions would have been recommended at that time. V19 confirmed adding the double portions prior to October could have helped stabilize R70's weight and if R70 is not receiving the recommended nutritional interventions it can contribute to weight loss. V19 stated R70's weight loss is a tough one. V19 was not sure what is causing R70's weight loss.
2.) R39's MDS dated [DATE] documents R39 has cognitive impairment and R39 has had a significant weight loss within the last month or six months. R39's undated weight log includes the following weights: 141.4 lbs. on admission 8/8/23. 137 on 10/1/23. 143 on 11/16/23. 120.2 on 11/29/23 and 12/3/23. 114.8 on 12/20/23. 119.0 on 1/3/24. 117.6 on 2/1/24 and 2/7/24. 122.2 on 3/4/24. There are no documented weights between 11/16/23 and 11/29/23.
R39's March 2023 MAR documents to administer nutritional supplement 120 ml three times daily with breakfast, lunch, and dinner.
R39's Dietary Note, recorded by V19, dated 12/23/2023 at 4:46 PM documents R39 is 63 inches tall, weighs 114.8 lbs. a 19.7% one month loss, and Body Mass Index is 20.3, underweight. R39's diagnoses include Vascular Leukoencephalopathy, Protein Calorie Malnutrition, Hypertension, Anemia, Malignant Neoplasm of breast, Gastritis, and Vascular Dementia. This note documents R39 has had ongoing weight loss since admission with recent hospitalization for COVID-19 (Human Coronavirus Infection) Pneumonia which likely contributed to weight loss. V19 recommended a nutritional supplement to be given daily. R39's Dietary Note, recorded by V19, dated 1/23/24 at 7:37 PM documents R39 has a 13% weight loss in three months, and R39 receives a nutritional supplement three times daily. This note documents that R39's weight is similar to R39's November weight and is showing some slight improvements. This note documents to continue nutritional supplement and recommend weekly weights.
There is no documentation in R39's medical record that R39's physician and family were notified of R39's November 2023 significant weight loss, or that a dietitian evaluated this weight loss prior to 12/23/23.
On 3/3/24 at 12:10 PM R39 was eating lunch. At 12:28 PM R39 ate half of a barbecue sandwich, and all the vegetables, mashed potatoes, and dessert. R39 drank all the lemonade and nutritional supplement. On 3/4/24 between 12:10 PM and 12:29 R39 ate lunch and R39 was not served a nutritional supplement.
On 3/4/24 at 1:02 PM V18 LPN stated V18 is unsure if R39 gets a nutritional supplement but V18 will check. V18 reviewed R39's MAR which documented V18 had signed out R39's nutritional supplement as administered as scheduled for morning and noon. V18 stated V18 signed the MAR, but V18 had not given R39's supplement.
On 3/5/24 at 12:16 PM V20 was asked to provide documentation that R39's family and physician were notified of R39's November significant weight loss. The facility failed to provide this requested documentation.
On 3/5/24 at 12:55 PM V19 stated V19 did not evaluate R39's November weight loss until December when V19 recommended adding the nutritional supplement, and this supplement was increased to three times daily in January 2024. V19 stated V19 identified R39's significant weight loss mid-December and probably would have recommended the house supplement sooner if V19 was notified of the weight loss prior. V19 stated V19 questions the accuracy of R39's 11/16/23 weight and ideally the facility should reweigh to verify weights.
4.) R62's Care Plan revised 2/16/24 documents, (R62) has unplanned/unexpected weight loss. Date Initiated: 09/21/2023 No new nutritional or weight loss interventions have been documented since 9/21/23.
On 09/02/2023, the R62 weighed 212 lbs. On 02/28/2024, the R62 weighed 167.2 pounds which is a -21.13 % Loss. There is no documentation in R62's medical record that the physician was notified of R62's significant weight loss.
On 3/5/24 at 2:26PM V8 Nurse Practitioner stated, If the facility did not notify me of a weight loss for (R62) I would not have known to address it when I visit.
5.) R60's Order Summary Report dated 3/4/24 documents diagnoses including Vitamin D Deficiency, Anemia, Abnormal Weight Loss, Type 2 Diabetes, Chronic Kidney Disease and Moderate Protein-Calorie Malnutrition.
R60's electronic medical record contains a weight log which documents R60's weight on 10/11/23 as 229.18 pounds. This weight record then documents R60's weight on 11/8/23 as 168.6 pounds and on 11/10/23 as 168.8 pounds.
R60's Nurse Progress notes do not document notification of the Physician or of the Registered Dietician of this weight loss, therefore there was nothing done to assess or treat this weight loss.
On 3/6/24 at 11:47 AM, V2 Director of Nursing confirmed that the Physician and the Registered Dietician should be notified of any significant weight loss in residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide feeding assistance in a dignified manner for o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide feeding assistance in a dignified manner for one (R113) of 28 residents reviewed for dignity in the sample list of 54.
Findings include:
The facility's Dignity policy revised April 2018 documents: The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and 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. Maintaining a resident's dignity should include but is not limited to the following: Promoting resident independence and dignity while dining, such as avoiding: Daily use of disposable cutlery and dishware; bibs or clothing protectors instead of napkins (except by resident choice); staff standing over residents while assisting them to eat; staff interacting/conversing only with each other rather than with residents while assisting with meals.
On 3/4/24 at 12:03 PM V15 Certified Nursing Assistant was standing while feeding R113 lunch in the dining room. R113 was sitting in a geriatric chair and other residents were present in the dining room. R113 had red beets smeared on R113's lips, chin, cheeks, and neck. V15 continued to spoon bites of pureed beets to R113's mouth and used the spoon to scrape excess food off of R113's lips. V15 did not wipe the beets off of R113's face/neck until 12:10 PM when all of the beets had been given.
R113's Minimum Data Set, dated [DATE] documents R113 has cognitive impairment and is dependent on staff for eating assistance.
On 3/5/24 at 9:26 AM V38 Memory Care Director stated staff should sit while feeding residents and they should not be using a spoon to scrape food off the resident's lips. V38 confirmed it is not dignified for a resident to have food on their face and neck, for staff to use a spoon to scrap food off a resident's lips, or for staff to stand while feeding a resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0551
(Tag F0551)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who is cognitively impaired was prov...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who is cognitively impaired was provided a health care surrogate. This failure affects one resident (R7) reviewed for resident representative in a sample list of 54.
Findings Include:
R7'2 Order Summary printed 3/6/24 includes the following diagnoses: Altered Mental Status, Pseudobulbar Affect, Moderate Intellectual Disability, Intermittent Explosive Disorder, Downs Syndrome, Generalized Anxiety Disorder, Restlessness, Agitation, Seizures, Conduct Disorder, and Dementia. This summary documents R7's admission date as 12/21/21.
R7's Minimum Data Set (MDS) dated [DATE] documents R7 is severely cognitively impaired.
R7's Care Plan revised 9/14/23 documents (R7) has explosive mood disorder & delusional disorder with behaviors of angry outburst & tearful episodes requiring meds. (R7) has impaired cognitive function or impaired thought processes related to altered mental status, moderate intellectual disability. (R7) has out burst verbal behaviors cursing & yelling. (R7) has a communication problem related to moderate intellectual disability. (R7) has impaired visual function related to diagnosis of Mental Retardation, Seizure disorder, and Glaucoma. (R7) has a behavior problem related to diagnosis of delusional thoughts and Anxiety; excessive noise triggers episodes of yelling.
(R7) has episodes where (R7) repetitively hits self in the head/face, banging head on the side rails and is inconsolable (R7) has a history of suicidal ideation. (R7) has a history of throwing food on the wall. (R7) has a history of eating paper napkins/Kleenex.
R7's Face Sheet printed 3/6/24 does not include a resident representative, guardian, or any other health care surrogate for R7.
On 3/3/24 at 9:30AM R7 was observed in her room sitting up in a reclining geriatric chair crying and screaming Help me mommy. R7 did not respond to verbal stimuli. R7's roommate spoke to R7. R7 continues to cry and scream and did not respond. At 12:00PM R7 was in the dining room continuing to scream and cry. R7 was not responding to verbal stimuli from staff.
On 3/4/24 at 2:00PM V2, Director of Nursing stated (R7) cries and shouts out almost all the time. (R7) is developmentally delayed and isn't cognitively intact.
On 3/4/24 at 3:00PM V6, Social Services Director stated (R7) can't make decisions and has behaviors. (R7) does not have family or friends available to represent (R7). We (the facility are looking into getting (R7) a state guardian.
On 3/6/24 at 2:00PM V3, Regional Nurse Consultant stated the facility does not have a policy for designating health care surrogates or resident representatives.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain the signature of resident representative for a cognitively im...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain the signature of resident representative for a cognitively impaired resident on a Do Not Resuscitate order for one resident (R7) of five residents reviewed for Physician's Orders for Life Sustaining Treatment (POLST) in a sample list of 54.
Findings Include:
R7'2 Order Summary printed [DATE] includes the following diagnoses: Altered Mental Status, Pseudobulbar Affect, Moderate Intellectual Disability, Intermittent Explosive Disorder, Downs Syndrome, Generalized Anxiety Disorder, Restlessness, Agitation, Seizures, Conduct Disorder, and Dementia. This summary documents R7's admission date as [DATE]. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is severely cognitively impaired.
R7's Care Plan documents, (R7) is a full code. Attempt resuscitation, CPR, including intubation and mechanical ventilation. Date Initiated: [DATE]
R7's POLST form dated [DATE] documents R7 as Do Not Resuscitate Comfort focused treatment. The required resident/representative signature documents verbal consent with R7's name printed in and was electronically signed by V8, Nurse practitioner as the Qualified Health Practitioner.
On [DATE] at 2:26PM V8 stated, A Do Not Resuscitate order should not be signed by a practitioner until the form was signed by the resident or in the case of a cognitively impaired resident the representative.
The facility's policy Advanced Directives dated 3/2024 documents, If a resident or health care representative indicates an advanced directive regarding CPR (Cardiopulmonary Resuscitation) or Scope of treatment (POLST or POST form), the appropriate forms will be completed. A written physician's order is required in response to the resident's Advanced Directive(s) Physician's order will be specific and address each Advanced Directive. Advanced Directives will be included in the resident's plan of care and be reviewed during the Care Plan meeting with the resident and/or the resident's legal representative when present.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to prevent misappropriation of resident's property for one of one resident (R138) reviewed for misappropriation of medication in t...
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Based on observation, interview and record review the facility failed to prevent misappropriation of resident's property for one of one resident (R138) reviewed for misappropriation of medication in the sample list of 54.
Findings include:
The facility's Medication Administration Policy with a revised date of January/2015 documents, Medications must be administered in accordance with a physician's order, e.g. (example), the right resident, right medication, right dosage, right route, and right time. Medications supplied to one resident may not be administered to another resident.
R138's Physician's Orders document an order for Humalog Solution (Insulin Lispro) 100 units/ml (milliliters), inject per sliding scale with a start date of 2/16/24.
On 3/4/24 at 8:18 AM, V9 Licensed Practical Nurse removed R138's vial of Humalog from the medication cart and withdrew 5 units of Humalog and administered those 5 units to R2. V9 stated that V9 noticed the insulin was not R2's insulin but used it anyway. V9 confirmed R2 did not have a vial of Humalog in the medication cart.
On 3/6/24 at 11:47 AM, V2 Director of Nursing stated nurses should not use another resident's medication for a resident. V2 confirmed V9 should not have given R138's insulin to R2.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent a decline in Activities of Daily Living (ADLs) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent a decline in Activities of Daily Living (ADLs) for one of three residents (R19) reviewed for ADLs in the sample list of 54.
Findings include:
R19's Order Summary Report dated 3/4/24 documents diagnoses including Unilateral Osteoarthritis of the Right Knee, Presence of Left Artificial Knee Joint, Lymphedema, Weakness and Morbid Obesity and documents and admission date of 7/5/23.
R19's Minimum Data Set (MDS) dated [DATE] documents assistance needed for transfers, dressing, toileting and personal hygiene as limited assistance of one person and locomotion as extensive assistance of one person and bathing as physical help of one person. This MDS documents R19 did not receive any therapy and was receiving restorative exercises for bed mobility and dressing.
R19's MDS dated [DATE] documents R19 is dependent on staff for toileting, bathing, dressing and transfers and required substantial/maximal assistance (helper provides more than half of the effort. This MDS documents R19 did not receive any therapy and was receiving restorative exercises for bed mobility and dressing.
R19's MDS dated [DATE] documents R19 is dependent on staff for toileting, showers, dressing and transfers. This MDS documents R19 did not receive any therapy and did not receive any restorative exercises.
On 3/3/24 at 9:47 AM, R19 stated that R19 wants to be able to get up to go to the bathroom but is not able to get out of bed without the mechanical lift. R19 was lying in bed in R19's room watching television.
On 3/6/24 at 11:47 AM, V2 Director of Nursing stated they have not done anything to help prevent the decline in ADLs for R19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide dressing and shaving assistance for three (R70...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide dressing and shaving assistance for three (R70, R113, R94) of four residents reviewed for activities of daily living in the sample list of 54.
Findings include:
1.) On 3/3/24 at 9:46 AM and 12:10 PM, and on 3/5/24 at 10:25 AM R70 had long facial hair to cheeks, chin, lips and neck.
R70's Minimum Data Set (MDS) dated [DATE] documents R70 has cognitive impairment and is dependent on staff for bathing and personal hygiene. R70's Care Plan revised 6/13/23 documents R70 requires assistance of two staff for personal hygiene. R70's Behavior Tracking with date range 2/5/24-3/5/24 documents R70 had no behaviors.
R70's shower sheets dated 2/3/24, 2/5/24, 2/10/24, 2/14/24, 2/18/24, 2/22/24, 2/25/24, 2/26/24, 2/29/24, and 3/4/24 do not document shaving was provided as indicated on the form.
On 3/4/24 at 4:11 PM V40 (R70's Family) stated staff were afraid to shave R70 with a razor and V40 was going to get an electric razor for R70. V40 stated the staff was behind in shaving R70 and shaved R70 last week, but it had been quite long, and it was quite awhile since R70 was last shaved. V40 stated R70 always had a little facial hair on the chin and mustache, R70 preferred to be clean kept and trimmed and not all that facial hair.
On 3/5/24 at 9:26 AM V38 Memory Care Director stated residents should be shaved at least on shower days. V38 stated R70 fights the staff and the staff should be documenting this on R70's behavior tracking.
2.) On 3/3/24 at 9:46 AM, 3/4/24 at 11:14 AM, and 3/5/24 at 10:47 AM R113 had long facial hair on R113's face and neck.
R113's MDS dated [DATE] documents R113 has cognitive impairment and is dependent on staff for bathing and personal hygiene. R113's Care Plan revised 6/20/23 documents R113 requires assistance of one to two staff for personal hygiene.
R113's shower sheets dated 2/25/24 and 2/29/24 do not document shaving was provided as indicated on the form.
3.) On 3/3/24 at 12:06 PM R94 was sitting in the dining room. R94 was wearing a mint green colored shirt that had a stain on the right shoulder. On 3/4/24 at 11:13 AM R94 was sitting in the dining room wearing the same clothing as on 3/3/24.
R94's MDS dated [DATE] documents R94 has cognitive impairment and requires supervision/touching assistance for dressing.
On 3/4/24 at 11:18 AM V15 Certified Nursing Assistant stated R94 is cooperative with cares and R94 was already dressed this morning when V15 arrived for work. V15 stated V15 planned to change R94's clothes later today after R94's shower. V38 Memory Care Director confirmed residents' clothing should be changed every morning and when soiled.
The facility's Morning Care (A.M. Care) policy revised January 2018 documents, Assist resident to get dressed as needed.
The facility's Clothing-Dressing policy revised November 2012 documents: Residents will be encouraged to change clothing daily or at regular intervals as often as needed to maintain a clean, attractive appearance and maintain dignity. Residents should wear clothing that is clean, and free of stains, rips and tears to maintain dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to transcribe hospital discharge orders and obtain laboratory results a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to transcribe hospital discharge orders and obtain laboratory results as ordered for two (R79, R60) of 28 residents reviewed for physician's orders in the sample list of 54.
Findings include:
The facility's Physician Orders-Entering and Processing policy revised January 2018 documents: Enter the order into the resident's chart under order tab and according to the instructions for the type of order that is received. Notify the resident's physician (if not the prescribing physician), for verification if applicable. Following a physician visit, a licensed nurse will check for any orders that require confirmation under Clinical>orders>pending orders. The orders will be confirmed by the nurse and the instructions for the order will be completed. Verbal and Telephone orders will be documented as such in the Electronic Medical Record.
1.) R79's Minimum Data Set, dated [DATE] documents R79 has cognitive impairment. R79's Nursing Note dated 2/21/2024 at 4:09 PM documents R79 complained of chest pain and shortness of breath and had vomited a dark substance twice. R79 was transported to the emergency room.
R79's After Visit Summary for hospital stay 2/21/24-2/24/24 documents vomiting as R79's admission diagnoses and includes orders to start taking Protonix (reduces stomach acid) 40 milligrams (mg) by mouth daily. This summary also includes orders to discontinue Naproxen 250 mg, Tramadol 50 mg, and Omeprazole 20 mg. There is no documentation that these orders were implemented or clarified with R79's physician prior to 3/5/24.
R79's March 2024 Medication Administration Record documents Naproxen 250 mg by mouth twice daily since 1/20/24, Omeprazole 20 mg by mouth daily since 10/19/23, and Tramadol 50 mg every six hours as needed since 2/14/24.
On 3/5/24 at 9:40 AM V18 Licensed Practical Nurse stated R79 returned from the hospital at the end of February. V18 stated V18 was working that evening, but R79 was readmitted on the previous shift. V18 stated the floor nurses are responsible for reviewing and transcribing the hospital discharge orders and if they are busy, they will ask V2 Director of Nursing to review them. V18 stated it should be documented in a nursing note if the orders were clarified. V18 reviewed R79's hospital discharge orders and confirmed R79's orders to discontinue Naproxen, Omeprazole, and Tramadol; and to start taking Protonix. V18 stated R79 still has orders for Omeprazole, Tramadol, and Naproxen, and V18 will have to follow up with the physician on R79's hospital discharge orders.
On 3/5/24 at 12:18 PM V2 stated the Care Plan Coordinator and Assistant Director of Nursing are responsible for following up on orders after residents are readmitted from the hospital.
On 3/5/24 at 2:26 PM V8 Nurse Practitioner reviewed R79's After Visit Summary. V8 stated Naproxen, Omeprazole, and Tramadol were R79's prior medications, and confirmed Naproxen can contribute to stomach upset/vomiting. V8 stated V8 has not yet evaluated these medication orders/changes for R79. 2.) R60's Order Summary Report dated 3/4/24 documents diagnoses including Vitamin D Deficiency, Anemia, Dysthymic Disorder, Abnormal Weight Loss, Type 2 Diabetes, Chronic Kidney Disease, Moderate Protein-Calorie Malnutrition and Acute Cough.
R60's Progress Note by V42 Nurse Practitioner dated 11/29/23 documents R60's WBC (White Blood Cell) count was elevated on 11/22/23 and orders to repeat a CBC (Complete Blood Count) to monitor and report if it remains elevated.
On 3/5/24 at 10:45 AM, V3 Regional Nurse Consultant stated V42 did not know the process for ordering laboratory work. V3 stated V42 was not the facility's regular Nurse Practitioner and did not put the order for the laboratory work in the computer and did not notify any nurses that this blood work needed be completed, therefore it did not get done. V3 confirmed the laboratory work did not get completed in November when it was ordered but confirmed it did get completed in February.
On 3/6/24 at 11:47 AM, V2 Director of Nursing stated labs (laboratory work) should be completed when ordered by a Physician or Nurse Practitioner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify a pressure ulcer, implement pressure relievin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify a pressure ulcer, implement pressure relieving interventions, develop a pressure ulcer care plan, report pressure ulcers to the physician upon identification and wound decline, and routinely assess pressure ulcers for one (R113) of five residents reviewed for pressure ulcers in the sample list of 54.
Findings include:
The facility's Pressure Ulcer Prevention policy dated January 2018 documents: Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. Specialty mattresses such as low air loss, alternating pressure, etc. (etcetera) may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds. Use pressure reducing pads in chairs (all types) to protect bony prominences for residents identified as Moderate/High/Severe Risk.
The facility's Pressure Injury and Skin Condition assessment dated [DATE] documents: A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by license nurse. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA (Certified Nursing Assistant). Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. Care givers are responsible for promptly notifying the charge nurse of skin breakdown. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. Pressure injuries and other ulcers (arterial, diabetic, venous) will be measured at least weekly and recorded in centimeters in the resident's clinical record. A wound assessment for each identified open area will be completed and will include: a. site location b. size (length x width x depth) c. Stage of Pressure ulcer d. Odor e. Drainage f. Description g. Date and initials of the individual performing the assessment. When there are weekly changes which require physician and responsible party notification, documentation of findings will be made in the clinical record. Physician and responsible party notification will be documented in the clinical record. These changes include but are not limited to: a. new onset of purulent drainage b. new onset of odor c. cellulitis d. increased pain related to wound e. significant increase in wound measurements f. onset of new ulcers. The resident's care plan will be revised as appropriate, to reflect altercation of skin integrity, approaches and goals for care.
R113's Minimum Data Set, dated [DATE] documents R113 has cognitive impairment, has no pressure ulcers, is frequently incontinent of bladder, frequently incontinent of bowels, and dependent on staff for bed mobility, toileting, and transfers.
R113's Physician Order dated 2/18/24 documents to cleanse coccyx wound with wound cleanser, apply calcium alginate, and cover with foam daily and as needed. There are no treatment orders for this wound prior to 2/18/24.
R113's Care Plan dated 5/31/23 documents R113 is at risk for skin impairment related to fragile skin, incontinence, and behaviors, and includes interventions to assess and record changes in skin and report changes to the physician. R113's care plan has not been updated since 5/31/23 to include any new pressure relieving interventions and R113's pressure ulcer.
R113's shower sheet dated 2/10/24 documents the coccyx area is circled, indicating abnormal skin. There are no other descriptions or assessments of these areas in R113's medical record prior to 2/21/24, and no documentation that the physician was notified prior to 2/17/24 when treatment orders were implemented. There is no documentation that the physician was notified of the second wound identified on 2/21/24.
R113's Weekly Skin Observation Note dated 2/21/24 at 11:09 PM documents Excoriation/Denuded Skin, 2 areas right buttock. Located to Right buttock - 2 cm (centimeters) X (by) 2 cm. Treatments include. Resident does not complain of pain, interventions include, No new skin concern or change in skin condition that required the md notification, MD was notified of new condition - family was notified of new condition - New orders received: Care plan reviewed. There are no other documented wound assessments besides this note in R113's medical record.
R113 is not included on the facility's February 2024 wound log.
On 3/3/24 at 12:22 PM V43 LPN stated R113 has a pressure ulcer on R113's buttocks that developed at the facility a month or two ago, and R113 is on hospice care.
On 3/5/24 at 8:45 AM R113 was sitting in a geriatric chair in the dining room. At 9:24 AM, 9:35 AM and 10:32 AM R113 was sitting in a geriatric chair in R113's room.
On 3/5/24 at 10:45 AM V15 Certified Nursing Assistant (CNA) stated R113 was already up in the geriatric chair when V15 came on shift this morning and R113 does not lay down until after lunch. V15 stated we recline R113's geriatric chair and R113 has not laid down yet this shift. Between 10:47 AM and 11:05 AM V15 and V16 CNA entered R113's room and transferred R113 from the geriatric chair into bed with a full mechanical lift so V18 could administer R113's pressure ulcer treatment. R113 did not have a pressure relieving mattress on R113's bed and R113's geriatric chair had a thin, built in seat cushion. V16 stated R113 was last provided incontinence cares around 7:00 AM when R113 was gotten up by night shift. V18 Licensed Practical Nurse entered R113's room and removed a dressing containing bloody drainage from R113's coccyx. There were two circular, open, red wounds. The wound to the top left coccyx contained black tissue. V18 stated the black area was newly identified by V18 last Thursday (2/29/24), and the wounds have gotten larger since they were first identified. V18 cleansed the wounds, applied calcium alginate and covered with a bordered foam dressing. V15 and V16 stated R113's pressure relieving interventions include turning and repositioning every two hours, use of wedge cushion, and pillow placed between legs. V15 stated R113 is kept up in the chair due to acid reflux. V18 stated V18 did not document assessments of the wounds last week when V18 noted changes in the wound. V18 stated V18 passed on the information to the oncoming dayshift nurse and did not notify the physician or V26 Wound Nurse. V18 stated if the oncoming nurse followed up with the physician, it would be documented in a nursing note. V18 stated to check with V26, but V18 tells the staff to check and reposition R113 every one to two hours and that they don't' have to wait for the two hour time frame. V18 stated R113 should be laid down between meals.
On 3/5/24 at 11:38 AM V26 Wound Nurse stated residents with coccyx pressure ulcers should be repositioned from side to side every 2 hours to offload wound pressure and referred to V44 Wound Doctor who determines additional recommendations such as an air mattress. V26 stated R113 has not been evaluated by V44 and V26 was not aware that R113 had pressure ulcers. V26 stated wounds should be reported to the physician when identified and when there is a decline in the wound. V26 confirmed there are no documented pressure ulcer assessments for R113's pressure ulcers. V26 stated the floor nurses in the North Building (where R113 resides) are supposed to document and assess wounds weekly and report to V26. V26 stated if V26 had been notified V26 would have had V44 see R113, implement the two hour repositioning, and V44 would have determined R113 needed a low air loss mattress. V26 stated we utilize pressure relieving wheelchair cushions and the same type of cushions can be used in the geriatric chairs. V26 confirmed sitting in a geriatric chair is not relieving pressure off of R113's coccyx wound. V26 stated V26 and V41 Care Plan Coordinator are responsible for updating the care plans with pressure ulcers once they are notified. V26 stated V44 is responsible for staging the wounds and V26 will have V44 see R113 today.
On 3/6/24 at 10:34 AM V28 Hospice Director of Nursing stated R113 had one coccyx pressure ulcer that was Stage 3 and present on admission to hospice on 2/17/24 and confirmed R113 did not have two coccyx wounds at that time. V28 stated the skilled nursing facility is responsible for providing the wound care and assessments, and hospice will observe when able. V28 stated the facility can consult with hospice about wound care as needed, but typically the resident is seen by the facility's wound physician. V28 stated there were no specialized pressure relieving equipment ordered or requested by the facility for R113 upon hospice admission. V28 stated it is up to the facility to determine what equipment is needed for the resident and notify hospice of those needs.
On 3/6/24 at 10:11 AM V20 Interim [NAME] President of Clinical Operations provided R113's hospice wound documentation and V44's Wound Evaluation. V20 confirmed these hospices wound notes had to be obtained and were not part of R113's electronic medical record. V20 stated we ordered an alternating pressure mattress and pressure relieving cushion for R113's geriatric chair from hospice today, and updated R113's care plan.
R113's Hospice Wound Assessment Tool Report dated 2/17/24 at 6:15 PM documents R113's coccyx stage 3 pressure ulcer measured 3 cm by 3 cm by 0.2 cm and there was no necrotic tissue visible. R113's Initial Wound Evaluation & Management Summary recorded by V44 and dated 3/5/24 documents R113's Sacral Unstageable Deep Tissue Injury of undetermined thickness measures 1.7 cm long by 1.5 cm wide and the Right Medial Buttock Stage 3 Pressure Ulcer measures 0.6 cm by 0.5 cm by 0.1 cm. The treatment was to apply calcium alginate and cover with a bordered foam dressing three times weekly and as needed. V44 recommended a low air loss mattress and repositioning per facility protocol.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to safely transfer one (R131) of three residents reviewed for accidents from a total sample list of 54 residents reviewed.
Findings include:
Th...
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Based on interview and record review the facility failed to safely transfer one (R131) of three residents reviewed for accidents from a total sample list of 54 residents reviewed.
Findings include:
The facility Transfer policy dated 8/2023 documents that in order to protect the safety and well-being of the staff and residents and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents who require a two person assist and a gait belt will be used with all physical transfers.
R131's undated diagnoses sheet documents: Contusion of Left Lower Leg (facility acquired), Weakness, Polymyositis, Acute Cholecystitis, Diabetes Mellitus, Malnutrition, Skin Cancer and Depression.
R131's 1/11/24 Minimum Data Set documents that R131 is cognitively intact.
1.) R131's progress notes dated 10/9/23 document an injury to R131's left leg during a transfer on 10/6/24.
R131's emergency room notes dated 10/11/23 document that on approximately 10/6/23, R131 was being transferred from a bed to a chair at the facility where an accident occurred, and she sustained a contusion to her left leg.
On 3/6/24 at 1:20PM, R131 said she was transferred, and her left leg was injured. R131 said, (V35 Certified Nursing Assistant CNA) and another unknown (CNA) transferred me from the bed to the shower chair and they wanted me to turn and as I was turning, I heard a crack and screamed in pain. (V35 CNA) held me while the other CNA abandoned us.
On 3/5/24 at 2:00pm, V3 Regional Nurse Consultant said she would expect there to be documentation of the injury and of the subsequent training and follow up that was completed at the facility and that no injury would come to a resident during transfer.
2.) R131's progress notes dated 1/31/24 document a complaint regarding V34 CNA and V36 CNA while transferring R131.
R131's final investigation to the Illinois Department of Public Health dated 2/7/24 documents R131 felt the staff were being careless and caused the mechanical lift to hit her lower extremity. This incident was corroborated by R131's roommate and by V34 CNA. V34 CNA was re-educated on transfers and V36 CNA was terminated.
On 3/5/24 at 10:30AM, R131 stated, The two CNAs who transferred me badly most recently just weren't careful. They didn't move my bed so that the lift would work right and when I complained, they said that they couldn't help but hit my leg.
On 3/6/24 at 11:45AM, V27 Shift Coordinator/CNA said that when (R131) got hurt in the last transfer, We had education in-services after that. (V36 CNA) was let go and (V34 CNA) was in serviced.
On 3/6/24 at 2:00PM, V3 Regional Nurse Consultant said no information or education regarding this incident could be located.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to maintain a suprapubic catheter in a safe sanitary manner for one resident (R92) of three residents reviewed for catheter care ...
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Based on observation, interview, and record review the facility failed to maintain a suprapubic catheter in a safe sanitary manner for one resident (R92) of three residents reviewed for catheter care in a sample list of 54.
Findings Include:
R92's Care Plan revised 1/29/24 documents, (R92) has a suprapubic catheter and history of recurrent Urinary Tract Infections, (UTI) is at risk for infection (UTI) related to complex Catheterization/Rectourethral fistula with colostomy placement. (R92) empties own urine without telling staff. (R92) has a diagnosis of obstructive uropathy. (R92) has times of pulling out catheter. (R92) removes dignity bag at times. (R92) moves catheter himself above the level of the bladder, even after education. Date Initiated: 03/25/2021
On 3/3/24 at 10:05AM V37, Certified Nurse's Aide was changing R92's pants and incontinence brief. R92 was sitting on the edge of the bed. As V37 pulled up R92's brief the catheter tubing fell to the floor. Red fluid was noted in R92's catheter tubing. As V37 continued to pull up R92's brief, the catheter bag fell to the floor. V37 then lifted the catheter bag above the level of R92's bladder and placed the bag on top of the bed sheet. R92's catheter tubing was not secured to R92's leg to prevent torsion of the tubing. When V37 was asked if the bag and tubing should be on the floor or if the bag should be lifted above the level of R92's bladder V37 stated, No it should not, but sometimes he does that himself. I should have made sure the bag was not on the floor.
On 3/3/24 V2, Director of Nursing confirmed a catheter bag or tubing should not be on the floor.
The facility's policy Urinary Catheter Care dated /2024 states Indwelling Catheters may be secured to prevent trauma or tension. Catheters shall be positioned to maintain a downhill flow of urine to prevent a back flow of urine into the into the bladder or tubing, during transfer, ambulation, and body positioning. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor directly. May place drainage bag and excess tubing in secondary vinyl bag or similar device to prevent primary contact with the floor or other surfaces.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to check placement, with gastric residual, of a Gastrostomy tube prior to medication administration and prior to restarting a Gast...
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Based on observation, interview and record review the facility failed to check placement, with gastric residual, of a Gastrostomy tube prior to medication administration and prior to restarting a Gastrostomy feeding for one of two residents (R97) reviewed for Gastrostomy tube in the sample list 54.
Findings include:
R97's electronic diagnosis list documents diagnoses including Unspecified Protein-Calorie Malnutrition, Dysphasia, Encephalopathy and Fibromyalgia.
R97's Medication Administration Record (MAR) dated 3/1/24 through 3/31/24 documents orders for Enteral Feeding every shift for supplement related to Unspecified Protein Calorie Malnutrition, Glucerna 1.2 at 75 ml (milliliters)/hr. (hour) continuous with a start date of 12/27/23. This MAR documents an order to check residuals before beginning a feeding and before medication administration, if greater than 100 ml hold feeding for one hour and recheck, if not resolved contact the Physician with a start date of 9/14/23. This MAR also documents an order for every shift to check tube placement before feeding, flushes and medications with a start date of 9/14/23.
On 3/5/24 at 11:53 AM, V9 Licensed Practical Nurse removed one capsule of Gabapentin 300 mg (milligrams) from R97's medication card and placed in a small cup. V9 washed her hands and obtained water from the bathroom faucet. V9 paused the feeding pump and located the connection. V9 opened the Gabapentin capsule and dumped the contents into the cup and dumped some water into the cup with the capsule contents. V9 placed a large syringe in the Gastrostomy tube connection and poured water into the syringe and pushed the water in with the plunger. V9 stated that R97 gets flushed with 150 mls. of water. V9 then withdrew some of the diluted medication into the syringe and pushed it into the Gastrostomy tube and then withdrew the remaining diluted medication in the syringe and pushed it into the Gastrostomy tube and then poured the remaining water into the Gastrostomy tube. Then V9 reconnected the feeding pump and restarted the feeding pump. At no point did V9 check placement of the feeding tube, not prior to flushing, not prior to medication administration and not prior to restarting the feeding.
On 3/3/24 at 11:20 AM, V45, R97's spouse stated that R97 has lost weight since being at this facility. At this time R97's feeding tube was leaking onto the floor from the disconnected feeding tubing. V45 left the room to get the nurse. On 3/3/24 at 11:25 AM, Nurses V9 LPN and V5 MDS (Minimum Data Set) LPN came into the room to reattach the tubing. V9 LPN obtained 50 mls of water and flushed the tubing and without checking for placement of the Gastrostomy tube, pushed the water into the tube and then reattached the continuous tube feeding.
On 3/6/24 at 11:47 AM, V2 Director of Nursing stated that nurses should check Gastrostomy tube placement prior to medication administration and prior to starting/restarting the feeding pump.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to administer medications in accordance with Physician's Orders and manufacturer's recommendations for two of five residents (R2, ...
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Based on observation, interview and record review the facility failed to administer medications in accordance with Physician's Orders and manufacturer's recommendations for two of five residents (R2, R112) reviewed for medication administration in the sample list of 54. The facility had 2 medication errors out of 27 opportunities resulting in a 7.41% medication error rate.
Findings include:
The facility's Medication Administration Policy with a revised date of January/2015 documents, Medications must be administered in accordance with a physician's order, e.g. (example), the right resident, right medication, right dosage, right route, and right time. Medications supplied to one resident may not be administered to another resident. Labels that do not contain the correct order, correct name of the resident, and/or correct name of the resident's physician should be returned to the pharmacy for relabeling.
1.) R2's Physician's Orders document orders for Humalog Kwik Pen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 5 units subcutaneously three times a day related to Type 2 Diabetes Mellitus with Hyperglycemia with a start date of 1/28/24.
On 3/4/24 at 8:18 AM, V9 Licensed Practical Nurse removed a vial Insulin Lispro with R138's name on it and withdrew 5 units from R138's vial. V9 administered the insulin to R2 in the lower abdomen. V9 confirmed that V9 gave R2 another resident's insulin and confirmed that it was R138's insulin she administered to R2.
2.) R112's Physician's Orders document an order for Calcium 600 mg (milligram) tablet by mouth every day for Bone Health with a start date of 12/28/23.
On 3/5/24 at 8:42 AM, V11 Licensed Practical Nurse removed one tablet from a bottle labeled Calcium 600 mg with Vitamin D 10 mcg (micrograms) (400 IU {international units}) and administered it to R112 with his other medications whole with water.
On 3/6/24 at 11:47 AM, V2 Director of Nursing stated the nurses should not give one resident's medication to another resident and the nurse should follow the Physician's Orders for strength of the stock medications given.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to remove a roommate from an isolation room for two of two residents (R58, R60) reviewed for Infection Control in the sample list ...
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Based on observation, interview and record review the facility failed to remove a roommate from an isolation room for two of two residents (R58, R60) reviewed for Infection Control in the sample list of 54.
Findings include:
The facility's Infection Precaution Guidelines policy with a revised date of January/2018 documents, Transmission-Based Precautions will be employed for known or suspected infections for which the route of transmission/prevention is known. The transmission-based categories are the following: Airborne, Droplet, Contact. Private room is preferred. When a private room is not available, place the resident in a room with another resident with the same infection, but with no other infection (cohorting).
R60's Nurse's Notes dated 2/28/24 documents that a CNA (Certified Nursing Assistant) notified the nurse to assess a rash found on R60's body. This note documents the Nurse Practitioner was notified. R60's Nurse's Note dated 2/2/9/24 at 5:21 PM documents an order was received for Acyclovir HCL (hydrochloride) (antiviral) 500 mg (milligrams) three times a day for Shingles for 7 days, give two tablets (1,000 mg).
R60's Nurse's Notes dated 3/1/24 at 8:04 AM documents R60 is on isolation precautions for skin.
R60's Medication Administration Record/Treatment Administration Record dated 3/1/24 through 3/31/24 documents an order for Contact Isolation precautions related to Zoster without complications with a start date of 3/3/24.
On 3/3/24 at 10:30 AM, both residents R60 and R58 were in the contact isolation room.
On 3/03/24 at 12:11 PM, staff were moving R58 out of her room. V46 (Licensed Practical Nurse) stated staff are moving (R58) because her roommate has shingles.
On 3/3/24 at 12:21 PM V47 Housekeeper stated R58 was being moved to a different hallway because V49 housekeeping supervisor told them to do it.
On 3/03/24 at 12:35 PM, V47 Housekeeper and V48 Housekeeper were in R58's room getting R58 ready to move without any Personal Protective Equipment on. They pushed R58's bed out of the room and down the hall with R58 in the bed.
On 3/03/24 at 12:21 PM, V49 Housekeeping Supervisor stated that V2 Director of Nursing instructed her to have R58 moved to a different room because the R60 is on isolation. V49 Housekeeping Supervisor stated she thinks R58 has been in isolation for a few days.
On 3/3/24 at 12:25 PM, V2 Director of Nursing stated R58's roommate has shingles. R60 (R58's roommate) was diagnosed last Thursday, 4 days ago. V2 Director of Nursing stated they reviewed the policy this morning and decided that they should move R58 out of the isolation room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain signed refusal of Flu vaccine for two residents (R7 and R92) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain signed refusal of Flu vaccine for two residents (R7 and R92) of five residents reviewed for immunizations in a sample list of 54.
Findings include:
R7's Minimum Data Set (MDS) dated [DATE] documents R7 has not received a flu immunization since 11/3/22. No rationale for omission of this immunization is documented. R7 electronic medical Immunizations record for 2023 flu season documents, Flu Consent refused No signed refusal is documented for R7.
R92 's Minimum Data Set (MDS) dated [DATE] documents R92 has not received a flu immunization since 11/3/22. No rationale for omission of this immunization is documented. R92's electronic medical Immunizations record for 2023 flu season documents, Flu Consent refused. No signed refusal is documented for R92.
On 3/6/24 at 2:30PM V3, Regional Nurse Consultant stated, I have looked through all the consent forms for this flu season and I cannot locate ones for (R7) or (R92).
The Infection Control policy provided by the facility does not address vaccines.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility repeatedly failed to provide written notifications of bed hold for one (R79) o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility repeatedly failed to provide written notifications of bed hold for one (R79) of two residents reviewed for hospitalizations in the sample list of 54.
Findings include:
The facility's Bed Hold and Return to Facility policy revised October 2021 documents: The facility's bed-hold policies apply to all residents. The facility bed hold policy will be given to the resident and/or resident representative as follows: Upon admission to the facility. At the time of a transfer from the facility; In cases of emergency transfer, notice at the time of transfer means that the family, surrogate, or representative are provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital.
R79's on-going census log documents R79 was hospitalized on [DATE], 1/22/24, 2/10/24, 2/21/24 and 2/21/24. There is no documentation in R79's medical record that a written notification of bed hold was provided for each of these hospital transfers. R79's Minimum Data Set, dated [DATE] documents R79 has cognitive impairment.
On 3/5/26 at 9:26 AM V38 Memory Care Director stated the nurses are responsible for sending the bed hold notices. V38 stated V38 thinks the bed hold notices are uploaded into the resident's electronic medical record but would need to check with V21 Assistant Administrator.
On 3/5/24 at 12:16 PM V20 Interim [NAME] President of Clinical Services stated V20 was not able locate written notifications of bed hold for R79's hospital transfers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R13's Care Plan revised 7/12/23 documents R13 has dementia and has behaviors of hiding personal belongings and wandering. R1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R13's Care Plan revised 7/12/23 documents R13 has dementia and has behaviors of hiding personal belongings and wandering. R13's Care Plan documents R13 receives antipsychotic medications related to dementia and does not identify the specific behaviors that justify the use of this medication. There is no documentation that R13 has a psychiatric diagnosis.
R13's Physician Order dated 9/19/23 documents to administer Quetiapine Fumarate (antipsychotic) 25 milligrams (mg) by mouth daily at bedtime for unspecified dementia without behavioral disturbance. R13's Psychotropic Medication Observation dated 2/28/24 documents a review of R13's psychotropic medications including Quetiapine but does not identify specific behaviors to justify the use of this medication or nonpharmacological interventions used to respond to these behaviors.
R13's January-March 2024 Behavior Tracking does not identify specific targeted behaviors and nonpharmacological interventions to respond to the R13's specific behaviors. This tracking is generic and lists a variety of behaviors and nonpharmacological interventions to select. The only documented behaviors on these tracking forms are on 1/28/24 at 1:48 PM for elopement/exit seeking and wandering, and on 1/25/24 at 11:18 PM for expressing frustration/anger at others, agitation, and wandering. Both document the intervention response of redirection and R13's behavior improved.
On 3/4/24 at 12:31 PM V15 Certified Nursing Assistant (CNA) stated, Oh my gosh (R13) does not have any behaviors. V18 Licensed Practical Nurse stated R13 looks for R13's spouse in the evening and is easily redirected.
On 3/5/24 at 9:06 AM V21 Assistant Administrator confirmed V21 oversees psychotropic medication monitoring for the memory care unit. V21 stated R13 has agitation that comes with frustration from dementia. V21 was asked what behaviors R13 has to justify antipsychotic medication use. V21 stated R13 paces, gets anxious and looks for R13's spouse. V21 confirmed these behaviors and specific nonpharmacological intervention responses are not documented on R13's psychotropic medication assessments, care plans, and behavior tracking.
5.) R79's Minimum Data Set, dated [DATE] documents R79 has cognitive impairment, had behaviors of wandering 1-3 days during the review period, and takes antipsychotic medication that has not had a gradual dose reduction (GDR) attempted. R79's Care Plan revised 11/21/23 documents R79 has impaired cognition related to dementia and has crying outbursts. R79's Care Plan revised 11/9/23 documents R79 receives antipsychotic medication related to dementia. R79's Care Plan documents R79 has a history of self-harming ideations and R79 has not voiced this since R79's admission.
R79's Psychiatry Note dated 2/6/24 documents R79's diagnoses include Psychotic Disorder with delusions, Bipolar Affective Disorder, Anxiety Disorder, and Moderate Dementia with Psychotic Disturbance. This note documents prior to admission R79 was living with family and was sent to the emergency room for hallucinations and suicidal ideation. R79 was transferred to an extended care facility and returned to the emergency room eight hours later for aggression and going into another resident's room. R79 was transferred to a behavioral hospital and then discharged to this facility.
R79's Physician Order dated 10/25/23 documents to administer Zoloft (antidepressant) 50 mg by mouth daily due to anxiety disorder. R79's Physician Order dated 11/22/23 documents to give Quetiapine Fumarate 50 mg by mouth twice daily for unspecified dementia with behavioral disturbances. R79's Psychotropic Medication Observation dated 2/10/24 documents no reduction for Quetiapine and does document R79's specific targeted behaviors and nonpharmacological interventions.
R79's January-March 2024 Behavior Tracking does not identify specific targeted behaviors and nonpharmacological interventions. This tracking is generic and lists a variety of behaviors and nonpharmacological interventions to select. These tracking reports document that R79 has not had any behaviors between 1/1/24 and 3/5/24.
On 3/4/24 at 12:58 PM V15 CNA stated R79 does not have any behaviors other than R79 does not like when R79's family doesn't answer R79's telephone calls.
On 3/5/24 at 9:14 AM V21 Assistant Administrator stated R79 admitted from a behavioral hospital and has not had a Quetiapine GDR attempted. V21 stated behaviors are documented by the CNAs in the behavior tracking. V21 stated R79's behaviors are being restless and looking for R79's family. V21 confirmed R79's targeted behaviors and specific nonpharmacological interventions/responses to these behaviors are not identified on R79's psychotropic assessments, behavior tracking, and care plan.
Based on interview and record review the facility failed to identify specific targeted behaviors/interventions and attempt nonpharmacological interventions for five residents (R8, R57, R62, R13, R79) of six residents reviewed for psychotropic medication in a sample list of 54.
Findings include:
The facility's policy Behavioral Health Services Program dated 2/2024 states, The facility will attempt to identify, to the extent possible, any previous history of mental illness, trauma, abuse, substance abuse, comorbidities, pattern of behaviors, preferences, interest, daily routines, medication use and effective behavior management interventions in developing an individual plan of care. The Care Plan should include well defined problem statement and should outline goals of care. It should include measurable objectives and timetables for individualized interventions. It should also identify the responsibilities of various staff to implement the approaches effectively.
1.) R8's Medication Administration Record MAR for March 1,2024 to March 31, 2024 includes orders for the following psychotropic medication: 1. Zolpidem Tartrate (hypnotic) Oral Tablet 5 MG (Milligrams) by mouth at bedtime. 2. Mirtazapine (Antidepressant) Tablet 45 MG 1 tablet by mouth at bedtime. 3. Quetiapine Fumarate (Antipsychotic) Oral Tablet 100 MG by mouth at bedtime. 4. Quetiapine Fumarate (Antipsychotic) Oral Tablet 25 MG by mouth at bedtime. 5. Imipramine HCl (Anti-depressant) Oral Tablet 25 MG by mouth|| at bedtime.
No specific targeted behavior is documented as identified for R8's medications. Nonpharmacological interventions are not documented for R8's medication.
2.) R57's 1. Clozapine (Antipsychotic) Oral Tablet 225MG (Milligrams) via Gastrostomy-Tube (G-tube) in the evening.
No specific targeted behavior is documented as identified for R57's medications. Nonpharmacological interventions are not documented for R57's medication.
3.) R62's Medication Administration Record MAR for March 1,2024 to March 31, 2024 includes orders for the following psychotropic medication: 1. Depakote (neuroleptic)Oral Tablet Delayed Release 250 MG (milligrams) by mouth two times a day 2. Escitalopram Oxalate (antidepressant) Oral Tablet 20 MG by mouth one time a day. 3. Risperidone (antipsychotic) Tablet 0.5 MG by mouth at bedtime 4. Olanzapine (antipsychotic) Oral Tablet 10 MG by mouth every 6 hours as needed.
No specific targeted behavior is documented as identified for R62's medications. Nonpharmacological interventions are not documented for R62's medication.
On 3/4/24 V2, Director of Nursing verified the facility utilizes the same list of possible behaviors and interventions and does not specify resident centered targeted behaviors and interventions for resident's using psychotropic medications. V2 stated We use the list (the documentation system) gives us.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to label insulin upon opening (R114, R30), failed to ensure insulin was labeled with resident's name, failed to secure medications...
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Based on observation, interview and record review the facility failed to label insulin upon opening (R114, R30), failed to ensure insulin was labeled with resident's name, failed to secure medications, and failed to ensure that a resident's medication card had the correct label with the correct dosage of medication (R97) for three of three residents reviewed for medication storage in the sample list of 54.
Findings include:
The facility's Medication Administration Policy with a revised date of January/2015 documents, Labels that do not contain the correct order, correct name of the resident, and/or correct name of the resident's physician should be returned to the pharmacy for relabeling.
The facility's Medication Storage policy with a revised date of July/2019 documents, Facility should ensure that medication and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart of locked mediation room that is inaccessible by resident and visitors. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened.
1.) R30's Physician's Orders document an order for Levemir Subcutaneous Solution 100 units/ml (milliliters), inject 2 units subcutaneous with a start date of 6/11/23.
On 3/3/24 at 12:11 PM, V46 Licensed Practical Nurse (LPN) withdrew 2 units of Levemir solution from a vial with R30's name on it. This vial of Levemir had no open date labeled on it. After injecting the Levemir into R30's arm V46 confirmed there was no open date labeled on the vial.
R114's Physician's Order document an order for Basaglar Kwik pen Solution 100 unit/ml, inject 45 units subcutaneous with a start date of 12/16/22. On 3/4/24 at 9:00 AM R114's Basaglar was in the medication cart, opened and used and had no open date labeled on it. V9 LPN confirmed that R114's Basaglar had no open date written on it.
2.) On 3/6/24 at 9:15 AM, there was an unattended medication cart in the East hallway. On top of the medication cart was a bottle of Aspirin 81 mg (milligrams) and the label stated 36 tablets and a bottle of Aspirin Adult Low Dose 81 mg and the bottle documents 300 tablets. Both bottles had tablets in them upon shaking them. V11 LPN came out of a resident's room and walked to the medication cart. V11 confirmed there were two bottles of Aspirin on the medication cart. V11 stated that she just got them out of the medication room and set them on the cart to go give a resident medication. At this time V11 opened the medication cart for review. There was an opened and used vial of Lantus in the top drawer of the medication cart. There was no name on the label and V11 could not identify who the Lantus belonged to and confirmed there was no label on the vial.
3.) R97's Physician's Orders document an order for Gabapentin 300 mg one tablet and on via G-tube (Gastrostomy tube) with a start date of 1/10/24.
On 3/5/24 at 11:53 AM, V9 LPN removed R97's Gabapentin medication card from the medication cart and the card's label documents Gabapentin two capsules for 600 mg. V9 removed one capsule and administered it to R97.
R97's medical record documents the Gabapentin 600 mg was discontinued on 12/15/23 and changed to Gabapentin 300 mg.
On 3/5/24 at 1:08 PM, V9 stated they do not usually send the card back to the pharmacy when the order changes, they just use up what they have.
On 3/6/24 at 11:47 AM, V2 Director of Nursing stated that medications should not be left on top of the medication cart unattended, insulin should be labeled with the open date when it is opened. V2 stated that they do not usually get a new medication card from the pharmacy when the order changes.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to complete annual performance evaluations for three Certified Nursing Assistants (CNAs). This failure has the potential to affect all 139 resi...
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Based on interview and record review the facility failed to complete annual performance evaluations for three Certified Nursing Assistants (CNAs). This failure has the potential to affect all 139 residents residing in the facility.
Findings include:
V29's and V33's (CNAs) personnel files including performance evaluations were requested. The facility provided V29's Employee Job Performance Evaluation dated 2/10/22 and V33's Employee Job Performance Evaluation dated 11/11/22. There was no documentation provided that V29 and V33 had performance evaluations completed after 2022.
The facility's daily staffing sheets dated 2/20/24-3/3/24 document V29 and V33 worked in the facility.
On 3/5/24 at 3:37 PM V2 Director of Nursing stated CNA performance evaluations are completed annually. On 3/6/24 at 11:47 AM V2 confirmed V29 and V33 work in both buildings of the facility.
On 3/6/24 at 11:02 AM V23 Human Resources (HR) confirmed there are no documented performance evaluations for V29 and V33 after 2022. V24 Regional HR stated the facility may have stopped doing annual evaluations for CNAS due to pay raises. V24 stated V24 was not aware there is a regulation that annual performance evaluations for CNAs are required.
The Long-Term Care Facility Application for Medicare and Medicaid with survey date of 3/3/24-3/6/24 documents 139 residents reside in the facility.
The facility's Facility Assessment Tool dated 2/12/24 documents, Required in-service training for nurse aides. In-service training must: Address areas of weakness as determined in nurse aide's performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff.
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 F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 139 resid...
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Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 139 residents in the facility.
Findings include:
On 3/3/2024 at 8:45AM, V14 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V14 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V14 reported the facility dietician only works in the facility one day per month. V14 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V14 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course.
On 3/6/2024 at 2:00PM, V1 (Administrator) reported V14 (Dietary Manager) did not meet the qualifications of a Certified Dietary Manager.
The facility Long-Term Care Facility Application for Medicare and Medicaid (3/3/2024) documents 139 residents reside in the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility to prevent the potential for physical cross-contamination of residents' food. This failure has the potential to affect all 139 resident...
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Based on observation, interview, and record review, the facility to prevent the potential for physical cross-contamination of residents' food. This failure has the potential to affect all 139 residents in the facility.
Findings include:
On 3/3/2024 at 8:45AM, a can opener was mounted on a food preparation table located in the main kitchen. The opener was soiled with accumulations of metal shavings where the cutting blade contacts canned food items being opened. V14 (Dietary Manager) was present and removed the opener from the table to be cleaned and sanitized.
On 3/3/2024 at 10:05AM, a can opener was mounted on a food preparation table located in the facility satellite kitchen. The opener was soiled with accumulations of metal shavings and sticky food residue where the cutting blade contacts canned food items being opened. V25 was present and observed the can opener and stated, Oh yeah, they (dietary staff) probably need to wash that (the soiled can opener). V25 proceeded to remove the opener to be cleaned and sanitized.
The facility Long-Term Care Facility Application for Medicare and Medicaid (3/3/2024) documents 139 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
Based on interview and record review the facility failed to ensure the required Quality Assurance Performance Improvement (QAPI) meetings were being held quarterly and failed to ensure required member...
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Based on interview and record review the facility failed to ensure the required Quality Assurance Performance Improvement (QAPI) meetings were being held quarterly and failed to ensure required members attended quarterly QAPI meetings. This failure has the potential to affect all 139 residents residing in the facility.
Findings include:
The facility Quality Assurance Performance Improvement Program Policy dated 10/2022 documents that the purpose of the QAPI committee is to ensure organized quality assessment and improvement including performance measurement, assessment, improvement and can address the care and services provided by the facility. The committee will meet at least quarterly to assure activities are performed and identified problems have corrective actions taken or an appropriate action plan is developed. The committee members include the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Wound Care Nurse, Social Services Director, Activities Director, Dietary Manager, Housekeeping/Laundry Director, Maintenance Director, Human Resources Director, and Minimum Data Set Coordinator. Minutes, related reports, and attendance of the Committee Members shall be maintained on file in the Administrator's office.
The facility is unable to provide documentation that required quarterly QAPI meetings had been held during the first, second or third quarter of 2023.
The facility was unable to provide any documentation of attendance sheets for the third quarter of 2023 QAPI meetings.
On 3/5/24 at 3:39PM, V1 Administrator stated that he held a quality meeting on 2/29/24 and that the Medical Director did not attend and was not on teams or the telephone during the meeting.
On 3/6/24 at 8:45AM, V1 Administrator stated that he could not find quality meeting documentation for 2023.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to ensure Certified Nursing Assistants (CNAs) received 12 hours of annual in-service training. This failure has the potential to affect all 139...
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Based on interview and record review the facility failed to ensure Certified Nursing Assistants (CNAs) received 12 hours of annual in-service training. This failure has the potential to affect all 139 residents residing in the facility.
Findings include:
The facility's Facility Assessment Tool dated 2/12/24 documents the facility will provide required in-service training for nurse aides to ensure continuing competence including: at least 12 hours annually, dementia management training, and abuse training. This policy documents additional training will be provided based on identified areas of weakness that is determined by the nurse aide's performance review. This policy documents to consider the following, but not all inclusive list of competencies, which includes person-centered care, activities of daily living, disaster planning, infection control, vital signs, caring for persons with Alzheimer's/Dementia, catheter care, and caring for persons with mental and psychosocial disorders and history of trauma.
V30's, V31's, and V33's (CNAs) 12 hour annual in-service training was requested.
On 3/5/24 at 3:37 PM V2 Director of Nursing stated V2 thinks the facility uses an electronic system to provide and track the 12 hours of annual CNA training.
On 3/6/24 at 11:11 AM V20 Interim [NAME] President of Clinical Services provided the electronic training logs for V30, V31, and V33. V20 confirmed the training is incomplete for all the assigned courses. V20 stated the courses are assigned and are opened on April 1st of each year. V20 stated V20 is going to check the facility's all staff in-services to see if V20 can provide additional documentation of CNA training. V20 stated the all-staff in-services are typically an hour long.
The facility provided a stack of in-service sign in sheets with date ranges March 2023-February 2024, some of which are undated or do not identify the topic reviewed. The facility provided a list of training for V30, V31, and V33, generated from an electronic software program. The lists included abuse, annual federal training summary, antibiotic stewardship, bloodborne pathogens, compliance and ethics, Elder Justice Act, emergency preparedness, emergency medical treatment, ethics for Long-Term Care, Health Insurance Portability and Accountability Act, Resident Rights, Risk Management, Sexual Harassment, and Workplace Violence are listed as Annual Federal Requirements with scheduled date 4/1/23. The other training topics listed as scheduled for 4/1/23 are abuse, wandering/elopement, customer service strategies, Clostridium Difficile, COVID-19 (Human Coronavirus), Hand Hygiene, Infection Prevention and Control, Cultural Competency, Diets, Trauma-Informed Care, Communication Basics, Fire Safety, and Safety in Long-Term Care. There is no documentation that V30, V31, and V33 completed these trainings or that they received the required 12 hours of annual training.
The facility's daily staffing sheets dated 2/20/24-3/3/24 document V30, V31 and V33 worked in the facility.
On 3/6/24 at 11:47 AM V2 confirmed V33 works in both buildings of the facility. At 11:53 AM V27 Staffing Coordinator/CNA confirmed V30 and V31 work in both buildings of the facility.
The Long-Term Care Facility Application for Medicare and Medicaid with survey date of 3/3/24-3/6/24 documents 139 residents reside in the facility.
Jan 2024
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to properly monitor a door alarm and failed to ensure a resident did no...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to properly monitor a door alarm and failed to ensure a resident did not exit the facility unnoticed (elopement). This failure resulted in R4 leaving the facility alone and unsupervised for over 1 hour and 16 minutes. This failure affects one (R4) of three residents reviewed for elopement in the sample of 5. R4 had potential for serious injury and/or death due to the inclement winter weather and residents' poor safety awareness of walking in the street. R4's hands and face were exposed to dangerously cold temperatures increasing potential of frostbite.
These failures resulted in an Immediate Jeopardy.
The Immediate Jeopardy began on 1/15/24 at 6:41pm when R4 left the facility unnoticed by staff. R4 walked eight tenths of a mile from the facility and was found by police walking in the street at night with an outside temperature of 6 degrees F. (Fahrenheit). R4 was located by the local police department, identified, and brought back to the facility at 9:03pm.
V1 Administrator was notified of the Immediate Jeopardy on 1/18/24 at 11:14am.
The surveyor confirmed by observation, record review, interview that the Immediate Jeopardy was removed on 1/18/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
Findings include:
R4's Facility Census documents R4 was admitted to the facility on [DATE] and has the following medical diagnoses; Schizophrenia, COPD, Malignant Neoplasm of Bladder, Epilepsy, Solitary Pulmonary Nodule, Hypertensive Urgency, Peripheral Vascular Disease, GERD, Dry Eye Syndrome, Hydronephrosis, Hyperlipidemia, Vitamin Deficiency, Constipation, Pain, and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris.
R4's Minimum Data Set (MDS) dated [DATE] documents R4's Brief Interview for Mental Status (BIMS) score 9, moderate cognitive impairment.
TheWeatherChannel.com documented the temperature in (city) at 6:53 pm was 6 degrees Fahrenheit.
Facilities Video Camera still photo's document R4 left the faciity on 1/15/24 at 6:41.22 pm and returned at 9:03.39 pm.
R4's Police Report#2024-00000349 documents on 1/15/24 at 7:06 pm V17 Police Officer was dispatched to (local address) avenue (local High School), (city) and arrived at 7:06 pm. Upon arrival, V17 located R4 just west of (local address) street walking westbound in the middle of the westbound lane. V17 had R4 get into V17's squad after R4 stated R4 was freezing. R4 stated R4 was looking for R4's residence (local address) Avenue but could not find it. R4 then explained that it was a glass house. V17 drove to (local address) Avenue and pointed it out to R4. R4 stated that wasn't the house and the house is on the Northside of (local address) Avenue. R4 was explained at the even addresses were on the Southside of the roadway. R4 appeared confused asking V17 if they nuked the area because R4 didn't recognize it. R4 also notified V17 that R4 was told to 'walk off' and that was why R4 was outside walking. V17 drove R4 up and down (local address) Avenue for about 15 minutes it was decided to take R4 to the emergency department at (local address). Prior to going to the ER dispatch attempted to locate an address for R4 but was unsuccessful. While in the ER the staff at the front desk notified V17 that R4's last known address was (local address) Avenue. V17 recognized that to be nursing home. ER staff provided V17 with the nursing homes phone number. After about a 5-minute conversation the staff initially stated R4 did not reside there then they recanted and found R4 lived in the North building. Staff at the south building put V17 on hold while they transferred V17's call to the North building. The staff at the North building answered and hung up almost immediately. V17 called back and was hung up again then had dispatch make the phone call to confirm R4 was residing at a local residential address. V17 transported R4 back to the nursing home. Outside in the parking lot was V19 off duty supervisor, who was on scene to pick up son. V19 escorted R4 back inside to the staff on scene working.
R4's Nursing Note dated 1/15/23 at 8:30 pm documents at 8:08 pm, call received from V8 Licensed Practical Nurse (LPN) regarding a call from the local police department that R4 was picked up. Call placed to V1 Administrator and Regional nurse consultant, Medical Doctor (MD) and R4's Power of Attorney (POA) made aware. Upon review of the camera footage, determined R4 left the facility at 6:41pm and shut alarm off. R4 was wearing street clothes, shoes, and winter coat. Call placed to police department to verify. Officer notes first call placed at 7:06 pm, second 7:07pm. Police contacted R4 and at that point was placed in police car. R4 stated R4 lived at (local address) Avenue and officer drove R4 up and down the block a few times before going to a particular house where R4 believes R4's dad lives. R4 was brought back to the facility. Called placed to the hospital and noted R4 had not been taken to the emergency room. On arrival to facility, head to toe assessment unremarkable. R4 confused and slightly agitated. R4 denies pain. Placed on 15-minute checks upon arrival.
On 1/16/24 at 11:15am R4 said, last night (1/15/23) after dinner R4 left the facility to go to R4's dad's house in (city). R4 said, R4 was wearing shoes, socks, blue jeans, a sweatshirt, and a winter jacket with a hood. R4 said, it was a little cold out. R4 said, it was dark out and R4 couldn't find the address on the building and kept looking. R4 said, a police officer picked R4 up and brought back to the facility.
On 1/17/24 at 9:35 am V9 Certified Nursing Assistant (CNA) said, V9 worked on 1/15/24 from 7:00 pm to 7:00 am in the North Building Psychiatric Unit. V9 said, when V9 got to work there were no residents outside smoking. V9 said, when V9 reports to work, V9 goes to the nurses' station and gets report from the prior shift, on resident behaviors, residents out of the facility and any other pertinent information regarding residents. V9 said, V9 then walked the halls, checking V9's residents to make sure they were all accounted for. V9 said, V9 is not sure if V9 saw R4 in the building that evening. V9 said, at around 8:00 pm V8 Licensed Practical Nurse (LPN) informed V9 that R4 was picked up by the police walking down (local address) Avenue and was bringing R4 back to the facility. V9 said, when R4 returned to the building R4 went back to R4's room and V8 assessed R4. V9 said, when the door alarm sounds, staff should go to the door and check to make sure no resident has left the facility. V9 said, there is a camera located at the nurses' station that captures the front door, and staff usually looks at it and check to make sure no one has left the building.
On 1/17/23 at 10:12 am V8 Licensed Practical Nurse (LPN) said, on 1/15/24 V8 was working the 7:00 am to 7:00 pm shift in the North Building Psychiatric Unit. V8 said, V8 got report from the previous shift and did not know that R4 was not in the building. V8 said, the Certified Nursing Assistant (CNA) should check to see if all their residents are accounted for, and report back to V8 is any were not accounted for. V8 said, around 8:00pm, V8 received a call from the local police department and was given R4's name and date of birth to check to see if R4 resided in the facility. V8 informed them R4 did reside in the facility. V8 said, the police informed V8 they had R4 at the hospital after several calls of R4 walking around the street. V8 said, they brought R4 to the hospital in an attempt to identify and find out where R4 lives. V8 said, the police brought R4 back to the facility a short time later. V8 said, when R4 came back to the facility, V8 asked if R4 was in any pain, and R4 said no R4 was fine. R4 just wanted to go to R4's room. V8 said, R4 would only let V8 assess R4's hands. R4 is always reluctant to get a body assessment. V8 said, R4's hands and face did not have frostbite. V8 said, V8 and V9 later went back to R4's room and were able to check R4's feet which were ok. V8 said, V8 notified V1 Administrator, V2 Director of Nursing and R4's Power of Attorney.
On 1/18/23 at 9:50 am V2 Director of Nursing said, on 1/15/23 at around 8:10pm, V2 received a call from V8 Licensed Practical Nurse (LPN) that R4 has exited the facility and was pick up by the local police department. V2 said, V8 informed V2 the police were bringing R4 back to the facility. V2 said, upon review of the camera footage, R4 left the facility at 6:41 pm and shut the audible alarm off at the front door. V2 said, R4 was wearing street clothes, shoes, and winter coat. V2 said, the alarm panel at the nurses' station was still ringing and flashing. V2 said, staff should have gone to the front door to determine what set the alarm off. V2 said, at this time the 7:00 pm shift was arriving to work, and the dietary workers were leaving to the main building. V2 said, V2 called the police department to verify. V2 said, police dispatch informed V2 they received the first call at 7:06 pm and second at 7:07 pm. V2 said, police made contact with R4 and R4 was placed in police car. V2 said, R4 informed the police officer that R4 lived at (local address) Avenue and the officer drove R4 up and down the block a few times before going to a particular house where R4 believes R4's dad lives. V2 said, the police officer brought R4 to the emergency room to see if they could assist in identifying where R4 lived. V2 said, staff were able to identify a last known address and the officer recognized it as the nursing home. V2 said, contact was made with the facility, and it was verified that R4 was a resident at the facility. V2 said R4 was brought back to the facility at 9:03pm.
On 1/19/24 at 11:40 am V1 Administrator said, on 1/15/23 V1 was notified by V2 Director of Nursing (DON) that R4 had left the North Psychiatric building and was brought back to the facility by the police. V1 said, as soon as it was learned that V4 was located outside of the facility by the police a head count was conducted, and all residents were accounted for. V1 said, R4 has been a resident at the facility since 7/1/13 and has never attempted to elope. V1 said, R4 has never been an elopement risk. V1 said after the incident V15 Maintenance went to the facility and reviewed the video footage of the North Psychiatric building front door. The video showed on 1/15/23 at 6:41 pm R4 leaving the building wearing gym shoes, blue jeans, winter jacket and maybe gloves, and returning to the facility at 9:03 pm. V1 said, V1's expectations of staff when a door alarm goes off, staff should verify by going to the site of the alarm and verifying that no resident has left the building. V1 said, if staff is unable to verify who has left the building should have performed a head count, which was not done on 1/15/24.
The Immediate Jeopardy that began on 1/15/24 was removed on 1/18/24 when the facility took the following actions to remove the immediacy:
1. Upon return to the facility1/15/24, R4 was assessed per V8 Licensed Practical Nurse with no skin or pain issues.
2. 1/16/24: R4 reassessed for risk of elopement and community survival skills. Plan of care updated to reflect current risk of elopement and associated behavioral needs per V23 Social Service Director.
3. Quality and Assurance meeting held on 1/16/24 at 11:30am with V1 Administrator, V23 Social Service Director, V24 Psychiatrist, V21 Psychiatric Mental Health Nurse Practitioner and V20 Regional Social Service and Activities Director.
4. On 1/15/24 after the incident V15 Maintenance Supervisor came to facility to review the incident and confirmed door alarm/system functional status.
5. Outside button control allowing the silencing of the door alarm was disabled on 1/16/24, by V15 Maintenance Supervisor.
6. R4 was put on 15-minute status checks. 15-minute checks are being documented on 24 hour/15-minute monitoring log. Certified Nursing Assistants are responsible for documenting the 15-minute checks, Completed by V8 Licensed Practical Nurse (LPN), V9 Certified Nursing Assistant (CNA) and V10 Certified Nursing Assistant (CNA) on 1/15/24.
7. Facility head count completed and continuous every shift, by staff. Completed by V8 Licensed Practical Nurse (LPN), V9 Certified Nursing Assistant (CNA) and V10 Certified Nursing Assistant (CNA) on 1/15/24 and continued every shift by Certified Nursing Assistants.
8. Code Pink Drill completed 1/18/24 for both buildings and premises, by V11 Memory Care Coordinator and V2 Director of Nursing (DON) for both buildings on the premises.
9. Between 1/16/24 and 1/17/24 all residents were reassessed by V23 Social Service Director, V11 Memory Care Coordinator, V28 Licensed Practical Nurse (LPN) and V22 Minimum Data Set Registered Nurse. Elopement/unauthorized Leave Risk Assessment.
10. Newly admitted residents or residents that display a new behavior related to elopement will be assessed or reassessed. This will be on-going, by V12 Psychiatric Rehabilitation Services Director, V11 Memory Care Coordinator and V23 Social Service Director started this responsibility on 1/17/24.
11. Facility all staff were reeducated to the elopement risk and Code Pink Policy, by V15 Maintenance Director, V22 Minimum Data Set Registered Nurse V29 Regional [NAME] President of operations and V26 Staffing Coordinator the education was conducted from 1/16/24 to 1/18/24.
12. Interdisciplinary Team educated on person centered interventions, reporting changes and behavior tracking, by V19 Director of Clinical Quality and Education, completed on 1/18/24.
13. The facility has an established policy regarding Code Pink Policy regarding responding to door alarms. On 1/17/24 all facility staff were in-serviced by V15 Maintenance Director, as to the existence and appropriate usage and response to facility alarm. Any agency staff or new staff will be educated prior to working on the floor. This will be on-going. The facility contacted agency staffing agencies with regard, etc. V15 Maintenance Director and V30 Human Resources Director.
14. V25 Director of Clinical and Education for Arcadia Care reviewed the establish policy on 1/18/24 and reviewed policy is being maintained.
15. Code Pink Drill was carried out on 1/18/24, by V11 Memory Care Coordinator and V2 Director of Nursing (DON) for both buildings on the premises.
16. V12 Psychiatric Rehabilitation Services Director and/or designee will audit 5 residents weekly, for a period of 8 weeks ensuring capture of any new behaviors related to elopement and reviewing resident care plans for necessary interventions. The results of the audit will be reviewed by Quality and Assurance (QAPI) Committee monthly ensuring appropriate interventions are in place for those at risk for elopement.
17. V15 Maintenance Director, or Designee performs door alarm checks 7 days a week. This audit will continue indefinitely, and results will report to QAPI monthly for the next 2 months.
The facility presented an abatement plan to remove the immediacy on 1/18/24. The facility presented a revised abatement plan on 1/19/24, and the survey team accepted the revised abatement plan on 1/20/2024 at 11:00am.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident (R2) was not subjected to physical abuse by R3. T...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident (R2) was not subjected to physical abuse by R3. This failure affects two (R2, R3) of 4 residents reviewed for abuse.
Findings include:
R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnoses; Progressive Vascular Leukoencephalopathy, Protein-Calorie Malnutrition, HTN, Anemia, Local Infection of the Skin and Subcutaneous Tissue, Pure Hypercholesterolemia, Malignant Neoplasm of Right Female Breast, Sciatica, Arthritis, Neurofibromatosis, COVID-19, Gastritis with Bleeding, Difficulty in Walking, Anxiety Disorder, History in Falling and Vascular Dementia. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 0, severe cognitive impairment.
R3's Facility Census documents R3 was admitted to the facility on [DATE] and has the following medical diagnoses; Alzheimer's Disease, Protein-Calorie Malnutrition, Non-Familial Hypogammaglobulinemia, Clubbing of Fingers, Vascular Dementia, with Agitation, Mild Cognitive Impairment, Chest Pain, Hypertensive Urgency, Gas Pain, Herpesvirus Infection of Male Genital Organs, Dementia and Acute Gastritis. R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview for Mental Status (BIMS) score 1, severe cognitive impairment.
R2's Nursing Note dated 1/1/24 at 5:12 pm documents at 4:45 pm, staff witnessed R2 wanting to enter the dining room. R3 was exiting the dining room. A Certified Nursing Assistant (CNA) went to assist R2 out of the doorway. R3 pushed R2's wheelchair. R2 said, 'Do not touch me' and hit R3's leg with the back of R2's hand. The note documents, R3 slapped R2 on the right side of R2's face with an open hand. Applied ice pack to R2's cheek for 15 minutes. Pain subsided. No injuries noted.
R3's Social Service Note dated 1/1/24 at 5:00 pm documents on 1/1/24, at approximately 5:00pm, staff reported an alleged resident to resident physical altercation having occurred in the facility dementia unit. This resident and the other involved were immediately separated. MD, POA, Law Enforcement, and Ombudsman were notified of the allegation. Investigation initiated.
R3's Nursing Note dated 1/1/24 at 5:28 pm documents at 4:45pm staff witnessed R3 wanting to exit the dining room. R2 was entering the dining room. V4 Certified Nursing Assistant went to assist R2 out of the doorway. R3 pushed R2's wheelchair. R2 said 'do not touch' R2 and hit R3's leg with the back of R2's hand. R3 slapped R2 on the right side of R2's face with an open hand. R3 placed on 1:1 monitoring.
On 1/16/24 at 11:34 am V4 Certified Nursing Assistant (CNA) said, on 1/1/24 at 4:45pm R2 was in R2's wheelchair attempting to enter the dining room. V4 said, R3 was standing in the doorway of the dining room. V4 said, R2 asked R3 to excuse R2. R3 pushed R2's wheelchair back. V4 said, R2 tapped R3's leg, and R3 slapped R2 in on the left side of R2's face with R3's right hand. V4 said, V4 immediately separated R2 from the area and R3 stormed down the hallway to R3's room, slamming the door. V4 said, R2 had a red mark on the left side of R2's face. V4 said, R3 does have anger issues and has gotten into altercations in the past. V4 said, V4 notified V5 Licensed Practical Nurse (LPN) who came and assessed R2 and applied and ice pack to R2's face.
On 1/16/24 at 12:50 pm V1 Administrator said, on 1/1/24 V1 was informed of a physical altercation between R2 and R3. V1 said, staff immediately separated R2 and R3. V1 said, both residents were assessed for injuries, and none were noted. V1 said, V1 immediately started an investigation. V1 said, V1 interviewed V4 Certified Nursing Assistant (CNA) and V5 Licensed Practical Nurse. V1 said, R2 and R3 are not interviewable. V1 said, V1 learned that R2 was in R2's wheelchair wanting to enter the dining room of the Dementia/Alzheimer's care area as R3 was trying to exit. V1 said, V4 went to assist R2 out of the doorway so that R3 could leave, at which time V3 inexplicably pushed R2's wheelchair trying to move R2 out of the way. V1 said, R2 then reached out and struck R3's leg with R2's hand, and R3 then automatic responded by striking R2 in the face. V1 said, both were separated and assessed. V1 said, facility contracted psychiatric services assessed R2 and R3 and initiated recommended changes to R2 and R3's medication regimen. V1 said, R2, R3's Power of Attorneys, Medical Doctor, Ombudsman and Police were notified.
Facilities Abuse Prevention and Reporting documents this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.
Nov 2023
7 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure dignity was maintained by talking to a resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure dignity was maintained by talking to a resident (R2) in a condescending manner during dining. The facility also failed to respond to a call light in a timely manner to meet a resident's (R9) toileting needs. R2 and R9 are two of 16 residents reviewed for dignity on the sample list of 19.
Findings include:
1.) R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental Status (BIMS) score of 15, out of a possible 15, indicating no cognitive impairment.
On 11/26/23 at 12:40 pm R2's food tray had approximately one tablespoon of mashed potatoes and gravy on her lunch plate. R2's Lunch diet ticket was on R2's meal tray and documents no double entree but does not mention side items.
On 11/26/23 at 12:45 pm, R2 requested a second portion of mashed potatoes. V19, Certified Nursing Assistant (CNA) raised R2's lunch plate cover. R2 had not eaten any of her meal. V19, CNA stated, You can't have more potatoes until you eat everything on your plate. V15, Dietary Assistant walked over to R2's table and stated You're not supposed to get seconds until your done with what is served first. Your diet slip says no double portions anyway. You can't get seconds until you eat what you have.
R2 turned to this surveyor and stated I feel like I am in kindergarten. I have a bachelor's degree in education, and they don't respect my opinion on the portion size of potatoes that I want. I have lived here twelve years. If that slip says no double portions, that would have been from a long time ago. I am not wanting a second portion anyway. I am wanting a full portion. A tablespoon of mashed potatoes is not enough for me. I have sat down with the dieticians over the years. I have been educated on my dietary intake needs. I still want a full serving of mashed potatoes. Is that too much to ask?
On 11/26/23 at 1:12 pm V6, Assistant Administrator acknowledged R2 being told she had to eat everything on her plate before receiving additional mashed potatoes was a dignity issue.
2.) R9's MDS dated [DATE] documents R9's BIMS score as 15 out of a possible 15, indicating no cognitive impairment. The same MDS documents R9's diagnoses as follows: Acquired Absence of Left Leg Below Knee, Morbid (Severe) Obesity Due to Excess Calories, Muscle Weakness Generalized, Polyneuropathy Unspecified, and Radiculopathy (nerve roots that make up the sciatic nerve) Lumbar Region. The MDS also documents R9 required physical staff assistance on admission [DATE].
On 11/28/23 between 1:56 pm - 2:55 pm R9 stated that on 11/20/23, R9 put R9's call light on. V24 Certified Nursing Assistant (CNA) put R9 onto the bed pan. When R9 finished toileting on the bed pan R9 stated R9's legs were numb. R9 stated V24, CNA had not come back. R9 stated R9 turned on R9's call light and waited for over an hour. R9 stated R9 then called up front and V24 came down to take R9 off the bed pan. R9 stated My back and bottom were sore. I have back problems, anyway. (V24) apologized, but that does not cut it with me. That is not any way to treat anybody. I was on the bed pan an hour. I (R9) am a CNA myself. If you get busy, you ask for help. Somebody else could have answered my damn call light.
The facility Concern/Compliment Form dated 11/20/23 documents an unidentified CNA brought R9's food tray in and put R9 on the bed pan. The same report documents the CNA did not return the remainder of that shift, resulting in a wet bed.
On 11/29/23 at 11:00 am V2, Director of Nursing stated, Call light response times vary contingent on time of day and the needs of the residents. I can't give an exact time frame, just a reasonable time frame. I can say (R9) should never have had to wait an hour to be assisted off the bed pan. I do believe this is a dignity issue. I will be addressing call lights in staff meetings. There have been issues for a while. It has been getting better.
On 11/29/23 at 2:50 pm V24, Certified Nursing Assistant stated V24 felt bad about a week ago when she left (R9) on the bed pan. V24 stated V24 was busy, call lights were going off all over the hall. V24 stated V24 knew it was a long time before V24 got back to help R9 off the bed pan. V24 stated R9 was pretty upset and told V24 it was almost an hour when she finished using the bed pan and put on R9's call light.
The facility policy Dignity dated as Last approved 09/2023 documents the following: Guidelines; The facility shall promote care for residents in a manner and in an environment that maintains or enhances each residents dignity and respect in full recognition of his or her individuality. The facility shall consider the resident's life style and personal choices identified through the assessment processes to obtain a picture of his or her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain non-pressure wound dressings and failed to re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain non-pressure wound dressings and failed to report new skin impairment for one of four residents (R16) reviewed for skin impairment on the sample list of 19.
Findings include:
R16's Minimum Data Set, dated [DATE] documents R16's Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15. R16's same MDS documents R16 is at risk for pressure ulcers and at the time of the assessment look-back period had no pressure ulcers.
R16's Physician Order Sheet (POS) dated 11/30/29 documents the following non-pressure treatment orders: Wound right upper posterior thigh, clean area with soap and water, dry then apply hydrocolloid to the area every day shift for wound healing. Active as of 11/22/2023.
The same POS documents a second non-pressure wound treatment as follows:
Wound left, posterior, upper thigh, clean area with soap and water, dry then apply hydrocolloid every day shift for wound healing. Active as of 11/23/2023.
On 11/29/23 at 2:05 pm, V35, Licensed Practical Nurse (LPN) entered R16's room complete R16's two, non-pressure wound dressings. V35, LPN set -up a clean field to provide for two wound dressing treatments. R16 was laying on her back, on an air mattress reading a book. V35, LPN and V24, Certified Nursing Assistant (CNA) assisted R16, to a right-side lying position. R16 did not have a treatment dressing on her right or left upper thigh non-pressure wounds. R16 had eleven non-pressure wounds present as V35, LPN assessed R16's bilateral buttocks and upper thighs. All non-pressure wounds were red, moist, open and raw in appearance. V35, LPN stated, I was not aware (R16) had this many open areas. I will have to check the orders again. I expected to see a wound dressing on two areas. That is all that I knew were there. I am not sure why there aren't dressing (wound treatments) over (covering) these ( scattered open areas). V24, CNA stated, I came in at 7:00 am. I did (R16's) peri-care then. There was not a dressing on there. I would have seen it in (R16's) (incontinence brief). I should have told the nurse (V23, LPN). I got busy. I did not know if the areas were new. I don't work this hall very often; I just know they did not have dressings (wound treatment) on them (non-pressure wounds). R16 stated, (V36, Wound Physician) and (V27, Wound LPN) looked at my bottom yesterday. (V27) put bandages on there. I did not know they had come off. V35 LPN stated, I will have to measure all of these. I can't tell which ones (V36, Wound Physician) saw yesterday (11/28/23). I will measure all of them, and report to the wound nurse (V27, Wound LPN) and (V36, Wound Physician) for orders.
On 11/29/23 at 3:10 pm V26, Regional Nurse Consultant stated, (V24, CNA) should have reported to (R16's) nurse (V23, LPN) that (R16's) wound dressings were not on when (V24, CNA) provided (R16) incontinence care this morning. V2, Director of Nursing was present and stated, (R16) does not like to be repositioned. She prefers to stay on her back and read, which may have been what caused the other skin to breakdown. That said, the CNA (V24) still should have reported the dressing was not on. I don't know if it would have prevented the new areas, since (R16) is non-compliant with positioning.
On 11/30/23 at 11:35 am V4, Nurse Practitioner stated, I do not think (R16's) wounds were preventable. She (R16) refuses to get out of her wheelchair, sometimes all day long. Other times she chooses to lay in her bed, on her back and read. She does not like to be repositioned or even reminded to reposition. She has bilateral assist rails and can turn herself to relieve some of the pressure on her buttocks. That may be what caused some of the new skin damage. No matter what the cause, the wound treatments needed to be replaced when they came off. They are ordered to prevent further damage to the compromised skin.
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 F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to provide a diabetic diet, as ordered by the physician, fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to provide a diabetic diet, as ordered by the physician, for one of 13 residents (R1) reviewed for meals on the sample list of 19.
Findings include:
R1's Physician Order Sheet dated 11/28/23 documents the following diagnosis and diet order: Type II Diabetes Mellitus Without Complications and LCS (low concentrated sweets) diet, regular texture, regular consistency.
R1's Minimum Data Set, dated [DATE] documents R1's Brief Interview of Mental Status score as 15 out of a possible 15, indicating no cognitive impairment.
On 11/25/23 at 11:00 am R1 stated his blood glucose level was 519 (could not verify) the other day, because the facility does not provide diabetic diets.
R1's Medication Administration Record dated 11/01/23- 11/30/23 documents R1's blood glucose level on 11/23/23 at 11:00 am was recorded as 500 milligrams per deciliter indicating a high glucose concentration. R1 was administered Lispro insulin (100 units/per milliliter), 12 units subcutaneous, per sliding scale to cover the elevated blood glucose level.
On 11/26/23 at 12:00 pm - 12:15 pm V15, Dietary Assistant plated residents meals off a steam table in the north building kitchen. R1 was seated just outside the kitchen door. R1 was served a cup-size portion of mashed potatoes with gravy, carrots, and a fried chicken breast.
V15, stated no one had ever told her what to serve for residents on a diabetic diet.
On 11/26/23 at 2:20 pm V7, Dietary Manager confirmed the diabetics diets are listed as Liberal Renal CCHO (Controlled Carbohydrate Diet) and is controlled sweets. V7 stated the staff should not be guessing what a resident can and can't have, or how much. The menu is reviewed by the dietician and should be followed unless a resident request something different.
The facility Diet Spreadsheet Menu: On tray Fall/Winter 23-24 Menu documents the following: Liberal Renal CCHO (Controlled Carbohydrate Diet) documents, Day:1 Sunday Lunch was to serve, four ounce portion Friend Chicken Breast, three ounce portion of Buttered Egg Noodles, four ounces portion of Corn, and #12 dip of Fruit Cobbler.
On 11/28/23 at 12:25 pm V4, Nurse Practitioner stated V4 has seen R1 on 11/3/23 and 11/13/23, and adjusted R1's insulin dose. I monitor his blood glucose and I adjusted his insulin accordingly. I talked at length with (R1) about what he eats. I have seen him numerous times eating snacks while playing cards with other residents. He is non-compliant with his diet. The facility is still responsible to serve him LCS diet as ordered. He has been gaining weight. He has had a very sedentary lifestyle.
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 F0557
(Tag F0557)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure residents had access to their personal clothin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure residents had access to their personal clothing. This failure affected five of ten resident (R1, R6, R8, R13 and R14) reviewed for access to personal possession/laundry on the sample list of 19.
Findings include:
On 11/26/23 at 9:27 am, during tour of the facility south building, main laundry room V11, Laundry Assistant stated the resident laundry has backed up. There were six, 55-gallon wheeled barrels of residents soiled clothes and two 55-gallon, plastic barrel liners full of soiled clothes laying on the laundry room floor. V11 confirmed they were all soiled clothing. V11 stated, We are still behind on laundry. There is still more in the north building, that has not been brought down here. That is where the last washer is that broke (north building). That was the only washer in the north building. We are down to washing the whole facility laundry in one washer (points to a commercial clothes washer actively washing clothes). It is crazy for everybody's laundry to be washed. We can't keep up, but we try.
On 11/26/23 at 10:25 am, V14 Activity Director stated during resident council group there have been complaints from residents not getting their clothes back in a timely manner because the washers are not operational.
1.) R1's Minimum Data Set, dated [DATE] documents R1's Brief Interview of Mental Status (BIMS) score as 15 out of a possible 15 which indicates no cognitive impairment.
On 11/25/23 at 11:00 am R1, stated, The facility washers have been down (not operational) for three weeks in the north building and longer than that in the south building. It has been three weeks since I (R1) have seen six pair of gym shorts and longer than that since I have seen a robe. R1 also stated R1 has two pair of shorts hanging in his room to dry that he had to hand wash because he has no clean pair. R1 stated, The facility must take north building clothes to south building to be washed. The other day nine large bins were rolled from this building (north) to south (building) to be washed. I haven't had anything come back clean yet.
2.) R13's MDS dated [DATE] documents R13's BIMS score as 15 out of a possible 15, indicating no cognitive impairment.
On 11/26/23 at 11:30 am R13 stated, I use body wash to wash my clothes. Right now, I have clothes hanging up in my room with a fan on them to dry. I heard people never got their clothes back from laundry taken up front ( to the south building main laundry). It has been about a month this has been going on. I have my own sheets. This is the first time I have had to use theirs. I put my personal sheets in a plastic bag in the bottom my closet. I don't want them to get lost in the facility laundry.
3.) R14's MDS also dated 10/07/23 documents R14's BIMS score as15 out of a possible 15, indicating no cognitive impairment.
On 11/26/23 at 1:35 pm R14 stated, I just asked some staff person (unidentified) to do my laundry yesterday. I only have one pair of clean jeans. The girl said no, she had too much right now to take mine with her (to the south building). She said she will get my clothes today. I will be wearing my only pair of clean jeans again tomorrow, while I wait for my clean clothes I sent last week. The staff take our laundry up to the other building (south) to wash. Ours (north building clothes washer) is broke down (not operational) here. It has been broken for over a month.
4.) R6's MDS dated [DATE] documents R6's BIMS score as 11 out of 15, indicating moderate cognitive impairment.
On 11/26/23 at 1:45 pm R6 stated, Laundry has recently gotten to be a problem. Prior we got our laundry back in two days. Now it has been over a week and a half since I have gotten anything back. (R6 opened R6's closet door there were no pants clean) No clean pants, I am still waiting.
5.) R8's MDS dated [DATE] documents R8's BIMS score of 15 out of a possible 15, indicating no cognitive impairment.
On 11/29/23 at 3:40 pm R8 stated, It was not unusual for clothes to be missing before the washers stopped functioning. The staff always seemed to find them. Now, it has gone to the extreme and nothing is coming back. It has been at least two weeks since my clothes were sent to be washed.
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 F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to employ dietary support staff with the appropriate competencies to carry out the functions of the food and nutrition service. ...
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Based on observation, interview, and record review, the facility failed to employ dietary support staff with the appropriate competencies to carry out the functions of the food and nutrition service. This failure has the potential to affect all 139 residents residing in the facility.
Findings include:
On 11/26/23 at 12:00 pm - 12:15 pm V15, Dietary Assistant plated residents meals off a steam table in the North building kitchen. V15 stated, (R7) is vegan. He won't get meat. V15 put six vegetable egg rolls on R7's plate, approximately a half cup (large serving spoon) of mashed potatoes, a small ladle of gravy and large serving spoon of cooked carrots. V15 stated, I had to look up what a vegan diet was. Just to be on the safe side. It is no-meat meals. I am not a cook; I just serve the food brought back here (north building) from the main kitchen on south (building). V15 then plated R6's meal. V15 stated, (R6) is a diabetic, he is on a special diabetic diet. I guess that means he can't have carrots today. They are the only sweet thing I am serving for lunch. I don't think there is any other difference. It is my decision. No one has really told me what to do. I serve the meals all the time back here and guess I am doing it right, or somebody would have said specifically on what to do. , breast, and approximately a quarter cup of mashed potatoes with gravy on a plate for R6. V15 did not provide a substitute menu item to replace carrots that V15 chose not to serve to R6. V15 stated, Generally, portion sizes I don't have to measure. No one has ever told me to use a certain size scoop or anything like that. I was running out of scrambled eggs this morning, and just divided what I had between all the residents that don't eat fried eggs. The main kitchen was out of eggs. I did what I had to do so everybody got some (scrambled eggs). It was not much, probably equal to about one egg each. Usually, I give the residents twice that.
On 11/29/23 at 12:50 pm V21, Regional Dietary Consultant stated, I will obtain a list of dietary staff, and make sure they all have the food handlers' certificates. There are some who don't, they will be getting them.
On 11/29/23 at 1:30 pm V7, Dietary Manager provided a list of facility staff, with the dietary staff highlighted. The highlighted dietary staff names are each marked with either has or needs to obtain a Food Handlers certificate. V7 stated V15, Dietary Aide did not have a food handlers certificate. V7 confirmed the following staff are documented on the list as needing to obtain their food handlers certificates to work in the facility kitchen. The Dietary Team With Names sheet dated 11/29/23 and signed by V7, Dietary Manager, documents the following Dietary Assistants: V15, V30, V39, V40, V41, and V42 that do not have food handlers certificates.
The (Facility) Resident List Report dated 11/26/23 documents 139 residents reside in the facility.
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain the supply of food to provide the quantity of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain the supply of food to provide the quantity of food portions, according to the menu and resident preference. These failures have the potential to affect all 139 residents residing in the facility.
Findings include:
On 11/26/23 at 8:53 am V8, Certified Nursing Assistant stated residents get scrambled eggs every morning and residents complain the portions of scrambled eggs are not large enough.
On 11/26/23 at 10:25 am V14 Activity Director stated she attends the resident council meetings each month. V14 stated the residents complain of food portions are too small.
1. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status (BIMS)score as 15 out of a possible 15 indicating no cognitive impairment.
On 11/25/23 at 11:00 am R1 stated, Portions are small every morning. I don't think I got more than two forks of eggs this morning.
2. R13's MDS dated [DATE] documents R13's BIMS score as 15 out of a possible 15, indicating no cognitive impairment
On 11/26/23 at 11:30 am R13 stated, This morning I only got a tablespoon of scrambled eggs. I asked (V15, Dietary Assistant) for more. She (V15) said they were out of eggs. She offered to get me something else. I wanted my eggs. The small portions of food happen all the time. Usually, we can get more of what we like. Not this morning they were out.
On 11/26/23 at 11:40 am V17, Dietary Assistant stated V17 has had resident complaints that the food portions are small.
On 11/26/23 at 12:00 pm - 12:15 pm V15, Dietary Assistant plated residents meals off a steam table in the north building kitchen. V15 was not consistent as V15 put approximately a half cup (large serving spoon) of mashed potatoes on R7's plate and a small ladle of gravy. V15 then plated R6's food. V15 did not measure. V15 put approximately a quarter cup of mashed potatoes and gravy on a plate for R6. V15 stated, Generally, portion sizes I don't have to measure. No one has ever told me to use a certain size scoop or anything like that. I was running out of scrambled eggs this morning and just divided what I had between all the residents that don't eat fried eggs. The main kitchen was out of eggs. I did what I had to do so everybody got some. It was not much, probably equal to about one egg each. Usually, I give the residents twice that.
3.) R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental Status (BIMS) score of 15, out of a possible 15, indicating no cognitive impairment.
On 11/26/23 at 12:15 R2 requested surveyor interview R2 as R2's meal had just been served.
R2 stated the facility food portions are terrible. R2 raised the lid over her lunch plate and stated they must have run out of mashed potatoes today. That can't be a full adult portion approximately one tablespoons mashed potatoes with gravy on R2's plate). R2 replaced the lid over her lunch plate and stated she would like to finish conversation and eat later. R2 stated the facility was out of white bread today and staff know R2 only eats white bread. R2 stated R2 likes toast with fried eggs in the morning. R2 stated she only got one egg instead of two and had to eat it with wheat bread this morning.
On 11/26/23 at 12:45 pm, R2's lunch tray with untouched food remained on R2's table. R2 requested a second portion of mashed potatoes. R2 stated to this surveyor R2 was not wanting a second portion of potatoes, R2 was wanting a full portion. R2 stated a tablespoon of mashed potatoes is not enough for R2.
On 11/26/23 at 2:20 pm V7, Dietary Manager (DM) stated, There are specific scoops for each different menu item and diets. The dietary spreadsheet measurement should have been followed. Dietary staff are not to use anything other than the scoops indicated on the menu. The resident's nutrition is calculated by this measurement for a reason. Mashed potatoes served today should have been eight-ounce portions. V7, DM stated, If the north building (kitchen) was running out of any menu item, all they need to do is let me know or send somebody here (south building kitchen). We had a loaf of white bread in this kitchen (south building). (R2) is the only resident on north (building) that prefers white bread over wheat. We had that. As far as running out of other items, I was supposed to get a delivery Friday. I ran out of butter for the mashed potatoes today. I did not put the butter in the potatoes on north and ran short of butter for the potatoes on south. Since Thanksgiving was the day before, my delivery got postponed until Tuesday. That would affect all the residents since I ran out of the butter in the mashed potatoes in both buildings. We had more eggs, there was no reason for north to serve smaller portions than they were supposed to. They need to send someone to south (building kitchen). V7 provided a dietary spreadsheet which identified each diet type, and the portion measurement required to meet the nutritional requirements for each type of diet order. The breakfast menu documents a regular diet serving was a three-inch-by-three-inch serving of breakfast casserole (scrambled eggs were the substitute menu item) on 11/26/23. The lunch portion, on a regular diet, one serving of mashed potatoes was to be an eight-ounce portion, a number eight scoop.
The (Facility) Resident List Report dated 11/26/23, documents 139 residents reside in the facility.
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
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to properly maintain essential laundry equipment which re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to properly maintain essential laundry equipment which resulted in one facility washing machine functioning to provide clean linen and clean personal laundry for all 139 residents residing in the facility.
Findings include:
On 11/26/23 at 9:27 am V11, Laundry Assistant walked down to the south building laundry room. There were two commercial size clothes washers. One clothes washer was not operable. One commercial size clothes washer was actively washing clothes. V11 stated, This is the only washer that works. We are doing everything we can do with one washer, just to stay on top of the facility laundry, sheets, and stuff. The residents laundry has backed up. We are trying. V11 stated, It has been about a month since the one on north broke down, and this other one (south main laundry) has been broken since I started back in June. The one in the north building has not been working for over three weeks. We are told the owners have not approved our facility to buy new ones yet. V11 stated, You can see we need a new dryer too. The glass has been like this for months. As far as I know, there has not been any glass get into laundry yet. Splinters of glass seem like they could get through the loose duct tape. There was a commercial clothes dryer with circle glass front window. The glass front window had duct tape around the full circle glass edges and duct tape crisscrossed over four large areas in the glass window. The duct tape extended from one side of the circled glass edge to the other. The four areas of the window that have the duct tape on the outside pane also have duct tape directly behind the glass on the inside of the dryer.
On 11/28/23 at 11:55 am V32, Maintenance Director stated, The tape on the clothes dryer is, so staff don't break the glass on the dryer when they close the door. I have been waiting on the proper dryer seal for eight months. The glass has fallen out onto the floor a couple of times. I don't think it has fallen inside the dryer. It is not broken. The tape is to keep it secure while we are waiting. (Private company) Sales and Service sent a seal about eight months ago. It was the wrong seal. He (private company owner) fell off the face of the earth, retired or something.
We have a (brand name) 50 lb. washer that has been out of service for a long time. It started blowing fuses. We changed the lock mechanism and water valves and the control board and the drain board. That is a project. We haven't used it in months. We have a (brand name) washer (clothes), 70 [NAME]. It is bigger and the only one working at this time. There used to be two 50 [NAME] and a 30 [NAME] (clothes washer). We only have the one (clothes washer) operational since the north building, on the 11/8/23, had bearing problems. V32, Maintenance Director stated, I have emails to confirm I sent a request for purchase. I have to wait to turn in the cost of the replace verses repair.
The (Facility) Resident List Report dated 11/26/23 documents 139 residents reside in the facility.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's(R2) right to be free from physical abuse by ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's(R2) right to be free from physical abuse by another resident (R1). This failure affects two residents (R1, R2) of six residents reviewed for abuse.
Findings include:
On 10/24/23 at 10:40 am V4 Licensed Practical Nurse (LPN) said, on 10/9/23 at 2:47pm V4 was notified by V3 Certified Nursing Assistant (CNA) R1 had grabbed R2 by the left wrist in the common area. V4 said, V3 immediately removed R1 from the common area. V4 said, V4 conducted a skin assessment of R2 and observed redness around R2's left wrist. V4 said, R2 complained of slight pain. V4 said, V4 notified V1 Administrator, V5 R2's Physician and V6 R1's Power of Attorney. V4 said an ice pack was applied to R2's wrist.
On 10/24/23 at 10:50am V3 Certified Nursing Assistant (CNA) said, on 10/9/23 at 2:45pm V3 was sitting at a table in the common area with R2. V3 said, R1 was walking around talking about bread or something, and R2 told R1 to be quiet. V3 said, R1 than came to R2's table and was visibly upset and grabbed R2 by the left wrist. V3 said, V3 immediately removed R1 from the common area, and notified V4 Licensed Practical Nurse (LPN) who came to the common area and checked on R2's wrist which was red from where R1 grabbed it.
On 10/24/23 at 1:50pm V1 Administrator said, on 10/9/23 at 3:00pm V1 was notified of an abuse incident involving R1 and R2. V1 said, V1 immediately started and investigation, and both parties were separated. V1 said, V1 interviewed staff and residents. V1 said, R1 and R2 are not interviewable. V1 said, V1's investigation determined R2 was sitting at a table in the facility's Alzheimer's/Dementia Care common area and R1 came into the vicinity of the common area. V1 said, R1 began yelling nonsensically regarding something and appeared to be upset about. R1 then became increasingly upset to the point R1 reached out and grabbed R2's left wrist. V1 said, R1 and R2 were separated immediately and R1 and R2 were assessed by V4. V1 said, R2 had redness around R2's left wrist was R1 grabbed.
R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnoses; Noninfective Gastroenteritis and Colitis, Body Mass Index [BMI] 27.0-27.9 Adult, Injury of Unspecified Kidney, Anxiety, Dementia, Gout, HTN, Insomnia, Solitary Pulmonary Nodule, Alzheimer's Disease with Early Onset, Abnormalities of Plasma Proteins, Urinary Tract Infection, Vertigo of Central Origin, Reduced Mobility, Need for Assistance With Personal Care, Muscle Weakness, Repeated Falls, Asthma, Low Back Pain, History of Falling, Bradycardia, Syncope and Collapse, Malignant Neoplasm of Skin, Arthrodesis Status and Weakness.
R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 7, severe cognitive impairment.
R2's Nursing Note dated 10/9/23 at 3:46pm documents R2 had a physical incident, with another resident in the commons area. R1 was ranting about a piece of bread as R2 was sitting in front of R1 coloring at a table, not engaged with R1. R1 attempted attack R2. R1 grabbed R2's left arm before staff was able to break up altercation. R1 was immediately removed from common area. Pain and skin assessments initiated right away. V1 Abuse Coordinator, V2 Director of Nursing (DON), Social services, and V6 R1's Power of Attorney (POA) all informed.
R2's Weekly Skin Observation dated 10/10/23 at 2:30pm (late entry) documents R1 has a new skin concern. Type of skin concern: Bruising, located to left arm, right under wrist. Treatments include Ice as needed. R1 complains of pain, interventions include pain assessment completed. V5 R1's Physician notified. A new skin concern or change in skin condition was noted required the V5 notification, V5 was notified of new condition on 10/09/2023. V6 was notified of new condition on 10/09/2023. New orders received: N/A. Care plan reviewed.
The Facility's Final Abuse Investigation Report Resident to Resident Physical Abuse dated 10/16/23 documents. Conclusion and Action Taken: Based on the results of the investigation the facility has found the follow: a. R2 was sitting at a table in the facility's Alzheimer's/Dementia Care common area. b. R1 came into the vicinity of the common area. c. R1 began yelling nonsensically regarding something appeared to upset about. R1 then became increasingly upset to the point R1 reached out and grabbed R2. d. R1 and R2 were separated.
Sept 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to assist with activities of daily living for one (R4) of three residents reviewed for activities of daily living (ADL).
Findings ...
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Based on observation, interview and record review the facility failed to assist with activities of daily living for one (R4) of three residents reviewed for activities of daily living (ADL).
Findings include:
On 9/7/23 at 8:30AM, R4 was walking throughout the dementia unit with wet jeans around his lap area. V16 Certified Nursing Assistant (CNA) told R4 to go to his room and change his pants. R4 went into his room and came out in dry jeans, carrying his wet jeans.
On 9/7/23 at 8:40AM, R4 took the wet jeans and placed them in a hallway laundry hamper.
R4's care plan dated 6/8/23 documents R4 has an ADL self-care performance deficit related to dementia. R4 will maintain his current level of function with staff assistance for toileting and personal hygiene.
On 9/7/23 at 8:45AM, V16 CNA said she was the only CNA in the dementia unit this particular morning and that, R4 will change himself. I don't know if he changed his brief or not.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R12's undated diagnoses sheet documents the following diagnoses including: acute kidney failure, end stage renal disease, ty...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R12's undated diagnoses sheet documents the following diagnoses including: acute kidney failure, end stage renal disease, type II diabetes mellitus, falls, wounds of the lower leg, malnutrition, dementia, morbid obesity and cellulitis.
R12's minimum data set (MDS) dated [DATE] documents R12 has moderate cognitive impairment and is totally dependent on staff for mobility.
R12's care plan dated 6/7/23 documents R12 has altered skin integrity and the interventions include monitoring and documenting the location, size and treatment of skin injury. Abnormalities are to be reported and the wound doctor is to be made aware for evaluation and treatment.
R12's medical record did not contain any information about the right buttock wounds.
The facility provided wound documentation list did not contain R12's buttock wounds.
On 9/7/23 at 10:00AM peri care was provided for R12 by V18 and V19 CNAs. Upon rolling R12 to the side, R12's right buttock had two open areas, each approximately the size of a nickel, with a crusty scab over the left wound and a yellow, moist pus like look to the right wound. V18 and V19 stated that they didn't think that the wound doctor treated R12 for the wounds on his buttock, only the wounds on his legs. V18 and V19 stated they hadn't told anyone that the wounds were there and then proceeded to use barrier cream over the open areas.
On 9/7/23 at 2:00PM, V1 Administrator stated, We didn't know that he had these wounds. Based on the way they look; they have to have been there for several days. We should have been notified that they were there. We are getting measurements and an order for them now.
Based on observation, interview, and record review; the facility failed to identify, assess, and complete wound treatments as ordered for two (R3, R12) of four residents reviewed for wound care from the sample list of 14.
Findings include:
1.) R3's undated Face Sheet, documents R3's diagnoses as: Type 2 Diabetes Mellitus with Periodontal Disease, Morbid Obesity due to excess calories, Dependence on other enabling machines and devices, Cerebral Infarction, Hemiplegia and Hemiparesis, Unspecified open wound right lower leg.
R3's Minimum Data Set (MDS) dated [DATE], documents R3 has moderate cognitive impairment and is total dependence with two plus physical assist for bed mobility, transfers, toilet use, and personal hygiene and that R3 uses a wheelchair for locomotion.
R3's Care Plan dated 8/28/23, documents R3 is at risk for skin impairment related to decreased mobility, diabetes, and incontinence.
On 9/6/23 at 1:47 PM, V14 Registered Nurse (RN) was observed doing wound treatments on R3's left lower thigh and left upper calf. V14 removed the old, dirty dressing then placed clean, new dressing directly on both wounds. V14 did not cleanse either area before placing clean, new dressing onto them. After the treatment was observed, V14 was asked if there was an order to cleanse each wound before placing clean, new dressing on them. V14 stated, I don't know, I will have to check. Surveyor walked with V14 to computer to check order, V14 read the order that states to clean the wound after removal of dirty dressing. V14 was asked why this part of the treatment was not completed and V14 said I don't know, I forgot.
On 9/6/23 at 2:10 PM, V1 Administrator stated R3's dressing should have been changed according to R3's order for the treatment.
The facility's Dressing Change (Clean/Non-Sterile) Policy dated Last Approved 8/2023, documents to remove soiled dressing, wash hands, apply clean gloves, clean area/wound with solution specified in treatment order, then apply prescribed dressing per doctor order.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the residents right to be free from physical abuse from anot...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the residents right to be free from physical abuse from another resident. This failure affects four of four (R4, R5, R6, R7) of eight residents reviewed for abuse in a sample list of 14.
Findings include:
The facility abuse policy dated 10/2022 documents the facility affirms the right of their residents to be free from abuse. The policy documents physical abuse includes willful hitting, slapping, pinching, kicking and controlling behavior.
R4's undated diagnosis sheet documents the following diagnoses including hypertensive crisis, vascular dementia with agitation, Alzheimer's dementia, mild developmental delay, and a history of drug use. R4's Minimum Data Set, dated [DATE] documents R4 has moderate cognitive impairment and is ambulatory. R4's care plan dated 8/21/23 documents R4 has a potential for aggressive behavior related to dementia. R4's August behavior sheet documents verbal and physical behaviors toward others.
Facility provided incident reports of physical abuse involving R4 are documented to have occurred the following dates: 8/21/23, 8/27/23 and 8/28/23.
R5's undated diagnosis sheet documents the following diagnoses including epilepsy, hyperlipidemia, altered mental status, encephalopathy, cellulitis, anxiety, unspecified dementia, and frequent falls. R5's Minimum Data Set, dated [DATE] documents R5 has severe cognitive impairment and is ambulatory.
The facility provided incident report dated 8/21/23, documents R4 was walking in the hallway and pushed R5 in the chest and then pulled R5's hair, without provocation. On 9/6/23 at 9:09AM, V9 Certified Nursing Assistant (CNA) said she witnessed R4 hit R5. V9 said, I witnessed (R4's) thing with (R5). (R5) and I were just talking at the nurse's station and without any provocation, (R4) hit (R5) on the shoulder and she (R5) turned away from him (R4) to get away and he (R4) then pulled her (R5) hair.
R6's undated diagnosis sheet documents the following diagnoses including chronic obstructive pulmonary disease, dementia, restless legs, falls and psychiatric disturbances. R6's Minimum Data Set, dated [DATE] documents R6 has severe cognitive impairment and requires an assist of one or a wheel chair for mobility.
The facility provided incident report dated 8/27/23, documents R4 punched R6 in the jaw in the hallway, without provocation. On 9/6/23 at 9:11AM, V9 CNA stated, I was in a room and (R4) was in the hallway with (R6) and I just heard (R6) yelling. When I got there, (R6) was holding her jaw and he (R4) was standing over her. There is no doubt he (R4) hit her (R6) on the jaw. They got an x-ray.
R7's undated diagnosis sheet documents the following diagnoses including deep vein thromboses, diabetes mellitus type 2, history of alcohol abuse, thrombocytopenia, delusional disorder, schizoaffective disorder, hypertension, and dementia. R7's Minimum Data Set, dated [DATE] documents R7 has severe cognitive impairment and is ambulatory.
The facility provided incident report dated 8/28/23, documents R7 punched R4 when R4 brushed up against him in the hallway, because R7 thought R4 touched him inappropriately.
On 9/5/23 at 12:05PM, V4 Licensed Practical Nurse stated she was present the day of the altercation between R4 and R7. V4 LPN said she saw something from the corner of her eye and R7 said he had to hit R4 because R4 grabbed his butt. R4 acknowledged R7 hit him.
Aug 2023
11 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete wound assessments, transcribe wound orders, a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete wound assessments, transcribe wound orders, and administer wound treatments as ordered for three (R1, R5, R6) of four residents reviewed for wounds in the sample list of 22. The facility also failed to prevent cross contamination during wound treatments by failing to perform hand hygiene and disinfect scissors resulting in R1, R5, and R6 developing wound infections.
Findings include:
1.) R1's Concern/Compliment Form dated 8/14/23 documents V22 (R1's Family Member) was concerned R1's knee infection is due to R1's wound treatment not being done daily as ordered.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and has a surgical wound. R1's Care Plan dated 7/20/23 documents R1 is at risk for skin impairment and includes an intervention to assess and record changes in R1's skin and report changes to the physician. This Care Plan documents R1's diagnoses include Left Artificial Knee Join and Aftercare Following Joint Replacement Surgery. R1's Care Plan revised 8/14/23 documents R1 is on antibiotics for a wound infection.
R1's Order Summary Report dated 7/23/23-8/23/23 documents the following orders: Bactrim (antibiotic) DS (Double Strength) Oral Tablet 800-160 Mg (milligrams) give one tablet by mouth twice daily for 2 weeks for wound infection. Daily wound packing to left knee (ordered from 8/10/23-8/20/23). There is no order which includes what to pack the wound with until 8/23/23 when an order was initiated to pack the wound daily with iodoform, covered with a sterile bordered gauze and elastic wrap.
R1's July and August 2023 Treatment Administration Records (TARs) document to apply an abdominal gauze and monitor site for infection daily 7/5/23-8/14/23. The gauze treatment and monitoring for infection are not signed as administered on three dates, and wound packing treatments are not signed as administered on three dates.
There are no documented assessments of R1's surgical wound in R1's medical record.
On 8/22/23 at 12:57 PM R1 stated R1 was admitted to the facility about a month ago after R1 was hospitalized for left knee replacement. R1 stated R1 has an infection in R1's left knee surgical wound due to staff not changing R1's dressing as ordered. R1 stated V4 Registered Nurse (RN) only looked at R1's left knee dressing, V4 did not change the dressing when R1 asked for it to be changed and told R1 V4 was not a nurse. R1 was lying in bed with an elastic wrap covering R1's left knee.
On 8/23/23 at 2:16 PM V3 Licensed Practical Nurse (LPN) removed the elastic wrap and dressing from R1's left knee. There was an open, red, moist wound approximately the size of a marble at the base of R1's left knee. V3 stated the surgeon made R1's wound slightly larger. V3 cleansed the wound and obtained scissors from V3's pocket. V3 placed the scissors on R1's overbed table and then without disinfecting the scissors, used the scissors to cut the iodoform. V3 packed the iodoform directly into R1's wound, covered with a bordered gauze dressing and applied the elastic wrap to R1's left knee. At 2:32 PM V3 stated R1's wound should be assessed weekly by the floor nurse who administers R1's wound treatment and documented under the assessments in R1's electronic medical record. V3 reviewed R1's assessments in R1's medical record and confirmed there are no documented assessments of R1's wound. V3 stated the wound started as a pinhole at the base of R1's surgical wound. V3 confirmed V3 did not disinfect V3's scissors prior to administering R1's wound treatment.
On 8/23/23 at 11:31 AM V14 Certified Nursing Assistant stated last week R1 asked V4 RN to change R1's wound dressing. V4 told R1 V4 did not have the supplies to do the treatment, left R1's room, and never returned to change R1's dressing. V14 stated R1's dressing was supposed to be changed on dayshift.
2.) R5's MDS dated [DATE] documents R5 is cognitively intact. R5's Care Plan dated 7/21/23 documents R5 has a wound to the left lower lateral leg and includes an intervention to administer treatments as ordered.
R5's Order Summary Report dated 7/1/23-8/23/23 documents an order dated 8/21/23 to apply calcium alginate to the left leg wound, cover with bordered gauze, and secure with a gauze/stretch wrap. This report documents an order dated 7/28/23-8/5/23 for Levofloxacin (antibiotic) 750 mg by mouth daily for a wound infection.
R5's Wound Evaluation & Management Summary dated 7/19/23, recorded by V31 Wound Physician documents R5's full thickness, non-pressure wound of the left, lower, lateral leg measured 3 centimeters (cm) long by 2.5 cm wide by 0.2 cm deep. The wound was due to trauma/injury and is improving/healing. R5's Wound Evaluation & Management Summary dated 7/29/23 by V31 documents R5's wound declined, measured 3.5 cm by 2 cm by 0.4 cm, and had purulent green colored drainage (pus). This wound was exacerbated due to infection. R5's Wound Evaluation & Management Summary dated 8/16/23 recorded by V30 Nurse Practitioner documents R5's wound measured 3 cm by 2.5 cm by 0.2 cm and a treatment order to apply Calcium Alginate daily.
R5's August 2023 TAR does not document R5's Calcium Alginate treatment was transcribed onto the TAR prior to 8/20/23, and this order is only documented as administered on 8/20/23 and 8/21/23.
On 8/22/23 at 3:22 PM R5 stated R5 has a wound to the leg which started as a blister, V31 evaluated the wound and lanced it. R5 stated R5 had an infection in the wound and received antibiotics.
On 8/23/23 at 12:56 PM V21 Licensed Practical Nurse (LPN)/Wound Nurse touched the treatment cart outside of R5's room and obtained wound care supplies. Scissors were on top of the treatment cart. Without performing hand hygiene, V21 applied gloves and entered R5's room. V21 used an alcohol prep pad to wipe the blades of the scissors and placed the scissors on the overbed table in R5's room. V21 had not disinfected the overbed table prior. V21 removed R5's dressing to the left outer calf which had minimal drainage. V21 changed V21's gloves and cleansed the wound. V21 changed gloves and used the scissors on R5's overbed table to cut the calcium alginate and placed it directly onto R5's wound. V21 cut a piece of an abdominal pad dressing secured with tape to cover R5's wound. V21 placed the scissors on top of the treatment cart and washed V21's hands. V21 did not perform hand hygiene between changing gloves and when moving from soiled to clean areas during the treatment. V21 then pushed the treatment cart to R6's room.
On 8/23/23 at 12:01 PM V2 Director of Nursing (DON) stated the facility has V31's notes by the following day after V31 rounds. V2 stated V31 also gives V31's order changes verbally when rounding. V21 rounded with V30 Nurse Practitioner on 8/16/23. V2 stated the order for Calcium Alginate was transcribed incorrectly and did not prompt treatment administration on the TAR until V3 corrected the order entry on 8/19/23.
3.) R6's Care Plan revised 7/31/23 documents R6 has a wound infection of the left great toe and is receiving antibiotic therapy. This Care Plan documents R6 has a diagnosis of Diabetes Mellitus.
R6's Order Summary dated 7/1/23-8/23/23 documents the following: Apply Collagen powder to the left great toe and cover with gauze bordered dressing once daily, initiated on 8/16/23. Administer Bactrim (antibiotic) DS (Double Strength) 800-160 mg by mouth twice daily for toe infection for 14 days beginning on 7/6/23 and again on 7/28/23. Administer Ceftriaxone (antibiotic) 1 gram intramuscularly daily for 14 days for toe infection beginning on 7/10/23.
R6's July and August 2023 TARs document to administer bleach-soaked gauze treatments twice daily from 7/6/23-7/20/23 and administer Betadine-soaked gauze treatments twice daily 7/20/23-8/16/23 for the left great toe wound. There are 10 entries that do not document these treatments were administered as ordered.
R6's Wound Evaluation & Management Summaries document the following: On 7/5/23 R6's diabetic left great toe wound measured 1.5 cm by 1.3 cm by 0.3 cm with 30% necrotic (dead) tissue, antibiotics were ordered for cellulitis (skin infection). On 7/19/23 the wound was larger and measured 1.5 by 1 by 0.3 cm with 30% necrotic tissue. On 7/29/23 the wound had recurrent peri wound cellulitis, was exacerbated due to infection, and measured 1.5 cm by 1 cm by 0.3 cm with 40 % necrotic tissue. On 8/16/23 R6's diabetic left great toe wound measured 1 cm by 0.7 cm by 0.4 cm.
R6's Toe Wound Culture dated as reported on 7/8/23 documents Heavy Morganella morganii (bacterial growth).
On 8/23/23 at 1:13 PM V21 pushed the treatment cart outside of R6's room. V21 did not perform hand hygiene, applied gloves, and removed the dressing on R6's left, great, toe. R6 had a circular, red, moist wound to the top of R6's toe. V21 changed gloves, used an alcohol prep pad to wipe the scissors which were on top of the treatment cart and laid the scissors back onto the cart. V21 then used the scissors to cut a piece of abdominal pad dressing. V21 cleansed R6's wound and applied the abdominal pad dressing secured with tape. V21 stated there is no order for anything else to be applied. V21 stated V31 Wound Physician told V21 today to change the order form Collagen powder to a gauze dressing.
On 8/23/23 at 2:36 PM V21 LPN/Wound Nurse stated V21 has not received any facility training on hand hygiene/infection control practices during wound treatments. V21 stated V21 thought V21's hands were considered clean prior to performing R5's and R6's wound treatments, and V21 did not consider V21's hands contaminated after touching the treatment cart and wound supplies. V21 confirmed V21 did not perform hand hygiene prior to or during the wound treatments and did not disinfect the top of the treatment cart or overbed tables prior to R5's and R6's treatments.
On 8/23/23 at 12:01 PM V2 DON stated the nurses should sign out the treatments on the TAR when administered. At 2:40 PM V2 stated bleach wipes are used to disinfect multi-use equipment. V2 confirmed an alcohol prep pad is not a disinfectant and scissors should be disinfected prior to cutting wound dressings. V2 confirmed wound assessments are documented under the assessments section of the resident's electronic medical record.
On 8/23/23 at 1:24 PM V31 Wound Physician stated V31 changed R6's treatment from Collagen powder to Betadine-soaked gauze. V31 stated poor hand hygiene and not disinfecting scissors during wound treatments, as well as not changing dressings as often as ordered are risk factors increase the risk for developing wound infections. V31 stated V31 had concerns that dressings ordered to be changed twice daily are only getting changed once daily.
The facility's Dressing Change policy dated August 2023 documents wound supplies may be placed on an overbed table after the table has been disinfected, wash hands prior to treatment administration, wash hands or use an alcohol-based hand rub to decontaminate hands when changing gloves after removing a soiled dressing, administer the wound treatment per physician's orders, sanitize scissors after use, and document on the TAR. This policy does not document to disinfect scissors prior to cutting wound dressings/supplies.
The facility's Skin Condition Assessment & Monitoring- Pressure and Non-Pressure policy dated March 2023 documents Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurses and documented in the resident's clinical record. Non-pressure skin conditions (bruises/contusions, abrasions, lacerations, rashes, skin tears, surgical, wounds, etc. (etcetera)) will be assessed for healing progress and signs of complications or infection weekly.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 8/22/23 at 12:57 PM R1 stated the staff do not answer call lights timely. R1 has waited an hour a few times for R1's call...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 8/22/23 at 12:57 PM R1 stated the staff do not answer call lights timely. R1 has waited an hour a few times for R1's call light to be answered, especially since R1 has been on isolation for COVID-19. R1 stated R1 can use the bathroom but needs help to get there. R1 stated R1 must wait so long that R1 has peed R1's pants. The other night the staff did not come for a long time. R1 tried to hold it, but R1 ended up having incontinent urine and bowel movement everywhere. R1 stated R1 was embarrassed and felt bad that staff had to clean R1 up.
R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact and is dependent on one staff person for toileting assistance.
The facility's Call Light log provided by V1 Administrator documents on 8/20/23 R1's call light was activated at 4:13 PM and answered at 5:58 PM, one hour and 45 minutes later.
On 8/23/23 at 5:13 PM V2 Director of Nursing stated call lights should be answered within 10 to 15 minutes. V2 stated (in reference to R1's call light response times while in isolation) that it is probably V2's fault, because V2 told staff that V2 did not want them going into COVID-19 positive rooms and then going into negative rooms and asked staff to try to group cares.
Based on observation, interview and record review, the facility failed to ensure that dignity was maintained by failing to respond to call light requests to provide a mechanical lift transfer for R11 and provide timely toileting assistance for R1. R1 and R11 are two of 10 residents reviewed for call lights/dignity on the sample list of 22.
Findings include:
The Resident Council Minutes dated 6/27/23 and 7/25/23 document concerns with call light response times.
1.) R11's Minimum Data Set (MDS) dated [DATE] documents R11 has a Brief Interview of Mental Status score of 15 out of a possible 15, indicates no cognitive impairment. The same MDS documents R11 is totally dependent on two physical staff assist for transfers.
R11's Care Plan dated 6/12/23 documents the following: (R11) has an ADL (Activity of Daily Living), self- care performance deficit related to history of falls, incontinence of bowel and bladder, musculoskeletal impairment, pain chronic back and knee, and psychotropic medications.
R11's same care plan documents the following:
*Transfer: (R11) requires total assistance by two staff to move between surfaces
as necessary.
*Transfer: (R11) requires Mechanical Lift (Brand Name) with (2) staff assistance for
transfers.
On 8/23/23 the call light in R11's room was activated at 9:38 am, answered by an unidentified staff member at 9:54 am, for a total of 15 minutes to respond to R11's call light.
The facility call light time log confirms the above observation and documents R11's call light was on at 15 minutes and 44 seconds.
On 8/23/23 at 3:00 pm, R11 stated, It sometimes takes one hour to answer call lights. That is the average time frame (one hour) really, for the CNA's (Certified Nursing Assistants) to answer my call light. I (R11) told my CNA (V18) today (8/23/23) at 7:30 am, I would like to get out of bed. She (V18) told me, she would get me out of bed when she (V18) gets another person to help her. I have to have a machine (full mechanical lift) and two people to get me up. I (R11) asked again after breakfast (recorded above in call light observations). I don't know what time. She (V18) told me the same thing. I just got up at 11:30 am (call light documented above at 11:30 am).
On 8/23/23 at 3:09 pm V18, Certified Nursing Assistant (CNA) stated, I was supposed to get (R11) up. She is (requires) a (full mechanical lift) (for transfers). I (V18, CNA) was the only CNA until after 10:00 am. When (R11) asked to get up around 7:30 am, I was passing (delivering) trays (breakfast). She (R11) asked again and again. I (V18) finally had a second person come in. I got her (R11) up right before lunch. (R15) is also a (full mechanical lift). I was supposed to get (R15) up too. I couldn't because (mechanical lift to transfer) takes two people. I couldn't keep up with the call lights this morning either. I was so busy. I think we are expected to answer call lights within five to 15 minutes. That is not possible when you're the only person working the hall.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the physician and resident's representative of a significant ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the physician and resident's representative of a significant weight loss for one (R2) of three residents reviewed for feeding assistance in the sample list of 22.
Findings include:
R2's MDS dated [DATE] documents R2 has severe cognitive impairment. R2's admission Record with admit date of 5/3/23 documents V6 as R2's Power of Attorney for Healthcare.
R2's Weight Log documents R2's weights as follows 134.0 pounds (lbs.) on 5/3/23, 134.2 lbs. on 6/7/23, 133.4 lbs 7/17/23, and 112.8 lbs on 8/2/2023 (a significant weight loss of 15.4% in one month). R2's Nutritional assessment dated [DATE] completed by V32 Registered Dietitian documents R2 had a weight loss of 20.6 lbs (15.4%) and some of the weight loss was related to edema upon admission. V6 recommended adding ice cream to R2's meals to increase calories per day. There is no documentation in R2's medical record that V6 or V20 (R2's Physician) were notified of R2's significant weight loss.
On 8/22/23 at 10:30 AM V6 stated V6 thought R2 had lost weight. V6 was unsure how much weight R2 has lost and stated the facility has never reported R2's weight loss to V6.
On 8/23/23 at 12:01 PM V2 Director of Nursing (DON) stated V33 Former Assistant DON/Registered Nurse was notifying physicians of significant weight loss, but V33 stepped down from that position at the end of July/beginning of August 2023. V2 stated physician and family notification should be documented in a progress note. V2 stated V28 Care Plan Coordinator was asked to notify R2's family and physician of significant weight loss a few weeks ago. V2 confirmed there is no documentation in R2's nursing notes that V6 and V20 were notified of R2's significant weight loss.
The facility's policy Physician-Family Notification- Change in Condition dated August 2023 documents the resident's representative and physician will be notified of significant changes in the resident's physical, mental, or psychosocial status and when there is a need to alter treatment significantly.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers as scheduled for three (R1, R2, R3) of seven residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers as scheduled for three (R1, R2, R3) of seven residents reviewed for showers in the sample list of 22.
Findings include:
The facility's Resident Council Meeting Minutes dated 6/27/23 documents concern with showers.
1.) On 8/22/23 at 12:57 PM R1 was in an isolation room. R1 stated R1's showers are supposed to be Monday and Thursday and R1 does not always get a shower twice per week. R1 stated R1 did not get a shower yesterday (Monday) because R1 has COVID-19 and staff don't want to come into R1's room to care for R1.
On 8/23/23 at 9:20 AM R1 was no longer on isolation. R1 stated R1 hasn't had a shower since last Thursday. R1 stated, It has been a week and I (R1) smell like a skunk.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and is totally dependent on one staff person for bathing assistance.
The facility's shower schedules document R1's showers are scheduled twice per week and (based R1's Census) R1's showers have been scheduled for Tuesday/Friday, Wednesday/Saturday, and Monday/Thursday.
R1's July and August 2023 shower sheets provided by V2 Director of Nursing document showers were offered/given on 7/10, 7/20, 7/24, 7/31, 8/3, 8/7, and 8/14/23. There are no documented showers after 8/14/23.
2.) On 8/22/23 at 10:30 AM V6 (R2's Power of Attorney) stated R2's showers aren't always given as scheduled, and R2 is supposed to have showers twice per week.
R2's MDS dated [DATE] documents R2 has severe cognitive impairment and is totally dependent on one staff person for bathing assistance.
The facility's shower schedules document R2's showers are scheduled on Wednesdays/Saturdays.
R2's July and August 2023 shower sheets provided by V2 document showers were offered/given on 7/8, 7/12, 7/15, 7/18, 7/22, 7/26, 7/28, 8/2, 8/5, 8/9, and 8/12/23. There are no documented showers after 8/12/23.
3.) R3's MDS dated [DATE] documents R3 requires physical assistance of one staff person for bathing.
The facility's shower schedules document R3's showers are scheduled on Wednesdays/Saturdays.
R3's July and August 2023 shower sheets provided by V2 document showers were offered/given on 7/8, 7/12, 7/15, 7/22, 7/26, 8/5, 8/9, 8/16/23, and 8/19/23.
On 8/23/23 at 12:01 PM V2 stated showers are scheduled to be given twice per week. V2 confirmed all shower documentation for R1, R2, and R3 for July and August 2023 was provided.
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide nutritional interventions as recommended by a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide nutritional interventions as recommended by a dietitian, consistently document meal intakes, and have a significant weight loss evaluated by a physician for one (R2) of three residents reviewed for feeding assistance in the sample list of 22.
Findings include:
R2's MDS dated [DATE] documents R2 has severe cognitive impairment. R2's Care Plan dated 8/17/23 documents R2 has had a significant weight loss and includes a goal that R2 will eat 50% of 3 meals daily, and interventions to monitor weight and administer supplements as ordered.
R2's Weight Log documents R2's weights as follows 134.0 pounds (lbs.) on 5/3/23, 134.2 lbs. on 6/7/23, 133.4 lbs 7/17/23, and 112.8 lbs on 8/2/2023 (a significant weight loss of 15.4% in one month). There are no documented weights after 8/2/23 in R2's medical record. R2's Meal Intakes dated 7/24/23-8/22/23 do not document recorded intakes for 16 meals.
R2's Nutritional assessment dated [DATE] completed by V32 Registered Dietitian documents R2 had a weight loss of 20.6 lbs (15.4%) and some weight loss was related to edema upon admission. V6 recommended adding ice cream to R2's meals to increase calories per day. There is no documentation that this recommendation was implemented. There is no documentation in R2's medical record that R2's significant weight loss was evaluated by a physician.
On 8/22/23 at 12:00 PM R2's lunch tray did not contain ice cream and ice cream was not listed on R2's meal ticket. On 8/23/23 at 8:42 AM R2's breakfast tray did not contain ice cream and ice cream was not listed on R2's meal ticket. V34 Certified Nursing Assistant (CNA) was feeding R2 and V34 was unsure if R2 receives any supplements or ice cream during meals.
On 8/23/23 at 11:58 AM V11 Dietary Manager stated R2 does not receive any supplements or ice cream routinely. V11 reviewed R2's 8/7/23 Nutritional Assessment and stated V11 will make sure R2 starts receiving ice cream with meals as of today.
On 8/23/23 at 12:01 PM V2 Director of Nursing stated meal intakes should be recorded for each meal by the CNAs in the electronic medical record. V2 stated V33 Former Assistant DON/Registered Nurse was notifying physicians of significant weight loss, but V33 stepped down from that position at the end of July/beginning of August 2023. V2 stated physician and family notification should be documented in a progress note. V2 stated V28 Care Plan Coordinator was asked to notify R2's family and physician of significant weight loss a few weeks ago. V2 confirmed there is no documentation R2 was evaluated by a physician for significant weigh loss after 8/2/23. V2 stated V2 believes R2's weight loss is related to advancing in disease process and overall decline in eating. V2 stated V2 was not aware that it was recommended for R2 to have ice cream at meals. V2 stated the registered dietitian gives V2 nutritional recommendations, and V2 did not think V2 received V32's recommendations for R2. V2 stated V2 would have completed a dietary slip that is given to the dietary department to update R2's diet order to include ice cream. V2 stated the facility has been through three Dietary Managers since July 2023.
The facility's undated policy titled Weight Assessment and Intervention documents weights are recorded in the resident's medical record and weight changes of 5% or more will be reweighed to confirm weight loss. Weight loss will be reported to the physician, Registered Dietitian, Dietary Manager, and/or other interdisciplinary team members. A loss of greater than 5% in one month is considered severe. The facility will analyze assessment data including target weight range, approximate caloric and nutrient needs compared to intakes, and medical conditions contributing to weight change. This policy documents the physician and the interdisciplinary team will identify increased risks for weight loss such as cognitive/functional decline, chewing/swallowing problems, pain, medication effects, environmental factors, increased caloric or protein needs, poor digestion/absorption, fluid/nutrient loss, or inadequate availability of food/fluids.
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
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure appropriate use of antibiotics for two (R1, R6) of three residents reviewed for wound infections in the sample list of ...
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Based on observation, interview, and record review the facility failed to ensure appropriate use of antibiotics for two (R1, R6) of three residents reviewed for wound infections in the sample list of 22.
Findings include:
1.) R1's Care Plan revised 8/14/23 documents R1 is on antibiotics for a wound infection. This Care Plan documents R1's diagnoses include Left Artificial Knee Join and Aftercare Following Joint Replacement Surgery.
R1's Order Summary Report dated 7/23/23-8/23/23 documents the following orders: Bactrim (antibiotic) DS (Double Strength) Oral Tablet 800-160 Mg (milligrams) give one tablet by mouth twice daily for 2 weeks for wound infection. There is no documentation that a wound culture was obtained or that the facility consulted with the physician to request a wound culture.
On 8/22/23 at 12:57 PM R1 stated R1 admitted to the facility about a month ago after R1 was hospitalized for left knee replacement. R1 stated R1 has an infection in R1's left knee surgical wound due to staff not changing R1's dressing as ordered. At 2:16 PM V3 Licensed Practical Nurse (LPN) administered R1's wound treatment. There was an open, red, moist wound approximately the size of a marble at the base of R1's left knee.
2.) R6's Care Plan revised 7/31/23 documents R6 has a wound infection of the left great toe and is receiving antibiotic therapy.
R6's Order Summary dated 7/1/23-8/23/23 documents the following: Administer Bactrim DS 800-160 mg by mouth twice daily for toe infection for 14 days beginning on 7/6/23 and again on 7/28/23. Administer Ceftriaxone (antibiotic) 1 gram intramuscularly daily for 14 days for toe infection beginning on 7/10/23.
R6's Wound Evaluation & Management Summaries document the following: On 7/5/23 R6's diabetic left great toe wound measured 1.5 centimeters (cm) by 1.3 cm by 0.3 cm with 30% necrotic (dead) tissue, antibiotics were ordered for cellulitis (skin infection). On 7/19/23 the wound was larger and measured 1.5 by 1 by 0.3 cm with 30% necrotic tissue. On 7/29/23 the wound had recurrent periwound cellulitis, was exacerbated due to infection, and measured 1.5 cm by 1 cm by 0.3 cm with 40 % necrotic tissue. On 8/16/23 R6's diabetic left great toe wound measured 1 cm by 0.7 cm by 0.4 cm.
R6's Toe Wound Culture dated as reported on 7/8/23 documents Heavy Morganella morganii (bacterial growth) and this organism was resistant to Bactrim DS and susceptible to Ceftriaxone. There are no documented wound cultures after 7/8/23.
R1's and R6's wound infections and antibiotic use are not listed on the facility's 2023 Infection Control Logs provided by V2 Director of Nursing.
On 8/23/23 at 11:25 AM V2 Director of Nursing/Infection Preventionist stated cultures are not always done for wound infections. V2 stated V2 has been working with V31 Wound Physician to order wound cultures when antibiotics are ordered. When V2 was asked how the facility ensures appropriate antibiotics are prescribed, V2 replied Well (V31) just knows. V2 confirmed R1's and R6's wound infections and antibiotic use should be listed on the facility's Infection Control Logs. At 1:50 PM V2 stated V2 did not have any wound cultures to provide for R1 and R6 (for R6's 7/28/23 Bactrim order).
The facility's Antibiotic Stewardship policy dated February 2023 documents the facility will implement this program to reduce the unnecessary use of antibiotics and guidance includes tracking/monitoring monthly antibiotic use, evaluating trends, and the use of laboratory microbiology reports which guide antibiotic choice based on bacterial susceptibility to antibiotics.
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 F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to offer and administer Pneumococcal vaccinations for three (R1, R2, R7) of five residents reviewed for immunizations in a sample list of 22 re...
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Based on record review and interview the facility failed to offer and administer Pneumococcal vaccinations for three (R1, R2, R7) of five residents reviewed for immunizations in a sample list of 22 residents.
Findings include:
1.) R1's undated face sheet documents diagnoses of Malignant Neoplasm of Lung, Pulmonary Embolism with Acute Cor Pulmonale, Reduced Mobility and History of COVID-19. This same face sheet documents R1's admission date of 7/1/23.
R1's medical record does not document any education provided to R1 regarding Pneumococcal vaccinations, nor does it document a Pneumococcal vaccination being offered or administered.
2.) R2's undated face sheet documents a diagnosis of Cerebral Infarction, Essential Hypertension, Dementia and Anxiety. This same face sheet documents R2's admission date of 5/3/23.
R2's medical record does not document any education provided regarding Pneumococcal vaccinations, nor does it document a Pneumococcal vaccination being offered or administered. R2's medical record documents R2's most recent Pneumonia vaccination was administered 8/1/96 with no vaccine type listed.
3.) R7's undated face sheet documents a diagnosis of: Metabolic Encephalopathy, Alcoholic Cirrhosis of the Liver with Ascites, Coagulation Defect, Anemia and Protein Calorie Malnutrition. This same face sheet documents R7's admission date of 7/17/23.
R7's medical record does not document any education provided regarding Pneumococcal vaccinations, nor does it document a Pneumococcal vaccination being offered or administered.
On 8/23/23 at 2:00 PM V2 Director of Nurses (DON)/Infection Preventionist (IP) stated I have only been at this facility since the beginning of July 2023 but I looked through all of the papers and could not find any documentation for (R1, R2, R7) being offered nor administered any type of Pneumococcal vaccinations when they (R1, R2, R7) admitted . I don't think the admission nurses are even asking about immunizations. All that we (facility) have is whatever is documented in the Electronic Medical Record (EMR). There are some very sick residents here (facility) who would benefit from this vaccination.
The facility policy titled 'Influenza and Pneumococcal Immunizations' reviewed August 2023 documents the facility shall provide pertinent information about the significant risks and benefits of vaccines to residents or residents legal representative. Before offering the Pneumococcal immunization, each resident or the resident's representative will be provided education regarding the benefits and potential side effects of the immunization. Each resident is offered a Pneumococcal immunization, unless the immunizations is medically contraindicated or the resident has already been immunized; A second Pneumococcal vaccine will be offered only when necessary, according to the Centers for Disease Control (CDC) guidelines. The resident's medical record includes documentation that indicates, at minimum, the following: The resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and that the resident either received or did not receive the Pneumococcal immunization due to medical contraindications or refusal.
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
Based on observation, interview and record review the facility failed to administer medications according to physician orders for four (R9, R10, R16, R17) of four residents reviewed for medications in...
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Based on observation, interview and record review the facility failed to administer medications according to physician orders for four (R9, R10, R16, R17) of four residents reviewed for medications in a sample list of 22 residents.
Findings include:
1.) R9's Physician Order Sheet (POS) dated August 2023 documents physician orders for Clopidogrel Bisulfate 75 milligrams (mg) daily at lunch for Atherosclerotic Heart Disease, Furosemide 40 mg daily at lunch for Essential Hypertension, Humalog 100 units/milliliter (ml) give 4 units daily at breakfast for Type II Diabetes Mellitus, Humalog 100 units/milliliter (ml) give 8 units daily at lunch for Type II Diabetes Mellitus, Lantus Subcutaneous Solution 100 UNIT/ML give 37 units subcutaneously daily at lunch for TYPE 2 DIABETES MELLITUS, Norvasc 5 mg daily at breakfast for Essential Hypertension, Divalproex Sodium Delayed Release (DR) 500 mg daily at lunch for Schizoaffective Disorder, Metoprolol Tartrate 25 mg daily at breakfast for Essential Hypertension and obtain blood glucose levels before meals and at bedtime for Type II Diabetes Mellitus.
R9's Medication Administration Record (MAR) dated August 2023 does not document medication administration for Clopidogrel Bisulfate 75 milligrams (mg) daily at lunch, Furosemide 40 mg daily at lunch, Humalog 100 units/milliliter (ml) give 4 units daily at breakfast, Humalog 100 units/milliliter (ml) give 8 units daily at lunch, Lantus Subcutaneous Solution 100 UNIT/ML give 37 units subcutaneously daily at lunch, Norvasc 5 mg daily at breakfast, Divalproex Sodium Delayed Release (DR) 500 mg daily at lunch, Metoprolol Tartrate 25 mg daily at breakfast. This same MAR does not document blood glucose results for lunch meal.
On 8/23/23 at 4:00 PM R9 stated, I haven't seen a nurse since last night. There was a Certified Nurse Aide (CNA) that came in twice today but no one else. I will have some words for that nurse when she does get in here. I have heart problems. I have COVID-19 right now. I am diabetic and no one even checked my sugar or gave me my Insulin. I could be dead in here and no one would know or care. This is the poorest care I have ever received.
2.) R10's Physician Order Sheet (POS) dated August 2023 documents physician orders for Amlodipine Besylate 2.5 milligrams (mg) daily at lunch for Essential Hypertension, Tresiba Flex Pen 100 units/milliliter (ml) give 28 units subcutaneously daily at 9:30 AM for Type II Diabetes Mellitus, Carvedilol 6.25 mg daily at breakfast and to obtain blood glucose levels before meals and at bedtime for Type II Diabetes Mellitus.
R10's Medication Administration Record (MAR) dated August 2023 does not document medication administration for Amlodipine Besylate 2.5 milligrams (mg) daily at lunch, Tresiba Flex Pen 100 units/milliliter (ml) give 28 units subcutaneously daily at 9:30 AM, Carvedilol 6.25 mg daily at breakfast and to obtain blood glucose levels before meals and at bedtime.
On 8/23/23 at 4:05 PM R10 stated, Do we get to see a nurse today? I haven't seen one yet. I would like my pills now.
3.) R16's Physician Order Sheet (POS) dated August 2023 documents physician orders for Depakene Oral Solution 250 milligrams (mg)/5 milliliters (ml) give 20 ml at breakfast and 10 ml at lunch for Convulsions, Lamotrigine Extended Release (ER) give 250 mg every breakfast for convulsions, Quetiapine Fumarate 25 mg daily at breakfast for Conduct Disorder, Lorazepam 0.5 mg daily at breakfast for Anxiety, Risperdal Solution 1 mg/milliliter (ml) give 2 mg every breakfast for Anxiety Disorder, and Phenobarbital 32.4 mg daily at breakfast and lunch for Convulsions.
R16's Medication Administration Record (MAR) dated August 2023 does not document medication administration for Depakene Oral Solution 250 milligrams (mg)/5 milliliters (ml) give 20 ml at breakfast and 10 ml at lunch, Lamotrigine Extended Release (ER) give 250 mg every breakfast, Quetiapine Fumarate 25 mg daily at breakfast, Lorazepam 0.5 mg daily at breakfast, Risperdal Solution 1 mg/milliliter (ml) give 2 mg every breakfast, and Phenobarbital 32.4 mg daily at breakfast and lunch.
On 8/23/23 at 9:25 AM observed R16 seated in a geriatric chair across from the nurses station, common area. R16 was crying loudly and pulling a blanket over her head. V19, Social Service Director talked to R16 for several minutes and R16 continued to cry and pull blanket over her head.
On 8/23/23, during continuous call light observations from 9:30 am - 11:30 am, R16 continued to cry and yell out. Multiple unidentified staff spoke to R16 as she continued to cry. At approximately 11:00 AM (after uninterrupted crying in the common area) R16's geriatric chair was pushed into the resident dining room. R16 continued to cry and scream uncontrollably and could be heard at the nurses station during continuous call light observations.
On 8/23/23 at 11:55 am R16 was reclined in her geriatric recliner, still screaming, and crying in the dining room.
On 8/23/23 at 12:20 PM R16 was assisted out of the dining room and taken to her room, by unidentified staff. R16 was still crying.
On 8/23/23 at 2:31 PM Observed R16 lying in bed crying and loudly screaming out 'help me'.
4.) R17's Physician Order Sheet (POS) dated August 2023 documents physician orders for Clopidogrel Bisulfate Tablet 75 MG give daily at breakfast for blood clot prevention, Digoxin Tablet 125 micrograms (mcg) daily at breakfast for Heart Failure, Metoprolol Succinate Emergency Release (ER) Tablet Extended Release give 25 mg daily at breakfast and Spironolactone 12.5 mg daily at breakfast for Hypertension.
R17's Medication Administration Record (MAR) dated August 2023 does not document medication administration for Clopidogrel Bisulfate Tablet 75 mg give daily at breakfast, Digoxin Tablet 125 micrograms (mcg) daily at breakfast, Metoprolol Succinate Emergency Release (ER) Tablet Extended Release give 25 mg daily at breakfast and Spironolactone 12.5 mg daily at breakfast.
On 8/23/23 at 2:20 PM Observed V10 Licensed Practical Nurse (LPN) and V21 LPN both at one medicine cart administering medications on East Hall of facility.
On 8/23/23 at 2:22 PM V10 LPN stated, I was asked to come in extra today because the regular day shift nurse called in. I just got here and am trying to decide where to start because nothing has been done all day.
On 8/23/23 at 2:25 PM V21 LPN stated, I normally work 7:00 AM-3:30 PM as the wound nurse. I came in this morning and was told to take the medication cart for East Hall because the day shift nurse called off at the last minute around 7:05 AM. I have been busy all day but have not had time to pass any medications. Literally I have not given out any pills yet to any of the residents on East Hall. I didn't even have time to ask for any help. This has been a crazy day. I feel bad. I hope nobody has any medical problems from not getting their pills today. I would feel awful for that.
On 8/23/23 at 3:00 PM V2 Director for Nurses (DON) state, (V21) Licensed Practical Nurse (LPN) not passing any medications for an entire hall for eight hours is completely unacceptable. V2 stated, Those residents could have strokes, behaviors, need extra insulin or any number of medical problems. I mean the doctor orders those for a reason. I will have to call our medical director (V20) about this.
On 8/23/23 at 4:30 PM V2 Director of Nurses (DON) stated, I called (V20) Medical Director about all of those residents not getting any of their pills today. (V20) was pretty upset about it. We (facility) are going to give all the daily meds now and anything that was prescribed more than once today will receive their first dose now and the second dose at 11:00 PM tonight. I will be filling out medication error reports until next week.
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 F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure food was not overcooked. This failure affects five of (R1, R2, R3, R5, R6) 12 residents reviewed for food palatability ...
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Based on observation, interview, and record review the facility failed to ensure food was not overcooked. This failure affects five of (R1, R2, R3, R5, R6) 12 residents reviewed for food palatability in the sample list of 22.
Findings include:
The Resident Council Meeting Minutes dated 7/25/23 documents, eggs are burnt.
On 8/22/23 at 10:30 AM V6 (R2's Power of Attorney) stated the food is often overcooked, It is horrible. V6 stated last week the chicken was hard and V6 had to ask for R2's food to be pureed since R2 had difficulty chewing the food.
On 8/22/23 at 12:00 PM R3 was eating lunch in R3's room. R3's meal tray included ravioli, broccoli, and bread. At 12:10 PM R3 stated the broccoli is overcooked and did not have much flavor. R3 ate R3's ravioli and a cup of broccoli remained on R3's meal tray. V6 was feeding R2 (R3's roommate). R2's meal tray included ravioli and broccoli. V6 stated the broccoli is overcooked.
On 8/22/23 at 12:27 PM R6 stated R6 did not care very much for the broccoli. Broccoli was observed left on R6's meal tray and R6 had eaten all R6's ravioli.
On 8/22/23 at 12:57 PM R1 stated R1 refuses to eat the facility's food because it is terrible and overcooked. R1 stated last Thursday R1 did not eat the chicken breast, because it was burnt and hard. On 8/23/23 at 9:39 AM V22 (R1's Family Member) stated last Thursday R1's lunch tray had chicken breast that was crispy and the top was dark/burnt, and the peas were dried up. R1 did not eat any of that meal.
On 8/23/23 at 9:58 AM R5 stated last Thursday the chicken was so overcooked and dry that R5 could not eat it. R5 stated the food is often overcooked and served cold.
On 8/22/23 at 12:07 PM a sample test tray was tasted. The broccoli was pale green, mushy, and flavorless.
On 8/22/23 at 12:18 PM V8 Certified Nursing Assistant stated the residents complain of the chicken being dry and having difficulty cutting and chewing the meat. Last week the chicken at lunch was burnt.
On 8/22/23 at 1:28 PM V11 Dietary Manager stated the broccoli was mushy probably because V7 [NAME] cooked it in too much water. We had previously been asked to cook it longer because it had been too tough. V11 stated V7 was the cook today and was also the cook this past Thursday. V11 moved V7 to dayshift so that V11 can coach V7 better. At 1:40 PM V11 stated V11 would expect staff to discard food that is cooked too long or burnt and make another batch. At 2:00 PM V11 stated V11 expects the staff to prepare food in accordance with the recipe. V11 confirmed food being overcooked only seems to be an issue when V7 is cooking. V11 stated the same problems were happening on night shift. V11 stated V11 was working in the other building today, so V11 was not able to provide much oversight/guidance to V7 for lunch preparation.
On 8/23/23 at 11:54 AM V7 [NAME] stated there were issues with the chicken breast last week, I (V7) baked it too long. V7 stated V7 boiled the broccoli yesterday, and let it sit/cook too long.
The facility's Week at a Glance Week 4 Menu documents on Thursday the noon meal included a fried chicken breast. The facility's recipe Fried Chicken Breast documents to dredge chicken in mixture of flour, dry milk, salt, paprika and pepper. Place the chicken breasts on a greased baking sheet, brush with melted margarine, and bake for 45 minutes to one hour at 350 degrees Fahrenheit (F.) until chicken is golden brown, tender, and has reached final cooking temperature. This recipe documents to cover the chicken with foil when the chicken starts to brown to quickly.
The facility's broccoli recipe documents to bring water to a boil in large pan, add broccoli, and cook until fork tender and desired internal temperature of 135 F. is reached.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure staff had access to Personal Protective Equipment (PPE) while under COVID-19 outbreak status, failed to wear appropriate...
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Based on observation, interview and record review the facility failed to ensure staff had access to Personal Protective Equipment (PPE) while under COVID-19 outbreak status, failed to wear appropriate PPE while providing direct cares for COVID-19 positive residents (R1, R7, R9, R10, R18, R22), failed to post isolation signage for COVID-19 positive rooms, and failed to maintain current/accurate infection control logs. These failures affect eight residents (R1, R4, R6, R7, R9, R10, R18, R22) of 11 residents reviewed for infection control in the sample list of 22 residents.
Findings include:
1.) R4's Concern/Compliment Form dated 8/17/23 documents staff were not wearing Personal Protective Equipment (PPE) when entering/exiting resident isolation rooms. The Reeducation Memo dated 8/17/23 with incident date of 8/16/23, documents a concern that V14 CNA was not wearing PPE in COVID-19 positive rooms and V14 was re-educated on the importance of PPE.
On 8/22/23 at 11:29 AM R4 stated last Thursday R4 witnessed V14 CNA enter a COVID-19 positive room and V14 was not wearing a gown, gloves, mask, or face shield. V14 left the positive room and then provided care for other unidentified residents who were not COVID-19 positive. R4 reported this to V1 Administrator.
2.) R9's Rapid Point of Care Testing Report dated 8/22/23 documents a positive result for COVID-19 rapid test.
On 8/23/23 at 11:40 AM observed R9's room door closed with no signs posted regarding R9's contact precaution status. There was an isolation three drawer bin sitting outside R9's room with no N95 masks and no gowns available.
On 8/23/23 at 12:30 PM observed R9's room door closed with no signs posted regarding R9's contact precaution status. There was an isolation three drawer bin sitting outside R9's room with no N95 masks and no gowns available.
On 8/23/23 at 2:10 PM observed R9's room door closed with no signs posted regarding R9's contact precaution status. There was an isolation three drawer bin sitting outside R9's room with no N95 masks available.
On 8/23/23 at 2:15 PM Observed V18 Certified Nurse Aide (CNA) enter COVID-19 positive (R9, R10) room wearing two surgical masks, gown, gloves and face shield. V18 was not wearing an N95 mask.
On 8/23/23 at 12:30 PM V18 Certified Nurse Aide (CNA) stated, I put on a gown, gloves, face shield and two surgical masks when I care for (R9, R10). We (facility) run out of the N95 masks all the time. I don't want to get the COVID-19 so I just use double layer of surgical masks.
3.) R10's Rapid Point of Care Testing Report dated 8/23/23 documents a positive result for COVID-19 rapid test.
On 8/23/23 at 11:40 AM observed R10's room door closed with no signs posted regarding R10's contact precaution status. There was an isolation three drawer bin sitting outside R10's room with no N95 masks and no gowns available.
On 8/23/23 at 12:30 PM observed R10's room door closed with no signs posted regarding R10's contact precaution status. There was an isolation three drawer bin sitting outside R10's room with no N95 masks and no gowns available.
On 8/23/23 at 2:10 PM observed R10's room door closed with no signs posted regarding R10's contact precaution status. There was an isolation three drawer bin sitting outside R10's room with no N95 masks available.
On 8/23/23 at 2:15 PM Observed V18 Certified Nurse Aide (CNA) enter COVID-19 positive (R9, R10) room wearing two surgical masks, gown, gloves and face shield. V18 was not wearing an N95 mask.
On 8/23/23 at 12:28 PM V25 Licensed Practical Nurse (LPN) observed wearing surgical mask pulled below chin.
On 8/23/23 at 12:29 PM V25 Licensed Practical Nurse (LPN) stated, I had nasal surgery so it makes it difficult to breathe in these masks. I know this building is in an COVID-19 outbreak status but if I wear my mask like I am supposed to then it fogs my glasses and I can't see.
On 8/23/23 at 12:39 PM V23 Housekeeper stated (R9, R10) are both on isolation for COVID-19. They (R9, R10) both live in the same room. That is the only isolation room on this (East) hall. We (facility) are supposed to wear N95 masks to go in (R9, R10) the room but we (facility) are always out. I put on two surgical masks instead. I hope that works.
On 8/23/23 at 1:10 PM V24 Environmental Services Director stated, The PPE supplies should be kept in the isolation bins outside resident rooms. If the supplies are out then we (staff) just have to make do until the truck comes in. The PPE supplies are kept in the nurses medication storage room, the CNA storage closet or the outside storage shed.
On 8/23/23 at 1:20 PM observed nurses medication storage room, the CNA storage closet and the outside storage shed to not have any N95 masks. Observed eight small boxes of N95 masks in Director of Nurses (DON) office.
4.) R7, R18 and R22's Rapid Point of Care Testing Report dated 8/14/23 documents a positive result for COVID-19 rapid test.
On 8/22/23 at 3:13 PM V12 CNA stated she wears an N95 mask, gown, and gloves into COVID-19 positive rooms, and COVID-19 rooms are located on the [NAME] Hall. V12 stated V12 did not wear eye protection when V12 provided care for COVID-19 positive residents R7 and R18. V12 stated the facility does not dedicate staff to provide care for COVID-19 positive residents and whoever is assigned to the hall provides care for both positive and negative residents.
On 8/23/23 at 11:31 AM V14 CNA stated the carts outside of the COVID-19 isolation rooms did not contain face shields, and therefore V14 did not wear face shields into the positive rooms. V14 stated last week V14 entered R18/R22 COVID-19 positive residents' room to turn off the call light. V14 stated V14 was not wearing a gown since V14 was not going to be in the room very long and did not apply an N95 mask prior to entering. V14 stated there were no N95 masks available in the PPE cart outside of the isolation room. V14 confirmed V14 was assigned to provide care for both COVID-19 positive and negative residents.
On 8/23/23 at 1:25 PM V2 Director of Nurses (DON) stated, These (eight boxes) boxes of N95 masks are the only ones we (facility) has. I keep them in my locked office so the staff don't use too many. The staff use them for residents that don't require an N95 and that is why we (facility) are out so often. That is why I have to keep them locked away. The overnight and weekend staff do not have keys to the office but I could come in if I had to. Our staff should not be wearing two surgical masks to care for COVID-19 positive residents. That is a good way to possibly spread COVID-19. All of our staff and residents who are COVID-19 positive all started on the same hall (East) so maybe that is why.5.) R1's Rapid Point of Care Testing Report dated 8/17/23 documents a positive result for COVID-19 rapid test.
On 8/22/23 at 9:33 AM observed V1 Administrator not wearing a surgical mask and walked up the [NAME] Hall which contained a COVID-19 positive room (R1).
On 8/22/23 at 9:44 AM and 12:57 PM R1's room door was closed and contained a sign to see the nurse prior to entering. The sign did not indicate the type of isolation precautions or what PPE is to be worn when entering the room. On 8/22/23 at 12:57 PM R1 stated R1 is COVID-19 positive and sometimes R1 must stop unidentified staff at the door, because they try to enter without wearing the proper PPE.
On 8/22/23 at 2:05 PM V2 stated staff should wear surgical masks when on hallways with COVID-19 positive residents.
6.) The facility's 2023 Infection Control Logs provided by V2, do not document R1's and R6's wound infections in July/August 2023.
R1's Care Plan revised 8/14/23 documents R1 is on antibiotics for a wound infection. This Care Plan documents R1's diagnoses include Left Artificial Knee Join and Aftercare Following Joint Replacement Surgery. R1's Order Summary Report dated 7/23/23-8/23/23 documents an order dated 8/10/23 for Bactrim (antibiotic) DS (Double Strength) Oral Tablet 800-160 Mg (milligrams) give one tablet by mouth twice daily for 2 weeks for wound infection.
R6's Care Plan revised 7/31/23 documents R6 has a wound infection of the left great toe and is receiving antibiotic therapy. R6's Order Summary dated 7/1/23-8/23/23 documents orders to administer Bactrim DS 800-160 mg by mouth twice daily for toe infection for 14 days beginning on 7/6/23 and again on 7/28/23 and administer Ceftriaxone (antibiotic) 1 gram intramuscularly daily for 14 days for toe infection beginning on 7/10/23. R6's Toe Wound Culture dated as reported on 7/8/23 documents Heavy Morganella morganii (bacterial growth) and this organism was resistant to Bactrim DS.
On 8/23/23 at 11:25 AM V2 Director of Nursing/Infection Preventionist confirmed R1's and R6's wound infections should be listed on the facility's Infection Control Logs.
The facility's Infection Prevention and Control Program documents the following: Antibiotic use will be logged and tracked. Periodic observations of care will be conducted based on identified infection trends.
The facility policy titled 'Infection Control-Interim COVID-19 Policy' revised June 2023 documents staff caring for residents with suspected or confirmed SARS CoV2 infection, an N95 respirator should be worn and the N95 should be removed and discarded after the resident care encounter and a new one should be donned. This policy documents staff entering a COVID-19 positive room should wear a gown, N95 respirator, gloves, and eye protection; and staff should wear source control (masks) when on hallways where COVID-19 positive residents reside.
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 F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to offer and administer COVID-19 vaccination boosters to four (R1, R3, R7, R8) residents of five residents reviewed for COVID-19 vaccinations i...
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Based on record review and interview the facility failed to offer and administer COVID-19 vaccination boosters to four (R1, R3, R7, R8) residents of five residents reviewed for COVID-19 vaccinations in a sample list of 22 residents.
Findings include:
1.) R1's undated face sheet documents diagnoses of Malignant Neoplasm of Lung, Pulmonary Embolism with Acute Cor Pulmonale, Reduced Mobility and History of COVID-19. This same face sheet documents R1's admission date of 7/1/23.
R1's medical record does not document any education provided regarding COVID-19, nor does it document a bivalent COVID-19 booster being offered or administered. R1's medical record documents COVID-19 vaccinations were administered on 9/21/21, 10/14/21 and 8/1/22. No further COVID-19 vaccination boosters were documented as offered or administered.
2.) R3's undated face sheet documents a diagnosis of End Stage Renal Disease, Hypertension and Dependence on Renal Dialysis. This same face sheet documents R3's admission date of 6/19/23.
R3's medical record does not document any education provided regarding COVID-19, nor does it document a bivalent COVID-19 booster being offered or administered. R3's medical record documents COVID-19 vaccinations were administered on 1/13/22 and 2/8/22. No further COVID-19 vaccination boosters were documented as offered or administered.
3.) R7's undated face sheet documents a diagnosis of: Metabolic Encephalopathy, Alcoholic Cirrhosis of the Liver with Ascites, Coagulation Defect, Anemia and Protein Calorie Malnutrition. This same face sheet documents R7's admission date of 7/17/23.
R7's medical record does not document any education provided regarding COVID-19, nor does it document a bivalent COVID-19 booster being offered or administered. R7's medical record documents COVID-19 vaccinations were administered on 8/2/21 and 9/9/21. No further COVID-19 vaccination boosters were documented as offered or administered.
4.) R8's undated face sheet documents a diagnosis of Cerebral Aneurysm, Pulmonary Nodule, Adult Failure to Thrive and History of COVID-19. This same face sheet documents R8's admission date of 4/21/23.
R8's medical record does not document any education provided regarding COVID-19, nor does it document a bivalent COVID-19 booster being offered or administered. R8's medical record documents COVID-19 vaccinations were administered on 4/3/21 and 5/4/21. No further COVID-19 vaccination boosters were documented as offered or administered.
On 8/23/23 at 2:05 PM V2 Director of Nurses (DON)/Infection Preventionist (IP) stated I have only been at this facility since the beginning of July 2023 but I looked through all of the papers and could not find any documentation for (R1, R3, R7, R8) being offered nor administered any type of COVID-19 vaccinations or boosters when they (R1, R3, R7, R8) admitted . I don't think the admission nurses are even asking about any immunizations. All that we (facility) have is whatever is documented in the Electronic Medical Record (EMR). There are some very sick residents here (facility) who would benefit from the COVID-19 vaccination or boosters.
The facility policy Offering COVID-19 Vaccine and Education revised August 2023 documents when COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized. Before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. In situations where COVID-19 vaccination requires multiple doses the resident, the resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects. The resident's medical record includes a declination form if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide incontinence care for one of three residents (R3) reviewed f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide incontinence care for one of three residents (R3) reviewed for incontinence care in the sample of three.
Findings Include:
On 7/8/23 at 4:30 PM R3 stated about four out of five nights staff does not check on her during the night shift and she wakes up very wet in the morning. Often the day shift Certified Nurses Assistants ask her if she was changed during the night because she is often soaked when they get her cleaned up and dressed for the day. R3 stated just this morning (7/8/23) she woke up soaking wet and she told the day shift staff that night shift had not checked on her and did not change her at all overnight. R3 stated she knows staying clean and dry is important because she wants to avoid skin breakdown and she has a history of urinary tract infections which she wants to avoid.
On 7/8/23 at 1:31 PM V10 Certified Nurses Assistant (CNA) stated she has come onto her day shift and found residents soaking wet. V10 stated that in fact this morning (7/8/23) she came on shift and found R3 soaking wet. R3 told V10 that staff had not come in to change her all night long. V10 stated R3 often has this complaint. R3's night gown, pad, and depend were all soaked with urine and V10 could tell she hadn't been changed in a long time.
On 7/8/23 at 5:00 PM V4 Assistant Director of Nurses (ADON) stated there is no excuse for the staff not changing R3 when she is incontinent and for her to be waking up soaked. V4 confirmed staff should be checking all incontinent residents every two hours even if they are sleeping in order to keep them clean and dry.
R3's Medical Diagnoses dated July 2023 documents R3 is diagnosed with Chronic Kidney Disease, Urinary Tract Infections, and Diabetes.
R3's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively intact and is totally dependent on at least two staff for physical assistance with toileting.
R3's Care Plan dated 5/3/23 documents R3 is at risk for impaired skin integrity and has bladder and bowel incontinence. Staff are to check R3 frequently, provide perineal care after each incontinence episode, and keep R3's skin clean and dry.
The facility's Incontinence Care policy dated March 2023 documents in order to prevent discomfort, excoriation, skin breakdown, and maintain dignity staff will check residents with incontinence at least every two hours or more if needed and will provide perineal care after each incontinence episode.
Jul 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of abuse to the state survey agency for two (R1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of abuse to the state survey agency for two (R1, R2) of four residents reviewed for abuse in the sample list of seven.
Findings include:
The facility's Abuse Prevention and Reporting policy dated as last revised October 2022 documents: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the
Department of Public Health immediately, but not more than two hours after the allegation of abuse.
On 6/29/23 at 8:49 AM R2 stated R1 (R2's roommate) is blind and cries out a lot. R2 stated on an unidentified date a Certified Nursing Assistant (V3) gave R1 liquid medication in R1's juice and R1 slept the rest of that day. R2 stated V3 obtained the bottle of medication from V3's personal bag. R1 stated R1 knew it wasn't right, so R1 reported the incident to V1 Administrator and to the head nurse (V2 Acting Director of Nursing (DON)).
R1's Minimum Data Set (MDS) dated [DATE] documents, R1 has a BIMs (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment, and R1 had verbal behaviors directed towards others 4-6 days during the 7-day review period.
R2's MDS dated [DATE] documents R2 has a BIMs score of 13, indicating R2 is cognitively intact.
On 6/29/23 at 12:06 PM V2 Acting DON stated sometime in May on second shift, V16 Licensed Practical Nurse told V2 that R2 reported a CNA had given R1 medication. V2 stated R2 told V2 that V3 gave R1 red cough medicine so that R1 could go to sleep. V2 stated it was reported on second shift and at that time R1 was alert and singing. V2 spoke with V3 and V22 Registered Nurse. V22 reported giving R1's liquid Valproic Acid medication, which is a red liquid, and V3 was also present at the time providing care to R1. V2 stated V2 spoke with V3 who reported R1 was awake and alert that shift and ate well. V3 reported V22 had given R1's medications, and V3 denied administering medications to R1. V2 stated V2 reviewed R1's medication orders and medication administration records, and R1 receives a red liquid medication Valproic Acid. V2 stated V2 reported R2's allegation to V1 Administrator immediately after R2 reported the allegation. V2 stated V2 did not think it was abuse because R1 was not drowsy. V2 stated V2 notified R1's physician that there was a possible medication error. V2 stated a CNA administering medications would be considered outside of their scope of practice and could possibly be considered an abuse allegation.
On 6/29/23 at 11:44 AM V1 Administrator confirmed the facility does not have an abuse allegation or investigation involving R1 being given medication from a Certified Nursing Assistant. On 7/3/23 at 9:12 AM V1 confirmed V1 was aware of an alleged incident that V3 administered medication to R1. V1 stated based on available information we ruled out immediately that abuse did not occur based on R1 being at/above R1's baseline, with no indication that R1 was drowsy. V1 stated V1 spoke to the nurse and V3 CNA and there was no indication that V3 had given R1 medication. V1 stated V1 did not consider this allegation to be an allegation of abuse since abuse was determined not to have occurred, and confirmed this allegation was not reported to the Illinois Department of Public Health (IDPH). V1 stated abuse allegations are to be reported to IDPH within two hours.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document and thoroughly investigate an allegation of staff to reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document and thoroughly investigate an allegation of staff to resident abuse for two (R1, R2) of four residents reviewed for abuse in the sample list of seven.
Findings include:
The facility's Abuse Prevention and Reporting policy dated as last revised October 2022 documents: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property to the administrator or an immediate supervisor who must then immediately report it to the administrator or the person acting as administrator in the administrator's absence. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Reports should be documented and a record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act as administrator in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation.
On 6/29/23 at 8:49 AM R2 stated R1 (R2's roommate) is blind and cries out a lot. R2 stated on an unidentified date a Certified Nursing Assistant (V3) gave R1 liquid medication in R1's juice and R1 slept the rest of that day. R2 stated V3 obtained the bottle of medication from V3's personal bag. R1 stated R1 knew it wasn't right, so R1 reported the incident to V1 Administrator and to the head nurse (V2 Acting Director of Nursing (DON)).
R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a BIMs (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment, and R1 had verbal behaviors directed towards others 4-6 days during the 7-day review period.
R2's MDS dated [DATE] documents R2 has a BIMs score of 13, indicating R2 is cognitively intact.
On 6/29/23 at 12:06 PM V2 Acting DON stated sometime in May on second shift, V16 Licensed Practical Nurse told V2 that R2 reported a CNA had given R1 medication. V2 stated R2 told V2 that V3 gave R1 red cough medicine so that R1 could go to sleep. V2 stated it was reported on second shift and at that time R1 was alert and singing. V2 spoke with V3 and V22 Registered Nurse. V22 reported giving R1's liquid Valproic Acid medication, which is a red liquid, and V3 was also present at the time providing care to R1. V2 stated V2 spoke with V3 who reported R1 was awake and alert that shift and ate well. V3 reported that V22 had given R1's medications, and V3 denied administering medications to R1. V2 stated V2 reviewed R1's medication orders and medication administration records, and R1 receives a red liquid medication Valproic Acid. V2 stated V2 reported R2's allegation to V1 Administrator immediately after R2 reported the allegation. V2 stated V2 did not think it was abuse because R1 was not drowsy. V2 stated V2 notified R1's physician that there was a possible medication error. V2 stated a CNA administering medications would be considered outside of their scope of practice and could possibly be considered an abuse allegation. V2 confirmed V2 had no documentation of V2's investigation into this alleged incident, including staff and resident interviews.
On 6/29/23 at 11:44 AM V1 Administrator confirmed the facility does not have an abuse allegation or investigation involving R1 being given medication from a Certified Nursing Assistant. On 7/3/23 at 9:12 AM V1 confirmed V1 was aware of an alleged incident that V3 administered medication to R1. V1 started this alleged incident was reported on 6/10/23. V1 stated based on available information we ruled out immediately that abuse did not occur based on R1 being at/above R1's baseline, with no indication that R1 was drowsy. V1 stated V1 spoke to the nurse and V3 CNA and there was no indication that V3 had given R1 medication. V1 stated V1 did not consider this allegation to be an allegation of abuse since abuse was determined not to have occurred. V1 stated normal protocol for abuse allegations involve talking with staff and residents who work with the alleged employee and reviewing the employee's personnel file. V1 stated V1 documents the steps taken for the investigation, including interviews conducted, and this is summarized on the final report. V1 stated V1 thought V2 had spoken to additional CNAs inquiring how R1 was the day of the alleged incident.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide timely response to care requests, provide assi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide timely response to care requests, provide assistance with transfers out of bed, and provide timely incontinence care for five residents (R1, R2, R3, R4, R5) reviewed for assistance with activities of daily living in the sample list of seven.
Findings include:
1.) R1's Minimum Data Set, dated [DATE] documents: R1 has a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. R1 is dependent on assistance of two staff for transfers and one staff for toileting. R1 is always incontinent of bowel and bladder.
R1's Care Plan revised on 3/7/23 documents R1 has an activity of daily living self-care deficit. R1 is totally dependent on staff for toileting and uses a mechanical lift for transfers. R1's Care Plan revised on 6/1/23 documents. R1 has bowel and bladder incontinence with interventions including the use of incontinence briefs and to check and change R1's brief frequently and as required.
On 6/29/23 at 8:56 AM, 10:43 AM, and at 11:42 AM R1 was sitting in a reclining back geriatric chair in R1's room. On 6/29/23 at 12:59 PM and 1:14 PM R1 was sitting in R1's geriatric chair in the dining room.
On 6/29/23 at 1:26 PM V8 Certified Nursing Assistant (CNA) stated R1 was last offered to lay down and be changed around 11:00 AM, but R1 refused. V8 stated R1 was gotten up before V8 came on duty and was last changed by night shift staff at an unknown time. V8 stated V8's shift began at 7:00 AM. V8 and V15 CNAs transferred R1 with a full mechanical lift from the geriatric chair into bed. V8 provided R1's incontinence care. R1's brief was saturated with urine. V8 changed R1's cloth incontinence bed pad that was wet with urine. V8 stated, We check for and provide incontinence care every 2 hours, but R1 is not a heavy wetter and R1 getting up and down frequently causes R1 to have behaviors.
On 6/29/23 at 3:02 PM V2 Acting Director of Nursing (DON) stated residents are to be checked and provided incontinence care at least every two hours.
2.) R2's MDS dated [DATE] documents R2 is cognitively intact and is dependent on assistance of two staff for transfers.
On 6/29/23 at 8:41 AM R2 was lying in bed. R2 stated R2 likes to attend activities such as BINGO, but R2 has not been able to attend due to R2's wheelchair being broken for the last two weeks. R2 stated today is the June birthday celebration in the dining room and R2 would like to attend. R2 stated R2 won't be able to attend because the staff do not transfer R2 out of bed due to R2's chair being broken. At 10:43 AM, 11:42 AM, and 1:46 PM R2 was lying in bed.
On 6/29/23 at 1:33 PM V8 CNA stated R2 usually transfers out of bed, but R2's (reclining geriatric chair) has been broken for a couple of weeks.
On 6/29/23 at 3:02 PM V2 Acting Director of Nursing stated residents should be transferred out of bed per their preference. V2 stated R2's chair is not broken, R2 just slides down in the chair because the foot rest won't elevate. V2 stated V10 Maintenance is aware and R2 has been working with therapy to evaluate R2's wheelchair. V2 stated the facility would have gotten R2 a different wheelchair if R2 had requested one so that R2 could get out of bed.
3.) On 6/29/23 at 10:26 AM R3 stated R3 receives dialysis three times per week and must leave the facility between 7:15 and 7:30 AM. R3 stated R3 wakes up at 5:30 AM and turns on R3's call light to request a basin of water to wash up and get ready for dialysis. R3 stated sometimes it takes staff a long time to answer R3's call light and bring the water. R3 stated R3 had an additional day of dialysis scheduled on 6/17/23. R3 turned on R3's call light at 5:30 AM. R3 stated R3 fell back asleep and R3's call light was still on at 7:00 AM when R3 woke up. R3 stated no one had answered the call light, brought R3's water, or woke R3 up. This caused R3 to be late for R3's dialysis session.
R3's MDS dated [DATE] documents R3 is cognitively intact, requires limited assistance of one staff person for personal hygiene, and requires physical staff assistance with bathing.
R3's Nursing Note dated 6/16/2023 at 11:53 AM documents R3 was scheduled for additional dialysis on 6/17/23 and needed to be transported at 7:30 AM.
The facility's call light logs document on 6/17/23 R3's call light was activated at 5:05 AM and cleared at 7:11 AM, over 2 hours later. R3's call light was activated on 7/2/23 at 5:49 PM and cleared at 6:53 PM (64 minutes) and activated at 12:22 PM and cleared at 1:35 PM (73 minutes).
4.) R4's MDS dated [DATE] documents R4 is cognitively intact, is frequently incontinent of urine, is always incontinent of bowel, and is dependent on two staff for assistance with transfers and one staff for assistance with toileting.
R4's Care Plan revised 6/4/23 documents R4 has mixed bladder incontinence and paralysis. The Care Plan includes an intervention to check for incontinence every two hours and as required, and wash/rinse/dry perineum. R4's care plan does not document that R4 refuses to get out of bed.
On 6/29/23 at 9:36 AM R4 was lying in bed. R4 stated it takes 1.5-2 hours for staff to answer R4's call light. R4 stated R4 stays wet a lot. Staff first changes R4 in the morning and at 2:00 PM, and then R4 is not changed again until 8:00 PM. R4 stated R4 is changed at 11:00 PM and then not again until 6:45 AM. R4 stated R4 was last changed at 6:45 AM today. R4 stated when R4 calls to request to be changed the staff tell R4 that R4 must wait until the staff are doing rounds. R4 stated so now R4 does not call to request to be incontinence care and waits for the staff to conduct their rounds. R4 stated every time you walk through the halls the CNAs are on their cellular phones at the nurse's station and in the hallway instead of doing care and answering call lights. R4 stated R4 needs assistance to get out of bed and R4 must beg to get up and then to get back in bed. R4 stated R4 would like to get out of bed every day, but the staff leave R4 sitting in R4's wheelchair for 5 hours.
On 6/29/23 at 9:46 AM V13 CNA answered R4's call light and provided incontinence care as requested by R4. R4's brief was wet with urine. At 12:26 PM V13 CNA stated R4 was last changed on night shift at an unknown time. V13 stated we change residents every 2 hours on dayshift, but R4 is aware of R4's incontinence and uses the call light to request be changed.
On 6/29/23 at 10:06 AM V11 Housekeeping Supervisor stated we do have a lot of times where bed linens are soiled with urine and sent to laundry.
On 6/29/23 at 10:45 AM V25 Licensed Practical Nurse stated the CNAs sit at the desk on their cellular phones and do whatever they want and staff smoke breaks are a problem. These things affect care and call light response times.
On 6/29/23 at 10:54 AM V14 CNA stated V14 usually works night shift and rounds for incontinence care/checks are completed twice during the night, at the beginning and end of the shift. V14 stated we do have some bed linen changes in the morning due to incontinence.
On 6/29/23 at 11:35 AM V4 Registered Nurse stated all CNAs should assist in answering call lights and not just on their assigned halls. V4 stated the CNAs just sit at the desk and confirmed residents' incontinence care is not done timely. V4 stated, Look, there is a call light going off now and they are just sitting there. V15 and V13 CNAs were sitting at the nurse's station.
The facility's call light log documents R4's call light was activated on 7/2/23 at 11:27 AM and cleared at 12:19 PM (52 minutes) and activated on 5:58 AM and cleared at 6:35 AM (37 minutes). On 7/1/23 R4's call light was activated at 7:10 PM and cleared at 8:49 PM (99 minutes).
5.) On 6/29/23 at 9:44 AM R5 stated 2nd and 3rd shift take 2-3 hours to answer call lights. R5 stated R5 has witnessed staff taking excessive smoke breaks and they're always on their phones. R5 stated it isn't that they don't have enough staff.
R5's MDS dated [DATE] documents R5 is cognitively intact.
The facility's call light log documents R5's call light log documents R5's call light was activated on 7/3/23 at 5:32 AM and was cleared at 6:34 AM (62 minutes).
On 6/29/23 at 3:02 PM V2 stated residents should be gotten out of bed per their preference, and residents should be checked and provided incontinence at least every two hours. V2 stated refusals of care should be documented in the nursing notes and care plan. V2 stated V2 expects call lights to be answered timely, the facility has a lot of total care residents, and a 30-minute call light wait time would be considered acceptable. V2 stated anything more than an hour would be considered an unacceptable response time.
The facility's Call Light policy dated as revised January 2022 documents, Resident call lights will be answered in a timely manner.
The facility's Incontinence Care policy dated as revised April 2021 documents, Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode.
Mar 2023
28 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Based on interview and record review the facility failed to monitor weights, follow physician orders, and promptly report a s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Based on interview and record review the facility failed to monitor weights, follow physician orders, and promptly report a significant weight gain for a resident (R27) with a diagnosis of Congestive Heart Failure. These failures resulted in a delay in treatment for R27's significant weight gain and R27 being hospitalized for 10 days with congestive heart failure and fluid volume overload. R27 is one of 34 residents reviewed for change in condition on the sample list of 55.
Findings include:
b. The facility's Physician-Family Notification- Change in Condition dates as revised [DATE] documents the physician will be notified of changes in a resident's condition and when there is a need to alter treatment.
On [DATE] at 2:06 PM R27 stated: R27 told V18 Licensed Practical Nurse that R27's legs and stomach were swelled up bad. V18 disagreed with R27 that there was not fluid in R27's stomach. V18 told R27 that V18 contacted the Nurse Practitioner and told R27 to stay in bed for a few days. Nothing had changed, so the next day R27 told a nurse that R27 needed to go to the hospital. R27 stated, either the facility was going to send R27 to the hospital, or R27 was going to contact R27's family to take R27 to the hospital. R27 was put on emergency dialysis at the hospital.
R27's After Visit Summary dated [DATE] documents to monitor weight daily and take medications as instructed. R27's discharge medications include Bumex (diuretic) 2 milligrams (mg) by mouth twice daily, Coreg 12.5 mg by mouth twice daily, Hydralazine 50 mg by mouth twice daily, and Imdur 60 mg by mouth daily.
R27's Post-Acute Transition Document dated [DATE] documents R27 has Congestive Heart Failure, continue Bumex (diuretic) 2 milligrams twice daily and R27 needs accurate intake/output monitoring. R27 has Chronic Kidney Disease Stage 4, needs hypertension controlled, and needs access for dialysis. R27's hypertension is uncontrolled and recommendations include Coreg, Hydralazine, and Imdur as listed previously. R27's weight upon discharge was 193 pounds (lbs.).
R27's [DATE] Medication Administration Record (MAR) documents: R27 had a daily fluid restriction of 1800 milliliters (ml) implemented on [DATE], 560 ml from nursing and 1240 ml from dietary. The intake is not recorded prior to night shift on [DATE]. 560 ml is incorrectly transcribed for 560 ml fluid allowance from nursing per shift, and not per day as ordered. R27 received more than the allotted 560 ml on 7 days between [DATE] and [DATE], including 1360 ml on [DATE], and 1400 ml on [DATE]. Daily weights were scheduled between [DATE] and [DATE], and do not document weights were obtained on 12/11-[DATE]. Bumex, Coreg, Hydralazine, and Imdur was not administered as ordered/scheduled on [DATE], and documents to refer to a nursing note. Post dialysis monitoring was initiated on [DATE].
R27's weight log dated [DATE] documents R27's weights as follows. [DATE] 191.2 lbs. (pounds), [DATE] 218.7 lbs. (27.5 lb. gain in 2 days). [DATE] 223.1 (additional 4.4 lb. gain in 6 days) and 223 on [DATE]. R27 had a total weight gain of 31.9 lbs. in 8 days.
R27's Nursing Notes documents R27 admitted to the facility on [DATE]. There is no documentation as to why R27's medications were not given on [DATE], or that the physician was notified of the missed doses. The Nurse Practitioner Progress Note with effective date of [DATE] and created date of [DATE] (late entry) documents: R27 recently admitted to the facility after a hospital admission for fluid volume overload and is scheduled to start dialysis in January. R27 had swelling to bilateral lower legs. R27's Chronic Kidney Disease was worsening and recommended to see a Nephrologist (kidney specialist) in one week.
R27's Nursing Note dated [DATE] at 9:59 AM documents R27 notified the nurse that R27 had gained 20 pounds since admission. R27 reported having difficulty breathing and requested to go to the emergency room. An ambulance was called and R27 was transported to the hospital. There is no documentation that R27's weight gain was reported to R27's physician after [DATE] or that an appointment was made for R27 to see a Nephrologist prior to [DATE].
R27's Hospital admission History & Physical dated [DATE] documents R27 presented to the emergency room for concerns of fluid overload. R27 reported gaining 20 pounds in one week and noted swelling in R27's lower legs and decreased urine output. R27's weight was 222 pounds on [DATE]. R27 had peripheral edema and course breath sounds. R27 was admitted for treatment of Congestive Heart Failure exacerbation.
On [DATE] at 1:44 PM V2 Director of Nurses stated the physician should be notified of a weight gain of 5 lbs. or more in a week for a resident with Congestive Heart Failure, and physician notification is documented in a progress note.
On [DATE] at 11:14 AM V2 stated intake/output is not recorded for fluid restrictions, dietary and nursing just give the designated amount. V2 confirmed a check mark on the MAR indicates medication was given. V2 stated a 9 on the MAR means other and prompts to record the reason the medications were not given in a nursing note. If a medication is not available the nurse should contact the pharmacy to have the medication delivered from a backup pharmacy, and the medications usually arrives within 4 hours. V2 reviewed R27's December MAR and confirmed the fluid restriction is incorrectly transcribed to allow for 560 ml fluids given by nursing per shift and not daily as ordered. V2 confirmed R27's medical record does not document daily weights were obtained between [DATE] and [DATE]. V2 was unable to provide documentation that R27 had seen a neurologist after [DATE], prior to [DATE].
On [DATE] at 10:00 AM V11 Nurse Practitioner stated the facility should have monitored R27's weights closely and followed up with the Nephrologist. Residents with Congestive Heart Failure should be weighed weekly and notified of weight changes per the physician's ordered parameter. V11 confirmed R27's Bumex should have been administered as ordered and the facility should have notified R27's physician of R27's significant weight gain prior to R27's hospitalization on [DATE]. V11 stated missed doses of Bumex could contribute to weight gain.
On [DATE] at 11:55 AM V26 Nephrologist stated: V26 began seeing R27 when R27 was admitted to the hospital for Congestive Heart Failure exacerbation and fluid volume overload on [DATE] and was dialyzed (fluid removed through dialysis). We were able to remove quite a bit of fluid weight off R27. R27 had Chronic Kidney Disease Stage 4 that progressed to Stage 5 gradually.
On [DATE] at 12:50 PM V1 Administrator stated the former Nurse Practitioner (V25) was not documenting her progress notes timely and charting during her visits. She was placed on suspension by her company due to not completing charting timely.
Failures at this level required more than one deficient practice statement.
A. Based on interview and record review the facility failed to address the physical needs of a resident by overlooking a provider ordered blood work-up for a resident experiencing weakness and feelings of impending death. This failure affects one of one resident (R114) reviewed for death on the sample list of 55. This failure resulted in R114 experiencing respiratory distress and being sent to the hospital. R114 was found to be hypoxic, expiring after cardiac arrest due to Severe Anemia, Adult Failure to Thrive, and Anorexia.
a. These failures resulted in an immediate jeopardy.
The Immediate Jeopardy began on [DATE] when the facility failed to follow through with an order for blood work. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 1:04 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training, conduct daily audits and hold weekly Quality Assurance meetings to ensure compliance.
Findings include:
R114's Death Certificate dated [DATE] documents R114 expired on [DATE] at 8:43 AM. This certificate documents R114 cause of death as Cardiac Arrest due to Severe Anemia and Failure to Thrive. This certificate documents other contributing factors as Anorexia.
R114's Progress Note written by V11 Nurse Practitioner dated [DATE] at 11:22 AM documents, New order blood work-up. This note also documents, ASSESSMENT/PLAN: #New order; Blood workup #Follow up visit; in one month or as needed. Plan of care discussed with nursing staff and patient.
On [DATE] at 10:20 AM, V11 Nurse Practitioner stated she evaluated R114 on [DATE] and that R114 told her she felt weak and felt like she wasn't going to make it. On [DATE] at 9:17 AM, V11 stated V11 was new to the facility and she saw R114 for the first time that day. V11 stated she gave a lab requisition to V13 Assistant Director of Nursing on [DATE]. V11 stated she ordered a Complete Blood Count (CBC), a Complete Metabolic Profile (CMP), a Thyroid Stimulating Hormone (TSH), Vitamin D, and Hemoglobin A1C.
R114's medical record does not contain orders for a CBC, CMP, TSH, Vitamin D, or Hemoglobin A1C after V11 made rounds on [DATE].
On [DATE] at 9:39 AM, V13 Assistant of Nursing stated she doesn't remember getting a lab order for R114. V13 stated V11 will fill out a lab requisition and then give it to me or the floor nurse. V13 stated then we take it and put an order into the computer. The lab will then come in and draw it. I am not aware of a change in condition. She wasn't a person we would talk about in clinical's. I guess we didn't notice her (R114) decline. We throw the lab requisitions away after a month. So that lab requisition would be recycled by now.
R114's nursing note written by V12 Licensed Practical Nurse dated [DATE] at 10:55 AM documents, Writer informed (V11) that (R114) is having abnormal breathing. (Blood pressure)123/58, (pulse) 77, (respirations) 30, (temperature) 98.0. (R114) has increased confusion. (V11) went and assessed (R114) and order to send (R114) to (emergency room) obtained. Writer called and notified ambulance of needed transport. Writer called and informed (V14) guardian of transport.
On [DATE] at 12:37 PM, V12 stated that morning ([DATE]) the CNAs (Certified Nursing Assistant) came to me and told me she wasn't breathing right I noticed her respirations were 30 and V11 came in and gave orders to send to the emergency room.
On [DATE] at 10:20 AM, V11 Nurse Practitioner stated she seen R114 on [DATE] and she was weak and telling her she wasn't going to make it. V11 stated she ordered labs and they never got done. V11 stated that when she returned on [DATE] that she sent her to the emergency room and she passed away. V11 stated if the labs were completed, I would have identified that she needed sent out. V11 stated that not getting the labs contributed to R114 expiring. They didn't notify me that she wasn't eating. They should call and tell me.
R114's Hospital notes dated [DATE] at 11:59 AM, document R114 was brought in via emergency medical services from the facility. R114 was diaphoretic, hypoxic, pale, and lethargic. These notes document the clinical impressions as Pneumonia of right lung due to infectious organism, Severe Anemia, Acute Renal Failure, Hyperkalemia, and Cardiac Arrest. These notes document that a Complete Metabolic Profile (CMP), a Pro time, a Lactic Acid, a Troponin and a Complete Blood Count (CBC)were obtained and all values were abnormal ([DATE] Laboratory results - CMP: Potassium 6.6 milliequivalent/Liter, Blood Urea Nitrogen (BUN) 125 milligrams/Deciliter, Albumin 2.6 grams/Deciliter, BUN to Creatinine Ratio 26 milligrams/Deciliter, A/G (Albumin/Globulin) ratio 0.7 grams/liter, GFR (Glomerular Filtration Rate) 9 milliliters/minutes; Lactic Acid 6.7 millimole/Liter; CBC: [NAME] Blood Cells 26.20 cells per microliter, Red Blood Cells 1.77 cells per microliter, Hemoglobin 5.8 grams per deciliter, Hematocrit 18.7 percent). These notes document that the hospital obtained consent for a blood transfusion and shortly afterwards R114 stopped breathing and went into asystole (heart stopped) and was pronounced dead at 1:08 PM. These notes documents R114's disposition as deceased .
On [DATE] at 1:00 PM, V2 Director of Nursing stated that after V11 visited and wanted blood work an order was not written in the EHR (Electronic Medical Record) to complete the blood work.
On [DATE] at 1:13 PM, V1 Administrator stated V11 was new to the building. V11 stated she heard there has been miscommunication between the nurses and V11. V1 stated the nurse managers should be reviewing progress notes after each visit to ensure all orders have been processed and written and then carried through. V1 stated the nursing staff should have called the physician and clarified what blood work needed obtained.
The facility's Lab policy with a revision date of 2/2023 documents, A requisition is to be completed and lab to be drawn on next scheduled lab draw day.
On [DATE] between 9:00 AM to 3:00 PM and on [DATE] between 9:00 AM to 11:00 AM, the surveyor confirmed through observation, interview, and record review that the facility took the following action to remove the immediacy:
1. On [DATE] at 1:59 PM, an audit was completed by V30 Regional Nurse Consultant to ensure all orders and labs are entered into the electronic health record.
2. On [DATE] at 2:21 PM, an audit was completed by V30 Regional Nurse Consultant to ensure all Nurse Practitioner Progress notes to ensure there were not missed orders for labs.
3. On [DATE] at 2:22 PM, all nursing staff were educated on physician notification of laboratory, radiology, diagnostic results policy, order transcription for labs, order entry requisitions, requirement to review all labs at end of shift to [NAME] lab work has been obtained after ordering, notification and documentation to medical providers and power of attorneys as needed by V30.
4. On [DATE] at 3:00 PM, V11 Nurse Practitioner was educated by V30 Regional Nurse Consultant on order entry into the electronic health record and the process on the 24-hour report review.
5. On [DATE], all other Nurse Practitioners working for the facility were educated on order entry and on the 24-hour report by V30 and V1.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0675
(Tag F0675)
A resident was harmed · This affected 1 resident
Based on observation, interview and record review the facility failed to develop a plan of care for skin impairment, monitor skin impairment, and notify the physician to alter treatment for one (R55) ...
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Based on observation, interview and record review the facility failed to develop a plan of care for skin impairment, monitor skin impairment, and notify the physician to alter treatment for one (R55) of two residents reviewed for skin conditions on the sample list of 55. These failures resulted in R55 developing psoriasis and erythema intertrigo to over half of her body. R55 experienced severe itching and pain that interfered with Activities of Daily Living and participation in activities.
Findings include:
On 3/12/23 at 11:21 AM R55 stated, Finally after all these weeks I get to see a dermatologist Tuesday (3/14/23). R55 stated R55 last saw a dermatologist for R55's psoriasis a few months ago. On 3/13/23 at 12:03 PM R55 stated R55 can't sit up in R55's wheelchair for extended periods or attend activities as often as R55 did previously due to R55's pain/itching caused from R55's psoriasis. R55 described the pain as an ache rated as an 8 on a 1-10 scale. R55 stated R55 itched R55's back so hard one time it bled. R55 became tearful and stated I (R55) just want to feel better.
On 3/12/23 at 10:54 AM V15 and V16 Certified Nursing Assistants entered R55's room and provided incontinence care. R55's incontinence brief was saturated with urine and a large amount of soft bowel movement. There was a small amount of urine on R55's bed sheets. There was a strong urine odor. R55's abdominal folds, groin, and underneath R55's breasts were red/inflamed. R55 said Ow when V15 cleansed R55's perineal area, groin, and abdominal fold. There were large scaly, red patches covering R55's back, buttocks, and posterior thighs. V15 stated R55 has had Psoriasis for a while now and this area (pointing to abdominal fold) looks worse.
R55's Diagnoses List dated 3/15/23 documents diagnosis of Psoriasis (skin disease with itchy, scaly patches, most commonly on the knees, elbows, trunk and scalp) as of 2/8/22 and Erythema Intertrigo (inflammation caused by skin-to-skin friction, often in warm, moist areas of the body, such as the groin, between folds of skin on the abdomen, under the breasts, under the arms or between toes) as of 9/26/19.
R55's Care Plan dated 9/1/21 documents R55 is at risk for skin impairment. Interventions include to administered medications, monitor the effectiveness, assess and record skin changes, avoid scratching, keep hands and body parts from excessive moisture, notify the physician of changes in skin condition, and wound doctor to assess and treat as needed. R55's Care Plan has not been updated since 9/1/21 and does not include R55's skin impairment and psoriasis.
R55's February and March 2023 Medication Administration/Treatment Administration Record (MAR/TAR) documents: R55 has received Ketoconazole Shampoo 2% topically to body twice weekly since 6/27/22 and Nystatin External Cream 100,000 Unit/gram topically to breasts and lower abdomen every 12 hours as needed for reddened areas as of 12/15/22. Nystatin is only documented as administered one time on 3/11/23. There are no other treatments for R55's skin impairment. R55's weekly skin assessments document a check as completed, but do not document a description of R55's skin.
R55's Skin Condition Report dated 1/28/23 documents R55 has moisture associated skin damage (MASD) and does not document the location or extent of the skin impairment. There are no other detailed skin assessments until 3/13/23. R55's 3/13/23 Skin Condition Report documents denuded/excoriation skin and MASD noted to groin, upper/mid back and under breasts. This report documents R55's skin condition was not new and did not warrant physician notification. R55's February and March 2023 Shower Sheets document R55 had reddened areas including R55's chest, back, buttocks and groin on 2/25, 3/1, 3/4, 3/8.
R55's Dermatology Progress Notes document R55 was evaluated on 9/30/22 for a rash beneath breasts and thighs. The rash is itchy and red/irritated. R55 had used topical steroids in the past that improved the rash. R55's diagnoses was Dermatitis and Triamcinolone 0.1% steroid cream was ordered for twice a day alternating between two weeks on and two weeks off. There is no documentation that R55's Dermatologist was contacted regarding R55's skin condition after 9/30/22, or that R55's skin condition was reported to R55's physician in February or in March 2023. R55's Dermatology After Visit Summary dated 3/14/23 documents: R55 has diagnoses of Psoriasis Vulgaris and Erythema Intertrigo, and orders for Triamcinolone 0.1% topical ointment applied to body twice daily for two weeks on and then two weeks off. New orders were given for the following laboratory tests for Complete Blood Count, Comprehensive Metabolic Panel, Hepatitis B Surface Antigen, human immunodeficiency virus Ag/AB screen, and tuberculosis infection QuantiFERON.
V23 Physician Progress Note dated 1/18/23 documents R55 has severe Psoriasis and Candidal Dermatitis (fungal infection). R55 receives Hydroxyzine 50 milligrams twice daily for refractory pruritis (itching not responding to system treatment). R55's active medication list includes Calcipotriene 0.005 % (psoriasis treatment) topically to psoriatic patches twice daily x 21 days, Betamethasone Dipropionate 0.05 % steroid cream topically to psoriatic patches daily x 21 days and (over the counter medicated power) twice daily x 21 days. V11 Nurse Practitioner Progress Note dated 3/6/23 documents R55 was evaluated for an eye infection. This note documents R55 had Psoriatic skin lesions to back of left thigh, between 2 legs, left arm fold, and back, and intermittent itching with Diflucan (antifungal) prescription. This note does not document new orders or adjustments in R55's psoriasis treatment. There is no documentation that R55 received Diflucan in February or March 2023.
On 3/12/23 at 1:48 PM V13 Licensed Practical Nurse stated: R55 does not have any scheduled treatments. R55 refuses to get out of bed and refuses R55's showers. R55's groin looks raw and it is really red. It flares up, goes away, and comes back again. R55 had a flare up and was supposed to see a dermatologist in December 2022. Treatment orders were implemented at that time. We have also had changes in the last three months with our physicians and nurse practitioners as well.
On 3/14/23 at 9:04 AM V2 Director of Nursing (DON) stated skin assessments are completed weekly and recorded on the MAR/TAR with a check mark indicating completed. V2 confirmed the MAR does not document a description of the resident's skin. V3 Psychiatric Rehabilitation Services Director stated the facility also uses skin assessments to document resident's skin assessments.
On 3/14/23 10:40 V13 Assistant DON stated V13 oversees skin/wounds in the facility. V13 stated R55 has psoriasis and excoriation of the grain. R55 sees a dermatologist, but was last seen a few months ago, has Ketoconazole shampoo and Nystatin ordered. V13 confirmed Nystatin is as needed and R55 has no topical creams scheduled routinely. V13 stated the nurses should follow up with the dermatologist when R55's skin conditions worsen or flair up to adjust R55's treatment orders.
On 3/14/23 at 11:46 AM V13 Assistant Director of Nursing stated skin conditions are expected to be on the resident's care plan.
On 3/14/23 at 4:18 PM V1 Administrator provided R55's 9/30/22 dermatology notes. V1 stated: 9/30/22 was the last time that R55 was evaluated by a dermatologist. R55 had COVID-19 in January 2023, and V1 wonders if staff had canceled a prior appointment and forgot to reschedule during that time. Either way we dropped the ball on this.
On 3/14/23 at 10:00 AM V11 Nurse Practitioner stated: V11 last saw R55 a few weeks ago, but it was for an eye infection and not for psoriasis. They should notify me or her physician of any changes in her skin or if there's no improvement. V11 is in the facility frequently. There are problems with the facility not regularly notifying us (the practitioners) of resident changes. V11 will need to follow up and evaluate R55 today.
The facility's Skin Condition Assessment & Monitoring- Pressure and Non-Pressure dated as revised June 2018 documents: non-pressure related skin conditions including rashes will be assessed weekly for healing progress and complications. Assessments are documented in the residents medical record.
The facility's Physician-Family Notification- Change in Condition dates as revised November 2018 documents the physician will be notified of changes in a resident's condition and when there is a need to alter treatment.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on interview and record review the facility failed to implement post fall interventions for two of six residents (R24, R81) reviewed for falls on the sample list of 55.
Findings include:
The fac...
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Based on interview and record review the facility failed to implement post fall interventions for two of six residents (R24, R81) reviewed for falls on the sample list of 55.
Findings include:
The facility's Fall Prevention Program with a revised date of May 2022 documents, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Safety interventions will be implemented for each resident identified at risk. Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. Foot wear will be monitored to ensure the resident has proper fitting shoes and/or footwear is non-skid.
1. R24's Order Summary dated 3/13/23 documents diagnoses including Osteoarthritis of the Knee, Altered Mental Status, Type 2 Diabetes Mellitus, Hypertensive Heart Disease Without Heart Failure, Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Unsteadiness on Feet, Hypertensive Encephalopathy and Hypothyroidism.
The facility's Accident/Incident log provided on 3/12/23 documents R24 had falls on 12/21/22, 12/26/22, 1/22/23 and 3/2/23. R24's Care Plan documents a post fall interventions dated 12/22/22 to provide assist rails to bed, a post fall intervention dated 12/28/22 of an Urinary Analysis with Culture and Sensitivity, a post fall intervention dated 1/23/23 to offer toileting during routine room rounds, and a post fall intervention dated 3/3/23 to remove wheelchair from bedside.
On 3/12/23 at 9:38 AM, R24 was in bed in R24's room and R24's wheelchair was on the right side of the bed in R24's sight.
On 3/14/23 at 10:37 AM, R24's wheelchair is on the right side of the bed.
On 3/14/23 at 11:00 AM, V29 Certified Nursing Assistant stated R24 will try to transfer R24's self out of bed. V29 stated that R24 likes to keep R24's wheelchair next to the bed.
On 3/15/23 at 10:22, AM, V2 Director of Nursing confirmed that R24's wheelchair is supposed to be kept out of R24's sight.
2. R81's Order Summary dated 3/14/23 documents diagnoses including Dementia with Anxiety, Post-Traumatic Stress Disorder, Anxiety Disorder, Altered Mental Status and Muscle Weakness.
The facility's Accident/Incident log provided on 3/12/23 documents R81 had falls on 1/29/23 and 2/4/23. R81's Care Plan documents a post fall intervention dated 1/30/23 to anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it, educate staff to ensure proper footwear and ensure that the resident is wearing appropriate footwear, a post fall intervention dated 2/6/23 to request (spouse) remove footwear that does not have a proper sole on the bottom from residents room.
On 3/14/23 at 10:45 AM, R81 was in R81's room sitting on the side of R81's bed, R81's shoes were off, R81's socks were halfway off both feet, balled up in the middle of R81's foot.
On 3/15/23 at 10:22, AM, V2 Director of Nursing confirmed R81's socks should be all the way on R81's feet and R81's shoes should be on R81's feet.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R114's meal intake log dated 2/1/23 through 2/13/23 does not document a meal intake for breakfast on 2/1/23, 2/2/23, 2/3/23, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R114's meal intake log dated 2/1/23 through 2/13/23 does not document a meal intake for breakfast on 2/1/23, 2/2/23, 2/3/23, or 2/6/23 through 2/10/23. This log does not document a meal intake for lunch on 2/2/23, 2/3/23, or 2/6/23 through 2/10/23. This log does not document a meal intake for dinner on 2/3/23 through 2/7/23 or on 2/10/23. R114's meal intake log documents R114 refused the lunch meal on 2/3/23 and 2/4/23, ate zero to 25 percent for breakfast and lunch on 2/11/23 and 2/12/23, and ate zero to 25 percent for breakfast on 2/13/22.
R114's Nutrition Care Plan dated 10/5/15 documents R114 is at risk for malnutrition and includes interventions to encourage R114 to eat part of the meal, encourage and monitor at meals to ensure adequate intake, monitor appetite and weights and report to physician.
R114's medical record does not document that R114 was encouraged to eat when refusing meals, that R114's meal intakes were monitored, or that refusals and poor intake were reported to the physician.
On 3/14/23 at 11:31 AM, V2 Director of Nursing stated the Certified Nurse's Assistants pass the trays and then they document when pick up the trays. If they don't document then it comes up on the Electronic Health Record Dashboard alerts and me and V13 Assistant Director of Nursing are supposed to monitor it. I did not know they weren't doing all this charting.
Based on observation, interview, and record review the facility failed to supervise and assist with meals and document meal intake for two of two residents (R78, R114) reviewed for Nutrition on the sample list of 55. This failure resulted in R78 losing 20 pounds in six months' time which is a significant weight loss of 10.95%.
Findings include:
1. R78's Physician Order Sheet (POS) dated March 2023 documents R78 is diagnosed with Dementia, Type II Diabetes, Chronic Kidney Disease Stage 4, Unspecified Protein-Calorie Malnutrition, and Altered Mental Status. R78 is ordered a Low Concentrated Sweets diet with thin liquids. Frozen Nutritional Supplement at lunch and supper, Fortified Cereal at breakfast, High Protein/Calorie Diet for Weight Loss, House Supplement (nutritional supplement) three times per day and Nutritional Drink two times per day for Weight Loss.
R78's Minimum Data Set, dated [DATE] documents R78 is Severely Cognitively Impaired and requires Supervision (Oversight, Encouragement, Cueing), for eating.
R78's Care Plan dated 3/2/23 documents the facility identified R78 has impaired cognitive function, is at nutritional risk related to Dementia, Diabetes Type II, Chronic Kidney Disease, Depression, and Advanced Age, and has nutritional issues (weight loss) related to loss of appetite. The facility is to provide and serve R78's diet as ordered, serve supplements as ordered, chart meal intakes, monitor/document/report any signs of Dysphagia- swallowing issues- meal refusals, encourage R78 to eat at least 50% of two meals, reorient and cue R78 as needed, and refer R78 to a registered dietician to evaluate when needed.
R78's Weight Records document R78 weighed 184.4 pounds on 9/6/22 and has since trended down to 164.2 pounds on 3/6/23. This is a significant weight loss of 10.95%.
R78's Task Documentation for Eating for February 2023 documents no meal intake recorded for 45 out of 84 meals. The March 2023 Task Documentation for Eating documents no meal intake recorded for 18 out of 38 meals so far for the month.
R78's Dietary Note dated 2/21/23 documents V22 Dietician completed an assessment for R78 and noted R78 had significant weight loss over three months and recommended fortified cereal at breakfast and pudding at lunch.
On 3/12/23 at 12:00 PM R78 was lying in R78's bed, food untouched, with no supervision or assistance.
On 3/12/23 at 12:15 PM R78 was still lying in R78's bed, food untouched, with no supervision or assistance.
On 3/12/23 at 12:30 PM R78 was still lying in R78's bed, food untouched, with no supervision or assistance.
On 3/13/23 at 12:00 PM R78 was lying in R78's bed, food untouched, with no supervision or assistance.
On 3/13/23 at 12:15 PM R78 was still lying in R78's bed, food untouched, with no supervision or assistance.
On 3/13/23 at 12:30 PM R78 was still lying in R78's bed, food untouched, with no supervision or assistance.
On 3/13/23 at 12:45 PM R78 was still lying in R78's bed food untouched. V21 Certified Nurse Assistant picked up R78's lunch tray to put back on the cart. R78's lunch tray had a nutritional shake that was untouched and unopened. The lunch meal did not include a pudding cup.
On 3/14/23 at 9:20 AM V11 Nurse Practitioner (NP) confirmed R78 has had significant weight loss and has dementia and a cognitive decline. V11 confirmed staff should be supervising and assisting R78 with eating R78's meals and should accurately record R78's intake. V11 stated the staff often leave R78 in bed and do not bring R78 to the dining room to eat and do not provide supervision or assist with eating. V11 stated it doesn't matter how many supplements are ordered, if the staff aren't encouraging R78 and assisting R78 with the consumption of the supplements and meals, R78 will continue to lose weight due to low intake. V11 confirmed R78 should be in the dining room, sitting upright, with supervision and assistance to eat.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to ensure residents were treated with dignity and respec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to ensure residents were treated with dignity and respect and provided privacy during care for three (R55, R27, R101) of 32 residents reviewed for resident rights in the sample list of 55.
Findings include:
1.) R55's Minimum Data Set (MDS) dated [DATE] documents R55 is cognitively intact.
On 3/13/23 at 12:03 PM R55 stated it bothers R55 that the staff do not always pull the curtain between R55 and R55's roommate during cares.
On 3/12/23 at 10:54 AM R55 was lying in bed. V15 and V16 Certified Nursing Assistants entered R55's room and provided incontinence care. The privacy curtain was pulled between R55 and R55's roommate but was not pulled to block the view from R55's door. R55's perineal area was exposed and in view of the door when V18 entered and left R55's room on two occasions and when V13 Assistant Director of Nursing left R55's room.
On 3/13/23 at 1:44 PM V2 Director of Nursing stated privacy curtains should be pulled between residents and to block the view from the door during cares.
2.) R55's Minimum Data Set (MDS) dated [DATE] documents R55 is cognitively intact.
On 3/12/23 at 9:08 AM R55 stated, (V18 Licensed Practical Nurse (LPN)) doesn't like me (R55). She chews me out about things. Chews my A** (expletive). I haven't talked to anyone about her. She's kind of a little cross with me, tells me I should do things more. It gets to me sometimes. I don't think I deserve to feel that way. On 3/13/23 at 12:03 PM R55 stated there were times where V18 treated R55 badly and yelled at R55. R55 stated, I'm not a child. I'm a resident here and don't deserve to be treated that way.
R27's Nursing Note dated 3/9/23 documents R27 is alert and oriented x 4 (person, place, time, and situation.) R101's MDS dated [DATE] documents R101 is cognitively intact.
On 3/13/23 at 2:06 PM R101 and R27 stated they both have orders for oxygen and V18 argues with them about their oxygen settings. R27 stated, V18 no longer speaks to me when V18 is in R27's room. V18 will place R27's medications on the table and walk out of R27's room without saying anything to R27.
On 3/13/23 at 2:26 PM V1 Administrator stated staff should not argue with the residents and confirmed residents should be treated with dignity and respect.
V18's Employee Job Performance Evaluation dated 9/21/22 documents V18 is rated as below average in communicating with supervisors, coworkers, and residents.
The facility's Resident Rights policy dated as revised August 2017 documents residents have the right to privacy and confidentiality.
The facility's Dignity policy dated as revised April 2018 documents: Residents shall be cared for in a manner that maintains or enhances residents' dignity and respect.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide routine foot care for one resident (R73) revie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide routine foot care for one resident (R73) reviewed for foot care on the sample list of 55.
Findings include:
On 3/13/23 at 8:49 AM V19, R73's Power of Attorney, stated: R73's toenails are long, but the facility has never told V19 that R73 needs to see a podiatrist. V19 would schedule a podiatry appointment if R73 needed one.
On 3/14/23 at 12:33 PM V17 Certified Nursing Assistant removed R73's socks and confirmed R73's toenails needed to be trimmed. R73's toenails were long and thick. Both great toenails were sticking up and approximately 1/2 past the tip of R73's toe.
On 3/14/23 at 12:38 PM V1 Administrator stated the podiatrist rounds at the facility every 3 months. At 12:50 PM V4 Social Services Director stated We are not able to trim R73's toenails, and R73 toenails need to be trimmed by a podiatrist. R73 has refused to allow a podiatrist to trim R73's toenails previously. R73 is cooperative for V4, and V4 thought about assisting R73 at the next podiatry visit. V4 confirmed V4 has not contacted V19 to assist with R73's podiatry visit. At 2:25 PM V1 Administrator stated R73 was on the podiatrist list on 12/29/22, but was ineligible and was not seen due to needing a new signed consent form since it had been over a year since R73 was last seen.
R73's Minimum Data Set, dated [DATE] documents R73 has severe cognitive impairment and is dependent on one staff person for personal hygiene.
The facility's podiatry list dated 12/29/22 documents R73 was not eligible to be evaluated, and R73 was last seen by a podiatrist on 1/18/21. There is no documentation in R73's medical record that R73 has seen a Podiatrist since 2021.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to treat a resident's pain by failing to obtain and administer ordered narcotic pain medications for one of two residents (R8) r...
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Based on observation, interview, and record review, the facility failed to treat a resident's pain by failing to obtain and administer ordered narcotic pain medications for one of two residents (R8) reviewed for pain on the sample list of 55.
Findings include:
R8's Face Sheet dated 3/14/23 documents diagnoses including Spina Bifida, Spastic Paraplegia, Syringomyelia, Syringobulbia, Scoliosis, and Migraines.
R8's Care Plan (current) documents: R8 is at risk for pain related to impaired mobility, urogenital implant, spastic paraplegia, and wound to buttock. Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness each shift.
R8's Physician Order Sheet dated 3/14/23 documents the following orders: Ultram (Tramadol/Opioid) 50 milligrams (mg), take 1 tablet by mouth two times a day for moderate pain; Acetaminophen (Tylenol/Analgesic) 650mg, take 1 tablet by mouth every 6 hours as needed for general discomfort; and document pain three times a day.
R8's March 2023 Medication Administration Record (MAR) documents R8 did not receive R8's evening dose of Ultram on 3/11/23 and did not receive any doses of Ultram on 3/12/23.
On 3/13/23 at 9:32am, during observation of medication administration, R8 rated pain as a 10 out of 10. R8 stated, Not sure if [R8] has any Tramadol and has been out for four days. They [staff] have been giving me Tylenol instead.
On 3/13/23 at 9:35am, V13 Assistant Director of Nursing (ADON) stated V13 called the pharmacy and stated the pharmacy needed a prescription to send R8's Tramadol. V13 stated V13 has contacted the Nurse Practitioner to send R8's prescription to the pharmacy.
On 3/14/23 at 11:14am, V2 Director of Nursing (DON) confirmed the check mark on the MAR indicates the medication has been given. V2 stated 9 means other and the reason not given should be recorded in a nursing note. V2 stated if a medication is not available staff should contact pharmacy in order for the medication to be delivered by the backup pharmacy. V2 stated medications from the back up pharmacy are usually delivered within four hours.
On 3/14/23 at 11:37am, R8 stated R8 did not receive Tramadol for two and a half days. R8 stated suffered through it [pain]. R8 rated pain 9 to 10 on 0 to 10 pain scale with 10 being the worse pain. R8 stated, I was told staff forgot to order the medication and that is why it was not available.
The facility's Pain Management Program Policy dated 3/2023 documents the following: Purpose: To establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. It is the goal of the facility to facilitate resident independence, promote resident comfort, preserve and enhance resident dignity and life involvement.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to monitor and document fluid intake and obtain vitals per physician orders for one (R25) of two residents reviewed for Dialysis ...
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Based on observation, interview, and record review the facility failed to monitor and document fluid intake and obtain vitals per physician orders for one (R25) of two residents reviewed for Dialysis on the sample list of 55.
Findings include:
On 3/12/23 at 10:00 AM R25 stated they don't keep track of my fluids. R25 pointed to a water pitcher and stated, I never know if I am drinking enough or too much.
R25's physician order with a revision date of 3/12/23 documents Fluid Restriction - Total: 1500 milliliters every 24 hours, 237 ml (8oz) beverage with meals, and Nursing to give 237 (8oz) per shift (3 shifts) for medication pass every shift. No Bedside water/drink.
R25's Medication Administration Record (MAR) for 3/1/23 through 3/31/23 documents an order for 1500 milliliters/day fluid restriction every shift. This MAR does not specify how much R25 is supposed to receive per shift.
R25's meal and fluid intakes documents R25's fluid intakes as the following: On 3/13/2023 there was no documentation of fluid intake for breakfast, 480 ml for lunch, and 840 ml for supper, on 3/14/2022 600 ml for breakfast, 480 ml for lunch, and 900 ml for supper, on 3/15/2023 no documentation for breakfast, 480 ml for lunch, and no documentation for supper, on 3/17/2023, 240 ml for breakfast, 240 for lunch, and no documentation for supper, on 3/18/2023 480 ml for breakfast, 600 ml for lunch, and 480 ml for supper, on 3/19/2023 360 ml for breakfast, 740 ml for lunch, and 640 ml for supper, and on 3/20/2023 480 ml for breakfast.
R25's physician orders documents and order dated 12/2/22 documents an order to obtain vital signs before and after dialysis every Monday, Wednesday, and Friday.
R25's MAR does not document R25's vital signs were taken pre-dialysis on Wednesday 3/8/23, Friday 3/10/23, Wednesday 3/15/23, or Monday 3/20/23. R25's MAR does not documents R25's vital signs were taken post dialysis on Wednesday 3/1/23, Friday 3/3/23, Friday 3/10/23, Monday 3/13/23, Wednesday 3/15/23, or Friday 3/17/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess for the use of side rails for one (R70) of two ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess for the use of side rails for one (R70) of two residents reviewed for side rails on the sample list of 55.
Findings include:
R70's Minimum Data Set, dated [DATE] documents R70 has moderate cognitive impairment. R70's Care Plan last revised 3/3/23 does not document the use of side rails.
R70's 11/1/22 Quarterly Side Rail Assessment documents R70's bed does not contain side rails and side rails are not indicated at this time. There are no documented Side Rail Assessments after 11/1/22.
On 3/12/23 at 10:04 AM R70 was lying in bed and R70's bed contained bilateral siderails. The siderail closest to the door was loose and moved side to side and back and forth. R70 stated R70 uses the siderails to turn in bed and during transfers.
On 3/13/23 at 1:44 PM V2 Director of Nursing stated: V2 completes Side Rail Assessments quarterly. We have been behind in completing the assessments quarterly and correctly. R70 uses side rails for turning and transfers. Side Rails should be care planned.
The facility's Side Rails/Bed Rails policy dated as revised October 2019 documents: Alternative interventions will be attempted prior to installing side rails. Once the alternative interventions do not meet the resident's needs, the facility will assess the resident for the risk of entrapment and benefits of side rail use. Record the alternative interventions attempted on the side rail assessment. Other risks that are assessed include accident hazards, barriers, physical restraint, and potential negative outcomes. Side Rail use will be included in the resident's plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to administer medications as ordered resulting in significant medication errors for one resident (R27) of 34 residents reviewed for changes in ...
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Based on interview and record review the facility failed to administer medications as ordered resulting in significant medication errors for one resident (R27) of 34 residents reviewed for changes in condition in the sample list of 55.
Findings include:
R27's After Visit Summary dated 12/7/22 documents R27's discharge medications include Bumex (diuretic) 2 milligrams (mg) by mouth twice daily, Coreg 12.5 mg by mouth twice daily, Hydralazine 50 mg by mouth twice daily, and Imdur 60 mg by mouth daily.
R27's December 2022 Medication Administration Record (MAR) documents Bumex, Coreg, Hydralazine, and Imdur were not administered as ordered/scheduled on 12/8/22, and documents to refer to a nursing note. There are no documented nursing notes explaining why the medications were not given or that the physician was notified.
R27's weight log dated 3/14/23 documents R27's weighed 191.2 lbs (pounds) on 12/8/22 and 218.7 lbs on 12/10/22 (27.5 lb gain in 2 days).
On 3/14/23 at 11:14 AM V2 Director of Nursing confirmed a check mark on the MAR indicates medication was given. V2 stated: A 9 on the MAR means other, and prompts to record the reason the medications were not given in a nursing note. If a medication is not available the nurse should contact the pharmacy to have the medication delivered from a backup pharmacy, and the medications usually arrive within 4 hours.
On 3/14/23 at 10:00 AM V11 Nurse Practitioner confirmed R27's Bumex should have been administered as ordered. V11 stated missed doses of Bumex could contribute to weight gain.
The facility's Medication Administration Policy dated as revised January 2015 documents: Medications are to be administered according to physician's orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to follow-up with a referral to an oral surgeon for one (R25) of two residents reviewed for dental on the sample list of 55.
Find...
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Based on observation, interview, and record review the facility failed to follow-up with a referral to an oral surgeon for one (R25) of two residents reviewed for dental on the sample list of 55.
Findings include:
On 3/12/23 at 10:00 AM, R25 stated R25 was supposed to have some teeth pulled and that was two years ago and I haven't gotten to go. R25's teeth had areas of decay.
R15's Nursing Note dated 4/30/21 at 2:23 PM documents, (R25) stated that (R25's) tooth broke off a few days ago, (R25) showed (Registered Nurse) and tooth was cracked. (R25) stated that (R25's) mouth feels swollen and there is pain. (R25) is requesting to see a dentist. This note also documents a dentist appointment was scheduled for 5/27/21.
On 3/14/23 at 10:38 AM, V3 Psychiatric Rehabilitation Service Director stated there is no documentation of R25 seeing the dentist on 5/27/21. V3 stated there is no documentation of R25 refusing to go to an appointment. V3 stated R25 did see the dentist in January and the dentist also made a referral for an oral surgeon. It has not been set up yet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide meals honoring food preferences for one (R17) of 32 residents reviewed for food preferences on the sample list of 55.
...
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Based on observation, interview, and record review the facility failed to provide meals honoring food preferences for one (R17) of 32 residents reviewed for food preferences on the sample list of 55.
Findings include:
On 3/12/23 at 9:20 AM, R17 stated the food is terrible. R17 stated eating pork is against his religion but they continue to serve it to him. R17 stated he is allergic to bananas but gets bananas on the tray. R17 stated R17 does not like hot cereal but they serve him hot cereal.
On 3/12/23 at 12:20 PM, V10 Certified Nursing Assistant took a tray over to R17, V10 took the lid off and walked away. V10 did not check the diet slip before providing the meal. R17 was served a pork chop with mashed potatoes and green beans. R17's diet card lying on the tray stated no pork.
On 3/12/23 at 12:25 PM, V9 Dietary Aide stated R17 isn't supposed to receive pork.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure side rails were secure and assess side rails fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure side rails were secure and assess side rails for the risk for entrapment for two (R70, R101) of two residents reviewed for side rails in the sample list of 55.
Findings include:
1.) R70's Minimum Data Set, dated [DATE] documents R70 has moderate cognitive impairment. R70's Care Plan last revised 3/3/23 does not document the use of side rails.
On 3/12/23 at 10:04 AM R70 was lying in bed and R70's bed contained bilateral siderails. The siderail closest to the door was loose and moved side to side and back and forth. R70 stated R70 uses the siderails to turn in bed and during transfers.
2.) On 3/12/23 at 10:13 AM R101 was lying in bed. R101's bed contained bilateral side rails. The side rail that was closest to the door was loose and moved back and forth. R101 stated R101 does not use the side rails.
On 3/13/23 at 3:48 PM V20 Maintenance Director stated V20 inspects side rails annually for risk for entrapment and was last completed on 10/20/22. If the resident had side rails installed after 10/20/22, then we would not have an assessment for the bed and side rails. V20 stated side rails are inspected monthly as part of our routine checks and the Certified Nursing Assistants should report when side rails are loose. At 3:57 PM V20 confirmed R101's side rail was loose and stated it needed tightened. At 3:59 PM V20 confirmed both of R70's side rails were loose and not secure. V20 stated they needed to be tightened. V20 stated the facility is gradually phasing out the use of this type of side rail. V20 was unable to provide documentation that R70's bed and side rails were inspected for risk of entrapment. V20 stated R101's and inspection of R101's bed and side rails were not completed after R101 changed beds.
The facility's Side Rails/Bed Rails policy dated as revised October 2019 documents: Assuring the correct installation and maintenance of bed rails is an essential component in reducing the risk of injury resulting from entrapment or falls. Inspect and regularly check the mattress and bed rails for areas of possible entrapment. Regardless of mattress width, length and/or depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a resident's head or body. Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the resident's physician and representative of a change in co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the resident's physician and representative of a change in condition and refusal of meals and poor food intake for four (R55, R27, R73, R114) of 32 residents reviewed for changes in condition in the sample list of 55.
Findings include:
The facility's Physician-Family Notification- Change in Condition dates as revised November 2018 documents the physician and resident representative will be notified of changes in a resident's condition and when there is a need to alter treatment.
1.) On 3/12/23 at 11:21 AM R55 stated, Finally after all these weeks I get to see a dermatologist Tuesday (3/14/23). R55 stated R55 last saw a dermatologist for R55's psoriasis a few months ago. On 3/13/23 at 12:03 PM R55 stated R55 can't sit up in R55's wheelchair for extended periods or attend activities as often as R55 did previously due to R55's pain/itching caused from R55's psoriasis. R55 described the pain as an ache rated as an 8 on a 1-10 scale. R55 stated R55 itched R55's back so hard one time it bled. R55 became tearful and stated, I (R55) just want to feel better.
On 3/12/23 at 10:54 AM V15 and V16 Certified Nursing Assistants entered R55's room and provided incontinence care. R55's abdominal folds, groin, and underneath R55's breasts were red/inflamed. R55 said, Ow when V15 cleansed R55's perineal area, groin, and abdominal fold. There were large scaly, red patches covering R55's back, buttocks, and posterior thighs. V15 stated R55 has had Psoriasis for a while now and this area (pointing to abdominal fold) looks worse.
R55's Skin Condition Report dated 1/28/23 documents R55 has moisture associated skin damage (MASD) and does not document the location or extent of the skin impairment. There are no other detailed skin assessments until 3/13/23. R55's 3/13/23 Skin Condition Report documents denuded/excoriation skin and MASD noted to groin, upper/mid back and under breasts. This report documents R55's skin condition was not new and did not warrant physician notification. R55's February and March 2023 Shower Sheets document R55 had reddened areas including R55's chest, back, buttocks and groin on 2/25, 3/1, 3/4, 3/8. There is no documentation that R55's worsening skin condition was reported to a physician in February 2023 and March 2023, prior to 3/14/23.
On 3/12/23 at 1:48 PM V13 Licensed Practical Nurse stated, R55 does not have any scheduled treatments. R55's groin looks raw and it is really red. It flares up, goes away, and comes back again.
On 3/14/23 10:40 V13 Assistant DON stated V13 oversees skin/wounds in the facility. V13 stated R55 has psoriasis and excoriation of the grain. R55 sees a dermatologist, but was last seen a few months ago, has Ketoconazole shampoo and Nystatin ordered. V13 confirmed Nystatin is as needed and R55 has no topical creams scheduled routinely. V13 stated the nurses should follow up with the dermatologist when R55's skin conditions worsen or flair up to adjust R55's treatment orders.
On 3/14/23 at 10:00 AM V11 Nurse Practitioner stated, V11 last saw R55 a few weeks ago, but it was for an eye infection and not for psoriasis. V11 stated, They should notify me or R55's physician of any changes in her skin or if there's no improvement. V11 is in the facility frequently. V11 stated, There are problems with the facility not regularly notifying us (the practitioners) of resident changes. V11 will need to follow up and evaluate R55 today.
2.) On 3/13/23 at 2:06 PM R27 stated that R27 told V18 (Licensed Practical Nurse) that R27's legs and stomach were swelled up bad. R27 said V18 argued with R27 that there was not fluid in R27's stomach. R27 said V18 told R27 that V18 contacted the Nurse Practitioner and told R27 to stay in bed for a few days. R27 said, nothing had changed, so the next day R27 told a nurse that R27 needed to go to the hospital. R27 said either the facility was going to send R27 to the hospital, or R27 was going to contact R27's family to take R27 to the hospital. R27 was put on emergency dialysis at the hospital.
R27's After Visit Summary dated 12/7/22 documents to monitor weight daily and take medications as instructed. R27's weight upon discharge was 193 pounds (lbs.).
R27's weight log dated 3/14/23 documents R27's weights as follows. 12/8/22 191.2 lbs. (pounds), 12/10/22 218.7 lbs. (27.5 lb. gain in 2 days). 12/16/22 223.1 (additional 4.4 lb. gain in 6 days) and 223 on 12/18/22. R27 had a total weight gain of 31.9 lbs. in 8 days.
There is no documentation that R27's weight gain was reported to a physician after 12/9/22 and prior to being hospitalized on [DATE] for fluid volume overload and Congestive Heart Failure exacerbation. R27's Nursing Note dated 12/19/22 at 9:59 AM documents R27 notified the nurse that R27 had gained 20 pounds since admission. R27 reported having difficulty breathing and requested to go to the emergency room.
On 3/13/23 at 1:44 PM V2 (Director of Nurses) stated the physician should be notified of a weight gain of 5 pounds or more in a week for a resident with Congestive Heart Failure, and physician notification is documented in a progress note.
3.) R73's Minimum Data Set, dated [DATE] documents R73 has severe cognitive impairment.
R73's Nursing Note dated 3/5/23 at 5:00 PM documents R73 had a coffee ground emesis (vomiting). There is no documentation that R73's physician or R73's Healthcare Power of Attorney (V19) was notified.
On 3/13/23 at 8:49 AM V19 stated, about a week ago R73 had vomiting, the facility did not notify V19. V19 stated V19 found out from R33, R73's roommate.
On 3/13/23 at 1:44 PM V2 Director of Nursing stated the physician and resident representative should be notified of changes in a resident's condition and recorded in a progress note. V1 stated the facility uses a lot of agency nurses and sometimes the notification does not get done.
4. R114's meal intake logs dated 2/1/23 through 2/13/23 document R114 refused the lunch meal on 2/3/23. This log does not document an intake for the dinner meal on 2/3/23. This log documents R114 ate between 26 to 50 percent for breakfast and refused lunch. This log also documents that R114 ate between zero and twenty-five percent on 3/11/23 and 3/12/23 for breakfast and lunch.
On 3/14/23 at 10:20 AM, V11 Nurse Practitioner stated the facility didn't notify me that she wasn't eating. They should call and tell me.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to timely report an allegation of verbal/mental abuse to the state survey agency for one resident (R55) of two residents reviewed for abuse in ...
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Based on interview and record review the facility failed to timely report an allegation of verbal/mental abuse to the state survey agency for one resident (R55) of two residents reviewed for abuse in the sample list of 55.
Findings include:
On 3/12/23 at 9:08 AM R55 stated, (V18 Licensed Practical Nurse (LPN)) doesn't like me (R55). She chews me out about things. Chews my A** (expletive). I haven't talked to anyone about her. She's kind of a little cross with me, tells me I should do things more. It gets to me sometimes. I don't think I deserve to feel that way. At 10:14 AM R55 stated V18 has yelled at R55. R55 stated, V1 Administrator spoke with R55 this morning about R55's concerns with V18. R55 told V1 what R55 previously reported about V18.
On 3/12/23 at 9:35 AM V1 Administrator stated R55 has not reported concerns involving V18, and V18 is the only staff person employed by the facility with the name given by R55. At this time R55's allegation was reported to V1. V1 stated V1 was going to follow up with R55.
On 3/13/23 at 11:49 AM V1 Administrator stated V1 filed a grievance regarding R55's concern with V18. Since R55 denied feeling abused by V18, V1 did not report R55's abuse allegation to the Illinois Department of Public Health.
R55's Concern/Compliment Form dated 3/12/23 at 9:30 AM documents an allegation that V18 chews her (R55) out and R55 requested that V18 no longer provide care for R55. There is no documentation that this allegation was reported to the Illinois Department of Public Health within 2 hours of the allegation being reported to V1.
The facility's Abuse Prevention and Reporting - Illinois policy dated as revised October 2022 documents: Mental abuse is nonverbal or verbal and causes or potentially causes a resident to feel humiliation, intimidation, fear, shame, agitation or degradation. Verbal abuse can be oral, written, gestures, or sounds directed towards residents or within hearing distance. Allegations of abuse will be reported to the state survey agency within two hours of the allegation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
Based on observations, interview, and record review the facility failed to initiate an investigation for an allegation of verbal/mental abuse and remove an alleged perpetrator (employee) from further ...
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Based on observations, interview, and record review the facility failed to initiate an investigation for an allegation of verbal/mental abuse and remove an alleged perpetrator (employee) from further contact with residents to prevent potential further abuse. This failure has the potential to affect 20 residents (R55, R51, R212, R101, R104, R71, R33, R57, R27, R70, R68, R60, R15, R59, R35, R73, R62, R5, R13, R90).
Findings include:
On 3/12/23 at 9:08 AM R55 stated, (V18) Licensed Practical Nurse (LPN)) doesn't like me (R55). She chews me out about things. Chews my A** (expletive). I haven't talked to anyone about her. She's kind of a little cross with me, tells me I should do things more. It gets to me sometimes. I don't think I deserve to feel that way. At 10:14 AM R55 stated: V18 has yelled at R55 before. R55 stated, V1 Administrator spoke with R55 this morning about R55's concerns with V18. R55 told V1 what R55 previously reported about V18.
On 3/12/23 at 9:35 AM V1 Administrator stated R55 has not reported concerns involving V18, and V18 is the only staff person employed by the facility with the name given by R55. At this time R55's allegation was reported to V1. V1 stated V1 was going to follow up with R55.
On 3/12/23 at 10:42 AM, 10:54 AM, 1:48 PM, and 2:05 PM V18 was present in the facility and working on R55's hallway.
On 3/13/23 at 11:49 AM V1 Administrator stated V1 did not report R55's abuse allegation to the state survey agency. V1 stated V1 spoke with R59 (R55's roommate), and other unidentified residents who had no concerns with V18. V1 has no documentation of this. V1 told V18 that V18 could no longer provide care for R55 and confirmed V1 did not remove V18 from care of other residents on 3/12/23.
R55's Concern/Compliment Form dated 3/12/23 at 9:30 AM documents an allegation that V18 chews her (R55) out and R55 requested that V18 no longer provide care for R55. There is no documentation that an investigation of R55's allegation was conducted or that R55 was removed from resident contact pending the results of an investigation.
The facility's Nursing Daily Schedule dated 3/12/23 documents V18 worked on the South hall of the South building. The facility's Resident List Report dated 3/12/23 documents R55, R51, R212, R101, R104, R71, R33, R57, R27, R70, R68, R60, R15, R59, R35, R73, R62, R5, R13, R90.
The facility's Abuse Prevention and Reporting - Illinois policy dated as revised October 2022 documents: Mental abuse is nonverbal or verbal and causes or potentially causes a resident to feel humiliation, intimidation, fear, shame, agitation or degradation. Verbal abuse can be oral, written, gestures, or sounds directed towards residents or within hearing distance. Reports of abuse allegations should be documented and investigated. Interviews will be conducted with the person who reported the allegation, anyone who may have knowledge of the incident, residents and employees who interact with the alleged perpetrator. Employees accused of abuse will immediately be removed from resident contact. The employee will not return to work until the investigation results are reviewed by the administrator and abuse is unsubstantiated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide timely incontinence care and failed to provide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide timely incontinence care and failed to provide assistance with shaving and nail care for four (R55, R5, R70, R73) of six residents reviewed for activities of daily living on the sample list of 55.
Findings include:
1. On 3/13/23 at 12:18 PM R55 stated R55 calls for staff during the night, but they tell her that they're short staffed and can't assist her. Sometimes R55 must wait until 6:00 AM before R55 is provided incontinence care. On 3/12/23 at 9:08 AM R55 stated R55 was incontinent and was last changed at approximately 7:00/8:00 PM. At 10:14 AM R55 stated R55 told V15 Certified Nursing Assistant (CNA) that R55 needed to be changed. At 10:38 AM V15 answered R55's call light. V15 stated V15 was waiting for staff assistance to change R55.
On 3/12/23 at 10:54 AM V15 and V16 Certified Nursing Assistants (CNAs) entered R55's room and provided incontinence care. R55's incontinence brief was saturated with urine and a large amount of soft bowel movement. There was a small amount of urine on R55's bed sheets. There was a strong urine odor. R55's abdominal folds, groin, and underneath R55's breasts were red/inflamed. R55 said Ow when V15 cleansed R55's perineal area, groin, and abdominal fold. V15 stated R55 has had Psoriasis for a while now and this area (pointing to abdominal fold) looks worse.
On 3/12/23 at 11:27 AM V15 stated: V15 was not sure when R55 was last changed, and V15 had not changed R55 earlier this morning. V10 CNA was initially on R55's hall this morning, but V10 got pulled to work the North building around 9:30 AM and V15 took over V10's hallway. There have been problems with night shift staffing due to call offs. They are supposed to have 3 CNAs, and about 2-3 times per week V15 comes in for dayshift and residents are incontinent as if they had not been changed on night shift.
On 3/12/23 at 11:38 AM, V10 CNA stated she did not provide care to R55. V10 stated she only took R55 a breakfast tray. At 11:56 AM, V10 stated that she just remembered that R55 refused cares this morning.
On 3/14/23 at 12:50 PM V1 Administrator stated residents should be offered/provided incontinence care at least every 2 hours.
There is no documentation in R55's medical record that R55 refuses incontinence care. R55's Minimum Data Set (MDS) dated [DATE] documents R55 is cognitively intact, is dependent on two staff for toileting, and is incontinent of bowel and bladder.
2. On 3/12/23 at 9:02 AM R5 stated they don't change R5 during the night, and R5's sheets are often wet with urine in the mornings. R5's Power of Attorney (V24) stated she comes to the facility in the mornings every day to assist R5 with morning care, and every morning R5's bed linens are soaked with urine.
R5's MDS dated documents R5 is dependent on two staff for toileting.
3. On 3/12/23 at 10:01 AM R70 stated: I need my lip shaved. I sure need it. I am growing a beard. I hate to be hairy. It's embarrassing. There was dark facial hair noted to R70's upper lip and chin.
On 3/14/23 at 12:33 PM V17 CNA stated facial hair is removed during shower days and residents are showered twice weekly. At 12:35 PM V17 CNA confirmed R70 had long, dark, facial hair.
R70's Care Plan updated 1/9/23 documents R70 is dependent on one staff person for hygiene.
On 3/14/23 at 12:50 PM V4 Social Services Director stated: R73 is cooperative with care provided by facility staff. R70 allows staff to shave R70's facial hair. If residents refuse care it is documented on the Care Plan.
4. On 3/12/23 at 8:35 AM R73 was lying in bed and R73's fingernails were approximately 1/2 past R73's fingertips. R73 stated the staff don't trim them very often, R73's fingernails are too long, and R73 would like them trimmed. On 3/12/23 at 10:30 AM R73's fingernails remained long, past R73's fingertips.
R73's MDS dated [DATE] documents R73 is dependent on one staff person for hygiene. R73's Care Plan dated as revised 11/20/20 documents R73's care needs and does not document R73 is resistive with cares.
On 3/13/23 at 8:49 AM V19 (R73's Power of Attorney) stated R73's fingernails are long and V19 usually must trim R73's fingernails.
On 3/14/23 at 12:33 PM V17 CNA stated resident's fingernails are trimmed by the CNAs at least weekly.
On 3/14/23 at 12:50 PM V4 Social Services Director stated: R73 is cooperative with care provided by facility staff. R70 allows staff to shave R70's facial hair. If residents refuse care it is documented on the Care Plan.
The facility's Nail Care policy dated as revised January 2018 documents: Observe condition of resident nails during each time of bathing. Note cleanliness, length, uneven edges, hypertrophied nails. Trim toe nails carefully in a straight fashion and fingernails in an oval fashion avoiding tissue after bathing or when needed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to change residents oxygen and nebulizer tubing. These failures affect four of five residents (R14, R43, R52, R110) reviewed for ...
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Based on observation, interview, and record review the facility failed to change residents oxygen and nebulizer tubing. These failures affect four of five residents (R14, R43, R52, R110) reviewed for respiratory care on the sample list of 55.
Findings include:
The facility's Oxygen & Respiratory Equipment - Changing/Cleaning policy with a revised date of January 2019 documents, Purpose: 1. To provide guidelines to employees for changing all disposable respiratory supplies. 2. Nasal Cannula. a. Nasal cannulas are to be changed once a week and PRN (as needed). c. A clean plastic bag with a zip lock or draw string, etc. will be provided to store the cannula when it is not in use. It will be dated with the date the tubing was changed.
1. R14's Physician Order Sheet (POS) dated March 2023 documents R14 is diagnosed with Shortness of Breath, Chronic Obstructive Pulmonary Disease, and Dependence on Supplemental Oxygen. The same POS documents an order for Oxygen at two liters nasal cannula every shift as needed for Shortness of Breath. The same POS documents an order to change oxygen tubing weekly and as needed.
R14's Care Plan dated 2/17/23 documents R14 is on Oxygen therapy due to Chronic Obstructive Pulmonary Disease and Shortness of Breath and the staff are to provide oxygen as ordered by the physician.
On 3/12/23 at 9:04 AM R14 was wearing R14's oxygen and the tubing was dated 3/2/23.
On 3/12/23 at 9:05 AM R14 stated the facility staff is supposed to change R14's oxygen tubing weekly but the one R14 is wearing is over a week old.
2. R43's Physician Order Sheet (POS) dated March 2023 documents R43 is diagnosed with Pneumonia, Asthma, Chronic Obstructive Pulmonary Disease, and Dependence on Supplemental Oxygen. The same POS documents an order for Oxygen at two (to) three liters nasal cannula every shift as needed. The same POS documents an order to change oxygen tubing weekly and as needed.
R43's Care Plan dated 2/8/23 documents R43 has an Impaired Respiratory System and is on Oxygen therapy due to Asthma, Congestive Heart Failure, and Chronic Obstructive Pulmonary Disease. The staff are to provide oxygen as ordered by the physician.
On 3/12/23 at 9:28 AM R43 was wearing R43's oxygen and the tubing was dated 3/2/23.
On 3/12/23 at 9:29 AM R43 stated the facility staff is supposed to change R43's oxygen tubing weekly but do not do it regularly.
3. R52's Physician Order Sheet (POS) dated March 2023 documents R52 is diagnosed with Bronchopneumonia and Chronic Obstructive Pulmonary Disease. The same POS documents an order for Oxygen at two liters nasal cannula every shift as needed. The same POS documents an order to change oxygen tubing weekly and as needed.
R52's Care Plan dated 2/21/23 documents R52 has an Impaired Respiratory System and is on Oxygen therapy due to Chronic Obstructive Pulmonary Disease. The staff are to provide oxygen as ordered by the physician.
On 3/12/23 at 10:35 AM R52 was wearing R52's oxygen and the tubing was not dated.
4. R110's Physician Order Sheet (POS) dated March 2023 documents R110 is diagnosed with Pulmonary Fibrosis, Emphysema, Shortness of Breath, Idiopathic Sleep Related Non-Obstructive Alveolar Hypoventilation. The same POS documents an order for Oxygen at two (to) three liters nasal cannula continuously. The same POS documents an order to change oxygen tubing weekly and as needed.
R110's Care Plan dated 2/15/23 documents R110 is on Oxygen therapy due to Respiratory Illness. The staff are to provide oxygen as ordered by the physician.
On 3/12/23 at 10:46 AM R110 was wearing R110's oxygen and the tubing was not dated.
On 3/12/23 at 10:47 AM R110 stated the facility staff is supposed to change R110's oxygen tubing weekly but do not do it unless R110 reminds them.
On 3/13/23 at 12:45 PM V1 Administrator confirmed oxygen tubing should be changed weekly and dated when changed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to administer medications in accordance with physician orders and manufacturer instructions and failed to administer gastrostomy ...
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Based on observation, interview, and record review the facility failed to administer medications in accordance with physician orders and manufacturer instructions and failed to administer gastrostomy tube medication separately for three (R20, R8, R54) of three residents reviewed for medication administration in the sample list of 55. The facility had 14 medication errors out of 31 opportunities resulting in a 45.16% medication error rate.
Findings include:
1. R20's Physician's Orders dated 3/15/23 documents: Check blood glucose before meals and at bedtime. Novolog (Insulin Aspart) 100 units (u)/milliliter (ml) administer subcutaneous 15 units three times daily. Levothyroxine 100 micrograms (mcg) by mouth daily. Ferrous Sulfate (Iron) 325 mg by mouth daily. Atorvastatin Calcium 40 mg Metoprolol Succinate Extended Release 50 mg by mouth daily, hold if systolic blood pressure is less than 120 or diastolic blood pressure is less than 55.
On 3/13/23 at 9:14 AM V13 Assistant Director of Nursing obtained R20's blood glucose level of 310. At 9:20 AM V13 Assistant Director of Nursing prepared and administered R20's Insulin Aspart, Metoprolol, Ferrous Sulfate, Januvia, Torsemide, Lantus, Metformin, Senna, Levothyroxine, and Lisinopril. V13 did not obtain R20's blood pressure prior to administering Metoprolol. Atorvastatin was not given. V13 stated R20 was out of Atorvastatin.
On 3/13/23 at 9:24 AM V13 stated breakfast is between 7:30 and 8:00 AM and confirmed R20 had already ate breakfast. At 10:03 AM V13 stated: R20's blood sugar runs low in the mornings so R20's insulin is given after R20 eats. V13 did not check R20's blood sugar prior to breakfast and did not check R20's blood pressure this morning prior to administering Metoprolol.
The Novolog Insulin Aspart Injection manufacturer's instructions for use dated 1/12/2007 documents: NovoLog should generally be given immediately before a meal (start of meal within 5 to 10 minutes after injection) because of its fast onset of action.
The undated Levothyroxine manufacturer's instructions for use, provided by V2 Director of Nursing, documents: Levothyroxine should be given on an empty stomach 30-60 minutes prior to breakfast and spaced at least 4 hours apart from medications and food that can cause decreased absorption. Iron supplements decrease the absorption of Levothyroxine and should be given spaced 4 hours apart.
2. R8's Order Summary Report dated 3/13/23 documents: Linzess Capsule 290 MCG by mouth daily. Tramadol 50 mg by mouth two times a day for moderate pain. Pulmicort Flexhaler Aerosol Powder Breath Activated 180 mcg per actuation give 1 puff twice daily.
On 3/13/23 at 9:30 AM V13 prepared and administered R8's morning medications including Linzess. The Linzess contained a label that instructed to administer on an empty stomach at least 30 minutes before meals. V13 gave the Pulmicort inhaler to R8. R8 self-administered one puff, and V13 did not instruct R8 to rinse R8's mouth after administration. At 9:32 AM R8 stated R8's pain was a 10 on a 1-10 scale. R8 told V13 that R8 had been out of Tramadol for the last 4 days. There was no supply of R8's Tramadol, and V13 did not administer Tramadol. At this time V13 contacted the pharmacy. V13 stated the pharmacy needs a signed prescription in order to refill the Tramadol, and V13 contacted the provider and requested a signed prescription. At 10:03 AM V13 confirmed R8 had already ate breakfast prior to administering R8's medications.
On 3/14/23 at 8:31 AM V13 stated R8's Tramadol was obtained from the (facility's back up medication system) and administered on 3/13/23 at 12:13 PM.
The undated Pulmicort Flexhaler manufacturer's instructions for use, provided by V2, documents to rinse the mouth with water after use and do not swallow the water.
The undated Linzess manufacturer's instructions for use, provided by V2, documents to administer on an empty stomach at least 30 minutes prior to breakfast. When the medication is given after breakfast it resulted in loose stools and increased stool frequency.
3.) R54's Order Summary Report dated 3/13/23 documents the following medications are to be administered through gastrostomy tube: Chewable aspirin 81 mg daily. Benztropine Mesylate 0.5 mg twice daily. Famotidine Tablet 20 mg daily. Glipizide 10 mg twice daily. Metoprolol Tartrate 25 mg twice daily. Sennosides Tablet 8.6 mg twice daily. Topamax 25 mg twice daily.
On 3/13/23 at 9:50 AM V13 crushed R54's Topamax, Sennoside, Metoprolol Tartrate, Glipizide, Famotidine, Benztropine, and Aspirin. At 9:53 AM V13 mixed 30 ml of water with R54's crushed medications and poured the mixture into a syringe connected to R54's gastrostomy tube. The mixture did not drain and V13 had to manually push the medications with a plunger through the syringe.
On 3/13/23 at 9:50 AM V13 stated R54 has an order to administer R54's crushed medications together.
The facility's Medication Administration- Gastrostomy or Nasogastric Tube dated as revised August 2020 documents: Use medications in liquid form whenever possible. Administer medications separately when multiple medications are given at one time. Flush with 10 ml of water between each medication. Medications should be crushed and dissolved in water.
The facility's Medication Administration Policy dated as revised January 2015 documents: Medications are to be administered according to physician's orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to serve palatable food at an appetizing temperature. This failure affected 12 (R26, R63, R112, R101, R33, R56, R27, R17, R105, R...
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Based on observation, interview, and record review the facility failed to serve palatable food at an appetizing temperature. This failure affected 12 (R26, R63, R112, R101, R33, R56, R27, R17, R105, R99, R85, and R25) of 32 residents reviewed for food on the sample list of 55 and all 116 residents residing in the facility.
Findings include:
The facility's Resident Council Meeting minutes dated March of 2022 through February 2023 all documented concerns with the food temperatures and taste.
1. On 3/13/23 at 1:43 PM, a group meeting was held with R26, R63, R112, R101, R33, R56, and R27. All seven residents reported and concurred there are several issues with the quality, temperature, and palatability of the food. The residents also voiced concern they are not able to access food choice alternatives readily. At that time, R27 had a tray in front of her and stated, I just got back from Dialysis, and they had a tray ready when I got back but it was cold and it can't be reheated.
2. On 3/12/23 at 9:20 AM, R17 stated the food is terrible.
On 3/12/23 at 12:00 PM, R17 stated the food is always cold. R17 stated they have a steam table in the kitchen but the staff don't use it and they will serve out of the pans brought over from the other side.
On 3/12/23 at 12:30 PM, R17 received a hamburger on white bread. The burger appeared overcooked and the bread was soaked with liquid. R17 put his burger on some wheat bread. R17 stated the facility doesn't provide wheat bread and R17 must buy it.
3. On 3/12/23 at 10:00 AM, R25 stated the kitchen doesn't use the warmer to ensure the food stays warm. R25 stated the food here makes me sick. We complain and it never gets better. The food is made next door and then they send it over.
4. On 3/12/23 at 9:10 AM, R85 stated R85 does not get enough food. R85 stated the serving size is too small. R85 stated R85 is still hungry after he eats.
On 3/12/23 at 12:30 PM, R85 stated, Another thing they don't wear hair nets. I have had hair in my food. Yesterday, I got on scoop of scrambled eggs and that was it. Nothing else. We don't get seconds. We had waffles one day with no syrup and no butter. And when we had biscuits and gravy it was one biscuit with a little bit of gravy. Look I took pictures! R85 then pulled up pictures on R85's phone. The first picture was of a plate with a scoop of scrambled eggs. There was nothing else on the plate. The second picture was a plate that had a single small biscuit with gravy on top of it.
5. On 3/12/23 at 9:20 AM, R99 stated the food is always cold and R99 does not like it.
6. On 3/12/23 at 9:15 AM, R105 stated the food is always cold and we don't get enough food. The portions are always small. We only get one egg when they have eggs. R105 stated they will only let them have one carton of milk and when they ask for more, they won't let them have it. R105 stated the pancakes can't possibly be made with pancake mix because they don't taste like pancakes. I used to love food and not I don't enjoy it.
On 3/12/23 at 12:25 PM, R105 took tray back to the cart. R105 ate 50 percent of the meal.
The facility's Census and Conditions report dated 3/12/23 signed by V3 Psychiatric Rehabilitation Service Director documents there are 116 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to act upon and respond to concerns made in the resident council monthly meetings. This failure has the potential to effect eight...
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Based on observation, interview, and record review the facility failed to act upon and respond to concerns made in the resident council monthly meetings. This failure has the potential to effect eight of eight residents (R26, R63, R112, R101, R33, R56, R27, and R74) reviewed for resident council on the sample list of 55 and all 116 residents residing in the facility.
Findings include:
The facility's Resident Council Minutes form dated 3/22/22 for the North building documents food is often cold when it is served. The facility's Resident Council Minutes form dated 3/29/22 documents concerns with call light response times and staff not returning after call light is shut off. This form documents concerns with staffing.
The facility's Resident Council Minutes form dated 4/26/22 does not document old business or a follow-up to concerns made in March's resident council. This form documents concerns with call light response times and concerns with snack availability.
The Resident Council Minutes for the North building dated 4/26/22 does not document old business or a follow-up to concerns made in March's resident council. This form documents concerns with cold food and that the food needs improved.
The facility's Resident Council Minutes form dated 5/31/22 documents concerns with call light response time. The Resident Council Minutes for the North building dated 5/31/22 documents, food needs improvement, the sausage is horrible, dinner is terrible, would like fresh fruits and snacks. This form does not document a follow-up to concerns made in the April resident council meeting.
The facility's Resident Council Minutes form dated 6/28/22 documents concerns with call light response times and would like more variety at meals. The Resident Council Minutes for the North building dated 6/21/22 does not document follow up for concerns made in the May resident council meeting.
The facility's Resident Council Minutes form dated 7/26/22 documents concerns with call light response times and that the residents would like more beef on the menu and concerns that the menu is not being followed and they would like substitutions for the meals.
The facility's Resident Council Minutes form dated 8/30/22 documents concerns with call light response time and wanting more beef on the menu and the kitchen not following the menu. This form documents old business but does not document step taken by the facility to resolve the concerns. The Resident Council Minutes dated 8/23/22 for the North building documents concerns with the portion size of the food.
The facility's Resident Council Minutes form dated 9/27/22 documents concerns with call light response times, concerns that the staff answer the lights and do not come back, and that they would like bigger portions. This form documents the concerns for August but does not document the facility's response. The Resident Council Minutes dated 9/28/22 for the North building documents concerns that there are more alternatives available for the food. These minutes do not document the facility's response to concerns brought forth in the August resident council meeting.
The facility's Resident Council Minutes form dated 10/25/22 documents the Certified Nurse's Assistants are working short. This form does not document the facility's response to concerns brought up in the September Resident Council meeting. The facility's Resident Council Minutes for the North Building dated 10/25/22 documents a request that more snacks are available. These minutes do not documents the facility's response to concerns brought forth in the September resident council meeting.
The facility's Resident Council Minutes form dated 11/29/22 documents concerns with call light times. This form does not document the facility's response to concerns brought up in the October resident council meeting. The facility's Resident Council Minutes for the North building dated 12/6/22 for November of 2022 documents the residents are requesting a pitcher of hot water so they can make their own coffee or hot tea and that more snacks are available for the evening snack. There is no follow-up or documentation of the facility's response to the October concerns.
The facility's Resident Council Minutes form dated 12/27/22 documents concerns with call light response times and that breakfast is cold. This form does not documents the facility's response to the November resident council concerns. The facility's Resident Council Minutes for the North building dated 12/28/22 documents the residents are not getting milk or cereal, the fold is cold, the portions need to be bigger, requesting hot water, no drinks for lunch, and no variety for the snacks. This form does not documents old business or the facility's response to the November resident council concerns.
The facility's Resident Council Minutes form dated 1/31/23 documents concerns with call light response times and answering the light and not coming back to help them. This form does not document the facility's response to the concerns made in the December resident council. The facility's Resident Council Minutes dated 1/31/23 for the North building documents the residents would like larger portions, stated for example they will receive one strip of bacon, three french fries, barely half a bowl of soup. This form states the facility upsets them when they are told they can't have seconds and then watch the dietary staff throw away food. Beverages are not full or not on their trays. This form does not documents the response to the resident council concerns for December.
The facility's Resident Council Minutes form dated 2/28/23 does not document the response to concerns given at the January resident council meeting. The facility's Resident Council Minutes dated 2/28/23 documents breakfast is horrible, food is cold, there are no snacks in the evening, and there are no substitutes. This form does not document the facility's response to concerns for January.
On 3/13/23 at 1:43 PM, a group meeting was held with R26, R63, R112, R101, R33, R56, and R27. All seven residents reported and concurred the following issues have not been addressed by the facility for several months: Call light noise level, call lights not being answered timely due to lack of staffing, food is overcooked, lacking utensils, food is cold and the facility will not reheat the food, lack of alternative food choices, lack of snacks due to insufficient amounts.
On 3/12/23 at 9:18 AM, R74 stated the food is always cold and the serving sizes are too small. R74 stated he is the [NAME] President of the resident council for the North building and they address all issues except for the food. R74 stated they never use the warming table so the food is always cold.
On 3/13/23 at 2:25 PM, V2 Director of Nursing stated the nursing staff is not allowed to reheat food. V2 stated food can not taken back into the kitchen to be reheated. V2 stated it is a rule from the kitchen. V2 stated there have been multiple complaints about the food. V1 stated they don't give them new trays if the food is cold.
On 3/13/23 at 3:00 PM, V1 Administrator stated call lights have been a problem. V1 stated V1 turned up the sound so that the staff will answer them quicker.
The facility's Census and Conditions report dated 3/12/23 signed by V3 Psychiatric Rehabilitation Service Director documents there are 116 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to promote a homelike environment by failing to ensure call light sounds levels were comfortable and by failing to ensure a non-i...
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Based on observation, interview, and record review the facility failed to promote a homelike environment by failing to ensure call light sounds levels were comfortable and by failing to ensure a non-institutional dining experience. This failure affected eight of eight (R26, R63, R112, R101, R33, R56, R27, and R74) residents reviewed for resident council and all 116 residents residing in the facility.
Findings include:
On 3/19/23 through 3/23/23 and on 3/21/23 from 9:00 AM to 3:00 PM, the call light system alarm could be heard throughout the facility. The sound was a high-pitched alarm sound that repeated over and over until the call light was answered. The call light alarm sounded repetitively throughout the day with infrequent breaks. The high pitch and constant sound level interrupted concentration and was pervasive.
On 3/13/23 at 1:43 PM, a group meeting was held with R26, R63, R112, R101, R33, R56, and R27. All seven residents reported and concurred the following issues have not been addressed by the facility for several months: Call light noise level, call lights not being answered timely due to lack of staffing, food is overcooked, lacking utensils, food is cold and the facility will not reheat the food, lack of alternative food choices, lack of snacks due to insufficient amounts. The residents reported the call light impact their quality of life as it is impacting their ability to sleep as well as their leisurely time during the day.
On 3/12/23 at 9:18 AM, R74 stated R74 is the [NAME] President of the resident council for the North building and stated the facility addresses all issues except for the food. R74 stated our quality of life is affected by our food. On 3/12/23 at 12:25 PM, R74 stated the atmosphere of the dining room was not home like. R74's lunch and all residents' food were served on trays.
The resident council meeting minutes dated March of 2022 through February of 2023 contained complaints about call lights and food service.
On 3/13/23 at 3:00 PM, V1 Administrator stated call lights have been a problem. V1 stated V1 turned up the sound so that the staff will answer them quicker. V1 stated she was not aware that residents couldn't use the microwave or that anyone put a rule in about no one using the microwave to heat up residents' food.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to sufficiently staff Certified Nursing Assistants (CNAs). This failure affects four residents (R3, R5, R27, R55) on the sample l...
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Based on observation, interview, and record review the facility failed to sufficiently staff Certified Nursing Assistants (CNAs). This failure affects four residents (R3, R5, R27, R55) on the sample list of 55. This failure has the potential to affect all 116 residents residing in the facility.
Findings include:
The facility's Resident Council Minutes document: On 1/13/23 residents had concerns with call light response times and residents not getting showers timely. On 2/28/23 residents voiced concerns with night shift not checking on them and answering call lights.
On 3/12/23 at 9:50 AM R3 stated there are not enough staff, and R3 does not get help every day to get dressed and assisted out of bed.
On 3/12/23 at 9:02 AM R5 stated they don't change R5 during the night, and R5's sheets are often wet with urine in the mornings. R5's Power of Attorney (V24) stated she comes to the facility in the mornings every day to assist R5 with morning care, and every morning R5's bed linens are soaked with urine.
On 3/12/23 at 8:44 AM R27 stated: The facility is short staffed on CNAs. There are times where there is only 1 CNA working on night shift and 2 CNAs working evening shift. We don't' get changed during the night. I'm wet when I wake up in the morning. I sleep soundly, and require staff to wake me and change me, but they don't. Every morning I request a bucket of water to wash up. Night shift CNAs tell me I must wait for first shift, because they don't have time due to staffing. This morning I waited for 30 minutes before my call light was answered.
On 3/13/23 at 12:18 PM R55 stated R55 calls for staff during the night, but they tell her that they're short staffed and can't assist her. Sometimes R55 must wait until 6:00 AM before R55 is provided incontinence care.
On 3/12/23 at 8:45 AM in the North building there were no staff present at the nurse's station or dining area. No staff responded upon knocking on the door entrance to the locked unit. There were no staff visible in the hallways. Residents sitting in the dining area stated they did not know where the staff are.
On 3/12/23 at 10:54 AM V15 and V16 Certified Nursing Assistants entered R55's room and provided incontinence care. R55's incontinence brief was saturated with urine and a large amount of soft bowel movement. There was a small amount of urine on R55's bed sheets. There was a strong urine odor. R55's abdominal folds, groin, and underneath R55's breasts were red/inflamed. R55 said Ow when V15 cleansed R55's perineal area, groin, and abdominal fold. There were large scaly, red patches covering R55's back, buttocks, and posterior thighs. V15 stated R55 has had Psoriasis for a while now and this area (pointing to abdominal fold) looks worse.
On 3/12/23 at 11:27 AM V15 stated: V15 was not sure when R55 was last changed, and V15 had not changed R55 earlier this morning. V15 CNA stated she's not sure when R55 was last changed, she had not changed her prior to this morning. V10 CNA was initially on R55's hall this morning, but V10 got pulled to work the North building around 9:30 AM and V15 took over V10's hallway. There have been problems with night shift staffing due to call offs. They are supposed to have 3 CNAs in the South building, and about 2-3 times per week V15 comes in for dayshift and residents are incontinent as if they had not been changed on night shift.
On 3/12/23 at 11:38 AM, V10 CNA stated she did not provide care to R55. V10 stated she only took R55 a breakfast tray. At 11:56 AM, V10 stated that she just remembered that R55 refused cares this morning.
There is no documentation in R55's medical record that R55 refused incontinence care.
On 3/14/23 at 12:50 PM V1 Administrator confirmed there have been staffing issues on night shift. V1 stated last night there was a CNA that called off and there was only 1 CNA and 1 nurse in the South building. At 3:25 PM V1 Administrator provided the facility's daily hall assignments. V1 stated: The hall assignment sheets accurately reflect the facility's daily staffing. We are to have 2 CNAs in the North Building for all shifts, and the South building should have 5-7 CNAs on 1st and 2nd shifts, and 2-3 CNA's on night shift. Ideally, we should have 3 CNAs on night shift in the South building. On 3/15/23 at 9:18 AM V1 stated: V1 is aware of the low weekend staffing. We staff fully, but then people don't show up or call off.
The facility's Facility Assessment updated 3/13/23 documents the facility will staff 7 CNAs on 1st and 2nd shifts and 4 or 5 CNAs on 3rd shift. The facility's Nursing Daily Schedules dated 2/28/23-3/14/23 document: There was 1 CNA working the North building on dayshift on 3/11, and night shift on 3/12/22. The South building had one CNA on night shift on 3/7, 3/8, and 3/13/23. There are less than 7 CNAs on 1st or 2nd shifts on 12 days. The Resident List Report dated 3/12/23 documents 71 residents reside in the South building. R3, R5, R27 and R55 reside in the South building.
Resident Census and Conditions of Residents dated 3/12/23 documents: 116 residents reside in the facility, at least 83 residents require assistance or dependent on one to two staff for bathing, dressing, transferring, toileting, or eating.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 116 resid...
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Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 116 residents residing in the facility.
Findings include:
On 3/12/23 at 10:05am, V5 Dietary Manager was actively supervising dietary operations in the facility kitchen during resident meal preparations. V5 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training.
The Resident Census and Conditions of Residents report dated 3/12/23 documents 116 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to maintain sanitary food storage areas and failed to maintain sanitary kitchen floor surfaces. These failures have the potentia...
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Based on observation, interview, and record review, the facility failed to maintain sanitary food storage areas and failed to maintain sanitary kitchen floor surfaces. These failures have the potential to affect all 116 residents residing in the facility.
Findings include:
On 3/12/23 at 8:25am, the floor areas throughout the kitchen and adjacent dishwashing areas were soiled with accumulations of decomposing food and grease deposits. V6 Dietary Aide was present and stated the floors are cleaned once per shift.
On 3/12/23 at 12pm, the kitchen refrigerator had water pooling on the bottom shelf. V5 Dietary Manager (DM) was present and stated this issue had been ongoing for a week or two. V5 stated V5 was not sure if it was a door seal issue or condenser issue V5 stated the condenser/evaporator had been blown out by V20 Maintenance Director and that seemed to help for a bit. V5 confirmed the kitchen and adjacent dishwashing area floors were dirty and stated staff are to clean the floors each shift.
On 3/12/23 at 1:15pm, V20 Maintenance Director replaced refrigerator door seal.
On 3/13/23 at 12:11pm, water was observed pooling on bottom shelf of refrigerator.
On 3/15/23 at 11:25pm, V20 Maintenance Director stated V20 replaced the refrigerator door seal on 3/12/23 but was not sure it [seal] was fitting properly. V20 stated a commercial kitchen repair vendor was coming out today to replace the door seal. V20 stated not sure if it is a condenser/evaporator issue but will know today after they come out to fix it either way. V20 stated the refrigerator started holding water a couple of weeks ago.
A repair service invoice dated 3/16/23 documents the following: Service performed: Evaporator condensate line plugged, leaking water into cabinet. Remove rear flex line and flush debris, break clog of lime from drain line in wall. Flush with hot water to test, now draining to condensate pan.
The Resident Census and Conditions of Residents report dated 3/12/23 documents 116 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure there is a Licensed Administrator managing the facility. This failure has the potential to affect all 116 residents res...
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Based on observation, interview and record review, the facility failed to ensure there is a Licensed Administrator managing the facility. This failure has the potential to affect all 116 residents residing in the facility.
Findings include:
On 3/12/23 at 11:17 AM, V1 acting Administrator was in the building. On 3/13/23, 3/14/23, 3/15/23 and 3/16/23 V1 was in the building as the acting Administrator.
On 3/15/23 at 11:07 AM, V1 stated that V1 does not have an Administrator's license nor does V1 have a temporary Administrator's license. V1 stated that the owner's license is on the wall. V1 stated that the owner usually comes to the facility once every two weeks. V1 stated that V1 tried to apply for a temporary license and it was denied.
The Resident Census and Conditions of Resident report dated 3/12/23 documents there are 116 residents reside in 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
Based on interview and record review the facility failed to have required members attend the Quality Assurance Performance Improvement (QAPI) meetings. This failure has the potential affect all 116 re...
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Based on interview and record review the facility failed to have required members attend the Quality Assurance Performance Improvement (QAPI) meetings. This failure has the potential affect all 116 residents residing in the facility.
Findings include:
On 3/13/23 at 3:19 PM the Quality Assurance meeting sign in sheets provided by V3 Psychiatric Rehabilitation Services Director, documents: The 4/20/22 meeting did not have a Medical Director or Director of Nursing in attendance. The undated meetings that reviewed April- September 2022 documents V1 Administrator was in attendance. V1 is not a Licensed Nursing Home Administrator. The undated meeting that reviewed October, November, and December documents there was no Medical Director or Administrator in attendance.
On 3/15/23 at 11:07 AM V1 Administrator confirmed the facility's QAPI meeting sign in sheets are missing some of the required members and confirmed V1 is not a Licensed Nursing Home Administrator.
Resident Census and Conditions of Residents dated 3/12/23 documents 116 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by failing to prevent cockroaches in the kitchen area. This failure has the potent...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by failing to prevent cockroaches in the kitchen area. This failure has the potential to affect all 116 residents in the facility.
Findings include:
On 3/12/23 at 8:20am, the kitchen and pantry flooring was soiled throughout with accumulations of food debris. The legs of food preparation tables and dishwasher drain boards were also soiled with splattered food debris. Live German cockroaches were observed on the wall underneath of the mechanical dishwasher and the three compartment sink. Dead cockroaches were observed on the floor near the employee handwashing sink.
On 3/12/23 at 10:35am, live German cockroaches were observed on the wall underneath of the mechanical dishwasher and the three compartment compartment sink. V5 Dietary Manager was present and confirmed the above insects were German cockroaches. V5 stated, They [pest control] come out monthly to treat for them [roaches] and not as bad as they used to be, but staff need to keep the floors cleaner.
On 3/13/23 at 12:11pm, live German cockroaches were observed on the wall underneath of the mechanical dishwasher.
The facility pest control reports (January 2022-March 2023) document the presence of cockroaches each month in the facility kitchen areas. The March 2023 report documents: Used a bait in some common areas where cockroach activity has been noticed. Please do not use store bought products for pest control. Other products can counteract what we use and will negate both or help pests gain resistances against all products.
The Resident Census and Conditions of Residents report dated 3/12/23 documents 116 residents reside in the facility.
Dec 2022
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to document timely and specific actions following resident grievances for one of four (R3) residents reviewed for call light response time in ...
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Based on interview and record review, the facility failed to document timely and specific actions following resident grievances for one of four (R3) residents reviewed for call light response time in the sample of four residents.
Findings include:
Facility Resident Council Minutes (September and November, 2022) document resident complaints of staff call light response times each month. The September and November Minutes both document call light response times are an old business item. The same records document call light response times are an ongoing issue for the months of September and November and the facility Response Form (undated) documents Education provided to staff on above statement. The Response Form does not document the investigative process the facility used to investigate the grievance, a summary of pertinent findings or conclusions regarding the concern, a statement about whether the facility substantiated the allegation or not, or the date the written decision was issued.
The November Concern/Compliment Form (11/29/2022) does not include a summary of pertinent findings or conclusions regarding the call light concerns, and whether or not the facility substantiated the concern.
On 12/13/2022 at 1:51PM, R3 reported being the [NAME] President of the Resident Council and routinely attending Resident Council meetings. R3 reported the facility is short staffed and sometimes R3 waits two-four hours after pressing R3's call light to get toileting assistance. R3 reported sitting in a soiled or wet brief during the wait and staff not answering R3's call light timely. R3 stated the concern (expletive) me off. R3 reports facility staff frequently answer call lights late. R3 reported the call light response time issues have been brought to Resident Council meetings repeatedly, but no follow up has occurred by staff.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 3 life-threatening violation(s), 9 harm violation(s), $439,062 in fines, Payment denial on record. Review inspection reports carefully.
- • 114 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $439,062 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is La Bella Of Danville's CMS Rating?
CMS assigns LA BELLA OF DANVILLE 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 La Bella Of Danville Staffed?
CMS rates LA BELLA OF DANVILLE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 60%, which is 14 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 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at La Bella Of Danville?
State health inspectors documented 114 deficiencies at LA BELLA OF DANVILLE during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 9 that caused actual resident harm, and 102 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates La Bella Of Danville?
LA BELLA OF DANVILLE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 200 certified beds and approximately 141 residents (about 70% occupancy), it is a large facility located in DANVILLE, Illinois.
How Does La Bella Of Danville Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, LA BELLA OF DANVILLE's overall rating (1 stars) is below the state average of 2.5, staff turnover (60%) 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 La Bella Of Danville?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is La Bella Of Danville Safe?
Based on CMS inspection data, LA BELLA OF DANVILLE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at La Bella Of Danville Stick Around?
Staff turnover at LA BELLA OF DANVILLE is high. At 60%, the facility is 14 percentage points above the Illinois average of 46%. Registered Nurse turnover is particularly concerning at 67%. 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 La Bella Of Danville Ever Fined?
LA BELLA OF DANVILLE has been fined $439,062 across 8 penalty actions. This is 11.7x the Illinois average of $37,469. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is La Bella Of Danville on Any Federal Watch List?
LA BELLA OF DANVILLE 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.