DECATUR REHAB & HEALTH CARE CT
For profit - Corporation
58 Beds
Independent
Data: November 2025
Trust Grade
20/100
#502 of 665 in IL
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Decatur Rehab & Health Care Center has received a Trust Grade of F, indicating significant concerns and a poor quality of care. It ranks #502 out of 665 facilities in Illinois, placing it in the bottom half, and #3 out of 7 in Macon County, meaning only two local options are worse. The facility is worsening, with the number of reported issues increasing from 30 in 2023 to 31 in 2024. Staffing is a notable strength, with a turnover rate of 0%, which is well below the state average, but the overall and health inspection star ratings are both just 1 out of 5, indicating severe deficiencies. Notably, there have been serious incidents, such as a resident's pressure sore deteriorating due to a lack of proper monitoring and care, and another resident falling and fracturing their wrist because the staff did not lower their bed after care. While the staffing stability is a positive aspect, the overall care quality raises serious concerns for families considering this facility for their loved ones.
- Trust Score
- F
- In Illinois
- #502/665
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ⚠ Watch
- $25,500 in fines. Higher than 100% of Illinois facilities. Major compliance failures.
- Skilled Nurses ○ Average
- RN staffing data not reported for this facility.
- Violations ⚠ Watch
- 89 deficiencies on record. Higher than average. Multiple issues found across inspections.
20/100
Bottom 25%
Review needed
30 → 31 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 30 issues
2024: 31 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
Federal Fines: $25,500
Below median ($33,413)
Moderate penalties - review what triggered them
The Ugly 89 deficiencies on record
3 actual harm
Nov 2024
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
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 notice which included date of transfer, discha...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide notice which included date of transfer, discharge location, Office of the State Long Term Care Ombudsman contact information, appeal rights, and contact information for the agencies for advocacy and protection of residents with intellectual/development disabilities and mental illness for four (R1, R2, R3, R4) of four residents reviewed for involuntary transfer in the sample list of four.
Findings include:
The facility's written notification dated 11/1/24, signed by V1 Administrator, documents this letter is to inform the facility's residents that the facility will voluntarily close on 2/1/25; and facility staff, consultants and government agencies are working together to ensure residents find placement at facilities that meet the resident's comprehensive needs and preferences. This notice does not include the right to appeal, Ombudsman contact information, or contact information for advocacy and protection agencies for residents with intellectual/developmental disabilities and mental illness.
The facility's undated Closure Plan documents this closure and relocation plan will be initiated on or about November 1, 2024, and will be completed February 1, 2025; and once placement is determined the facility will notify the resident and family of the proposed relocation and their right to an appeal in accordance with federal and/or state laws.
On 11/13/24 at 9:40 AM V1 Administrator stated the facility will be closed after the four remaining residents (R1-R4) are discharged today. At 9:50 AM V1 provided the facility's resident roster dated 11/13/24 that documents R1-R4 are the only residents that reside in the facility. V1 stated R1 and R2 are leaving between 10:00 AM and 10:30 AM, R3 is leaving around 11:00 AM, and R4 is leaving around noon.
The facility's ongoing resident move roster documents residents started transferring/discharging from the facility as of 11/5/24.
1.) On 11/13/24 at 9:58 AM R1 was sitting in a wheelchair in the dining room. R1 stated about a week ago the facility notified the residents verbally and in writing that the facility was closing.
R1's Face Sheet dated 8/26/24 documents R1's diagnoses include Schizoaffective Disorder, Major Depression, and Anxiety Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact.
2.) On 11/13/24 at 10:08 AM R2 was lying in bed and stated R2 has lived at the facility for a few years and was told yesterday that the facility is closing.
R2's Face Sheet dated 8/26/24 documents V12 (R2's Family) as R2's responsible party, and R2's diagnoses include epilepsy, history of traumatic brain injury, and developmental disorder of scholastic skills. R2's MDS dated [DATE] documents R2 has severe cognitive impairment.
3.) On 11/13/24 at 10:00 AM R3 was lying in bed wearing oxygen. R3 stated the facility notified the residents verbally and in writing on 11/1/24 of the facility's closure. R3 provided the written notice of closure that was dated 11/1/24 and documented the facility would close on 2/1/25. This notice did not include date of transfer, location of discharge, Ombudsman contact information, appeal rights, or contact for information for the advocacy and protection agencies for residents with intellectual/developmental disabilities and mental illness. R3 stated V1 Administrator has helped R3 with discharge planning and R3 is transferring today to a facility of her choice today.
R3's Face Sheet dated 8/26/24 documents R3's diagnoses include Dementia, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Dementia, Cerebrovascular Disease, Anxiety, and Depression; and no family or guardian is listed. R3's MDS dated [DATE] documents R3 has moderate cognitive impairment.
4.) On 11/13/24 at 9:53 AM R4 was walking independently in R4's room and there were boxes of R4's belongings. R4 stated the facility came in here like crooks and told us they're closing. R4 stated R4 is transferring to another skilled nursing facility today, which is his choice and close to his family. R4 was unable to say what day R4 was notified of the closure or discharge planning that the facility assisted with. R4 deferred further questioning to the facility's staff and R4's Family (V10).
On 11/13/24 at 10:39 AM V10 stated V10 was notified both verbally and in writing on 11/2/24 of the facility's closure.
R4's Face Sheet dated 8/8/24 documents R4's diagnoses include Type Two Diabetes Mellitus, Pervasive Developmental Disorder, Cognitive Communication Deficit, Glaucoma, Sarcoidosis of Lung, History of Traumatic Brain Injury, and other problems related to life management difficulty. R4's MDS dated [DATE] documents R4 as cognitively intact.
There is no documentation in R1's, R2's, R3's, and R4's medical records that the residents and their families/representatives were provided notice, which includes all of the required information, prior to discharging from the facility on 11/13/24.
On 11/13/24 at 12:45 PM R1-R4 had been discharged and there were no residents residing in the facility.
On 11/13/24 at 10:52 AM V1 stated staff were notified on 11/1/24 of facility closure by 2/1/25 and that day V1 met with residents in small groups and one to one to notify of the closure and answer any questions. V1 stated V1 called all of the residents' families between 11/2/24 and 11/4/24 to notify of the closure after letters were mailed on 11/1/24 by V5 Chief Executive Officer of (contracted company). V1 stated V1 doesn't know that anything has been documented about each resident's discharge planning, other than the managers documenting the discussion of facility closure in the nursing notes or social service notes. V1 stated V1 did not receive a lot of guidance on what should be documented. At 11:52 AM V5 provided a copy of the notice that was sent to residents and families on 11/1/24. At 12:32 PM V1 confirmed no other notices regarding transfers/discharges were provided to the residents/families besides the notice on 11/1/24 by V5. V1 confirmed the written notice provided on 11/1/24 did not include date of transfer, discharge location, Ombudsman information, appeal rights, and advocacy agency for developmental disabilities and mental illness information, and confirmed the facility had residents with developmental disabilities and mental illnesses that were discharged after 11/1/24.
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 F0660
(Tag F0660)
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 coordinate and document discharge planning for four (R...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to coordinate and document discharge planning for four (R1, R2, R3, R4) of four residents reviewed for involuntary transfer in the sample list of four.
Findings include:
The facility's written notification dated 11/1/24, signed by V1 Administrator, documents this letter is to inform the facility's residents that the facility will voluntarily close on 2/1/25; and facility staff, consultants and government agencies are working together to ensure residents find placement at facilities that meet the resident's comprehensive needs and preferences.
The facility's undated Closure Plan documents the facility intends to close on 2/1/25 and the plan is to ensure safe, orderly and clinically appropriate resident transfers, and to assure successful adjustment for reach resident with minimal stress. This plan includes the following approximate time frames: notification on days 1-5, resident assessments on days 2-30, and transfer/relocation of residents on days 10-45. The resident assessments to be completed include Medicaid Coverage Determination, Medical and Social Assessments by a nurse and Qualified Mental Retardation Professional, and Psychological Preparation of Residents for Transfer. This plan documents the facility will hold on-site conferences for residents and resident representatives to discuss the relocation plans for each resident; the resident's needs, alternative placement, and preferences will be discussed and family or guardian involvement is essential to assure successful relocation for residents and that residents' rights are protected.
On 11/13/24 at 9:40 AM V1 Administrator stated the facility will be closed after the four remaining residents (R1-R4) are discharged today. V1 stated the facility staff found out on 11/1/24 that the facility would be closing, and social services staff and V1 worked with the residents to find placement, and all were able to go to facilities of their choice. At 9:50 AM V1 provided the facility's resident roster dated 11/13/24 that documents R1-R4 are the only residents that reside in the facility. V1 stated R1 and R2 are leaving between 10:00 AM and 10:30 AM, R3 is leaving around 11:00 AM, and R4 is leaving around noon.
The facility's ongoing resident move roster documents residents started transferring/discharging from the facility as of 11/5/24.
1.) On 11/13/24 at 9:58 AM R1 was sitting in a wheelchair in the dining room. R1 stated about a week ago the facility notified the residents verbally and in writing that the facility was closing. R1 stated staff have been helping R1 with discharge planning and R1 has decided to transfer to (facility's sister facility). R1 stated R1 was told (sister facility) is similar to this one since it has younger residents and mental health services.
R1's Face Sheet dated 8/26/24 documents R1's diagnoses include Schizoaffective Disorder, Major Depression, and Anxiety Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. R1's Care Plan dated 7/9/24 does not document discharge planning. R1's Social Service Progress Note dated 11/6/24, recorded by V11 Maintenance Director, documents discussed with R1 today about facility closure and upcoming move. R1's only concern is that R1 would like to continue to receive the same services so R1's mental stability continues to improve. R1 was reassured that the facility would make sure R1 gets to the proper facility with the services that R1 needs. There is no other documentation in R1's medical of coordination of discharge planning, besides this note.
2.) On 11/13/24 at 10:08 AM R2 was lying in bed and stated R2 has lived at the facility for a few years and was told yesterday that the facility is closing. R2 stated he was unsure of where he was transferring to and that no one had talked with him about discharge planning; and R2 has no family involved in his care.
On 11/13/24 at 10:11 AM V2 Resident Care Coordinator stated R2 is transferring to (sister facility) today, R2 is alert with confusion and has no guardian or Power of Attorney. V2 stated R2 was aware of R2's discharge today and has been reminded, but R2 must have forgot.
R2's Face Sheet dated 8/26/24 documents V12 (R2's Family) as R2's responsible party, and R2's diagnoses include epilepsy, history of traumatic brain injury, and developmental disorder of scholastic skills. R2's MDS dated [DATE] documents R2 has severe cognitive impairment. R2's Care Plan dated 5/9/24 documents the following: R2 wishes to eventually be discharged to another facility, V12 believes R2 needs more care than V12 can provide. The interdisciplinary team will review this with V12 and R2 on comprehensive care plans. Interventions listed are evaluate R2's motivation to return to the community and inform on each comprehensive MDS availability of discussions with a Local Contact Agency to assist with setting up services to discharge to the community.
There is no documentation in R2's medical record of the facility's closure and coordination of discharge planning.
3.) On 11/13/24 at 10:00 AM R3 was lying in bed wearing oxygen. R3 stated the facility notified the residents verbally and in writing on 11/1/24 of the facility's closure. R3 provided the written notice of closure that was dated 11/1/24 and documented the facility would close on 2/1/25. R3 stated V1 Administrator has helped R3 with discharge planning and R3 is transferring today to a facility of her choice. At 11:08 AM R3 entered V1's office to say goodbye, R3 was in a wheelchair and wearing oxygen. R3 left the facility with R3's personal belongings.
R3's Face Sheet dated 8/26/24 documents R3's diagnoses include Dementia, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Dementia, Cerebrovascular Disease, Anxiety, and Depression; and no family or guardian is listed. R3's MDS dated [DATE] documents R3 has moderate cognitive impairment. R3's November 2024 Physician Orders document R3 receives hospice care. R3's Care Plan dated 10/24/24 documents a problem area for discharge planning to return home, but as of 10/24/24 R3 and R3's family no longer wish for R3 to discharge. Interventions include to encourage R3 to discuss feelings and concerns, and monitor/address episodes of anxiety, fear, and distress, and to inform R3 on each comprehensive MDS of the availability to discuss contacting the Local Contact Agency to assist with setting up services to discharge to the community.
R3's Social Services Progress note dated 10/15/24 documents R3's daughter is R3's Power of Attorney. R3's Social Service Progress Note dated 11/6/24, recorded by V11 Maintenance Director, documents V11 discussed R3's upcoming discharge with R3, R3's only concern was where her boyfriend, an unidentified resident, would be transferring to. R3 was reassured that the facility would assist in finding placement for the residents that the residents are happy with. There is no other documentation in R3's medical record of the facility's closure and coordination of discharge planning.
4.) On 11/13/24 at 9:53 AM R4 was walking independently in R4's room and there were boxes of R4's belongings. R4 stated the facility came in here like crooks and told us they're closing. R4 stated R4 is transferring to another skilled nursing facility today, which is his choice and close to his family. R4 was unable to say what day R4 was notified of the closure or discharge planning that the facility assisted with. R4 deferred further questioning to the facility's staff and R4's Family (V10).
On 11/13/24 at 10:39 AM V10 stated V10 was notified on 11/2/24 of the facility's closure. V10 stated we were given up to 2/1/25 to find placement, but staff have been helpful in finding residents placement sooner than anticipated. V10 stated the facility started transferring residents last week, the facility assisted with discharge planning, and V10 was able to choose the facility for R4 to be transferred to.
R4's Face Sheet dated 8/8/24 documents R4's diagnoses include Type Two Diabetes Mellitus, Pervasive Developmental Disorder, Cognitive Communication Deficit, Glaucoma, Sarcoidosis of Lung, History of Traumatic Brain Injury, and other problems related to life management difficulty. R4's MDS dated [DATE] documents R4 as cognitively intact. R4's Care Plan dated 10/25/24 does not include discharge planning. There is no documentation in R4's medical record of the facility's closure and coordination of R4's discharge planning.
On 11/13/24 at 12:45 PM R1-R4 had been discharged and there were no residents residing in the facility.
On 11/13/24 at 10:12 AM V3 Social Services Assistant stated staff found out on 11/1/24 that the facility was closing and residents and families were notified that same day, and letters were sent out on 11/4/24. V3 stated residents were given opportunity to choose their facilities and they were asked about their preferences, referral packets were sent out and calls were placed to facilities, and residents were accepted to their chosen facilities. At 11:23 AM V3 confirmed V3 had not documented resident discharge planning.
On 11/13/24 at 10:16 AM V4 Social Services Director stated V4 assisted in sending referrals to facilities and following up. V4 stated residents were given options and choice of facility, if residents weren't able to decide then it was up to their guardian or family. V4 stated R3 has been involved in discharge planning, but R3 did not get accepted at a few facilities, R3 had no facility preference and has no family. V4 stated R3 has been reminded of being transferred today to (sister facility). At 10:50 AM V4 stated V4 was not sure where discharge planning is documented and V4 was not instructed to document discharge planning. At 11:18 AM V4 stated V4 sent R4's referral packet to (sister facility), per V10's request and V4 spoke to V10 yesterday to inform of discharge plan. V4 stated V4 had not spoken to V10 about discharge planning prior to 11/12/24.
On 11/13/24 at 10:52 AM V1 stated staff were notified on 11/1/24 of facility closure by 2/1/25 and that day V1 met with residents in small groups and one to one to notify of the closure and answer any questions. V1 stated residents were asked that day of places they would prefer to be transferred to and we made a list that day. V1 stated management staff followed up with the residents to ask how they were feeling and if they had any questions or concerns. V1 stated V1 called all of the residents' families between 11/2/24 and 11/4/24 to notify of the closure after letters were mailed on 11/1/24. V1 stated all residents were assisted with finding placement in facilities that they wanted to go, all of the facilities have psychiatric services and all but two of those facilities use the same psychiatry provider. V1 stated R3 is on hospice and the same hospice company will continue to follow R3 at the receiving facility, and all of the residents on hospice were able to keep the same hospice company at the receiving facilities. V1 stated we started sending referral packets to facilities last week, which included included face sheets, insurance information, Preadmission Screening and Resident Reviews, trust fund information, Physician Order for Life Sustaining Treatment, Power of Attorney forms, physician orders, progress notes/nursing notes, care plans and laboratory results, as well as additional medical records. V1 stated V1 gave notice to terminate V1's employment as of 11/15/24 and V1 wanted to make sure all of the residents had placement accepted prior to V1's last day. V1 stated V1 has visited residents at their new facilities to follow up after their discharge. V1 stated V1 doesn't know that anything has been documented about each resident's discharge planning, other than the managers documenting the discussion of facility closure in the nursing notes or social service notes. V1 stated V1 did not receive a lot of guidance on what should be documented. V1 stated V11 was assigned to follow up with R1 and R3 regarding discharge. V1 stated V4 should have put in a note for R4's discharge planning and V3 should have put in a note for R2's discharge planning. V1 stated R2 had no facility preference, we had tried to communicate with R2's family (V12), but he is hard to get a hold of and messages were left. V1 stated on 11/5/24 (sister facility) representative came to the facility and talked with R2 about the facility and how it was similar to this one, and R2 was in agreement to transfer there.
The facility's undated Transfer and Discharge Policy and Procedure documents: Involuntary transfers or discharges Except for the case of late payment or nonpayment, the facility shall notify the resident and the residents family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record. In all other instances of involuntary transfer or discharge the mandated federal and state 30 day ''Notice Transfer or Discharge will be issued and the following steps taken.
1.
The planned involuntary transfer or discharge shall be discussed with the resident, guardian, residents representative and/or the person or agency responsible for the residents placement, maintenance and care in the facility.
2.
The discussion shall be carried out by the administrator or his/her designee. The content of the discussion and explanation shall be summarized in writing, including the names of those in attendance. The summary shall be made a part of the residents clinical record.
3.
A physicians discharge order shall be obtained in the residents record prior to discharge.
4.
Prior to transfer or discharge the Social Service Director shall counsel the resident and summarize the counseling session in the residents record.
Sept 2024
20 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess, monitor, implement pressure relieving intervent...
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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, monitor, implement pressure relieving interventions, complete treatments, and obtain weekly documentation for a pressure sore for one of one (R31) residents reviewed for pressure sores in a sample list of 34 residents. These failures resulted in R31's right heel pressure sore deteriorating requiring mechanical debridement and delaying prosthetic device placement for R31's Left Below the Knee Amputation.
R31's Medical Record documents R31's medical diagnoses of Cardiomyopathy, Diabetes Mellitus Type II, Grade One Diastolic dysfunction, Severe Protein Calorie, Malnutrition, recent Left Below the Knee Amputation and Right Heel Stage 3 Pressure Ulcer.
R31's undated Face Sheet documents R31 admitted to facility on 1/15/2024.
R31's Nursing admission assessment dated [DATE] does not document any skin impairment to R31's Right Heel.
R31's Nursing Summary dated 2/2/24 documents R31's skin as intact with no skin impairment.
R31's Careplan intervention dated 3/5/24 instructs staff to complete a Skin Risk Assessment weekly for four weeks on admission and readmission then quarterly thereafter. This same careplan does not include R31's Right Heel Stage 3 Pressure Ulcer.
R31's Minimum Data Set (MDS) dated [DATE] documents R31 as cognitively intact. This same MDS documents R31 requires moderate assistance from staff for toileting, bathing, dressing, personal hygiene, and transfers.
R31's Treatment Administration Record (TAR) dated June 2024 documents a treatment order (right heel) starting 6/24/24 to cleanse wound with Normal Saline or wound cleanser. Cover wound bed with honey (medical grade) (not intact skin) and cover with dry dressing daily. This treatment was signed as refused on 6/24/24, 6/25/24 and discontinued on 6/26/24.
R31's Nurse Progress Note dated 6/26/24 at 2:00 AM documents Current (Right) Heel treatment discontinued due to (R31's) declination and continues to take dressing off each time applied treatment. Changed back to Skin Prep twice daily. Continue no shoe to Right Foot. Heel protector when up in wheelchair. Float Right Heel when in bed every shift.
R31's Nurse Progress Note dated 7/1/24 at 1:00 PM documents Received order for (R31's) Right Heel. Cleanse with wound cleanser or Normal Saline. Cover with honey (medical grade) and dry dressing. Wrap with roll gauze.
R31's Nurse Progress Note dated 7/6/24 at 5:00 PM documents Received new order for Doxycycline 100 milligrams (mg) twice daily for ten days for (R31's Right Heel) wound healing.
R31's Treatment Administration Record (TAR) dated July 2024 documents a treatment order (right heel) starting 7/15/24 to cleanse wound with Normal Saline or wound cleanser, apply Betadine to cover Eschar/black area, cover with absorbent pad and wrap with gauze twice daily. This same TAR does not document R31's treatment was completed for the evening shift on 7/18 and 7/19, day shift on 7/20 and 7/21 and neither day nor evening shift from 7/22/24-7/31/24. This same TAR does not document weekly skin assessments as being completed on 7/2, 7/9, 7/23 and 7/30/24.
R31's Initial Wound Clinic Progress Note dated 7/30/24 documents R31's Right Calcaneus Pressure Ulcer as a Stage 3 wound.
R31's Physician Order Sheet (POS) dated September 2024 documents a physician order to Cleanse (R31's) Right Heel wound with wound cleanser, apply Calcium Alginate, and cover with roll gauze or cushion twice daily. The order also instructs staff to apply heel protectors when R31 is up in the wheelchair, float Right Heel when in bed/chair every shift and no shoe for R31's Right Foot.
R31's Wound Clinic Progress Note dated 9/10/24, 9/17/24 and 9/24/24 documents R31's Right Calcaneus Pressure Ulcer as a deteriorating Stage 3. These same reports document Heel suspension boot to: (R31) NEEDS HEEL SUSPENSION BOOT. FACILITY TO ORDER This same assessment documents float heels off of bed/chair. (R31) (Right) Heel needs floated 24/7. (R31's) wound has deteriorated and appears to have had more pressure applied to the area. No skin prep or lotion in (R31's) wound. Please lotion (R31's) foot with dressing changes.
R31's Medical Record does not document any Skin Risk Assessment since R31's admission on [DATE]. This same medical record does not document any measurements, or weekly assessment details of R31's Right Heel Stage 3 Pressure Ulcer.
On 9/22/24 at 10:15 AM R31 was using her Right Foot to propel herself along in her wheelchair in the main dining room. R31 was not wearing a heel protector nor had her Right Foot floated. Multiple staff present in the main dining room did not encourage/instruct R31 to offload pressure from her Right Heel Stage 3 Pressure Ulcer.
On 9/25/24 at 11:35 AM V16 Wound Clinic Nurse Practitioner (NP) stated R31 has been seen at the offsite wound clinic for two months for the treatment of her Right Heel Stage 3 Pressure Ulcer. V16 stated R31 is alert and oriented and needs encouragement and verbal reminders to keep her Right Foot offloaded from any pressure. V16 NP stated R31 will keep her own foot up if you remind her. V16 stated R31 is motivated to get her Right Heel healed up. V16 stated the facility is responsible for reminding R31 to keep R31's Right Foot off of the floor and to not place any pressure on it. V16 NP stated The last few times (R31) has come into the clinic, she is not wearing any heel protector. As soon as (R31's) Right Heel heals up, then we can work on getting her a prosthetic for her Left stump. (R31) is looking forward to that so she can go home. The facility has not helped (R31) facilitate the healing of her Right Heel Pressure Ulcer. (R31's) Right Heel Pressure Ulcer should be healing faster. (R31) has the internal mechanisms and power to get that healed with the help of the facility but unfortunately they (facility) are delaying the healing of her Right Heel Pressure Ulcer due to not making sure that her pressure relief interventions are in place.
On 9/25/24 at 2:00 PM V1 Administrator stated R31's Right Heel Stage 3 Pressure Ulcer is facility acquired and has worsened during R31's stay at this facility. V1 Administrator stated (R31) did not have any pressure wound when she was admitted . (R31) was admitted because she had just had her Left Below the Knee Amputation done at the hospital. V1 stated R1 has had two separate pressure ulcers on her Right Heel. V1 Administrator stated R31 previously had a facility acquired Suspected Deep Tissue Injury (SDTI) on the same area on her Right Heel which had healed. V1 stated We (facility) should never have discontinued (R31's) treatment to her Right Heel on 6/26/24. I don't think (R31's) wound was completely healed. Within a week (R31's) Right Heel opened up and now (R31) currently has a facility acquired Right Heel Stage 3 Pressure Ulcer with orders in place. (R31's) Stage 3 Pressure Ulcer should have been listed on her careplan and it wasn't. There are no interventions on her careplan that show that (R31) had an open pressure ulcer. (R31) is alert and oriented but the staff should be providing a heel protector or whatever else she needs and also making sure to remind her to offload pressure to that Right Heel.
The facility policy titled Decubitus Care/Pressure Areas revised January 2018 documents it is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. The pressure area will be assessed and documented on the Treatment Administration Record (TAR) or the Wound Documentation Record. Document size, stage, site, depth, drainage, color, odor and treatment. When a pressure ulcer is identified additional interventions must be established and noted on the careplan in an effort to prevent worsening or re-occurring pressure ulcers.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure equipment is in good working repair, and the en...
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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 equipment is in good working repair, and the environment is clean and free of debris for three (R25, R26, R6) of 12 residents reviewed for safe homelike environment out of a sample list of 34.
Findings include:
The facility's 11/2018 Resident Right's policy provided by V1 (Administrator) documents the facility must provide a safe, clean, comfortable and homelike environment.
1.) On 9/23/24 at 1:30 PM, R25 stated his dresser in his room is broken and missing the front of his top dresser drawer. R25 stated he made staff aware a week ago, but nobody has fixed his dresser yet. R25 stated since his dresser has been broken it has become harder to get to his items he needs.
On 9/23/24 at 1:38 PM, the face to the top drawer of R25's dresser was missing. The floor of this drawer was broken in half. R25's clothes from the top drawer were falling out of the drawer and into the next dresser drawer. These clothes included socks and underwear.
On 9/23/23 at 1:50 PM, V5 (Maintenance Director) stated that's an issue. V5 confirmed at this time that R25's dresser should be in good working repair.
2.) On 9/25/24 at 10:05 AM, R26's bed was unmade. The top of the mattress had large, dark, brown, and black discolorations covering eighty percent of the mattress. The mattress was indented and broken down in the middle.
On 9/25/24 at 10:10 AM, V12 (Housekeeper) stated R26's mattress always looks that way and V12 does her best to clean the mattress but the stains are permanent. V12 stated I wouldn't want my family member on that mattress. V12 further stated that many mattresses in the facility are in bad shape and need replaced. 3.) R6's Physician's Order Sheet dated 9/1/24 through 9/30/24 documents diagnoses including Unspecified Dementia, Cerebral Infarction and Altered Mental Status. R6's Minimum Data Set (MDS) dated [DATE] documents R6 requires assistance to roll from left to right and back in bed and documents that R6 is dependent for transfers from the bed to the chair.
On 9/22/24 at 8:36 AM, R6 was not in his room but the bilateral side rails were up and there was foam wrapped around and taped to the side rails. The foam was ripped and the tape was shredded and frayed. On 9/22/24 at 12:57 PM the side rails were in the same condition.
On 9/22/24 at 9:39 AM, R6 was in his room in his wheel chair. R6 was yelling for someone to help him up and he had his hand on the side rail shaking it and rattling it back and forth.
On 9/24/24 at 2:44 PM, V5 Maintenance Supervisor confirmed R6's side rails are in poor condition and look bad. V5 stated that he has new foam and tape in the garage that he can replace R6's with.
CONCERN
(D)
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 physical abuse to the Abuse Coordinator for ...
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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 physical abuse to the Abuse Coordinator for one of one resident (R4) reviewed for abuse in a sample list of 34 residents.
Findings include:
The facility policy titled 'Abuse Prevention Program' revised 11/28/2016 documents the facility affirms the right of the residents to be free from abuse, neglect, misappropriation of property and exploitation. Abuse is the willful injection of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This same policy documents the facility must ensure all allegations of abuse are reported immediately to the Administrator of the facility. The report must be made to Illinois Department of Public Health (IDPH) within 24 hours after forming the suspicion.
R4's undated Medical Diagnosis List documents medical diagnoses of Psychotic and Mood Disturbance, Anxiety, Congestive Heart Failure, Bipolar without psychotic features, Dementia with Agitation, Schizophrenia and Weakness.
R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. This same MDS documents R4 requires moderate assistance with dressing, eating, personal hygiene, bathing, toileting and transfers.
R4's Nurse Progress Note dated 9/17/24 at 4:00 AM documents (R4) complained '[NAME] cut my privates.' (R4) reoriented to surroundings and escorted for safety. No further behavior noted.
R4's Initial Report to the State Agency dated 9/22/24 documents (R4) made a statement that someone named '[NAME]' cut her private parts. No one in the facility with that name.
On 9/22/24 at 1:30 PM V1 Administrator stated V1 was never notified of R4's allegation. V1 Administrator stated I am just now seeing this nurse progress note. I didn't know anything about it. We (facility) do not have a resident or staff member named [NAME]. (R4) has a lot of behaviors like Hallucinations and Delusions. There was no indication that (R4) ever had anything like that happen. The staff did assess her with no findings but just did not report it to me. I will get that reported to the State Agency right away.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
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 a Level 2 Preadmission Screening and Resident Review (PASRR) ...
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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 a Level 2 Preadmission Screening and Resident Review (PASRR) after a new diagnosis of mental illness for one (R30) of three residents reviewed for PASRR in the sample list of 34.
Findings include:
R30's Face Sheet dated 8/26/24 comments R30 admitted to the facility on [DATE], a diagnosis of unspecified psychosis was added on 10/10/23, and a diagnosis of anxiety was added on 10/18/23.
R30's Notice of PASRR Level 1 Screen Outcome dated 8/16/22 documents a Level 2 screening was not required since R30 did not have a mental illness diagnosis. There is no documentation that a Level 2 PASRR was completed after R30 was diagnosed with psychosis.
On 9/23/24 at 10:47 AM V11 (Business Office Manager) confirmed V11 coordinates PASRRs. V11 reviewed R30's Level 1 PASRR and stated that a Level 2 was not required. V11 stated V11 has not had any residents with new diagnosis of mental illness after admission, so she was unaware that a Level 2 PASRR would be required.
On 9/23/24 at 10:50 AM V18 (Licensed Practical Nurse) stated R30 has a history of behaviors of hallucinations and yelling out, but his behaviors have been better. V18 stated R30 self isolates since R30 has paranoia and anxiety when around a lot of people. V18 stated R30 sees (Psychiatry Services) and has had medication adjustments.
On 9/23/24 at 12:40 PM V1 (Administrator) confirmed R30 has not had a Level 2 PASRR completed. V1 stated neither V1 nor V11 were aware that PASRRs needed to be done after a new diagnosis of mental illness.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R37's undated Facesheet documents R37 was admitted to the facility on [DATE].
R37's September 2024 Physician Order Sheet do...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R37's undated Facesheet documents R37 was admitted to the facility on [DATE].
R37's September 2024 Physician Order Sheet documents an order for Quetiapine (antipsychotic) 25mg (milligrams) in the morning and 50mg at bedtime.
R37's Care Plan dated 08/14/2024 documents R37 uses an anti-psychotic medication related to diagnoses of Alzheimer's, end of life care, and anxiety. There is no specific behavior for the use of the antipsychotic, no appropriate diagnosis to justify the use of an antipsychotic medication, and no non-pharmacological interventions documented on the Care Plan.
On 09/24/24 at 1:45 PM, V10 MDSC (Minimum Data Set Coordinator) stated R37's Care Plan dated 8/14/24 was the only Care Plan completed for R37. V10 stated Comprehensive Care Plans should be completed within 21 days of admission and confirmed that R37's was not completed during that timeline. V10 also stated that V10 only writes a basic Care Plan due to not knowing the residents well enough to do specific interventions due to working as MDSC in multiple facilities.
Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for three (R35, R36, R37) of 12 residents reviewed for care plans in the sample list of 34.
Findings include:
The facility's Comprehensive Care Planning policy dated 11/1/17 documents the facility shall complete periodic assessments for each resident which is used to develop the resident's person centered comprehensive plan of care, and this care plan should reflect medical and nursing needs.
1.) R35's September 2024 Physician Order Summary (POS) documents R35 receives Lurasidone (antipsychotic) 60 milligrams (mg) every morning and 80 mg every evening and Xarelto (anticoagulant) 20 mg daily.
R35's Nursing Notes document the following: On 6/23/24 at 9:00 AM R35's thumb was bleeding from R35 biting his hand due to anxiety. On 7/9/24 at 3:00 PM R35 was biting his fingers due to anxiety/nerves. On 8/12/24 at 8:45 PM R35 had a verbal outburst related to wanting his medications. On 9/15/24 at 6:30 AM R35 banged R35's fists on the dining room table and cried wanting R35's medications. R35 yelled Give me them now. On 9/15/24 at 2:25 PM R35 demanded R35's scheduled 4:00 PM medications and yelled in the dining room.
R35's Care Plan revised 9/23/24 documents anticoagulant use, antipsychotic use, behaviors of self harm and fixation on medications was not included in R35's plan of care prior to 9/23/24.
On 9/23/24 at 1:25 PM V1 (Administrator) stated R35's anticoagulant and antipsychotic use should be care planned. At 1:47 PM V1 confirmed R35's self harm and fixation on medications should be care planned.
2.) On 9/22/24 at 8:19 AM R36's Continuous Positive Airway Pressure (CPAP) mask and tubing was uncovered and on top of the CPAP machine on R36's night stand. R36 stated the nurses clean it and fill it with water. On 9/23/24 at 10:04 AM R36's CPAP mask and tubing was uncovered and on top of the machine on R36's night stand. On 9/24/24 at 9:58 AM R36 stated R36 is not sure of the settings for R36's CPAP. R36 stated R36 uses the CPAP every night and just turns the machine on as the settings were previously preset.
R36's September 2024 Physician Order Summary documents R36 uses CPAP independently and the nurses are responsible for cleaning it weekly.
R36's Care Plan dated 5/20/24 does not document R36's CPAP use.
On 9/23/24 at 12:20 PM V1 (Administrator) confirmed R36's care plan did not include CPAP use prior to 9/23/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 restorative care services for one of three resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide restorative care services for one of three residents (R7) reviewed for restorative services in the sample list of 34.
Findings include:
R7's Physician's Order Sheet dated 9/1/24 through 9/30/24 documents a diagnosis of Hemiparesis and documents an admission date of 4/12/24. R7's Minimum Data Set (MDS) dated [DATE] documents R7 had moderately impaired cognition and was not receiving any therapy or restorative services. R7's MDS dated [DATE] documents R7 is cognitively intact but did not receive any therapy and had 7 days of range of motion.
On 9/22/24 at 9:35 AM, R7 was in his room and when asked if he had any concerns about his care he raised his left arm and tried to open his left hand. R7's left hand is contracted and he says that he thinks it just happened in the last couple months. R7 stated that he is not sure how it happened. R7 stated that he does not receive therapy or any exercises for his hand.
R7's Restorative Nursing Program Documentation for August 2024 and September 2024 documents R7's restorative programs were to wheel himself in his wheelchair from the dining room to his room and for bilateral lower extremity exercises. There is no documentation that R7 has received any range of motion exercises for his left hand.
On 9/23/24 at 1:18 PM, V6 Director of Rehab confirmed R7's left hand is contracted. She stated that R7's hand contracture was recently brought to her attention. V6 stated that she is waiting for orders to be signed for the therapy to begin. V6 stated that the last time R7 was on the case load his hand was not like that. V6 stated that she does not know what happened to it. V6 stated that she does not know the last time R7 had therapy services as it was a different therapy company and they do not have access to their records. V6 stated that she would assume they are doing range of motion exercises. V6 stated they will try to loosen that hand as much as possible and possibly try some splinting. V6 confirmed to her knowledge nothing has been done for the left hand contracture.
On 9/24/24 at 10:18 AM, V7 Certified Nursing Assistant stated that R7's left hand has been contracted since she has known him at least 1 1/2 years. V7 stated that they have tried opening it and placing a wash cloth in it but he takes it out. V7 stated she tries to open it when washing and doing ADLs (Activities of Daily Living) and stretching but it goes right back contracted. V7 stated she does not know if there is any restorative program for R7's left hand.
On 9/25/24 at 9:07 AM, R7 was in his wheelchair in his room with his left hand contracted and laying across his chest.
On 9/25/24 at 10:16 AM, V3 Assistant Director of Nursing/RCC (Resident Care Coordinator) stated that staff should be doing range of motion exercises to R7's left hand.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to obtain orders for Continuous Positive Airway Pressure (CPAP) settings and maintain hygienic care and storage of CPAP equipment...
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Based on observation, interview, and record review the facility failed to obtain orders for Continuous Positive Airway Pressure (CPAP) settings and maintain hygienic care and storage of CPAP equipment for one (R36) of two residents reviewed for CPAP in the sample list of 34.
Findings include:
The facility's Bilevel Positive Airway Pressure/CPAP policy dated 3/8/13 documents CPAP and BiPAP use must have orders that includes the type of unit, pressure settings, inspiratory/expiratory positive airway pressure, frequency, oxygen if applicable, and humidification if applicable; and to clean the circuits weekly and as needed.
1.) On 9/22/24 at 8:19 AM R36's CPAP mask and tubing was uncovered and on top of the CPAP machine on R36's night stand. R36 stated the nurses clean it and fill it with water. On 9/23/24 at 10:04 AM R36's CPAP mask and tubing were uncovered and on top of the machine on R36's night stand. On 9/24/24 at 9:58 AM R36 stated R36 is not sure of the settings for R36's CPAP. R36 stated R36 uses the CPAP every night and just turns the machine on as the settings were previously preset.
R36's September 2024 Physician Order Summary documents R36 uses CPAP independently and the nurses are responsible for cleaning it weekly. There is no order for the settings or airway pressure for R36's CPAP.
On 9/23/24 at 10:06 AM V18 Licensed Practical Nurse stated R36 is independent with CPAP care, but the night nurses clean it between 5:00 AM and 6:00 AM. V18 stated the CPAP mask should be stored in a clear plastic bag when not in use.
On 9/24/24 at 9:46 AM V1 Administrator confirmed R36's orders should include settings and airway pressure. V1 stated R36 does a lot of things independently, but doesn't always know things medically. V1 stated V1 will follow up to see what R36's CPAP settings should be.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R37's undated Facesheet documents R37 was admitted to the facility on [DATE].
R37's Physician's Orders dated September 2024...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R37's undated Facesheet documents R37 was admitted to the facility on [DATE].
R37's Physician's Orders dated September 2024 document R37 was admitted to the facility with the following orders: Quetiapine (antipsychotic) 25mg (milligrams) in the morning and 50mg at bedtime and Mirtazapine (antidepressant) 45mg at bedtime. These Physician Orders also document an order received on 8/18/24 for Lorazepam (antianxiety) 1mg twice daily and every 4 hours as needed.
R37's medical record does not contain a consent for any psychotropic medications.
R37's medical record documents a GDR (Gradual Dose Reduction) for Quetiapine to be reduced to 25mg BID (twice daily) that was declined on 07/18/24 by V20 (Hospice Medical Director), but no justification/rationale was provided for the decline.
R37's medical record only contained one Psychotropic Medication Evaluation dated 07/03/2024. This document is not complete and does not document indications for use or resident specific behaviors.
On 09/24/2024 at 1:15 PM, V1 (Facility Administrator) stated no psychotropic drug reviews are done on admission, only quarterly, and explained I (V1) didn't know we (facility) were suppose to do them on admission. V1 stated no consents for the psychotropic medications were completed for R37.
Based on observation, interview, and record review the facility failed to obtain consent, implement Gradual Dose Reductions, complete assessments, and track targeted behaviors for psychotropic medication use. These failures affect three (R21, R35, R37) of five residents reviewed for unnecessary medications in the sample list of 34.
Findings include:
The facility's Psychotropic Medication Policy dated 11/28/17 documents attempt to rule out causes of behaviors, attempt non-pharmacological interventions, initiate a Pre-Psychotropic Medication Assessment prior to starting a new psychotropic medication, complete Psychotropic Medication Assessments within 14 days of admission and at least quarterly, obtain informed consent, and document behaviors on the behavior tracking sheets. This policy documents residents receiving psychotropic medications will have either a psychiatric diagnosis or maladaptive behaviors that could be harmful to themselves/others, cause emotional distress, or destruction of property. This policy documents gradual dose reductions (GDR) will be attempted at least twice per year unless clinically contraindication is documented by the physician, the pharmacy will request GDRs as needed on a monthly basis, these recommendations will be sent to the physician in a timely manner and the nurses will transcribe the physician's recommendations once received.
1.) R21's Minimum Data Set (MDS) dated [DATE] documents R21 has severe cognitive impairment, R21 has verbal behaviors towards others, R21 takes an antipsychotic, a GDR has not been attempted since the last assessment and there is no physician documented clinical contraindication for a GDR.
R21's September 2024 Physician Order Summary (POS) documents the following orders: a referral to (Psychiatry Services) 9/16/24, Divalproex (mood stabilizer) Sodium Extended Release (ER) 250 milligrams (mg) give two tablets every morning and three tablets every evening 5/26/23, Risperidone (antipsychotic) 0.25 mg daily five times per week 1/14/20, and Mirtazapine (antidepressants) 7.5 mg daily 1/18/22. This POS documents R21's diagnoses include Dementia, Alcohol Abuse, and Bipolar Disorder.
There are no documented consents for Risperidone or Mirtazapine in R21's medical record. There is no documentation of attempted GDRs for Divalproex, Risperidone, and Mirtazapine within the last year in R21's medical record, or physician documented clinical rational as to why GDRs should not be implemented.
On 9/24/24 at 11:16 AM V8 Regional Clinical Director provided R21's psychotropic medication consents, which only documented consent for Divalproex.
On 9/25/24 at 9:20 AM V1 Administrator stated V1 can't locate R21's August 2024 pharmacy recommendation that was in R21's medical record. V1 stated she recalls seeing it, and it should not have been sent to (Psychiatry Services). V1 confirmed R21 had not been seen by (Psychiatry Services) prior to the order 9/16/24. V1 stated GDR requests and physician declination are documented on the pharmacy recommendations. V1 confirmed September 2024 pharmacy recommendations have not been returned from the physicians yet. V1 stated all of R21's psychotropic medication consents have been provided. On 9/25/24 at 9:45 AM V1 Administrator provided R21's pharmacy recommendations dated 4/3/24, 5/1/24, 8/1/24, and 9/4/24, all of which are blank/incomplete.
The pharmacy Consultation Reports dated 4/3/24, 5/1/24, 8/1/24 and 9/4/24 document R21 receives Risperidone 0.25 mg five times weekly, Depakote (Divalproex) ER 500 mg every morning and 750 mg every evening, and Mirtazapine 7.5 mg every evening for Bipolar Depression and to consider a GDR. These reports suggest reducing Risperidone 0.25 mg to every other evening. These forms are incomplete and do not document the recommendation was followed up with R21's physician.
On 9/25/24 at 10:00 AM V3 Assistant Director of Nursing stated pharmacy recommendations are sent from pharmacy to V1, V1 then gives the forms to the nurses to send to the physician for follow up and implement the orders. V3 stated the completed forms are given back to V1.
On 9/25/24 at 10:03 AM V1 stated V1 would look to see if R21's pharmacy recommendations were completed, if they weren't completed there would be repeat GDR requests. The facility failed to provide documentation that these pharmacy recommendations were implemented.
2.) On 9/22/24 at 9:05 AM R35 stated R35 does not see a psychiatrist, only his primary physician. On 9/23/24 at 10:30 AM R35 was participating in BINGO activity and loudly asked when R35 was going to get R35's medications. V9 Licensed Practical Nurse (LPN) told R35 that V18 LPN was doing something first and then V18 would administer R35's medications.
R35's Face Sheet dated 8/26/24 documents R35 admitted on [DATE] and R35's diagnoses include Panic Disorder, Schizophrenia, and Major Depressive Disorder.
R35's MDS dated [DATE] documents R35 has moderate cognitive impairment, R35 refuses cares and wanders, R35 takes an antipsychotic, a GDR has not been attempted since the last assessment and there is no physician documented clinical contraindication for a GDR.
R35's September 2024 POS documents the following orders: Lurasidone (antipsychotic) Hydrochloride 60 mg every morning and 80 mg every evening 2/1/24, Buspirone (antianxiety)10 mg twice daily 2/1/24, Hydroxyzine (used for anxiety) 25 mg twice daily 7/20/24, and Trazodone (antidepressant) Hydrochloride 100 mg daily. There are no documented consents for these psychotropic medications and no documented psychotropic medication assessments for the use of Hydroxyzine in R35's medical record.
R35's July and August 2024 Medication Administration Records document Hydroxyzine 25 mg twice daily PRN (as needed) was initiated on 7/19/24. This medication was given nine times prior to being scheduled twice daily on 8/14/24.
R35's Nursing Notes document the following: On 6/23/24 at 9:00 AM R35's thumb was bleeding from R35 biting his hand due to anxiety. On 7/9/24 at 3:00 PM R35 was biting his fingers due to anxiety/nerves. Between 8/7 and 8/10/24 R35 was given Hydroxyzine as needed for anxiety. On 8/12/24 at 8:45 PM R35 had a verbal outburst related to wanting his medications. On 9/15/24 at 6:30 AM R35 banged R35's fists on the dining room table and cried wanting R35's medications. R35 yelled Give me them now. On 9/15/24 at 2:25 PM R35 demanded R35's scheduled 4:00 PM medications and yelled in the dining room.
R35's August 2024 and September 2024 Behavior Tracking does not include R35's behaviors of biting his hands/fingers or fixation on medications. Crying is the only documented targeted behavior on these tracking forms.
The pharmacy Consultation Reports dated 8/1/24 and 9/4/24 document R35 has received Lurasidone 60 mg every morning and 80 mg every evening and Trazodone 100 mg every evening since 2/1/24 and documents to attempt a GDR for these medications and to consider implementing a GDR. These forms document to consider decreasing Lurasidone to 60 mg twice daily. These forms are incomplete and do not document the recommendation was followed up with R35's physician. The 8/1/24 report included a handwritten note that this form was sent to (Psychiatry Services) for review.
On 9/22/24 at 10:50 AM V17 LPN stated R35 has Schizophrenia and has not received any psychiatric services after admitting to the facility. V17 stated last week V17 requested that R35 be evaluated by (Psychiatric Services) and the facility was in the process of getting R35 a guardian at that time. V17 stated R35 would benefit from psychiatry services due to R35's behaviors of crying and temper tantrums when R35 does not get his way.
On 9/23/24 at 1:44 PM V18 LPN stated R35's behaviors consist of self harm by biting his thumb until it bleeds if he doesn't get his way, fixating and frequently asking about his medications, and R35 charged at V18 the other day.
On 9/23/24 at 1:25 PM V1 Administrator stated R35 has not had psychiatric services since admission and will be seeing (Psychiatry Services) next visit. V1 stated the facility recently initiated obtaining a guardian for R35, but prior to that we were obtaining medication consents from R35 since R35's Brief Interview for Mental Status Score is high enough. V35 stated psychotropic medication assessments should be documented quarterly, with significant changes, upon initiation, and with increases in dosages. V1 stated these assessments are documented in the assessment section of the medical record. V1 verified R35's medical record did not contain assessments for Hydroxyzine. V1 stated V1 will see if V1 could find consents for R35's medications. V1 stated the facility has not gotten the September 2024 pharmacy recommendations back yet from the physicians. V1 confirmed R35's August pharmacy recommendation was not signed by a provider and V1 thinks the form was sent to (Psychiatry Services) by mistake. On 9/23/24 at 1:47 PM V1 confirmed R35's self harming behaviors and tantrum behaviors should be included in R35's behavior tracking. V1 stated V1 thinks V4 Social Services Director misinterpreted that when V4 documented crying behaviors on R35's behavior tracking. On 9/24/24 at 3:11 PM V1 stated V1 was unable to locate R35's psychotropic medication consents and assessments for Hydroxyzine.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
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 palatable foods for two (R14, R22) residents ou...
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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 palatable foods for two (R14, R22) residents out of two residents reviewed for palatable foods in a sample list of 34 residents.
Findings include:
1. R14's Cognitive assessment dated [DATE] documents R14 as moderately cognitively impaired.
On 9/22/24 at 11:43 AM V13 [NAME] pureed R14's pot roast with vegetables, placed R14's blended pot roast in his divided plate and sat it on the counter for 55 minutes with no cover. R14's food was not warmed prior to serving at 12:38 PM.
On 9/22/24 at 11:50 AM The blended pot roast lacked flavor, was not appealing to look at and had multiple pieces of meat that required mechanical chewing to break down.
On 9/22/24 at 11:54 AM V13 [NAME] blended R14's serving of beets to a watery, pourable consistency. V13 then placed the entire portion of blended beets in R14's divided plate with the blended pot roast and set it back on the counter with no lid.
On 9/22/24 at 12:20 PM V13 [NAME] mixed two breadsticks with 1.5 cups of water to blend to a watery, pourable consistency. The blended bread was light tan colored and had no flavor. V13 then added R14's blended bread to his partially made plate and returned R14's plate to the counter with no lid.
On 9/22/24 at 1:05 PM R14 stated This food is so cold. I don't like cold food.
2. R22's Minimum Data Set (MDS) dated [DATE] documents R22 as cognitively intact. This same MDS documents R22 requires set up for eating.
R22's Physician Order Sheet (POS) dated September 2024 documents a physician order for a regular consistency diet with thin liquids.
On 9/22/24 at 9:00 AM R22 was laying in bed with her breakfast tray laying in front of her on her bedside table.
On 9/22/24 at 9:03 AM R22 stated Our food is always cold. Look at this. They (staff) come in here and leave my tray but don't wake me up to eat or they wake me up but serve me cold food. I don't like cold oatmeal. It is nasty. I have asked them to reheat my food before but they never come back to do it. You don't have to take its temperature to know that it is too cold after its been sitting here for 45 minutes.
On 9/24/24 at 2:50 PM V1 Administrator stated Resident's food should be warm to taste. We (facility) have ways to warm up the food if it is too cold but I know the staff might get busy and forget. The kitchen staff should not set food aside for an hour and then give it to the residents without warming it up first. I will provide education to the kitchen staff and Certified Nurse Aides (CNA) about making sure the meals are served warm. I don't know if we have a policy for this but it should just be the standard.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow a physician order to provide a pureed diet by no...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow a physician order to provide a pureed diet by not providing the appropriate consistency of pureed foods for one (R14) out of one resident reviewed for diet consistency in a sample list of 34 residents.
Findings include:
R14's Cognitive assessment dated [DATE] documents R14 as moderately cognitively impaired.
R14's Physician Order Sheet (POS) dated September 2024 documents R14's medical diagnoses of Hypertension, Dysarthria, Gastroesophageal Reflux Disorder (GERD) with Esophagitis, Cerebral Infarction, Hemiplegia and Hemiparesis. This same POS documents a physician ordered diet of Carbohydrate Controlled diet of pureed texture and thin liquids.
R14's Careplan intervention dated 6/16/24 instructs staff to serve R14 his diet as ordered by Physician.
The facility recipe for Pureed Pot Roast and Vegetables documents 2.0 servings of pot roast and vegetables should be mixed with one quarter cup of thickener.
The facility recipe for Harvard Beets documents 2.0 servings of beets should be mixed with two tablespoons of thickener.
The facility recipe for Bread/Toast/Roll documents 2.0 servings of bread should be mixed with two fluid ounces of milk and one and one-quarter teaspoon of thickener.
On 9/22/24 at 11:43 AM V13 [NAME] added approximately two cups of pot roast with vegetables with 3.5 cups of tap water to blend to a pureed texture. The blended pot roast was pourable consistency with bits of meat.
On 9/22/24 at 11:50 AM The blended pot roast lacked flavor, was not appealing to look at and had multiple pieces of meat that required mechanical chewing to break down.
On 9/22/24 at 11:54 AM V13 [NAME] placed one serving of beets, one cup of water and three pumps of liquid thickener together to blend. The blended beets were very watery and pourable.
On 9/22/24 at 12:45 PM R14 was served his pureed meal of pot roast, beets and breadsticks. R14 used a standard teaspoon to attempt to feed self. R14 had difficulty keeping his menu items on the spoon and spilled his pot roast, beets and bread on his lap. R14 took several bites of watery consistency foods served and began coughing. V17 Licensed Practical Nurse (LPN) walked over to R14, patted him on the back and asked if he was having trouble eating his meal due to the consistency was too thin. R14 continued to cough for 10 minutes. V17 LPN offered R14 drinks stating to R14 This will help clear your throat'. Your food is too thin for you.
On 9/22/24 at 1:00 PM R14 stated That meal was too thin for me to eat. I spilled it all over me and what I did get down made me cough. I didn't choke or anything. I am not supposed to eat food that thin.
On 9/22/24 at 1:30 PM V17 Licensed Practical Nurse (LPN) stated R14 has a history of difficulty swallowing and sometimes coughs during meals. V17 stated Our kitchen staff need to make sure (R14's) foods are at the right pureed consistency. Last week (R14) was served food so thick he was pocketing and coughing because he tried to swallow food that was so thick you could cut it. Today (R14's) meal is watery. We (facility) need to train our cooks how to prepare the resident's meals right before something really bad happens.
On 9/22/24 at 2:30 PM V1 Administrator stated Our kitchen staff is fairly new. We (facility) are in the process of training them. (R14's) meals are supposed to be a pureed consistency which should be like pudding. Too thick or too thin (R14) could end up aspirating and get Pneumonia.
The facility policy titled Therapeutic and Mechanically Altered Diets revised October 2020 documents the facility should prepare and serve all therapeutic and mechanically altered diets as planned. A therapeutic diet is a diet ordered to manage problematic health conditions. A mechanically altered diet is a diet specifically prepared to alter the consistency of food in order to facilitate oral intake.
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 to maintain documentation of influenza and pneumonia vaccination history and o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility to maintain documentation of influenza and pneumonia vaccination history and offer influenza and pneumonia vaccinations for two (R30, R35) of five residents reviewed for vaccinations in the sample list of 34.
Findings include:
The facility's Immunization of Residents policy dated 5/19/23 documents the facility will offer vaccinations to aid in the prevention of infectious diseases unless contraindicated by the physician or medically. This policy documents to obtain vaccination consents and obtain proof of vaccinations, and document vaccinations on the resident's Immunization Record. This policy documents to offer the pneumonia vaccine within 30 days of admission and offer the PCV13, PCV15, PCV20, or pneumococcal polysaccharide vaccine (PPSV23) according to the Pneumonia Vaccination Timing Guidelines. This policy documents to offer the influenza vaccine annually between September 1st and March 31st, and assess the resident's current influenza season immunization status upon admission.
The Centers for Disease Control and Prevention Pneumococcal Vaccine Timing for Adults dated 3/15/23 documents for adults age [AGE] and older who have only received PCV13 should have PCV20 or PPSV23 a year or more later to be considered up to date. These guidelines document to administer PCV20, or PCV15 followed by PPSV23 a year or more later, for adults age [AGE] and older.
1.) R30's Minimum Data Set (MDS) dated [DATE] documents R30 is not up to date on pneumonia vaccinations and one has not been offered.
R30's Resident Pneumonia Vaccine Consent dated 8/15/22 documents R30 received Pneumococcal Conjugate Vaccine 13 on 8/18/22 and documents consent to receive the Pneumonia Vaccine. There is no documentation that R30 was offered any additional pneumonia vaccines after 8/18/22.
2.) R35's Face Sheet dated 8/26/24 documents R35 admitted to the facility on [DATE], R35 is [AGE] years old, and R35's diagnoses include obstructive sleep apnea and hypertension. R35's 8/6/24 MDS documents R35 is not up to date on pneumonia vaccinations and one has not been offered.
R35's medical record did not contain documentation of influenza or pneumonia vaccination history. There is no documentation that the facility offered R35 the influenza or pneumonia vaccinations after admission.
The Illinois Comprehensive Automated Immunization Registry Exchange dated 9/24/24 documents R35 received the influenza annually between 2020 and 2022, with the last one given on 10/4/22; and R35 was due for the pneumonia vaccine as of 11/17/23.
On 9/22/24 at 1:12 PM R30's and R35's vaccine information including consents and declinations were requested from V1 Administrator.
On 9/23/24 at 12:16 PM V1 stated V1 is the facility's Infection Preventionist and assists in overseeing resident vaccinations. V1 stated R35 transferred from a group home and no information regarding R35's vaccination history was provided and R35 has no family to ask about vaccinations. V1 stated the facility was unable to obtain any vaccination history for R35, a guardian was recently appointed for R35, R35 wants the influenza and pneumonia vaccinations, and V1 is waiting for the consent forms to be returned. V1 stated V1 was uncertain what to do in the situation where vaccination history is unknown since this had not happened before.
On 9/24/24 at 10:20 AM V1 stated residents are offered pneumonia vaccination as part of their admission packet and the Director of Nursing (DON) is responsible for overseeing this. V8 Regional Clinical Director stated the facility has had a turnover in DONs. On 9/24/24 at 3:11 PM V1 stated V1 is still trying to locate R30's and R35's vaccine information. On 9/25/24 at 9:20 AM V1 stated V1 has provided all of the immunization information including consents/declinations for R30 and R35. On 9/25/24 at 10:03 AM V1 stated V1 was unable to find any additional vaccine information for R30. V1 confirmed PCV13 is the only documented pneumonia vaccine for R30.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide an accessible working call light for one (R25) of twelve residents reviewed for call lights out of a sample list of 34...
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Based on observation, interview, and record review the facility failed to provide an accessible working call light for one (R25) of twelve residents reviewed for call lights out of a sample list of 34.
Findings include:
The facilities undated Maintenance and Preventative Service Policy documents to ensure all nurse call light systems are working properly.
R25's care plan last revised 5/20/24 documents R25 needs supervision with Activities of daily Living (ADL's). The same care plan documents a revision on 8/9/24, the Interdisciplinary team documents a referral for Physical Therapy and Occupational therapy for an ADL decline and increased fall risk.
On 09/23/24 at 1:38PM, R25 stated R25 does not have his own call light in his room. R25 stated at night if R25 needs help he must wake up R90 (roommate) to push the call light for him. R25 stated he made V5 (Maintenance Director) aware that he had no call light a month ago, but nobody has replaced it.
On 9/23/24 at 1:45 PM, R25 did not have his call light within reach. There was one working call light plugged into the wall and that call light was attached to R90's bed. There was no other call light in room.
On 09/23/24 at 2:23 PM, V1 (Administrator) stated R25 and R90 should never share the same call light in a room.
On 09/23/24 at 02:05 PM, V5 stated residents should never have a missing call light.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 accurately complete resident assessments for four (R35...
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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 accurately complete resident assessments for four (R35, R36, R7, R27) of 12 residents reviewed for Minimum Data Sets (MDS) in the sample list of 34.
Findings include:
The facility's Comprehensive Assessments/MDS policy dated 11/1/17 documents the Resident Assessment Instrument should be utilized to comprehensively assess residents and to use resident observations and communications with the resident and staff to obtain resident information.
1.) R35's September 2024 Medication Administration Record documents R35 receives Xarelto (anticoagulant) 20 milligrams daily as of 2/1/24.
R35's MDS dated [DATE] does not document anticoagulant use.
On 9/24/24 at 12:40 PM V10 (MDS/Licensed Practical Nurse) stated V10 floats between three facilities as the MDS Coordinator and relies on V3 (Assistant Director of Nursing) to complete assessments that are related to the MDS coding. V10 stated V10 expects the assessments to be accurate since V10 does not really know the residents and their medical needs. V10 stated R35's MDS incorrectly documented antiplatelet use instead of anticoagulant.
2.) On 9/22/24 at 8:19 AM R36's Continuous Positive Airway Pressure (CPAP) mask and tubing was uncovered and on top of the CPAP machine on R36's night stand. R36 stated the nurses clean it and fill it with water. On 9/24/24 at 9:58 AM R36 stated R36 is not sure of the settings for R36's CPAP. R36 stated R36 uses the CPAP every night and just turns the machine on as the settings were previously preset.
R36's September 2024 Physician Order Summary documents R36 has a diagnosis of Obstructive Sleep Apnea and R36 uses CPAP independently and the nurses are responsible for cleaning it weekly.
R36's MDS dated [DATE] does not document CPAP use or R36's pulmonary disease.
On 9/24/24 at 12:40 PM V10 stated V10 reviews physician orders for respiratory care needs such as oxygen and CPAP use. V10 confirmed R36's MDS does not document CPAP use.
3.) R27's Physician's Order Sheet (POS) dated 9/1/24 through 9/30/24 documents diagnoses including Pacemaker, CVA (Cardiovascular Accident), A-Fib (Atrial Fibrillation) Respiratory Failure, OSA (Obstructive Sleep Apnea), COPD (Chronic Obstructive Pulmonary Disease), Asthma, Tachy-[NAME] Syndrome, Acute on Chronic Hypoxemic Respiratory Failure and COPD Exacerbation. This POS documents an order for Circuit mask and tubing, clean weekly on Sundays on day shift and order for CPAP (Continuous Positive Airway Pressure) on at night via mask IPAP (Inspiratory Positive Airway Pressure) at 12.0.
R27's medical record documents that R27 was diagnosed with Pneumonia in June, 2024.
On 9/22/24 at 8:45 AM, there was a CPAP machine on a cart on the left hand side of R27's bed. There was a mask and tubing attached to the machine.
On 9/24/24 at 11:40 AM, R27 stated that she does have a CPAP machine but she states that it is missing parts so she hasn't been using it lately.
R27's Minimum Data Sets dated 4/20/24 and 7/25/24 does not indicate that R27 uses a CPAP machine. The area Non-invasive Mechanical Ventilator CPAP is blacked out.
On 9/24/24 at 12:17 PM, V10 Minimum Data Set Nurse confirmed that the CPAP was not coded on the MDS. V10 stated that it does not allow her to mark it as using while in facility for some reason.
4.) R7's Physician's Order Sheet dated 9/1/24 through 9/30/24 documents a diagnosis of Hemiparesis.
On 9/22/24 at 9:35 AM, R7 was in his room in his wheel chair and his left hand was contracted. R7 raised his left arm up and tried to open his left hand and could only open slightly.
R7's Minimum Data Set (MDS) dated [DATE] documents Range of Motion impairment to both sides of the body on the upper and lower portions. R7's Range of Motion assessment dated [DATE] documents R7 is at a moderate risk and documents that R7 has greater than 80% functional range of motion in his wrist, fingers and thumb of the left hand.
R7's Range of Motion Assessments dated 1/4/24, 4/4/24 and 7/2/24 document R7 has full range of motion to his left wrist, thumb and fingers. R7's Functional Abilities and Goals Review dated 10/5/23, 1/4/24, 4/4/24 and 7/2/24 document R7 has no impairment his upper extremities.
On 9/23/24 at 1:18 PM, V6 (Director of Rehab) confirmed R7 has a left hand contracture.
On 9/24/24 at 10:18 AM V7 (Certified Nursing Assistant) confirmed that R7's left hand has been contracted since she has known him at least 1/1/2 years.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to store and secure portable oxygen cylinders appropriately for five of five residents (R27, R20, R5, R29 and R13) reviewed for o...
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Based on observation, interview and record review, the facility failed to store and secure portable oxygen cylinders appropriately for five of five residents (R27, R20, R5, R29 and R13) reviewed for oxygen on the sample list of 34.
Findings Include:
On 9/25/24 at 10:24 AM, there were three oxygen cylinders sitting on the floor in the medication storage room, not secured or in a cart, along with three oxygen carts that had three oxygen cylinders in them. At this time, V3 Assistant Director of Nursing confirmed that three oxygen cylinders were not secured in a cart and should be. V3 also stated that the oxygen cylinders should not be stored in the medication storage room and explained all oxygen is supposed to be stored outside.
The facility's undated Residents On Oxygen form documents R27, R20, R5, R29 and R13 all use oxygen.
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 according to physician orders and manufacturer recommendations for four of 13 residents (R13, R24, R90,...
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Based on observation, interview, and record review the facility failed to administer medications according to physician orders and manufacturer recommendations for four of 13 residents (R13, R24, R90, R31) reviewed for medication administration on the sample list of 34. The facility had five errors out of 26 opportunities resulting in a medication error rate of 19.23 percent.
Findings include:
1.) R13's September 2024 Physician Order Sheet documents an order for Benztropine (Parkinson's medication) 2mg (milligram) three times daily with meals scheduled to be given at 12:00 PM and Novolin R (Fast Acting Insulin) 100 units sliding scale coverage according to R13's glucose level (151-200=two units, 201-250=four units, 251-300=six units, 301-350=8 units) scheduled to be given at 11:00 AM.
On 09/23/24 at 11:17 AM, V18 LPN (Licensed Practical Nurse) stated V18 had already administered R13's oral medications before 11:00 AM, but is now ready to administer the ordered Insulin. V18 entered R13's room and checked R13's glucose level which read 199.
On 09/23/24 at 11:21 AM, V18 withdrew 2 units of Novolin R Insulin out of a vial that was labeled with another resident's name and administered it to R13. At this time, V18 stated there was only one vial in the medication cart and it was the same Insulin that R13 uses so V18 administered that instead of going and getting R13's Insulin out of the refrigerator.
On 09/23/24 at 12:21 PM, R13 was sitting in dining room waiting on lunch and stated he last ate at approximately 8:30 AM.
On 09/25/24 at 1:00 PM, V1 (Administrator) stated Insulin should be given within 15 minutes of mealtimes and insulin vials should not be shared between residents.
2.) R24's September 2024 Physician Order Sheet documents an order for Ferrous Sulfate (Iron) 325mg three times daily with meals.
On 09/23/24 at 11:34 AM, V18 LPN (Licensed Practical Nurse) administered R24's Ferrous Sulfate 325mg.
On 09/23/24 at 12:21 PM, R24 was sitting in dining room waiting on lunch and stated he last ate at breakfast.
3.) R90's September 2024 Physician Order Sheet documents an order for Lispro (Fast Acting Insulin) 100 units sliding scale coverage according to glucose level scheduled to be given at 11:00 AM.
On 09/23/24 at 11:40 AM, V18 LPN (Licensed Practical Nurse) entered R90's room and checked R90's glucose level which read 159.
On 09/23/24 at 11:45 AM, V18 administered 5 units of Lispro Insulin to R90 according to R90's sliding scale order.
On 09/23/24 at 12:18 PM, R90 was in his room waiting on lunch to be served. R90 stated he has had nothing to eat since breakfast, which was around 8:30 AM.
On 09/25/24 at 1:00 PM, V1 (Administrator) stated Insulin should be given within 15 minutes of mealtimes.
4.) R31's September 2024 Physician Order Sheet documents an order to administer Lispro (Fast Acting Insulin) according to R31's glucose level, to be given at 11:00 AM.
On 09/24/24 at 11:07 AM, V9 LPN (Licensed Practical Nurse) entered R31's room and checked R31's glucose level which read 212.
On 09/24/24 at 11:13 AM, V9 administered 3 units of Lispro Insulin to R31 according to R31's sliding scale orders.
On 09/24/24 at 11:19 AM, R31 stated she has not eaten anything since breakfast at 8:00 AM.
On 09/24/24 at 11:49 AM, R31 was sitting in the dining room waiting on lunch to be served.
On 09/25/24 at 1:00 PM, V1 (Administrator) stated Insulin should be given within 15 minutes of mealtimes.
The package insert for Novolin R and Lispro Insulin dated February/2012 documents this fast acting insulin is to be administered within 30 minutes of the start of a meal.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to ensure medications were labeled and stored appropriately in the medication storage room and medication cart. This has the pote...
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Based on observation, interview, and record review the facility failed to ensure medications were labeled and stored appropriately in the medication storage room and medication cart. This has the potential to affect all 39 residents who reside in the facility.
Findings Include:
1. R15's Physicians Orders dated September 2024 documents an order for a Combivent Inhaler 20mcg (micrograms)/100mcg (inhaler) one puff four times a day.
On 09/23/24 at 11:55 AM, V9 LPN (Licensed Practical Nurse) administered a Combivent Inhaler 20mcg/100mcg to R15. This inhaler was loose in the medication cart and did not contain a pharmacy label with R15's name or instructions for use. At this time, V9 stated I don't know where the label is for the medication, but V9 knows the inhaler belongs to R15 because R15 is the only resident that gets Combivent.
On 09/24/24 at 11:24 AM, V9 LPN administered a Combivent Inhaler 20mcg/100mcg to R15. This inhaler was loose in the medication cart and did not contain a pharmacy label with R15's name or instructions for use. At this time, V9 stated, I (V9) meant to get the pharmacy label in a bag with the inhaler but I forgot all about it.
2. On 09/25/24 between 10:20 AM and 10:41 AM, the medication refrigerator in the medication storage room had a silver padlock present on the refrigerator door but was not locked. Located in the medication refrigerator on the second shelf was a bottle of Lorazepam (antianxiety) {Controlled Substance} oral solution 2mg (milligram)/ml(milliliter) for R6 and a pharmacy metal box, unsecured in the refrigerator, with a pharmacy sheet indicating that the box contained Lorazepam 2mg/ml.
On 09/25/24 at 10:37 AM, V3 ADON (Assistant Director of Nursing) stated the medication refrigerator should be locked at all times, and confirmed that it was not locked. V3 also stated the Lorazepam in the locked metal box could be used for any resident in the facility who would get an order for it.
3. On 9/25/24 at 10:39 am, the drawer labeled 25 and 26 of the treatment cart contained an opened bottle of Nystatin powder (Antifungal) without a label.
On 09/25/24 at 10:41 AM, V1 (Facility Administrator) stated the Nystatin Powder would be for either R18, R9, or R1 however V1 did not believe that any of those residents had an order for Nystatin Powder. V1 then reviewed treatment orders for R18, R9 and R1 and confirmed neither of them had an order for the Nystatin Powder, therefore it should not be in the treatment cart.
4. On 09/25/24 at 11:02 AM, the top drawer of the medication cart contained the following: an open bottle of Azelastine HCL (Hydrochloride) 0.05% eye drops for R35 that was dispensed by pharmacy on 7/28/24 but did not document when the bottle was opened and an open bottle of Azelastine HCL 0.05% eye drops for R13 that was dispensed on 07/09/24 but did not document when the bottle was opened.
On 9/25/24 at 11:10 AM, V3 Assistant Director of Nursing stated that eye drops should be dated when opened.
The facility's Procurement and Storage of Medications policy reviewed 11/06/18 documents all medications brought into the Facility shall be labeled with at least the following information: Name, address and phone number of dispensing pharmacy; resident name, physician name, name and strength of medication, directions for administering, last date dispensed and prescription number; both the brand and generic name if substitution is made; appropriate auxiliary labeling. All medication containers shall be labeled with the date opened by the person breaking the container seal. Schedule II drugs are to be stored under double-lock subject to different key.
The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 09/22/24 documents 39 residents reside in the facility.
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 full time Certified Dietary Manager. This failure has the potential to affect all 39 residents residing in the facilit...
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Based on observation, interview and record review the facility failed to employ a full time Certified Dietary Manager. This failure has the potential to affect all 39 residents residing in the facility.
Findings include:
The Facility Daily Census dated 9/22/24 documents 39 residents reside in this facility,
The Facility Assessment updated 7/15/24 documents the facility resources needed to provide competent support and care for the resident population every day and during emergencies includes a Certified Dietary Manager.
On 9/22/4-9/25/24 during various times on first and second shifts there was no Certified Dietary Manager onsite during survey timeframe.
On 9/22/24 at 8:25 AM V13 [NAME] stated the facility does not have a Dietary Manager. V13 stated It would be nice. There are so many things that need cleaned up, fixed and taken care of in our kitchen. That is the Dietary Manager's job to make sure we have the temperatures right, the residents get the right orders and make sure our kitchen runs smoothly. You can see that we (facility) need a lot of help.
On 9/22/24 at 2:55 PM V1 Administrator stated the facility does not have a Certified/Dietary Manager. V1 stated the facility kitchen is overseen by V1 Administrator and V5 Maintenance Director. V1 stated We (facility) know our kitchen is struggling. There are new staff working in there with little to no guidance or training. We (facility) are working on that. We are working to make it better but it takes time. The errors in the kitchen may not have happened if we (facility) did have a Dietary Manager.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to ensure the food products served were within the recommended date, failed to monitor food temperatures during meal service, fail...
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Based on observation, interview and record review the facility failed to ensure the food products served were within the recommended date, failed to monitor food temperatures during meal service, failed to monitor temperatures and/or sanitizer level on dishwasher, failed to ensure to dishes were sanitized prior to resident use, failed to maintain sanitation practices in the facility kitchen, failed to monitor temperatures for the facility reach in cooler, reach in freezer, and chest freezer and failed to properly label and store foods. These failures have the potential to affect all 39 residents residing in facility.
Findings include:
The Facility Daily Census dated 9/22/24 documents 39 residents reside in facility.
The facility Week four Sunday menu included Pot Roast and Vegetables, Harvard beets, roll/margarine and pie of choice.
The facility was unable to provide temperature logs for the facility kitchen reach in refrigerator, reach in freezer, chest freezer and dishwasher.
On 9/22/24 at 8:10 AM initial tour of the facility kitchen was completed with the following findings:
1. The facility large reach in freezer stored multiple large bags of frozen potatoes, waffles, waffle sticks and a plastic bag of pre-sliced unidentifiable pink deli meat which did not have any labels or expiration dates.
2. The facility large reach in refrigerator contained items with no label and no expiration date including: a clear plastic gallon sized container with an unknown red gel like substance, six deli sandwiches with meat substance and slice of yellow cheese, gallon sized clear container of mashed potatoes floating in hazy liquid on all sides/top and bottom, clear plastic bag of black crumbled substance and two whole cucumbers in clear plastic bag all with no label and no expiration date.
3. The facility large reach in refrigerator contained six quarts of lactose free milk all dated 9/19/24, multiple clear squeeze bottles of various condiments with no label and no date, a gallon sized mayonnaise container and buttermilk ranch dressing containers both with lids laying over top of open containers and neither had expiration dates or opened dates.
4. The air vents on the ceiling were filled with dust and brown grime. Occasional pieces of debris would float down from the ceiling vents onto the food prep area.
5. The facility reach in freezer is positioned directly next to the food holding table. The entire side of the facility freezer two feet deep by six feet tall was covered in unknown brown splatters and food debris. The food holding table does not have lighting over it. The area where the food holding table is located is very dim.
6. The facility food temperature log dated September 2024 did not have any entries for 9/19, 9/20 and 9/21.
7. Dozens of small flying gnats were swarming an open bag of yellow onions in the dry storage room. One onion near bottom of the bag had a foul odor and was oozing brown liquid onto floor.
8. The facility small white chest freezer containing breadsticks, loaves of sliced bread and dinner rolls all with no label or expiration date did not have a thermometer inside the freezer.
9. The facility range hood located directly over the stovetop cooking area was covered with brown grime and grease splatters. The range hood had a sticker on it that read 'Range Hood Cleaning Inspection.' This same sticker has lines for dates to be written in for cleaning inspections. There were no dates filled in for dates of service.
On 9/22/24 at 11:10 AM V14 Dietary Aide obtained a temperature of 105 degrees Fahrenheit during the wash cycle of the mechanical dishwasher. V14 then used a litmus strip to test the Ph level with a result of a faint purple line which correlated to less than 50 parts per million (PPM). V13 [NAME] observed the entire process.
On 9/22/24 from 11:20 AM-1:30 PM V14 Dietary Aide and V13 [NAME] both used the dishwasher to wash holding pans, utensils, cups and covers for plates during meal service and then used the same dishes to serve resident foods during lunch service.
On 9/22/24 at 8:40 AM V14 Dietary Aid stated (R23) gets that (lactose free milk). I used the carton that is sitting on the serving table (pointing at the same carton). (R23) gets it every morning. V14 Dietary Aide confirmed V14 served R14 expired lactose free milk.
On 9/22/24 at 11:20 AM V14 Dietary Aide stated That dishwasher isn't running hot enough water and isn't cleaning the dishes like it should. I don't know what is wrong with it but the dishes still need done. V13 [NAME] stated That thing (dishwasher) didn't work right last week. I told them (facility) but nothing happened to it after that. Nothing got fixed.
On 9/24/24 at 9:00 AM V5 Maintenance Director stated the facility has a contract with a cleaning company to clean the range hood. V5 stated I help to oversee the kitchen sometimes, so I know a lot about what goes on in there. We (facility) need a lot of help in that kitchen. It needs a deep clean for the entire kitchen. There are no cleaning schedules really. We (staff) just clean as we go or if we see something that needs cleaned, then we are supposed to clean it up. The contracted cleaning company comes once every five years to do a deep clean on the range hood. In between the five year mark there is no regular cleaning schedule.
On 9/24/24 at 2:00 PM V1 Administrator stated the dietary staff should monitor the temperatures of the foods being served and stored. V1 stated the refrigerator, freezer, dishwasher and food temperatures should all be logged either daily or with each meal. V1 stated The kitchen needs a lot of work. I am not surprised there are issues. I know there have been logs in the past but I don't have anything now. I don't know if the staff are checking temperatures or not. I hope they are. V1 stated serving foods that are expired, not labeled or not temperature checked prior to serving could make a resident ill.
The facility policy titled Kitchen Sanitation revised October 2020 documents the facility policy is to comply with local health standards and local and state sanitation regulations. The food service manager will develop a cleaning schedule for the department and ensure that the dietary employees complete cleaning tasks as scheduled.
The facility policy titled Ware-Washing Dish Machine revised October 2009 documents for low temperature dish machines the temperature of the wash water shall not be less than 120 degrees Fahrenheit. Before washing anything, use a test strip to check the sanitizer level. For Chlorine sanitizers the level should be 50-100 parts per million (PPM). Record either the temperatures or the sanitizer level on the dishwasher temperature log.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to ensure it's antibiotic stewardship policy was comprehensive, and failed to track organisms and implement use of infection assessment tools. ...
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Based on interview and record review the facility failed to ensure it's antibiotic stewardship policy was comprehensive, and failed to track organisms and implement use of infection assessment tools. These failures have the potential to affect all 39 residents residing in the facility.
Findings include:
The facility provided Antibiotic Stewardship Program dated 12/10/21 documents to utilize core elements for antibiotic stewardship including accountability by identifying physicians, nursing, and pharmacy leadership responsible for oversight, action by implementing at least one policy/practice for antibiotic use, and tracking by monitoring at least one process measure and outcome. This policy does not document who is responsible for implementation and oversight of the program, what information should be tracked/monitored and the frequency, and what infection surveillance tools are used to ensure antibiotics are appropriately prescribed.
The facility's Resident Infection Control and Antimicrobial Logs dated May-August 2024 document the following: R12 was prescribed different antibiotics on 4/26/24 and 5/22/24 for Urinary Tract Infection (UTI), but does not list the organism as prompted by the log. R27 was prescribed antibiotics on 5/23/24 for UTI and does not list the organism. R34 was prescribed different antibiotics on 6/11/24, 6/17/24, and 7/1/24 for other infection of urinary signs/symptoms, and a culture or infectious organism is not listed. R3 was prescribed different antibiotics on 7/20/24 and 8/16/24 for UTI, and a culture and organism are not listed. R190 was prescribed antibiotics on 8/3/24 for UTI, and a culture and organism are not listed.
On 9/24/24 at 11:36 AM V1 Administrator/Infection Preventionist stated V8 Regional Clinical Director has been overseeing the infection control logs since the facility does not have a Director of Nursing. At 11:38 AM V8 stated the facility is ensuring appropriate symptoms for antibiotic usage and antibiotics aren't ordered until cultures are obtained as part of antibiotic stewardship. V8 stated the facility is only using McGreer Criteria (infection assessment tool) for UTIs and the AIM (Assess Intervene Monitor for wellness) communication forms document symptoms for other infections. V8 confirmed the infection logs do not document UTI cultures and resulting organisms after May 2024 and confirmed this is part of surveillance monitoring for infection control/antibiotic stewardship. On 9/24/24 at 12:18 PM V8 stated R34 kept having urinary symptoms despite a urinalysis that was negative for infection, and R34 has since been referred to a urologist. V8 reviewed the facility's Antibiotic Stewardship Program and confirmed it is not comprehensive to include who is responsible for oversight and implementation, what information is reviewed and the frequency, the use of cultures, and the use of any infection assessment tools. At 1:46 PM V8 stated V8 was unable to provide documentation that McGreer's Criteria or similar infection assessment tool was completed for R34, R3, and R190.
On 9/25/24 at 10:03 AM V1 stated organisms should have been tracked on the infection control logs, and the Director of Nursing was responsible for doing that.
The facility's Long Term Care Facility Application for Medicare and Medicaid dated 9/22/24 documents 39 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0912
(Tag F0912)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to provide at least 80 square feet of floor space for each resident in resident bedrooms. This failure affects all 39 residents ...
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Based on observation, interview, and record review, the facility failed to provide at least 80 square feet of floor space for each resident in resident bedrooms. This failure affects all 39 residents residing in the facility.
Findings include:
Historical room size documentation and actual measurements demonstrate the double occupancy resident bedrooms do not meet the minimum required square footage of 80 square feet per resident (160 total square feet) including Rooms 3-13, 14 (current Nursing Director Office), 16 (current therapy room), 17- 28 and 30.
The Medicare/Medicaid Certification and Transmittal effective 8/22/23, from the most recent prior survey, documents all 58 resident beds are certified for Title 19 (Medicaid).
The facility's Resident Census and Conditions of Residents form dated 9/22/24 documents 39 residents reside in the facility, all of whom reside in one of the double occupancy rooms.
On 9/25/24 at 8:50 AM R12 was laying in her bed. R12 had a bed, dresser, walker, wheelchair and bedside table on her side of her room. R12 had multiple personal items on the dresser and on the floor.
On 9/25/24 at 8:30 AM V5 Maintenance Director measured the square footage of rooms 11, 17 and 19 which all measured at 69.19 square foot total space for each resident, dual occupancy rooms.
On 9/25/24 at 8:51 AM R12 stated This room is too small. We (R12 and roommate) both have a lot of things that we need to use every day. I have to move my wheelchair every time my roommate wants to use the bathroom because I don't have anywhere else to store my wheelchair when I am not using it. It is too cramped.
On 9/25/24 at 8:25 AM V5 Maintenance Director stated None of the rooms in this facility meet the regulations. They are all too small. Some of the residents complain about it but there is not much we can do.
Sept 2024
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
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 employ a Registered Nurse to serve as full time Direct...
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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 employ a Registered Nurse to serve as full time Director of Nurses (DON). This failure has the potential to affect all 39 residents in the facility.
Findings Include:
Upon survey entrance and throughout the survey (9/18/24) there was no Director of Nurses present and employed by the facility.
On 9/20/24 at 2:58 PM, V1 (Administrator) confirmed the facility does not currently employ a full time DON. There has not been a full time DON employed by the facility since August 15, 2024. V1 confirmed the facility census is currently 39 residents.
The Facility assessment dated [DATE] documents, a full time nursing supervisor (Director of Nurses) is required in order to meet the resident's needs and provide competent support and care for the facility's resident population.
Aug 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to treat one resident (R1) with respect of three residents reviewed for dignity in a sample list of three.
Findings Include:
R1's Progress Not...
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Based on interview and record review the facility failed to treat one resident (R1) with respect of three residents reviewed for dignity in a sample list of three.
Findings Include:
R1's Progress Note documents R1 was admitted to the facility 8/7/24 at 4:00PM.
On 8/19/24 at 10:19AM R1 stated I fell at home and broke my knee cap and my arm. Then I went to (the local hospital) and was sent to (the facility) The CNA's (Certified Nurses Assistant) here didn't know how much help I needed. There was once when a CNA on night shift (does not remember name) pulled my right arm. I told her I had broken that arm and the CNA stated 'no you didn't you just broke your left knee'. They were just generally uncaring and rude.
R1's progress note dated 8/7/24 at 5:00PM documents (V9) Registered Nurse (RN) went back in (R1's room) and told (R1) once again how (R1) was going to transfer to the bed pan and that (V9) is in charge and we both (V9 and R1) have to go by the doctor's orders not what we want to do. (V9) told (R1) (V9) understood (R1) didn't want to be there. (R1) was asking the CNA's to go to a hotel. When (V9) left the room (R1) was on the phone saying 'they are lying'.
On 8/20/24 at 11:00AM after reviewing the above quoted progress note V1 (Administrator) stated I do not think that note is respectful at all. We definitely should treat residents with more respect than 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a resident room in a clean sanitary manner 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 maintain a resident room in a clean sanitary manner for two residents (R1, R2) of three residents reviewed for housekeeping in a sample list of three.
Findings include:
On 8/19/24 at 10:19AM R1 stated (R2) was my roommate when I was at (the facility). (R2) urinated all over the bed, and it smelled bad. The facility did not clean the floor in our room and it was covered in urine. The shower also smelled like urine. I just couldn't live with that.
R1's Progress Note documents R1 was admitted to the facility 8/7/24 at 4:00PM and left against medical advice on 8/13/24 at 3:00PM.
R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact and frequently incontinent of urine.
On 8/19/24 at 11:30AM R2's room was very cluttered with belongings and there was a strong ammonia like odor. The floor was so sticky the surveyor's shoes stuck to the floor when walking. The floor was stained with a yellow brown substance. At this time, R2 was sitting in the dining room waiting for lunch socializing with other residents. R2 had the same ammonia like odor observed in R2's room.
On 8/20/24 at 9:00AM V1 (Administrator) stated Sometimes (R2) wants to change herself when wet. (R2) is very modest. We realize the floor in (R2's) room gets dirty and we were discussing doing floor cleaning in the whole facility doing that room first. V1 verified there was an odor in (R2's) room.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to initiate a base line care plan and initiate resident centered interventions for one resident (R1) reviewed for Care Plans in a sample list o...
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Based on interview and record review the facility failed to initiate a base line care plan and initiate resident centered interventions for one resident (R1) reviewed for Care Plans in a sample list of three.
Findings Include:
The facility's policy Baseline Care Planning revised 11/1/17 states It is the policy of (the facility) to promptly asses the plan (of) care for each resident admitted to the facility. Pending completion of the Comprehensive Resident Assessment and Care Plan, the interdisciplinary team shall asses each resident for potential needs. A Plan of Care (Baseline Care Plan) shall be developed to include instructions needed to provide effective person centered care to each resident, based on his/her initial assessment and professional standards of quality care, to serve as a functional guide in the delivery of care until such time as a comprehensive plan is developed.
R1's Physician's Order Sheet (POS) for 8/7/24 to 8/31/24 includes the following diagnoses: Chronic Anemia, Chronic Depression, Frequent Falls, Closed Fracture of the Distal End of the Right Humerus, Open Reduction Internal Fixation of Left Patella, T12 Compression Fracture, Orthostatic Hypotenson, Alcohol Abuse, and Anxiety. R1's Progress Note documents R1 was admitted to the facility 8/7/24 at 4:00PM and left against medical advice on 8/13/24 at 3:00PM. There is no documentation of a baseline Care Plan or resident specific interventions for care for R1.
On 8/19/24 at 10:19AM R1 stated I fell at home and broke my knee cap and my arm. Then I went to (the local hospital) and was sent to (the facility) The CNA's (Certified Nurses Assistant) here didn't know how much help I needed. There was once when a CNA on night shift (does not remember name) pulled my right arm. I told her I had broken that arm and the CNA stated 'no you didn't you just broke your left knee'. I just didn't get the help I needed,
On 8/20/24 at 10:00AM V1 (Administrator) stated I can see that no Baseline care plan was documented for (R1). V1 verified without a Care Plan staff would not have been aware of what level of assistance (R1) required.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to complete an admission Fall Risk Assessment for a resident with history of falls with injury. Ths failure affects one (R1) of three residents r...
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Based on observation and interview the facility failed to complete an admission Fall Risk Assessment for a resident with history of falls with injury. Ths failure affects one (R1) of three residents reviewed for falls in a sample list of three residents.
Findings Include:
The facility's policy Fall Prevention revised 11/10/18 states Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor resident's wishes/desires for maximum independence and mobility. Procedure: Conduct fall assessments on day of admission, quarterly, and with a change in condition. Identify, on admission, the resident's risk for falls. Assessment of fall risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. The admitting nurse will assign a temporary category.
R1's Physician's Order Sheet (POS) for 8/7/24 to 8/31/24 includes the following diagnoses: Chronic Anemia, Chronic Depression, Frequent Falls, Closed Fracture of the Distal End of the Right Humerus, Open Reduction Internal Fixation of Left Patella, T12 Compression Fracture, Orthostatic Hypotenson, Alcohol Abuse, and Anxiety. R1's Progress Note documents R1 was admitted to the facility 8/7/24 at 4:00PM and left against medical advice on 8/13/24 at 3:00PM. There is no documentation of a complete admission nursing assessment, an admission fall risk assessment, or other baseline assessment.
On 8/19/24 at 10:19AM R1 stated I fell at home and broke my knee cap and my arm. Then I went to (the local hospital) and was sent to (another hospital) to have surgery on my knee. I was then sent back to the local hospital where I started therapy. I thought I was coming to this facility to get more therapy, but that never happened. The CNA's (Certified Nurses Assistant) here didn't know how much help I needed.
On 8/19/24 at 2:00PM V5 (Licensed Social Worker/Hospital Case Manager) stated When we discharged (R1) from the hospital we did not feel (R1) was safe to go home. We had issued a Notice of Medicare Noncoverage to (R1) which (R1) did not choose to appeal. We placed (R1) at (the facility) with a plan for (R1) to continue with intermittent therapy until (R1) was safe to return home.
On 8/20/24 at 10:00AM V1 (Administrator) stated I can see that no admission fall risk assessment or complete admission assessment were documented. (R1) was here to get stronger and have some therapy. The problem with the therapy was since we are an intermediate care facility there would be a co-pay for therapy and (R1) was not wanting to apply for Medicaid to have that.
Feb 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 observation, interview, and record review the facility failed to develop pressure ulcer plans of care for three of thre...
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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 develop pressure ulcer plans of care for three of three (R1, R2, and R3) residents reviewed for care plans on the sample list of 20.
Findings include:
1. On 2/10/24 at 8:25 AM, a dime sized necrotic pressure area was on the heel of R1's right foot. R1 also had sheared areas to the coccyx.
R1's medical record did not contain a care plan for R1's pressure ulcers.
On 2/9/24 at 1:20 PM, V1 Administrator stated R1's medical record did not contain a care plan for R1's pressure ulcers.
2. On 2/10/24 at 8:15 AM, R2 was sitting up in the wheelchair. A half dollar sized necrotic pressure area was on R2's left heel.
R2's medical record did not contain a care plan for R2's pressure ulcer.
On 2/9/24 at 1:20 PM, V1 Administrator stated R2's medical record did not contain a care plan for R2's pressure ulcers.
3. On 2/10/24 at 9:00 AM a dressing dated 2/10/24 was present to R3's coccyx.
R3's wound assessment dated [DATE] documents R3 has an unstageable pressure ulcer to the coccyx.
R3's medical record did not contain a care plan for R3's pressure ulcer.
On 2/9/24 at 1:20 PM, V1 Administrator stated R3's medical record did not contain a care plan for R3's pressure ulcers.
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
Based on observation and interview the facility failed to ensure the right to a safe, clean, and homelike environment for seven (R10, R11, R12, R13, R14, R15, and R16) of 20 residents reviewed for env...
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Based on observation and interview the facility failed to ensure the right to a safe, clean, and homelike environment for seven (R10, R11, R12, R13, R14, R15, and R16) of 20 residents reviewed for environment on the sample list of 20.
Findings include:
On 2/9/24 at 8:10 AM, the bathroom tile on R10 and R11's bathroom floor was broken around the toilet and multiple tiles on the floor were cracked. The floor was stained, and dirt and debris were accumulated along the base. The tiles on R12 and R13's floor was stained and there was dirt and debris accumulated along the base. R14, R15, and R16's toilet was not secured and moved when V2 Maintenance Director pushed it. The floor around this toilet was stained with a dark orange, brown residue all around the toilet. At that time, R14 stated the toilet moves when I sit on it.
On 2/9/24 at 8:30 AM, V2 Maintenance Director confirmed that R10, R11, R12, R13, R14, R15, and R16's bathroom tiles were broken and stained, and that dirt and debris was accumulated along the cove base.
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 F0918
(Tag F0918)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure a room was equipped with a working toilet for seven (R4, R5, R6, R7, R8, R9, and R18) of twenty residents reviewed for ...
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Based on observation, interview, and record review the facility failed to ensure a room was equipped with a working toilet for seven (R4, R5, R6, R7, R8, R9, and R18) of twenty residents reviewed for toilets on the sample list of 20.
Findings include:
On 2/9/24 at 8:10 AM, an out of order sign was taped to R4, R5, R6, R7, R8, R9, and R18's bathroom doors. At that time, V2 Maintenance Director stated the toilets clog up and he will unclog them but the next day it will happen again. V2 stated a plumber has not been called. V2 stated the piping to these rooms meet in the middle under the hallway. V2 stated he has had problems with these toilets for a couple months.
On 2/9/23 at 11:24 AM, R9 stated R9's bathroom has been out of order for a month and a half. R9 stated R9 will have to go to the shower room to use the toilet. R9 stated when another resident is getting a shower, R9 will have to go and ask other residents to use their restrooms.
Maintenance Work Order dated 1/12/24 documents R7, R8, R9 and R18's toilet was leaking.
Hand written list dated 1/16/24 provided by V2 documents R7, R8, R9 and R18's plumbing in the respective rooms needs routed.
Hand written list dated 1/24/24 provided by V2 Maintenance Director documents R9's toilet flooded.
Hand written sign dated 1/27/24 documents R9's toilet is broken.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to employee the services of a full time Director of Nursing. This failure has the potential to affect all 42 residents residing i...
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Based on observation, interview, and record review the facility failed to employee the services of a full time Director of Nursing. This failure has the potential to affect all 42 residents residing in the facility.
Findings include:
On 2/9/24 at 7:45 AM and at 2:00 PM during a tour of the facility, a Director of Nursing was not working in the facility. On 2/10/24 at 7:30 AM during a tour of the facility, a Director of Nursing was not working in the facility.
The facility's Nurse's schedule for January 2024 and February 2024 does not document that a Director of Nursing was scheduled in the facility.
On 2/9/24 at 2:42 PM, V1 Administrator stated the facility has not had a Director of Nursing since January 15, 2024.
The facility's February 2024 Census sheet provided by V19 Regional Director of Operations documents there are 42 residents residing in the facility.
Aug 2023
19 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by another...
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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 right to be free from verbal abuse by another resident and a staff member. These failures affect four residents (R26, R30, R244, R22) out of four residents reviewed for abuse in a sample list of 42 residents.
Findings include:
1.) R26's Physician Order Sheet (POS) dated August 2023 documents medical diagnoses of Schizophrenia, Right Knee Total Arthroplasty, Major Depression, Morbid Obesity, Bipolar Disorder and Anxiety.
R26's Cognitive assessment dated [DATE] documents R26 as cognitively intact.
R26's Minimum Data Set (MDS) dated [DATE] documents R26 requires total dependence of two staff using a total body mechanical lift for transfers, extensive assistance of two people for bed mobility, dressing, and toileting, extensive assistance of one person for personal hygiene, limited assistance of one person for locomotion, and supervision for eating.
R26's Nurse Progress Note dated 5/31/23 at 1:15 PM documents, (R26) continues to yell using profanity. Can hear (R26) from her room to nursing station. (R22) went into (R26's) room and started to yell at (R26). Then (R22) closed (R26's) door and (R26) tried to get out of bed several times after that.
On 8/16/23 at 2:45 PM R26 stated, I remember that day (R22) came right into my room and yelled at me. I didn't feel good. (R22) just walked in and yelled so loud it scared me. (R22) scared the (expletive) out of me. (R22) was yelling 'Shut up (expletive)! Shut up!' over and over at me. I yelled and yelled for someone to come down and get (R22). They (staff) finally came down and took (R22) away.
On 8/16/23 at 2:55 PM V1 Administrator stated, After reading (R26's) progress note from 5/31/23, they (staff) wrote the word 'yell' and that would indicate to me that (R22) yelled at (R26) and that is the definition of verbal abuse. Since this was never reported to me, I can only say that this could have been considered verbal abuse.
2.) R244's Minimum Data Set (MDS) dated [DATE] documents R244 as cognitively intact. This same MDS documents R244 as requiring extensive assistance of one person for personal hygiene and dressing, limited assistance of one person for bed mobility, transfers, and toileting, and supervision for locomotion and eating.
R22's Minimum Data Set (MDS) dated [DATE] documents R22 as independent in bed mobility, transfers, walking in room, locomotion on unit, and toileting, requires supervision in walking in corridor, locomotion off unit, eating and limited assistance of one person for dressing and personal hygiene.
R244's Nurse Progress Note dated 7/20/23 at 6:30 AM documents, (R244) complained of verbal abuse from roommate (R22). (R244) reports (R22) calls her a (expletive) and uses profanity at her. (R244) stated she doesn't like being in her room due to the verbal abuse. (R244) cried while reporting this. (R244) reported she told staff plenty of this and nothing is being done about it.
R244's Final Incident Report to Illinois Department of Public Health (IDPH) dated 7/24/23 documents, (R244) reported to V13 Licensed Practical Nurse (LPN) that (R22) had used verbal profanity towards (R244). This same report documents, (R244) stated 'Last night I was in the room crying and my roommate (R22) was mocking me and earlier in the day yesterday called me a '(expletive)'. It hurt my feelings because I am always nice to (R22). This same report documents, (R22) stated (R244) is a good roommate sometimes but at night she starts to complain and yell. I can't get any sleep. (R244) lies on me. (R244) told them I called her a (expletive). I said that in the dining room not last night. Nothing happened but I am glad (R244) switched rooms.
On 8/16/23 at 2:45 PM R244 stated, I pretty get along with everybody here. The staff are good to me and help me. I did have an awful roommate (R22) that called me names and cussed and yelled at me but I haven't had any trouble from her since I changed rooms.
On 8/18/23 at 9:00 AM V1 Administrator stated, (R22) did have a tendency to yell at her roommates. (R22) hasn't had any types of altercations that I know of since we (facility) placed her in a private room. (R22) said she didn't want a roommate so I think she would treat them bad so that we (facility) would move them out. After we (facility) figured this out we decided to just leave her in a private room and since then (R22) has not had any more behaviors.
3.) R30's current medical diagnosis list documents medical diagnoses of Spastic Paraplegia, Seizure Disorder, Memory Impairment, Mental Retardation, Cerebral Vascular Accident (CVA) and Depression.
R30's Cognitive assessment dated [DATE] documents R30 as cognitively intact.
R30's Minimum Data Set (MDS) dated [DATE] documents R30 as requiring total dependence of two people using a total body mechanical lift for bed mobility, transfers, dressing, and toileting, total dependence of one person for locomotion, eating and personal hygiene.
R30's Nurse Progress Notes do not document R30's assessment after the allegation of staff to resident verbal abuse.
R30's current Care Plan does not include focus area, goal nor interventions for being at risk of abuse.
R30's current Medical Record does not include an assessment for being at risk of being abused.
The facility Resident Council Minutes dated 7/11/23 document, Nursing Concerns: When I tell them to call (V23) (R30) Power of Attorney (POA) they (staff) tell me they don't have time. (V22) Certified Nurse Aide (CNA) has attitude that (R30) does not appreciate, letting (V22) know about his pain. (V22) stated it is not her fault' being (V22's) verbal response. (V22) not treating him poorly and care is not being met.
On 8/18/23 at 1:10 PM R30 stated, (V22) Certified Nurse Aide (CNA) makes me get out of bed when I don't want to. (V22) yells at me and forces me to get up. (V22) says 'you are going to get up whether you like it or not.' and then gets me up even though I tell her I don't want to. (V22) scares me. (V22) is mean to me. (V22) doesn't have to be so mean to me.
On 8/18/23 at 1:20 PM V1 Administrator stated, We (facility) have done abuse trainings on 7/20/23 and again on 8/1/23. By the way the resident council minutes read, that could definitely be considered abusive behavior by (V22) Certified Nurse Aide (CNA) towards (R30).
The facility policy titled 'Abuse Prevention Program' dated 11/28/2016 documents the following, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. Verbal abuse is the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their Abuse Prevention Policy by failing to promptly report 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 follow their Abuse Prevention Policy by failing to promptly report allegations of verbal abuse to the Abuse Coordinator and by failing to suspend a staff member after an allegation of staff to resident verbal abuse. This failure affects three (R26, R30, R22) out of three residents reviewed for abuse in a sample list of 42 residents.
Findings include:
The facility policy titled 'Abuse Prevention Policy' revised 10/14/2016 documents the facility must ensure all allegations of abuse are reported immediately to the Administrator of the facility. The report must be made to Illinois Department of Public Health (IDPH) within 24 hours after forming the suspicion. This same policy documents the facility will remove the staff member from the property pending investigation of allegation of abuse.
1.) R26's Physician Order Sheet (POS) dated August 2023 documents medical diagnoses of Schizophrenia, Right Knee Total Arthroplasty, Major Depression, Morbid Obesity, Bipolar Disorder and Anxiety.
R26's Cognitive assessment dated [DATE] documents R26 as cognitively intact.
R26's Nurse Progress Note dated 5/31/23 at 1:15 PM documents, (R26) continues to yell using profanity. Can hear (R26) from her room to nursing station. (R22) went into (R26's) room and started to yell at (R26). Then (R22) closed (R26's) door and (R26) tried to get out of bed several times after that.
R26's current Medical Record does not document an allegation of verbal abuse being reported to V1 Administrator.
2.) R30's current medical diagnosis list documents medical diagnoses of Spastic Paraplegia, Seizure Disorder, Memory Impairment, Mental Retardation, Cerebral Vascular Accident (CVA) and Depression.
R30's Cognitive assessment dated [DATE] documents R30 as cognitively intact.
The facility Resident Council Minutes dated 7/11/23 documents, Nursing Concerns: When I tell them to call (V23) (R30) Power of Attorney (POA) they (staff) tell me they don't have time. (V22) Certified Nurse Aide (CNA) has attitude that (R30) does not appreciate, letting (V22) know about his pain, (V22) stated it is not her fault' being (V22's) verbal response, (V22) not treating him poorly and care is not being met.
R30's current Medical Record does not document an allegation of verbal abuse being reported to V1 Administrator.
The facility was not able to provide documentation that V22 CNA was immediately suspended after allegedly verbally abusing R30.
On 8/17/23 at 10:30 AM Observed V22 Certified Nurse Aide (CNA) assisting residents and walking down both the men's and women's halls.
On 8/18/23 at 1:45 PM Observed V22 Certified Nurse Aide (CNA) assist residents in the dining area.
On 8/18/23 at 1:20 PM V1 Administrator stated, By the way the resident council minutes read, that could definitely be considered abusive behavior by (V22) Certified Nurse Aide (CNA) towards (R30). (V24) Previous Activity Director was present during the 7/11/23 resident council meeting to take minutes. (V24) never relayed this allegation to me and should have. I was made aware of this abuse allegation on 8/16/23. My staff never told me about this. (V22) CNA has a loud tone and we (facility) have talked with (V22) about this before. (V22) had been in serviced on 7/20/23 on our abuse policy, 7/25/23 on general attitudes towards residents and was in serviced on 8/1/23 for dignity and voice tone to use around residents. We in serviced all staff on these things on those dates but (V22) was present. I did not suspend (V22) after being made aware of (R30's) allegation of verbal abuse. I should have followed my own Abuse Policy. Now because I didn't, all of the other residents are at risk of possible verbal abuse. I hope (V22) was just using her loud voice but I have not investigated this matter and have not yet suspended (V22) CNA. I will start today. I was also made aware of (R26's) allegation of verbal abuse from (R22) from 5/31/23 on 8/16/23. (V13) Licensed Practical Nurse (LPN) did not report this to me. None of my staff ever told me about those incidents. Our (facility) policy states all allegations of abuse should be reported to me (V1) as Abuse Coordinator.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their Abuse Prevention Policy by not reporting allegations of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their Abuse Prevention Policy by not reporting allegations of verbal abuse to the State Agency. This failure affects three (R26, R30, R22) out of three residents reviewed for abuse in a sample list of 42 residents.
Findings include:
The facility policy titled 'Abuse Prevention Policy' revised 10/14/2016 documents the facility must ensure all allegations of abuse are reported immediately to the Administrator of the facility. The report must be made to Illinois Department of Public Health (IDPH) within 24 hours after forming the suspicion.
1.) R26's Physician Order Sheet (POS) dated August 2023 documents medical diagnoses of Schizophrenia, Right Knee Total Arthroplasty, Major Depression, Morbid Obesity, Bipolar Disorder and Anxiety.
R26's Cognitive assessment dated [DATE] documents R26 as cognitively intact.
R26's Nurse Progress Note dated 5/31/23 at 1:15 PM documents, (R26) continues to yell using profanity. Can hear (R26) from her room to nursing station. (R22) went into (R26's) room and started to yell at (R26). Then (R22) closed (R26's) door and (R26) tried to get out of bed several times after that.
The facility was not able to provide documentation of the Initial nor Final Incident Reports to Illinois Department of Public Health (IDPH).
2.) R30's current medical diagnosis list documents medical diagnoses of Spastic Paraplegia, Seizure Disorder, Memory Impairment, Mental Retardation, Cerebral Vascular Accident (CVA) and Depression.
R30's Cognitive assessment dated [DATE] documents R30 as cognitively intact.
The facility Resident Council Minutes dated 7/11/23 document Nursing Concerns: When I tell them to call (V23) (R30) Power of Attorney (POA) they (staff) tell me they don't have time. (V22) Certified Nurse Aide (CNA) has attitude that (R30) does not appreciate, letting (V22) know about his pain, (V22) stated it is not her fault' being (V22's) verbal response, (V22) not treating him poorly and care is not being met.
The facility was not able to provide documentation of the Initial nor Final Incident Reports to Illinois Department of Public Health (IDPH).
On 8/18/23 at 1:20 PM V1 Administrator stated, I was made aware of these abuse allegations on 8/16/23. Our (facility) policy states all allegations of abuse should be reported to me (V1) as Abuse Coordinator and that I should complete and send in an Initial Report within 24 hours and a Final Report within five days of the allegation being reported. I have not sent in any reports to the State Agency for either of these two incidents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
3. On 8/17/2023 at 11:42AM, R30's annual comprehensive resident assessment (4/5/2023) sections C, D, F, G, J, and Q were partially or fully incomplete.
On 8/17/2023 at 3:25PM, V1 (Administrator) repor...
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3. On 8/17/2023 at 11:42AM, R30's annual comprehensive resident assessment (4/5/2023) sections C, D, F, G, J, and Q were partially or fully incomplete.
On 8/17/2023 at 3:25PM, V1 (Administrator) reported R30's assessment was not completed due to staff turnover.
Based on interview and record review, the facility failed to conduct comprehensive annual and initial minimum data set assessments according to the required timeframe within 366 days. This failure affects three residents (R8, R30, and R41) out of six reviewed for annual assessments on the sample list of 44.
Findings include:
1. R8's annual comprehensive Minimum Data Set was dated with an Assessment Reference Date (ARD) of 10/6/22.
On 8/16/23 at 1:23 PM, V4, Minimum Data Set (MDS) Coordinator stated, For (R8), he had an annual dated 10/6/22 which was incomplete. Our corporate MDS specialist has been coming in to try to help us get everything up to date, so a lot of the sections did not get completed. All of this has been going on longer than I have been working here. We have had a lot of staff turnover with this position which has created problems all around.
2. R41's comprehensive initial Minimum Data Set was dated with an ARD of 5/22/23. Sections C for cognitive status, D for mood state, and F for personal preferences were incomplete.
The facility provided Manual instructions dated October 2019 documents resident interviews must be attempted with all residents (sections C, D, and F) unless the interviews are not conducted or are conducted outside of the look back period of the ARD, then to code the section with dashes, but to leave the staff assessment sections blank.
On 8/17/23 at 10:50 AM, V4, MDS Coordinator, stated, (R41's) MDS was dated 5/22/23 but it was incomplete for the sections usually done by the social services. We didn't have anyone in the social services to complete those sections so our corporate MDS specialist put the dashes in those sections to submit them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to complete a Level 2 PASARR (Preadmission Screening and Resident Review) within 40 days of admission for a resident admitted to the facility ...
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Based on interview and record review, the facility failed to complete a Level 2 PASARR (Preadmission Screening and Resident Review) within 40 days of admission for a resident admitted to the facility as an exempted hospital discharge. This failure affects one resident (R18) of one reviewed for admission screening in the sample list of 44.
Findings include:
08/16/23 at 10:40AM, R18's PASARR Level 1 screen (6/8/2022) documents R18 was screened for mental disorders and intellectual disabilities upon admission to the facility on 6/7/2022. The same record documents R18's admission to the facility was approved for only a 30 day or less stay and the facility must re-screen (complete a Level 2 PASARR) for R18 by or before the 30th day if R18 remained in the facility beyond the authorized timeframe.
On 8/17/2023 at 2:34PM, V1 (Administrator) reported a Level 2 PASARR was not completed for R18.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document any care plan focus area or non-pharmacologi...
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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 document any care plan focus area or non-pharmacological therapeutic interventions for a resident with diagnosed and exhibited symptoms of depression. This failure affects one resident (R41) out of two reviewed for behavioral and emotional indicators on the sample list of 44.
Findings include:
On 8/15/23 at 9:54 am, R41 was in bed with the blanket pulled over his face, the lights were out in the room, and the blinds were pulled shut. R41 stated, I do have some depression. I do take an antidepressant. I don't know if there is a social service person I can talk to if I need to.
R41's current Face Sheet documents R41 was admitted to the facility 5/11/23. R41's Physician Order Sheet documents R41 has medical diagnoses including Major Depressive Disorder and was prescribed Sertraline (antidepressant) 100 milligrams daily.
R41's Minimum Data Set assessment dated [DATE] was incomplete with section C for cognitive status assessment, section D for mood assessment, and section F for personal preferences assessment not completed.
R41's Care Plan dated 7/1/23 did not include any focus areas nor staff interventions for R41's mood disturbance.
On 8/18/23 at 12:15 PM, V4, Minimum Data Set and Care Plan Coordinator stated, When (R41) first got here he was dejected. Now he says that is what he did at home, just to sit around and not do much. Unfortunately, that is a going trend around here, we don't have an activity person right now, and now we don't have a social services person any more, and no business office manager. We don't have many activities so they all just sit around and watch television because there isn't anything to do.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R243's Minimum Data Set (MDS) dated [DATE] documents R243 as cognitively intact.
R243's Physician Order Sheet (POS) dated A...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R243's Minimum Data Set (MDS) dated [DATE] documents R243 as cognitively intact.
R243's Physician Order Sheet (POS) dated August 2023 documents a physician order for Bi-pap with oxygen at 4 Liters to be worn every night.
On 8/15/23 at 9:30 AM Observed R243's BIPAP nasal mask laying directly on floor under R243's bed. No plastic bag observed in R243's room to contain Bi-Pap/oxygen tubing. R243's Oxygen tubing was dated 7/30/23.
On 8/15/23 at 9:35 AM R243 stated, I know they (staff) are supposed to keep the tubing off of the floor. I would rather not put that in my nose after its been touching the floor.
On 8/16/23 at 2:30 PM V2 Assistant Director of Nurses (ADON) stated all oxygen tubing should be dated and placed in a plastic bag when not in use. V2 stated, Oxygen tubing should be changed every Sunday night on night shift. (R243's) Bi-PAP nasal mask should not have ever touched the floor. That is a great big infection control problem. I wouldn't want to put that back on my face and neither should our residents.
The facility policy titled Oxygen Therapy with review date March 2019 states the following: Change oxygen tubing/mask/cannula/and /or tracheostomy mask on a weekly basis. Date tubing changes and document on treatment sheet.
Based on observation, interview and record review the facility failed to properly date and store oxygen tubing for three (R33, R34, R243) residents out of three residents reviewed for respiratory care in a sample list of 42 residents.
Findings include:
During the facility tour on 8/15/23 at 10:30 AM R34 was sitting on her bed with her nasal cannula in her nose and the oxygen concentrator was sitting next to her bed. R34's oxygen tubing was checked for dates and the date on the tubing was 7/23/23. In checking the humidifier on the concentrator for a date there was no date.
Continuing with facility tour R33's oxygen tubing, humidifier and CPAP (Continuous Positive Airway Pressure) tubing did not have any dates on 8/15/23 at 10:45 AM. R33 stated she only uses her oxygen tubing at night along with her CPAP.
Follow up checks on oxygen tubing, humidifier and CPAP tubing were done on 8/16/23 and 8/17/23 at 2:30 PM both days. There were no changes in the oxygen tubing, humidifier or CPAP tubing. R34's tubing still had the tag on the tubing dated 7/23/23 and no tags dating any tubing for R33.
V 2, LPN/RCC (Licensed Practical Nurse/Resident Care Coordinator) was asked on 8/16/23 at 2:50 PM the facility policy on changing and dating tubing for oxygen concentrator, CPAP machines and humidifiers. V2 stated the policy is for the tubing to be changed every Sunday night on Night shift by the staff.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
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 conduct a social service assessment upon admission an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct a social service assessment upon admission and conduct any therapeutic interventions for a resident with diagnosed and exhibited symptoms of depression. This failure affects one resident (R41) out of two reviewed for behavioral and emotional indicators on the sample list of 44.
Findings include:
On 8/15/23 at 9:54 am, R41 was in bed with the blanket pulled over his face, the lights were out in the room, and the blinds were pulled shut. R41 stated, I do have some depression. I do take an antidepressant. I don't know if there is a social service person I can talk to if I need to.
R41's Face Sheet documents R41 was admitted to the facility 5/11/23. R41's Physician Order Sheet documents R41 has medical diagnoses including Major Depressive Disorder and was prescribed Sertraline (antidepressant) 100 milligrams daily. R41's medical record did not include a social service initial evaluation or assessment, and there were no social service notes.
R41's Minimum Data Set assessment dated [DATE] was incomplete with section C for cognitive status assessment, section D for mood assessment, and section F for personal preferences assessment not completed.
On 8/16/23 at 3:06 PM, V5, Social Service Director, stated, I just started working here around a month ago in the middle of July, around the 17th or 18th, so I am not sure why there isn't any social service admission assessment or any notes for (R41). I can only pick up where my time here started and try to make sure everything stays up to date from there.
On 8/16/23 at 3:18 PM, V1, Administrator, stated, A social service assessment is supposed to be a part of the admission process, I do expect an initial assessment to be completed. V1, Administrator, and V4, Minimum Data Set Coordinator, both confirmed it has been typical behavior for R41 to remain in his room with the lights off, blinds pulled shut, and rarely come out of his room. V1 searched through 2 file cabinets and a cardboard box then stated, I can't find any paperwork for (R41) so I am just going to say it wasn't done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
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 transmit minimum data set assessments in the required timeframe wit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transmit minimum data set assessments in the required timeframe within 14 days after the assessment reference date. This failure affects six residents (R8, R15, R24, R30, R31, and R41) out of six reviewed for minimum data set transmission on the sample list of 44.
Findings include:
1. On 8/16/23 at 1:23 PM, V4, Minimum Data Set (MDS) Coordinator, reviewed the minimum data set information on the facility's computer screen and stated, For R8, he had an annual (MDS) dated [DATE] which was submitted (transmitted) 12/8/22, a quarterly dated 1/6/23 submitted 4/13/23, a quarterly dated 4/6/23 submitted 6/22/23, and his current quarterly is dated 7/5/23 has not been submitted yet.
2. V4, Minimum Data Set Coordinator reviewed the computer screen and stated, (R15) had a quarterly (MDS) dated [DATE] submitted 6/22/23, this one was submitted late. (R15) has a current quarterly dated 7/5/23 which has not yet been submitted, this one should have been submitted by 7/19/23.
3. V4, Minimum Data Set Coordinator, stated, (R41) was admitted [DATE], his admission MDS is dated 5/22/23, it was submitted incomplete on 6/23/23, it should have been submitted by 6/7/23.
On 6/17/23 at 9:02 AM, V4, Minimum Data Set Coordinator, provided and hand written sheet of paper with the MDS information from her computer screen. V4 stated, My computer is not connecting to my router so I had to write all of this on paper. This sheet of paper documented the following:
4. R24 had a quarterly MDS dated [DATE] submitted 12/8/22, a quarterly MDS dated [DATE] submitted 4/13/23, a comprehensive (annual) MDS dated [DATE] submitted 6/22/23, and a quarterly MDS dated [DATE] which had not yet been submitted.
5. R30 had a quarterly MDS dated [DATE] submitted 11/11/22, a quarterly MDS dated [DATE] submitted 4/13/23, a comprehensive (annual) MDS dated [DATE] submitted 6/22/23, and a quarterly MDS dated [DATE] which had not yet been submitted.
6. R31 had a quarterly MDS dated [DATE] submitted 11/11/22, a quarterly MDS dated [DATE] submitted 1/27/23, a quarterly MDS dated [DATE] submitted 4/13/23, a quarterly MDS dated [DATE] submitted 6/7/23, and a comprehensive MDS dated [DATE] which had not yet been submitted.
On 8/17/23 at 9:02 AM, V4, Minimum Data Set Coordinator, stated, We have had a lot of staff turnover with this position so our corporate MDS specialist has been coming to try to help get everything caught up so there have been a lot of MDS submitted incomplete and late.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0642
(Tag F0642)
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 certify the accuracy and completion of resident assessments by obta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to certify the accuracy and completion of resident assessments by obtaining required Assessor and Coordinator signatures. These failures affect four residents (R8, R15, R30, R41) of six reviewed for resident assessments in the sample list of 44.
Findings include:
1. On 8/18/2023 at 2:47PM, R30's 4/5/2023 and 7/6/2023 resident assessments do not document the required assessment Coordinator signatures verifying assessment completion.
On 8/17/2023 at 3:25PM, V1 (Administrator) reported R30's assessment was not completed due to staff turnover.
2. R8's Minimum Data Set (MDS) assessment dated [DATE] did not include the signatures of the staff members who participated in the completion of this assessment, nor did it include the signature of the Registered Nurse certifying the completion.
3. R15's MDS dated [DATE] did not include the signatures of the staff members who participated in the completion of this assessment, nor did it include the signature of the Registered Nurse certifying the completion.
4. R41's MDS dated [DATE] did not include the signatures of the staff members who participated in the completion of this assessment, nor did it include the signature of the Registered Nurse certifying the completion.
On 8/16/23 at 1:23 PM, V4, MDS Coordinator, stated, We have had a lot of staff turnover with this position and with social services. The social services person usually completes sections B through F, so there isn't anyone to complete those sections and sign that they participated. Our corporate MDS specialist has been coming to do the signing to certify the MDS because I am an Licensed Practical Nurse, not a Registered Nurse.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level required more than one deficient practice statement.
A. Based on observation, interview, and record revie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level required more than one deficient practice statement.
A. Based on observation, interview, and record review, the facility failed to maintain safe water temperatures to prevent the potential for scalding injuries on the facility's South Hall. This failure has the potential to affect 17 residents (R1, R4, R10, R11, R12, R13, R16, R22, R23, R24, R26, R31, R33, R34, R93, R243, and R244) residing on the South Hall from the sample list of 44.
B. Based on interview and record review the facility failed to ensure a severely cognitively impaired resident (R245) was monitored to prevent elopement from the building. This failure affects one resident out of one resident (R245) reviewed for elopement in a sample list of 44 residents.
C. Based on observation, interview, and record review, the facility failed to install and maintain a handrail in the North Hall with an adequate gap between the wall and the handrail to prevent a risk of an entrapment incident. This failure affects eight ambulatory residents (R5, R19, R25, R27, R28, R29, R144, and R145) residing on the North Hall from the sample list of 44.
Findings include:
A. The facility's Resident Council Meeting Minutes dated 3/14/23 document (R24) was burned by the water being too hot.
On 8/16/23 at 10:06 AM, the water temperature in the hand sink in the common resident shower room on the facility's South Hall measured 137.8 degrees Fahrenheit (F) with an Illinois Department of Public Health thermometer.
On 8/16/23 at 10:09 AM, V3, Maintenance Director, stated, I check the water temperatures weekly. I keep a log of when I check them.
On 8/16/23 at 10:10 AM, V3, using the facility's thermometer, measured the water temperature in the same hand sink in the common resident shower room on the South Hall at 138 degrees F. V3 stated, The range should be 100 to 110 F, this is way too hot.
On 8/16/23 at 10:14 AM, V3 measured the water temperature in the hand sink of resident room [ROOM NUMBER] on the facility's South Hall at 121 degrees F with the facility thermometer. V3 stated, There are 2 water systems in the building, one for the men's hall (North Hall) and one for the women's hall (South Hall). This room (room [ROOM NUMBER]) is far enough down the hall that it is probably taking a while to flush out the cold water and get the hot water down here, but 121 is still too hot.
On 8/16/23 at 10:30 AM, R24 stated, I got burned in the shower one time a couple months back. I didn't report it to anyone, I didn't need to go to the hospital, I didn't have any red marks or blisters, I just told the CNAs (Certified Nursing Assistants) I will adjust the temperature of my own shower from now on.
On 8/16/23 at 10:40 AM, V3, Maintenance Director, provided the Weekly Water Temperature Logs for the Month of August. The second week of August was not completed, and there were not yet any documented temperatures for the third week (current week).
On 8/16/23 at 11:15 AM, V1, Administrator, confirmed the second week of the water temperature log should have been completed because the second week would have been from 8/8/23 through 8/14/23.
The facility's Resident Room Roster documents R1, R4, R10, R11, R12, R13, R16, R22, R23, R24, R26, R31, R33, R34, R93, R243, and R244 reside on the facility's South Hall.
B. R245's Undated Face Sheet documents an admission date of 6/26/23.
R245's Cognitive assessment dated [DATE] documents R245 as severely cognitively impaired.
R245's Medical Record documents diagnoses of Lewy Body Dementia with Behavioral Disturbance, Cognitive Impairment and Self Care Deficit. This same medical record documents R245 as able to self-propel in wheelchair and as known for elopement attempts multiple times throughout stay at facility.
R245's Nurse Progress Note dated 7/9/23 at 3:00 PM documents, (R245) has been put on one on one with a male staff member.
R245's Nurse Progress Notes do not document R245 eloping from facility on 7/10/23.
On 8/20/23 at 1:15 PM V1 Administrator stated I found out when (R245) eloped. It was on 7/10/23 the day after he had attempted to put his hands down (R12's) pants. (R245) should never have gotten out of the building if he was really on continual monitoring. I don't know how (R245) eloped. (R245's) Nurse (V11) LPN and CNA (V20) were on lunch and the other CNA on the hall (V22) was in another male resident's room while (R245) rolled himself out of the building. (R245) ended up across the street and had fallen out of his wheelchair in the grass on the other side of the road. That is a busy road. I am surprised (R245) didn't get run over. Someone who was delivering supplies came in the facility and let us (staff) know that (R245) was out in the grass across the road. (R245) should have been placed on continual monitoring after the first incident on 7/9/23 when he attempted to place his hands down (R12's) pants. (R245) was unattended long enough on 7/10/22 to elope from the facility to get across the street. I know for sure that (R245) was never on 15-minute checks but we (facility) did place him on continual monitoring after the first incident on 7/9/23.
On 8/20/23 at 3:30 PM V34 Licensed Practical Nurse (LPN) stated That delivery driver came running and yelled that there was a male resident (R245) laying in the grass on the other side of the street. I immediately knew who (V35) Driver was talking about. (R245) tries to get out all of the time. I ran outside and sure enough, there (R245) was. (R245) was just lying on his left side in the grass across the street from the building. That is a pretty busy road too. I am surprised (R245) didn't get hit. I ran back in and got some help. We (V34, V22 CNA) got him up and back inside the building. (R245) was in that wheelchair with no brakes like the Olympic athletes use so I am surprised he didn't get thrown any farther. (R245) must have caught some speed going down that hill where the driveway is. It was a miracle (R245) wasn't injured really bad.
On 8/21/23 at 10:40 AM V35 Delivery Driver stated, I delivered groceries and kitchen products to this facility on 7/10/23. I normally come through the back door. That is where all the traffic comes and goes. I loaded up the dolly cart and walked into the back door. They (facility) had already given me the number code. I pushed in the number code and walked in. I delivered the groceries to the kitchen area and then left through the same door. I did not leave the door open other than to walk through. I did not prop the door or anything like that. Those doors need to be shut. There are people who live here who aren't supposed to be out on their own. I never leave the door open. So, I left the building through the back door and I made sure it was shut. No one was outside. There is a smoking area out there so sometimes you will see people but that day there was no one outside. I got back in my truck and was working on paper work for my next stop when I saw a male (R245) resident in a wheelchair pushing himself. (R245) pushed himself around the back of the semi-truck, around the passenger side and went down the hill of the drive, across the street and hit the curb which threw him out of the wheelchair. (R245) couldn't have stopped if he tried because he was going so fast down the hill. I jumped out and ran inside and told one of the nurses. I don't know which one but they (staff) ran out and helped him. I don't know (R245's) name but I can say he sure did go for a ride that day!
C. On 8/16/23 at 10:40 AM, the handrail on the North Hall between the resident common shower room and room [ROOM NUMBER] was obviously and visibly bowed inwards towards the wall. The gap at the center section of the handrail was ¾ inch from the wall while the remainder of the handrail had a 1 ½ inch gap from the wall. There was not enough space at the center section of the handrail to insert fingers up to the knuckles. Walking along the hall holding the handrail with the palm of the hand resulted in the hand getting stuck at the center section.
The North Hall Resident Roster provided by V11, Licensed Practical Nurse, documents R5, R19, R25, R27, R28, R29, R144, and R145 are ambulatory residents residing on the North Hall.
On 8/18/23 at 9:05 AM, V3, Maintenance Director, stated, I will have to get a spacer in there.
On 8/18/23 at 9:08 AM, V11, Licensed Practical Nurse, stated, A resident could get stuck in there, there's plenty of room on these other rails but not this one.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to complete Psychotropic Assessments and failed to obtain an end date for a Psychotropic medication. These failures affect four re...
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Based on observation, interview and record review the facility failed to complete Psychotropic Assessments and failed to obtain an end date for a Psychotropic medication. These failures affect four residents out of four residents (R4, R20, R24, R243) reviewed for unnecessary Psychotropic medications in a sample list of 42 residents.
Findings include:
1.) R4's Undated Medical Diagnosis list documents medical diagnoses of Depression, Psychosis and Generalized Anxiety Disorder.
R4's Physician Order Sheet (POS) dated August 2023 documents physician orders for Risperidone (antipsychotic) 3 milligrams (mg) twice daily starting 11/10/21, Buspirone Hydrochloride (HCL) (anxiolytic) 5 mg twice daily starting 11/12/21.
R4's medical record documents the last psychotropic assessment was completed 12/21/22. There is no other psychotropic assessment completed.
R4's Medication Administration Record (MAR) dated August 2023 documents R4 has been administered Risperdal 3 mg twice daily and Buspirone HCL twice daily from 8/1/23-8/18/23.
On 8/16/23 at 3:08 PM Observed V17 Registered Nurse administer Risperidone 3 mg, Divalproex 750 mg and Buspirone HCL 5 mg to R4.
2.) R20's Undated Medical Diagnosis list documents medical diagnosis of Anxiety.
R20's Physician Order Sheet (POS) dated August 2023 documents a physician order starting 6/1/23 for Lorazepam 0.5 milligrams (mg) every bedtime as needed (PRN) with no end date.
R20's medical record does not document a Psychotropic Assessment for the use of Lorazepam (anxiolytic). This same medical record does not include Physician documentation regarding R20's need for Lorazepam PRN with no end date.
R20's Narcotic Count Sheet dated 6/12/23 documents R20 was administered seven separate doses of Lorazepam 0.5 mg from 6/23/23-7/25/23.
3.) R24's medical record documents R24 as cognitively intact.
R24's Physician Order Sheet (POS) dated August 2023 documents a physician order starting 12/15/22 for Divalproex sprinkles (mood stabilizer) 250 milligrams (mg) three times per day, Quetiapine (antipsychotic) 25 mg daily every morning starting 4/10/21 and Quetiapine 50 mg daily every bedtime starting 4/4/23.
R24's Medication Administration Record (MAR) dated August 2023 documents R24's Divalproex 250 mg, Quetiapine 25 mg and Quetiapine 50 mg have been recorded as administered by physician order.
R24's medical record does not document psychotropic assessments for Divalproex 250 mg, Quetiapine 25 mg nor Quetiapine 50 mg.
On 8/16/23 at 3:15 PM Observed V17 Registered Nurse (RN) administer Divalproex 250 mg.
4.) R243's medical record documents R243 is cognitively intact.
R243's Physician Order Sheet (POS) dated August 2023 documents physician orders for Duloxetine Hydrochloride (HCL) Delayed Release (DR) 30 milligrams (mg) daily in the morning starting 5/26/23 and Duloxetine HCL DR 60 milligrams (mg) daily in the evening starting 5/26/23.
R243's Medication Administration Record (MAR) dated August 2023 documents Duloxetine HCL DR (antidepressant) 30 mg and Duloxetine HCL DR 60 mg have been recorded as administered from 8/1/23-8/18/23 per physician order.
R243's medical record does not document Psychotropic Assessments for the use of Duloxetine HCL DR 30 mg nor 60 mg.
On 8/17/23 at 3:00 PM V2 Assistant Director of Nursing (ADON) stated I have looked all over for the initial and quarterly Psychotropic assessments for (R4, R20, R24, R243) and cannot find them anywhere. (R20's) initial assessment probably didn't get done because our management staffing at that time was bare bones. (R4, R24 and R243) have all been here (facility) long enough they should have their' s completed. I found last years but nothing from 2023. The Psychotropic assessments help the facility to determine if there needs to be some type of change in a resident's psychotropic medication and are definitely helpful when doing the gradual dose reductions (GDR). I don't know where they went but I can say we (facility) can't provide them.
The facility policy titled 'Psychotropic Medication Policy' revised 11/28/2017 documents the facility will initiate a Pre-Psychotropic Medication Assessment prior to administration of a newly prescribed psychotropic medication. The facility will initiate a Psychotropic Medication Quarterly Evaluation within 14 days of admission for those residents currently receiving psychotropic medication. Psychotropic medications may be prescribed on an as needed (PRN) basis in certain situations. The attending Physician or prescribing practitioner must document the diagnosed specific condition and indication for the PRN medication in the medical record. The attending Physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration. Any resident receiving psychotropic medication will have the Psychotropic Medication Assessment done at a minimum of every quarter. Quarterly documentation will be done on a progress note of any resident that currently receives psychotropic medications. This is to include, but is not limited to, individual resident response and/or progress, psychotropic medication assessment, behaviors exhibited, problems or issues which the resident may be having, current medications recent medication changes, and tolerance of medication regimen.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to serve bread as planned on the menu. This failure affected four residents (R12, R14, R15, R17) of 42 reviewed for diets in the...
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Based on observation, interview, and record review, the facility failed to serve bread as planned on the menu. This failure affected four residents (R12, R14, R15, R17) of 42 reviewed for diets in the sample list of 42 residents.
Findings include:
On 8/15/2023 at 12:25PM, no puree bread/margarine was noted on the food service line during the lunch meal and no residents who receive pureed diets received a portion of pureed bread/margarine. V21 (Cook) was present and reported no pureed bread/margarine was prepared for the lunch meal on 8/15/2023.
The facility dietary menu for 8/15/2023 documents residents receiving pureed diets should be served a #20 scoop of pureed bread/margarine during the lunch meal service.
The facility Diet Listing (7/28/2023) documents R12, R14, R15, and R17 all received puree diets.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 prevent cross contamination during medication administr...
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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 medication administration for three (R2, R4, R24) out of six residents reviewed for medication administration in a sample list of 42 residents.
Findings include:
1.) R2's Physician Order Sheet (POS) dated August 2023 documents a physician order for Lactulose 10 grams (gm)/15 milliliter (ml). Give 30 ml daily. This same POS documents a physician order for Divalproex sprinkles 500 mg daily.
On 8/16/23 at 3:25 PM Observed V15 Licensed Practical Nurse (LPN) open a new bottle of R2's Lactulose using bare thumbnail to break foil seal. V15 LPN did not use hand hygiene nor wear gloves prior to opening new Lactulose bottle.
On 8/16/23 at 3:26 PM Observed V15 Licensed Practical Nurse (LPN) use V15's bare hands to open R2's Divalproex capsules emptying the sprinkles into a medicine cup. V15 LPN did not use hand hygiene nor wear gloves prior to opening R2's Divalproex capsules.
On 8/16/23 at 3:30 PM V15 Licensed Practical Nurse (LPN) stated, I should have worn gloves right? I am bad at that. I used the hand sanitizer before I started my medication pass but I have touched a lot of things since then.
2.) R24's Physician Order Sheet (POS) dated August 2023 documents a physician order starting 12/15/22 for Divalproex sprinkles 250 milligrams (mg) three times per day.
On 8/16/23 at 3:15 PM Observed V17 Registered Nurse (RN) open and administer R24's Divalproex capsule with bare hands emptying into medicine cup. V17 RN did not use hand hygiene nor wear gloves prior to opening R24's Divalproex sprinkles.
On 8/16/23 at 3:17 PM Observed V17 Registered Nurse (RN) apply gloves to pick up R24's medicine cup with prepared medication. Observed V17 RN hand the medicine cup to R24 at R24's dining table with multiple pieces of small food debris on top of table. Observed V17 RN place Right gloved hand directly on contaminated table touching food debris, then used same contaminated gloves to break R24's medicine pill in half. V17 RN did not change gloves nor use hand hygiene before contaminating R24's medication. R24 then swallowed pills administered by V17 RN.
3.) R4's Physician Order Sheet (POS) dated August 2023 documents physician orders for Divalproex sprinkles 750 milligrams (mg) daily.
On 8/16/23 at 3:08 PM Observed V17 Registered Nurse (RN) open and administer R4's Divalproex capsule with bare hands emptying into medicine cup. V17 RN did not use hand hygiene nor wear gloves prior to opening R4's Divalproex sprinkles.
On 8/16/23 at 3:20 PM V17 RN stated, I shouldn't have opened (R4, R24) Divalproex with my bare fingers. I know better. You should always wear gloves for that. [NAME], when I did wear gloves, I messed that up too. I should not even touch the table. That is cross contamination 101.
08/17/23 10:23 AM On 8/17/23 at 10:00 AM V16 pharmacist stated licensed nurses should use gloves when handling all medications for infection control purposes.
On 8/19/23 at 10:00 AM V2 Assistant Director of Nursing (ADON)/Infection Preventionist (IP) stated Nurses should always use hand hygiene between each resident. Any time you touch a medication the nurse should always wear gloves. The medication could absorb into your skin and it is also a cross contamination issue that could introduce bacteria to the resident. I will be doing a lot of education to all of our nurses for this issue.
The facility policy titled Medication Administration revised 11/18/2017 documents appropriate hand washing is to be completed and/or alcohol-based gel rub must be used, throughout the medication pass. This should occur before and after medication pass, after touching any inanimate object possibly contaminated with microorganisms. Hand washing between every resident is not required according to Centers for Disease Control (CDC) guidelines. It is acceptable to use an antiseptic gel type solution between residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain a handrail in the facility's North Hall in a manner securely attached to the wall. This failure had the potential to...
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Based on observation, interview, and record review, the facility failed to maintain a handrail in the facility's North Hall in a manner securely attached to the wall. This failure had the potential to affect eight ambulatory residents (R5, R19, R25, R27, R28, R29, R144, and R145) residing on the North Hall from the sample list of 44.
Findings include:
On 8/15/23 at 10:10 AM, the section of handrail between on the facility's North Hall was loose and easily moveable more than 1 inch up and down. There was a hole 2 inches in diameter in the drywall behind the section of handrail where the securing bolt penetrated the wall.
On 8/17/23 at 12:40 PM, V20, Certified Nursing Assistant noted the loose handrail and stated, Did you see that, I don't think it's supposed to do that.
On 8/17/23 at 12:50 PM, V3, Maintenance Director, stated, It looks like the bolt is loose behind the wall. I can see if I can tighten it up.
The North Hall Resident Roster provided by V11, Licensed Practical Nurse, documents R5, R19, R25, R27, R28, R29, R144, and R145 are ambulatory residents residing on the North Hall.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to follow residents' rights by not allowing residents to receive their mail which is to be delivered unopened on Saturdays. This failure affect...
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Based on record review and interview the facility failed to follow residents' rights by not allowing residents to receive their mail which is to be delivered unopened on Saturdays. This failure affects all 42 residents which reside in the facility.
Findings include:
Resident Council meeting held on 8/16/23 at 10:00 AM consisted of R144, R23, R24 and R29 (Resident Council President). All four residents stated individually, No we do not receive our mail on Saturdays. R24 stated she received mail opened at one time and stated this upset her immensely and R24 told them not to every open her mail again.
V18, Transport/Medical Records person stated at 12:40 pm on 8/17/23, When the Business Office Manager was here, she delivered the mail to the residents. I went yesterday (8/16/23) to the mail box and retrieved Saturday thru Wednesday mail and gave it to (V1 Administrator). I don't know who will be getting the mail and passing it out to the residents.
V1, Administrator confirmed on 8/18/23 at 12:35 PM, The residents will be receiving their mail on Saturday. The charge nurse will get the mail for the residents.
The Resident Rights revision date of 11/18 handout, which residents receive upon admission, documents on page 5 of the handout Your facility must deliver and send your mail promptly. Your facility may not open your mail without your permission.
The Resident Census and Conditions of Residents Report dated 8/15/23 documents the census in the facility is 42.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to employ a Full Time Director of Nurses. This failure has the potential to affect all 42 residents residing in facility.
Findings...
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Based on observation, interview and record review the facility failed to employ a Full Time Director of Nurses. This failure has the potential to affect all 42 residents residing in facility.
Findings include:
The facility daily census report dated 8/15/23 documents 42 residents residing in facility.
On 8/15/23-8/22/23 Director of Nurses (DON) was not observed on site at various times during first and second shifts.
On 8/15/23 at 10:00 AM V1 Administrator stated the facility has not had a full time Director of Nurses since January 2023. V1 stated (V2) Assistant Director of Nurses (ADON)/Licensed Practical Nurse (LPN) has been the go-to person for all the DON questions and programs. V1 Administrator stated, We (facility) have had a couple of leads but DON's are very hard to find.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0912
(Tag F0912)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide at least 80 square feet of floor space per 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 provide at least 80 square feet of floor space per resident bed in 28 of 30 resident rooms on 2 of 2 resident living corridors. 25 of these rooms were occupied by residents. This failure affects all 42 residents residing in the facility.
Findings include:
Historical room size documentation and actual measurements demonstrate that the double occupancy resident bedrooms do not meet the minimum required square footage of 80 square feet per resident bed (160 total square feet). room [ROOM NUMBER] measured 77.9 square feet per bed. room [ROOM NUMBER] measured 76.5 square feet per bed. Rooms 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 (current Nursing Director Office), 16 (current therapy room), 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 28 measured 74.3 square feet per bed. room [ROOM NUMBER] measured 68.5 square feet per bed. room [ROOM NUMBER] (current Minimum Data Set office) measured 77.5 square feet per bed. room [ROOM NUMBER] (current administrative office), and room [ROOM NUMBER] (current resident care coordinator office), are single occupancy rooms.
The Medicare/Medicaid Certification and Transmittal effective 7/27/22, from the most recent prior survey, documents all 58 resident beds are certified for Title 19 (Medicaid).
The facility's Resident Census and Conditions of Residents dated 8/15/23 documents 42 residents reside in the facility, all of whom reside in one of the double occupancy rooms.
On 8/15/23 at 10:20 AM, R34 stated, This room is too small with 2 people, wheelchairs, and my oxygen concentrator. R34's roommate, R31, stated, I agree.
On 8/15/23 at 10:40 AM, R23 stated, This room is too small for 2 people, beds, and wheelchairs.
On 8/15/23 at 10:45 AM, R33 stated, This room is too small with 2 people, 2 beds, 2 dressers, 2 wheelchairs, and my oxygen machine we barely have room to move around.
On 8/15/23 at 3:35 PM, R37 stated, The rooms are too small, me and my roommate we have 2 wheelchairs, 2 tables, 2 dressers, a walker, and the room is too small.
On 8/15/23 at 2:10 PM, V1, Administrator, and V8, Corporate Consultant, confirmed all the room numbers and locations. V8 confirmed all the double occupancy rooms were smaller than the requirements. V1 and V8 confirmed all the rooms are included in the facility's certified bed capacity.
On 8/15/23 at 3:40 PM, R9, using hand gestures and head movements, began pointing at his roommate's bed, then his own bed, then the room doorway when asked what he thought about the room size. R9 then held up 2 fingers and shook his head no. When asked if the room was a good size for 2 people, R9 shook his head no again. R9 then held up 1 finger and nodded his head yes and smiled when asked if it would be ok for 1 person.
On 8/15/23 at 3:45 PM, R30 stated, I think the room is not big enough, I am not comfortable with it, it's a problem.
On 8/16/23 at 9:40 am, R41 stated, The room is kind of tight with myself and a roommate.
On 8/16/23 at 12:50 PM, R8 stated, The room could be a little bit bigger. When I have a roommate, it seems smaller and there isn't enough room.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0801
(Tag F0801)
Minor procedural issue · 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 42 reside...
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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 42 residents residing in the facility.
Findings include:
On 8/15/2023 at 9:20AM, V19 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V19 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 Facility Assessment (8/4/2023) documents a full-time clinically qualified nutrition professional is needed to provide competent support and care for the facility's resident population every day and during emergencies.
The Resident Census and Conditions of Residents report (8/15/2023) documents 42 residents reside in the facility.
Jul 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide cares with respect and dignity for one (R3) of six residents reviewed for abuse on the sample list of ten.
Findings include:
The f...
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Based on interview and record review the facility failed to provide cares with respect and dignity for one (R3) of six residents reviewed for abuse on the sample list of ten.
Findings include:
The facility's final report dated 7/26/23 documents on 7/22/23 at approximately 2:17 PM, it was reported by nurse (V9, Registered Nurse) that V9 heard loud tones and yelling. V9 went to R3's doorway and V9 reported V6 Certified Nurse's Assistant and R3 were talking in loud tones while V6 was providing cares to R3. This report documents R3 is alert and oriented to person, place, and time.
On 7/31/23 at 1:47 PM, V9 stated on 7/22/23, she just got to work and heard yelling. V9 stated she was walking down the hall and V6 was yelling at R3. V9 stated she couldn't remember what V6 was yelling. V9 stated V6 then began to yell at V9 and asked if V9 was going to help V6 with R3. V9 stated she asked V6 why she was yelling and V6 yelled, I got a loud voice.
On 7/27/23 at 1:42 PM, V6 stated on 7/22/23 she was helping R3 with incontinence cares and laying R3 down. V6 stated R3 was yelling and hollering. V6 stated she was struggling to get R3's chair up. V6 stated when R3 yells she must elevate her voice.
On 7/26/23 at 3:00 PM, R3 stated V6 yells all the time. R3 stated V6 yells to get R3 up and yells on purpose. R3 stated V6 is loud.
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 resident's right to be free of sexual abuse by...
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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 resident's right to be free of sexual abuse by another resident. This failure affects two (R1, R2) of six residents reviewed for abuse on the sample list of ten.
Findings include:
R1's hospital records dated 6/22/23 documents R1's mood/behavior as sexually inappropriate. These records document R1 can move around in his wheelchair. These records document R1 is having periods of hypersexuality.
R2's Quarterly Minimum Data Set assessment dated [DATE] documents R1 has severe cognitive impairment, is rarely to never understood, and requires limited to extensive assistance with bed mobility, transfers, ambulation, and dressing.
R2's Nurse's note dated 7/9/23 at 1:00 PM documents, (R2) was sitting in TV area and (V17, Certified Nurse's Assistant) caught (R1) groping (R2).
The facility's final report to the state agency dated 7/14/23 documents on 7/9/23, V17 witnessed R1 attempting to put R1's hands down R2's pants. This report documents R2 as not being interviewable.
On 7/27/23 at 9:08 AM, V17 stated on 7/9/23, R2 was sitting in a blue chair in the television room facing the dining room. V17 stated R1 was wandering around in the dining room in his wheelchair. V17 stated when V17 came out of the bathroom, V17 was walking through the dining room and she saw R1's right hand on R2's pants over the stomach area and R1 was attempting to put his hand down R2's pants. V17 stated R2 would not be able to stop R1 from doing this. V17 stated earlier that day R1 was seen rubbing R2's back. V17 demonstrated how R1 and R2 were sitting. V17 demonstrated R1's right hand was moving over R2's stomach area and R1's hand was attempting to reach into R2's pants.
On 7/27/23 at 1:00 PM, R2 was sitting in a blue chair in the dining room. R2's stomach area was visible when walking through the dining room. R1 was also in the dining room propelling self in R1's wheelchair.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to develop a plan of care or behavioral interventions for one (R3) of six residents reviewed for abuse on the sample list of ten.
Findings inc...
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Based on interview and record review the facility failed to develop a plan of care or behavioral interventions for one (R3) of six residents reviewed for abuse on the sample list of ten.
Findings include:
R1's hospital records dated 6/22/23 document R1's mood/behavior as sexually inappropriate. These records document R1 can move around in his wheelchair. These records document that R1 is having periods of hypersexuality.
R1's admission noted dated 6/26/23 at 9:40 AM documents R1 was admitted to the facility by ambulance. R1's family is no longer able to care for himself and he can be sexually inappropriate with female staff.
R1's nurse's note dated 7/9/23 at 1:30 PM documents, It was brought to nurse's attention that (R1) was attempting to grope a female resident (R2) with Dementia (while R2) was sitting in chair. CNA (V17, Certified Nurse's Assistant) caught (R1) in act and removed him from the area. (R1) was upset that (V17) removed him away from (R2). This note also documents, (R1) is very sexual with staff, groping women staff and being verbally sexually inappropriate.
R1's nurse's note dated 7/24/23 at 12:45 PM documents, R1 was in the dining room with his private parts out screaming that he's going to pee on the floor. This note documents R1 was holding his private parts and started urinating yelling, I gave you what you asked for.
On 7/26/23 at 9:46 AM, V11 Licensed Practical Nurse stated when R1 was admitted V11 asked why R1 wasn't at home. V11 stated she was told R1's wife didn't want R1 at home because R1 was always touching them when they gave R1 showers. V11 stated R1 is now a one on one for touching R2. No behavioral interventions were put into place until after R1 touched R2.
On 7/26/23 at 11:29 AM, V14 Certified Nurse's Assistant stated last week, R1 was in the dining room sitting in his wheelchair and he flipped out his penis, stroked it several times and then he began urinating everywhere. V14 stated it happened during lunch. V14 stated V14 rushed over to stop him and clean him up. V14 stated V14 heard R1 did the same thing another day. V14 stated staff can't give him a shower because he has erections and gets an erection every time, we clean him up. V14 stated R1 touched R2 in the dining room. V14 stated no interventions were put into place until he was a one on one after he touched R2 in the dining room.
On 7/26/23 at 11:44 AM, V15 Care Plan Coordinator stated she witnessed R1 pull his penis out in the dining room on Monday night and was urinating while moving his penis left and right. V15 stated R1 was urinating all over the dining room yelling, that is what you get.
R1's interim care plan dated 7/1/23 does not document a plan of care for sexually inappropriate behaviors. This care plan documents an intervention dated 7/9/23 which states R1 is a one on one care checks due to sexual abuse towards another resident. This care plan does not document any resident specific behaviors or interventions for R1's behaviors.
R1's Behavior Tracking Records have a start date of 7/11/23 and documents R1 has behaviors of making sexually inappropriate comments and R1 being sexually inappropriate to staff and residents. These records do not document tracking or interventions for the behavior of exposing self and urinating in the dining room.
On 7/26/23 at 12:06 PM, V2 Resident Care Coordinator stated R1 came about a month ago and R1 had a history of hypersexuality. V2 stated R1 touched R2 and was trying to put his hand down R2's pants. V2 stated R1 is sexually inappropriate to staff and they try to keep him away from the female residents. V2 stated she heard R1 exposed himself in the dining room and urinated everywhere. V2 stated R1's behavioral care plan and interventions were not put into place until after R1 touched R2. V2 stated behavioral tracking sheets were not put into place until 7/11/23.
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
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a CPAP (Continuous Positive Airway Pressure) machine was operating during an electrical outage for one (R10) of three r...
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Based on observation, interview, and record review the facility failed to ensure a CPAP (Continuous Positive Airway Pressure) machine was operating during an electrical outage for one (R10) of three residents reviewed for equipment on the sample list of ten.
Findings include:
R10's Care plan dated 9/6/22 documents R10 requires the use of a CPAP due to Obstructive Sleep Apnea. This care plan documents an intervention to ensure proper functioning of the device.
On 7/31/23 at 12:33 PM, R10 was lying in bed. A CPAP machine was lying next to the bed. R10 stated she must have it on due to sleep apnea.
On 7/26/23 at 9:35 AM, V7 Maintenance Director stated they had an electrical storm on 6/29/23 and the lights went out for a total of 24 hours in a 30-hour period. V7 stated the power went out at 3:30 PM and did not come back on until 8:00 PM on 6/30/23. V7 stated they did not have a generator until noon on 6/20/23. V7 stated none of the outlets in the resident's rooms were working.
On 7/27/23 at 12:39 PM, V2 Resident Care Coordinator stated R10 would not have had her CPAP on during the electrical outage on 6/29/23 due to no power in the building.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to employ a registered nurse for eight consecutive hours per day and failed to employ a full-time Director of Nursing. This failu...
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Based on observation, interview, and record review the facility failed to employ a registered nurse for eight consecutive hours per day and failed to employ a full-time Director of Nursing. This failure has the potential to affect all 47 residents residing in the facility.
Findings include:
On 7/26/23, 7/27/23, and 7/31/23 between the hours of 7:30 AM to 3:00 PM, a Director of Nursing was not working in the facility.
On 7/26/23 at 10:41 AM, V1 Administrator provided a nurse's schedule for July of 2023. This schedule did not document that a Registered Nurse was scheduled for 7/6/23, 7/18/23, 7/19/23, or 7/20/23. V1 stated there was not a Registered Nurses working in the facility on those days. V1 stated the facility does not currently have a Director of Nursing. V1 stated there has not been a Director of Nursing since January of 2023.
The facility's Facility Assessment with a review date of 5/9/23 documents a Director of Nursing is required under Part 3: Facility Resources needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies.
The facility's Daily Roster dated 7/31/23 provided by V1 Administrator documents there are 47 residents residing in the facility.
May 2023
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to provide the services of a Registered Nurse for eight consecutive hours a day and failed to designate a Registered Nurse to serve as the Dire...
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Based on interview and record review the facility failed to provide the services of a Registered Nurse for eight consecutive hours a day and failed to designate a Registered Nurse to serve as the Director of Nursing. This failure has the potential to affect all 42 residents residing in the facility.
Findings include:
The facility's Nursing Master Schedule by shift indicates there were no Registered Nurses working in the facility at any time on the following dates: 5/2/23, 5/4/23, 5/6/23, 5/7/23, 5/8/23, 5/11/23, 5/15/23, 5/18/23, 5/20/23 and 5/21/23.
On 5/25/23 at 9:45 AM V1 Administrator stated we do not currently have a Director of Nursing. V2 (Corporate Nurse) is here about 2 days a week. We have no other RN's except V7, V8 and V9. A DON/RN wound not have been covering on the days that V7, V8 and V9 were off duty.
Facility Assessment, with a review update of 3/13/23, documents, Facility resources needed to provide competent support and care for our resident population every day and during emergencies: Staff type- Administration, Nursing Services (DON, RN, LPN, Care Plan Coordinator, Infection Preventionist, Certified Nursing Assistants), Environmental Services, Food and Nutrition, Social Services, Activities, Housekeeping, Transportation, Therapy, Medical/Physician Services. Staffing plan: based on our resident population and their needs for care and support we analyze staffing numbers to ensure that you have sufficient staff to meet the needs of the residents at any given time.
Facility Daily Roster provided by the facility on 5/25/23 documents 42 total residents currently reside at the facility.
Apr 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 supply incontinence products to five residents (R1, R2, R3, R4, R5)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supply incontinence products to five residents (R1, R2, R3, R4, R5) of eight residents reviewed for incontinence care in the sample list of eight.
Findings include:
R1's Physician Order Sheet (POS) dated 4/1/23 - 4/30/23, documents R1's diagnoses as Dementia with Psychotic Features and Degenerative Disc Disease. R1's Minimum Data Set (MDS) dated [DATE], documents R1 is frequently incontinent of urine. R1's Bowel and Bladder assessment dated [DATE], documents R1 is usually incontinent both day and night. R1's Care Plan dated 3/15/23, documents R1 is at risk for pressure ulcers due to incontinence.
On 4/4/23 at 2:05 PM, R1 stated she is incontinent. R1 stated R1 ran out of pull ups and R1's family has brought more incontinent briefs in for R1 at least two times. R1 stated when the facility runs out of incontinent briefs, they go to the store and get more but we must wait. R1 stated R1 has not waited 3 days to be changed but had to wait until her family brought more incontinent briefs.
R2's POS dated 4/1/23 - 4/30/23, documents R2's diagnoses as Severe Obesity, Hemiparesis Affecting Right Side, and Cerebral Infarction Unspecified. R2's MDS dated [DATE], documents R2 is always incontinent of urine and frequently incontinent of bowel and requires total dependence of two or more physical assist for toilet use. R2's Bowel and Bladder assessment dated [DATE], documents R2 is frequently incontinent both day and night with a history of Urinary Tract Infections. R2's Care Plan dated 1/25/23, documents R2 has an alteration in bladder elimination related to incontinence.
On 4/4/23 at 2:10 PM, R2 stated the facility always runs out of incontinent briefs and then must go to the store to get more. R2 stated R2 had to have R2's family bring some incontinent briefs to R2. R2 stated R2 has not waited 3 days to get changed but waited on R2's family to get her more incontinent briefs.
R3's POS dated 4/1/23 - 4/30/23, documents R1's diagnosis as History of Urinary Tract Infections and has an order for Oxybutynin 5 milligram tablet, take one tablet by mouth two times a day. R3's Care Plan dated 12/5/22, documents R3 has an alteration in bladder elimination related to incontinence and a moderate risk for pressure ulcer related to incontinence.
On 4/4/23 at 1:40 PM, R3 stated the facility runs out of incontinent briefs a lot. R3 stated staff must go to the store and buy more. R3 stated her family must buy R3's incontinent briefs so R3 won't run out of incontinent briefs and the facility never has any here. R3 stated R3 has not waited 3 days to be changed but that's why R3 had R3's family bring some incontinent briefs so R3 wouldn't run out.
On 4/4/23 at 1:16 PM, V1 Administrator stated the had facility had a mixture of small, medium, large, x-large and bariatric incontinent briefs and kept running out of the bigger sizes. V1 stated the facility was running out of the larger sizes and had to borrow from a sister facility. V1 stated R1 did complain about not having incontinent briefs about 3 to 4 weeks ago. V1 stated the first time R1 ran out of incontinent briefs, R1's family went to buy more incontinent briefs for R1.
On 4/4/23 at 1:33 PM, R4 stated the facility runs out of incontinent briefs on weekends especially so R4's family has been buying R4 her own incontinent briefs 2 to 3 times on and off for the past few months.
On 4/4/23 at 1:36 PM, R5 stated R5 went to get more incontinent briefs one evening and the facility was out of incontinent briefs. R5 stated it has been going on for the last 2 to 3 months that the facility has no incontinent briefs.
On 4/4/23 at 2:15 PM, V3 Licensed Practical Nurse (LPN) stated, yes, they run out of incontinent briefs a lot.
On 4/5/23 at 1:13 PM, V6 Certified Nursing Assistant (CNA) stated the facility has run out of incontinent briefs a lot.
On 4/5/23 at 1:17 PM, V7 CNA stated the facility does run out of incontinent briefs especially when it comes time to re-order more.
On 4/5/23 at 1:25 PM, V8 CNA stated the facility does run out of incontinent briefs and it has been an ongoing problem. V8 stated we must change the residents when they are wet, so we need incontinent briefs in stock.
On 4/5/23 at 1:29 PM, V9 CNA stated they do run out of incontinent briefs.
On 4/5/23 at 3:27 PM, V10 LPN stated the facility has run out of incontinent briefs and it's been going on for a while. V10 stated the CNA's are the ones who complain to V10 about not having incontinent briefs.
Mar 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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to complete weekly wound assessments for residents with pressure ulcers for two of three residents (R11 and R12) reviewed for pres...
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Based on observation, interview and record review the facility failed to complete weekly wound assessments for residents with pressure ulcers for two of three residents (R11 and R12) reviewed for pressure ulcers on the total sample list of 12.
Findings include:
The facility's policy, with a revision date of January 2018, titled Decubitus Care/Pressure Areas documents, Policy: It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Procedure: 3) Complete all areas of the Treatment Administration Record or Wound Documentation Record. i) Document size, stage, site, depth, drainage, color, odor and treatment. 5) Documentation of the pressure area must occur upon identification and at least once each week on the TAR or Wound Documentation Form. The assessment must include: i) Characteristic (i.e.: size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.) ii) Treatment and response to treatment. 6) Reevaluate the treatment for response at least every two to four weeks. Most pressure areas will respond to the treatment in this amount of time. If no improvement is seen in the time frame, contact the physician for a new treatment.
1. R11's medical record documents on 2/10/23, resident noted to have an open area at coccyx 1.0 centimeters by 0.5 centimeters, bilateral buttocks macerated with multiple small open areas. R11's Physician order sheet documents on 2/10/23, barrier cream to coccyx and bilateral buttocks every shift and as needed.
R11's medical record, including Treatment Administration Records dated February 2023 and March 2023, do not document any further wound assessments of R11's open wound to the coccyx from 2/10/23 through 3/8/23.
On 3/8/22 at 10:45 AM R11 had an open pressure wound to the coccyx area approximately 3 centimeters by 1 centimeter. The center of the wound bed had beefy red tissue, with macerated white tissue surround the open area. V6 Certified Nursing Assistant stated, R11 has had the area for about a month now, we put cream on it.
2. On 3/8/23 at 10:50 AM V6 Certified Nursing Assistant stated, I always work this hallway. V6 CNA assisted R12 with rolling over onto R12's right hip, R12 had a hydrocolloid dressing covering the upper left buttock area. V6 lifted the hydrocolloid dressing up, R12 had an open area to the left upper buttocks that was approximately 1.5 centimeters by 0.5 centimeters, the wound bed was beefy red in appearance with macerated white tissue surrounding the wound. V6 CNA stated, (R12) had one on the right buttock in the past but it healed a long time ago, this one on the left buttock has been there for probably a month or more, they have been putting a patch on it.
R12's medical record documents on 1/9/23, noted dark non blanchable area to left buttock, area cleansed and (treatment applied), measures 3.0 cm by 1.7 cm without depth or drainage.
R12's Physician Order Sheet documents an order on 1/9/23 Exuderm (Hydrocolloid dressing) to right buttock change every 3 days.
After several requests, the facility was not able to locate R12's Treatment Administration Records for January 2023.
R12's Treatment Administration Records dated February 2023 document on the back of the TAR, (undated) stage 2 pressure ulcer on coccyx and left buttock, Exuderm applied. There were no measurements or wound characteristics documented. On 2/16/23 and 2/23/23, these same TAR's document right buttock pressure area improving, scrotum and coccyx area improving, pink in color. There was no measurements or wound characteristics for R12's pressure wound to the left buttock area.
On 3/8/23 at 1:35 PM V11 Care Plan Coordinator stated, I think (R12) just developed the area to the left buttock and the right buttock has healed. Upon the review of R12's medical record and the documentation on 1/9/23 in R12's medical records, V11 stated, maybe they did write the wrong buttock (on the nurses notes or with the physicians order), I am not sure. V11 confirmed there is no weekly wound measurements or wound descriptions of the wound documented, V11 stated the nurses are supposed to be doing daily skin checks and measuring wounds weekly and documenting it on the back of the TAR.
On 3/8/23 at 10:30 AM V11 Care Plan Coordinator stated, I am currently doing infection prevention, I am trying to keep up with the Director of Nursing duties as well, but I just returned yesterday after being off with COVID and things are a mess. The nurses are to be doing the weekly wound monitoring and documenting it on the backs of the Treatment Administration Records.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to provide the services of a Registered Nurse for eight consecutive hours a day and failed to designate a Registered Nurse to serve as the Dire...
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Based on interview and record review the facility failed to provide the services of a Registered Nurse for eight consecutive hours a day and failed to designate a Registered Nurse to serve as the Director of Nursing. This failure had the potential to affect all 40 residents residing in the facility.
Findings include:
The facility's Nursing Master Schedule by shift indicates there were no Registered Nurses working in the facility at any time on the following dates: 2/23/23, 2/24/23, 2/25/23, 2/26/23, 2/27/23, 2/28/23, 3/1/23 and 3/2/23.
On 3/8/23 at 11:10 AM V1 Administrator in Training stated, I only had one registered nurse V14. V14 was off with COVID the end of February (2023) into March (2023). V1 confirmed there was no Registered Nursing working in the facility for eight consecutive hours on 2/23/23, 2/24/23, 2/25/23, 2/26/23, 2/27/23, 2/28/23, 3/1/23 and 3/2/23.
On 3/7/23 at 11:00 AM V1 stated, We currently do not have a Director of Nursing. (V10) former Resident Care Coordinator's (Director of Nursing) last day was on 2/15/23.
The facility's Employee termination sheet documents V10 (former Resident Care Coordinator) last day worked was 2/15/23.
Facility Assessment, updated 9/1/22, documents, Facility resources needed to provide competent support and care for our resident population every day and during emergencies: Staff type- Administration, Nursing Services (DON, RN, LPN, Care Plan Coordinator, Infection Preventionist, CNA's), Environmental Services, Food and Nutrition, Social Services, Activities, Housekeeping, Transportation, Therapy, Medical/Physician Services. Staffing plan: based on our resident population and their needs for care and support we analyze staffing numbers to ensure that you have sufficient staff to meet the needs of the residents at any given time. The table below shows standard staffing patterns for our current census. Licensed Nurses providing direct care: first shift: one, second shift: one, third shift: one. Other nursing personnel: Director of Nursing (full time), MDS/CPC (full time).
The facility's Resident Census and Condition Report, dated 3/8/23 documents total residents: 40.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, interview and record review the facility failed to post accurate Nurse Staffing information. This failure has the potential to affect all residents 40 residents in the facility. ...
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Based on observation, interview and record review the facility failed to post accurate Nurse Staffing information. This failure has the potential to affect all residents 40 residents in the facility.
Findings include:
On 3/8/23 at 9:00 AM The facility's Daily Nursing Staff forms hanging at the front entrance on the wall, above a table did not document accurate or completed staffing ratios on 2/7/23, 2/12/23, 2/13/23, 2/15/23, 2/16/23, 2/17/23, 2/18/23, 2/19/23, 2/20/23, 2/21/23, 2/24/23, 2/25/23, 2/26/23, 2/27/23, 2/28/23, 3/1/23, 3/2/23, 3/3/23, 3/4/23, 3/5/23 and 3/6/23.
On 3/8/23 at 11:10 AM V1 Administrator in Training stated, The Daily Nursing Staff posting forms are not accurate, V10 (former Resident Care Coordinator/Director of Nursing) was doing them, until she left. V1 confirmed the information posted on 2/7/23, 2/12/23, 2/13/23, 2/15/23, 2/16/23, 2/17/23, 2/18/23, 2/19/23, 2/20/23, 2/21/23, 2/24/23, 2/25/23, 2/26/23, 2/27/23, 2/28/23, 3/1/23, 3/2/23, 3/3/23, 3/4/23, 3/5/23 and 3/6/23 was not accurate and or completed.
The facility's Resident Census and Condition report dated 3/8/23 documents Total Residents: 40.
Feb 2023
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to employ the services of a Registered Nurse (RN) eight consecutive hours every day. This failure has the potential to affect all 40 residents...
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Based on interview and record review, the facility failed to employ the services of a Registered Nurse (RN) eight consecutive hours every day. This failure has the potential to affect all 40 residents residing in the facility.
Findings include:
On 2/21/23 at 10:47 AM, V1 Administrator, presented the Nursing Master Schedule by Shift. This schedule indicates there were no Registered Nurses (RN) working in the facility at any time on the following days: February 3, 6, 11, 12, 17, 20, 2023. At this same time, V1 stated we are looking for RN's and verified there was no RN working on the dates previously mentioned.
The facility's Midnight Census Report presented on 2/21/23, documents 40 residents residing in the facility.
Jul 2022
28 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/25/22 at 12:10 PM, multiple scarred areas were present on R9's buttocks. R9 stated she used to have sores on her bottom....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/25/22 at 12:10 PM, multiple scarred areas were present on R9's buttocks. R9 stated she used to have sores on her bottom. R9 stated that her bed deflates frequently and she has told the staff about it and that they taped the hose. R9 stated that the bed was semi-deflated now. The mattress was about halfway deflated when touched. Duct tape was taped around the middle of the air mattress hose and at the connection to the air mattress pump.
On 7/25/22 at 11:26 AM, V14 Hospice Nurse stated that R9 has the air mattress to prevent pressure ulcers. V14 stated the air mattress hose should not be taped. V14 stated the facility should have called and notified her that the air mattress was not working so that it could be replaced.
R9's Baseline care plan dated 5/16/22 documents R9 is at high risk for pressure ulcers.
Based on record review, observation and interview the facility failed to perform timely incontinence care to prevent shearing over R28's bilateral ischium (pressure ulcers), continued to implement nursing order while waiting for physician to be notified for a pressure ulcer treatment for two newly, facility acquired, Stage II pressure ulcers (shearing over bony prominence) 7/2/22-7/27/22 (25 days) and failed to measure the new, worsening pressure ulcers in accordance with facility policy for R28. These failures affected R28 and resulted in avoidable Stage II pressure ulcers with deterioration of the pressure ulcer as evidence by an increase in size. The facility also failed to ensure pressure relief device was in working order for R9. R9 and R28 are two of three residents reviewed for pressure ulcers on the sample list of 21.
Findings include:
1. R28's Physician Order Sheet (POS) dated 7/1/22- 7/31/22 documents the following diagnoses: Dementia, CVA (Cerebrovascular Accident/ Stroke), Cellulitis, and HX (history) DVT (deep vein thrombosis/blood clot). The same POS does not have a treatment order documented until 7/27/22. (Pressure ulcer were identified 7/1/22 as documented below).
R28's Minimum Data Set (MDS) dated [DATE] (same day pressure ulcers discovered) documents the following: R28's Brief Interview of Mental status score was 10 out of a possible 15 indicating moderate cognitive impairment. The same MDS documents R28 had a history of pressure ulcers with no pressure ulcers at the time of the MDS assessment. The same MDS documents R28 is always incontinent of bladder and frequently incontinent of bowel and has had no behaviors of rejecting care. The same MDS documents R28 is dependent on total physical assistant of two staff for hygiene needs and requires extensive assistance of one staff with toileting and transfers.
R28s Care Plan dated 5/12/22 documents the following:
P (Problem) High Risk for Pressure Ulcers per (Formal) Risk Assessment. (Formal) Risk score of 13 on 5/12/22. Risk factors Include bladder incontinence, history of pressure ulcers to left fourth toe, healed January 2015. Resident Specific Information: Requires assistance with toileting, bathing, dressing, needing reminders and physical assistance.
G. (Goal) Will have no open areas caused by pressure or friction for the next review.
A (action to be implemented) Apply house stock (Brand name) to peri-area with every (sic)after incontinent episode and as needed. Toilet/change brief when wet and upon rising, hs (bedtime) and after meals.
The same Care Plan documents the following: P (Problem) Alteration in bladder elimination as related to incontinence.
G (Goal) Skin will remain intact thru (through) next review.
A (action to be implemented) Toilet and/or change padding and give proper hygiene before/after meals, upon rising, upon request, before retiring for the evening, after napping, and prn (as needed) for incontinence.
R28's (Formal) scale for predicting pressure ulcer risk date 7/1/22 (the same date as the MDS look back assessment) documents R28 is at high risk for level for developing pressure ulcers.
07/24/22 at 10:05 am R28 stated I (R28) have sores on my (R28's) bottom from not getting changed often enough. R28 also stated The night staff got me (R28) up (out of bed) and dressed between 5:00 am - 6:00 am. I (R28) have not been changed (provided incontinence care) since. R28 also stated R28 incontinence brief is very wet at this time and has soaked through R28's pants.
On 7/24/22 at 10:12 am V11, Certified Nursing Assistant (CNA) stated R28 was already up and dressed when V11, CNA came in to work at 6:00 am. V11, CNA stated (R28) usually gets up around 4:00 am, but I (V11, CNA) am not sure what time night shift (staff) changed (provided incontinence care) (R28). (R28) has not been changed since I (V11, CNA) came in at 6:00 am. I have been very busy.
On 7/24/22 at 10:25 pm R28 had wheeled R28's wheelchair to the hall bathroom door. V11, CNA assisted R28 assisted to a standing position. R28's sweat pants were visibly saturated across the full seat of R28's pants. R28's incontinence brief was totally saturated, hanging down between her legs to mid-thigh, and dripped with urine onto R28's bilateral legs and the floor. V11, CNA removed R28's saturated incontinence brief. R28 stated Oh my sores hurt so bad. R28 did not have a treatment dressing on either of two Stage II pressure ulcers at the back of her thigh/buttock fold. R28 had two nickel sized open areas of shearing over the bony prominence, (Stage II pressure ulcers), one on each upper inner thigh crease, ischial region. Both areas were red and raw in appearance. R28's buttocks and thigh skin were deeply indented and red. V11, CNA stated Usually (in general) those open areas have a wound dressing on them. R28 asked V11, CNA if V11, CNA would put some cream on the areas because they 'hurt so bad.' V11, CNA could not find a barrier cream to apply to R28's open wounds. V11, CNA stated to R28 All I can do is get you washed up. You don't have any cream (barrier). I will make sure you are clean and dry and that will fill better (relieve pressure ulcer pain).
R28's A.I.M for Wellness nursing note dated 7/1/22 documented by V7, Licensed Practical Nurse (LPN) documents the following: Assess; This change in condition, symptoms, or signs observed and evaluated are MASD (Moisture-Associated Skin Damage) to bilat (bilateral) back thighs. This started on 7/1/22. This condition, symptom, or sign has occurred before (blank checked) Yes. Other relevant information: Is at risk for skin breakdown per (formal skin evaluation). The same AIM for Wellness nursing note documents the following: ' (Number) 7. Skin Evaluation, Contusion (bruise) check marked, Other MASD to back bilat (bilateral) thighs. (Number) 8. Pain Evaluation; Does the resident have pain? (checked) Yes. Is the pain new (checked) Yes. Description /location of pain; While performing peri-care (incontinence care). Intensity of pain (rate on scale of 1-10, with 10 being the worst): 5 (moderate). The same AIM for Wellness nursing note documents the following: Manage; Physician recommendations and /or nursing interventions, Assist c (with) toileting q (every) 2 (two) hours and prn (as needed) and toileting hygiene. Assist c (with) T and P (turning and repositioning) while in bed and wheelchair q two hours and prn. Implement physician ordered treatment. V7, LPN also provided a hand written pressure ulcer plan of care for additional interventions dated 7/1/22. The hand written plan documents: P (problem).) Resident (R19) has 2 (two), Stage 2 (two) pressure injuries on posterior thighs. G (goal). Residents wounds will heal and no new skin issues by next review. (first bullet) Start 7/1/22 nsg (nursing) A (action to be implemented).) Apply ordered TX (treatment)- see POS (Physician Order Sheet) for current TX (treatment) orders. (bullet number 10) Start 7/1/22 nsg A. Daily skin (check mark) c (with) documentation and prn with any new skin issues.
On 7/26/22 at 9:30 am V7, Licensed Practical Nurse (LPN) reviewed a quality assurance document and stated she can give me the information from the document but is not allowed by the corporation to give a copy to the surveyors. V7, LPN stated I can tell you what happened, I was the nurse that found (R28's) shear wounds from (R28's) excessive incontinence on 7/1/22. (R28's) skin breakdown was obvious (obviously) from being so wet. I was helping (not sure which it was) CNA's with resident care. I cleansed (R28) peri-area. (R28) had two areas, very irritated and open. (R28's) Left, back inner thigh open area (identified below on plan of care as Stage II) measured 1.2 centimeter (cm) long by 0.2 cm wide, and superficial so depth could not be measured. (R28's) second open area (identified below on plan of care as Stage II) to her right, inner back thigh open wound measured 1.3 cm long by 0.4 cm long and the depth was superficial and could not be measured. I (V7, LPN) cleaned them with Theraworx (wound cleaner), applied skin prep around the outside of the wounds and put hydrocolloid dressings on them to prevent further destruction of the tissue. I did this as a nursing judgment and faxed (facsimile) the doctor for actual orders (physician). I notified the family and (V1, Administrator in Training), we don't have a DON (Director of Nursing who is required to be notified of new pressure ulcers). I faxed the orders to (V23, Physician) and reported off to the next shift nurse. I can't remember which one (nurse). I thought they (nurses) would follow-up and get an order (physician, pressure ulcer treatment order). I didn't put (document) the treatment (V7, LPN implemented as a nursing judgement) on (R28's) POS (Physician Order Sheet) because the next nurse had to confirm that is what the doctor wanted. (R28) has a history of skin breakdown, MASD (Moisture-Associated Skin Damage) the cause. I (V7, LPN) educated the CNA's (unidentified) on turning and repositioning resident (R28), and proper timely incontinence care.
R28's Treatment Administration Record (TAR) dated 7/1/22-7/31/22 documents R28 was not provided weekly skin assessments 7/11/22, and 7/25/22. R28's same TAR documents on 7/4/22, R28's had redness to buttocks and groin, on 7/8/22, R28 had irritation at an unidentified location, and on 7/18/22, R28 had redness and/or irritation in the groin area. On the same TAR there are no measurements documented of R28's bilateral, posterior thigh pressure ulcers (identified 7/1/22) until 7/27/22.
The same TAR does not document the following treatment was completed until 7/27/22. The treatment order documents: R28's Bilateral thigh had shearing related to Moisture-associated Skin Damage, clean area with (name brand wound cleaner) and apply hydrocolloid dressing, every three days and as needed. The back of the same TAR documents measurements were obtained on 7/27/22 as follows:
Left, posterior med (medial) thigh, shearing (Stage II, shearing over bony prominence) related to MASD, measured 1.4 cm long, by 0.2 cm wide, by 0 cm,
(increased from 7/1/22 Stage II measurement of left, posterior thigh 1.2 cm long by 0.2 cm wide by 0 cm depth).
Right, posterior med (medial) thigh, shearing (Stage II, shearing over bony prominence) related to MASD, measured 3.0 cm long, by 0.4 cm wide, by 0 cm,
(increased from 7/1/22 Stage II measurement of right, posterior thigh 1.3 cm long by 0.4 cm long by 0 cm depth).
In comparison to the only measurements obtained prior to 7/27/22, from the quality assurance document 7/1/22 mentioned above, and reviewed by V7, LPN, R28's left thigh pressure ulcer increased by .2 cm in length, and R28's right thigh pressure ulcer increased by 1.7 cm in length.
On 7/26/22 at 1:55 pm V17, Medical Director/Physician (MD) stated V17, MD expects all incontinent resident to receive timely incontinence care. MASD (Moisture-associated skin damage) causes skin breakdown. V17 also stated V17, MD was not informed (R28) had open areas caused by MASD. V17, MD stated V17, MD should have been informed. A treatment order would have been given. V17, MD also stated the Hydrocolloid dressing applied by the V7, LPN that found the open areas was appropriate and should have been continued to prevent further breakdown. V17, MD also stated R2's incontinence saturation observed, and no dressings on the open wounds after R28 complained of being wet for hours, Absolutely, caused the added pain, pressure ulcers and possibly further skin impairment.
SERIOUS
(G)
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 lower R19's bed after providing cares and left R19 unat...
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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 lower R19's bed after providing cares and left R19 unattended in an elevated bed by resulting in a fall with serious injury and failed to complete neurological assessments for R19's fall. This failure resulted in R19 sustaining a fracture of the left wrist. R19 is one of three residents reviewed for falls on the sample list of 21.
Findings include:
R19's Face Sheet dated 6/30/17 documents the following diagnoses: Guillain-Barre syndrome, Paraneoplastic Neuromyopathy and Neuropathy, Muscle Weakness Generalized, and Unsteadiness on Feet.
R19's Physician Order Sheet (POS) dated July 1-31, 2022 documents the following: Continue to wear splint, make appointment with (Private Hospital) 7/9/22.
R19's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status score of 15 out of a possible 15, (no cognitive impairment). The same MDS documents R19 has limited range of motion in one upper extremity, and bilateral lower extremities. The same MDS documents R19 is totally dependent on two staff for transfers and bed mobility.
R19's Care Plan dated 6/26/22 documents the following: (R19) will use bed rail for repositioning at every opportunity thru (through) next review. Bed in lowest position. The same Care Plan documents: (R19) rolled out of bed, alleged fall. Fall mat placed, ed (education) given to (R19) and staff (unidentified) on bed in the lowest position.
On 07/24/22 at 10:48 am, R19 was seated in R19's wheel chair next to R19's bed. R19 had a splint on the left wrist. R19 stated the following: All is good here except, I fell out of my bed about a month ago (6/26/22) and fractured my (left) wrist. I had to wait several days before the facility would get an X-ray (second X-ray). I don't think I would have broke my wrist if the bed was in a lower position. It was high like it is now. (R19 points to the elevated bed. R19's bed was three and a half feet above the floor). I (R19) Fell far and hard. They were worried about my head. I am hard headed. It (R19's head) didn't hurt but I kept telling them my left wrist hurt and I wanted an X-ray (completed 6/27/22 and 7/8/22). I should have put on my call light and waited for staff to turn me. I thought I could adjust my position in bed on my own. Obviously, I won't do that again.
R19's A.I.M. (Assess, Intercommunicate, Manage) for Wellness (nurses note) dated 6/26/22 (Sunday), signed by V6, Regional Director of Clinical Operations, documents the following: Alleged fall. The same AIMS for Wellness note documents the following; Manage, Physician recommendations and/or nursing interventions. X-Ray to L (left) wrist, may wait till Monday d/t (due to) patient (R19) request of not wanting to leave the facility and wait till Monday (6/27/22). Fall mat placed, and resident and staff educated on bed in lowest position. There was no documentation of neurological assessments noted on the AIM note or in the Nurse Notes after R19's unwitnessed fall.
R19's X-ray report dated 7/8/22 was ordered by V17, Medical Director documents the following: Reason: Swelling, pain with movement post fall (6/26/22). The same report documents Left wrist, two views. Findings; see impressions. Impression: Acute distal ulnar fracture.
R19's Illinois Department of Public Health (IDPH), Final report (initial report 7/8/22 after second X-ray) dated 7/14/22 documents the following: (R19) Rolled out of bed and landed on her arm. It was not fractured at the time of the incident but was later determined that her wrist was fractured. The same IDPH report documents: Staff Interview: (V20, Certified Nursing Assistant) CNA, I had laid resident (R19) down to use the bathroom, when I went back a few minutes later she (R19) was on the floor. I put a pillow under her head and the other CNA (V22) went to get the nurse (unidentified).
On 7/26/22 at 9:55 am V7, Licensed Practical Nurse (LPN)/ Minimum Data Set Coordinator stated V7, LPN was the nurse that cared for R19 the day of R19's fall on 6/26/22. V7, LPN stated the fall was not witnessed. V7, LPN also stated I should have initiated neurological assessment according to the policy, but I did not. V7, LPN stated (V20, Certified Nursing Assistant/CNA) was the CNA that worked that day. I re-educated (V20, CNA) to lower the resident beds after providing resident care so, this kind of thing doesn't happen to anybody else. I had noticed (R19's) bed was too high, immediately when I did her assessment (6/26/22). V7, LPN also stated When (R19) fell, (R19) complained of serious left arm pain. I can't remember if I gave her Tylenol, but I think I gave it (Tylenol). V7, LPN also stated (V17, MD) gave and order that day for x-ray that showed no fracture. It was about six days later that (R19) continued to complain of wrist pain and another X-ray was done. The second (X-ray) did show a fracture (left wrist). (R19) only had a skin tear the day of the fall from her bed. There was no swelling. I wanted to send (R19) to the hospital but (R19) refused. (R19) said she was ok and did not hit her head. I am pretty sure I gave Tylenol for the pain.
On 7/26/22 at 2:10 pm V17, Medical Director stated the height of R19's bed should have been in the lowest position. The elevated height of the bed would increase the impact during the fall and was the likely the cause of R19's wrist fracture. V17, Medical Director also stated R19's fall was unwitnessed, therefore neurological assessments should have been ongoing as our policy documents.
The facility policy Fall Prevention dated December 2009 documents the following: Policy: To provide for resident safety and minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Responsibility: All staff. Procedure: (Number 5). Immediately after any resident fall the unit nurse will assess the resident and provide any care and treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. Number 6. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM for Wellness form along with any new interventions deemed appropriate at the time. The unit nurse will also place any new interventions on the CNA assignment worksheet. The same Fall Prevention policy documents the following: Fall Prevention Interventions: (Number 10.) Bed in lowest position-wheels locked.
The facility policy Head Injury: dated reviewed 12/22/17 documents the following: It is the policy of (Private Corporation) to evaluate head injuries for a minimum period of 72 hours, to determine any negative effects, and to allow for immediate treatment to minimize permanent damage.
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 resident dignity was maintained during dining. T...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure resident dignity was maintained during dining. This failure affected one (R10) of one resident reviewed for dignity on the sample list of 21.
Findings include:
R10's Physician Order Sheet dated 7/1/22-7/31/22 documents the following diagnoses: Dementia, Severe Front Temporal Type, with Behavioral Problems Unimproved, and Picks Disease.
R10's Minimum Data Set, dated [DATE] documents R10 has severe cognitive impairment and requires extensive physical staff assistance with dining.
On 07/24/22 at 12:10 pm R10 was seated at a dining table, adjacent to the television lounge with other unidentified residents. R10 was eating with R10's fingers. R10's hands were thickly covered in food. R10 was eating barbeque meatballs, au gratin potatoes, green beans and diced peaches in syrup with her fingers. Food debris was scattered around R10's plate, and on R10's chest. R10 had a table spoon size metal spoon and a plastic spoon on the table across and out of R10's reach. V1, Administrator, V9, Dietary Manager, V11, Certified Nursing Assistant, and other unidentified staff were delivering other resident meals in the dining room. All staff walked past R10 but did not stop and assist R10 with dining or provide utensils for R10 to eat with.
On 7/24/22 at 12:20 pm V1, Administrator stated It is a dignity issue. (R10) should not be eating her food with her fingers. She should have proper utensil and feeding assist.
The facility Illinois Long-Term Care Ombudsman Program Resident Rights for People in Long-Term Care Facilities pamphlet documents the following: Your rights to dignity and respect. (Bullet #2) Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to prevent the physical abuse of one resident (R25) by another resident (R7) for two (R25, R7) of three residents reviewed for abuse on the sam...
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Based on interview and record review the facility failed to prevent the physical abuse of one resident (R25) by another resident (R7) for two (R25, R7) of three residents reviewed for abuse on the sample list of 21.
Findings include:
R7's nurse's note dated 7/7/22 at 7:00 AM, written by V3 Licensed Practical Nurse documents, (R7) was yelling at another (R25) and hit him on the arm. Writer separated them and brought (R7) to the desk. Notified (doctor) and Administrator (V1).
On 7/25/22 at 8:39 AM, V3 stated on 7/7/22 at 7:00 AM that, I was passing meds and I don't know what was said but I heard a smack and (R25) said, Don't you smack me. I separated them (R7 and R25) and called the Administrator.
The facility's final abuse investigation report form dated 7/11/22 written by V1 Administrator documents an allegation of physical abuse was reported on 7/7/22 at 7:00 AM. This form documents that R7 hit R25 on the arm.
On 7/27/22 at 10:16 AM, V1 Administrator stated R7 is alert and oriented and knows what R1 is doing. V1 stated R7 did hit R25 on the arm on 7/7/22 at 7:00 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to request a re-screening of a Preadmission Screening and Resident Revi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to request a re-screening of a Preadmission Screening and Resident Review (PASRR) after the current PASRR expired for one (R25) of three residents reviewed for PASRR on the sample list of 21.
Findings include:
R25's Face Sheet documents R25 was admitted to the facility on [DATE].
R25's PASRR dated [DATE] documents, Review Date: [DATE] Level I Outcome: Exempted Hospital Discharge Rationale: Exempted Hospital Discharge 30 Day Approval-A 30 day or less stay in the NF (nursing facility) is authorized. Re-screening must occur by or before the 30th day if the individual is expected to remain in the NF beyond the authorization timeframe. As the individual was medically admitted and is currently psychiatrically stable, they meet criteria for a 30 day EHD (Exempted Hospital Discharge) approval. Should their stay require more than the 30 days, or they develop any signs of psychiatric decompensation, please submit a Conclusion of a Time Limited approval Level l and a Level ll referral will be initiated.
R25's medical record did not contain an additional PASRR screen dated after [DATE].
On [DATE] at 12:27 PM, V1 Administrator stated the facility did not request a re-screening of R25's PASRR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a discharge summary prior to discharge for one (R30) of one...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a discharge summary prior to discharge for one (R30) of one resident reviewed for discharge on the sample list of 21.
Findings include:
R30's Nursing Notes dated 4/12/22 at 9:50 AM, documents R30 was admitted to the facility on [DATE]. R30's nursing notes documents R30 was discharged on 5/25/22 at 9:30 AM. R30's medical record does not contain an Discharge summary.
On 7/25/22 at10:39 AM, V13 Medical Records stated R30 was discharged went to a different facility. V13 stated there is not a discharge summary for R30.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to assist with nail care for one (R9) of 16 residents reviewed for activities of daily living on the sample list of 21.
Findings ...
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Based on observation, interview, and record review the facility failed to assist with nail care for one (R9) of 16 residents reviewed for activities of daily living on the sample list of 21.
Findings include:
On 7/25/22 at 1:20 PM, R9 was laying in bed. R9's toenails were long and past the tips of the toes. R9 stated she can not trim them herself and doesn't like them that long. R9 stated no one in the facility has assisted her with nail care. At that time, V4 Certified Nursing Assistant (CNA) stated that R9's toenails were needing trimmed and that R9 could not trim them herself.
On 7/27/22 at 9:26 AM, R9 stated no one has trimmed her toenails yet. R9 stated she needs them trimmed because they drag across the sheet and it is uncomfortable. At that time V4 CNA stated they had not trimmed R9's nails yet.
R9's baseline care plan dated 5/17/22 documents R9 has poor mobility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to apply an orthotic boot to help correct foot drop for one (R9) of one residents reviewed for range of motion on the sample list...
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Based on observation, interview, and record review the facility failed to apply an orthotic boot to help correct foot drop for one (R9) of one residents reviewed for range of motion on the sample list of 21.
Findings include:
On 7/25/22 at 1:20 PM, R9 was lying in bed. R9's right foot was noted to be dropping forward towards the mattress. A boot was not on R9's right foot. R9 stated the boot is in the closet and the staff has never applied it. R9 stated it is used for foot drop. At that time, the boot was lying on the top shelf of the closet
07/25/22 01:25 PM Physician order date 5/16/22 documents an order for an orthotic boot while in bed.
On 7/25/22 at 2:17 PM, V17 (R9's Physician) stated the orthotic boot should be worn while R9 is lying in bed.
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** 2. On 7/26/22 at 8:50 AM, R25 was sitting in dining room. R25's catheter tubing was hanging out of the bag and dragging on the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/26/22 at 8:50 AM, R25 was sitting in dining room. R25's catheter tubing was hanging out of the bag and dragging on the floor.
R25's Care Plan dated 7/26/22 documents R25 has a indwelling catheter and has a goal for R25 to be free from Urinary Tract Infections by the next review date.
On 7/27/22 at 11:00 AM, V1 Administrator stated R25's catheter tubing should be kept from dragging on the floor to prevent Urinary Tract Infections.
Based on observation, interview and record review the facility failed to provide timely incontinence care, failed to perform incontinence care in a manner to prevent cross contamination and potential infection for R28, and failed to maintain R25's urinary indwelling catheter tubing off the floor to prevent cross contamination. R25 and R28 are two of four residents reviewed for bowel and bladder/catheter care on the sample list of 21.
Findings include:
1. R28's Physician Order Sheet (POS) dated 7/1/22- 7/31/22 documents the following diagnoses: Dementia, and CVA (Cerebrovascular Accident/ Stroke).
R28's Minimum Data Set (MDS) dated [DATE] documents the following: R28's Brief Interview of Mental status score was 10 out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R28 is always incontinent of bladder and frequently incontinent of bowel and has had no behaviors of rejecting care. The same MDS documents R28 is dependent on total physical assistant of two staff for hygiene needs and requires extensive assistance of one staff with toileting.
R28's Care Plan dated 5/12/22 documents the following:
P. (Problem) Alteration in bladder elimination as related to incontinence.
G. (Goal) Skin will remain intact thru (through) next review.
A. (action to be implemented) Toilet and/or change padding and give proper hygiene before/after meals, upon rising, upon request, before retiring for the evening, after napping, and prn (as needed) for incontinence.
On 07/24/22 at 10:05 am, R28 stated I (R28) have sores on my (R28's) bottom from not getting changed often enough. R28 also stated The night staff got me (R28) up (out of bed) and dressed between 5:00 am - 6:00 am. I (R28) have not been changed (incontinence brief) since. R28 also stated R28 incontinence brief is very wet at this time and has soaked through R28's pants.
On 7/24/22 at 10:12 am V11, Certified Nursing Assistant (CNA) stated R28 was already up and dressed when V11, CNA came in to work at 6:00 am. V11, CNA stated (R28) usually gets up around 4:00 am, but I (V11, CNA) am not sure what time night shift (staff) changed (provided incontinence care) (R28). (R28) has not been changed since I (V11, CNA) came in at 6:00 am. I have been very busy.
On 7/24/22 at 10:25 pm R28 had wheeled R28's wheelchair to the hall bathroom door. V11, CNA brought clean towel, wash cloth and clean sweat pants. V11, CNA did not wash V11, CNA hands, use the facility preferred hand cleaner or hand sanitizer. V11, CNA donned gloves and pushed R28's wheelchair over to the toilet. V11, CNA assisted R28 to a standing position. R28's sweat pants were visibly saturated across the full seat of R28's pants. R28's incontinence brief was totally saturated, hanging down between her legs to mid-thigh, and dripped with urine onto R28's bilateral legs and the floor. V11, CNA removed R28's saturated incontinence brief. R28 stated Oh my sores hurt so bad. R28 had an open area on bilateral inner posterior thighs. R28's buttocks and thighs were deeply indented and red. Both open wounds were red and raw in appearance. R28 asked V11, CNA if V11, CNA would put some cream on the open areas because they 'hurt so bad.' V11, CNA asked resident to sit still on the toilet and V11, CNA would go to R28's room and see if V11, CNA can find some barrier cream. Wearing the same contaminated gloves V11, CNA removed R28's saturated incontinence brief and wet clothes, V11, CNA left the hall bathroom and went down the hall to R28's room. V11, CNA opened several R28's dresser drawers. Continuing with the same contaminated gloves, V11, CNA went back to the bathroom and reported to R28, V11, CNA could not find a barrier cream to apply to R28's sore buttocks. V11, CNA stated to R28 All I can do is get you washed up. You don't have any cream. I will make sure you are clean and dry and that will fill better (relieve pressure ulcer pain). V11, CNA continued with the original gloves, now contaminated and completed R28's incontinence care, applied a clean incontinence brief and clothing change. V11, CNA, with the same soiled gloves, straighten R28's clothes and pushed R28's wheel chair to the bathroom door way. V11, CNA stated I know I messed up. I should have washed my hands and changed my gloves several times. I just get nervous being watch by state (Illinois Department of Public Health Surveyor).
The facility policy Perineal Cleaning dated December 2017 documents to wash hand and don clean gloves repeatedly. The same policy documents the following:
Policy: To eliminate odor; to prevent irritation or infection and to enhance resident's self-esteem.
Responsibility:
All nursing personnel
Equipment:
1.
Washcloth and towel
2.
Soap, other cleansing agent or Theraworx
3.
Gloves
4.
Wash basin
5.
Plastic Bag
Procedure:
Female-without catheter
1.
Position resident on back with knees bent and slightly apart.
2.
Keep resident's gown at mid-abdomen with bed linens pulled to the knees.
3.
Place half of the towel lengthwise under the buttocks with the remaining half to be used for covering and drying the perineum.
4.
Wet washcloth with cleansing agent chosen.
5.
Wash pubic area including upper inner aspect of both thighs and frontal portion of perineum.
a.
Use long strokes from the most anterior down to the base of the labia
b.
After each stroke refold the cloth to allow use of another area.
6.
Follow same sequence for rinsing area, if applicable.
7.
Place soiled items in plastic bag.
8.
Dry thoroughly.
9.
Instruct or assist resident to turn on side with top leg slightly bent.
10.
Rinse cloth and apply cleansing agent chose, if applicable.
11.
Wash peri-anal area thoroughly with each stroke beginning at the base of the labia and extending up over the buttocks.
a.
Refold cloth, as before, to provide clean area.
b.
Washing should alternate side to side, ending with the center anal area.
12.
Place soiled items in plastic bag.
13.
Rinse cloth and entire area in the same sequence as above, if applicable.
14.
Dry area thoroughly.
15.
Remove gloves and wash hands with soap & water, cleansing gel or Theraworx.
16.
Apply new incontinent product, clothes or reposition comfortably.
17.
Wash hands with soap & water, cleansing gel or Theraworx.
Note: The basic infection control concept for peri-care is to wash from the cleanest to the dirtiest area and remember to change or remove gloves and wash hands when going from working with contaminated items to clean items.
CONCERN
(D)
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 interview and record review the facility failed to ensure that a resident maintained a usual body weight and when weigh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident maintained a usual body weight and when weight loss continued, the facility failed to implement any new interventions to prevent, address, or treat the underlying cause of the weight loss which resulted in the resident experiencing a significant weight loss. This failure effected one (R6) of two residents reviewed for nutrition on the sample list of 21.
Findings include:
R6's Physician Order Sheet dated July 2022 documents R6 is diagnosed with Dementia with Psychoses, Mood Affective Disorder, Depression, Cerebral Vascular Accident, Muscle Weakness, and Insomnia.
R6's Minimum Data Set (MDS) dated [DATE] documents R6 is moderately cognitively impaired and requires limited assistance of one person for eating. The same MDS documents R6 lost 5% or more in the last month or 10% or more in the last six months and is not on a physician weight loss program.
R6's Report of Monthly Weights and Vitals dated 2022 documents R6 weighed 156 pounds in January 2022 and now weighs 137 pounds in July 2022. This is a significant weight loss of 12.18% in a six month time.
The undated Resident Weight Monitoring policy documents if a resident has a significant weight change, it is documented in the care plan with goals and approaches/intervention listed. The sample policy documents if a resident has a significant weight change, the resident, family/guardian, physician, and dietitian are notified. The date of the notification for physician and family/guardian is documented on the Report of Monthly Weight form. The same policy documents with significant weight loss, the dietician or food service manager review the resident's nutritional status and makes recommendation for intervention in the nutritional progress notes. Then nursing contacts the physician to convey the recommendations and obtain any new orders.
On 7/26/22 at 2:12 PM V23 Medical Director confirmed it is the facility's responsibility to address weight loss before it becomes significant and implement interventions to attempt to prevent further loss.
On 7/27/22 at 1:00 PM V1 Administrator confirmed there was no documentation of new interventions for R6's significant weight loss. V1 confirmed that R6 has continued to lose weight since January and there have been no newly implemented interventions put into place to prevent further loss.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to utilize a continuous airway pressure machine for one (R9) of one resident reviewed for sleep apnea on the sample list of 21.
F...
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Based on observation, interview, and record review the facility failed to utilize a continuous airway pressure machine for one (R9) of one resident reviewed for sleep apnea on the sample list of 21.
Findings include:
On 7/25/22 at 1:20 PM, R9 stated that she has a continuous airway pressure machine (C-PAP) machine in the bedside table and the staff have never taken it out and applied it. R9 stated she has Sleep Apnea and she has a hard time sleeping at night and feels that the C-PAP would help. A C-PAP machine was in the bedside table in a box.
On 7/25/22 at 2:17 PM, V17 (R9's Physician) stated he evaluated R9 on 5/19/22. V17 stated R9 has a diagnosis of Sleep Apnea and that he wrote orders for R9 to have the C-PAP. V17 stated he expects that the facility would be using the C-PAP while she is sleeping.
R9's physician progress dated 5/19/22 written by V17 documents R9 has Obstructive Sleep Apnea and requires a C-PAP.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to redirect a resident (R7) from the dining room when an escalation of behaviors occurred for one (R7) of one resident reviewed for behaviors o...
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Based on interview and record review the facility failed to redirect a resident (R7) from the dining room when an escalation of behaviors occurred for one (R7) of one resident reviewed for behaviors on the sample list of 21. This failure resulted in an escalation from verbal to physical behaviors in the dining room in which R7 slapped R25 on the arm.
Findings include:
R7's nurse's note dated 7/7/22 at 6:00 AM, written by V3 Licensed Practical Nurse documents, (R7) up in dining room wheelchair out in the dining room. Yelling out inappropriate comments at times. Cussing other residents and calling them names. 1:1 with (R7) ineffective.
R7's nurse's note dated 7/7/22 at 6:30 AM, written by V3 Licensed Practical Nurse documents, Writer gave (R7) his medicine. (R7) states, I like that. Then threw the water and the medicine. Continues to yell out.
R7's nurse's note dated 7/7/22 at 7:00 AM, written by V3 Licensed Practical Nurse documents, (R7) was yelling at another (R25) and hit him on the arm. Writer separated them and brought (R7) to the desk. Notified (doctor) and Administrator (V1).
R7's Behavior tracking record dated for 7/1/22 through 7/31/22 documents R7 will make inappropriate comments to staff and other residents. This sheet documents interventions of to allow venting of feelings/concerns, orient to reality of situation, and to redirect to other areas.
On 7/25/22 at 8:39 AM, V3 stated on 7/7/22 at 7:00 AM that, (R7) was having behaviors. I was passing meds and I don't know what was said but I heard a smack and (R25) said, Don't you smack me. I separated them (R7 and R25) and called the Administrator. V3 stated, Prior to that he (R7) was yelling and making statements against the staff. Since he (R7) was just yelling and having verbal behaviors I didn't take him out of the dining room until he hit (R25).
On 7/27/22 at 11:15 AM, V1 Administrator and V6 Regional Director of Clinical Operations stated that V3 should have removed R7 from the dining room when R7 was yelling out at other staff or residents and throwing his medication and water.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to justify the use of an antibiotic for one (R25) of two residents reviewed for catheters on the sample list of 21.
Findings inc...
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Based on observation, interview, and record review the facility failed to justify the use of an antibiotic for one (R25) of two residents reviewed for catheters on the sample list of 21.
Findings include:
R25's Physician Order sheet documents an order dated 7/12/22 for Keflex 500 milligrams two times a day for one week.
R25's urine culture results dated 7/12/22 documents a result as not indicative of a UTI (Urinary Tract Infection). R25's medical record does not contain documentation that R25's physician was notified that R25's urine culture did not indicate a UTI.
R25's Nurse's Note dated 7/13/22 at 3:30 AM documents, T 98.5 (Temperature 98.5 degrees). Resting quietly in bed with eyes closed. (Continues) on (antibiotic) therapy for UTI. No adverse reactions noted. (Indwelling catheter) patent with light amber urine.
On 7/27/22 at 11:00 AM, V1 Administrator stated there are no assessments or documentation in R25's medical record to justify the use of the antibiotic. V1 stated there was no documentation in R25's medical record that indicated R25 had an Urinary Tract infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R25's Physician Order Sheet dated 7/1/22 through 7/31/22 documents orders dated 6/16/22 for the following psychotropic medica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R25's Physician Order Sheet dated 7/1/22 through 7/31/22 documents orders dated 6/16/22 for the following psychotropic medications: Buspar 7.5 milligrams (mg) one tablet twice a day, Risperidone 0.5 mg three times a day, Risperidone 3 mg once a day, and Trazodone 100 mg at bedtime.
R25's medical record does not contain a psychotropic assessment for the use of these medications.
On 7/27/22 at 11:15 AM, V1 Administrator stated there is no psychotropic assessments for R25's psychotropic medications.
Based on interview and record review the facility failed to assess the need for psychotropic medications, complete quarterly psychotropic medication assessments, attempt gradual dose reductions, and failed to complete an abnormal involuntary movements scale. This failure effected two (R6, R15) of five residents reviewed for unnecessary medications on the sample list of 21.
Findings include:
1. R6's Physician Order Sheet dated July 2022 documents R6 is diagnosed with Dementia with Psychosis, Mood Affective Disorder, Depression, and Insomnia. R6 is prescribed Citalopram (Antidepressant) 40 milligrams once per day, Risperidone (Antipsychotic) 0.125 milligrams every morning and 0.25 milligrams every evening, and Trazodone (Sedative) 100 milligrams at bedtime.
R6's undated Face Sheet documents R6 is under the care of a Legal Guardian.
R6's Minimum Data Set, dated [DATE] documents R6 is moderately cognitively impaired.
R6's Citalopram, Risperidone, and Trazodone Psychotropic Medication Quarterly Evaluations dated 5/6/22 were the only quarterly evaluations the facility completed within the last year.
There was no documentation that showed R6's Citalopram dose or Trazodone dose had been reviewed and attempted to be reduced within the last year.
There was no documentation of any AIMS (Abnormal Involuntary Movement Scale) being completed for R6's Antipsychotic medication Risperidone.
The facility's Psychotropic Medication Policy dated 11/28/17 documents any resident receiving psychotropic medications will have a Psychotropic Medication Assessment done at a minimum of every quarter. The same policy documents residents who use psychotropic medications will be reviewed at a minimum of every quarter and medication reductions shall be attempted at least twice in one year unless the physician documents the need to maintain the residents current regimen. The same policy documents any resident receiving psychotropic medications will have an AIMS (Abnormal Involuntary Movement Scale) assessment completed at a minimum of every six months.
On 7/26/22 at 12:30 PM V1 Administrator confirmed the facility failed to assess R6's psychotropic medications quarterly, failed to attempt a gradual dose reduction for R6's Citalopram and Trazodone, and failed to complete an AIMS (Abnormal Involuntary Movement Scale) for R6's Risperidone Antipsychotic.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident was provided assistive dining devices...
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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 was provided assistive dining devices, according to the physician order. This failure affected one of four resident (R10) reviewed for dining/dignity on the sample list of 21.
Findings include:
R10's Physician Order Sheet (POS) dated 7/1/22-7/31/22 documents the following diagnoses: Dementia, Severe Front Temporal Type, with Behavioral Problems Unimproved, and Picks Disease. The same POS documents the following Diet Order and assistive devices: Mechanical Soft Solids; With 1 (one) on 1 (one) supervision, thin liquids, patient (R10) is to use (a) divided plate, regular spoon, and her (R10's) cup with lid, and removable straw all (for all) meals.
R10's Minimum Data Set, dated [DATE] documents R10 has severe cognitive impairment and requires extensive physical staff assistance with dining.
On 07/24/22 at 12:10 pm R10 was seated at a dining table alone, with no staff assistance. There was a large tablespoon/serving spoon and a plastic spoon on the dining the dining table out of R10's reach. R10 was eating with R10's fingers from a divided plate. R10 had two open mouth plastic tumblers, one with iced tea and one with water. There was a two-inch chunk a bread-like substance floating at the top of the water in one of the un-lidded plastic tumblers. R10 did not have a regular spoon, a cup with lid or removable straw as the physician ordered.
On 7/24/22 at 12:20 pm V, Administrator stated It is a dignity issue. (R10) should not be eating with her food with her fingers. She should have proper utensil and feeding assist.
On 7/24/22 at 12:25 pm V11, Certified Nursing Assistant (CNA) sat down to assist R10. V11, started feeding R10 with the plastic spoon. As noted above, R10's POS documents R10 should be assisted with eating using a regular spoon.
On 7/24/22 at 12:30 pm V11, CNA stated We have been using mostly plastic spoons for (R10). Sometimes we do get this big spoon (points to the large tablespoon/serving spoon on R10's table) with (R10's) meal. She doesn't much care for it. I don't know if we even have real teaspoons. As far as the lids and straws. I have been here almost two years. (R10) used to get them but chewed on them (lids and straws). I don't think they every got replaced.
On 7/24/22 at 12:35 pm V9, Dietary manager stated We didn't replace (R10's) lids and straws like, we should have. I think it was the first round of Covid when (R10) chewed the first ones (lids and straws) and I (V9, Dietary Manager) never got those ordered. Staff are supposed to feed her with a real spoon. That is on her diet card. She should have gotten that with her meal. (R10) shouldn't be eating with her fingers.
The facility Illinois Long-Term Care Ombudsman Program Resident Rights for People in Long-Term Care Facilities pamphlet documents: Your rights to dignity and respect. (bullet #2) Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a bedroom door had the ability to open and close appropriately for one (R9) of 16 residents reviewed for environment on...
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Based on observation, interview, and record review the facility failed to ensure a bedroom door had the ability to open and close appropriately for one (R9) of 16 residents reviewed for environment on the sample list of 21.
Findings include:
On 7/24/22 at 10:00 AM, the door to R9's room would not close. R9 stated, You have to lift up on it to get it to close. It is always broken. The top hinge to the door at the frame was loose and the screw were not screwed in all the way. To close the door the door had to be lifted and pushed closed. The door was stuck closed and had to be pulled forcefully to open it.
On 7/25/22 at 8:51 AM, V4 Certified Nurse's Assistant stated she told V8, Maintenance Director about the door a week ago and it still is not working right. V4 stated the door won't open or close correctly.
On 7/25/22 at 9:45 AM, V8 stated he fixed the door yesterday. V8 stated they requested that it be fixed last week. V8 stated it has been fixed before and that he put some screws in it but it keeps coming loose because it's hollowed out. V8 stated the door frame needs replaced.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R6's Physician Order Sheet dated July 2022 documents R6 is diagnosed with Dementia with Psychosis, Mood Affective Disorder, D...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R6's Physician Order Sheet dated July 2022 documents R6 is diagnosed with Dementia with Psychosis, Mood Affective Disorder, Depression, and Insomnia. R6 is prescribed Citalopram (Antidepressant) 40 milligrams once per day and Trazodone (Sedative) 100 milligrams at bedtime.
R6's undated Face Sheet documents R6 is under the care of a Legal Guardian.
R6's Minimum Data Set, dated [DATE] documents R6 is moderately cognitively impaired.
R6's Psychotropic Medication Consent dated 8/9/21 documents consent for Citalopram 20 milligrams per day.
R6 does not have a consent for Trazodone.
The facility's Psychotropic Medication Policy dated 11/28/17 documents Psychotropic medication should not be prescribed or administered without the informed consent of the resident, the resident's guardian, or other authorized representative.
On 7/26/22 at 12:30 PM V1 Administrator confirmed the facility failed to obtain informed consent for R6's Trazodone medication and failed to accurately document the correct dosage on R6's Citalopram medication consent. V1 confirmed R6 had been receiving both medications without accurate informed consent for administration.
Based on observation, record review and interview, the facility failed to inform a resident (R2) on seven different occasions of missed administration of medications to prevent chest pain and failed to obtain informed psychotropic medication consent for R6. These failures had the potential to affect two of six residents (R2 and R6) reviewed for psychotropic/medications on the sample list of 21.
Findings include:
1. R2's Physician Order Sheet (POS) dated 7/1/22-7/31/22 documents the following diagnoses and medication order: Pericardial Effusion (extra fluid collects between the heart and pericardium that causes pressure on the heart), and Hypertension. Isosorbide Mononitrate 20 milligrams (mg) tablet, take one tablet by mouth once daily, at least 30 minutes before meal.
R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental Status score of 14 out of a possible 15, indicating R2 has no cognitive impairment.
On 7/25 at 8:20 am V12, Licensed Practical Nurse (LPN) administered all of R2's medications scheduled at 8:00 am except Isosorbide Mononitrate 20 milligrams tablet. V12, LPN stated (R2) has missed several doses. They are circled (nurses initials circled to indicate the medication was not given) off.
R2's Medication Administration Record (MAR) dated July 1-31, 2022 documents the following: July 19 - July 25, 2022 (seven doses) R2 did not receive Isosorbide Mononitrate (circled to indicate, not given).
The facility Delivery Receipt dated 7/25/22 documents R2's Isosorbide Mononitrate tablets were not delivered from the pharmacy until 7/25/22.
The facility Medication Discrepancy Report dated 7/25/22 documents R2's Isosorbide Mononitrate 20 milligrams (mg) tablet was not administered for seven days.
There is no documentation in R2's medical record that R2 was informed that R2 has missed seven doses of Isosorbide Mononitrate.
On 7/26/22 4:00 pm R2 stated he was not informed until 7/25/22 that R2's Isosorbide Mononitrate (medication had not come in from the pharmacy, so it was not given for 7 days.
On 7/27/22 at 2:40 pm V1, Administrator confirmed R2 had not been informed until 7/26/22 that he did not receive his Isosorbide Mononitrate medication for seven days.
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
2. R3's Physician Order Sheet (POS) dated July 2022 documents R3 is diagnosed with Dementia and Depression.
R3's Report of Monthly Weights and Vitals dated 2022 documents R3 weighed 191.2 pounds in Ja...
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2. R3's Physician Order Sheet (POS) dated July 2022 documents R3 is diagnosed with Dementia and Depression.
R3's Report of Monthly Weights and Vitals dated 2022 documents R3 weighed 191.2 pounds in January 2022 and 168.5 pounds in February 2022. This is a significant weight loss of 11.87% in one months time.
The undated Resident Weight Monitoring policy documents if a resident has a significant weight change, the resident, family/guardian, physician, and dietitian are notified. The date of the notification for physician and family/guardian is documented on the Report of Monthly Weight form.
On 7/26/22 at 2:12 PM V23 Medical Director confirmed it is the facility's responsibility to notify a resident's physician of significant weight loss so the physician can address the possible causes and prevent further loss.
On 7/27/22 at 1:00 PM V1 Administrator confirmed there was no documentation that the physician was notified of R3's significant weight loss.
The facility policy Notification for Change in Resident Condition or Status revised 12/7/17 directs the facility Administrator, Director of Nursing and Charge Nurse to notify the physician in the event of significant weight loss.
Based on record review and interview, the facility failed to notify a resident's (R2) physician, on seven separate occasions, of missed administration of medication used for heart-related chest pain. The facility also failed to notify resident's (R3) physician of significant weight loss. R2 and R3 are two of two residents reviewed for physician notification of change in condition on the sample list of 21.
Findings include:
R2's Physician Order Sheet (POS) dated 7/1/22-7/31/22 documents the following diagnoses and medication order: Pericardial Effusion (extra fluid collects between the heart and pericardium and causes pressure on the heart), and Hypertension. Isosorbide Mononitrate 20 milligrams (mg) tablet, take one tablet by mouth once daily, at least 30 minutes before meal.
R2's Medication Administration Record (MAR) dated July 1-31, 2022 documents the following: On July 19 - July 25, 2022 (seven doses) R2 did not receive Isosorbide Mononitrate (circled to indicate not given).
There is no documentation in R2's chart that documents V17, Medical Director was notified R2 had missed administration of Isosorbide Mononitrate.
The facility Medication Discrepancy Report dated 7/25/22 documents R2 Isosorbide Mononitrate 20 milligrams (mg) tablet was not administered for seven days, was out of stock, and the the physician was not notified until 7/25/22.
On 07/26/22 at 1:50 pm, V17, Medical Director (MD) stated V17, MD would have contacted the facility pharmacy himself for R2's Isosorbide Mononitrate medication STAT had V17, MD been informed R2's medication was out of stock.
The facility policy Adverse Drug Reactions and Medication Discrepancy dated as reviewed November 06, 2018 documents the following: Policy; It is the policy of the facility adverse drug reactions and drug errors are to be reported to the resident's physician, documented in the nurses notes, and documented on an Adverse Drug Reaction or Medication Discrepancy Report. The reports are to be completed in coordination with the Director of Nursing and filed with the Administrator, and reviewed by the Medical Director and Consultant Pharmacist.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R9's face sheet documents R9 was admitted to the facility on [DATE].
On 7/25/22 at 12:00 PM, R9 was lying in bed on an air m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R9's face sheet documents R9 was admitted to the facility on [DATE].
On 7/25/22 at 12:00 PM, R9 was lying in bed on an air mattress. The air mattress hose was taped in multiple places. A sit to stand lift was positioned under the extra bed in R9's room. R9 stated hospice brought the sit to stand lift but that the facility utilizes a full body mechanical lift to transfer her. R9 stated she has foot drop and an orthotic is in the closet and has not been utilized. An orthotic was on the top shelf in the closet. A C-PAP (Continuous Positive Airway Pressure) machine was inside the bedside table.
R9's medical record did not contain a comprehensive care plan or a plan of care for the use of the air mattress, R9's transfer status, the use of the orthotic boot, or the use of the C-PAP.
3. On 7/26/22 at 8:50 AM, R25 was sitting in dining room. R25's indwelling urinary catheter tubing was hanging out of the dignity bag and dragging on the floor.
R25's Physician Order Sheet dated 7/1/22 through 7/31/22 documents R15 orders dated 6/16/22 for the following psychotropic medications: Buspar 7.5 milligrams (mg) one tablet twice a day, Risperidone 0.5 mg three times a day, Risperidone 3 mg once a day, and Trazodone 100 mg at bedtime.
R25's medical record did not contain a care plan or a plan of care for R25's indwelling urinary catheter or use of psychotropic medications.
4. On 7/24/22 at 11:35 AM, R15 was lying in bed. R15 was using humidified oxygen through a nasal cannula.
R15's medical record did not contain a care plan for the use of oxygen.
Based on observation, interview and record review the facility failed to develop a comprehensive care plan for four (R3, R9, R15 and R25) of 21 residents reviewed for care plans on the sample list of 21.
Findings include:
1. R3's Physician Order Sheet (POS) dated July 2022 documents R3 is diagnosed with Dementia and Depression.
R3's Report of Monthly Weights and Vitals dated 2022 documents R3 weighed 191.2 pounds in January 2022 and 168.5 pounds in February 2022. This is a significant weight loss of 11.87% in one month's time.
The undated Resident Weight Monitoring policy documents if a resident has a significant weight change, it is documented in the care plan with goals and approaches/intervention listed.
On 7/27/22 at 1:00 PM V1 Administrator confirmed there was no documentation in R3's care plan of R3's significant weight loss, goals, or interventions to address it.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
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, repeatedly that one resident (R14) had physic...
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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, repeatedly that one resident (R14) had physician ordered, narcotic pain medication available to treat pain post a fall with fracture. R14 is one of one resident reviewed for pain on the sample list of 21.
Findings include:
R14's Minimum Data Set (MDS) dated [DATE] documents R14's Brief Interview of Mental Status score of 15 out of a possible 15, indicating no cognitive impairment.
On 07/24/22 at 10:20 am R14 was lying in bed with R14's left arm in a sling. R14 stated About three weeks ago (7/02/22), I (R14) was walking down the hall as I (R14) usually does with no problem. I got to the main dining room corridor, tripped and fell. My arm was in severe pain. The facility finally got strong pain medication (Hydrocodone/ Acetaminophen) ordered from the doctor (unidentified). The strong pain medication was working well until a couple days ago. The facility ran out of the strong (narcotic) pain meds (medication) and all I get is Tylenol. Tylenol helps a little but has only brought pain down to a 5 (moderate) on a scale of 1-10. Pain radiates from the fracture at my shoulder area all the way down to the tips of my fingers. R14 stated the facility said the doctor (unidentified) must sign the prescription in order for (R14) to get more of the strong pain meds. R14 stated. I have been waiting for several days. The nurses say it has not come in yet.
R14's A.I.M. for Wellness (Nurses Note) form dated 7/1/22 (sic) documents R14 had a fall on 7/2/22. The AIM form documents the form was completed on 7/4/22. The A.I.M. form also documents R14 had new pain of the left upper arm with an intensity of 8 on a scale of 1-10, 10 being the worst. The AIMS form also documents the pain was related to a fracture (identified below on the X-Ray report).
R14's (Private Company) x-ray report dated 7/2/22 documents the reason for the X-ray: Fall, Limited Range of Motion, Pain, Unable to Lift Arm at all.
The same X-Ray report documents the following impression: Acute humeral (long bone at the top of the arm) neck (just below the top of the bone) fracture.
R14's (Private) hospital emergency room After Visit Summary dated 7/2/22 documents: Take pain medication as needed, follow- up Orthopedic Physician, Keep arm in sling. The same After Visit Summary documents that R14 was administered an unknown dose or strength Morphine (Narcotic medication for the treatment of moderate to severe pain) while in the emergency room at 11:40 pm. The same After Visit Summary documents to start taking the following medication: Hydrocodone (Narcotic medication, also known as Norco, to treat moderate to severe pain) - Acetaminophen 5 milligrams (mg)/325 mg tablet, one tablet by mouth every six hours as needed for acute pain.
R14's Physician Order Sheet dated 7/7/22 documents an active order for Hydrocodone/Acetaminophen 5 mg/325 mg tablet, one tablet by mouth every six hours as needed.
R14's Pain Assessment form documents an assessment on 6/2/22, R14 had no pain in the past five days. R14 same form documents a second pain assessment date 7/4/22 that documents R14 has had frequent pain in the last five days, on a scale of 1-10, zero being no pain and 10 being the worst pain, R14 rated her pain intensity as 88 (eighty-eight), and 3 (three) on the severity pain scale identified as severe.
R14's Medication Administration Record documents R14 receive the last dose of Hydrocodone - Acetaminophen 5 mg/325 mg tablet on 7/22/22 at 9:00 pm. R14's corresponding Controlled Substance Proof of Use count sheet for R14's Hydrocodone - Acetaminophen 5 mg/325 mg tablet supply documents the last Hydrocodone - Acetaminophen 5 mg/325 mg tablet, was administered 7/22/22 at 9:00 pm, with no remaining Hydrocodone - Acetaminophen 5 mg/325 mg tablets available.
R14's Pharmacy Facsimile dated 7/22/22 documents R14 refill request for Hydrocodone - Acetaminophen 5 mg/325 mg tablet. The same facsimile documents there are no refills available for this prescription.
On 7/26/22 at 2:00 pm V17, Physician / Medical Director (MD) stated he evaluated R14 the evening of R14's fall while doing rounds in the facility and sent R14 to the Emergency Room. V17, MD also stated V17, MD was not informed of any script was needed for new supply of R14's Hydrocodone/Acetaminophen 5 mg/325 mg tablet.
On 7/26/22 3:30 pm V21, registered Nurse (RN) stated (R14) is alert and oriented and is good about taking her meds. I can see (R14) has not had any Norco available for several days. My understanding is orthopedic (department of the local hospital) saw (R14) today has not signed the hard script, nor has V17, MD. I will have to follow up with that. It is ordered prn (as needed) and should have been requested a refill when the supply was running out. Her (R14) fracture has to be painful. I haven't worked in several days, and she has not asked me for anything since I came in. She (R14) has Tylenol, and that is all we can give her till Norco comes in if she needs something for pain management.
R14's Pharmacy Facsimile dated 7/27/22 contained a prescription for Norco signed by V17, MD. The Pharmacy Facsimile documents R14 refill request for Hydrocodone - Acetaminophen 5 mg/325 mg tablets and was stamped as sent at 5:55 pm. The refill request was not sent for four days, eight hours and 55 minutes after R14's medication supply was depleted as noted above. Therefore, not available to be administered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on record review, observation and interview the facility failed to provide prescribed medication on seven separate occasions, for one (R2) of four residents reviewed for medication administratio...
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Based on record review, observation and interview the facility failed to provide prescribed medication on seven separate occasions, for one (R2) of four residents reviewed for medication administration on the sample list of 21.
Findings include:
R2's Physician Order Sheet (POS) dated 7/1/22-7/31/22 documents the following diagnoses and medication order: Pericardial Effusion (extra fluid collects between the heart and pericardium and causes pressure on the heart), and Hypertension. Isosorbide Mononitrate 20 milligrams (mg) tablet, take one tablet by mouth once daily, at least 30 minutes before meal.
On 7/25 at 8:20 am V12, Licensed Practical Nurse (LPN) administered all of R2's medications scheduled at 8:00 am except Isosorbide Mononitrate 20 milligrams tablet.
V12, LPN stated, We are out of that (Isosorbide Mononitrate), I
don't know why. I will have to re-order this. Nobody (unidentified staff) else did. I can see on the MAR (Medication Administration Record) he (R2) has missed several doses. They are circled (nurses initials circled to indicate the medication was not given) off. I would think that (missed doses of Isosorbide Mononitrate) is a significant med (medication) error since he hasn't gotten it for so long.
R2's Medication Administration Record (MAR) dated July 1-31, 2022 documents the following: July 19 - July 25, 2022 (seven doses) R2 did not receive Isosorbide Mononitrate (circled to indicate, not given).
The facility Delivery Receipt dated 7/25/22 documents R2's Isosorbide Mononitrate tablets were not delivery from the pharmacy until 7/25/22.
The facility Medication Discrepancy Report dated 7/25/22 documents R2's Isosorbide Mononitrate 20 milligrams (mg) tablet was out of stock times, seven days.
On 07/26/22 at 1:50 pm, V17, Medical Director (MD) stated V17, would have contacted the facility pharmacy himself for R2's Isosorbide Mononitrate medication STAT had he been informed R2's medication was out of stock.
The facility policy (Corporation) Procurement and Storage of Medication dated November 2018 documents the following: 2. Refills are ordered from the pharmacy as needed by reattaching the top copy of the duplicate prescription label and affixing to the reorder form.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on record review, observation and interview the facility failed to prevent a significant medication error. The facility failed to administer a medication used for heart-related chest pain, as or...
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Based on record review, observation and interview the facility failed to prevent a significant medication error. The facility failed to administer a medication used for heart-related chest pain, as ordered by the physician. This failure was repeated on seven separate occasions for one (R2) of four residents reviewed during medication administration observation on the sample list of 21.
Findings include:
R2's Physician Order Sheet (POS) dated 7/1/22-7/31/22 documents the following diagnoses and medication order: Pericardial Effusion (extra fluid collects between the heart and pericardium and causes pressure on the heart), and Hypertension. Isosorbide Mononitrate 20 milligrams (mg) tablet, take one tablet by mouth once daily, at least 30 minutes before meal.
On 7/25 at 8:20 am V12, Licensed Practical Nurse (LPN) administered all of R2's medications scheduled at 8:00 am except Isosorbide Mononitrate 20 milligrams tablet.
V12, LPN stated, We are out of that (Isosorbide Mononitrate), I
don't know why. I will have to re-order this. Nobody (unidentified staff) else did. I can see on the MAR (Medication Administration Record) he (R2) has missed several doses. They are circled (nurses initials circled to indicate the medication was not given) off. I would think that (missed doses of Isosorbide Mononitrate) is a significant med (medication) error since he hasn't gotten it for so long.
R2's Medication Administration Record (MAR) dated July 1-31, 2022 documents the following: July 19 - July 25, 2022 (seven doses) R2 Isosorbide Mononitrate medication was not administered.
On 07/26/22 at 1:50 pm, V17, Medical Director (MD) stated this is a very serious medication to dilate the vessels of the heart. Isosorbide Mononitrate should never be stopped abruptly. V17, MD also stated yes, this is a significant medication error.
The facility Medication Discrepancy Report dated 7/25/22 documents R2's Isosorbide Mononitrate 20 milligrams (mg) tablet was not given for seven days.
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 properly secure residents' medications. This failure has the potential to effect eight (R1, R3, R6, R13, R16, R21, R29, R130) ...
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Based on observation, interview, and record review the facility failed to properly secure residents' medications. This failure has the potential to effect eight (R1, R3, R6, R13, R16, R21, R29, R130) of eight residents reviewed for medication storage on the sample list of 21.
Findings include:
On 7/24/22 at 11:10 AM V2 Registered Nurse was passing medications. The medications were divided up into medication cups on top of a tray. Each medication cup had multiple medications in it and each one was labeled with a resident's initials. V22 (Certified Nurse Assistant) was standing by the tray 'keeping watch' over the medications for V2 RN while V2, RN took one medication cup into a resident's room and then came back for another one.
On 7/24/22 at 11:15 AM V2 stated he had pulled up all the medications for the eight residents on isolation at the same time. V2 RN stated while he took the medications for an isolation resident into their room to them, he had V22 CNA watch over the other resident's (unsecured) medications in the medication cups. V2 RN admitted that he knew this wasn't per policy but felt it helped to keep the medication cart from being contaminated. V2 confirmed that at the time he had prepared and dispensed medications on the tray into the medication cups for R1, R3, R6, R13, R16, R21, R29, and R130.
On 7/24/22 at 11:16 AM V22 CNA stated she has watched the medications for V2 RN on other occasions as well.
On 7/26/22 at 12:30 PM V1 Administrator confirmed V2 RN should never pull up and dispense more than one resident's medications at a time and should not allow an un-licensed non-nurse staff member to guard the medications.
The Medication Administration policy dated 11/18/17 documents drugs and biologicals are only administered by physicians and licensed nursing personnel. Nurses are instructed to never leave prepared medications unattended and to destroy prepared medications if not used immediately.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to employ the services of a full time Director of Nursing. This failure has the potential to affect all 29 residents residing in ...
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Based on observation, interview, and record review the facility failed to employ the services of a full time Director of Nursing. This failure has the potential to affect all 29 residents residing in the facility.
Findings include:
On 7/24/22 from 8:00 AM to 4:00 PM and on 7/25/22, 7/26/22, and 7/27/22 from 7:30 AM to 4:30 PM there was not a Director of Nursing working in the facility.
On 7/26/22 at 12:00 PM, V1 Administrator stated that the facility has not had a Director of Nursing since the end of May 2022.
The facility's Census and Condition report dated 7/24/22 documents that there are 29 residents residing 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, and interview the facility failed to prevent the potential for cross-contamination and foodborne illness by failing to close and seal stored food, failing to dispose of expired r...
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Based on observation, and interview the facility failed to prevent the potential for cross-contamination and foodborne illness by failing to close and seal stored food, failing to dispose of expired refrigerated food, failing to maintain a can opener in a sanitary operable condition, failing to maintain mixer blades, failing to maintain sanitary food preparation areas from grease, debris and dust, and failing to maintain a three-well sink free of paint chips, caulking, and dust. These failures have the potential to affect all 29 residents residing in the facility.
Findings include:
1. On 07/24/22 at 08:15 am, during the initial tour of the facility kitchen, V24, [NAME] , confirmed upright three door refrigerator contained opened food items, unwrapped exposed and undated. The food items included the following:
Two opened, exposed to air, undated one pound packages of turkey breast sliced sandwich meat, one opened five-pound container of cottage cheese dated as opened 5/16/22,
two, five-pound plastic bags of opened, exposed to air, shredded mozzarella cheese with no opened date, and one, five pound plastic bag of opened, exposed to air, shredded cheddar cheese, with no open date.
2. Also observed during the initial tour of the kitchen were the following in dry storage room:
a twenty-five pound, open to air, partial bag of flour,
a twenty-five pound, open to air, partial bag of brown sugar,
a twenty-five pound, open to air, partial bag of powder, and a
a twenty-five pound, open to air, partial bag of flour.
There was also a six pound can of tomatoes and zucchini in the dry storage room at the front of the can rack. The six pound can was indented five inches across and 2 full inches deep at the center side of the can.
On 7/25/22 at 8:25 am V24, [NAME] confirmed all the opened partial bags of food should have been sealed to prevent cross contamination. V24, [NAME] also stated the six pound dented can of tomatoes/zucchini should have been thrown away.
3. On 7/25/22 at 3:00 pm V9, Dietary Manager (DM) toured the facility kitchen.
V9, DM confirmed the opened bags of flour, sugar, powdered sugar and brown sugar all remained wide open and exposed to air and potential contaminants, as they had been on the initial tour of the kitchen on 7/24/22. V9, DM stated, I ordered plastic covered bins to store those bags in. The dietary staff should be making sure these bags are securely closed at all times between use.
On the same tour of the facility kitchen the following was observed:
Table top can opener, gears and blade had a buildup of rust. There was dried black and brown food debris on table top can opener mount. The can opener blade had a silver finish that was worn off exposing rust at the tip of the blade. V9, DM stated I will replace the gears and blade.
4. On 7/25/22 at 3:05 pm during the same facility kitchen tour the following observation were made. Dust build-up dangling from an air conditioner and air conditioner vent that was mounted in the window above the sanitizer compartment of three well sink. Chipped, loose paint and caulking were crumbling below the window air conditioner and across the five foot, top edge of the three-well dish sink. There was also scattered small patches of a green sticky substance patches on wall above the three well sink, between the three well sink and window ledge. V9, DM stated That looks bad, but I don't think it's mold. That needs taken care of and cleaned badly.
During the same tour of the facility kitchen, an overhead shelf, immediately above the kitchen grill line and stove burners, where food is prepared, was completely covered with a heavy accumulation of grease and strings of hanging dust-like substance. V9, DM was present and acknowledged the grease and dust needed removed from the shelf to prevent food contamination.
5. During the same kitchen tour, there were the following damaged pieces of equipment and cooking utensil: Five large rubber spatulas all had chunks of rubber missing around the edges and deep knife- like divots throughout the rubber spatulas, one extra large metal potatoes masher had a rubber grasp handle sleeve that had slid down from the handle to encapsulate the first four inches of the food contact surface. The rubber grasp sleeve had chunks of rubber missing with frayed strands of the rubber dangled down towards the bottom of the potatoes masher, four large two foot by 18 inch plastic cutting boards had deep knife-like divots. Food-like debris filled the deep crevices of the cutting boards. There were two (name brand) puree type metal mixer blades that had multiple chips of metal missing.
On 7/25/22 at 3:15 pm V9, DM stated That needs cleaned. and all those cutting boards and utensils will be getting replaced. I have been making progress getting the kitchen in shape. Obviously, I have a lot to do to make that happen.
The Resident Census and Conditions of Residents report dated 7/24/22 documents 29 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 hold quarterly Quality Assurance meetings and failed to ensure a Director of Nursing was present at these meetings. This failure has the pot...
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Based on interview and record review the facility failed to hold quarterly Quality Assurance meetings and failed to ensure a Director of Nursing was present at these meetings. This failure has the potential to affect all 29 residents residing in the facility.
Findings include:
The facility's Quality Assurance sign in sheets provided by V1 Administrator documents that a Quality Assurance meeting was held on 6/8/21, 7/12/21, and 5/17/22. These sheets do not document that a Director of Nursing was present at the 6/8/21 or 5/17/22 meeting.
On 7/26/22 at 12:00 PM, V1 Administrator stated that the facility had three Quality Assurance meetings in the last year. V1 stated the 6/8/21 was for the first quarter of 2021, 7/12/21 was held for the second quarter. V1 stated there was not a third or fourth quarter meeting. V1 stated they just had their first quarter meeting for 2022 on 5/17/22. V1 stated the Director of Nursing was not present for the meetings held on 6/8/21 or 5/17/22.
The facility's Census and Condition report dated 7/24/22 documents that there are 29 residents residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
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 designate a qualified and trained person to serve as I...
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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 designate a qualified and trained person to serve as Infection Preventionist. This failure has the potential to effect all 29 residents residing in the facility.
Findings include:
On 7/24/22 at 8:00 AM, there was no one in the the facility designated as the Infection Preventionist.
The Facility assessment dated [DATE] documents in order to provide competent support and care for the resident population, the facility will employ an Infection Preventionist.
On 7/24/22 at 8:30 AM V1 Administrator stated the facility did not currently have anyone designated as the Infection Preventionist. V1 confirmed there was no one available that was qualified and trained as an Infection Preventionist. V1 confirmed the facility's census was 29 residents.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0565
(Tag F0565)
Minor procedural issue · This affected most or all residents
Based on interview and record review the facility failed to hold regular resident council meetings. This failure had the potential to affect all 29 residents residing in the facility.
Findings include...
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Based on interview and record review the facility failed to hold regular resident council meetings. This failure had the potential to affect all 29 residents residing in the facility.
Findings include:
The facility's Resident Council Meeting minutes provided by V1, Administrator did not contain minutes for March of 2022, June 2022, or July 2022.
On 7/26/22 at 10:00 AM, R25 stated he goes to the Resident Council meetings regularly. R25 stated that there haven't been any meetings in the last couple months. R25 stated that they usually have the meetings monthly to discuss issues in the facility. R25 stated the staff member who used to hold them is no longer employed at the facility, so the facility hasn't been having them.
On 7/25/22 at 9:30 AM, V1 Administrator stated the facility has Resident Council Meetings monthly. V1 stated there was not a Resident Council meeting in March 2022 or June 2022. V1 stated a Resident Council Meeting has not been scheduled for July 2022 because she doesn't have time and the facility currently does not have an Activity Director who usually holds them.
The facility's Resident Census and Condition report dated 7/24/22 provided by V1 Administrator documents there are 29 residents residing in the facility.
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
- "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: 3 harm violation(s), $25,500 in fines, Payment denial on record. Review inspection reports carefully.
- • 89 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
- • $25,500 in fines. Higher than 94% of Illinois facilities, suggesting repeated compliance issues.
- • Grade F (20/100). Below average facility with significant concerns.
Bottom line: Trust Score of 20/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Decatur Rehab & Health Care Ct's CMS Rating?
CMS assigns DECATUR REHAB & HEALTH CARE CT 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 Decatur Rehab & Health Care Ct Staffed?
CMS rates DECATUR REHAB & HEALTH CARE CT's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Decatur Rehab & Health Care Ct?
State health inspectors documented 89 deficiencies at DECATUR REHAB & HEALTH CARE CT during 2022 to 2024. These included: 3 that caused actual resident harm, 83 with potential for harm, and 3 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Decatur Rehab & Health Care Ct?
DECATUR REHAB & HEALTH CARE CT 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 58 certified beds and approximately 0 residents (about 0% occupancy), it is a smaller facility located in DECATUR, Illinois.
How Does Decatur Rehab & Health Care Ct Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, DECATUR REHAB & HEALTH CARE CT's overall rating (1 stars) is below the state average of 2.5 and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Decatur Rehab & Health Care Ct?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Decatur Rehab & Health Care Ct Safe?
Based on CMS inspection data, DECATUR REHAB & HEALTH CARE CT has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Decatur Rehab & Health Care Ct Stick Around?
DECATUR REHAB & HEALTH CARE CT has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Decatur Rehab & Health Care Ct Ever Fined?
DECATUR REHAB & HEALTH CARE CT has been fined $25,500 across 1 penalty action. This is below the Illinois average of $33,334. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Decatur Rehab & Health Care Ct on Any Federal Watch List?
DECATUR REHAB & HEALTH CARE CT 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.