Fondulac Rehabilitation & HCC
For profit - Corporation
98 Beds
PETERSEN HEALTH CARE
Data: November 2025
4 Immediate Jeopardy citations
Trust Grade
0/100
#528 of 665 in IL
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Fondulac Rehabilitation & HCC has received a Trust Grade of F, indicating significant concerns about the quality of care provided. With a state rank of #528 out of 665 facilities in Illinois and a county rank of #5 out of 8 in Tazewell County, they are in the bottom half of all local options. Although the facility is improving, with the number of issues decreasing from 17 in 2024 to 10 in 2025, it still faces serious challenges, including $58,003 in fines, which is concerning. Staffing is a notable strength, with a turnover rate of 0%, but there is less RN coverage than 93% of facilities in Illinois, which may affect care quality. Recent incidents include a failure to supervise a cognitively impaired resident during meals, resulting in choking and death, and a serious incident where a resident suffered burns due to inadequate supervision during designated smoking time, highlighting the facility's critical safety issues. Overall, while there are some strengths, families should be cautious given the facility's poor ratings and serious findings.
- Trust Score
- F
- In Illinois
- #528/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- $58,003 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 67 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 21%
Review needed
17 → 10 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 10 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: $58,003
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: PETERSEN HEALTH CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 67 deficiencies on record
4 life-threatening 3 actual harm
May 2025
9 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect a resident (R2) from resident-to-resident sexu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect a resident (R2) from resident-to-resident sexual abuse for one of four residents (R2) reviewed for abuse in the sample of ten. This failure resulted in R1 a cognitively intact resident sexually assaulting R2 a cognitively impaired resident on more than one occasion.
This failure resulted in an Immediate Jeopardy.
The Immediate Jeopardy began on 5/3/25 when the facility failed to protect a resident (R2) from resident-to-resident sexual abuse.
V2 (Director of Nursing) was notified of the Immediate Jeopardy on 5/24/25 at 9:00 AM.
On 5/24/25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:
While the immediacy was removed on 5/24/25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.
Findings include:
On 5/21/25 at 9:25 AM, V6 (Certified Nursing Assistant/CNA), stated on Saturday 5/3/25 during breakfast V6 saw R1 sitting in the dining room at a table with R2. R1 had R2's toy in R1's right hand and R1's left hand was between R2's legs touching R2's vagina. V6 told R1 don't touch her like that and V6 moved R2 to the middle of the dining room away from R1.V6 stated she left the dining room and came back 20 minutes later and R1 was sitting next to R2 again, with R1's hand further up between R2's legs. V7 couldn't see R1's hand because it was all the way up R2's shorts. V7 stated she told R1 this is the second time I have told you not to do that. V7 stated V15 (Licensed Practical Nurse)/LPN called V1 (Administrator in Training) to report the abuse allegation. V6 stated V1 did not come to the facility and did not give the staff guidance on safety interventions to put in place to keep R2 from further sexual abuse from R1.
On 5/21/25 at 10:16 am, (V7 CNA) stated Saturday morning on 5/3/25, V7 walked in the dining room and saw R1 and R2 sitting at the table, and R1 was sitting next to R2. R1 had R2's baby doll in R1's right hand and R1's left hand was in between R2's legs up R2's shorts and touching R2's private area. V7 stated V7 stopped R1 and told R1 it's not right to touch R2. V7 stated V7 immediately told V15 (LPN) of what V7 witnessed in the dining room. V7 stated we immediately removed R2, and R1 starting crying and said, I'm sorry. V7 further stated R2 has been having increased behaviors where R2 is crying out and pointing to her vagina since this incident happened.
On 5/22/25 at 12:36 PM, V15 (LPN) stated V7 and V6 came up to V15 and stated they had witnessed R1 touching R2 between R2's legs and on R2's vagina. V15 stated V15 first contacted V5 (Assistant Director of Nursing) who told V15 to call V1 (Administrator in Training). V15 called V1 to report the sexual abuse between R1 and R2 to V1. V1 told V15 to leave it alone and not do anything until V1 came in to do the investigation. V15 stated V1 did not come to the facility that weekend to do the investigation. V15 stated V1 did not give any further interventions or instructions to keep R1 away from R2.
On 5/20/25 at 4:00 PM, V4 CNA, stated one day after the occurrence between R1 and R2, R1 told V4 that R1 shouldn't have, but R1 touched R2. V4 stated R2 has the mindset of a four-year-old and is nonverbal. V4 stated R1 can self-propel in manual wheelchair around the facility.
On 5/21/25 at 11:53 AM, V9 (Guardian), stated V9 was not made aware of an allegation of sexual abuse towards R2. V9 stated R2 would be so upset and scared that this happened to R2. R2 has been mentally and physically handicapped R2's entire life.
On 5/20/25 at 4:01 PM, R2 was lying in bed in low position with a fall mat on the floor. R2 was alert but nonverbal.
On 5/20/25 at 3:30 PM, R1 was laying in R1's bed watching television. R1 was alert and answered questions appropriately. R1 stated R1 didn't want to talk about what happened with R2.
On 5/21/25 at 12:19 PM, R1 was observed in the dining room sitting two tables away from R2.
R2's Minimum Data set (MDS) dated [DATE] documents R2 is severely cognitively impaired.
R2's current Medical Diagnosis list documents R2 has diagnoses of cerebral palsy, intellectual disabilities, anxiety, and depression.
R2's current care plan does not contain documentation of interventions to keep R2 free from sexual abuse.
R2's current medical record does not include any documentation or assessment of R2 after being sexually abused by R1.
R2's medical record does not include a completed trauma care assessment after the alleged sexual abuse on 5/3/25.
R1's current care plan does not include interventions to address R1's sexual behaviors.
R1's current medical record does not include documentation of R1's sexual abuse allegation that occurred on 5/3/25.
The facility's Abuse, Prevention, &Prohibition Policy dated 12/2024 documents each resident has the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, agency staff, family members or legal guardians, friends, or other individual. While the facility investigation is under way, steps will be taken to prevent further abuse. The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process. A licensed Nurse will assess the resident for injuries and notify the residents physician and responsible party. Social Services will complete a Trauma Informed care assessment and provide follow up care regardless of if allegation is substituted. This policy documents sexual abuse is defined as non-consensual sexual contact of any type with a resident.
The Immediate Jeopardy began on 5/3/25 when the facility failed to protect a resident (R2) from resident-to-resident sexual abuse.
V2 (Director of Nursing) was notified of the Immediate Jeopardy on 5-24-25 at 9:00 AM.
On 5-24-25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:
1.
R2 was assessed by V2 (Director of Nursing) with no changes noted 5/24/2025.
2.
R2's trauma assessment was completed by V14 (Social Service Director) on 5/24/25.
3.
R2's plan of care was reviewed by interdisciplinary team (IDT) and updated on 5/24/25, by minimum data set (MDS) to include to have R2 in staff visual when not in room.
4.
R1's plan of care updated on 5/24/25 to include counseling 1:1 (one to one) with social services, educated to not be within proximity of R2, 15-minute visual checks plan to care updated on 5/23/2025 and reviewed with IDT again on plan of care updated by minimum data set on 5/24/2025.
5.
V16 (Medical Director) in conjunction with interdisciplinary team (IDT) reviewed abuse policy and procedure and assured policy and procedure included steps to report to appropriate parties and agencies including state agency, police department, resident representative, and abuse coordinator as well as proper investigation on 5/24/2025.
6.
All staff in-service initiated on Abuse by V2 (DON) to be done prior to next scheduled shift for all staff. Inservice to include emphasis on preventing abuse including sexual abuse and reporting requirements on 5/24/2025.
7.
All residents reviewed by IDT for risk to be victim of sexual abuse and if identified to have been a high risk, plan of care reviewed, and new interventions added, if necessary, on 5/24/2025.
8.
V1 (Administrator in Training) willfully resigned employment effective 5/24/2025.
9.
Abuse Coordinator role assigned to V23 (Corporate Administrator), and staff educated on clear signs posted for Abuse Coordinator Contact Information on 5/24/2025.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to initiate a resident head count once an exit door was a...
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 initiate a resident head count once an exit door was alarming without known cause, failed to ensure a gait to the outside smoking patio was kept secure, failed to develop a care plan and implement interventions for residents at risk for elopement, and failed to provide adequate supervision for two of three residents (R6 and R7) reviewed for elopement risk in the sample of 10. These failures resulted in cognitively impaired resident (R6) who required assistance with ADL's (Activities of Daily Living) exiting the facility without staff knowledge or supervision on 4-22-25, and being found 2.2 miles away from the facility, on a concrete median, by a stop light, in the dark, with complaints of being cold. The road R6 traveled along was a busy main road that had numerous steep hills and curves.
These failures resulted in an Immediate Jeopardy.
The Immediate Jeopardy started on 4-22-24 at 2:00 AM when R6, a cognitively impaired resident, exited the facility without staff knowledge or supervision and was found 2.2 miles away from the facility, on a concrete median, by a stop light, in the dark, with complaints of being cold.
V1 (Administrator-In-Training) and V18 (Assistant [NAME] President of Operations) were notified of the Immediate Jeopardy on 5-23-25 at 10:48 AM.
While the immediacy was removed on 5-23-25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.
Findings include:
1. R6's MDS (Minimum Data Set) dated 4-4-25 documents R6 is cognitively impaired.
R6's admission Record documents R6 was admitted to the facility on [DATE] with the diagnoses of Chronic Obstructive Pulmonary Disease, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Type II Diabetes Mellitus, Obstructive Sleep Apnea, Chronic Pain, and Depression.
R6's Elopement Risk assessment dated [DATE] documents R6 was a moderate risk for elopement and exit-seeks at times.
R6's admission Care Plan dated 6-24-25 through discharge date d 4-24-25 documents R6 has impaired cognitive function or thought processes and requires staff assistance with transfers and toilet use.
R6's Care Plan does not include any interventions to address R6's exit-seeking or risk for elopement as identified on R6's Elopement Risk assessment dated [DATE], until after R6 eloped on 4-22-25.
R6's Fall Risk assessment dated [DATE] documents R6 was at high risk for falling and has intermittent confusion.
R6's Final Report dated 4-22-25 and signed by V1 (Administrator-in-Training) documents, Summary: (R6) noted off facility grounds by oncoming staff. Noted (R6) to have left facility without notification or staff knowledge. Staff Interviews: (V11/Licensed Practical Nurse/LPN) reported noting smoking patio alarm sounding. Did not note anyone around, assumed wind to have blown open. Stated did not enact facility procedure as this was not an exit and residents typically would not be able to exit facility grounds through this door or patio.
R6's Social Service Progress Note dated 4-4-25 at 10:12 AM and signed by V14 (Social Service Director) documents, (V14) has reviewed (R6's) assess (assessment). (R6) initially kept saying he needed to get to the bank, transportation took (R6) to the bank, (and) it was not the correct bank. As I had noted before (R6) has poor cognition but doesn't feel he does. This has all recently started with (R6) wanting to go to the bank.
R6's Social Services Progress Note dated 4-22-25 at 2:58 PM and signed by V14 documents, (R6) left the facility without alerting staff. (R6) was located and brought back to the facility.
On 5-22-25 at 10:20 AM this surveyor observed the smoking patio where R6 exited the facility. The exit to this patio leads to a rocky embankment and then to a sidewalk that leads to the front parking lot. This surveyor drove from the front parking lot to the college campus where R6 was found. During the drive there was a steep hill that leads to the main road. From this main road to the local college where R6 was found per odometer reading was 2.2 miles from the facility and the road had many curves and hills.
On 5-22-25 at 9:00 AM V12 (LPN) stated, I came into work early on 4-22-25 and came by the (community college) at 5:00 AM. I was at a stop light, and I saw (R6) standing with a wheeled walker in the middle of a concrete divider that separates two streets. I asked (R6) what he was doing, and he said he was going home. (R6) said he wasn't going back there (the facility). I tried several times to get (R6) to get in the car with me. I called the nursing home and (V1/Administrator-in-Training) and I had to turn around because I was at stop light. By the time I turned around (R6) was gone. It was dark and (R6) had dark colored clothes on. (V13/CNA/Certified Nursing Assistant) came and met with me to look for (R6). (R6) had gotten inside a college building and (V13) brought (R6) to my car and we were able to get (R6) in and bring him back to the facility. The weather was chilly and (R6) had a black jacket and stocking cap on. It was 47 degrees out. (R6) stated he was cold. (R6) stated he had left the facility around midnight. I called (V11/LPN) and (V11) was not aware that (R6) had left the facility unattended. I brought (R6) back to the facility. The road (R6) was found on is very busy with stop lights and lots of traffic from college students and other traffic.
On 5-22-25 at 9:10 AM V13 (CNA) stated, (R6) was very quiet and had confusion. (R6) went out to the front parking lot around two months ago and threatened to leave and I was able to get (R6) back inside. (R6) was walking with a walker within the facility. On 4-22-25 I was told (R6) went out the door where the residents smoke. The alarm went off and the nurse (V11) thought the alarm was going off due to a resident going outside to smoke. (V11) shut the alarm off. V12 (LPN) called me and had me come and help find (R6). (R6) was over two miles away. (V12) lost sight of (R6). I found (R6) inside the college. It was 5:50 AM, dark, and cold. (R6) wanted to go home. (R6) was wanting to get on a bus to go home. (R6) would not be safe to by outside by himself.
On 5-22-25 at 10:25 AM V14 (Social Service Director) stated, (R4) had poor cognition at times. (R4) was not safe to walk outside on the road by himself. (R4) needed a walker.
On 5-22-25 at 11:15 AM V2 (Director of Nursing) stated, (R4) had confusion and needed a walker. (R4) was not safe to leave the facility unattended and away from the facility 2.2 miles. A lot of the road (R4) used did not have sidewalks.
On 5-22-25 at 1:00 PM V11 (LPN) stated, I was working the night of 4-22-25 and heard the smoking patio door alarming around 2:00 AM. I went to the alarm and thought the wind blew the door open and sounded the alarm. I did not see any residents outside, so I shut the alarm off. I should have done a resident head count and did not. Sometime after 5:00 AM that morning, (V12/LPN) called the facility and said she had found (R6) wandering around by the college. I had no idea (R6) was even missing from the facility.
On 5-22-26 at 1:30 PM V10 (LPN) stated, (R6) has a lot of confusion and would try to exit-seek. Prior to (R6's) elopement, (R6) would set off alarms and try to leave the facility. (R6) would not be safe leaving the building unattended by staff, especially after dark.
2. R7's current Care Plan documents Potential risk for elopement related to cognitive deficits, history of wandering, walks, or wheels about aimlessly without a purpose. (R7) is at high risk. Interventions: Place electronic sensor device to alert staff of exit attempt (or if unavailable, place on 1:1 (one on one) observations). Routinely check device placement, check battery function, check door device functioning, and evaluate effectiveness.
R7's Elopement Risk assessment dated [DATE] documents R7 is a high risk for elopement.
On 5-22-25 from 12:45 PM to 1:05 PM R7 was wandering aimlessly up and down the hallways and the dining room. R7 did not have one on one staff supervision or and electronic sensor device in place during this time.
On 5-23-25 at 9:45 AM R7 was lying in bed and V12 (LPN) and V13 were providing incontinence cares. R7 did not have an electronic sensor device in place.
On 5-23-25 at 9:50 AM V12 (LPN) stated, (R7) has never had an electronic monitoring device on or one-on-one staff supervision that I am aware of.
The facility's Elopement Policy dated 04/2025 documents, Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. Responsibility: All staff is responsible. Definitions: For the purpose of this policy, missing resident or eloped if he/she is seen leaving the buildings or is seen walking away as a result of responding to a door alarm. 4. When a door alarm sounds, staff shall immediately respond to and determine the cause of the alarm. The staff person responding to the alarm will check the outside of the building to determine if a resident has exited the building. If, upon investigation, no reason can be found for the sounding off that alarm the charge nurse will initiate an accounting of all residents at risk for elopement. If, after all at-risk residents are accounted for, the cause of the alarm is still undetermined, a complete head count of all residents will be conducted.
The Immediate Jeopardy started on 4-22-24 at 2:00 AM when R6, a cognitively impaired resident, exited the facility without staff knowledge or supervision and was found 2.2 miles away from the facility, on a concrete median, by a stop light, in the dark, with complaints of being cold.
V1 (Administrator-In-Training) and V18 (Assistant [NAME] President of Operations) were notified of the Immediate Jeopardy on 5-23-25 at 10:48 AM.
On 5-24-25 this surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:
1. R6 was assessed on 4-22-25, after the elopement, and no injuries were found.
2. On 4-22-25 V16 (R6's Physician) was made aware of R6's elopement and plan of care for a safe discharge back to home.
3. On 4-22-25 and 5-23-25 V16 and the Inter-Disciplinary Team reviewed facility policies and procedures to assure that processes are in place to supervise and prevent further residents from eloping.
4. On 5-23-25 all staff were in-serviced by V1 (Administrator-In-Training) on the facility's Elopement Policy and contacting all necessary parties, including law enforcement, when an elopement occurs.
5. On 5-23-25 V14 (Social Service Director) assessed all residents for elopement risk accuracy and completeness.
6. On 5-23-25 all residents deemed moderate or high risk on the Elopement Assessments were included in an elopement book located at the nurses' station.
7. On 5-23-25 V14 updated all residents at moderate to high risk for elopement care plans with interventions to increase safety.
8. On 5-23-25 V22 (Maintenance Director) checked all door alarms to ensure all door alarms were in proper working order.
9. On 4-22-25 V22 secured the smoking patio door with a padlock.
10. On 4-22-25 V11 (LPN) was provided one-on-one education and disciplinary action from V1 on the company's policy for responding to door alarms.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to implement their abuse policy and procedures to identify and report resident to resident suspected crime and sexual abuse immedi...
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Based on observation, interview and record review the facility failed to implement their abuse policy and procedures to identify and report resident to resident suspected crime and sexual abuse immediately to local law enforcement, resident representatives, and the state agency for two (R1, R2) of three residents reviewed for reporting abuse in the sample of ten. These failures resulted in R1 having unsupervised access to all 79 residents within the facility after R1 sexually assaulted R2.
Findings include:
The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility.
On 5/21/25 at 10:30 AM, V6 (Certified Nursing Assistant) stated on 5/3/25 V6 witnessed R1 putting R1's hand up R2's shorts, placing R1's hand on R2's vagina on two occasions. V6 stated she made V15 (Licensed Practical Nurse) aware after R1 touched R2 on the vagina for the second time. V6 stated V15 called V1 (Administrator in Training) while V6 was standing at the nurse's station.
On 5/21/25 at 10:35 AM V7 (Certified Nursing Assistant) stated on 5/3/25 V7 witnessed R1 putting R1's hand up R2's shorts, placing R1's hand on R2's vagina on two occasions. V7 confirmed the first interaction between R1 and R2 was not reported to V1. V7 stated she and V6 made V15 aware of R1 touching R2's vagina after the second interaction and V15 called V1 to report the allegation.
On 5/20/25 at 3:15 PM, V1 (Administrator in Training) stated a report was not sent to the state agency regarding V6 and V7 witnessing R1 putting his hand up R2's shorts and touching R2's vagina. V1 also verified that V1 did not report V6 and V7's allegations of R1 and R2 to the local police department, resident representative, or state agency.
R1's was observed from 5/20/25-5/24/25 between 9:00 AM and 3:30 PM, self-propelling in R1's manual wheelchair throughout the facility.
The facility's Abuse, Prevention, &Prohibition Policy dated 12/2024 documents each resident has the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, agency staff, family members or legal guardians, friends, or other individuals. Resident abuse must be reported immediately to the administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. The facility will complete summarized investigation within five business days and submit to required agencies. Resident to Resident abuse means the individual's action was deliberate, regardless of whether the individual intended to inflict injury or harm. This policy further documents Administrator will report all allegations of abuse to the mandated state agency and Law enforcement. The allegation will be reported no later than two hours, or per state regulations, after the allegation is made.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to implement their abuse policy and procedure to thoroughly investigate an allegation of resident-to-resident sexual abuse, imple...
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Based on observation, interview, and record review the facility failed to implement their abuse policy and procedure to thoroughly investigate an allegation of resident-to-resident sexual abuse, implement measures to provide safety and supervision to prevent further abuse, and failed to submit a final report of the final investigation to the state agency within five working days for two of three residents (R1 and R2) reviewed for protection from abuse in the sample of ten. These failures resulted in R1 having unsupervised access to all 79 residents within the facility after R1 sexually assaulted R2.
Findings include:
The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility.
On 5/9/25at 10:30 AM, V6 (Certified Nursing Assistant) and V7 (Certified Nursing Assistant) stated they witnessed R1 putting R1's hand up R2's shorts, placing R1's hand on R2's vagina on two occasions.
On 5/20/25 at 3:15 PM, V1 (Administrator in Training) stated there was not an investigation, and a report was not sent to the state agency regarding V6 and V7 witnessing R1 putting his hand up R2's shorts and touching R2's vagina.
R1 and R2's electronic medical record did not include interventions or increased supervision to protect R2 from R1 further sexually abusing R2 or other residents in the facility.
On 5/21/25 at 10:30 AM, V6 and V7 stated V15 Licensed Practical Nurse called V1 and made V1 aware of the allegations of R1 touching R2's vagina in the dining room. V1 did not provide any safety interventions for the staff and told V15 that V1 would be in the facility on Monday to start the investigation.
On 5/21/25 at 12:19 PM, R1 was observed in the dining room sitting two tables away from R2.
R1's was observed from 5/20/25-5/24/25 between 9:00 AM and 3:30 PM, self-propelling in R1's manual wheelchair throughout the facility.
The facility's Abuse, Prevention, & Prohibition Policy dated 12/2024 documents each resident has the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, agency staff, family members or legal guardians, friends, or other individuals. Resident abuse must be reported immediately to the administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While the facility investigation is under way, steps will be taken to prevent further abuse. The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process. A licensed Nurse will assess the resident for injuries and notify the residents physician and responsible party. Social Services will complete a Trauma Informed care assessment and provide follow up care regardless of if allegation is substituted. Complete summarized investigation within five business days and submit to required agencies. Resident to Resident abuse means the individual's action was deliberate, regardless of whether the individual intended to inflict injury or harm.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to employ a licensed Administrator to ensure all residents were protected from abuse and all abuse allegations were investigated and reported t...
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Based on record review and interview the facility failed to employ a licensed Administrator to ensure all residents were protected from abuse and all abuse allegations were investigated and reported to the police, State Agency, and residents' representatives, to ensure all staff received mandatory annual in-servicing, and to maintain positive staff feedback. These failures have the potential to affect all 79 residents residing within the facility.
Findings include:
The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility.
The facility's Job Description Manual (undated) documents, Job Title Variations: Acting Administrator. Position Description: Manages all business-related activity to achieve the company vision and supporting strategies and assures that the company image as an ethical and high-quality provider of health services is maintained. Assist in the overall operation of the facility in accordance with current applicable federal, state, and local standards, guidelines and regulations while completing the required training hours for skilled nursing and long-term care and achieving a proficient level of competency within all departments of the facility. Principle Responsibilities: Conduct continuing education programs and in-service training to all department managers and special in-services for all staff. Promotes and maintains pro-active, positive feedback to staff while they are working. Maintains frequent, daily, informal interaction, and provides positive feedback to staff while they are working. Resident Rights: Reports allegations of resident abuse, neglect, and/or misappropriation of resident property. Staff Development: Attends and participates in scheduled in-service training, educational classes, and meetings to maintain current certification as applicable and as managed by regulatory agencies and company policies. Qualifications: Bachelor's degree in nursing home administration or related field required. Master's degree preferred. License as required by state law. Current knowledge of local, state, and federal guidelines and regulations.
V1's (Administrator-In-Training's/AIT's) Employee File documents V1 was hired on 6-1-24 as the Administrator of the facility.
V1's Employee File does not include evidence of V1 having a bachelor's degree or a temporary license to act as the facility's Administrator at any time between 6-1-24 through 5-24-25.
On 5-23-25 at 1:00 PM V2 (Director of Nursing/DON) provided all the facility's in-services provided to the employees within the last year. These in-services do not include the mandatory 12-hour CNA (Certified Nursing Assistant/CNA) annual trainings, staff trainings related to QAPI (Quality Assurance and Performance Improvement), staff trainings related to behavioral health services, staff training on the facility's infection control program and policies, and staff training regarding the facility's Compliance and Ethics Program.
On 5-21-25 at 9:25 AM, V6 (CNA) stated that V6 and V7 (CNA) witnessed R1 putting R1's hand up R2's shorts, placing R1's hand on R2's vagina on two occasions on 5-9-25. V6 stated that V1 (AIT) tried to make the sexual abuse incident between R1 and R2 seem like the staff were making it up and stated that V1 sweeps a lot of issues under the rug. V1 wrote witness statements in pencil and then changed what was wrote.
On 5-20-25 at 3:15 PM, V3 (LPN/Licensed Practical Nurse) stated that V1 (AIT) is part of the problem, and you can't trust anything V1 says.
On 5-20-25 at 4:00 PM, V4 (CNA) stated that V1 (AIT) has not investigated the sexual abuse allegations between R1 and R2 and V1 tries to cover stuff up.
On 5-20-25 at 4:05 PM, V5 (Assistant Director of Nursing) stated that V1 (AIT) does not tell the truth and V1 can be intimidating towards staff.
On 5-20-25 at 3:15 PM, V1 (AIT) stated that there was not an investigation and the state agency, resident representatives, or the police were not notified regarding V6 and V7 witnessing R1 putting his hand up R2's shorts and touching R2's vagina.
On 5-21-25 at 9:35 AM, V10 (LPN) stated that V10 called V1 (AIT) on 5-3-25 to report the sexual abuse allegation between R1 and R2. V10 stated V1 did not provide any direction to the staff to remove R1 from having contact with R2 or other residents in the facility.
On 5-21-25 at 10:16 AM, V7 (CNA) stated that V1 (AIT) wrote V7's witness statement in front of V7 in pencil. V7 stated the statement V1 documented is not what V7 told V1. V7 stated that V7 told V1 that R1 touched R2's private parts and V1 documented R1 touched R2's inner thigh. V7 stated that V1 is just trying to cover this situation up.
On 5-23-25 at 1:20 PM V1 (AIT) stated, This company did not have a good training plan. Whatever (V2/DON) gave you for in-services is the only training the staff would have had. I have never received a temporary administrator's license from the state, and I am not a licensed administrator. I do not have a bachelor's degree.
On 5-24-25 at 9:10 AM V2 (DON) verified the CNA's have not had the required annual 12-hour trainings, and the staff have not had annual training related to QAPI, behavioral health services, the infection program and policies, or the Compliance and Ethics Program.
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 F0944
(Tag F0944)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to ensure all staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to...
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Based on record review and interview the facility failed to ensure all staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 79 residents residing within the facility.
Findings include:
The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility.
The facility's Annual In-Servicing Calendar Policy dated 09/2022 documents, March: QAPI All Staff.
On 5/24/25 at 9:10 AM V2 (Director of Nursing) verified no staff received annual QAPI training.
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 F0945
(Tag F0945)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to ensure all staff received annual Infection Control and Prevention in-service training. This failure has the potential to affect all 79 resid...
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Based on record review and interview the facility failed to ensure all staff received annual Infection Control and Prevention in-service training. This failure has the potential to affect all 79 residents residing within the facility.
Findings include:
The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility.
The facility's Annual In-Servicing Calendar dated 09/2022 documents, April: Infection Prevention and Control All Staff
On 5/24/25 at 9:10 AM V2 (Director of Nursing) verified no staff received Infection Control and Prevention Training.
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 F0946
(Tag F0946)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to ensure all staff received annual Compliance and Ethics in-service training. This failure has the potential to affect all 79 residents residi...
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Based on record review and interview the facility failed to ensure all staff received annual Compliance and Ethics in-service training. This failure has the potential to affect all 79 residents residing within the facility.
Findings include:
The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility.
The facility's Annual In-Servicing Calendar dated 09/2022 documents, April: Ethics and Corporate Compliance All Staff.
On 5/24/25 at 9:10 AM V2 (Director of Nursing) verified no staff received annual Compliance and Ethics training.
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 F0949
(Tag F0949)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to ensure all staff received annual Behavioral Health in-service training. This failure has the potential to affect all 79 residents residing w...
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Based on record review and interview the facility failed to ensure all staff received annual Behavioral Health in-service training. This failure has the potential to affect all 79 residents residing within the facility.
Findings include:
The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility.
The facility's Annual In-Servicing Calendar dated 09/2022 documents, January: Behavioral Health All Staff. October: Behavioral Management All Staff.
On 5/24/25 at 9:10 AM V2 (Director of Nursing) verified no staff received annual Behavioral Health training.
Mar 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on interview and record review, the facility failed to ensure resident safety prior to repositioning for one of three residents (R1) reviewed for incidents and accidents in the sample of three. ...
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Based on interview and record review, the facility failed to ensure resident safety prior to repositioning for one of three residents (R1) reviewed for incidents and accidents in the sample of three. This failure resulted in R1 sustaining a deep leg laceration requiring a hospital visit, receiving 13 stitches, and antibiotic treatment.
Findings include:
The facility's Skin condition Monitoring policy and procedure, dated 1/18, documents It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. 1. Upon notification of a skin lesion, wound, or other skin abnormality, the Nurse will assess and document the findings in the nurses' notes and complete the QA (Quality Assurance) form for Newly Acquired Skin condition . 3. Any skin abnormality will have a specific treatment order until area is resolved . 4. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: c. Prevention techniques that are in use for the resident.
The Residents' Rights for People in Long-Term Care Facilities, dated 1/18, documents Your rights to safety includes the following: The facility must provide services to keep your physical and mental health at their highest practical levels and Your facility must be safe, clean, comfortable and homelike.
The undated Certified Nurses Aide/CNA Job Summary documents CNAs provide personal care and assistance to residents to assure their safety and comfort and demonstrates support of the philosophy of (the facility) by adhering to policies, procedures, and established Standards of Nursing Practices.
The Clinical Medical Record for R1 documents R1 with the following diagnoses: Chronic Obstructive Pulmonary Disease, Emphysema, Dysphagia, Scoliosis, Osteoporosis, Abnormal Posture, and Muscle Wasting.
The Nurse Progress Note for R1, dated 2/4/25 at 6:44 am, documents nurse was notified of R1 with leg injury and noted R1 with deep tissue skin tear. CNA reported R1 was injured during transfer from bed to the chair and was sent to the local hospital.
The Skin Tear report for R1, dated 2/4/25, documents Nurse was notified by V6 CNA that R1's leg was injured with deep tissue skin tear to her right lower leg, No injuries observed at the time of incident, and was sent to the local hospital for evaluation.
The local hospital record for R1, dated 2/4/25, documents the reason for R1's visit as Laceration of right lower extremity, initial encounter. Primary Dx (diagnosis): Leg pain, anterior right with laceration repair. The Medication Administration Record documents R1 received the pain medication Norco 7.5-325 mg (milligrams) one time at 8:44 am and lidocaine-Epinephrine 1% 10 ml (milliliters) was injected one time on 2/4/25 at 10:03 am. An x-ray of R1's right tibia and fibula was obtained on 2/4/25 at 9:02 am and findings as: Laceration related soft tissue changes are seen overlying the mid anterior tibia. R1 was treated for a laceration of right lower extremity.
The current Order Summary Report for R1, documents a 2/5/25 physician order for Cephalexin (antibiotic) 500 mg (milligrams) one capsule four times daily for leg wound.
The Infection Progress Note for R1, dated 2/4/25, documents R1 to receive Keflex 500 mg (milligrams) one capsule four times daily for 7 days for leg wound.
The Nursing Progress Note for R1, dated 2/4/25 at 1:47 pm, documents R1 returned from the local hospital with 10.5 cm (centimeter) deep tissue laceration with 13 stitches to R1's right leg mid-calf.
The Nursing Progress Note for R1, dated 2/4/25 at 8:09 pm, documents New order for Abt (antibiotic) d/t (due to) laceration on LLE (left lower extremity).
The current Care Plan for R1, documents 2/4/25 Laceration to right lower extremity with intervention to monitor for s/s of infection and on 2/10/25 exchange bed frame.
The Incident Progress Note for R1, dated 2/10/25, documents After investigation it was determined that the skin tear/laceration occurred while CNA was titling (reclining wheelchair) back due to restlessness. (R1) put her leg over side of chair and received a 10.5 cm (centimeter) laceration to right lower extremity from bottom edge of bed requiring 13 stitches. Intervention: replace bed frame, terminate CNA (V6), and monitor s/s (signs and symptoms) of infection.
The facility Investigation for R1's incident, dated 2/4/25, documents V5 CNA assisted V6 Former CNA to mechanically transfer R1 from her bed to a reclining back wheelchair and left R1 in her room. V5 reported there were no injuries at the time of the transfer. Shortly after V6 saw R1, in her room, attempting to get out of the wheelchair. V6 reported R1's leg got stuck under edge of bed as V6 was tipping R1's reclining wheelchair backward. V4 RN (Registered Nurse) was notified and assessed R1 with a large bleeding wound on lower anterior and lateral aspect of right lower leg. V3 ADON (Assistant Director of Nursing) reported assessed R1's leg and noted a large skin tear to anterior/lateral aspect of distal right leg. V6 Former CNA reported to V3 ADON that R1 was attempting to get out of the reclining wheelchair, so V6 Former CNA attempted to recline R1 back and R1's leg hit the lower edge of the bed causing the skin tear.
The facility Final Notification Form for R1, dated 2/10/25, documents R1 received a laceration to right lower leg, was sent to the local hospital. After investigation it was determined that skin tear/laceration occurred while CNA (V6) was tilting (reclining) chair back due to restlessness. (R1) put her leg over side of chair and received a 10.5 cm (centimeter) laceration to right lower extremity from bottom edge of bed requiring 13 stitches. Intervention: Replaced bed frame, terminated CNA and monitor for s/s (signs and symptoms) of infection.
The Incident Log dated 3/20/25 documents R1 with skin tear on 2/4/25.
On 3/20/25 at 11:00 am. V1 AIT (Administrator in Training) stated R1 required help for everything, was not cognitively intact, and did not move around on her own. V6 Former CNA was moving R1's wheelchair and caught R1's leg on a bolt on the bend of the bed causing a skin tear to R1's leg. R1 was sent out to the hospital and came back with stitches.
On 3/21/25 at 12:12 pm, V3 ADON (Assistant Director of Nursing) stated she was called down to R1's room to assess R1's right leg due to the nurses doing shift change report and noted a deep open wound bleeding wound to R1's right leg and a small amount of blood on R1's bed frame. V6 reported (V6) reclined R1's wheelchair and R1's right leg hit the lower edge of the bed frame causing the skin tear. V3 ADON confirmed V6 should have looked to see where R1's legs were prior to moving R1's wheelchair and that V6 was terminated for sleeping on third shift and causing the skin care.
On 3/21/25 at 12:20 pm, V5 CNA stated she helped V6 mechanically lift R1 from her bed into her wheelchair, there were no injuries during that time, and then V5 left R1's room. V5 stated she didn't see R1's wound until R1 returned from the hospital. It was a pretty large skin tear that was stitched back up.
On 3/21/25 at 3:30 pm, V1 AIT stated V6 should have looked to see where R1's legs were prior to moving R1 and V6 was terminated after working that shift for poor work performance and sleeping on the job. V1 stated the facility does not have a QA form for Newly Acquired Skin condition for R1 due to no longer using the form.
Aug 2024
17 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
Based on interview and record review the facility failed to administer physician ordered insulin to a resident (R12) with a diagnosis of Type Two Diabetes Mellitus with Diabetic Chronic Kidney disease...
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Based on interview and record review the facility failed to administer physician ordered insulin to a resident (R12) with a diagnosis of Type Two Diabetes Mellitus with Diabetic Chronic Kidney disease for one of one resident reviewed for insulin use in a sample of 47. This failure resulted in R12's emotional distress feeling like the facility was going to kill him because he wasn't getting his insulin as ordered and resulted in multiple abnormal laboratory values that reflected hyperglycemia.
Findings include:
The facilities Adverse Drug Reactions and Medication Discrepancy policy dated 11/6/18 documents, Procedure: 1. A medication discrepancy/error has been made when one of the following occurs: wrong medication administered, wrong dose administered, medication administered by wrong route, medication administered to wrong resident, medication administered at wrong time, and medication not administered.
The facilities Medication Administration policy, undated documents, The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. Procedure: Medications must be prepared and administered within one hour of the designated time or as ordered; after a drug is given, record the date, time, name of drug, dose and route on the resident's individual medication administration record; document any medications not administered for any reason by circling initials and documenting on the back of the MAR (medication administration record) the date, the time, the medication and dosage, reason for omission and initials; notify the physician as soon as practical when a scheduled dose of a medication has not been administered for any reason.
According to the CDC's (Centers for Disease Control) Testing for Diabetes and Prediabetes: A1C, dated 5/15/24, The A1C test measures your average blood sugar levels over the past 3 months. When sugar enters your bloodstream, it attaches to hemoglobin, a protein in your red blood cells. Everybody has some sugar attached to their hemoglobin, but people with higher blood sugar levels have more. The A1C test measures the percentage of your red blood cells that have sugar-coated hemoglobin. Your red blood cells regenerate roughly every 3 months. That's why the A1C test measures your blood sugar levels from that time period. A1C results: The following ranges are used to diagnose prediabetes and diabetes: Normal: below 5.7% (percent); Prediabetes: 5.7% to 6.4%; Diabetes: 6.5% or above. When living with diabetes, your A1C also shows how well managed your condition is. Your A1C can estimate your average blood sugar: A1C% 9=Estimated average glucose of 212. A1C goals: For most people with diabetes, the A1C goal is 7% or less. Your doctor will determine your specific goal based on your full medical history. Higher A1C levels are linked to health complications, so reaching and maintaining your goal is key to living well with diabetes.
On 08/18/24 at 9:59 AM, R12 was smiling and pleasant at first but became angry and belligerent when asked about his use of insulin. R12 was distressed explaining about staff not doing his insulin correctly. R12 does not feel that he is getting his insulin and that they (nurses) are going to kill him.
R12's current care plan documents R12 has a diagnosis of Type Two Diabetes Mellitus with Diabetic Chronic Kidney Disease. Care Plan also documents the intervention to administered diabetes medication as ordered by the doctor, and to monitor/document for side effects and effectiveness.
R12's physician orders dated 08/2024, documents that R12 has orders for Tresiba Flextouch 100u/ml (units/milliliter) 50 units subcutaneous in the am and 20 units subcutaneous at bedtime, Trulicity 3mg (milligrams)/0.5ml give 0.5ml subcutaneous every week on Saturday, Insulin Lispro Kwikpen 100u/ml per sliding scale starting at blood glucose level of 200 four times a day and blood glucose level checks four times a day.
R12's Medication Administration Record, dated May 5/1/24 to 5/31/24, has no documentation of blood glucose level checks done for 40 of 124 opportunities, 9 of 62 opportunities of no Tresiba insulin being administered, and 65 of 124 opportunities of no Lispro sliding scale insulin being administered.
R12's Medication Administration Record, dated June 6/1/24 to 6/30/24, has no documentation of blood glucose level checks done for 48 of 120 opportunities, 7 of 60 opportunities of no Tresiba insulin being administered, 3 of 5 opportunities of Trulicity insulin not being administered, and 59 of 124 opportunities of no Lispro sliding scale insulin being administered.
R12's Medication Administration Record, dated July 7/1/24 to 7/31/24, has no documentation of blood glucose level checks done for 65 of 124 opportunities, 2 of 62 opportunities of no Tresiba insulin being administered, 3 of 4 opportunities of Trulicity insulin not being administered, and 59 of 124 opportunities of no Lispro sliding scale insulin being administered.
R12's Medication Administration Record, dated August 8/1/24 to 8/19/24 2024, has no documentation of Lispro sliding scale insulin being administered for 11 of 76 opportunities.
R12's Fasting Glucose laboratory results, dated 4/23/24, documents R12's blood glucose level is high at 132 (range 65-99). The laboratory results also document the physician's response to the high glucose level to obtain a hemoglobin A1C.
R12's Fasting Glucose laboratory results, dated 7/30/24, documents R12's blood glucose level is high at 169 (range 65-99).
R12's Hemoglobin A1C laboratory results, dated 8/5/24, documents R12's Glycohemoglobin-HGBA1C level is high at 9.3 (range 4.1-6.1%). R12's medical records has no documentation of a hemoglobin A1C being done prior to these results.
On 08/20/24 at 12:44 AM, V3 (Assistant Director of Nursing) stated that the expectation for the nurses when it comes to documenting blood glucose levels and units of insulin given is they (nurses) will initial the box for blood glucose level and write the level and then in a separate box the nurses will initial and document the amount of insulin units given. V3 stated that if the glucose level and insulin units are left blank it can be interpreted as not completed. V2 (Director of Nursing) was present and agreed with V3's statement.
On 08/21/24 at 08:18 AM, V21 (R12's physician) stated he had ordered a Hemoglobin A1C based on R12's glucose level on a Basic Metabolic Panel in April, and his expectation was to have it done next lab day. V21 is aware that R12's Hemoglobin A1C was not done until 8/5/24 and the level of 9.3 which he states is higher than expected and he wants it 8 or below. V21 stated that not receiving insulin or having routine monitoring of blood sugars could have an effect on R12's hemoglobin A1C levels.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of staff to resident mental abuse to the state...
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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 staff to resident mental abuse to the state agency for one of three residents (R23) reviewed for abuse in the sample of 47.
Findings include:
The facility's Abuse Prevention Program policy, dated 11/28/16, documents The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This policy also documents Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, misappropriation or resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency or jurisdiction and (the state agency) immediately after forming the suspicion (but no later than two hours after forming the suspicion), otherwise the report must be made not later than 24 hours after forming the suspicion.
R23's Cognitive assessment dated [DATE] documents R23 is cognitively intact.
On 8/18/24 at 11:37 AM, R23 stated I was a resident at the facility until last Friday when I moved to my own apartment. The nurse (V8, Licensed Practical Nurse) works day shift is not liked by several residents. (V8) would always hold my medications and then laugh about it. (V8) would give me a hard time, mostly with medications and then laugh when I would get upset. She would laugh about how long it would take her and I take a lot of medications. She would make me the last person but for sure if I came up and asked for my medications then she would make me wait even longer on purpose and give me mine last. I spoke to the administrator (V1, Administrator in Training) about this, and I talked mostly to the Director of Nursing (V2) and Assistant Director of Nursing. I saw them go and talk to (V8) and then they both acted funny towards me afterwards. I don't know what she told them, but they believed her over me. This happened on 8/6/24 that I told (V3) all of this.
On 8/19/24 at 11:00 AM, V1 (Administrator in Training) stated I do not have any abuse allegations or investigations since I have been here. I don't see where the prior there was any for the last year. But I have been here since June, and I don't have anything for Abuse.
08/19/24 1:53 PM, V10 (Certified Nursing Assistant, CNA) stated she was working on the day (R23) was very upset about (V8) being his nurse. V10 stated (R23) is normally a cool and calm resident with little complaint. That day however, he was very upset, angry and emotional. He said she (V8) is evil and had been verbally abusive. The ADON (V3) was aware. She was the one who gave him his medications that day and she was down there talking to him about the situation.
On 8/19/24 at 2:02 PM, V3 (Assistant Director of Nursing) confirmed she talked to R23 at some point over the last three weeks about V8. V3 stated (R23) told me (V8) would not do his insulin and blood glucose checks the way he felt they should be done. There was a personality conflict there. He would call me on the facility phone and ask me to give his medications. (R23) refused to take them from (V8) because he said he didn't trust her. When he brought this to our attention, we talked with him and with (V8) and I stopped putting her on that hall until (R23) was out of the building. (R23) would tell me I am not going to take my medications from (V8), I don't trust her. (V1, Administrator in Training) is the Abuse coordinator. He did the investigation with us (V2 Director of Nursing and V3), and we determined that we would avoid conflict and keep her off of (R23's) hall until he discharged .
On 8/19/24 at 2:11 PM, V1 confirmed he did not submit an Abuse report to the state agency when he was informed that R23 had conflicts with V8. V1 stated (R23) stated he didn't like (V8). He said when she works his hall, he didn't like her and (R23) didn't want (V8) to give him his medications. He did not like her personality. I didn't see that as abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record the facility failed to immediately remove an employee accused of mental abuse from resident care a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record the facility failed to immediately remove an employee accused of mental abuse from resident care and complete an abuse investigation for alleged staff to resident abuse for one of three residents (R23) reviewed for Abuse in the sample of 47.
Findings include:
The facility's Abuse Prevention Program policy, dated 11/28/16, documents The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This policy also documents Employees of this facility who have been accused of mistreatment, neglect, abuse or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment, neglect, abuse or misappropriation of resident property shall not complete their shift as a direct care provider to residents. Once the administrator or designee receives an allegation of mistreatment, neglect or abuse, including injuries of unknown or source and misappropriation of resident property; the administrator will appoint a person to take charge of the investigation. The person in charge of the investigation will obtain a copy of any documentation relative to the incident and follow the resident protection investigation procedures.
R23's Cognitive assessment dated [DATE] documents R23 is cognitively intact.
R23's Care Plan, dated 6/4/24, documents R23 was admitted on [DATE] and has a care plan of (R23) may display pattern of voicing allegations of mistreatment by caregivers. Intervention: Investigate statements/allegation per facility protocol. Check resident for any physical marks, injury, interview persons assigned to provide care.
On 8/18/24 at 11:37 AM, R23 stated I was a resident at the facility until last Friday when I moved to my own apartment. The nurse (V8, Licensed Practical Nurse) works day shift is not liked by several residents. (V8) would always hold my medications and then laugh about it. (V8) would give me a hard time, mostly with medications and then laugh when I would get upset. She would laugh about how long it would take her and I take a lot of medications. She would make me the last person but for sure if I came up and asked for my medications then she would make me wait even longer on purpose and give me mine last. I spoke to the administrator (V1, Administrator in Training) about this, and I talked mostly to the Director of Nursing (V2) and Assistant Director of Nursing. I saw them go and talk to (V8) and then they both acted funny towards me afterwards. I don't know what she told them, but they believed her over me. This happened on 8/6/24 that I told (V3) all of this.
On 8/19/24 at 11:00 AM, V1 (Administrator in Training) stated I do not have any abuse allegations or investigations since I have been here. I have been here since June, and I don't have anything for Abuse.
08/19/24 1:53 PM, V10 (Certified Nursing Assistant, CNA) stated she was working on the day (R23) was very upset about (V8) being his nurse. V10 stated He would complain about (V8) all the time. The day that he was most upset was when he was in the dining room. (R23) was yelling and complained of (V8) not giving him his medication and always chooses to give them to him last. He didn't want (V8) to be his nurse. It was either the fifth or the sixth of August that this incident with (R23) happened. The ADON (V3, Assistant Director of Nursing) gave him his medication that day because he refused to have (V8) as his nurse any longer. (R23) is normally a cool and calm resident with little complaint. That day however, he was very upset, angry and emotional. He said she (V8) is evil and had been verbally abusive. The ADON (V3) was aware. She was the one who gave him his medications that day and she was down there talking to him about the situation.
On 8/19/24 at 2:02 PM, V3 (Assistant Director of Nursing) confirmed she talked to R23 at some point over the last three weeks about V8. V3 stated (R23) told me (V8) would not do his insulin and blood glucose checks the way he felt they should be done. There was a personality conflict there. He would call me on the facility phone and ask me to give his medications. (R23) refused to take them from (V8) because he said he didn't trust her. When he brought this to our attention, we talked with him and with (V8) and I stopped putting her on that hall until (R23) was out of the building. (R23) would tell me I am not going to take my medications from (V8), I don't trust her. (V1, Administrator in Training) is the Abuse coordinator. He did the investigation with us (V2 Director of Nursing and V3), and we determined that we would avoid conflict and keep her off of (R23's) hall until he discharged .
On 8/19/24 at 2:11 PM, V1 confirmed he did not remove the employee (V8) from resident contact, interview other residents, or complete an abuse investigation when he was informed that R23 had conflicts with V8. V1 stated (R23) stated he didn't like (V8). He said when she works his hall, he didn't like her and (R23) didn't want (V8) to give him his medications. He did not like her personality. I didn't see that as abuse.
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** 3. R44's current Care Plan, dated 8/8/24, documents R44 has a diagnosis of Bipolar Disorder and has a most recent admission date...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R44's current Care Plan, dated 8/8/24, documents R44 has a diagnosis of Bipolar Disorder and has a most recent admission date of 2/1/24.
R44's Minimum Data Set assessment, dated 8/8/24, documents R44 has Delusions and
Psychiatric/Mood Disorders of Anxiety, Depression and Bipolar Disorder.
R44's medical record does not document a PASARR screen has ever been completed for R44.
On 8/20/24 at 12:08 PM, V3 (ADON) stated I do not have a PASARR on (R44). I can't find it in any of our records. She has been here a while so we have a request out now to have a screen done for her.
Based on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed for three of four residents (R1, R44 and R58) reviewed for PASARR screenings in the sample of 47.
Findings include:
1. R1's current Physician's Orders document R1's current diagnoses to include: Schizophrenia and Psychosis.
R1's current medical record has no documentation of a PASARR Level I completed.
On 08/20/24 at 10:05 AM, V3 (Assistant Director of Nursing/ADON) stated the facility has no record of R1 ever receiving a PASARR Level I.
2. R58's current Physician's Orders document R58 was admitted to the facility on [DATE] with a diagnoses of Schizophrenia.
R58's Notice of PASARR Level I Screen Outcome (dated 01/23/24) documents the following: Your PASARR Level I screening is complete. Your Level I screen shows you may have a serious mental illness or intellectual/developmental disability. You meet the criteria for Convalescent Care, and you may stay for up to 60 calendar days in nursing facility without further PASARR Assessment as long as you also require the level of services provided by a nursing facility.
R58's medical record has no further documentation of any additional PASARR Level I screening completed once R58's stay at the facility exceeded 60 calendar days.
On 08/20/24 at 10:30 AM, V3 (ADON) stated the facility has not reached out for an additional PASARR screening to be completed on R58, as previously indicated in R58's 01/23/24 PASARR Level I Screen Outcome.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
3. On 8/18/24 at 11:05 AM, R44 was sitting in her room in a wheelchair. R44 was pleasantly confused with conversation.
R44's Wound Assessment Plans, dated 8/12/24, document R44 has an active left foot...
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3. On 8/18/24 at 11:05 AM, R44 was sitting in her room in a wheelchair. R44 was pleasantly confused with conversation.
R44's Wound Assessment Plans, dated 8/12/24, document R44 has an active left foot lateral pressure injury with 100% eschar and an active stage three right hip pressure injury.
R44's Treatment Administration Record (TAR), dated 8/2024, documents R44 has an order for Weekly Skin Documentation on back of TAR Wednesday. This administration record documents from 8/1/24-8/19/24, one skin check was completed (two missed scheduled skin checks). This same TAR documents R44 has an order to Right hip cleanse with Normal Saline or wound cleanser, pat dry and apply Calcium Alginate (medicated dressing) and dry dressing three times a week Tuesday, Thursday, Saturday. This administration record documents from 8/6/24-8/19/24, three scheduled hip wound treatments were not administered. This same TAR documents R44 has an order to Left lateral foot cleanse with Normal Saline or wound cleanser, pat dry and apply gauze for padding/dry dressing three times a week, Tuesday, Thursday, Saturday. This administration record documents from 8/1/24-8/19/24, three scheduled foot wound treatments were not administered.
R44's current care plan, dated 8/8/24, does not document a care plan for R44's pressure ulcer.
R44's significant change Minimum Data Set (MDS) assessment, dated 8/8/24, documents R44 does not have any pressure ulcers.
On 8/20/24 at 2:08 PM, V4 (Licensed Practical Nurse) administered dressing changes to R44's left foot and right hip wounds. V4 confirmed the TAR for August 2024 contains several holes in administration documentation. V4 stated I round for wounds weekly and that is all. (R44) has had these pressure ulcers. I am not the one responsible for daily treatments. Whoever is working the floor is responsible for the scheduled treatment administrations. I have seen the holes in charting on the TAR where it looks like several were treatments were missed. They should be charting the treatments on the TAR, otherwise we cannot prove that they are being done.
On 8/21/24 at 9:55 AM, V5 (Minimum Data Set/ Care Plan coordinator) stated I do not have (R44's) pressure ulcer coded on her 8/8/24 MDS or on her care plan and that is something that should be on there. Any staff can add to the care plan and wounds should go right to the care plan when they discover a wound.
Based on observation, interview and record review, the facility failed to ensure physician ordered daily skin checks and scheduled pressure ulcer treatments were completed and a pressure ulcer care plan was developed for three of three residents (R34, R35, R44) reviewed for pressure ulcers in the sample of 47.
Findings include:
The facility's Decubitus Care/ Pressure Areas policy, dated 1/2018, documents It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote healing of any pressure ulcer. This policy also documents The pressure area will be assessed and documented on the Treatment Administration Record (TAR) or the Wound Documentation Record. Initiate physician order on treatment sheet. When a pressure ulcer is identified additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers.
The facility's Comprehensive Care Plan Planning policy, dated 11/1/17, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining for determining each Resident's strengths, needs, goals, life history and preferences to develop a person-centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being.
The facility policy, Pressure Sore Prevention Guidelines, dated (revised) 01/18 documents, It is the facility policy to provide adequate interventions for the prevention of pressure ulcers for residents who are identified as High or Moderate risk for skin breakdown as determined by the Braden Scale. The nurse will complete a skin assessment on all residents upon admission, then weekly for four weeks. After the weekly skin assessments are completed they must be done with an Annual, Quarterly and Significant Change Assessment. The following guidelines will be implemented for any resident assessed as a Moderate or High skin risk: Daily skin checks. Any resident scoring a High or Moderate risk for skin breakdown will have scheduled skin checks on the Treatment Record. Skin checks will be completed and documented by the nurse.
1. R34's current Physician Order Sheet, dated August 2024 includes the following diagnoses: Spastic Cerebral Palsy, Malnutrition, Epilepsy and Scoliosis. This same form also includes the following physician orders: Skin check once daily.
R34's most current Braden Scale for Predicting Pressure Ulcer Risk form, dated 6/11/24 documents, TOTAL SCORE= 13 (16 and less is High Risk).
R34's Treatment Administration Record dated 8/1/24- 8/17/24 documents 10 of 17 physician ordered daily skin checks as not being performed by facility staff.
On 8/20/24 at 10:15 A.M., V2/Director of Nurses (DON) verified the missing documentation indicating staff failed to perform the required daily skin checks.
2. R35's current Physician Order Sheet, dated August 2024 includes the following diagnoses: History of Bilateral Knee Amputation, Chronic Kidney Disease, Type 1 Diabetes Mellitus, Chronic Diastolic Heart Failure and Depression with Anxiety. This same form also includes the following physician orders: Skin check once daily.
R35's most current Braden Scale for Predicting Pressure Ulcer Risk form, dated 7/16/24 documents, TOTAL SCORE= 17 (17-20 is Moderate Risk).
R35's Treatment Administration Record dated 8/11/24- 8/17/24 documents 3 of 7 physician ordered daily checks as not being performed by facility staff.
On 8/20/24 at 10:15 A.M., V2 (DON) verified the missing documentation indicating staff failed to perform the required daily skin checks.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to perform hand hygiene during suprapubic catheter care for one of two residents (R7) reviewed for urinary catheters in a sample o...
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Based on observation, interview and record review the facility failed to perform hand hygiene during suprapubic catheter care for one of two residents (R7) reviewed for urinary catheters in a sample of 47.
Findings include:
The facility's Standard Precautions policy, dated 4/11/22, documents Procedure: 1. Handwashing: wash hands after touching blood, body fluids, secretions, excretions and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed between resident contacts and when otherwise indicated to avoid transfer of microorganism to other residents or environments. It maybe necessary to wash hands between task and procedures on the same resident to prevent cross-contamination of different body sites. 3. Gloves: Wear gloves (clean , nonsterile gloves are adequate) when touching blood, body fluids, secretions, excretions and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use , before touching noncontaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments.
R7's care plan, dated 8/16/24, documents R7 has a suprapubic catheter for the diagnoses of Neurogenic Bladder and Obstructive Uropathy. The care plan also documents a goal for R7 to show no signs and symptoms of urinary infection.
On 08/20/24 at 10:15 AM, V4 LPN (Licensed Practical Nurse) removed a gauze dressing saturated with bloody drainage from R7's supra pubic catheter insertion site. Then, V4 removed her gloves, and without performing hand hygiene proceeded to apply a new pair of gloves. V4 continued to perform suprapubic catheter care. V4 removed her gloves, and again without performing hand hygiene proceeded to apply new gloves. Then, V4 applied a new clean gauze dressing to R7's suprapubic catheter insertion site. V4 stated she should have performed hand hygiene between all glove changes and stated that R7 has a history of urinary tract infections.
R7's urinalysis, dated 7/19/24, documents abnormal urinalysis with growth of 60-70,000 CFU/ml (Colony-Forming Unit per milliliter) of Providencia Stuartii .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a licensed pharmacist reviewed a resident's medication regimen monthly for six consecutive months for one of five residents (R57) re...
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Based on interview and record review, the facility failed to ensure a licensed pharmacist reviewed a resident's medication regimen monthly for six consecutive months for one of five residents (R57) reviewed for unnecessary medications in a sample of 47.
Findings include:
The Facility Psychotropic Medication Policy, dated 11/28/17, documents, Nursing Administration will meet with the consultant Pharmacist on a monthly basis to discuss any resident who may need or is due for a possible medication reduction.
R57's current medical record, as of 8/20/24, has no documentation of R57 having any Medication Regimen Reviews completed by a licensed pharmacist for the months of March, April, May, June, July, and August 2024.
On 8/20/2024 at 9AM, V2 (Director of Nursing) confirmed that for the time span of 2/2024-8/2024, R57 only had one medication regimen review completed by a licensed pharmacist in February 2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
3. R7's Physician orders, dated 8/2024, documents that R7 has orders to receive: Aripiprazole (antipsychotic) 15mg by mouth at bedtime with a start date of 3/1/23; Luvox (antidepressant) 100mg by mout...
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3. R7's Physician orders, dated 8/2024, documents that R7 has orders to receive: Aripiprazole (antipsychotic) 15mg by mouth at bedtime with a start date of 3/1/23; Luvox (antidepressant) 100mg by mouth twice a day with a start date of 8/13/21; Luvox 50mg by mouth daily at noon with a start date of 8/13/21; Remeron (antidepressant) 7.5mg by mouth six times a week omitting Wednesdays with a start date of 2/18/22.
R7 Behavior tracking records, dated June-August 2024, documents that R7 is being monitored for behaviors of irritability, restlessness, and self-injury. The records also document that during this time span R7 only had two occurrences of behaviors.
On 8/18/24 at 10:00 AM, R7 was sitting up in his wheelchair in the dining room. R7 was calm, pleasant but had repetitive verbalizations during conversation regarding his stroke. R7 answered questions when spoken to and no outward behaviors were displayed.
On 08/20/24 at 10:15 AM, while V4 LPN (Licensed Practical Nurse) performed R7's supra pubic catheter care R7 was pleasant and interacted appropriately with V4.
R7's Pharmacy consultation reports, dated 3-28-24, 4-30-24, 5-30-24, and 6-28-24, all document the following, R7 has received Aripiprazole 15mg po (by mouth) q (every) hs (night), Fluvoxamine (Luvox) 100mg po BID (twice a day) and 50 mg po once daily at Noon, and Mirtazapine (Remeron) 7.5mg po q hs 6 days per week for depression with impulse control disorder since March 2023 when the Aripiprazole was reduced. Recommendation: Please attempt a gradual dose reduction (GDR) for the above medications, perhaps by reducing the Aripiprazole to 10mg po q HS when current supply is finished. Rationale for Recommendation: CMS (Centers for Medicaid and Medicare Services) requires that antipsychotics, used to treat an enduring condition other than dementia, be evaluated at least quarterly with documentation regarding continued clinical appropriateness. Dose reductions should occur in modest increments over adequate periods of time to minimize withdrawal symptoms and to monitor symptom recurrence (e.g., GDR is attempted in 2 separate quarters, with at least 1 month between attempts, within the first year in which an individual is admitted on a psychotropic medication or after the prescriber has initiated such medication, unless clinically contraindicated). Also, all four of R7's pharmacy consultation reports have no documentation of a physician's response to the pharmacist's recommendations.
On 8/21/24 at 10:40 a.m., V2 (Director of Nursing) stated that R7's fluvoxamine (Luvox), aripiprazole, and mirtazapine have not had a gradual dose reduction in the last year, and they are all past due to be reduced. V2 also stated that R7's pharmacy recommendations should document the doctor's response, however R7's do not have any documentation of the doctor acknowledging nor responding to the pharmacist's recommendation.
Based on observation, interview and record review, the facility failed to document a diagnosis and target behaviors to warrant the use of an antipsychotic medication, provide justification for the continued use of an antipsychotic medication, and attempt a gradual dose reduction of psychotropic medications for three of seven residents (R7, R49, R60) reviewed for psychotropic medications in the sample of 47.
Findings include:
The facility's Psychotropic Medication Policy, dated/revised November 28th, 2017, documents, It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drugs are any drug used: 1. In an excessive dose, including in duplicate therapy. 2. For excessive duration. 3. Without adequate indications for its use. 4. Without adequate indications for its use. 5. In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. The policy also documents, 7. Any resident receiving such medications shall have a psychiatric diagnosis or documented evidence of maladaptive behavior, which can be considered harmful to themselves or others, destructive to property, or if emotional problems exist which cause the resident frightful distress. 8. The Behavioral Tracking sheet of the facility will be implemented to ensure behaviors are being monitored. 9. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs. Any at a minimum of every quarter by the interdisciplinary team. 10. Reductions shall be attempted at least twice in one year, unless the physician documents the need to maintain the resident regimen according to the Regulatory Guidelines for such. In addition, the policy documents, 19. Any resident receiving any psychotropic medication will have certain aspects of their use and potential side effects addressed in the resident's care plan at least quarterly. The care plan will identify target behaviors causing the use of psychotropic medications. The care plan will address the problem, approaches, and goals to address these behaviors. Any suspected problems will be reported to the physician. Attempts to rule out social and environmental factors as causative agents will be made in the care plan assessment.
1. R60's Physician Order Sheet, order dated 8/2024, documents R60 has orders for quetiapine (Seroquel) (antipsychotic medication) 25 mg (milligrams) one tablet by mouth twice a day. R60's Physician Order Sheet has no diagnosis documented for the use of R60's Seroquel.
R60's Care Plan, dated 6/25/24, does not document that R60 receives antipsychotic medication.
R60's Behavior Tracking Record, dated June 2024, documents R60's Target Behavior is monitor for a mood and behavior.
R60's Behavior Tracking Record, dated July 2024, documents R60's Target Behavior is restive to cares resident new admit please report all mood and behaviors. R60 has no behavior episodes documented in both her June and July 2024 Behavior Tracking Records.
On 8/18/24 at 10:40 AM, R60 was in her room on her bed. R60 was quiet, calm, and conversing with no issues. R60 did not display any outward behaviors.
On 8/20/24 at 11:30AM, V13 (Certified Nursing Assistant) stated that R60 never shows any type of negative behavior or violence or says anything inappropriate towards other residents. V13 also stated, Sometimes she can have an attitude when it's time to get up and get around, but I wouldn't call that any type of behavior.
On 8/20/2024 at 11:40AM, V3 (Assistant Director of Nursing/ADON) stated that she does not know why R60 was receiving Seroquel. V3 also stated that R60 doesn't have behaviors or a diagnosis that would warrant the use of Seroquel. V3 stated the only behaviors she was aware of was, R60 can be very repetitive and does not remember what she has said. 2. R49's current Diagnosis Report documents R49's diagnoses to include: Schizophrenia; Schizoaffective Disorder; Mood Disturbance and Anxiety; and Depression.
R49's current Physician's Orders document the following medication order: Clozaril (antipsychotic, date of order 06/12/22) 1500 milligrams twice daily.
R49's Monthly Behavior Tracking Records (dated February 2024 - August 2024) do not document any target behaviors or a consistent pattern of adverse behaviors displayed by R49. These same forms had multiple days throughout each month that were left blank, and R49's Behavior Tracking Record (dated May 2024) is completely blank for the entire month.
R49's current care plan has no mention of any target behaviors displayed by R49 and has no documentation of any behavioral interventions in place.
From 08/19/24 - 08/21/24, multiple observations of R49 were conducted, and no adverse behaviors were displayed by R49 during this time.
R49's Consultation Report (dated 05/30/24) does not address the suggested gradual dose reduction for R49's Clozaril.
On 08/21/24 at 08:40 AM, V3 (ADON) stated that R49 occasionally displays the following behaviors: hoarding, agitation when someone interferes with his hoarded items, and withdrawn/self isolation. V3 stated R49 is not a harm to himself or others, and he has been, pretty stable with not a lot of behaviors. V3 stated that none of R49's target behaviors are noted on his Behavior Tracking Record, or his care plan and should be. V3 also confirmed that R49 does not have a consistent pattern of any adverse behaviors documented, and several days on R49's Behavior Tracking Records are blank with nothing documented. V3 then stated that R49 has been on the same dose of Clozaril since June 2022, and no gradual dose reduction has been attempted when suggested.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain physician ordered laboratory tests for one of one resident (R67) reviewed for lab monitoring in a sample of 47.
Findings Include:
Th...
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Based on interview and record review, the facility failed to obtain physician ordered laboratory tests for one of one resident (R67) reviewed for lab monitoring in a sample of 47.
Findings Include:
The facility policy, Laboratory Tests, dated (reviewed) 9/27/2017 directs staff, Appropriate laboratory monitoring of disease processes and medications requires consideration of many factors including concomitant disease(s) and medications(s), wishes of the resident and family and current standards of practice. Laboratory testing will be completed in collaboration with Medicare guidelines, pharmacy recommendations and physician orders. Obtain laboratory orders upon admission, readmission and PRN (as needed) for medication and condition monitoring per the physician's order.
R67's admission Physician Order Sheet/POS, dated 7/16/24 includes the following diagnoses: Acute Hypoxic Respiratory Failure, Diabetic Ketoacidosis, Acute Kidney Injury, Diabetes Mellitus, Dizziness and Weakness. This same POS also includes the following physician orders for labs: CMP (Complete Metabolic Profile) and CBC (Complete Blood Count) on 7/19/24.
A review of R67's Medical Record on 8/19/24 indicates no lab test results are available.
On 8/19/24 at 1:45 P.M. V2/Director of Nurses confirmed the missing lab test for R67. V2/Director of Nurses stated, Staff missed getting that lab ordered for (R67).
CONCERN
(E)
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** 3. R45's electronic Census List documents R45 was sent from the facility to the hospital on 5/24/24, 6/17/24, 7/20/24 and 8/5/24...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R45's electronic Census List documents R45 was sent from the facility to the hospital on 5/24/24, 6/17/24, 7/20/24 and 8/5/24.
R45's current medical record does not document that a written notice of transfer was provided to R45 at the time of transfer on 5/24, 6/17, 7/20 or 8/5/24.
Based on interview and record review the facility failed to notify the facility Ombudsman monthly of a resident transfer to the hospital and failed to provide the resident and resident representative with a written notice of transfer. This failure has the potential to affect all 47 facility residents.
Findings Include:
1. R25's facility Census List, provided by V9/Business Office Manager on 8/19/24 documents that R25 was transferred to a local hospital on 2/9/24 and on 6/8/24. No evidence of a facility notification to R26 of a transfer/discharge was present on R25's chart.
2. R35's facility Census List, provided by V9/Business Office Manager on 8/19/24 documents that R35 was transferred to a local hospital on 4/24/24, 7/6/24 and 8/6/24. No evidence of a facility notification to R26 of a transfer/discharge was present on R35's chart.
On 8/20/24 at 11:09 A.M., V7/Social Services Director verified that the facility did not provide R25, R35 or their representatives with a written notice of transfer. At that time, V7/Social Services Director also confirmed that she had not sent notification to the local Ombudsman of monthly facility transfers/discharges.
4. R70's Progress Note dated 06/08/24 and timed 02:00 PM documents the following: [AGE] year-old male arrived per (local facility) transport. On 2 Liters of Oxygen via nasal cannula. Is No Known Allergies and on cardiac diet. Is a full code and per hospital weight of 104 pounds. Hospital Admitting Diagnosis: Cardiac Arrest possible due to cocaine abuse with acute respiratory failure post arrest, as well as hypertension episode. Arrived per wheelchair and was admitted to (facility room). On cardiac diet at this time.
R70's Progress Note dated 06/08/24 and timed 06:30 PM documents, Resident complained of Shortness of Breath, Oxygen Saturation 79%. This nurse called 911 and resident was transported out. Resident took his belongings per him will not return.
R70's medical record did not contain documentation that a written notice of transfer was provided upon R70's transfer to the local hospital on [DATE], or documentation that the Ombudsman was notified of R70's transfer.
On 08/20/24 at 04:30 PM, V1 (Administrator) stated a written notice of transfer was not provided to R70 upon his transfer to the local hospital on [DATE]. V1 also confirmed that the Ombudsman was not made aware of R70's transfer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R45's electronic Census List documents R45 was sent from the facility to the hospital on 5/24/24, 6/17/24, 7/20/24 and 8/5/24...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R45's electronic Census List documents R45 was sent from the facility to the hospital on 5/24/24, 6/17/24, 7/20/24 and 8/5/24.
R45's current medical record does not document that a bed hold was provided to R45 at the time of transfer on 5/24, 6/17, 7/20 or 8/5/24.
Based on interview and record review the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital, for four of four residents (R25, R35, R45 and R70), reviewed for bed holds, in the sample of 47.
Findings Include:
The facility Bed Hold Guarantee Policy, dated (revised) 8/1/17 directs staff, The resident, resident family or legal representative will be given the appropriate 'Notice of Bed Hold Policy'' at the time of discharge or therapeutic leave, if possible, but notice will be given no longer than 24 hours after discharge or initiation of leave.
1. R25's medical record documents that R25 was hospitalized on [DATE] and 6/8/24. R25's medical record does not contain documentation of written notice to R25 or R25's resident representative, of the facility bed hold policy.
2. R35's medical record documents that R35 was hospitalized on [DATE], 7/6/24 and 8/6/24. R35's medical record does not contain documentation of written notice to R35 or R35's resident representative, of the facility bed hold policy.
On 8/20/24 at 11:09 A.M., V7/Social Services Director verified that the facility did not provide R25 or R35 or his representative with a a Bed Hold Policy or a written Notice of Transfer.
4. R70's Progress Note dated 06/08/24 and timed 02:00 PM documents the following: [AGE] year-old male arrived per (local facility) transport. On 2 Liters of Oxygen via nasal cannula. Is No Known Allergies and on cardiac diet. Is a full code and per hospital weight of 104 pounds. Hospital Admitting Diagnosis: Cardiac Arrest possible due to cocaine abuse with acute respiratory failure post arrest, as well as hypertension episode. Arrived per wheelchair and was admitted to (facility room). On cardiac diet at this time.
R70's Progress Note dated 06/08/24 and timed 06:30 PM documents, Resident complained of Shortness of Breath, Oxygen Saturation 79%. This nurse called 911 and resident was transported out. Resident took his belongings per him will not return.
R70's medical record did not contain documentation that R70 was provided notice of the facility's bed hold policy prior to his transfer to the local hospital on [DATE].
On 08/20/24 at 04:30 PM, V1 (Administrator) stated the facility's bed hold policy was not provided to R70 upon his transfer to the local hospital on [DATE].
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
2. R4's Physician orders, dated 8/2024, document R4 has an order to receive Eliquis (anticoagulant) 5mg by mouth twice a day.
R4's Current Care Plan, as of 8/20/24, has no comprehensive care plan for...
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2. R4's Physician orders, dated 8/2024, document R4 has an order to receive Eliquis (anticoagulant) 5mg by mouth twice a day.
R4's Current Care Plan, as of 8/20/24, has no comprehensive care plan for the use of an anticoagulant.
On 08/21/24 at 08:46 AM, V5 (Care Plan Coordinator) stated that there is no care plan for the use of R4's anticoagulants.
3. R7's Physician orders, dated 8/2024, documents R7 has orders to receive Aripiprazole (antipsychotic) 15mg by mouth at bedtime, Buspar (antianxiety) 10mg two tablets by mouth three times a day, Klonopin (antianxiety) 0.5mg by mouth in the evening, Luvox (antidepressant)100mg by mouth twice a day, Luvox 50mg by mouth at noon, and Remeron (antidepressant) 7.5mg by mouth six times a week omitting Wednesdays.
R7's current care plan, as of 8/21/24, has no comprehensive care plan for the use of antipsychotic, antidepressant, and antianxiety medications.
On 8/21/24 at 10:30 AM, V5 (Care Plan Coordinator) confirmed that R7's care plan had no documentation of a comprehensive care plan addressing R7's use of antidepressant, antianxiety, and antipsychotic medications.
4. R12's Physician orders, dated 8/2024, documents R12 has orders to receive Sertraline (antidepressant) 100mg by mouth in the morning with Sertraline 50mg for total dose equaling 150mg.
R12's current care plan, as of 8/21/24, has no documentation of comprehensive care plan addressing R12's use of an antidepressant.
On 08/20/24 at 1:00 PM, V5 (Care Plan Coordinator) confirmed that R12's care plan had no documentation of a comprehensive care plan addressing R12's use of antidepressant.
Based on interview and record review, the facility failed to develop a care plan addressing target behaviors exhibited, anticoagulant use, and psychotropic medication use for four of 19 residents (R4, R7, R12, and R49) reviewed for care plan accuracy in the sample of 47.
Findings include:
The facility's Comprehensive Care Planning, dated 11/1/17, documents, It is the policy of the facility to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person-centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being.
1. R49's current Physician's Orders document the following medication order: Eliquis (anticoagulant) 5 milligrams (mg) take one tablet by mouth twice daily.
R49's current care plan does not address the use of R49's Eliquis.
On 08/20/24 at 11:19 AM, V5 (Licensed Practical Nurse/Minimum Data Assessment Coordinator/Care Plan Coordinator) verified that R49 has no care plan in place. V5 then stated she is currently not developing care plans for any resident at the facility who take the anticoagulant, Eliquis.
R49's current Diagnosis Report documents R49's diagnoses to include: Schizophrenia; Schizoaffective Disorder; Mood Disturbance and Anxiety; and Depression.
R49's current care plan has no mention of any target behaviors displayed by R49, and has no documentation of any behavioral interventions in place.
On 08/21/24 at 08:40 AM, V3 (Assistant Director of Nursing) stated that R49 occasionally displays the following behaviors: hoarding, agitation when someone interferes with his hoarded items, and withdrawn/self isolates. V3 stated that none of R49's target behaviors are noted on his current care plan and should be.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to perform the required nurse shift to shift controlled substance reconciliation for 19 of 19 residents, (R2, R3, R8-R10, R13, R1...
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Based on observation, interview and record review, the facility failed to perform the required nurse shift to shift controlled substance reconciliation for 19 of 19 residents, (R2, R3, R8-R10, R13, R17, R19, R22, R25, R34, R37, R43, R44, R47, R50, R52, R59 and R65) reviewed for controlled substances in a sample of 47.
FINDINGS INCLUDE:
The facility policy, Controlled Substances, dated (reviewed) 11/6/18 directs staff, It is the policy of the facility that all drugs listed as Schedule II drugs are subject to specified handling, storage, disposal and record keeping. The drugs in Schedule II will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. These records shall be retained for at least one (1) year.
On 08/18/24 at 9:21 A.M., a review of the facility A Hall and C Hall narcotic Shift Change Accountability Record Sheet for Controlled Substances for August 2024, for residents residing in the facility A Hall and C Hall, shows missing, nursing documentation, to confirm facility nurses performed the required shift to shift controlled substance reconciliation, on August 1-10 and 12-17, 2024. At that time, V6/Licensed Practical Nurse confirmed the missing documentation.
A review of the facility Controlled Substances Proof of Use sheets for the facility, documents that R2, R3, R8-R10, R13, R17, R19, R22, R25, R34, R37, R43, R44, R47, R50, R52, R59 and R65 all receive a controlled substance from facility nurses.
On 8/20/24 at 10:35 A.M., V2/Director of Nurses confirmed the missing documentation to the facility August 2024 nurse shift to shift controlled substance sheet for A Hall and C Hall.
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 interview and record review, the facility failed to have a Registered Nurse for eight consecutive hours in a 24 hour period on four of 31 days per the Facility's July Nursing Schedule. This h...
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Based on interview and record review, the facility failed to have a Registered Nurse for eight consecutive hours in a 24 hour period on four of 31 days per the Facility's July Nursing Schedule. This has the potential to affect all 63 residents living in the facility.
Findings.
The Facility Assessment, dated 8/12/24, states, The facility's plan to ensure sufficient staff to meet the needs of the residents at any given time.
The Facility's 2024 July Nurses Schedule shows there are no Registered Nurses working on four weekend days: 7/06/24, 7/07/24, 7/20/24, 7/21/24.
On 8/21/24 at 12:05 PM, V3, Assistant Director of Nursing, stated, Yes, we did have gaps in the July schedule that we did not have Registered Nurse Coverage.
The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 8/18/24, signed by V1, Administrator, documents 63 residents currently reside within the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to serve foods as written on the menu. This has the potential to affect all 63 residents living in the facility.
Findings:
The Fa...
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Based on observation, interview and record review, the facility failed to serve foods as written on the menu. This has the potential to affect all 63 residents living in the facility.
Findings:
The Facility's Week at a Glance, dated 8/18/24, Week four, Luncheon Menu, states, Oven Fried Chicken Breast; Mashed Potatoes; Chicken Gravy; Mixed Vegetables; Roll/Margarine; Pie (menu does not specify what kind of pie as required). Residents were served: Plain Baked Chicken (no breading); Mashed Potatoes; Carrots; Bread; Strawberry Pie.
On 8/18/24 at 12:35 PM, V5, Dietary Manager, stated, I don't know why the chicken was plain, carrots were served instead of mixed vegetables and bread was served instead of rolls. The frozen mixed vegetables didn't come in, but we do have canned mixed vegetables; there are frozen rolls in the freezer that could have been used. I'll talk to the cook. He's new and doesn't know things.
On 8/19/24 at 10 AM, during the Group Interview with Resident Council, R3, R10, R11, R15, R29, R33, R38, all complained that often the menu will say one thing, and another will be served. R15 stated, When you ask why something on the menu wasn't what we were served, we are told that the truck didn't come in or that the cook wanted to make something else. They don't like it when you ask them about what we get to eat.
On 8/18/24 at 11:45 AM, V5, Dietary Manager, stated, Yes, we write down all of the substitutions. When the substitution book was reviewed there were few entries and the Registered Dietitian had not signed off as required for the substitutions. One of the entries was Strawberries and Bananas. The substitution was Banana Pudding (which is not a substitute for a serving of fruit unless half of eight-inch banana was in each serving. This was a flavored Pudding. When asked why fruit was not substituted V5 said, oh, we did but did not specifically what the fruit was. This was not written in the substitution book.
The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 8/18/24, signed by V1, Administrator, documents 63 residents currently reside within the facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure use of a safe sanitation solution; place food on the steam table at the appropriate time; maintain clean appliances/fix...
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Based on observation, interview and record review, the facility failed to ensure use of a safe sanitation solution; place food on the steam table at the appropriate time; maintain clean appliances/fixtures in the kitchen; label, date and appropriately package all opened food; use only institutional approved storage containers; date, label and discard as required, all food items in the resident's floor refrigerator. This has the potential to affect all 63 residents living in the facility.
Findings:
The document Food from Outside Sources/Personal Food Storage, dated 4/2017, states, Food and beverages brought in from outside sources, that are to be stored in the facility refrigerators and freezers, will be checked by a dietary staff member. Any suspicious or obviously contaminated food or beverage will be discarded immediately. Food and beverages will be labeled with the resident's name, food item and date. These foods and or beverages will be placed on a designated tray/shelf. Facility storage procedures apply.
On 8/18/24 at 11:15 AM, the floor refrigerator (for resident's use) had a strong sour odor and contained the following food items: opened 2.5 ounce cheese package, no label or date; two restaurant take-out containers with a chopped chicken meal no label, that had a slimy appearance and sour odor; two plates of dried spaghetti with a sour smell; a restaurant purchased sandwich, unknown filling which was dried out, hard, loosely covered and dated 7/25/24; a murky bottle of water that slices of lemon had been added, lemon skins had turned brown, no label or date; a bag of grapes, cherries and strawberries, loosely covered, no labels of ownership or date; an unidentified glass of pink substance in the freezer without a label or date; several items in the freezer that do not have labels of resident ownership or date they were received: one pound tube of sausage; a box containing six premade cheeseburgers; Containers of grocery store labeled ice cream, opened, no label or date.
On 8/18/24 at 11:30 AM, V11, Dietary Manager, and V2, Director of Nursing, confirmed that these items should have been discarded and should have been labeled with dates. V11 stated, I'm not responsible for the items that are put into the resident's refrigerator on the floor.
The document In-Place Equipment, dated 4/2013, states, to mix a chlorine solution, mix at a rate of one teaspoons of bleach per gallon of water. Water temperature should be 75 degrees Fahrenheit. (For in-place equipment) the chlorine level is 100 parts per million (ppm). (note this is for in-place equipment only).
On 8/18/24 at 9:30 AM, V20, Cook, mixed a sanitation solution. V20 opened a bottle of bleach and, using the cap, not a measuring spoon, poured chlorine into the bucket of water. The test strip was black, indicating over 200 parts per million (ppm), which is considered to be at a poisonous level. V11, Dietary Manager, instructed V20 to dump some of the water out of the bucket and add more water to it. V20 did so and when the solution was retested the level was still over the required level. V11 told V20 to dump out the solution and make another bucket of sanitation solution with a smaller amount of chlorine. When asked, V20, who speaks little English, was unable to state if he always checked the level of chlorine or what the level of chlorine tests at or should test at in the sanitation buckets.
The document, Storage, dated 10/2020, states, It is the policy of this facility that food shall be stored (to) provide the best preservation. Food shall be stored at the proper temperature and for appropriate lengths of time to protect quality of food. Store (food) in covered, labeled and dated containers under refrigeration or (in the) freezer.
The document, Refrigerator and Freezer Storage, dated 10/2014, states, Any item placed in the refrigerators must be covered, labeled and dated with a date-marking system that tracks when to discard perishable foods. [NAME] container with the name of the item. [NAME] the date that the original container is opened or date of preparation. Label refrigerated, potentially hazardous food with the day/date by which the food shall be consumed or discarded (maximum of seven days from time of preparation/opened). Designated Dietary employee is to check, pull and throw away any potentially hazardous foods that have been in the refrigerator longer than seven days.
On 8/18/24 at 9:40 AM, the following items were in the reach in and walk in refrigerators: a 46 ounce container of thickened water, one third remaining, no label dated with marker, 7/18/24; A 46 ounce container of thickened orange juice, one half remaining no label, dated with marker, 7/20/24; one pound of cheese slices, no wrapper or container, no label or date; a five pound container of sour cream, one half remaining, no label or open date; a one pound container of Parmesan cheese, one third remaining, no label or open date. V11, Dietary Manager, confirmed these items needed labels/dates and should be discarded. I don't think some of these items (thickened liquids) need to be discarded, though.
On 8/18/24 and 9:50 AM, the stock room had the following items: A large garbage can, no liner, three fourths full, was used for oats. The lid was cracked and was missing part of its rim, exposing the oats to the environment. Five cereal containers had numerous labels that had been left on. These old stickers were readable, showing various types of cereal other than what the container held. The label only stated what the item was, no open date. The flour container, one half full and a bag of streusel topping, one fourth full were not dated or labeled. An empty, scrunched Parmesan cheese container, not an institutional required container, was being used for sugar. V11 acknowledge these things stating, I will remind the staff to label and date food items. We'll need to check the dates of food.
On 8/18/24 at 10:00 AM, the steam table already had the chicken, pureed chicken, ground chicken sitting in place. V20, Cook, indicated that he had put the chicken into the steam table at 8:30 AM. V11, Dietary Manager, stated that the chicken they serve comes pre-cooked and only needs to be heated before serving. V20, who speaks or understands very little English was unable to say if he routinely put foods on the steam table early.
The document Kitchen Sanitation, dated 10/2020, states, It is the policy of (this facility) to comply with Public Health Standards of Sanitation Regulations. The Food Service Manager will monitor sanitation of the Dietary Department on a daily basis. The Food Service Manager shall provide cleaning instructions for each area and piece of equipment in the kitchen.
On 8/18/24 at 9:15 AM, the interior baffles and the wall of stainless steel surrounding the baffles, which is over the range, ovens, and food preparation area, had a layer of dust. The fans, blowing air directly on the food preparation area and clean dishes area of the dish machine, had a layer of black, greasy dust over the grill. V11, Dietary Manager, stated, I'll tell Maintenance to come in a clean the area.
The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 8/18/24, signed by V1, Administrator, documents 63 residents currently reside within the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
B. The facility's Enhanced Barrier Precautions policy, dated 7/13/23, documents Enhanced Barrier Precautions (EBP) should be used when contact precautions do not apply, for the residents with any of t...
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B. The facility's Enhanced Barrier Precautions policy, dated 7/13/23, documents Enhanced Barrier Precautions (EBP) should be used when contact precautions do not apply, for the residents with any of the following: Open wounds that require a dressing change, Indwelling medical devices, Infection or colonized with MDRO (Multi-Drug-Resistant Resistant Organisms). Enhanced Barrier Precautions require use of gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. EBP is primarily intended for care that occurs within a resident's room, when high-contact resident care activities are bundled together. This policy also documents High Contact care activities include: Dressing, Bathing/Showering, Transfers, Hygiene, Changing linens, Changing briefs or toileting, Caring for medical devices (such as: central lines, urinary catheters, feeding tubes, tracheostomies, drainage tubes, ports), Wound Care (pressure ulcers, diabetic ulcers, unhealed surgical wounds, chronic venous stasis wounds), Skilled Therapies. Procedure: Educate staff on EBP. Identify residents with an infection or colonized with a MDRO, residents with medical devices or chronic wounds that do not require contact precautions. Post approved EBP signage that indicates high-contact activities. Ensure that disposable or washable isolation gowns and gloves are available to healthcare providers, where high contact resident care activities may be required. Keep a container or hamper inside resident's room for healthcare providers to dispose of PPE.
On 8/18/24 at 11:08 AM, R45 was in his room lying in bed. R45's indwelling urinary catheter bag was dangling on bed rail below the mattress, draining urine. R45's room did not contain any EBP signage or PPE inside or outside of R45's room.
On 8/19/24 at 10:08 AM, V14 (Licensed Practical Nurse) stated, Enhanced Barriers sounds foreign to me. They are not doing that here.
On 8/20/24 at 10:15 AM, V4 (Licensed Practical Nurse) performed R7's supra pubic catheter care with dressing change. V4 stated that R7 has a history of urinary tract infections. V4 did not wear a gown during cares, no Enhanced Barrier sign was on R7's door and no other PPE was available except for gloves.
On 8/20/24 at 2:08 PM, V4 completed R44's pressure ulcer dressing changes. V4 confirmed R44's pressure wound on her hip is open and was staged at a stage three upon discovery. V4 did not wear a gown throughout R44's care. R44's room did not contain any signs for EBP, and no PPE was present inside or outside of the room. V4 stated No one is on TBP (transmission-based precautions) right now. I don't know about the EBP requirements.
On 8/21/24 at 9:40 AM, V3 (Assistant Director of Nursing) provided a list that documented R35 and R44 currently have open wounds and R7 and R45 have indwelling urinary catheters. V3 confirmed she and V2 (Director of Nursing) handle the facility's infection control procedures. V3 stated We are aware what EBP's are and that any residents who have indwelling urinary catheters, open lines like feeding tubes or central lines and anyone who may develop an open wound should be in EBP. I guess I wasn't aware that it is not being implemented throughout the facility, but it should be.
The facility's Long Term Care Facility Application for Medicare and Medicaid dated 8/18/24 and signed by V1 (Administrator in Training) documents 63 residents reside in the facility.
This failure resulted in two deficient practice statements.
A. Based on observation, interview, and record review the facility failed to perform hand hygiene during medication administration for two residents (R22 and R35) of three reviewed for medication administration, in a sample of 47.
B. Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions throughout the facility to protect vulnerable residents and prevent the spread of multi-drug resistant organisms (MDROs). This failure has the potential to affect all 63 residents residing in the facility.
Findings include:
A. The facility policy, Standard Precautions, dated (reviewed) 4/11/22 directs staff, Standard precautions will be instituted to prevent the spread and contamination of pathogenic microorganisms in a manner that voids transfer to residents, personnel and environment. Gloves: Wear gloves when touching blood, body fluids, secretions, and contaminated items. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments.
The facility policy, Medication Administration, dated 11/18/17 directs staff, Avoid touching medication. If contact with the medication is likely, prepare medication using gloves.
On 8/18/24 at 9:21 A.M., V6/Licensed Practical Nurse (LPN) prepared to administer mediations for R22. V6/LPN removed one tablet each of Amlodipine 10 MG (Milligrams), Clopidogrel 75 MG, Farxiga 10 MG, Furosemide 40 MG, Gabapentin 100 MG, Sertraline 25 MG, and Hydrocodone 5/325 MG from individual prepackaged bubble packs directly into her bare hands and then placed them into a small, plastic medication cup. V6/LPN then removed one tablet each of Ferrous Sulfate 325 MG, Loratadine 10 MG, Acidophilus 500 MG, and Vitamin D3 50 MCG (Micrograms) from facility stock bottles directly into her bare hands and placed them into the same medication cup. V6/LPN then primed an insulin pen with Lantus Insulin 20 Units and a second Insulin pen with Novolog Insulin 4 Units and entered R22's room. V6/LPN poured the pills into R22's mouth while she was lying in bed, placed a straw into her mouth and instructed R22 to take the medication. After that, without performing hand hygiene or applying gloves, V6/LPN swabbed R22's abdomen with an Alcohol swab, injected the Lantus Insulin, swabbed another area on R22's abdomen, injected R22 with the Novolog Insulin, adjusted R22's bed covers and exited R22's room. Without performing hand hygiene, V6/LPN then poured one tablet of Tylenol 500 MG directly into her hand, placed the tablet in a plastic cup and handed the cup to R35 who took the pill. At that time, V6/LPN verified she had touched R22's and R35's medications with ungloved hands and administered R22's Insulin without applying gloves.
Aug 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's schedule II narcotic was free from misappropriat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's schedule II narcotic was free from misappropriation for two of three residents (R1 and R3) reviewed for misappropriation of property in a sample of three.
Findings include:
The facility's Abuse Prevention Program, revised 11/28/16, documents that it is the right of the resident to be free from abuse, neglect, misappropriation of resident property, and exploitation. This form documents that misappropriation of resident property means deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.
R1's current Physician Order Sheet, documents for R1 to take Hydrocodone (schedule II)-Acetaminophen 5mg (milligrams)325mg every six hours as needed.
The facility's shipment details invoice details sheet documents that 30 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered on 7/28/23 for R1. There is no Controlled Substance Proof of Use sheet in R1's medical record.
R3's Physician Order Sheet, dated 8/1/23-8/11/23, documents to take Hydrocodone-Acetaminophen 5mg-325mg every six hours.
The facility's pharmacy shipment details sheet documents that on 8/2/23 60 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered to the facility.
R3's Controlled Substance Proof of Use, dated 8/2/23, documents that the quantity delivered was 60 tablets, but only 30 tablets are accounted for. This form documents that 14 tablets of R3's Hydrocodone-acetaminophen 5mg-325mg were signed out as given at the facility and 16 were sent home with R3 at the time of her discharge on [DATE]. Thirty of R3's Hydrocodone-Acetaminophen 5mg-325mg were not accounted for.
On 8/15/23 at 10:30am, V2, Director of Nursing, stated that R1 and R3's Hydrocodone-Acetaminophen 5mg-325mg tablets could be accounted for.
On 8/15/23 at 1:00pm, V1, Administrator, verified that Controlled Substance Proof of Use could not be found for R1 and R3.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility establish a system for the receipt and reconciliation of controlled drugs for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility establish a system for the receipt and reconciliation of controlled drugs for two of three residents (R1 and R3) reviewed for controlled drugs in a sample of three.
Findings include:
The facility's Controlled Substances policy, revised 10/06, that all drugs listed as schedule II are subject to specified handling, storage, disposal, and record keeping. This form also documents that the drugs in Schedule II will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty.
The facility's shipment details invoice details sheet documents that 30 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered on 7/28/23 for R1. There is no Controlled Substance Proof of Use sheet in R1's medical record.
The facility's pharmacy shipment details sheet documents that on 8/2/23, 60 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered to the facility for R3.
R3's Controlled Substance Proof of Use, dated 8/2/23, documents that the quantity delivered was 60 tablets, but only 30 tablets are accounted for. This form documents that 14 tablets of R3's Hydrocodone-acetaminophen 5mg-325mg were signed out as given at the facility and 16 were sent home with R3 at the time of her discharge on [DATE]. Thirty of R3's Hydrocodone-Acetaminophen 5mg-325mg were not accounted for.
On 8/15/23 at 10:30am, V2, Director of Nursing, stated that R1 and R3's Hydrocodone-Acetaminophen 5mg-325mg tablets could not be accounted for.
On 8/15/23 at 1:00pm, V1, Administrator, verified that Controlled Substance Proof of Use could not be found for R1's Hydrocodone-Acetaminophen 5mg-325mg delivered on 7/28/23. V1 also stated that 30 of R3's Hydrocodone-Acetaminophen 5mg-325mg could not found.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure the privacy of medical records for two of three residents (R1, R3) reviewed for medical records in a sample of three.
Findings inclu...
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Based on interview and record review the facility failed to ensure the privacy of medical records for two of three residents (R1, R3) reviewed for medical records in a sample of three.
Findings include:
The facility's Notice of Privacy Practices, undated, documents that the facility is required by law to maintain the privacy of your health information and to provide to you and your representative this notice of duties and privacy practices.
R1's Controlled Substances Proof of Use form, documents R1's full name and place of residents. This form documents for R1 to take Hydrocodone-Acetaminophen 5mg (milligrams) 325mg tablets every six hours as needed for pain.
R3's Controlled Substances Proof of Use form, documents R3's full name and place of residency. This form also documents for R3 to take Hydrocodone-Acetaminophen 5mg-325mg every six hours.
On 8/14/23 at 10:45am, V4, Detective, verified that during the autopsy of V3, Licensed Practical Nurse, two cards of Hydrocodone-Acetaminophen 5-325mg, along with the reconciliation forms were found in V3's upper breast pocket of her scrubs. The reconciliation forms did have R1 and R3's names, dosages, and frequency of the medication.
On 8/15/23 at 1:00pm, V1, Administrator, verified that personal information of the residents is not to be taken out of the facility.
Aug 2023
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a physician's order was obtained for code status (Do Not Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a physician's order was obtained for code status (Do Not Resuscitate/DNR) for one resident (R419) of 26 residents, in a total sample of 26 residents reviewed for DNR Physician orders.
FINDINGS INCLUDE:
Facility policy, entitled Advance Directive, Revised [DATE], documents, 4. Any decision made by the resident shall be indicated in the chart in a manner easily understood by all staff. Advance directives specifying full code/attempt resuscitation/CPR [Cardio-Pulmonary Resuscitation] or the absence of determination shall be recorded as a Full Code. Those residents indicating Do Not Attempt Resuscitation/DNR shall be recorded as DNR. Staff must be aware of any requests for limited Medical Interventions shall be recorded appropriately on the care plan. DNR or requests for comfort measures only shall be recorded as signifying DNR-Comfort. Code status shall also be recorded on the resident's Physician Order Sheet.
R419's IDPH [Illinois Department of Public Health] Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, signed by R419 on [DATE], and R419's physician on [DATE], document: Section A: Attempt Resuscitation/CPR has the box and lined out with error written and the Do Not Attempt Resuscitation/DNR is marked with an X; and Section B: Full Treatment has the box with a lined out with error written and the Comfort Focused Treatment is marked with an X.
R419's Physician's Orders sheet, for [DATE] to [DATE], document under the Code Status section as R419 being a *** FULL CODE ***.
On, [DATE], at 8:40 AM, V2/Director of Nursing confirmed V2's expectation is R419's Physician's Order Sheet should have been updated to reflect R419's change in code status to DNR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to submit correct MDS (Minimum Data Set) assessments for two residents (R5 and R56) reviewed for MDS correctness in a sample of 26.
Findings i...
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Based on interview and record review, the facility failed to submit correct MDS (Minimum Data Set) assessments for two residents (R5 and R56) reviewed for MDS correctness in a sample of 26.
Findings include:
The facility's Comprehensive Assessment/MDS (Minimum Data Set) Policy, dated 11/1/17, documents: It is the policy of (facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis of determining resident strengths, needs, goals, life history and preferences to develop a comprehensive plan of care for each resident with the goal of attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well-being.
1. R5's current Physician Orders, dated 8/1/23, documents R5 has a diagnosis of Bipolar; R5's current Physician Orders does not document a diagnosis of Post Traumatic Stress Disorder/PTSD.
R5's MDS (Minimum Data Set), dated 5/15/23 Section I Active Diagnoses, does not document R5's diagnosis of Bipolar but does document (with a checkmark at 16100) a diagnosis of PTSD (Post Traumatic Stress Disorder).
On 8/4/23 at 10:30 AM, V5 Minimum Data Set/MDS/Care Plan Coordinator stated, (R5) does not have PTSD; the MDS diagnosis of PTSD was an error on my part; I shouldn't have checked that, and I did not put a checkmark at (R5's) diagnosis of Bipolar and I should have; that was an error on my part. I will correct those today.
At this time, V5 also stated, We have gotten a signed Progress Note (dated 8/4/23) from (V14/Physician Assistant) stating that (R5) does not have a diagnosis of PTSD.
2. The POS (Physician's Orders Sheet) for R56, dated August 2023, documents R56's diagnoses as: Left MCA (middle cerebral artery) stroke, right flaccid Hemiplegia. This same POS documents Physician orders for: Isosource (Dense Complete Nutrition Formula with Fiber) 1.5 calorie to infuse at 120 ml (milliliters) per hour via gastrostomy tube using enteral feeding pump for 12 hours; flush gastrostomy feeding tube with 200 ml of water three times daily during enteral feeding; regular mechanical soft, very moist diet, with nectar thick liquids orally; Med Pass (nutritional supplement) 60 ml by mouth three times daily; and Mighty Shake (nutritional supplement) 4 ounces by mouth three times daily.
On 8/2/23 at 12:42 PM, R56 was sitting in a wheelchair in the dining room eating a mechanical soft diet. On 8/3/23 continuous observation between 8:00 AM through 8:30 AM, R56 was sitting in the dining room and ate 100% of breakfast tray served. On 8/3/23 at 12:20 PM, R56 was sitting in a wheelchair and eating noon meal.
On 8/4/23 at 7:50 AM, V1 DON (Director of Nursing) stated R56 has been refusing his gastrostomy tube feedings but does have an oral diet and eats meals in the dining room.
The Quarterly MDS (minimum data set) assessment for R56, dated 7/13/23, documents R56 with a feeding tube and does not include diet or liquids being received orally. This same MDS documents R56 with no swallowing concerns identified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the Facility failed to document a completed admission Smoking Assessment in R219's Medical Chart for one Resident (R219) of 12 reviewed for Smoking in...
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Based on observation, interview and record review the Facility failed to document a completed admission Smoking Assessment in R219's Medical Chart for one Resident (R219) of 12 reviewed for Smoking in a sample of 26.
Findings include:
Facility Resident Smoking Policy, undated, documents that each Resident whom chooses to smoke will have a Smoking Assessment completed prior.
Facility Smoking and Vaping Policy, revised 10/27/22, documents: the Facility works to provide appropriate care for Residents keeping safety and comfort in mind; implementation of the Smoking Safety Risk Assessment will be conducted once the Resident indicates they may want to smoke; and development of the Resident Smoking Contract will be completed by the Social Service Designee and the Resident.
Facility Residents Who Smoke List, undated, documents R219 as a smoker.
R219's admission Nursing Assessment, dated 7/19/23, documents that R219 is alert/oriented and has an orthopedic cast to the right wrist/forearm.
R219's current Care Plan, documents R219 has chosen to continue smoking.
On 8/2/23, during the hours of 9:00 AM and 3:00 PM, R219's Medical Chart did not document a Resident Smoking Assessment.
On 8/3/23, during the hours of 7:45 AM and 3:00 PM, R219's Medical Chart did not document a Resident Smoking Assessment.
On 8/2/23, at 9:03 AM, R219 was smoking on the designated Facility Smoking Patio.
On 8/3/23, at 9:00 AM, R219 was smoking on the designated Facility Smoking Patio.
On 8/3/23, at 9:03 am, R219, via electronic application (cell phone app) that translates Chinese to English, stated, I go outside and smoke about two to three times a day.
On 08/03/23, 9:18 AM, V5 (Minimum Data Set/MDS) stated, I was on vacation when R219 admitted to the Facility. Honestly, the nurses should be completing the assessments upon admission, and then I do them quarterly when I do the (MDS's), but I help the nurses out and usually end up doing all of them. Do you see this huge stack of assessments (sitting in a storage rack on V5's desk)? I bet there are at least twenty-five of them in this stack and R219's is probably in here. I am trying to get caught up on, I am so far behind.
On 08/03/23, at 9:15 AM, V2 (Director of Nursing/DON) stated, I was at a work training on the day that (R219) admitted to the Facility. That is the day that the nurse had three admissions all at once and got behind. I try and help them get assessments and paperwork completed, but I was gone that day, then I went on vacation for a week. The assessments should be in the Resident charts, but we have had so many problems with medical records and nursing that we are playing catch up on all of the Resident Assessments. (V8/Social Service) sometimes does the Smoking Assessments, but she is not here this week, she is on vacation. We probably should have completed the Smoking Assessment for (R219's) safety, especially since he has a cast on his arm. I do not see a Resident Smoking Contract for (R219) in his chart either.
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 observation, interview and record review, the Facility failed to follow Physician Orders for Resident weights for one (...
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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 Physician Orders for Resident weights for one (R219) of 26 Residents reviewed for Weights in a sample of 26.
Findings include:
Facility Resident Weight Monitoring Policy, revised 9/2008, documents: it is the policy of the Facility that the Resident weights are recorded and monitored at least monthly; new admission weight is obtained within 24 hours of admit; weights and re-weigh results are recorded by nursing staff on the Report of Monthly Weight Form in the medical record; Residents who have been determined by the Weight Committee to be increased risk for weight loss will be put on weekly weights for at least four weeks; and all new admissions and re-admissions will be weighed weekly for at least four weeks.
R219's Physician Order Sheet/POS, dated 7/19/23, documents that R219 admitted to the facility on [DATE]. The POS also documents an order, on 7/19/23, for daily weights for three days, then every week for four weeks.
R219's Treatment Administration Record/TAR, dated 7/19/23 through 7/31/23, documents an order on 7/19/23 for Daily Weights for three days, then every week for four weeks. The TAR does not document R219's daily weight on 7/19/23, 7/20/23 or 7/21/23. The TAR does not document R219's weekly weight on 7/26/23.
Facility Monthly Weight Grid, dated 8/2022 through 7/2023 (provided on 8/2/23 by V2/Director of Nursing), does not document an entry with R219's name or weight record.
On 8/3/23, at 11:26 AM, V2 (Director of Nursing) stated, Our policy says that all new admissions are supposed to be weighed upon admission, then for the first three days after admission, then weekly for four weeks. The weights are supposed to be signed off on the 'TAR (Treatment admission Record). I am not sure where they recorded (R219's) weights, but they should be on his 'TAR,' especially since there is a designated spot for them to log it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 8/02/23 at 9:30 AM, R29 had an empty bag of tube feeding on an IV pole with a pump dated 8/1/23 with an expiration of 8/3/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 8/02/23 at 9:30 AM, R29 had an empty bag of tube feeding on an IV pole with a pump dated 8/1/23 with an expiration of 8/3/23. At that same time R29 was in bed with a right chest port in place. R29 stated she gets her tube feeding thru her right chest port and it runs for 12 hours from about 7 PM till 7 AM. R29 stated six years ago her small intestine was taken out due to an infection.
R29's Physician Order Sheets (POS), dated 8/1-8/31/23, has no documentation R29 gets a tube feeding, what time it is supposed to run over, or the amount to be infused.
On 8/03/23 at 9:30 AM, V6 Licensed Practical Nurse/LPN stated Pharmacy provides us with the tube feeding bag, it runs for 12 hours at night, and I don't see her tube feeding orders on her physician order sheet and it should be.
Based on observation, interview, and record review the facility failed to meet the professional standards of quality care to ensure required care and services were provided for residents receiving enteral nutritional feedings for two (R29 and R56) of two residents and failed to implement a physician referral for a resident who is refusing gastrostomy tube cares, feedings, and flushes for one (R56) of two residents reviewed for gastrostomy tubes in the sample of 26.
Findings include:
The facility's Daily Cleansing of G/J/Peg Tube Site policy and procedure, dated 4/2007, documents It is the policy of (the facility) to provide care and services to the resident with a gastrostomy or Jejunostomy tube to maintain the site in clean and safe manner as to minimize the risk of infection. This policy documents the procedure for cleansing the tube site.
The Facility Conformance with physician medication orders, reviewed 9/27/17, documents A complete and accurate listing of current medication orders will be maintained on the residents Physician Order Sheet.
The facility's Quality Assurance Nursing Care - Gastric/Feeding Tube policy and procedure, revised 4/2007, includes the following documentation: Diagnosis supports tube requirement (Speech or Swallow Evaluation);Continued need is supported by MD (medical doctor) documentation; Care Plan reflects interventions for care, maintenance, feeding ad medications; Care Plan addresses reason for tube; Care Plan addresses psychosocial needs of altered eating pattern; Care Plan addresses risks of aspiration, diarrhea, vomiting, dehydration, and metabolic abnormalities; TAR (Treatment Administration Record) reflects sit care/monitoring; Tube is properly positioned/secured; Residual is checked/recorded; Flushes are performed as ordered; Site care is done - documented daily; No S&S (signs and symptoms) of infection at the insertion site.
1. The POS (Physicians Orders Sheet) for R56, dated August 2023, documents the following diagnoses: Left MCA (middle cerebral artery) Stroke, right Flaccid Hemiplegia, Cerebral Edema, Aphasia and Depression. This same POS lists the following physician orders: Iso-Source (Dense Complete Nutrition Formula with Fiber) 1.5 Cal (calorie) 120 ml (milliliters) per electronic feeding pump for 12 hours; 200 ml water flush three times daily during feeding; 30 ml water flush before and after medications; and Cleanse and change split sponge daily.
On 8/02/23 at 12:42 PM, on 8/3/23 at 8:00 AM and 12:20 PM, R56 was sitting in a standard wheelchair in the dining room eating a mechanical soft diet with nectar thick liquids. On 8/2/23 at 2:42 PM, and on 8/3/23 at 10:20 AM and 3:40 PM, R56 was lying in bed on his back with his gastrostomy feeding tube tied in a knot visible at edge of shirt. R56 refused to allow surveyor to see his Gtube insertion site. During this investigation, between 8/2/2023 and 8/4/2023, R56 refused his Gtube feeding, flushes, and cares.
On 8/3/23 at 8:37 AM, V4 LPN (Licensed Practical Nurse) stated R56 refuses his Gtube (gastrostomy tube) feedings and flushes and hasn't let anyone do anything with his Gtube for a really long time. V4 LPN stated, I am really surprised (R56) hasn't tried to yank it (Gtube) out yet.
On 8/4/23 at 7:50 AM, V2 DON (Director of Nursing) stated R56 refuses to allow his gastrostomy feeding tube to be used, flushed, or cleaned and will tie the tube in a knot so that no one can use it. V2 DON stated the facility began talking with R56's Physician on 7/11/23 about R56's refusals and of possibly getting the Gtube removed. V2 DON also stated the facility has been trying to find the Physician who put the Gtube in, but so far have not been able to figure that out.
R56's Medical Record does not contain documentation that a Speech or Swallow Evaluation was completed, Physician supported documentation for the continued use of R56's feeding tube.
The facility's monthly weight log documents the following dates and weights for R56 as: [DATE].6 pounds; [DATE].0 pounds; [DATE].2 pounds; April 136.7 pounds; May 141.1 pounds; June 141.8 pounds; and July 144.1 pounds. These weights indicate R56 with 7.91% weight loss in 30 days from January to February 2023; 5.85% weight loss in 30 days from March to April 2023; and 6.75% weight in three months from January to April 2023.
The RD (Registered Dietitian) Note for R56, dated 5/9/23, documents R56 refusing Gtube feedings at times. Weight trending up appropriately due to weight loss last month. The RD Note, dated 7/7/23, documents R56 meets estimated nutrient needs with current Gtube feeding order. Noted R56 refusing tube feeding at this time. Nurse confirms resident refusing tube feedings, all medications, and does not allow staff to flush the tube. RD recommendation was to obtain a Physician consult related to R56's refusal of Gtube feedings and flushes.
The Progress Notes for R56, dated April 2023 through August 2023 document R56's continuous refusals of Gtube use for feedings, flushes and medication, including R56 tying Gtube in a knot to prevent use. The Progress Notes do not include documentation of R56's insertion site or that cares were provided and does not document whether there are signs and symptoms of infection. The Progress Notes do not include Physician documentation supporting the continued use of R56's Gtube.
The current Dietary Care Plan for R56, dates a problem area on 4/11/23 as R56 has history of refusing Gtube feedings with weight documented as 135 pounds. This Care Plan does not reflect interventions for care and maintenance, feeding and medications, reason for the Gtube, pyschosocial needs of altered eating pattern and does not address the risks of aspiration, diarrhea, vomiting, dehydration, or metabolic abnormalities.
On 8/4/23 at 8:15 am, V2 DON confirmed the facility does not have any documentation regarding the facility efforts to address R56's Gtube concerns and refusals.
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 have oxygen orders on one (R29) of one resident reviewed for oxygen in a sample of 26.
Findings include:
Facility Conformance...
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Based on observation, interview, and record review, the facility failed to have oxygen orders on one (R29) of one resident reviewed for oxygen in a sample of 26.
Findings include:
Facility Conformance with physician medication orders, reviewed 9/27/17, documents A complete and accurate listing of current medication orders will be maintained on the residents Physician Order Sheet.
On 8/02/23 at 9:30 AM, R29 was in bed and had 4 liters of oxygen on via nasal cannula. R29 stated she has oxygen only because she had a hard time breathing due to excess fluid. R29 was able to answer questions but becomes short of breath with talking.
R29's Physician Order Sheets (POS), dated 8/1-8/31/23, has no documentation R29 is on oxygen.
On 8/03/23 at 9:30 AM, V6 Licensed Practical Nurse/LPN stated I don't see (R29's) oxygen orders on her physician order sheet and it should be. (R29) wears oxygen for comfort at night, and as she needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to have Dialysis orders, failed to obtain a daily weight, and failed to coordinate communication between the Dialysis facility a...
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Based on observation, interview, and record review, the facility failed to have Dialysis orders, failed to obtain a daily weight, and failed to coordinate communication between the Dialysis facility and the nursing home on one (R29) of one resident reviewed for Dialysis in a sample of 26.
Findings include:
Facility Conformance with physician medication orders, reviewed 9/27/17, documents A complete and accurate listing of current medication orders will be maintained on the residents Physician Order Sheet.
Facility Outpatient Dialysis Services Agreement, dated 3/17/07, documents The Nursing Facility shall ensure that all appropriate medical and administrative information accompanies all residents at the time of transfer to the Dialysis Unit. The parties will mutually develop a written protocol governing specific responsibility's, policies and procedures to be used in rendering Dialysis services to residents including the development and implementation of a resident's care plan relative to the provision of Dialysis services. The Nursing Facility will provide for the interchange of information useful or necessary for the care of the resident and will inform the Dialysis unit of a contact person at the nursing facility whose responsibilities include oversight of provision of care of the patient at the Nursing Facility.
R29's Physician Order Sheet (POS), dated 8/1/31-8/31/23, documents Kidney Disease Stage Three.
R29's Physician Order Sheets (POS), dated 8/1-8/31/23, has no documentation R29 is on Dialysis, and no daily weights.
R29's current medical record has no documentation R29 is on Dialysis, no daily weights documented, and no regular communication sheets or documentation in nursing notes from R29's Dialysis provider.
On 8/02/23 at 9:30 AM, R29 had was in bed with a right chest port in place with a dressing dated 8/1/23. R29 stated she gets her Dialysis through her right chest port on Tuesday, Thursday, and Saturday at a (local) Dialysis center, and has been on Dialysis for one year.
On 8/03/23 at 9:30 AM, V6 Licensed Practical Nurse/LPN stated (R29) goes to Dialysis Tues, Thurs, and Sat in East Peoria. They weigh her there, we do not weigh her daily here, but we should be, or should be getting the communication from Dialysis. Dialysis updates us if we need it, but we do not communicate every day she goes, and we do not send a communication form to them. We get paperwork monthly from them on the labs and draw labs when ordered. We don't weigh her daily, I don't have a daily weight sheet in my MAR/Medication Administration Record or TAR/Treatment Administration Record for her, and the CNA's/Certified Nurse Aides document the monthly weights in a binder here at the nurse's station. We probably need to be weighing her daily, she gets Dialysis three days a week and they don't communicate weights, and we need to start doing daily weights on her because she has been gaining. I don't see any orders in her medical record for her Dialysis days and where she goes, and it should be.
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. On 8/02/23 at 9:30 AM, R29's left arm was edematous. R29 stated she has a blockage and needs a stent put in place. R29's left...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 8/02/23 at 9:30 AM, R29's left arm was edematous. R29 stated she has a blockage and needs a stent put in place. R29's left arm has a compression sleeve in place from hand all the way up to the shoulder and was on 4 liters of oxygen per nasal cannula.
R29's current physician orders, dated 7/21/23, documents Refer to vascular due to blockage in the left arm.
R29's current care plan does not have her left arm edema or oxygen use noted on the problem/need area with a goal and interventions.
On 8/03/23 at 9:30 AM V6 Licensed Practical Nurse/LPN stated (R29) has a referral to (local) vascular surgeon in November 2023 and uses oxygen when she gets short of breath.
On 8/4/23 at 10:25 AM, V5 Care plan coordinator verified R29 did not have edema or her oxygen marked on her care plan under its own problem/need area, and should be with a goal and interventions in place.
Based on observation, interview and record review, the facility failed to develop a person-centered plan of care for four of 16 residents (R23, R29, R37, R56) reviewed for care plans in the sample of 26.
Findings include:
The facility's Comprehensive Care Planning Policy, revised 7/20/22, states, 4. Comprehensive Care Plans shall strive to describe a. The resident's preferences, choices, and goals to the extent possible to assist in attaining or maintaining the resident's highest practicable quality of life. b. The resident's medical, nursing, physical, mental, and psychosocial needs and preferences. c. Person centered measurable objectives and timeframes for ease of evaluating resident progress toward achieving goals. 8. Communication of the Care Plan contents is paramount to the success of consistent care delivery.
1. R37's Face sheet documents R37 was admitted to the facility on [DATE].
R37's Cumulative Diagnosis Log documents R37 as a smoker.
The facility's Smoking List documents R37 as a current smoker in the facility.
R37's Smoking assessment dated [DATE] documents R37 as a supervised smoker.
On 8/2/23 at 12:55 PM, R37 stated R37 is a current smoker. R37 stated R37 does not always have cigarettes available but R37 smokes when R37 can.
As of 8/3/23 at 9:00 AM, R37's current Care Plan did not document any information regarding R37 being a current smoker in the facility.
On 8/3/23 at 10:51 AM V5 (Care Plan Coordinator) verified R37's current Care Plan did not contain any documentation regarding R37's smoking status and it should. V3 stated, It's on there now.
3. The facility's AIM (Assess, Intercommunicate, Manage) for Wellness form for R23, dated 5/14/23, documents the nurse entered the resident room and resident was sitting on the springs of the unoccupied bed in her room. R23 had her legs drawn up underneath her and was only dressed in a bra and underwear and was asking the nurse not to leave her alone. R23 was unable to state her name and had increased confusion. R23 was sent to the local hospital emergency room for an evaluation of her altered mental status.
The Progress Note for R23, dated 5/14/23 at 7:30 AM, documents R23 was sent to and admitted to the local hospital.
The Progress Note dated 5/17/23 at 6:00 PM, documents R23 was readmitted to the facility.
The facility's AIM for Wellness form for R23, dated 5/21/23 documents R23 was in bed all day with eyes closed, not responding to verbal stimuli, not speaking, not eating, not taking medications, and not following verbal commands. R23 was sent to the local hospital for an evaluation for altered mental status.
The Progress Note for R23, dated 5/21/23 at 5:00 PM, documents R23 was sent to the local emergency room for an evaluation.
The Progress Note dated 5/22/23 at 1:14 PM, documents R23 returned to the facility.
The current Care Plan for R23, does not include R23's hospitalizations or risk for re-hospitalization.
On 8/3/23 at 11:06 AM, V1 Administrator confirmed a Hospitalization Care Plan was not developed for R23 and should have been and stated the residents Care Plans are generic, sloppy and have not updated.
4. The POS (Physician's Orders Sheet) for R56, dated August 2023, documents R56's diagnoses as: Left MCA (middle cerebral artery) stroke, right flaccid Hemiplegia. This same POS documents Physician orders for: Isosource (Dense Complete Nutrition Formula with Fiber) 1.5 calorie to infuse at 120 ml (milliliters) per hour via gastrostomy tube using enteral feeding pump for 12 hours; flush gastrostomy feeding tube with 200 ml of water three times daily during enteral feeding; regular mechanical soft, very moist diet, with nectar thick liquids orally; Med Pass (nutritional supplement) 60 ml by mouth three times daily; and Mighty Shake (nutritional supplement) 4 ounces by mouth three times daily.
On 8/02/23 at 12:42 PM, R56 was sitting up in a wheelchair in the dining room eating lunch. On this same date at 2:42 PM, R56 was lying in bed with gastrostomy tube visible at edge of shirt and tied in a knot. On 8/03/23 from 08:00 AM through 8:30 AM and at 12:20 PM, R56 was sitting in a wheelchair in the dining room feeding self-meal.
On 8/4/23 at 7:50 AM V1 Administrator confirmed R56 refuses to allow the use of his gastrostomy feeding tube for nutrition or medications and has a physician order for an oral diet. V2 DON also stated the facility started talking with R56's physician about possibly getting the feeding tube out due to R56's refusals.
The facility's monthly weight book documents the following date and weights for R56 as: [DATE].6 pounds; [DATE].0 pounds; [DATE].2 pounds; April 136.7 pounds; May 141.1 pounds; June 141.8 pounds; and July 144.1 pounds.
The RD (Registered Dietitian) Note for R56, dated 7/7/23, documents a recommendation for Physician consult related to R56's refusal of gastrostomy tube.
The Dietary Quarterly Note for R56, dated 4/11/23, documents R56 refuses gastrostomy tube nutritional feeding a lot, Mighty Shakes ordered, and R56 with aphasia (without speech) and the RD monitoring weights and labs.
The QA (Quality Assurance Notes) for R56, document meetings being held and include R56 refusal of gastrostomy tube feedings.
The current Care Plan for R56, does not document a Nutritional Care Plan and R56 at Risk for weight loss or fluctuation in weights was developed for R56.
On 8/3/23 at 11:06 AM, V1 Administrator confirmed a Care Plan was not developed for R56's risk of weight loss due to his refusals of Gtube feedings and there should be. V1 Administrator stated the residents' Care Plans are generic, sloppy, and have not been updated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R419's IDPH [Illinois Department of Public Health] Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, sig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R419's IDPH [Illinois Department of Public Health] Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, signed by R419 on [DATE], and R419's physician on [DATE], document: Section A: Attempt Resuscitation/CPR [Cardio-Pulmonary Resuscitation] has the box and lined out with error written and the Do Not Attempt Resuscitation/DNR is marked with an X; and Section B: Full Treatment has the box x'd with a lined out with error written and the Comfort Focused Treatment is marked with an X.
R419's current care plan, not dated, document, No Advanced Directives Chosen-Resident will be resuscitated; Resident has chosen to be resuscitated. If found unresponsive-begin CPR.
On, [DATE], at 8:40 AM, V2/Director of Nursing confirmed V2's expectation is R419's Care Plan should have been updated to reflect R419's change in code status from Full Code/Attempt CPR to DNR. V2 confirmed R419's Code Status was changed, from Attempt CPR to DNR, while V2 was on vacation.
Based on observation, interview, and record review, the facility failed to review and revise a care plan for six (R29, R38, R68, R419, R43, and R56) of 26 residents reviewed for care plan revision in a sample of 26.
Findings include:
Facility policy, entitled Comprehensive Care Planning, revised [DATE], document, The following procedures shall be utilized in the development and maintenance of care plans: 1.b. The Care Plan shall be revised as necessary when the needs/problems and care and services specified in the plan of care no longer reflect those of the resident.
1. R29's Physician Order Sheet (POS), dated [DATE]-[DATE], documents Kidney Disease Stage Three.
On [DATE] at 9:30 AM, R29 had was in bed with a right chest port in place with a dressing dated [DATE]. R29 stated she gets her Dialysis thru her right chest port on Tuesday, Thursday, and Saturday at a (local) Dialysis center, and has been on Dialysis for one year.
On [DATE] at 9:30 AM, V6 Licensed Practical Nurse/LPN stated (R29) goes to Dialysis Tues, Thurs, and Sat in East Peoria.
R29's current care plan has no documentation specifying R29's Dialysis location, frequency, or daily weights.
On [DATE] at 10:25 AM, V5 Care plan coordinator verified R29 did not have R29's Dialysis care plan individualized to her care, and it should be.
2. R38's POS, dated [DATE]-[DATE], documents Fluoxetine 40mg/milligrams daily, and Olanzapine 10mg at bedtime.
R38's current care plan has no documentation specific to R38's behavior monitoring while taking an antidepressant and antipsychotic.
On [DATE] at 10:25 AM, V5 care plan coordinator verified R38 did not have R38's mood and behavior care plan individualized to his care, and it should be.
3. R56's current care plan has no documentation specific to R56's behavior monitoring while taking an antidepressant and antipsychotic.
R56's current physician order sheet, dated 8/1-[DATE], documents Haloperidol 0.5mg by mouth daily at noon and Haloperidol 10mg by mouth twice a day for mood disorder; Zoloft 25mg by mouth daily for depression; and Benztropine 2mg by mouth twice a day for mood disorder.
R38's current care plan has no documentation specific to R38's behavior monitoring while taking an antidepressant and antipsychotic.
On [DATE] at 10:25 AM, V5 care plan coordinator verified R56 did not have R56's mood and behavior care plan individualized to their care, and it should be.
5. The POS (Physicians Orders Sheet) for R43, dated [DATE], documents R43 with diagnoses of Anxiety, Bipolar Disorder, Depression, and Physical Deconditioning. This same POS lists the following psychotropic medications physician orders: Divalproex Sodium ER (Extended Release) 500 mg (milligrams) twice daily; Lorazepam 1 mg at bedtime; Lorazepam 0.5 mg twice daily; Risperidone 1 mg three times a day; and Sertraline (Zoloft) HCL (hydrochloride) 100 mg nightly. A physician order, dated [DATE], documents admit R43 to local hospice service with no hospitalizations or labs.
On [DATE] at 11:35 AM and 2:42 PM and on [DATE] at 8:00 AM and 10:24 AM, R43 was sitting up in a high back reclining wheelchair with a mechanical lift transfer sling underneath her. On [DATE] at 3:44 PM, R43 was transferred from the high back reclining wheelchair to her bed with a mechanical lift via the sling.
On [DATE] at 3:45 PM, V6 LPN (Licensed Practical Nurse) stated R43 used to be in a regular wheelchair and would propel herself but stopped doing that quite a while ago. R43 hasn't been able to walk or transfer and is total care for her cares. V6 LPN stated R43 is transferred with a mechanical lift and went on Hospice due to decline in her condition and only behavior V6 LPN is aware of is anxiety at times.
The fall investigation for R43, dated [DATE], documents R43 attempted to get up unassisted and lost balance falling to the floor with intervention to ensure R34 is positioned correctly in the chair and to Use (high back reclining) chair instead of standard wheelchair for more support. The Hospice Note for R43, dated [DATE], documents R43 was provided a high back reclining wheelchair.
The current Care Plan for R43 was not revised to include the use of R43's psychotropic medications with R43's identified targeted behaviors and interventions; Was not revised with R43's use of a high back reclining wheelchair; Was not revised to include resident centered hospice services and interventions. This same Care Plan was not revised and still documents: Assist for transfers and ambulation; and attempt more frequent lab draws.
On [DATE] at 11:06 AM, V1 Administrator confirmed R43's Care Plan was not revised, and the residents Care Plans are generic, sloppy, and have not updated.
6. The POS (Physicians Orders Sheet) for R56, dated [DATE], documents the following diagnoses: Left MCA (middle cerebral artery) Stroke, right Flaccid Hemiplegia, Cerebral Edema, Aphasia and Depression. This same POS lists the following orders: Iso-Source (Dense Complete Nutrition Formula with Fiber) 1.5 Cal (calorie) 120 ml (milliliters) per electronic feeding pump for 12 hours; 200 ml water flush three times daily during feeding; 30 ml water flush before and after medications; Med Pass (nutritional supplement) 60 ml three times daily; Mighty Shake (nutritional supplement) 4 ounces three times daily; Cleanse and change split sponge daily; Regular mechanical soft - very moist diet with nectar thick liquids
On [DATE] at 10:00 AM, R56 refused to be interviewed, raised left arm, and waved arm toward door and grunted for surveyor to leave the room. On [DATE] at 12:42 PM, on [DATE] at 8:00 AM and 12:20 PM, R56 was sitting in a standard wheelchair in the dining room with his right arm flaccid resting next to him in his lap and was eating a mechanical soft diet. On [DATE] at 2:42 PM, and on [DATE] at 10:20 AM and 3:40 PM, R56 was lying in bed on his back with a visible gastrostomy feeding tube tied in a knot at edge of shirt. R56 refused to allow surveyor to see his Gtube insertion site.
On [DATE] at 7:50 AM V2 DON (Director of Nursing) stated R56 was on Hospice but was taken off sometime last year because he was doing better, and therapy was initiated. Restorative Rehabilitation picked him up after therapy. V2 DON stated R56 refuses to allow his gastrostomy feeding tube to be used, flushed, or cleaned and will tie the tube in a knot. V2 DON confirmed R56 uses a standard wheelchair and no longer uses the high back reclining wheelchair.
On [DATE] at 8:37 AM, V4 LPN (Licensed Practical Nurse) stated R56 refuses Gtube feedings and flushes and hasn't let anyone do anything with his Gtube for a long time. R56 will take his medications by mouth but will refuse them sometimes too. V4 LPN stated, I am really surprised he hasn't tried to yank it (Gtube) out yet.
On [DATE] at 7:58 AM and 8:01 AM, V9 and V10 CNA's (Certified Nursing Assistants) respectively stated R56 refuses to participate in his restorative programs and won't allow staff to do any of his restorative programs.
The Progress Notes for R56, dated April through [DATE], document R56's refusal of Gtube cares, feedings, flushes, and medications and R56 tying his Gtube in a knot to prevent use.
The Quarterly Dietary Note, dated [DATE], documents R56 refuses his Gtube feedings a lot. The RD (Registered Dietitian) Note, dated [DATE], documents R56 continues to refuse Gtube feedings at times, weight trending up due to weight loss last month. The RD Note, dated [DATE], documents R56's continued refusal of Gtube feedings, flushes, and Nurse confirming and recommendation for physician consult related to R56's continued refusal of Gtube feeding and flush.
The Dietary Services Communication form for R56, dated [DATE], documents R56 with Gtube feeding and oral diet, R56 refusing all Gtube feeding and water flushes. Recommend MD (medical doctor) consult related to Gtube feeding and water flush refusals.
The facility Laboratory testing forms for R56, dated [DATE], document R56's refusal of labs and document to redraw on [DATE] with no other laboratory results in R56's medical record.
The Social Service Notes for R56, document R56 admitted to the facility on [DATE] and signed hospice service contract on [DATE]. The Social Service Note, dated [DATE], documents R56 was discontinued from hospice due to family wanting therapy services and on [DATE] R56 was refusing Gtube feedings, eating most meals in the dining room with appetite varying, refusing to wear helmet, and propelling own wheelchair independently.
The current Care Plan for R56 was not revised to include: R56's refusal of Gtube care, feedings, water flushes, and medications; R56 ties Gtube in a knot to prevent use; Refusing Restorative programing; Refusal of oral medications at times; No longer uses a high back reclining wheel chair and uses a standard wheel chair; Refuses to wear helmet when up; Consumes oral diet only; Weight fluctuations and risk for weight loss; and refusal of laboratory testing.
On [DATE] at 11:06 AM, V1 Administrator confirmed R56's Care Plan was not revised and should have been to include and/or remove R56's: Refusal of Gtube cares, feedings, and flushes; Tying Gtube in a knot to prevent use; wheelchair use and not high back reclining wheel chair use; Refusal of restorative programming; Refusal to wear helmet while up; and Refusal of laboratory testing. V1 Administrator also stated the residents Care Plans are generic, sloppy, and have not been updated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R38's current physician order sheet, dated 8/1-8/31/23, documents Fluoxetine 40mg/milligrams by mouth daily as an antidepress...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R38's current physician order sheet, dated 8/1-8/31/23, documents Fluoxetine 40mg/milligrams by mouth daily as an antidepressant; and Olanzapine 10mg by mouth at bedtime as an antipsychotic.
R38's consent form, dated 7/19/23, for Fluoxetine has no behavior identified for the medication use.
R38's medical record has no documentation the facility is monitoring R38 for any behaviors, was unable to provide daily behavior documentation for May, June, July, or August 2023, and has no documentation of any identified behaviors to warrant the use of the medications on the consent form.
On 8/4/23 at 11:30 AM, V2 DON/Director of Nursing verified there was no behavior tracking or identified behaviors in R38's chart and should be.
3. R65's current physician order sheet, dated 8/1-8/31/23, documents Haloperidol 0.5mg by mouth daily at noon and Haloperidol 10mg by mouth twice a day for mood disorder; Zoloft 25mg by mouth daily for depression; and Benztropine 2mg by mouth twice a day for mood disorder.
R65's medical record has no documentation the facility is monitoring R65 for any behaviors, was unable to provide daily behavior documentation for May, June, July, or August 2023, and has no documentation of any identified behaviors to warrant the use of the medications.
On 8/4/23 at 11:30 AM, V2 DON/Director of Nursing verified there was no behavior tracking or identified behaviors in R65's chart and should be.
Based on observation, interview and record review, the facility failed to obtain consents for residents on psychotropic medications, failed to provide clinical justification for the use of dual therapy, failed to identify and track behaviors that warranted the use of psychotropic medications, failed to ensure behavior tracking logs and resident care plans identified specific target behaviors, failed to document non-pharmacological interventions prior to the use of psychotropic medications, and failed to complete psychotropic medication assessments for five of six residents (R23, R37, R38, R43, R65) reviewed for unnecessary medications in the sample of 26.
Findings include:
The facility's Psychotropic Medication Policy revised 11/28/17, states, It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drugs is any drug used: 1. In an excessive dose, including in duplicative therapy. 2. For excessive duration. 3. Without adequate monitoring. 4. Without adequate indications for its use. 5. In the presence of adverse consequences that indicate the drugs should be reduced or discontinued. Procedure: 1. Attempt to rule out social and environmental factors as causative agents of the maladapted behavior. 2. Psychotropic medications shall not be prescribed prior to attempted non-Pharmalogical interventions to decrease behavior. 3. Initiate a Pre-Psychotropic Medication Assessment prior to administration of a newly prescribed psychotropic medication. 4. Initiate a Psychotropic Medication Quarterly Evaluation within 14 days of admission for those residents currently receiving psychotropic medication. 5. Psychotropic medication shall not be prescribed or administered without the informed consent of the resident, the resident's guardian, or other authorized representative. Side effects of the medicine shall be described. 8. The Behavioral Tracking Sheet of the facility will be implemented to ensure behaviors are being monitored. 18. Any resident receiving psychotropic medications will have the Psychotropic Medication Assessment done at a minimum of every quarter. 19. Any resident receiving any psychotropic medication will have certain aspects of their use and potential side effects addressed in the resident's care plan at least quarterly. The care plan will identify target behaviors causing the use of psychotropic medications. The care plan will address the problem, approaches and goals to address these behaviors.
1. R37's Face sheet documents R37 was admitted to the facility on [DATE].
R37's Cumulative Diagnosis Log documents R37 with a diagnosis of Depression with Anxiety.
R37's Minimum Data Set (MDS) assessment dated [DATE] documents the following: R37 is cognitively intact, took Antidepressant Medications for seven out of seven days reviewed, Diagnoses of Depression and Anxiety, feeling down, depressed or hopeless for two to six days out of 14 reviewed; and documents no behavioral symptoms present.
R37's Physician Order Sheet for the months of July and August 2023 document orders with a start date of 7/3/23 for the following medications: Cymbalta 60 milligrams (mg) by mouth daily and Trazodone 50 mg by mouth nightly. On 7/13/23, a new medication order for Elavil 25 mg daily was received.
R37's Medication Administration Record (MAR) for August 2023 documents R37 received R37's Cymbalta, Trazadone and Elavil (Amitriptyline) medications as prescribed. The class of these three medications is labeled as Antidepressants.
R37's current Care Plan documents R37 requires the use of psychotropic medication to manage mood and/or behavior issues and documents an intervention of obtain informed consent prior to administration of medication. This same Care Plan does not document specific target behaviors for R37's use of psychotropic medications.
The facility's Behavior Tracking Logs were noted in white binders at the nurses' station. These binders did not contain any behavior tracking logs for R37.
On 8/3/23 at 12:17 PM, V5 (Care Plan Coordinator) verified that no behavior tracking logs for July or August 2023 were completed for R37. V5 stated, Due to (R37's) diagnoses and medications, there should be. At this same time, V5 verified R37's psychotropic medication assessments were blank, had not been completed and should have been. V5 denied being aware of R37 exhibiting any behaviors. V5 stated, (R37) has pain and will sometimes cry because of it but that's not a reason for psych (psychotropic) meds (medications).
On 8/3/23 at 12:15 PM, V1 (Administrator) denied being aware of R37 exhibiting any behaviors.
On 8/03/23 at 12:10 PM, in a joint interview, V7 (Certified Nursing Assistant/CNA) and V12 (CNA) stated R37 has pain but denied witnessing any behaviors from R37. V7 stated R37 is compliant with cares, gets along with others, is mostly independent and seems happy.
On 8/4/23 at 2:30 PM, V2 (Director of Nursing) denied being aware of R37 displaying any type of mood or behavioral issues. V2 stated R37 is quiet and cooperative with cares. V2 verified R37 is R37's own person and is able to sign her own consents.
During the days of 8/2/23-8/4/23, R37 was observed at various times. No mood or behavior issues of any kind was noted from R37. R37 appeared well-groomed and dressed. R37 was observed out of R37's room, socializing with tablemates for the lunch meals.
On 8/4/23 at 2:55 PM, the facility stated they were unable to provide the following regarding R37's psychotropic medications: Consent Forms; Psychotropic Medication Assessments, Attempted Non-Pharmalogical Interventions prior to the initiation of a new psychotropic medication; Behavior Tracking Logs; or documentation to support R37's duplicative drug therapy.
4. On 8/2/23 at 11:35 AM, 11:54 AM, 2:42 PM, on 8/3/23 at 8:00 AM and 10:24 AM R43 was sitting up in a reclining wheelchair with no behaviors noted. On 8/3/23 at 3:44 pm, R43 was transferred from her high back reclining wheelchair to her bed with no behaviors noted.
The Quarterly MDS for R43, dated 7/13/23, documents R43's cognition is severely impaired, R43 is mildly depressed with delusions with no identified behaviors. R43 receives antipsychotic, antianxiety, and antidepressant medication daily.
The current Behavior Care Plan for R43 documents R43 has history of displaying inappropriate behavior and/or resisting care/services with diagnosis Bipolar disorder and GAD (Generalized Anxiety Disorder). R43 is known to have false accusation against care givers and derogatory name calling to staff. Goal documents initiate Behavior Monitoring program to attempt to identify patterns, precursors, and causes of behavior and to attempt to understand the meaning of the behavior.
The current Psychotropic Drug Care Plan for R43 documents R43 requires use of psychotropic medications to manage mood and/or behavior issues. This Care Plan does not include any resident specific behaviors for R43's use of Antidepressant, Antianxiety and Antipsychotic medications. This same Care Plan documents an intervention to Obtain informed consent prior to administration of medication.
On 8/3/23 at 3:45 pm, V6 LPN (Licensed Practical Nurse) stated R43 has had a decline in her condition and has been on hospice for about a month and half, used to be in a regular wheelchair, would propel herself but stopped doing that quite a while ago. V6 stated R43 hasn't been able to walk or transfer, is total assist for her cares and transfers with a mechanical lift. V6 stated R43 gets anxious at times but is unaware of any other behaviors.
The Physician's Order Sheet for R43, dated August 2023, lists a Physician Order dated 6/14/23 for Antianxiety medication Lorazepam (Ativan) 1 mg at bedtime and 7/19/23 Lorazepam 0.5 mg twice daily.
The Psychotropic Medication Consent, dated 4/3/22, documents R43's Representative signed consent on 4/16/22 for R43 to receive Lorazepam 0.5 mg every am for anxiety. There was no consent obtained after the increase of this medication.
The Psychotropic Medication Quarterly Evaluation for R43, dated 5/7/23, documents a medication assessment for Ativan was completed with targeted behaviors documented as anxious and delusions.
The Behavior Tracking Forms, dated May, July and August 2023, do not include resident centered identified targeted behaviors for the use of Ativan. There is no Behavior Tracking completed for June 2023.
The Physician's Order Sheet for R43, dated August 2023, lists a Physician Order dated 5/3/23 for Antipsychotic medication Risperidone (Risperdal) 1 mg three times a day.
The Psychotropic Medication Consent for R43, dated 4/3/22, documents R43's Representative signed consent on 4/16/22 for R43 to receive Risperidone 1 mg with 0.5 mg at every bedtime and 1 mg every morning for Bipolar behavior. There was no consent obtained after the increase of this medication.
The Psychotropic Medication Quarterly Evaluation for R43, dated 5/7/23, documents a medication assessment for Risperdal was completed with targeted behaviors documented as anxious and delusions.
The Behavior Tracking Forms, dated May, July, and August 2023, do not include resident centered identified targeted behaviors for the use of Risperidone. There is no Behavior Tracking completed for June 2023.
The Physician's Order Sheet for R43, dated August 2023, lists a Physician Order dated 3/10/23 for Antidepressant medication Sertraline (Zoloft) HCL (hydrochloride) 100 mg nightly.
The Psychotropic Medication Consent for R43, dated 4/3/22, documents R43's Representative signed consent on 4/16/22 for R43 to receive Sertraline 100 mg every evening for depression.
The Psychotropic Medication Quarterly Evaluation for R43, dated 5/7/23 documents a medication assessment for Zoloft was completed with targeted behaviors of anxious and delusions. This evaluation does not include behaviors of depression as the consent was signed for.
The Behavior Tracking Forms, dated May, July, and August 2023, do not include behavior tracking was completed for the use of Sertraline (Zoloft). There is no Behavior Tracking completed for June 2023.
The Physician's Order Sheet for R43, dated August 2023, lists a Physician Order dated 2/6/23 for Divalproex Sodium (Depakote) ER (Extended Release) 500 mg (milligrams) to twice daily.
The Psychotropic Medication Consent for R43, dated 4/3/22, documents R43's Representative signed consent on 4/16/22 for R43 to receive Divalproex Sodium ER 250 mg at bedtime for manic behavior and Bipolar behavior. There was no consent obtained after the increase of this medication.
The Psychotropic Medication Quarterly Evaluation for R43, dated 5/7/23, documents a medication assessment for Depakote was completed with targeted behaviors of anxious and delusions.
The Behavior Tracking Forms for R43, dated May, July and August 2023, do not include behavior tracking being completed for the use of Divalproex Sodium ER. There is no Behavior Tracking completed for June 2023.
On 8/4/23 at 8:00 AM V2 DON (Director of Nursing) provided Behavior Tracking Records for R43, dated May, July, and August. V2 DON stated that is all she was able to find.
5. On 8/2/23 at 10:05 AM, R23 was lying in bed on her right side with eyes closed. On 8/2/23 at 2:44 PM, R23 was sitting in a stationary chair in the activity area participating in activity. On 8/3/23 from 8:00 AM through 8:30 AM, R23 was sitting in a stationary chair in the dining room eating breakfast independently. On 8/3/23 at 10:22 AM and 3:45 PM, R23 was ambulating the facility hallways. There were no identified behaviors for R23 between 8/2/23 and 8/3/23.
The Quarterly MDS (minimum data set) assessment for R23, dated 6/7/23, documents R23 is cognitively intact with no depression or identified behaviors and receives Antidepressant medication daily for Depression.
There is no Behavioral Care Plan for R23.
The current Psychotropic medication Care Plan for R23, documents R23 requires use of psychotropic medication to manage mood and/or behavior issues. resident specific behaviors for R23's use of Antidepressant medication. This same Care Plan documents intervention to: Obtain informed consent prior to administration of medication.
The current Lifestyle Preferences Care Plan for R23, documents start dated 7/20/23 as Recent onset of cognitive behavior changes r/t (related to) Dementia progression. (R23) unaware of social limits as well as safety. There are no resident centered identified documented behaviors for R23.
On 8/3/23 at 8:37 AM V4 LPN (Licensed Practical Nurse) stated R23 had a mental episode a few months ago but no others since. V4 LPN stated R23 walks around the facility all day and will sometimes go into other resident rooms but that is about it.
The Physician Order Sheet for R23, dated August 2023, documents a Physician Order dated 5/30/23 for Trazodone 50 mg at bedtime.
The facility was unable to provide a signed Consent for R23's use of the Trazodone medication for R23.
The Psychotropic Medication Evaluation for R23 is blank and has not been completed.
Behavior Tracking Forms for R23, dated August 2023, documents R23 with a Diagnosis of Depression and Dementia with target behavior documented as: Monitor for s/s (signs and symptoms) of depression and (R23) unaware of social limits and do not include resident centered identified targeted behaviors for the use of Trazodone. There is no Behavior Tracking completed prior to August 2023.
On 8/4/23 at 8:00 AM V2 DON (Director of Nursing) provided Behavior Tracking Records for R23, dated August 2023. V2 DON stated that is all she was able to find.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0572
(Tag F0572)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to inform residents of their rights during their stay in the facility. This has the potential to affect all 62 residents residing...
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Based on observation, interview and record review, the facility failed to inform residents of their rights during their stay in the facility. This has the potential to affect all 62 residents residing in the facility.
Findings include:
Long Term Ombudsman Program Resident Rights for People in Long-term care Facilities, dated 12/04, documents Your rights as a citizen and a facility resident you do not lose your right as a citizen of Illinois and United States because you live in a long-term care facility. You have the right to vote.
On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom. During the resident council meeting, R39, R42, R33, and R11 were asked if they knew what the rules and their rights were at the facility, R39, R41, R33, and R11 were unaware of what the facility rules and rights were, and stated nothing has ever been gone over in resident council or posted in the facility that they knew of. R33 was unaware she could still vote while a resident of the facility.
On 8/03/23 at 10:50 AM, a tour of the facility was taken, and no postings were found on resident rights.
On 8/03/23 at 11:50 AM, a tour of the facility was conducted with V1 Administrator and she verified the facility did not have resident rights posted, and was unsure if they were gone over in resident council because V8 SSD/Social Service director usually performed the resident council meetings and took care of the resident rights but was unavailable for an interview during the survey. At that same time, V1 was unable to provide any documentation V8 had informed the residents in the facility of their rights. V1 verified the provided resident council minutes did not include any documentation on resident rights.
R39, R41, R33, and R11's medical records document they are moderately impaired and cognitively intact for cognition.
Resident Census and Conditions form, dated 8/2/23, documents 62 resident live in the facility.
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 observation, interview and record review, the facility failed to deliver mail six days a week. This has the potential to affect all 62 residents residing in the facility.
Findings include:
Lo...
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Based on observation, interview and record review, the facility failed to deliver mail six days a week. This has the potential to affect all 62 residents residing in the facility.
Findings include:
Long Term Ombudsman Program Resident Rights for People in Long-term care Facilities, dated 12/04, documents Your facility must deliver your mail to you promptly.
On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom.
During the resident council meeting, R39, R42, R33, and R11 were asked if they got mail delivered on Saturdays and during the week. R39, R42, R33, and R11 all stated they did not get mail delivered on weekends, and if a package was delivered on Saturday they had to wait until Monday when V13 Activity Director came back to work because V13 is who delivers the mail and packages and only works Monday through Friday.
On 8/03/23 at 10:50 AM, a tour of the facility was taken, and a paper was posted in the clear glass display case at the nurse's desk that documents All mail that is available to be handed out will be given to activities by 1:00pm for distribution. Exceptions for the weekends, when there may not be anyone available.
On 08/04/23 at 11:25 AM V13 Activities stated, I work Monday thru Friday from 8:30 to 4:30pm and pass the mail/packages after management takes out their financial information.
R39, R41, R33, and R11's medical records document they are moderately impaired and cognitively intact for cognition.
Resident Census and Conditions form, dated 8/2/23, documents 62 resident live in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to inform residents of their rights and where/whom to file a grievance. This has the potential to affect all 62 residents residing in the faci...
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Based on interview and record review, the facility failed to inform residents of their rights and where/whom to file a grievance. This has the potential to affect all 62 residents residing in the facility.
Findings include:
Facility Resident Grievances/Complaints, revised 11/1/17, documents It is the policy to actively encourage residents and their representatives to voice grievances and complaints on behalf of themselves or others. The facility shall provide contact information including: grievance official name, business address, business phone, a reasonable timeframe for completing the review of the grievance.
On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom.
During the resident council meeting, R39, R42, R33, and R11 were asked if they knew who their grievance official was and how to file a grievance. R39, R41, R33, and R11 were unaware of who their grievance official was and stated there was no posting they were aware of on who to file a grievance to.
On 8/03/23 at 10:50 AM, a tour of the facility was taken, and no postings were found on how to file a grievance and where/whom was responsible for assisting with filing a grievance for residents.
On 8/03/23 at 11:50 AM, a tour of the facility was conducted with V1 Administrator and she verified the facility did not have any postings on how to file a grievance and where/whom was responsible for assisting with filing a grievance for residents.
R39, R41, R33, and R11's medical records document they are moderately impaired and cognitively intact for cognition.
Resident Census and Conditions form, dated 8/2/23, documents 62 resident live in the facility.
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 record review and interview, the facility failed to ensure a Registered Nurse/RN was staffed eight hours per day, every day in July 2023. This failure has the potential to affect all resident...
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Based on record review and interview, the facility failed to ensure a Registered Nurse/RN was staffed eight hours per day, every day in July 2023. This failure has the potential to affect all residents residing in the facility on those days.
FINDINGS INCLUDE:
The facility's Nurse Staffing Schedule, for July 2023, document the facility failed to staff a Registered Nurse on July 8, 9, 25, and 28, 2023.
On 8/4/2030, at 11:38 AM, V2/Director of Nursing confirmed the facility did not provide a RN for at least 8 hours on July 8, 9, 25, and 28, 2023. V2 confirmed resident census, on the aforementioned days, was 61, 61, 65, and 64, respectively.
Resident Census and Conditions form, dated 8/2/23, documents 62 resident live in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to offer residents snacks outside of the scheduled meal service times. This has the potential to affect all 62 residents residing in the facil...
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Based on interview and record review, the facility failed to offer residents snacks outside of the scheduled meal service times. This has the potential to affect all 62 residents residing in the facility.
Findings include:
Facility Diet Listing, undated, documents 62 residents eat at the facility.
Facility posted mealtimes documents Breakfast: 7:30am; Lunch: 12:00pm; and Dinner 5:30pm.
Facility Evening Snacks, revised 10/15, documents It is the policy to offer each resident an evening snack and document whether the resident accepted or declined the evening snack. All residents will be offered a bedtime snack.
On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom.
During the resident council meeting, R39, R42, R33, and R11 were asked if they were offered snacks throughout the day. R39, R41, R33, and R11 all stated they were not offered snacks and R41, R11, and R33 stated they were all diabetics and not offered a bedtime snack.
On 8/03/23 11:40 AM, V7 Certified Nurse Aid/CNA stated There are no resident snacks passed by us, I just came to day shift off of PM shift and we did not pass snacks at night or bedtime to anyone or the diabetics. Dietary doesn't send snacks on a tray or have available for the residents, we pass ice water but no nourishment cart, and I have never seen any prepared snacks from dietary.
R39, R41, R33, and R11's medical records document they are moderately impaired and cognitively intact for cognition.
Resident Census and Conditions form, dated 8/2/23, documents 62 resident live in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
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 accurately complete, document, systematically organize ...
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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, document, systematically organize and have readily accessible medical records for all 62 Residents residing in the Facility. This failure has the potential to affect all 62 Residents residing in the Facility.
Findings include:
Resident Census and Condition Report, dated 8/2/23, document 62 residing in the Facility.
Facility Administrator Job Summary, undated, documents: the Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting and the physical management of the Facility, Residents and equipment in a way that the purpose of the Facility shall be maintained in accordance with all established practices, policies, laws and applicable State Regulations; the Administrator will manage and conduct the business of the Facility in a manner that protects the Facility license and certification at all times; and the major goal of the Administrator is to provide an atmosphere in which residents may achieve their highest physical, mental and social wellbeing.
Facility Medical Records Personnel Job Summary, undated, documents maintain Resident files and statistics by ensuring that all the proper forms are present and signed and make certain that the medical information is correct and accessible to doctors, nurses, government agencies, etc.; and responds to requests for medical records; and performs clerical duties.
1. R219's Physician Order Sheet/POS, dated 7/19/23, documents that R219 admitted to the facility on [DATE]. The POS also documents an order for daily weights for three days, then every week for four weeks.
R219's Treatment Administration Record/TAR, dated 7/19/23 through 7/31/23, documents an order on 7/19/23 for Daily Weights for three days, then every week for four weeks. The TAR does not document R219's daily weight on 7/19/23, 7/20/23 or 7/21/23. The TAR does not document R219's weekly weight on 7/26/23.
Facility Monthly Weight Grid, dated 8/2022 through 7/2023 (provided on 8/2/23 by V2/Director of Nursing), does not document an entry with R219's name or weights.
On 8/2/23 (during the hours of 9:00 AM and 3:00 PM) and 8/3/23 (during the hours of 7:30 and 3:00 PM), R219's Assessments (Braden Scale for Predicting Pressure Ulcer Risk, Respiratory/Orthopnea Assessment, Pain Assessment, Elopement Evaluation, Range of Motion Assessment, Hydration Assessment, Bed Rail/Transfer Bar Evaluation and Bed Rail Algorithm) were all undated and not completed.
2. R36's Physician Order Sheet, dated 6/26/23, documents that R36 admitted to the facility on [DATE].
R36's Minimum Data Set/MDS Transmission Schedule, undated, documents R36's last MDS was scheduled and completed on 6/8/23.
On 8/2/23 (during the hours of 9:00 AM and 3:00 PM), 8/3/23 (during the hours of 7:30 AM and 3:00 PM, and 8/4/23 (7:45 AM to 11:40 AM, R36's current Medical Chart, Tab MDS (Minimum Data Set), documents R36's most recent MDS, dated [DATE], Sections B through Section S was accessible and documented in R36's Medical Record. R36's MDS, dated [DATE], was not accessible or documented in R36's Medical Chart.
R36's current updated Care Plan was not documented or available in R36's Medical Chart.
3. R48's Physician Order Sheet, dated 8/1/23, documents that R48 admitted to the facility on [DATE].
R48's Minimum Data Set/MDS Transmission Schedule, undated, documents R48's last MDS was scheduled and completed on 7/4/23.
On 8/2/23 (during the hours of 9:00 AM and 3:00 PM), 8/3/23 (during the hours of 7:30 am and 3:00 pm, and 8/4/23 (7:45 AM to 11:40 PM), R48's current Medical Chart, Tab MDS (Minimum Data Set), documents R48's most recent MDS, dated [DATE], Sections A through Section Z was accessible and documented in R48's Medical Record. R48's MDS, dated [DATE], was not accessible or documented in R48's Medical Chart.
R48's current updated Care Plan was not documented or available in R48's Medical Chart.
On 8/3/23, at 11:26 AM, V2 (Director of Nursing/DON) stated, We are not electronic charting yet, it is coming soon. Hopefully that will solve a lot of our problems with all of our medical records and charts not updated. We do not keep everything in the Resident's charts like I know we probably should, it is kind of scattered all over the place, so it makes it hard to find stuff. Plus, I have had problems with keeping Medical Records staffed, so we are playing catch up.
4. On 8/4/23 at 11:30 AM, V5 LPN (Licensed Practical Nurse) MDS/CPC (Care Plan Coordinator) stated she is responsible for the residents MDS and Care Plans. V5 also stated she is the facility's Restorative Nurse, among other titles, works as a floor Nurse at times, and has not been able to get everything done. V5 stated all the Care Plans in the residents' charts are working Care Plans and she tries to keep them updated. V5 LPN provided the MDS Transmission Report for R23.
The MDS (minimum data set) Assessment Transmission Report for R23, documents: Quarterly MDS was submitted on 7/3/23; Significant change MDS was submitted on 6/7/23; Quarterly MDS was submitted on 3/20/23; Annual MDS was submitted on 12/13/22; and Quarterly MDS was submitted on 9/6/22. None of these MDS's are located in R23's Medical Record.
R23's Medical Record does not include any MDS assessment for 2022 or 2023. The last MDS Assessment included in R23's medical record is an Annual MDS dated [DATE].
R23's Medical Record documents the last IDT (Interdisciplinary Team) Progress Note was made on 3/2/20 and does not contain hospital transfer orders for R23's 5/14/23 and 5/21/23 hospitalizations. The working Care Plan is not resident centered and has not been updated.
On 8/3/23 at 11:06 AM, V1 Administrator confirmed the resident's charts do not contain all the required documents they should, and the Care Plans are generic, sloppy, and have not been updated like they should. V1 stated there are stacks of papers everywhere that need to go into the charts and doesn't know why they aren't.
5. On 8/4/23 at 11:30 AM, V5 LPN (Licensed Practical Nurse) MDS/CPC (Care Plan Coordinator) stated she is responsible for the residents MDS and Care Plans. V5 also stated she is the facility's Restorative Nurse, among other titles, works as a floor Nurse at times, and has not been able to get everything done. V5 stated all the Care Plans in the resident's charts are working Care Plans and she tries to keep them updated. V5 LPN provided the MDS Transmission Report for R43.
The MDS (minimum data set) Assessment Transmission Report for R43, documents: Quarterly MDS was submitted on 7/14/23; Significant Change MDS was submitted on 5/3/23; Quarterly MDS was submitted on 4/26/23; Quarterly MDS was submitted on 2/23/23; Annual MDS was submitted on 4/26/23; Annual MDS was submitted on 11/11/22; Quarterly MDS was submitted on 11/10/22; and Quarterly MDS was submitted on 8/18/22. None of these MDS's are located in R43's Medical Record.
R43's Medical Record does not include any MDS Assessments for 2022 or 2023. The last MDS Assessment included in R43's medical record is an Annual MDS dated [DATE].
R43's Medical Record includes a working Care Plan which is not resident centered and has not been updated.
On 8/3/23 at 11:06 AM, V1 Administrator confirmed the resident's charts do not contain all the required documents they should and the Care Plans are generic, sloppy, and have not been updated like they should. V1 stated there are stacks of papers everywhere that need to go into the charts and doesn't know why they aren't.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. (b) On 8/2/23, at 12:19 AM, V4 (Licensed Practical Nurse/LPN), with a soiled protectant adhesive (band aid) on V4's right thu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. (b) On 8/2/23, at 12:19 AM, V4 (Licensed Practical Nurse/LPN), with a soiled protectant adhesive (band aid) on V4's right thumb, was dispensing medication (Calcium) to R15. With V4's bare hands, V4 touched each end of the medication tablet and broke the medication tablet in half and placed in a medicine cup, then administered the tablet to R15. No hand sanitizing was performed before the preparation or administration of R15's medication.
On 8/2/23, at 12:22 PM, V4 stated, Whoops, I have been making mistakes all day. I have formed bad habits over the years and I should know better than to break that apart with my bare hands.
Based on observation, interview and record review the facility failed to perform hand hygiene and maintain glove use for two residents (R3 and R15) observed during medication pass and failed to ensure physician ordered contact isolation precautions were initiated for one of 16 residents (R37) reviewed for infection control in the sample of 26. This failure has the potential to affect all 62 residents who currently reside in the facility.
Findings include:
1. The facility's Contact Precautions Policy reviewed 12/17/18 states, In addition to Standard Precautions, use Contact Precautions, or the equivalent for specified residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident (hand or skin to skin contact that occurs when performing resident care activities that require touching the residents dry skin) or indirect contact (touching with environmental surfaces or resident care items in the residents environment). This same policy documents gown and gloves will be worn when entering the resident's room.
R37's Cumulative Diagnosis Log documents R37 with diagnoses to include but not limited to: Sepsis; Left Fibula Osteomyelitis; Type I Diabetes Mellitus and bilateral lower extremity amputations.
R37's Nurses Notes documents the following: R37 admitted to the facility on [DATE]; R37 was transferred and admitted to the local area hospital on 5/14/23 with a diagnosis of sepsis; R37 did not return to the facility again until 7/3/23; and R37 was re-admitted to the hospital on [DATE] with R37 returning to the facility on 7/19/23.
R37's Nursing admission assessment dated [DATE] documents R37 with a left stump incision measuring 17 centimeters (cm) by 2 cm and a left stump wound measuring 9 cm by 2 cm by 0.3 cm.
R37's Weekly Wound Tracking for the month of July 2023 documents R37's left below the knee surgical incision/wound was being monitored.
R37's Physician Order Sheet/POS dated 7/3/23-7/31/23 documents an order for contact isolation for MRSA (Methicillin-resistant Staphylococcus aureus) wound and ESBL (Extended Spectrum Beta-Lactamase) VRE (Vancomycin-resistant Enterococci) urine.
R37's Physician Order Sheet/POS dated 7/19/23-7/31/23 documents an order for contact isolation precautions. This same POS documents on 7/19/23, V3 (Licensed Practical Nurse/Infection Preventionist) received a telephone order from V11 (R37's Physician); this order states, Readmit to (name of skilled nursing facility) with transfer orders, admit labs and Contact Isolation Precautions.
R37's Hospital Records documents the following laboratory results: Urine Culture on 5/14/23 states, Culture Results: Greater than 100,000 CFU/ML (colony-forming unit per millilitre) Klebsiella pneumoniae. Comment: Multidrug resistant organism (CRE/Carbapenem-Resistant Enterobateriaceae) found.; Aerobic Culture of bone specimen on 5/20/23 states, Few Klebsiella pneumoniae. Comment: ESBL (Extended Spectrum Beta-Lactamase) positive status; and Urine Culture dated 7/14/23, states, Vancomycin Screen is positive. This is VRE. Please follow appropriate patient isolation protocols.
R37's Post Acute Care Transition Document dated 7/19/23 documents discharge orders for R37's return to the skilled nursing facility. This same document states, Infection: Carbapenem-Resistant Enterobateriaceae (CRE) Wound 1/25/23 (CRE Klebsiella pneumonia) CP-CRE (Carbapenemase-producing Carbapenem-Resistant Enterobateriaceae) confirmed from urine 5/14/23. This infection does not expire. (R37) will need to be in contact isolation for every future stay. This same discharge document notes R37 with infection types of ESBL (Extended Spectrum Beta-Lactamase), MRSA (Methicillin-resistant Staphylococcus aureus) and VRE (Vancomycin-resistant Enterococci). Isolation type is ordered as contact.
Throughout the days of 8/2/23-8/4/23, no contact isolation precaution sign was noted on the outside of R37's bedroom door and no personal protective equipment was noted outside R37's bedroom ready for use.
On 8/2/23 at 12:15 PM, R37 was observed in the main dining room eating the lunch meal.
On 8/03/23 at 12:04 PM, in a joint interview, V7 (Certified Nursing Assistant/CNA) and V12 (CNA) stated R37 has not been placed in contact isolation precautions after either of R37's July admission dates and stated they were not aware R37 needed to be. V7 and V12 stated they work in all areas of the facility, including R37's room.
On 8/04/23 at 8:15 AM, R37 was sitting in R37's room in a wheelchair. Two white garbage bins labeled trash were on the right side of R37's room. The trash bins were both empty. At this time, R37 denied being placed in contact isolation while at the skilled nursing facility. R37 stated, They brought those bins in here but never did anything with them.
On 8/04/23 at 11:45 AM V3 (Infection Preventionist/Licensed Practical Nurse) stated V3 admitted R37 back from hospital on 7/3/23 and 7/19/23. V3 stated on both dates, R37 came with documentation that stated R37 needed to be in contact isolation for several different type of infections. V3 stated V3 ordered R37's contact isolation precautions as it was on R37's discharge paperwork. V3 stated V3 asked housekeeping to place isolation barrels in R37's room. V3 denied calling V11 to clarify R37's isolation precaution orders. V3 verified that R37 being in contact isolation precautions was appropriate until R37 could be seen by a physician.
On 8/04/23 at 9:48 AM, V11 (R37's Physician) stated V11 would have expected the facility to place R37 in contact isolation precautions according to the hospital's discharge paperwork until calling V11 to clarify. V11 stated depending on the conversation V11 had with the facility regarding R37's status, V11 would have determined R37's contact isolation precautions. At this time, V11 denied recalling anyone from the facility calling to clarify R37's isolation status.
The Resident Census and Conditions of Residents Form dated 8/2/23 documents 62 residents currently reside in the facility.
2. The facility's Medication Administration policy and procedure, Revised 11/18/17, documents 11. Avoid touching medication. If contact with medication is likely, prepare medication using gloves. 12. Appropriate hand washing is to be completed and/or alcohol based get rub or (cleansing agent) must be used, throughout the medication pass. This should occur: Before and after medication pass. After touching an oral medication during administration. It is acceptable to use an antiseptic gel type solution between residents.
On 8/2/23 at 8:18 am V4 LPN (Licensed Practical Nurse) stepped up to the medication cart and did not perform hand hygiene prior to preparing medications for R15. V4 LPN noted to have a soiled protective adhesive bandage to her right thumb. V4 LPN reached into her uniform pocket, pulled out set of keys, unlocked the medication cart, and using keys unlocked the narcotic lock box. V4 LPN pulled out R15's Phenobarbital 64.8 mg bubble packed medication card and using her ungloved soiled right thumb pushed the Phenobarbital pill from the bubble pack into the palm of her soiled left hand. V4 LPN placed the medication card back into the narcotic box, picked up the Phenobarbital pill from her ungloved soiled left hand with her ungloved soiled right first finger and right soiled bandaged thumb and placed the pill into a plastic medication cup. After preparing and administering the medications to R23 V4 LPN returned to the medication cart. Without performing hand hygiene V4 LPN began preparing medications for R3.
On 8/2/23 at 8:25 am, V4 LPN stated I probably shouldn't have touched her pill with my hands.
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
Based on interview and record review, the facility failed to ensure the facility's designated Infection Control Preventionist (ICP) was scheduled to work at the facility in a manner that allowed the I...
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Based on interview and record review, the facility failed to ensure the facility's designated Infection Control Preventionist (ICP) was scheduled to work at the facility in a manner that allowed the Infection Control Preventionist role to be fulfilled and failed to ensure the DON (Director of Nursing) who assists in the ICP role completed an approved ICP Certification. This failure has the potential to affect all 62 residents who currently reside in the facility.
Findings Include:
The facility's Infection Control Surveillance and Monitoring Policy, revised 4/11/22, states, It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained. The facility shall employ, at a minimum, a part time Infection Control Preventionist (ICP). These duties may be performed by the Director of Nursing (DON) with an approved Infection Control Certification. This same policy documents that the DON/ICP will: Investigate and implement controls to prevent infections in the facility; Direct the correct procedures to prevent the spread of infections; Follows up on documentation and reporting of infections to the physicians; Maintains programs that prohibits employees with communicable diseases from direct resident contact; Maintains and enforces hand washing by all staff; Updates the Infection Control Log on a daily basis; and Prepares quarterly Infection Control reports for presentation to the Quality Assurance Committee.
On 8/4/23 at 10:29 AM, V3 (Infection Preventionist/Licensed Practical Nurse) stated V3 has received an Infection Control Certification but that V3 has not been able to work in the ICP role due to staffing issues in the facility. V3 stated, I have only worked as the ICP nurse for maybe ten days this entire year. V2 (Director of Nursing) does most of it. We are so short staffed; I have only been working the floor. V3 stated V3 never has time to work on ICP requirements.
On 8/3/23 at 11:40 AM, V2 (Director of Nursing) stated that V3 has been having to work the floor as a bedside nurse on second shift and that V3 has not been able to complete ICP tasks. V2 stated that V2 has been assisting V3 with maintaining Infection Control Logs and Antibiotic Tracking. At this time, V2 verified that V2 has not completed the required training to receive an Infection Control Certification.
The Resident Census and Conditions of Residents (Centers for Medicare and Medicaid Services/CMS 672) Form, dated 8/2/23, documents 62 residents currently reside in the facility.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
Based on observation, interview and record review, the facility failed to post and have reports from the most recent survey of the facility available. This has the potential to affect all 62 residents...
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Based on observation, interview and record review, the facility failed to post and have reports from the most recent survey of the facility available. This has the potential to affect all 62 residents residing in the facility.
Findings include:
Long Term Ombudsman Program Resident Rights for People in Long-term care Facilities, dated 12/04, documents Your facility must let you see reports of all inspections by the Illinois Department of Public Health.
On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom.
During the resident council meeting, R39, R42, R33, and R11 were asked if they knew where the state survey book was located at the facility. R39, R41, R33, and R11 were unaware of where the state survey book was located because it was located in the front lobby at one time, but it had been removed quite a while ago when the lobby was remodeled.
On 8/03/23 at 10:50 AM, a tour of the facility was taken and unable to find the state survey binder. A paper posted in the clear glass display case at the nurse's desk documents state survey results are available for residents and visitors to view in the front lobby, however no binder or results of state inspection found in the lobby.
On 8/03/23 at 11:50 AM, a tour of the facility was conducted with V1 Administrator and she verified the facility did not have the state survey book in the lobby. I have it in my office because it was not updated, they remodeled the lobby and it hasn't had a place to go since the remodel, and I suppose it will go on the table when we take off the magazine.
R39, R41, R33, and R11's medical records document they are moderately impaired and cognitively intact for cognition.
Resident Census and Conditions form, dated 8/2/23, documents 62 resident live in the facility.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to control a resident in a wheelchair during a transportation and prevent injury and failed to report a resident injury to the nu...
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Based on observation, interview and record review, the facility failed to control a resident in a wheelchair during a transportation and prevent injury and failed to report a resident injury to the nurse for one resident (R1) out of three residents reviewed for accidents in a sample of three.
Findings include:
The facility's Notification for Change In Resident Condition or Status policy revised 12/7/17 documents The facility and/or facility staff shall promptly notify appropriate individuals of changes in the resident's medical/mental condition and/or status. 2. The nurse supervisor/charge nurse will notify the DON (Director of Nursing), physician and unless otherwise instructed by the resident the resident's next of kin or representative when the resident has any of the afore mentioned situations or: A. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source.
The facility's Transportation Driver job summary undated documents Responsibilities: e. Transports resident to and from scheduled appointment and approved locations in a safe and responsible manner. h. Responsible for the care and well-being of all residents.
R1's minimum data set (MDS) documents a brief interview for mental status (BIMS) score of 15. A BIMS score of 12-15 indicates a resident is cognitively intact. R1's MDS also documents R1's locomotion off the unit requires a one person physical assist.
On 7/5/23 at 8:25 AM, R1 observed sitting in her bed with bilateral bruising to her face, bloodshot right eye, bruising to the left arm, skin tear to her right first knuckle and a skin tear to her left forearm. R1 stated All this (point to her arm, facial bruising and skin tears to her right hand knuckle and left forearm) happened while I was getting in the van for dialysis on Saturday (7/1/23). I was going out the front door and all the sudden I started rolling downhill because the driver didn't have a hold of my wheelchair. They always hold my wheelchair when I come out of the facility because of that slope in the walkway. I started rolling and I couldn't stop myself. I wound up rolling downhill and slammed into the van's lift. The nurse never came out and looked at anything before I went to dialysis.
On 7/5/23 at 9:00 AM, V3, Van Driver (VD), stated I pulled open the front door and (R1) started pushing herself through the doors with their feet. I didn't grab her wheelchair because she was wheeling herself toward the van. It looked like she lost control of the wheelchair and started rolling toward the van. She put her hands up in the air trying to brace herself for impact when she hit the lift. I didn't see her hit her head. When I looked at her, she had a cut on her right hand. I grabbed the emergency kit out of the van looking for a Band-Aid, but I couldn't find one. So I grabbed a rag and wiped the blood off her hand. I then loaded her up in the van and took her to dialysis. When I got her to dialysis, I told the technician and he put a Band-Aid on her hand. I don't know why I didn't tell the nurse before loading her up in the van and taking her to dialysis.
On 7/5/23 at 9:13 AM, V2, DON, verified there is a downhill grade to the walkway outside the facility entrance and stated When going out the front entrance of the facility, the staff should have control of the resident's wheelchair for safety. (V3, VD) should have immediately reported the incident and gotten a nurse to assess (R1) prior to loading her in the van. She shouldn't have loaded her up without a nurse looking at her. I was called by the dialysis unit and informed of the injuries so I requested she be sent to the hospital for evaluation. (R1) wasn't assessed by us until she got back from the hospital. When I saw all the bruising on her face, I was surprised when the hospital said she didn't have any fractures. She only has the bruising to her face, left arm and the skin tears to her left arm and hand. She also had a right black eye when she came back from the hospital.
On 7/5/23 at 11:21 AM, V4, VD, stated When I take (R1) to dialysis, I always hold onto her wheelchair when we go out the front door because of that slope. I don't want her rolling out into the parking lot. Last week we started using the side door because it's flat.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff provided an appropriate transfer to preve...
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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 staff provided an appropriate transfer to prevent a fall for one resident (R4) and safe turning assistance for one resident (R5) of three residents reviewed for falls in the sample of eight.
Findings include:
The Fall Prevention policy dated 11/10/18, documents To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility.
The Limited Lift Program not dated, Documents Section 1- 'The Limited Lift program eliminates all manual transfers requiring more than 35 lbs. (pounds) of assistance from one caregiver. Any resident requiring more than this will be transferred with either 2 employees, a sit to stand or a total lift. Safe Resident Handling and Movement Requirements: Use mechanical lifting devices and other approved patient handling aids for high-risk residents handling and movement tasks except when absolutely necessary, such as in a medical or environmental emergency or evacuation. Definition - High-Risk Resident Handling and Transfer Tasks: Resident handling tasks that have a high-risk of musculoskeletal injury for safe performing the task. These include but are not limited to transferring tasks, lifting tasks, repositioning tasks, bathing residence in bed, making occupied beds, dressing residents, turning residents in bed, and tasks with long duration. All Certified Nurses Aids and licensed nursing personnel engaged in the lifting and transferring of residents will use gate belts. Mechanical lifts will be used when the use of gait belts does not provide an adequate margin of safety. The use of gait belts and mechanical lifts is essential to reduce the risk of accident and injury to both residents and employees. Section Three - Full Electric Mechanical Lift (Dependent Resident) A total mechanical transfer may be done with a resident who generally fits the following characteristics: Are non-weight bearing or have contraindications to putting pressure on lower extremities. Any other transfer type is excluded due to a medical condition or comorbidity. Are unable to assist during the transfer process. If the caregiver is required to lift more than 35 # (pounds), the caregiver will consider the resident dependent and will utilize mechanical equipment. Specific Best Practice Transfer Guidelines - The transfer status will be noted on the care plan. A caregiver has the ability to increase the level of assistance at any time if that caregiver feels that the resident is not safe to perform the noted transfer method on the care plan. Turning A Resident Over in Bed, Lock the bed in place to prevent movement. Section Five - Fulfilling Fall Prevention Responsibilities- All Staff: Know resident falls status (high risk): Know resident strengths/weaknesses with regard to fall risk. CNA: Know resident's care plan; Know resident fall status; Know resident strengths/weaknesses; Know and Ensure resident's preventive measures and they are in place.
1. The facility Final Report for R4 sent to (the state agency) dated 3/21/23, documents [AGE] year-old female resident with a BIMS ((Brief Interview for Mental Status) score of 12 (Mildly Impaired) was lowered to the floor by (V4/Certified Nursing Assistant). During transfer of (R4) from bed to chair, (R4) began to fight against (V4) and was complaining of pain. (R4) stated she hit her head on wheelchair and an abrasion was noted to her left side. (R4) is on a blood thinner. Order was obtained by (V10/R4's Primary Physician) to send to ED (Emergency Department) for evaluation and treatment. Conclusion: hospital notes state that (R4) has an old T (Thoracic) 5 fracture of undetermined age.
R4's Minimum Data Set assessment dated [DATE], documents that R4 is an extensive assist of two staff for bed mobility and transfers.
R4's current Care Plan documents that R4 has a restorative nursing program due to R4 needing assist from two staff for all transfers and mechanical lift. R4 is unable to transfer independently related to diagnosis of past Cerebrovascular Accident with left sided weakness, as evidenced by left side paralysis. R4's left arm and leg remain flaccid.
On 3/26/23 at 10:03 AM, R4 stated that V4 (Certified Nursing Assistant/CNA) that was taking care of her made her fall. (V4) was trying to kill me. I told (V4) I was a (mechanical) lift. (V4) was pulling me up. (V4) said no (mechanical) lift.
On 3/25/23 at 10:30 AM, V2 (Director of Nursing/DON) stated that on 3/18/23, around 4:30 PM, V4 (CNA) went to transfer R4 with a stand pivot transfer. V4 lowered R4 to the floor when V4 was unable to transfer R4 by herself. R4 was a mechanical lift transfer.
On 3/25/23 at 5:29 PM, V4 (CNA) stated (3/18/23) was the first day I came back from being off for a couple of weeks. I was getting the residents up for supper. I went into (R4's) room and she wanted me to transfer her to the chair. I didn't know (R4) was a (mechanical) lift. When I was helping (R4) to stand she started fighting against standing. (R4) got off the bed and refused to go to her chair. (R4) started yelling that she hurt. I lowered (R4) to the floor.
On 3/27/23 at 11:28 AM, V11 (Registered Nurse/RN) stated On Saturday (3/18/23) around 4:30 PM, I was notified that (R4) fell. (V4/CNA) was the only person in the room with (R4) when (R4) fell. (R4) is a (mechanical) lift and has been for at least a year. (V4) should have known that (R4) required a (mechanical) lift. I went and checked the book that the CNAs use to know how to transfer the residents. It was in the book that (R4) required a (mechanical) lift. (V4) told me that she slid (R4) to the floor because (R4) was starting to fall.
R4's Incident Investigation Form written by V2 (DON) dated 3/20/23 at 11:00 AM documents (V4/Certified Nursing Assistant) states that she entered (R4's) room on her first day back (from medical leave). (R4) ask (V4) to transfer her to her wheelchair. (V4) attempted to transfer (R4) to wheelchair and (R4) began to fight (V4) and complained that (V4) was hurting her. (V4) states that she eased (R4) to the floor. (V4) then went and got (V12/CNA) and put (R4) in the wheelchair.
R4's Incident Investigation Form written by V2 (DON) dated 3/18/23 at 5:00 PM documents that V12 (Certified Nursing Assistant) brought R4 by wheelchair to V11 (Registered Nurse) stating that V4 (CNA) lowered R4 to the floor.
R4's Restorative Nursing Program sheet not dated, documents R4 needs an assist from staff for all transfers with two staff present and mechanical lift. (This document is kept in a book on each hall for the Certified Nursing Assistants to reference to know how resident's transfers.)
R4's Emergency Department Provider Notes written by V8 (emergency room Doctor) dated 3/20/23 at 11:56 AM, documents R4 is a [AGE] year-old female presenting to the emergency department with the chief complaint of fall with back pain. Notable findings in the history and physical include R4 has left sided deficits at baseline due to remote history of Cerebrovascular Accident. Thoracic 5 compression fracture of indeterminate age, pending Neurosurgical Rapid Cognitive Screen at this time.
2. On 3/25/23 at 10:18 AM, V5 (CNA) was trying to dress R5 in his bed. V5 tried to roll R5 to his right side and the bed moved towards the center of the room. V5 went to the end of the bed and pushed on the red brake lever but did not push it to the locking position. V5 went and tried to roll R5 again and once again the bed moved. V5 took a blanket from R5's bed and wrapped it against the wheel on the foot of the bed trying to block the wheel from moving. V5 stated I'm probably going to be in trouble for this. V5 then went to try to roll R5 to his right side and the bed started to move again. V5 stated I'm going to have to go get some help.
R5's Minimum Data Set assessment dated [DATE], documents that R5 is an extensive assist of two staff for bed mobility and transfers.
On 3/25/23 at 10:49 AM, V7 (Maintenance Supervisor) stated As far as I know there are no beds that the locks don't work. The beds are to be locked at all times when a resident is in them. That is for the safety of the resident and the staff. The resident can wiggle around and fall out or the bed can move when they are being transferred causing a fall.
On 10:52 AM, V7 stated I just checked (R5's) bed and the lock does work. (V5/CNA) must not have pushed on the red pedal hard enough to engage it.
On 3/25/23 at 11:49 AM, V2 (DON) stated They (staff) are never to prop anything to block the wheels of the bed. That should not have happened. The bed lock should have been applied. That is not how we do things.
Jan 2023
1 deficiency
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise a cognitively impaired resident during an evening dinner ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise a cognitively impaired resident during an evening dinner meal and follow a Physician's Diet Order for a Mechanically Altered Diet for one resident (R2). These failures results in R2 choking, requiring Cardiopulmonary Resuscitation and subsequently died. These failures have the potential to affect all twelve residents (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) residing in the facility that receive a Mechanically Altered Diet for residents reviewed for diets received in a sample of 14.
These failures resulted in an Immediate Jeopardy.
While the Immediate Jeopardy was removed on 1/6/23, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits.
Findings include:
The Facility COVID Policy, revised 11/7/22, documents the Residents on Transmission Based Precautions/TBP cannot participate in communal dining.
The Facility Dietary Policy/Cycle Menu, revised 4/21, documents: A Mechanical Soft diet is designated for individuals who have difficulty chewing but are able to tolerate a wide variety of foods; this diet is designed to permit easy chewing, ground meat and soft bread and cereal products; modifications in the diet need to be individualized according to the Resident's needs; and diet ordered which are not found on the modified spreadsheets shall be referenced using the Diet Manual and have posted instructions in the serving area.
The Facility Room Trays Policy, dated 10/08, documents: It is the policy of the Facility that residents who choose not to or are unable to attend the dining room for meals will be served appropriate meals in his/her room.
Facility Diet Listing, dated 12/22/22, and provided on 1/4/22, documents that twelve residents receive a Mechanically Altered Diet (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14). The Facility Diet Listing documents R2's diet order as Regular, Thin Liquids with Finger Foods.
Facility Resident Council Minutes, dated 11/30/22, document that the Facility is under COVID precautions and Residents have been eating in their rooms.
Facility Licensed Practical/LPN Nurse Job Description, undated, documents: The LPN responsibility is to assist in completing the nurse admission assessment on admission or assigned residents; participates in identification of problems on assigned residents; reviews Physician Orders on assigned Residents prior to care; demonstrates support of the philosophy of the nursing department by adhering to policies, procedures and established standards of nursing; and maintains current knowledge in present nursing practice area.
Facility Registered Nurse/RN Job Description, undated, documents: Must possess a general knowledge and understanding of the State and Federal laws as they pertain to long term care; completes the nursing admission assessment on admission or assigned residents per procedure utilizing proper techniques, tools and history and for caring for each resident; consults other departments as required or needed; reviews Physician Orders on assigned Residents prior to care and integrates therapeutic plans of care in collaboration with the Interdisciplinary Team.
Facility Daily Assignment Sheet, dated 1/1/23, documents that V5 (Licensed Practical Nurse/LPN), V7 (Certified Nursing Assistant/CNA) and V8 (CNA) were scheduled on the A Hall (R2's Hall). V4 (Certified Nursing Assistant/CNA) was scheduled on B Hall.
Facility Week at a Glance Menu, dated Sunday 1/1/23, documents that Salisbury Steak with Gravy, Asparagus, Bread/Margarine, Fruit of Choice, Gelatin and Milk were served for the evening dinner meal.
Facility admission History Report, documents that R2 admitted to the facility on [DATE] and re-admitted to the facility on [DATE].
R2's Physician Order Sheet, dated 12/24/22, documents a Physician Diet Order for Mechanical Soft, Nectar Thick Liquids.
R2's current Baseline Care Plan documents that R2 requires the assistance of one staff member for eating, has poor safety awareness, cognitive deficits, forgetful and poor mobility requiring staff assistance. The Care Plan does not document R2's Mechanical Soft Diet, Swallow Precautions or Nectar Thick Liquids.
R2's Nutritional Assessment, dated 12/28/22, does not document R2's Physician Diet order of Mechanical Soft, Nectar Thick Liquids. The Nutritional Assessment documents Regular, Thin Liquids and Finger Foods.
The current Diet Order Form, dated 12/14/22, documents a Physician Diet Order of Regular, Thin Liquids. The Facility could not provide an updated Diet Order for the 12/24/22 admission.
R2's current Minimum Data Set, dated [DATE], documents that R2 requires one person physical assistance with eating.
R2's AIM for Wellness Assessment, dated 1/1/23 (no time), documents that R2 was found unresponsive. The AIM for Wellness documents Approximately four minutes earlier (V4/Certified Nursing Assistant) readied (R2) for evening (PM) meal and set up tray. Called (V5/Licensed Practical Nurse) to Resident room per (V4) observed resident slumped over to the left of the bed, pupils fixed, no pulse or respirations. (R2) was lowered to the floor and Cardiopulmonary Resuscitation (CPR) initiated. Emergency Services (AMT) called, when arrived took over 'code.' Pronounced time of death at 6:42 pm.
R2's Nursing Note, dated 12/24/22 at 4:00 pm, documents that R2 admitted back to the Facility with a Physician Diet Order of Thickened, Honey Liquids. The Nursing Note does not document the Mechanical Soft Diet Order. The Nursing Note documents that R2 is not able to use the call light and does require assistance of staff for Activity of Daily Living.
R2's Nursing Note, dated 1/1/23 at 6:07 pm, documents, Approximately four minutes earlier (V4/Certified Nursing Assistant) readied (R2) for evening (PM) meal and set up tray. Called (V5/Licensed Practical Nurse) to Resident room observed resident slumped over to the left of the bed Pupils fixed, no spontaneous respirations, no radial pulse palpated, no apical heart tones. (R2) lowered to the floor and CPR initiated, Emergency Services (911) called.
R2's Nursing Note, dated 1/1/23 at 6:20 pm, documents, Emergency Services (AMT) here and took over 'code.' Called time of death at 6:42 pm.
R2's Hospital After Visit Summary Record, dated 12/24/22, documents that R2's diet upon discharge is Mechanical Soft Restrictions and Nectar Thick Liquids. The After Visit Summary Record documents diagnoses including Right Ankle Fracture, Diabetes, Acute Encephalopathy, Hypoglycemia, Chronic Obstructive Pulmonary Disease, Acute Kidney Injury and Right Side Lucanar Stroke.
The Emergency Services Report/EMS Report, dated 1/5/23, documents that on 1/1/23, EMS responded to a call that R2 was unresponsive and had a dinner tray delivered approximately 20 minutes prior and the staff found R2 unresponsive approximately ten minutes after the dinner tray was delivered. The staff denied R2 being sick recently or change in medications. The EMS Report documents there was noted emesis in R2's mouth and R2 required suctioning. The EMS Report documents that EMS relieved staff of CPR upon arrival to the Facility.
R2's Preliminary Autopsy Report, dated, 1/6/23, documents the cause of death as Aspiration of food, with bits of food within the bilateral bronchi of the lungs and residual bits in the trachea.
On 1/4/23 at 3:35 pm, V4 (CNA) stated, I was not assigned to that hallway, but they called a 'code' on the A Hall, so I started compressions. (R2) was already blue. (V7/CNA) and myself alternated CPR (Cardiopulmonary Resuscitation) for about fifteen to twenty minutes until the Paramedics arrived. V7 (CNA) delivered R2's room tray and said she cut up (R2's) food and started her eating, then went down the hallway to deliver more room trays, because the whole facility was on quarantine status and eating in their rooms, because of the positive COVID in the building.
On 1/4/23 at 3:14 pm, V5 (Licensed Practical Nurse/LPN) stated, I was (R2's) nurse on 1/1/23 at about 6:00 pm, for the evening meal. We were under quarantine, so all residents were eating in their rooms. (V7/CNA) told me that (V7) delivered (R2's) room tray and cut up the meat (Salisbury Steak) and gave her a bite, left (R2's) room, then delivered the other room trays down the hall. When (V7) came back up the hallway, after delivering the trays, (V7) noticed that (R2) was blue, so (V7) came and got me. I went down to (R2's) room and there were no respirations or pulse and R2 was already mottling at (R2's) neck. I looked in (R2's) mouth and did not see anything. We got her to the floor and (V4 and V7) started CPR (Cardiopulmonary Resuscitation), while I went and called Emergency Services (911). They arrived and took over and she was pronounced dead around 6:42 pm.
On 1/20/23 at 3:14 pm, V13 (Certified Nursing Assistant/CNA) stated, Everyone was talking about how (R2) got the wrong diet on 1/1/23. They served her the wrong food consistency; she got a Regular, Thin Liquid tray. She re-admitted back on 12/24/22, and had been getting Regular, Thin Liquids since 12/24/22. They never corrected her diet tray. I took care of her and when she came back on 12/24/22, she was confused on and off. When someone has a diet order of Mechanical Soft and Honey Thick Liquids, they should not be left in their room alone. We do not have enough staff to accommodate all those people being quarantined in their rooms that need assistance with eating. We normally only have about one or two people available to watch over the residents that need supervised with eating. None of the nurses or management staff help us, and it would be nice if they did.
On 1/4/23 at 4:51 pm, V11 (Dietary Manager) stated, (R2) was served a Regular, Thin Liquid meal tray on 1/1/23. The meal was Salisbury Steak, broccoli, bread/butter and fruit cocktail. We substituted the broccoli for asparagus because no one like asparagus and we did not serve jell-o, because someone forgot to make it. My documentation shows that she (R2) is on a General, Regular Diet with thin liquids and finger foods.
On 1/4/23 at 2:20 pm, V1 (Administrator) stated, The whole facility was eating in their rooms because we were in quarantine status because we had a positive COVID test. That is our protocol. (R2) was passed a room tray on 1/1/23 of Salisbury Steak, mashed potatoes and finger foods. She came to us around 12/14/22 and was sent out to the hospital and came back on 12/24/22. I know that four to five minutes went by from the time she received the wrong tray until V7 (CNA) went back and found her unconscious in bed. They performed CPR (Cardiopulmonary Resuscitation) and (R2) was pronounced dead at 6:42 pm. I did not notify the Local Health Department, because I did not think (R2's) death needed to be. I thought it was a natural death.
On 1/10/23 at 9:28 am, V1 stated, After we looked at the COVID Policy, (R2) should have come out of her room for dining, only COVID positive should have stayed in their room for dining.
On 1/10/23 at 9:28 am, V1 stated, We did all of the audits and found that the Dietary Department was delivered the new diet order for (R2), but no one could find it, so (R2's) diet never got changed to the Mechanical Soft, Honey Thick Liquids. It is hard to cover all of the assuasive feeders with the amount of staff we have, especially when they are all room trays.
On 1/10/23 at 3:07 pm, V12 (Coroner) stated, The Death Certificate is not available yet. It will take about three weeks, but (R2's) death is ruled accidental and the cause of death is Aspiration of food. We performed an autopsy so that is what is delaying the Death Certificate. The autopsy showed Aspiration of food, with bits of food within the bilateral bronchi of the lungs and residual bits in the trachea. A lot of times if CPR is being performed in a forceful way, the debris gets 'stuffed deeper' into the airway, so that is why I performed an autopsy. The Emergency Services Report stated that (R2) aspirated and there was debris in the airway. (V9/R2's Physician) stated initially upon death, before the autopsy, that (V9) was leaning towards Aspiration as the cause of death.
The Immediate Jeopardy started on 1/1/23, when R2 was served a General, Regular Diet with Thin Liquids for the Evening meal tray.
V1 (Administrator) and V2 (Director of Nursing/DON) were notified of the Immediate Jeopardy on 1/6/23 at 11:58 am.
The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:
1. On 1/6/2023 Dietary Manager and Administrator in Training reconciled all diets to ensure resident's diet orders were current and correct.
2. On 1/6/2023 Quality Assurance members completed an audit to ensure care plans included correct diet and interventions.
3. On 1/6/2023 MDSC (Minimum Data Set/Care Plan Nurse) and SSD (Social Service Director) initiated an audit of Cognitive Assessments and Cognitive Care Plans to assure accuracy.
4. All residents identified at risk will have a food and swallowing precautions card on the meal tray in addition to the diet card.
5. On 1/6/2023 all staff was in-serviced on Abdominal Thrust Maneuver, Emergency Care CPR, Diet Cards, Cognitive Assessments, New admission Notices and Comprehensive and Baseline Care Plans by the Director of Nursing.
6. On 1/6/2023 Quality Assurance Member and Licensed staff was in-serviced on Conformance with Physicians' orders by the Director of Nursing.
7. Any staff not in attendance at the Mandatory 3:00 PM in-service will not be allowed to punch in for their next tour of duty until the training is completed with a Nurse Manager or the Administrator in Training.
8. The facility has updated the daily staffing assignment sheet to include hall assignments during mealtimes for any hall trays/sick trays being served. The staffs have been in-serviced 1/6/2023 to the updated form.
9. The Regional Director of Clinical Operations has formulated and posted a Manager Team Meal Schedule Calendar that requires a manager to attend meal pass three times a day.
Nov 2022
4 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess, monitor, and supervise a cognitively impaired,...
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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, and supervise a cognitively impaired, oxygen dependent resident (R5) during a designated smoking time for three residents reviewed for smoking in a sample of five. This failure resulted in R5 suffering burns to the face and requiring hospitalization causing R5 to become intubated and admitted to the burn unit. These failures have the potential to affect all eleven smoking residents residing in the Facility.
These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 11/2/22, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols, education, and monitoring.
Findings include:
Facility Resident Smoking Policy, undated, documents: the patio area to the side of the dining room has been designated as the only resident smoking area for the facility; each resident whom chooses to smoke will have a smoking assessment completed prior; and all residents choosing to smoke will have a responsible staff member outside on the patio at the designated smoke times (9:00 am to 9:15 am, 10:30 am to 10:45 am, 1:30 pm to 1:45 pm, 4:00 pm to 4:15 pm and 7:00 pm to 7:15 pm).
Facility List of Smoker's, undated, documents R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14 as smokers. The list also documents R5 and R6 as the only two Resident's on oxygen therapy.
Facility Smoking Policy, undated, documents that residents must always be accompanied by a staff member to smoke and may not keep his/her own smoking materials.
Facility Local Health Department Five Day Final Report, dated 10/31/22, documents that R5's Brief Interview for Mental Status/BIMS score shows that (R5) has moderate cognitive deficit (score of 9/15). (R5) was on the Facility smoking patio and a staff member witnessed R5 with an oxygen tank turned on flames coming from the side of his (R5's) face and that the employee hollered for help and went outside to ensure the safety of the resident and other resident that was smoking. The Report concludes that R5 was admitted to a local Hospital for burns to the face.
R5's Physician Order Sheet, dated 10/1/22 through 10/31/22, documents diagnoses including Traumatic Brain Injury, Cognitive Deficit, Cataracts, Neurocognitive Disorder with Behaviors, Emphysema, Asthma and Epilepsy.
R5's Facility Smoking Assessment, undated, documents that the Resident must be evaluated with the following physical abilities to be permitted to smoke per Facility Policies and Procedures and that a Physician's Order is in place to permit the Resident to smoke. R5's Smoking assessment dated [DATE] documents a handwritten note, no changes on 12/31/21 and 4/6/22. The Smoking Assessment documents that R5 was able to flick the lighter on and off, demonstrate safety measures for handling cigarette, exhibit clear understanding of the smoking policy and require moderate assistance with smoking. The Facility could not produce a Smoking Disclosure Form or any additional Smoking Assessments for R5.
R5's Hospital History and Physical/H&P, dated 10/27/22, documents: that R5 presented to the Hospital, and admitted to the Burn Unit, after suffering burns to the face while smoking a cigarette on oxygen, there was soot noted to the patient's nares (nose) and visualized in the nasopharynx/oropharynx, hair burnt off on right eyebrow and singed left eyebrow, burns to lips and eye; R5 was intubated and started on a medication for post intubation hypotension; facial burns required Intravenous medication (Rocephin (antibiotic), Levophed (elevates blood pressure) and Propofol (sedation) and topical (apply to skin) medication treatment (Bacitracin, mineral oil-hydrophilic and Balsam Peru Castor (topical that creates a protective layer) and a wound consultation; R5 was diagnosed with Acute Hypoxic and Hypercapnia (rapid breathing) Respiratory Failure and was Intubated and on minimal Ventilator settings. The H&P documents that R5 had a high probability of imminent or life-threatening deterioration, high probability of imminent threat to life, acute impairment of one or more vital organ systems and/or required high complexity medical decision making due to Respiratory Failure and Shock. The H&P also documents that R5 had superficial partial and deep partial thickness burns to significant areas of the face and neck.
On 11/2/22, at 10:32 am, R7 was on the smoking patio and stated, There is never anyone out here with us.
On 11/1/22, at 10:24 am, R4 stated, I was on the smoking patio with (R5) when (R5's) oxygen tubing caught his face on fire. (R5) was not able to use his lighter, he was not able to use the lighter, you know, so I helped him light his cigarette. All of the sudden, I saw (R5's) face shoot up in flames, so I immediately went over to him and pulled his oxygen hose off and unwrapped it and threw it on the ground, because it was still burning, and it burned for a little while, while it was still on the ground. (V15/Activity Director) then came running out. (R5) had his face covered in soot and his beard was singed off. See that large black burn spot right there on the ground, right outside of the exit door, that is where I threw (R5's) oxygen tubing. There was no staff out there, just me and him (R5). We never usually have any staff out here with us, we even know the code to get out of the door.
On 11/1/22, at 10:28 am, an approximate one foot by one foot black circular area was within five feet of the Facility's smoking patio exit door. R7, entered the exit code and the smokers proceeded out the exit door to the patio. (V17/Certified Nursing Assistant) was present in the smoking area, handing out smoking supplies.
On 11/1/22, at 11:09 am, (V15/Activity Director) stated, Around 4:00 pm, I was walking through the small dining area, with my arms full of board games, and I saw (R5) through the window to the smoking patio, and I started screaming, because (R5) had flames coming from his face. I dropped the games and ran outside, and (R4) was pulling his oxygen tubing off of his face. R1's Nurse (V16) came running out and told me to shut off (R5's) oxygen tank, and (V16) started to pat the flames out on (R5's) face and neck. No staff was present and there was only one other person out on the smoking patio and that was (R4).
On 10/31/22, at 1:10 pm, V2 (Director of Nursing) stated, On 10/27/22, at 4:00 pm, during the designated smoking time, R5 stopped at the nursing station with an empty tank of oxygen. (R5) got two cigarettes and (V10/Licensed Practical Nurse) identified that (R5's) oxygen tank was empty, so (V10) put on a new full oxygen tank and (R5) proceeded to the Facility smoking patio. No staff were on the smoking patio when this happened, but (V15/Activity Director) saw flames coming from R5's face, through a window, and screamed for help and ran outside onto the smoking patio. (V15) saw (R4) pulling (R5's) oxygen tubing away from (R5's) face and (R5's) nurse (V16) started emergent care. (R5's) face was covered in soot and (R5's) beard was singed. (R5) was sent out to the Emergency Room, admitted to the Hospital and eventually became intubated. (R5) is still in the Hospital.
On 11/2/22, at 11:47 pm, V1 (Administrator) stated, The Smoking Assessments should be completed every quarter. We should have had a Smoking Disclosure Form for (R5) but we did not get one from him, but we will when he gets back to the Facility. V1 verified that the handwritten entry on to the Smoking Assessment Form should have been re-evaluated due to (R5's) cognition and the Facility should have completed a new form.
The Immediate Jeopardy started on 10/27/22 when R5, receiving oxygen therapy, was unsupervised on the Facility smoking patio.
V1 (Administrator) and V2 (Director of Nursing/DON) were notified of the Immediate Jeopardy on 11/02/22 at 11:34 am.
The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:
1. Inservice of all staff on smoking policy and Resident's receiving Oxygen Therapy that smoke.
2. Locked all smoking supplies up at the nurses station.
3. Assigned a staff member to the outside smoking patio for the Facility smoking times.
4. Inservice to smoking resident's on the Smoking Policy.
5. Reviewed all Resident Smoking Assessments.
As part of the facility's ongoing quality improvement program, the following measures will be taken to ensure the practice does not recur:
QAT to conduct random rounds to ensure residents and staff are following the assigned smoking times.
QAT to conduct random rounds to ensure the residents and staff are practicing safe smoking practices and not smoking with oxygen in place.
Administrator or designee will educate new staff members and new residents on the assigned smoking schedule.
Administrator or designee will in-service on Smoking Assessment, Smoking Disclosures, Smoking Policy including designated smoking times and locations, Emergency care of Burns, Oxygen Safety, Oxygen Therapy and Nasal Canula weekly x 4 weeks then monthly times 3 months starting 11/3/2022
Administrator and/or Director of Nursing will conduct random chart audits to ensure the smoking assessments, and Care Plans are completed upon admission, quarterly and as needed for the residents who smoke.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
Based on record review and interview the facility failed to obtain and administer physician ordered medications for a new admission for one (R1) resident of four reviewed for medication administration...
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Based on record review and interview the facility failed to obtain and administer physician ordered medications for a new admission for one (R1) resident of four reviewed for medication administration in a sample of four. This failure resulted in R1 being hospitalized for treatment of an altered mental status due to an elevated Ammonia blood level.
Findings include:
Facility Medication Administration Policy, revised 11/18/2017, documents: the complete act of administration entails verifying the physician's orders, giving the individual dose to the proper resident and promptly recording the time and dose given; medications much be prepared and administered within one hour of the designated time or as ordered; medications must be identified by using the seven rights of administration including right time and right documentation; after a drug is given, record the date, time and name of drug, dose and route on resident's Administration Record/MAR, document any medications not administered for any reason by circling initials and documenting on back of the MAR the reason for omission; if the medication is not available for a resident, call the pharmacy and notify the physician when the drug is to be expected to be available; notify the physician as soon as practical when a scheduled dose of medication has not been administered for any reason; and report errors in medication administration immediately per policy.
R1's Nursing Note, dated 10/11/22, at 5:20 pm, documents that R1 arrived and admitted to the Facility.
R1's Physician Order Sheet, dated 10/11/22, documents that R1 admitted to the Facility with diagnoses including Cirrhosis of the Liver, Asthma, Diabetes, Chronic Obstructive Pulmonary Disease, Vitamin Deficiency, Celiac Disease and Ascites.
R1's Medication Administration Record/MAR, dated 10/11/22 through 10/18/22, does not document administration of medication (Lactulose): for Hepatic Encephalopathy secondary to Cirrhosis (degenerative disease of the liver) on 10/12/22 at 8:00 am and 12:00 pm; Cirrhosis medication (Xifaxan, treats diarrhea) on 10/12/22, 10/14/22 and 10/18/22, at 8:00 am.
R1's MAR, dated 10/11/22 through 10//18/22, also does not document administration of Facility stock and other medication: Vitamins (Vitamin C, Multivitamin, Vitamin D, Iron and Folic Acid) on 10/12/22 and 10/14/22, at 8:00 am; diuretic (Lasix) on 10/12/22 and 10/18/22, at 8:00 am; liver medication for fluid build-up (Spironolactone) on 10/12/22 at 8:00 am; Steroid Nasal Spray for (Flovent) and on 10/12/22 and 10/18/22 at 8:00 am; and a Proton Pump Inhibitor for Esophagus Disorders (Pantoprazole) on 10/12/22 at 8:00 am.
R1's Nursing Notes, dated 10/11/22 through 10/18/22, does not document that R1's Physician was notified of the missed doses of medication.
R1's Nursing Note, dated 10/18/22, at 10:00 pm, documents that R1 was sent to the local hospital for evaluation of Altered Mental Status.
R1's Hospital admission History and Physical Record, dated 10/19/22, documents that R1 admitted to the hospital with the clinical impression diagnoses including a Subdural Hemorrhage, Altered Mental Status, Liver Cirrhosis secondary to Non-Alcoholic and Hepatic Encephalopathy. The Hospital Record also documents factors that made the patient critically ill were the subdural hematoma and Patient's sister is in the room with her and provides history. States that she is been altered since going to rehab facility last week. Last known normal was earlier last week, over a week ago. The Record also documents, on 10/19/22, Labs remarkable for elevated ammonia. Neurosurgery evaluated the patient and advised based on Commuted Tomography (CT) and their exam they believe subdural hemorrhage is not the cause of her presentation. With ammonia being elevated most likely hepatic encephalopathy and sister says this is consistent with previous episodes of hepatic encephalopathy. Discussed with general medicine team who agreed to admit the patient and noted on CT, regarding the subdural Hemorrhage, while in the Emergency Department unlikely to be cause of her AMS (Altered Mental Status) as level of consciousness out of proportion size of hemorrhage. The Hospital Records also document Patient was discharged on 10/11/22, with strict instructions take her Lactulose and Rifaximin/Xifaxan. Patient unfortunately had worsening encephalopathy from ammonia retention and was readmitted in the hospital 10/19/2022. Patient subsequently got better with Lactulose anemia, oral Lactulose and was back to her baseline.
On 10/28/22, at 8:05 am, V13 (R1's Sister) stated, I had to talk (V2/Director of Nursing) on 10/12/22, because my Sister (R1) had not gotten any of her (R1) medication since she admitted the night before. (V2) told me that when a new admission comes to the Facility after 4:00 pm, it is too late for the Facility to get the medications in, and that the Facility will not get them in until the next night. My Sister (R1) went without important medication for her Cirrhosis and if she does not get that Lactulose or Xifaxan it can cause her ammonia level to rise and makes her have extremely confused.
On 10/28/22, at 12:12 pm, V10 (Licensed Practical Nurse) stated, I was the nurse that admitted (R1) and she was alert and oriented. I sent her medications off to the pharmacy to be filled. Some of her medications could have been given through the stock supply, but the Lactulose and Xifaxan needed to be delivered. From what I know, the medications did not come in until around noon the next day.
On 10/28/22, V2 (DON) stated, (R1) admitted to the Facility late on the night of October 11, 2022. If our Pharmacy does not have the new orders by 4:00 pm the day prior, the Resident's medication does get delivered until the next night. We have a backup pharmacy that can be called, and also have stock box of medications that we can use, even Lactulose is not a stock medication. The nurses should document all of this, especially if the back up pharmacy was called and they should also document that the Physician was called if the medication is not available. I actually saw (R1's) medications get delivered at lunch time on October 12, 2022, the next day, I think it came from the backup pharmacy. (V12/R1's sister) called me and was upset about (R1) not getting (R1's) Lactulose and Xifaxan medication for (R1's) Cirrhosis. (V12) had concerns about (R1) getting confused and having problems, if any doses were missed. I told her (V12) that I could not give (R1) any medications that were already missed, even though we had just received them, because it was against the law.
On 11/1/22, at 10:25 am, V2 (Director of Nursing) stated, We have a back up stock box and I am not sure why the nurses did not even pull out the stock medications like the Vitamins and give them for her morning dose on 10/12/22, until her medications were delivered. (R1) has been in the hospital since 10/19/22 and has still not been discharged back to us.
On 10/31/22, at 1:24 pm, V13 (R1's Physician) stated, I was not notified that (R1) had not received her prescribed medication. Ammonia buildup is due to her (R1) hospitalization problems and can definitely cause confusion. The only way to get the ammonia out of (R1's) body is by 'pooping' and that is the purpose of the Lactulose and Xifaxan. There really is no alternative and they also kill bacteria. Missed doses of these medications could definitely cause (R1's) Ammonia levels to rise, which caused her altered mental status.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to notify the Physician for an unavailable medication (R1) and a smoking accident involved with oxygen (R5) for two of six resident's reviewed ...
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Based on interview and record review the facility failed to notify the Physician for an unavailable medication (R1) and a smoking accident involved with oxygen (R5) for two of six resident's reviewed for Physician notification.
Findings include:
Facility Notification of Change Policy, revised 12/7/17, documents: that the Facility shall promptly notify the appropriate individuals (Physician and Guardian/Health Care Power of Attorney) of changes in the resident's medical/mental condition or status; the need to alter the resident's medical treatment significantly; an accident or incident involving the resident; and a transfer resident to the hospital.
1. R1's Medication Administration Record, dated 10/11/22 through 10/18/22, does not document administration of medication: for Hepatic Encephalopathy secondary to Cirrhosis (Lactulose) on 10/12/22 at 8:00 am and 12:00 pm; Cirrhosis medication (Xifaxan) on 10/12/22, 10/14/22 and 12/18/22, at 8:00 am; Vitamins (Vitamin C, Multivitamin, Vitamin D, Iron and Folic Acid) on 10/12/22 and 10/14/22, at 8:00 am; diuretic (Lasix) on 10/12/22 and 10/18/22, at 8:00 am; liver medication for fluid build-up (Spironolactone) on 10/12/22 at 8:00 am; Steroid Nasal Spray for (Flovent) and on 10/12/22 and 10/18/22 at 8:00 am; and a Proton Pump Inhibitor for Esophagus Disorders (Pantoprazole) on 10/12/22 at 8:00 am.
R1's Nursing Notes or Medication Administration Record, dated 10/11/22 through 10/18/22, do not document that V13 (R1's Physician) was notified of the missed doses of medication.
2. Facility Local Health Department Five Day Final Report, dated 10/31/22, documents that R5's Brief Interview for Mental Status/BIMS score shows that (R5) has moderate cognitive deficit (score of 9/15). On 10/27/22, (R5) was on the Facility smoking patio and a staff member witnessed R5 with an oxygen tank turned on flames coming from the side of his (R5's) face and that the employee hollered for help and went outside to ensure the safety of the resident and other resident that was smoking. The Report concludes that R5 was admitted to a local Hospital for burns to the face. The Report documents that the Physician (V13) was notified.
R5's Nursing Notes or AIM For Wellness (not completed), dated 10/27/22 through 10/28/22, does not document that V13 (R5's Physician) was notified of the incident involving smoking.
On 10/28/22, V2 (DON) stated, (R1) admitted to the Facility late on the night of October 11, 2022. If our Pharmacy does not have the new orders by 4:00 pm the day prior, the Resident's medication does get delivered until the next night. We have a back up pharmacy that can be called and also have stock box of medications that we can use. The nurses should document all of this, especially if that the back up pharmacy was called and they should also document that they notify the Physician if a medication is not available.
On 10/30/22, at 1:21 pm, V14 (R1's and R5's Nurse Practitioner) stated, I was not notified of (R1) not getting the medication. I was not notified of (R5) smoking with oxygen on and requiring hospitalization. I did not know anything about either of these. Maybe they contacted (V13/Physician).
On 10/31/22, at 1:24 pm, V13 (R1's and R5's Physician) stated, I was not notified that (R1) had not received her prescribed medication. I also was definitely not notified of R5 having an smoking accident while wearing (R5's) oxygen.
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
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure there is a licensed administrator managing the facility. This failure has the potential to affect all 58 residents resi...
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Based on observation, interview and record review, the facility failed to ensure there is a licensed administrator managing the facility. This failure has the potential to affect all 58 residents residing in the facility.
Findings include:
The facility's Daily Roster dated 10/28/2022 documents 58 residents reside in the facility.
Facility Assessment, dated 10/2022, documents: the purpose is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies; use the Assessment to make decisions about your direct care staff needs as well as your capabilities to provide services to the residents in your facility; facility resources needed to provide competencies, education and training; and identify the type of staff members that are needed to provide support and care for residents.
On 11/2/22, at 11:34 am, during an Extended Survey, V1 (Administrator) could not provide a copy of V1's Temporary Administrator License or Administrator License.
On 11/2/22, at 11:36 am, V1 (Administrator) stated, I can give you the former Administrator's License. I do not have my license, I have not even applied for it yet. On 10/5/22, I took the State Test, but failed it. I cannot provide you with an Administrator License.
Jun 2022
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to perform daily skin checks and failed to follow dietary...
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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 perform daily skin checks and failed to follow dietary recommendations for the use of a high protein supplement for a resident with multiple pressure wounds for one of two residents (R57) reviewed for pressure wounds in a sample of 27.
FINDINGS INCLUDE:
The facility policy, Decubitus Care/ Pressure Areas, dated (revised) 01/18 directs staff, 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. Nursing personnel are to notify dietary personnel of any pressure areas to seek nutritional support and monthly reviews by the Registered Dietician. When a pressure ulcer is identified additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers.
R57's current Physician Order Sheet, dated June 2022 documents that R57 was admitted to the facility on [DATE] with the following diagnoses: CVA (Cerebral Vascular Accident) with left sided weakness, Dementia, Chronic Kidney Disease, Neurogenic Bladder, Aphasia and Delirium.
R57's Care Plan documents, (R57) has pressure wound present. Approaches/Interventions: Assess skin daily.
The facility Weekly Wound Tracking Sheet, dated March 2022 documents, (R57) March 29, 2022, Stage 2 pressure wound to coccyx, area measures 2 CM (Centimeters) X 2 CM with minimal drainage present. Treatment obtained from physician.
The facility Weekly Wound Tracking Sheet, dated April 2022 documents, (R57) April 15, 2022, Stage 2 pressure wound to left medial heel, area measures 1 CM X 2 CM X 0.1 CM with minimal drainage present. Treatment obtained from physician.
R57's facility Dietary Notes, dated 4/14/22 and signed by V19/Registered Dietician (RD) document, Stage 2 Pressure Injury to coccyx (measuring) 2 CM X 1 CM, no depth documented at this time. Recommendation: Recommend 30 ML (Milliliters) Prostat daily for 21 days to assist with wound healing.
R57's facility Dietary Notes, dated 4/27/22 and signed by V19/Registered Dietician (RD) document, RD notified of Stage 2 (PI) Pressure Injury of left medial heel (measuring) 1 CM X 1.5 CM X 0.1 CM. Noted RD recommendations for Prostat (increased Protein supplement indicated for Stage 2 to Stage 4 Pressure Injuries to enhance wound healing) on last assessment, not implemented at this time. Recommendation: Recommend 30 ML (Milliliters) Prostat daily for 21 days to assist with wound healing.
R57's facility Dietary Notes, dated 5/10/22 and signed by V19/Registered Dietician document, Unstageable Pressure Injury to left, medial heel (Measures) 0.5 CM X 1 CM. Noted RD recommendations for Prostat on last assessment, not implemented at this time. Recommendation: Recommend 30 ML (Milliliters) Prostat daily for 21 days to assist with wound healing.
R57's facility Dietary Notes, dated 6/7/22 and signed by V19/Registered Dietician document, Stage 3 Pressure Injury to left medial heel. Noted (R57) with recent hospital stay. Noted RD recommendations for Prostat on last assessment, not implemented at this time. Recommendation: Recommend 30 ML (Milliliters) Prostat AWC daily for 21 days to assist with wound healing.
R57's monthly Treatment Record, dated June 2022 includes the following physician orders: Daily Skin Check, Day shift. A review of document indicates the treatment as only being performed one day from June 1, 2022 to June 12, 2022.
On 6/15/22 at 11:44 A.M., V11/Registered Nurse (RN) prepared to perform wound care for R57. With the assistance of V9/Certified Nursing Assistant (CNA), V11 rolled R57 to the right side. R57's coccyx area skin was discolored, with some denuded skin present.
On 6/15/22 at 1:10 P.M., V2/Director of Nurses (DON) verified the missing daily skin checks for R57 and stated, I don't know why the Dietician's recommendations for the Prostat for (R57) were never implemented. We must have missed it (orders).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to perform a resident bed to wheelchair transfer to min...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to perform a resident bed to wheelchair transfer to minimize the risk of injury for one resident (R57) of three residents, reviewed for transfers, in a sample of 27.
FINDINGS INCLUDE:
The Facility's Fall Prevention policy (undated) documents, All staff must observe residents for safety. Interventions (fall) will be implemented for residents. New interventions will be written on the care plan.
R57's current Physician Order Sheet, dated June 2022 documents that R57 was admitted to the facility on [DATE] with the following diagnoses: CVA (Cerebral Vascular Accident) with left sided weakness, Dementia, Aphasia and Delirium.
R57's Minimum Data Set assessment, dated 5/26/22, documents R57 has functional limitation in range of motion impairments to one side of both upper and lower extremities. This same form documents that R57 is totally dependent on two staff members for bed to chair transfers.
R57's current Care plan includes the following Problem/Need Area: (R57) is at high risk for falls. Also included are the following Approaches/Interventions: requires assistance of two (staff) and gait belt for all transfers.
On 6/12/22 at 11:05 A.M., V9/Certified Nursing Assistant (CNA) prepared to transfer R57 from the bed to his wheelchair. V9 did not apply a gait belt or request assistance from another staff member, V9/CNA grabbed R57 under his arms and swung him around, dropping R57 into his chair.
At that time, V9/CNA stated, Boy, you're heavy (R57). I'm glad I didn't drop you.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
2, On 6/12/22 at 10:30am, R13 was in bed with the urinary drainage bag hanging on the side of R13's bed, touching the floor. R13 stated that the urinary drainage bag is always hanging there and touchi...
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2, On 6/12/22 at 10:30am, R13 was in bed with the urinary drainage bag hanging on the side of R13's bed, touching the floor. R13 stated that the urinary drainage bag is always hanging there and touching the floor. R13 stated that the urinary drainage bad is never covered for privacy. On 6/12/22 at 11:45am, R13 was in the main dining area with the urinary catheter drainage bag hooked under the wheel chair, uncovered and dragging on the floor.
On 6/15/22 at 11:00am, V11, Registered Nurse, stated that the urinary drainage bags are not covered and should be for privacy and infection control purposes.
On 6/15/22 at 1:00pm, V2 Director of Nursing, verified that the urinary drainage bags are not to be touching the floor and are to be covered at all times, unless they are being emptied.
Based on observation, interview and record review, the facility failed to minimize the risk of infection by keeping a urinary collection bag off of the floor and failed to place a urinary collection bag in a privacy bag for two of two residents (R13 and R57), reviewed for urinary catheters, in a sample of 27.
FINDINGS INCLUDE:
The facility policy, Urinary Drainage Collection Unit, dated (revised) 2/18 directs staff, To provide a sterile collection unit for urinary drainage to minimize entry of bacteria into the bladder. Hang the urinary drainage unit below the bladder level, not touching the floor. Keep urinary drainage bag in a catheter cover (dignity bag).
1. R57's current Physician Order Sheet, dated June 2022 includes the following diagnoses: Urinary Retention, Neurogenic Bladder, History of Urinary Tract Infection and Proteinuria. Also included are the following physician orders: Catheter change monthly with #16 Coude, 10 ML (Milliter) balloon and Supra Pubic Catheter Site Care every shift.
On 06/12/22 at 9:15 A.M., R57 was lying in bed. A urinary catheter collection bag with yellow urine, was visible from the hallway. The urinary collection bag was laying on the floor. At that time, V9/Certified Nursing Assistant (CNA) verified the presence of the urinary collection bag on the floor.
On 06/15/22 at 9:16 A.M., V57 was sleeping in bed. A urinary collection bag was visible from the hallway and was laying on the floor of R57's room. At that time, V11/Registered Nurse (RN) verified the collection bag visible from the doorway and stated, These girls (Certified Nursing Assistants) need to be careful with these (urinary collection bags) and make sure they are in a privacy bag and up off of the floor.
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 observation, interview and record review the facility failed to provide behavioral health care services and develop individualized interventions/programs recommended in the PASRR (pre-admissi...
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Based on observation, interview and record review the facility failed to provide behavioral health care services and develop individualized interventions/programs recommended in the PASRR (pre-admission screening and resident review) for one of one resident (R51) reviewed for behavioral health services in a sample of 27.
Findings include:
The Facility Assessment, dated March 2022, documents services and care we offer based on our Residents' need. Mental health and behavior to manage medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individual with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individual with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. This form also documents that the facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.
R51's Progress Notes, dated 1/5/22, document that R51 was admitted to the facility for aftercare, impaired mobility and ADL's (Activities of Daily Living), fall with a femoral shaft fracture, fracture of proximal end of the right humerus, fracture right ulna, nasal fracture, pelvic fracture, Schizoaffective disorder, Schizophrenia-paranoid type. Suicide and self-inflicted injuries by jumping from a high place and a fracture of the right foot. R51's Progress Notes, dated 1/7/22, documents that R51 removed his leg splint. On 1/8/22 R51 was sent to the local hospital for splint replacement. On 1/18/22 R51 was observed sticking a toothbrush inside his penis. On 5/20/22 the facility received a call stating that R51 was suicidal and wants to go to the hospital. R51 was sent to the hospital for an evaluation and all parties notified.
R51's PASRR, dated 4/2/22, documents that R51's birthdate is 5/11/1979. This form also documents that R51 requires a structured environment such as socialization activities to diminish tendencies toward isolation and withdrawal. This form also documents that the nursing facility should monitor R51 for symptoms of isolation. This form documents the development, maintenance, and consistent implementation across settings of those programs designed to teach individuals daily living skills necessary to become more independent and self-determining including, but not limited to, grooming, personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of the living environment. In addition, this form documents that a crisis intervention plan is necessary should R51 begin to have thoughts of hurting R51's self including an individual, group, and family psychotherapy so R51 can talk to someone about their feelings that led up to R51 jumping off of a high place.
R51's current care plan documents an intervention for psychotherapy/psychiatry services. This form documents that R51 has risk factors that require monitoring and interventions to reduce the potential for self harm. The intervention for this is 15-minute checks.
On 6/12/22 at 10:30am, R51 was lying in bed, holding a toothbrush straight up and down, on his abdomen, staring at it. At 1:30pm, R51 was in bed again, staring at the toothbrush he was holding on his abdomen. On 6/13/22 at 11:00am, R51 was in bed with the toothbrush in the same position. At 11:45pm, R51 was in the main dining area sitting at a table by himself. On 6/14/22 at 1:30pm, R51 was lying in bed holding the toothbrush on his abdomen, staring at it.
On 6/14/22 at 1:00pm V17, Certified Nursing Assistant, stated that there are no residents being monitored with 15 minute checks. V17 stated that there is a sheet that is filled out for every 15 minute checks, in the binder at the nurses station. V17 demonstrated that the binder has no documentation of 15 minute checks for R51.
On 6/14/22 at 1:15pm, V5, Licensed Practical Nurse, verified that no one in the facility is on 15 minute checks. V5 stated that R51 is not receiving any specialized psychotropic care, nor is he on any suicidal precautions.
On 6/14/22 at 1:30pm, V2, Director of Nursing, stated that the facility does not offer any psychiatric services. V2 stated that the residents primary care physician manages all psychiatric medications.
On 6/14/22 at 1:45pm, V15, Social Service Director, stated that R51 is not in any Psych. programs. V15 verified that the facility does not offer any psychiatric programming including those listed on R51's PASRR form. V15 stated that after R51 is finished with his therapy he will be discharged .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to follow manufacturer's warnings for administration of medications, for two residents (R36, R42) in the sample of twelve residen...
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Based on observation, interview and record review, the facility failed to follow manufacturer's warnings for administration of medications, for two residents (R36, R42) in the sample of twelve residents, reviewed for medication pass. This failure resulted in two medication errors out of thirty opportunities for error, for a 6.67% medication error rate.
FINDINGS INCLUDE:
The facility policy, Medication Administration (revised 11/18/17) directs staff, Medications must be identified by using the seven rights of administration: right resident, right drug, right dose, right consistency, right time, right route and right documentation.
1.) R36's current Physician Order Sheet, dated June 2022 includes the following diagnosis: Diabetes Mellitus. This same document includes the following medication: Lispro Insulin 18 Units subcutaneous after meals.
On 6/12/22 at 11:47 A.M., V4/Licensed Practical Nurse (LPN) prepared to administer medications to R36. V4/LPN withdrew an Insulin pen from the top of the medication cart, applied a needle and without following the printed manufacturer's warning of administering the Insulin after R36 had eaten, injected R36 with 18 Units of Lispro Insulin. At 12:30 P.M., R36 was served the noon meal.
On 6/12/22 at 11:53 A.M., V4/LPN confirmed she did not follow the manufacturer's printed warnings when administering medications to R36.
2.) R42's current Physician Order Sheet, dated June 2022 includes the following diagnosis: Severe Protein Calorie Malnutrition. This same document includes the following medication: Ceravite take one tablet daily.
On 6/13/22 at 8:24 A.M., V5/Licensed Practical Nurse (LPN) prepared to administer medications for R42. V5/LPN withdrew a medication card labeled as Ceravite. The printed manufacturer's warning label on the medication card stated, Take one tablet daily one hour before meals or 2 to 3 hours after meals. V5/LPN punched one tablet into a small plastic medication cup and despite the manufacturer's warning to administer the medication one hour prior to a meal, handed the plastic cup to R42, who had just finished eating the morning meal. R42 swallowed the medication with sips of water.
On 6/13/22 at 8:30 A.M., V5/LPN confirmed she did not follow the manufacturer's printed warnings when administering medications to R42.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to do accuchecks (test for blood sugar levels) or give insulin to one resident (R36) of three residents reviewed for insulin in a sample of 27....
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Based on record review and interview the facility failed to do accuchecks (test for blood sugar levels) or give insulin to one resident (R36) of three residents reviewed for insulin in a sample of 27.
Findings include:
The facility Medication Administration policy revised 11/18/17, documents Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it was the physicians order, giving the individual dose to the proper resident, and promptly recording the time and dose given. Medications must be prepared and administered within one hour of the designated time or as ordered.
R36's current medical record documents R36 has a diagnosis of Diabetes Mellitus.
R36's Physician Order dated 6/1/22 - 6/30/22 documents ACCUCHECK (before meals and bedtime) daily at 8:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. Humulin R 100 units/ml (milliliters) 3ml vial (give per sliding scale Sub-Q (subcutaneous) four times a day) at 8:00 AM, 12:00 PM, 5:30 PM, and 8:00 PM. Lantus Pen 100 units/ml 3ml (inject 35 units Sub-Q once daily) at 7:00 AM. Insulin Lispro 100 unit/ml pen (inject 18 units Sub-Q three times daily after meals) at 8:00 AM, 12:00 PM, and 5:00 PM. Insulin Lispro 100 unit/ml pen (inject 16 units Sub-Q at bedtime) at 8:00 PM.
R36's Medication Administration Record dated 6/1/22-6/30/22, documents the 8:00 AM ACCUCHECK on 6/10/22 was 231. This required 4 units of Humulin R 100 Units/ML(Milliliters) and there was no insulin documented as given. There were no ACCUCHECKS done at 11:00 AM, 4:00 PM, or 8:00 PM on 6/10/22 to determine the sliding scale required for Humulin R 100 units/ml insulin. There was no Humulin R 100 units/ml insulin given at 12:00 PM, 5:30 PM, or 8:00 PM on 6/10/22. There were no ACCUCHECKS done at 11:00 AM, 4:00 PM on 6/11/22 to determine the sliding scale required for Humulin R 100 units/ml insulin. There was no Humulin R 100 units/ml insulin given at 12:00 PM or 5:30 PM on 6/11/22. Lantus Pen 100 units/ml insulin (inject 35 units Sub Q once daily) was not given at 7:00 AM on 6/10/22. Lispro 100 unit/ml insulin pen (inject 18 units Sub Q three times a day) at 8:00 AM, 12:00 PM, and 5:00 PM. Lispro was not given at 8:00 AM on 6/10, 6/11, or 6/12/22. Lispro was not given on 6/8, 6/9, 6/10, or 6/12/22 at 12:00 PM. Lispro was not given on 6/8, 6/10, or 6/11/22 at 5:00 PM. Lispro 100 unit/ml insulin pen (inject 16 units Sub Q at bedtime) at 8:00 PM. Lispro was not given on 6/10/22 at 8:00 PM. Lantus 100 unit/ml insulin pen (inject 35 units Sub Q once daily) at 7:00 AM. Lantus was not given on 6/10/22.
On 6/15/22 at 11:20 AM, R36 stated that she is on a sliding scale for insulin and is to have an accucheck done at 8:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM daily to determine her insulin needs. R36 stated that on 6/9 and 6/10/22, V4 (Licensed Practical Nurse) did not do any accuchecks and did not give any insulin as ordered for R36. (R36) stated (V4/LPN) doesn't like me so she doesn't always give me my insulin.
On 6/15/22 at 10:30 AM, V2 (Director of Nursing) stated The accuchecks and insulin should have been given for (R36). (V4/Licensed Practical Nurse) worked on the 10th (6/10/22) and (V11/Registered Nurse) worked on the 11th (6/11/22).
On 6/15/22 at 11:55 AM, V4 (Licensed Practical Nurse) stated I think I did them (accuchecks and insulin for (R36). I made a mistake and didn't write them down. V11 (Registered Nurse) was not available for an interview.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. 06/15/22 09:59 AM R49's Range of Motion Assessment, dated 5/19/22, documents a score of 14 indicating that R49 is a moderate ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. 06/15/22 09:59 AM R49's Range of Motion Assessment, dated 5/19/22, documents a score of 14 indicating that R49 is a moderate risk for contractures. This form documents that treatments may include, but is not limited to basic ROM (range of motion), positioning, turning, ambulating, as indicated by individual resident needs. R49's care plan documents a Restorative Nursing Program-Range of Motion-Problem/Need to maintain current functional ability. R49 will actively participate in moving/exercising joints with verbal cues twice daily through 90 days. Staff will assess and document Restorative participation and response to the program. R49's Restorative Nursing Program Documentation for June of 2022, has no documentation that R49's AROM to upper and lower extremities twice daily to maintain current level of functioning was not completed at all on 6/6/22. This form has no documentation of any AROM being completed a second time from 6/3/22 through 6/11/22. R49's Restorative Nursing Program Documentation indicates that R49 needs assist from staff for bed mobility such as side to side turning and repositioning. This form has no documentation that R49's bed mobility was not done on 6/6/22. This form also has no documentation that R49's bed mobility was not done from 6/3/22 through 6/11/22, on the second shift. R49's current care plan documents a Restorative Nursing Program-Range of Motion.
On 6/14/22 V2 (Director of Nurses) verified that R49's were not signed out as being completed as required. V2 stated that V16, Licensed Practical Nurse/Minimum Data Set Nurse, sets up the restorative programs and the Certified Nursing Assistants are to follow up with the programs.
6. R6's Profile Face Sheet documents diagnosis of Hemiplegia, affecting the right dominant side.
R6's Care Plan documents Restorative Nursing Program- Range of Motion, Problem/Need to maintain current level of functioning. Goal- Will actively participate in moving/exercising joints with verbal cues twice daily thru next 90 days.
R6's Restorative Nursing Program Documentation for 6/1/22 - 6/12/22, documents (R6) needs to perform AROM (Active Range of Motion) to upper and lower extremities twice daily to maintain current level of functioning. AROM was not performed on 6/1, 6/8, 6/11 and 6/12/22. AROM was performed once on 6/2- 6/6/22.
R6's Minimum Data Set assessment dated [DATE], Functional Status (Section G) documents R6 is a total dependence of one - two staff for Activities of Daily Living. Restorative Nursing Programs (Section O) documents R6 was receiving Range of motion (active).
On 6/12/22 at 10:35 AM, R6 was lying in bed unable to reposition herself.
7. R35's Medical Record, documents R35 has a diagnoses of Acute Ischemic Cerebrovascular Accident.
R35's Care Plan documents Restorative Nursing Program- Range of Motion, Problem/Need to maintain current functional ability. Will actively participate in moving/exercising joints with verbal cues twice daily thru next 90 days.
R35's Range of Motion (ROM) Assessment documents a score of 10 (Moderate). Treatment may include, but is not limited to basic ROM, positioning, turning, ambulating, as indicated by individual resident needs.
R35's Restorative Nursing Program Documentation for 6/1/22 - 6/12/22, documents (R35) needs to perform AROM (Active Range of Motion) to upper and lower extremities twice daily to maintain current level of functioning. AROM was not performed on 6/1 and 6/8 - 6/12/22. AROM was performed once on 6/2- 6/6/22.
R35's Minimum Data Set assessment dated [DATE], Functional Status (Section G) documents R35 is a limited assist of one staff for Activities of Daily Living and uses a wheelchair. Restorative Nursing Programs (Section O) documents R35 was receiving Range of motion (active).
On 6/12/22 at 9:40 AM, V18 (Certified Nursing Assistant) was assisting R35 from his bed to his wheelchair. R35 was unsteady on his feet.
On 6/15/22 at 10:00 A.M., V2/Director of Nurses (DON) stated, We (facility) do not have a Restorative Nurse. The CNAs (Certified Nursing Assistants) are supposed to do range of motion exercises for each resident on a program, two times daily and document it on the Restorative Nursing flow sheet. At that time, V2/DON confirmed the areas of blank documentation on their Range of Motion (ROM) flow sheets for R6, R9, R35, R40, R49, R55 and R57 and further stated, I don't know that the CNAs did range of motion (exercises) for those residents or not.
Based on observation, interview, and record review, the facility failed to provide Range of Motion exercises for limited range of motion, for seven of seven residents (R6, R9, R35, R40, R49, R55 and R57) reviewed for range of motion, in a sample of 27.
Findings Include:
The facility policy, Restorative ADL (Activities of Daily Living) Programs, dated (revised) 01/02 directs staff, Restorative programs shall be planned for any resident with a reasonable likelihood for improvement in their functioning levels or to prevent a loss of function. Documentation or program implementation, follow through and individual resident progress towards goals will be done as follows: The Nursing Assistant performing the program as part of the daily care will document and initial the daily flow sheet as indicated for each restorative program.
1. On 06/12/22 at 10:29 A.M., R9 was seated in a reclining wheelchair, in a resident room. R9's bilateral hands were in a contracture position.
R9's Minimum Data Set assessment, dated 6/9/21, documents R9 has functional limitation in range of motion impairment to both upper and lower extremities.
R9's facility Range of Motion Assessment, last dated 3/15/22 documents that R9 is at High Risk for contracture development with contractures already present in bilateral upper and lower extremities.
R9's current Care Plan, dated 2/3/20 includes the following Problem/Need: Range of Motion problem. Also included are the following Approach/Interventions: Active Range of Motion exercises twice daily.
R9's Restorative Nursing Program Documentation, dated June 2022 documents staff failed to perform the required range of motion exercises seven times in the past twelve days.
2. On 6/12/22 at 9:46 A.M., R40 was lying in bed, sleeping. Contractures were present in R40's bilateral hips, legs and feet.
R40's Minimum Data Set assessment, dated 5/9/22, documents R40 has functional limitation in range of motion impairments to both lower extremities.
R40's Range of Motion Assessment, last dated 5/16/22 documents that R40 is at Moderate Risk for developing further contarctures, with moderate contractures already present in R40's lower extremities.
R40's current Care Plan, dated 4/1/20 includes the following Problem/Need: Range of Motion problem. Also included are the following Approach/Interventions: Active Range of Motion exercises twice daily.
R40's Restorative Nursing Program Documentation, dated June 2022 documents staff failed to performed the required range of motion exercises eight times in the past twelve days.
3. On 6/12/22 at 9:54 A.M., R55 was lying in bed, awake. At that time R55 was unable to recall staff performing range of motion exercises for her. Contractures were present in R55's bilateral hips, legs and feet.
R55's Minimum Data Set assessment, dated 4/11/22, documents R55 has functional limitation in range of motion impairments to both lower extremities., requires the use of a wheelchair and is totally dependent on staff for most activities of daily living.
R55's Range of Motion Assessment, last dated 3/9/22 documents that R55 is at Moderate Risk for developing further contarctures, with moderate contractures already present in R55's lower extremities.
R55's current Care Plan, dated 9/22/20 includes the following Problem/Need: Range of Motion problem. Also included are the following Approach/Interventions: Active Range of Motion exercises twice daily.
R55's Restorative Nursing Program Documentation, dated June 2022 documents staff failed to performed the required range of motion exercises seven times in the past twelve days.
4. On 6/12/22 at 10:05 A.M., R57 was asleep in bed. Contractures were present in R57's left shoulder, arm, hand, fingers, hip, knee and ankle.
R57's Minimum Data Set assessment, dated 5/26/22, documents R57 has functional limitation in range of motion impairments to one side of both upper and lower extremities.
R57's Range of Motion Assessment present in R57's Medical Record is incomplete.
R57's current Care Plan, dated 5/24/22 includes the following Problem/Need: Range of Motion problem. Also included are the following Approach/Interventions: Active Range of Motion exercises twice daily.
R57's Restorative Nursing Program Documentation, dated June 2022 documents staff failed to performed the required range of motion exercises eight times in the past twelve days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to reconcile controlled medications for 29 of 29 residents (R1, R5, R6, R9, R12, R14, R18, R19, R21, R22, R24, R26, R28, R29, R31...
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Based on observation, interview and record review, the facility failed to reconcile controlled medications for 29 of 29 residents (R1, R5, R6, R9, R12, R14, R18, R19, R21, R22, R24, R26, R28, R29, R31, R32, R33, R35, R36, R37, R38, R47, R48, R49, R52, R54, R209, R308 and R309) reviewed for medications, in the sample of 29.
FINDINGS INCLUDE:
The facility policy, Controlled Substances, dated (revised) 11/6/18 directs staff, It is the policy of the facility that all drugs listed as Schedule II drugs are subject to specified handling, storage, disposal and record keeping. Schedule II drugs are to be kept under two separate locks requiring two separate keys. A permanently affixed locked cabinet within the locked medication cart may be used for safe keeping. The Schedule II cabinet must remain locked and the Charge Nurse shall have the key in her possession at all times. Only Licensed Nurses will have access to Controlled Substances. A control sheet for each prescription will be initiated. The control sheet will contain: Resident's Name, ordering physician name, Issuing Pharmacy, Name and strength of drug, Quantity received and Date and time received. The drugs in Schedule II (and those in other schedules which have been restricted and stored in the Controlled Substance cabinet) will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. These records shall be retained for at least one year.
R52's current Physician Order Sheet, dated June 2022 includes the following medications: Norco (controlled substance) 7.5/325 MG (Milligrams) Give 1 tablet by mouth every six hours for pain.
On 6/12/22 at 11:34 A.M., V3/Licensed Practical Nurse (LPN) prepared to administer medications for R52. V3/LPN unlocked the A Hall Controlled Substance box, located in the A Hall Medication Cart, withdrew a medication punch card and punched one tablet of Norco 7.5/325 MG into a plastic medication cup. V3/LPN then opened the black A Hall Narc (Narcotic) Book and signed out the medication. At that time, the Shift To Shift Count Sheet, dated 6/1/22 through 6/30/22 documented twenty six missed shift to shift nursing narcotic counts. An inventory of the A Hall Controlled Substance box included controlled substances for (R1, R5, R9, R14, R18, R21, R22, R26, R31, R32, R33, R38, R47, R52, R54, R308 and R309). At that time, V3/LPN verified the missing shift to shift narcotic counts.
On 6/12/22 at 11:45 A.M., the Shift To Shift Count Sheet, for the facility B Hall, dated 6/1/22 through 6/30/22 documented forty four missed shift to shift nursing narcotic counts. An inventory of the B Hall Controlled Substance box included controlled substances for R6, R12, R19, R24, R28, R29, R35, R36, R37, R48, R49 and R209. At that time, V4/Licensed Practical Nurse (LPN) verified the missing shift to shift narcotic counts.
On 6/14/22 at 1:30 P.M., V2/Director of Nurses (DON) stated, The on-coming Nurse and the off-going Nurse are supposed to count all controlled medications for each (medication) cart, in the facility, and both sign the Controlled Substance Shift Count form. At that time, V2/DON verified the missing signatures and verified the facility nurses work eight hour shifts.
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 a cooked pork roast was cooled to a safe temperature before storing in the refrigerator, open containers of food were c...
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Based on observation, interview, and record review the facility failed to ensure a cooked pork roast was cooled to a safe temperature before storing in the refrigerator, open containers of food were covered to prevent contamination and labeled with the date opened, foods with expired dates were discarded, staff food was not stored in the refrigerator with residents' food, refrigerators were clean and without debris, and clean bowls in the kitchen were stored to prevent debris from falling into the eating surface. These failures have the potential to affect all 67 residents in the facility.
Findings include:
A Storage policy dated 10/2020 states, When using only part of a product, the remaining product should be in the original package or airtight container and labeled and dated. This policy also states, Do not leave serving utensils or tools in food containers.
A Food from Outside Sources/Personal Food Storage policy dated 4/2017 states, All residents have the right to accept food brought to the facility by any visitor (s) and/or food from a facility garden, however, the food must be handled in a way to ensure resident safety. This policy states, Any suspicious or obviously contaminated food or beverage will be discarded immediately. Food and beverages will be labeled with the resident's name, food item, date. In addition, this policy states, Housekeeping staff, or designee shall clean and sanitize the refrigerators once a month or as required.
A Food and Drug Administration (FDA) document dated as current documents that the FDA has rules for cooling food safely which includes, The FDA recommends that food be cooled from 135°F(Fahrenheit) to 41°F (57°C (Celsius) to 5°C) in six hours or less. This time limit helps prevent dangerous bacteria growth. In addition, this document states, Food must be cooled from 135°F to 70°F (57°C to 21°C) in two hours or less. In this range, bacteria can double in as little as 20 minutes (https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/how-temperatures-affect-food). The faster food passes through this temperature range, the better. Food workers have the rest of the six hours to take food through the remaining temperature danger zone, from 70°F down to 41°F (21°C to 5°C).
On 6/12/22 at 9:25a.m. V6 (Cook) was in the kitchen preparing the noon meal. There was a cooked roast on the food prep table which was wrapped in plastic. V6 stated the meat was a pork roast that was cooked yesterday. V6 stated that after the roast was cooked, it was refrigerated overnight and was going to be sliced and made into sandwiches as an alternative for the residents' lunch. V6 stated the facility no longer keeps cool down logs on cooked meat and, therefore, there is no documentation of the temperature the roast was when it was placed in the refrigerator or whether the FDA's two step method of cooling cooked food was utilized. V6 proceeded to take the internal temperature of the roast using a digital food thermometer. The internal temperature of the meat was 62.6F, well above the FDA's safe food refrigeration temperature of 41F. V6 stated she did not think the meat could have warmed up that much since the time she removed it from the refrigerator. V6 proceeded to open the cooler where cold food for residents' meals is stored. Inside the cooler was a rack with shelves which contained nine glasses of cranberry juice and five cups of diced peaches, one cup of pureed peaches, and one cup of thickened juice which were unlabeled and uncovered. There was an unsealed and partially used bag of lunch meat which was not labeled with opened date. There were two pitchers of juice which were unlabeled. V6 verified the food items in the refrigerator that were uncovered, partially used, and without labels. V6 closed the refrigerator and walked over to the steam table where there was a table adjacent on top of which were four small disposable plastic cups which were uncovered and contained a purple substance under a brown substance. V6 stated these were peanut butter and jelly cups for residents. V6 verified the cups were uncovered and unlabeled. On a table next to the stove was a small plate containing a piece of toast which was uncovered. At 11:36a.m. V7 (Dietary Manager) opened the freezer in the facility's kitchen located across from the food preparation table. Inside the freezer was a partially consumed water bottle containing a pink liquid. V7 stated that staff's personal drinks are not supposed to be kept in that freezer. V7 proceeded to enter the dry storage room where there was a large plastic container of granulated sugar with the lid partially removed exposing the contents. V7 attempted to replace the lid but it did not fit over the container of sugar. There was a large plastic container of a powdered substance next to the sugar which also had the lid partially removed. The lid to this container was covered with the powdered substance. V7 stated the powder is used to thicken liquids for residents requiring thickened liquids in their diets. V7 proceeded to remove the lid and brushed off the powder into the waste basket. There was a smaller plastic nine by thirteen sized container which contained granulated sugar which was in clumps, and which contained a small scoop within the container on top of the sugar. V7 stated that was sugar used in the dining room when staff were serving drinks and which water had dripped into the container causing the sugar to clump. V7 stated she was saving that container of sugar to be used for residents again. Across from the sugar containers was a small food preparation table with additional containers of dry cereals. Also on the table was a stack of cereal bowls facing upward. V7 stated the bowls are kept like that so staff can easily fill the bowls when residents request cereal. There was brown and tan debris visible inside the top bowl in the stack. On a bottom shelve of the storage rack was a large electric food slicer which was uncovered and had visible debris just below where the blades were attached. V7 verified the slicer was being stored without a cover and stated she did not know where the debris on the slicer came from.
On 6/13/22 at 1:00p.m. V18 (Housekeeping Supervisor) unlocked the residents' nourishment room door and opened the refrigerator containing stored residents' foods. The refrigerator interior was covered with dried liquids, pieces of paper and food debris. There were numerous food items which were partially used and unlabeled which included a small bottle of chocolate syrup, a large bottle of chocolate syrup, four jars of salsa of various sizes, a carton of milk, two bottles of Worcestershire sauce, a bottle of ketchup and mustard, Italian salad dressing, strawberry jelly, liquid coffee creamer, a vegetable drink, barbeque sauce, a liter of soda, a large bag of bacon pieces, an opened can of soda, a jar of relish, a container of sour cream, a bottle of liquid tea, a plastic water bottle. Also in the refrigerator was a partially eaten rotisserie chicken, wilted grapes, a container of margarine, an unsealed plastic bag with a sandwich with hard bread and an unknown brown substance between the bread, two commercially prepared sandwiches with labels instructing to use by 5/23/22, a commercially prepared macaroni and cheese container and a container of a tofu dish both labeled with a use by date of 5/23/22. Additionally, there was a partially used bottle of a nutritional supplement drink and a plastic container of food which V18 stated belonged to one of the nursing staff. V18 verified the contents of the refrigerator and stated that all the foods within the refrigerator should be labeled with the resident's names and date they were opened. V18 stated the expired food should have been discarded. V18 stated that facility staff are not supposed to store their food in the residents' nourishment refrigerator. At 1:15p.m. V1 (Administrator) entered the residents' nourishment room and verified the soiled condition of the refrigerator and verified that the contents were expired, not labeled, not completely covered, or belonged to nursing staff. V1 proceeded to open the freezer to examine the contents. Inside the freezer were four therapeutic ice bags on top of which was a partially consumed fast-food chocolate drink laying on its side. There was a frozen dinner in a box, a chicken burrito, a pastry roll, a partially empty water bottle, an unwrapped partially eaten ice cream sandwich. None of these items were labeled with who they belonged to or when they were opened. Additionally, there were pieces of paper, food debris and drops of frozen brownish liquid all over the interior of the freezer. V1 verified the freezer was soiled and contained expired, unlabeled and open partially consumed foods. V1 also verified there was a partially consumed fast food chocolate drink laying on top of therapeutic ice bags used in medical treatments for residents. V1 stated that the refrigerator and freezer needed to be cleaned and expired or unlabeled foods discarded. V1 stated that therapeutic ice bags should not be stored in the refrigerator with food.
On 6/15/22 at 9:00a.m. and 1:00p.m. V1 stated that the facility no longer keeps cool down temperatures on cooked roasts because all cooked foods are supposed to be consumed the same day they are cooked. V1 stated that if there are any leftovers of foods such as a cooked pork roast, that food is offered to staff for their meals that same day. V1 stated the cooked pork roast that had an internal temperature of 62.6F the day after it was cooked should have been discarded and not saved to serve to residents.
A Resident Census and Conditions of Residents form dated 6/12/22 and signed by V16 (Minimum Data Set Coordinator) documents that at the time of the survey 57 residents resided in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record reviews the facility failed to ensure staff wore masks covering their noses and mouths while in the resident areas of the facility. This failure has the p...
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Based on observations, interviews, and record reviews the facility failed to ensure staff wore masks covering their noses and mouths while in the resident areas of the facility. This failure has the potential to affect all 57 residents in the facility.
Findings include:
A COVID-19 Control Measures policy dated as revised 2/21/22 states, Anyone entering the facility must wear a facemask.
On 6/12/22 at 9:15a.m. V4 (Licensed Practical Nurse/LPN) walked from the residents' hallway through the facility's dining room to the side entrance of the building without wearing a face mask. V4 proceeded to talk with visitors who just entered the building before walking back through the dining room into the patient hallway where the nurses' desk was located. At 9:40a.m. V3 (LPN/Infection Preventionist) was standing behind the nurses' station which was centrally located between the three resident hallways. V3 was wearing a facemask which was placed under her chin and not covering her nose or mouth. V3 stated that staff are supposed to wear a facemask covering their noses and mouths while in the facility. During this conversation, V3 maintained her mask under her chin without adjusting it to cover her nose and mouth.
On 6/14/22 at 11:00a.m. V9 (Certified Nurse Aide/CNA) was standing at the end of the residents' hall. V9's mask was under V9's chin and not covering V9's nose or mouth. At that time, V9 proceeded to walk from the end of the residents' hall past the nurses' station, through the residents' dining room to exit the side door while wearing V9's mask under V9's chin. At 1:30p.m. V9 was standing in the dining room in the presence of residents who were eating popsicles for a snack. V9 had removed V9's mask and was also eating a popsicle in the presence of these residents.
On 6/15/22 at 10:15a.m. V9 and V10 (CNA) were seated at the end of a residents' hall. V9's facemask was below V9's chin and not covering V9's mouth or nose. V11 (Registered Nurse) was standing next to V11's medication cart on the same residents' hall as V9 and V10. V11 was wearing a facemask under V11's chin and not covering V11's nose or mouth. V11 proceeded to talk to a visitor then talk to V9 and V10 while continuing to wear the facemask under V11's chin.
On 6/15/22 at 11:00a.m V2 (Director of Nurses) stated that the facility requires all staff to wear face masks to cover their noses and mouths while working in resident areas of the facility as an infection control measure to prevent the potential spread of COVID-19. V2 stated that V9 should not have removed V9's facemask to eat a popsicle in the presence of residents in the dining room. V2 stated that V4 should not have walked through the facility without a facemask. V2 stated that V3 and V11 should not have been in the residents' hall or at the nurses' station without wearing a mask over their noses and mouths.
A Resident Census and Conditions of Residents form dated 6/12/22 and signed by V16 (Minimum Data Set Coordinator) documents that at the time of the survey 57 residents resided in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to have documented efforts to obtain COVID-19 laboratory test results within 48 hours or that it attempted to contact its local and state healt...
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Based on interview and record review the facility failed to have documented efforts to obtain COVID-19 laboratory test results within 48 hours or that it attempted to contact its local and state health departments for assistance with timely COVID-19 laboratory testing. These failures have the potential to affect all 57 residents in the facility.
Findings include:
A COVID-19 Testing policy dated 6/4/20 gives as its purpose, To identify asymptomatic cases, to confirm infection symptomatic cases, to evaluate quality indicators, to follow-up on infection control programs and to support decision making.
On 6/12/22 at 10:16a.m. and 6/14/22 at 2:00p.m. V2 (Director of Nurses) stated the facility recently had an outbreak of COVID-19 among its staff and residents. V2 stated that the facility's community transmission levels are high, and the facility was already testing unvaccinated staff two times weekly using a point of care (POC) rapid test. V2 stated that on 5/16/22 the facility had its first case of COVID-19 at which time they began a broad testing program for all residents and staff two times weekly to continue for two weeks following the last positive COVID-19 test. V2 stated the facility continued testing staff using the POC rapid test but used a laboratory (Lab) to perform PCR (Polymerase Chain Reaction) testing for all residents twice weekly. V2 stated that since 5/16/22 the lab has not given the facility results within 48 hours on multiple occasions. V2 stated that the facility's corporate office has been informed but no other measures have been attempted. V2 stated the facility's corporate office does not allow for residents to have POC rapid testing which would ensure the facility can determine a resident's COVID-19 status within 15 minutes. V2 stated that the facility's local and state health departments have not been contacted for assistance with this matter. V2 provided a compilation of residents' PCR test results which documents that residents' PCR testing performed 5/23/22 were not returned to the facility until 6/2/22; results of residents' PCR testing performed 5/26/22 were not returned to the facility until 6/2/22; results of residents' PCR testing performed 5/30/22 were not returned to the facility until 6/2/22; results of residents' PCR testing performed 6/2 22 were not returned to the facility until 6/6/22; results of residents' PCR testing performed 6/9/22 were not returned to the facility until 6/14/22.
A Resident Census and Conditions of Residents form dated 6/12/22 and signed by V16 (Minimum Data Set Coordinator) documents that at the time of the survey 57 residents resided 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
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 4 life-threatening violation(s), Special Focus Facility, 3 harm violation(s), $58,003 in fines. Review inspection reports carefully.
- • 67 deficiencies on record, including 4 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $58,003 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Fondulac Rehabilitation & Hcc's CMS Rating?
CMS assigns Fondulac Rehabilitation & HCC 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 Fondulac Rehabilitation & Hcc Staffed?
CMS rates Fondulac Rehabilitation & HCC's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Fondulac Rehabilitation & Hcc?
State health inspectors documented 67 deficiencies at Fondulac Rehabilitation & HCC during 2022 to 2025. These included: 4 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, 59 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Fondulac Rehabilitation & Hcc?
Fondulac Rehabilitation & HCC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PETERSEN HEALTH CARE, a chain that manages multiple nursing homes. With 98 certified beds and approximately 76 residents (about 78% occupancy), it is a smaller facility located in EAST PEORIA, Illinois.
How Does Fondulac Rehabilitation & Hcc Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, Fondulac Rehabilitation & HCC'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 Fondulac Rehabilitation & Hcc?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Fondulac Rehabilitation & Hcc Safe?
Based on CMS inspection data, Fondulac Rehabilitation & HCC has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 4 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Fondulac Rehabilitation & Hcc Stick Around?
Fondulac Rehabilitation & HCC 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 Fondulac Rehabilitation & Hcc Ever Fined?
Fondulac Rehabilitation & HCC has been fined $58,003 across 2 penalty actions. This is above the Illinois average of $33,659. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Fondulac Rehabilitation & Hcc on Any Federal Watch List?
Fondulac Rehabilitation & HCC is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.