THE HAVEN OF FARMER CITY
For profit - Limited Liability company
56 Beds
HAVEN HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
3/100
#648 of 665 in IL
Photo by Haven of Farmer City
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Haven of Farmer City has received a Trust Grade of F, indicating significant concerns about the quality of care provided, which is in the bottom tier of nursing homes. It ranks #648 out of 665 facilities in Illinois, placing it in the bottom half of all nursing homes in the state and #2 out of 2 in De Witt County, meaning only one other option is available locally. The facility is showing some signs of improvement, reducing issues from 16 in 2024 to just 2 in 2025, but still has a long way to go. Staffing is rated poorly at 1 out of 5 stars, although the turnover rate is 39%, which is better than the state average of 46%, suggesting some staff stability. However, the facility has incurred $122,236 in fines, which is concerning and indicates repeated compliance problems. Additionally, there have been serious incidents reported, including a case of physical abuse where a resident was hit in the mouth by a spouse during unsupervised visits, and another incident where a resident was not safely transferred, resulting in a broken arm. While there is average RN coverage, the presence of these critical issues highlights the need for significant improvement to ensure resident safety and well-being.
- Trust Score
- F
- In Illinois
- #648/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 39% turnover. Near Illinois's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $122,236 in fines. Higher than 85% of Illinois facilities, suggesting repeated compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Illinois. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 52 deficiencies on record. Higher than average. Multiple issues found across inspections.
3/100
Bottom 3%
Review needed
16 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 16 issues
2025: 2 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (39%)
9 points below Illinois average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 39%
Near Illinois avg (46%)
Typical for the industry
Federal Fines: $122,236
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: HAVEN HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 52 deficiencies on record
1 life-threatening 2 actual harm
Aug 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safely transfer a resident (R1) from the bed to the wheelchair. Thi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safely transfer a resident (R1) from the bed to the wheelchair. This failure resulted in R1 sustaining a broken arm requiring emergency evaluation and treatment at the hospital. R1 is one of three residents reviewed for accidents in the sample list of four. This past non-compliance occurred from 8/13/25 to 8/14/25. Findings Include: The facility Safe Lifting and Movement of Residents Policy (revised August 2008) documents the following: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses mechanical lifting devices for the lifting and movement of residents. Mechanical lifting devices shall be used for any resident needing a two person assist. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. R1's Face Sheet dated 8/22/25 documents R1 was admitted to the facility on [DATE] and R1's diagnoses include: Presence of Right Artificial Shoulder Joint, Paraplegia, Glaucoma, Osteoarthritis, Rheumatoid Arthritis, Contracture, and Dementia. R1's Comprehensive assessment dated [DATE] documents R1 is moderately cognitively impaired, has bilateral lower extremity impairments, uses a wheelchair (motorized) for mobility, and is dependent on staff for all activities of daily living (ADL) including transfers.R1's Care Plan (current) documents R1 has an ADL self-care performance deficit related to Paraplegia, Rheumatoid Arthritis, Weakness and cognitive decline. Further documents R1 is totally dependent on physical assist of two staff for transferring (bed-to-chair/chair-to-bed, toilet transfers, tub/shower transfers) with use of mechanical lift.R1's Injury of Known Cause Report dated 8/13/25 documents R1 was transferred from R1's bed to wheelchair without the use of a mechanical lift. This same report documents R1 was manually transferred from R1's bed to wheelchair by V5 (Certified Nursing Assistant/CNA) and V6 (CNA) when a pop was heard during said transfer and R1 complaining of right shoulder pain. This same report documents R1 would not allow V4 (Licensed Practical Nurse/LPN) to assess for injuries and R1 stating, it hurts, it hurts, please don't touch it and R1 sent out to the emergency department for evaluation and treatment. R1's Hospital Record dated 8/13/25 documents R1 was seen for upper arm trauma and R1 had an acute comminuted periprosthetic fracture of the proximal humerus (upper arm). This same record documents R1 received four intravenous (IV) injections of Hydromorphone (narcotic medication used to treat severe pain) and one IV injections of Ketorolac (nonsteroidal anti-inflammatory drug used for the short-term treatment of moderate to moderately severe acute pain) while in the emergency department. V5 (CNA) witness statement dated 8/13/25 documents, went into [R1's] to assist V6 with [R1]. We sat resident up on side of bed and two person assisted to wheelchair. As we transferred resident, I heard a loud pop. Immediately alerted nurse to assess.On 8/22/25 at 10:45am, R1 was lying in bed with an immobilizer present on R1's right arm. R1 stated, I told them I was a mechanical lift. I told them to use a mechanical lift. They dropped me in my chair. R1 stated R1 has no use of lower extremities.On 8/22/25 at 10:52am, R4 (R1's Roommate) stated R4 witnessed the incident. R4 stated staff (V5 and V6 CNAs) did not use a mechanical lift to transfer R1. R4 stated, they dropped [R1] in [R1's] wheelchair and [R1] hit arm on chair. On 8/22/25 at 11:13am, V6 (CNA) stated on the date of the incident (8/13/25) V6 had mechanical lift sling underneath R1 and the mechanical lift in the room ready to hook R1 up to the mechanical lift. V6 stated, [V5 CNA] entered the room and said 'we need to get [R1] up. Can you lift?' V6 stated V6 advised V5 not to lift R1, we have mechanical lift and need to be doing it the proper way. V6 stated V5 already started lifting R1 and V6 then assisted. V6 stated R1 started screaming immediately once in chair. V6 stated V5 ran out of the room at that time and V6 stayed with R1. V6 stated V4 (Licensed Practical Nurse) came into the room to assess R1 and R1 was sent out to the emergency department. V6 stated, I didn't feel the transfer was proper or correct. V6 stated V6 went by what the CNA communication book stated for resident transfer status. V6 stated V7 (Assistant Director of Nursing/ADON) made a cheat sheet for staff to use that listed resident transfer status. On 8/22/25 at 11:35am, V9 (Director of Physical Therapy) stated after a resident is screened for their transfer status, the recommendations are given to the nursing department who updates residents care plan with the appropriate transfer status. V9 stated if a resident is a mechanical lift transfer, the lift should be done with two staff, and the resident should never get transferred any other way especially a stand and pivot. V9 stated there is a reason they are a mechanical lift transfer. V9 confirmed R1 is a two staff assist mechanical lift transfer.On 8/22/25 at 11:47am, V4 (LPN) stated on the date of the incident (8/13/25) V4 was either at the nurses' station or the medication cart when V5 approached claiming V4 need to come to R1's room due to an emergency. V4 stated when V4 entered R1's room, R1 was sitting upright in R1's wheelchair screaming, it hurts, it hurts, don't touch it. V4 stated V4 asked R1 what hurts and R1 stated my right shoulder. V4 stated R1 would not let V4 assess R1. V4 stated R1 was sent out to the emergency department at that time for evaluation and treatment. V4 stated both V5 and V6 admitted to transferring R1 without a mechanical lift. V4 stated V6 was ready to go with the mechanical lift and the mechanical lift sling was present under R1. V4 stated, [V5 stated] ‘they weren't going to use that (sling), we don't have time.' V4 stated staff are aware R1 is a mechanical lift transfer and has been since admission to the facility. On 8/22/25 at 11:01am, V7 (ADON) stated nursing staff have transfer competency done upon hire and yearly. V7 stated nursing staff are provided a cheat sheet with resident transfer status listed on it and it is documented in the CNA communication binder. Prior to the survey date of 8/22/25, the facility had taken the following actions to correct the non-compliance: 1. On 8/13/25, R1 was sent to the hospital for evaluation and treatment and then returned to the community.2. On 8/13/25, the Quality Assurance Committee developed a Plan of Correction for the 8/13/25 incident and a Performance Improvement Plan.3. On 8/13/25, the Director of Nursing provided in-service education to nursing staff on the transfer policy, following individualized transfer procedures, baseline care plans and how to communicate ADL needs of residents.4. Starting on 8/13/25, the Director of Nursing will audit resident transfers four times a week for four weeks to ensure staff are appropriately transferring.5. Starting on 8/13/25, the Director of Nursing will audit resident charts for current transfer status in baseline and/or comprehensive care plan four times a week for four weeks.6. The facility QAPI Committee will continue to monitor the facility's performance to ensure corrective actions to the 8/13/25 incident is effective.7. Completion date of substantial compliance: 8/14/25.
Mar 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
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 develop a discharge plan for administration of diabetic medications...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to develop a discharge plan for administration of diabetic medications and wound care for one of three residents (R2) reviewed for discharge in the sample list of six.
Findings include:
The facility's undated Transfer and Discharge Policy documents the facility will assure resident transfers and discharges will be conducted in accordance with resident's rights, physician orders, and in such a manner as to maintain continuity of care for the resident.
The Medication Administration Record dated 3/12/25 documents orders for R2 to have blood glucose checks before meals and at bedtime, Metformin (antidiabetic)1000 milligrams (mg) in the morning and at bedtime, Trulicity (antidiabetic) 3mg subcutaneously every Thursday, and Lantus insulin 10 units (subcutaneously) every morning.
The Treatment Administration Record dated 3/12/25 documents and order for R2 to have a dressing change to R2's right great toe wound daily.
The facility's Release of Responsibility for Discharge against Medical Advice (AMA) form dated 3/13/25, contains R2's signature on the resident signature line, and at the bottom of the document a handwritten statement documents the consent form was read out loud to R2 because resident is unable to read.
R2's medical record does not contain a discharge plan or notification of the physician of R2's discharge.
On 3/17/25 at 9:40 AM, V1 (Administrator) stated R2 was homeless prior to his admission from the hospital on 3/12/24. V1 stated the facility ran R2's background check prior to admission and nothing concerning came back so R2 was admitted on [DATE]. V1 further stated on 3/13/25 V1 was made aware that R2's CHIRP (Criminal History Information Response Process) came back that R2 was an identified offender. V1 stated she went to R2's room to discuss the CHIRP with him and R2 confirmed the report. V1 stated she told him that she needed to make room moves and put R2 in a private room. V1 stated V1 made R2 aware they would have to look for different placement because R2 would not be able to stay at the facility with his conviction. V1 stated R2 asked if there were any local facilities that would take R2 because he wanted to stay in the area. V1 stated she told R2 that individuals convicted as sex offenders usually go to Northern facilities, and they probably could not find a facility in the area. V1 stated R2 stated then just take him back to the (homeless shelter) because R2 did not want to leave the area. V1 stated V1 told R2 that he would have to sign out against medical advice (AMA) if that's what he wanted to do. V1 stated R2 was not able to read or write so they read him the AMA paperwork and R2 signed the papers and then the facility took R2 to the shelter with a bag of food and dropped him off. V1 stated that no referrals to outside agencies were done, and discharge planning was not initiated because R2 signed an AMA paper. V1 stated the facility did not consult the physician or law enforcement prior to discharge.
On 3/17/25 at 11:00 AM, R2 stated V1 (Administrator) told R2 that he had to go and that R2 was not able to stay at the facility because of a past conviction. R2 stated V1 asked where R2 wanted to go and then dropped him off at the (homeless shelter) because that's where R2 was before admission to the hospital. R2 stated he cannot read and did not understand what he was signing. R2 stated he told V1 that he could not read the document, but V1 told R2 he had to sign the paper, and then they would take R2 where he wanted to go. R2 further stated he was not given medications or any wound care supplies, so he walked from the homeless shelter to V12 (Nurse Practitioner's) office to try and get some medications. R2 stated V12 admitted R2 to the hospital for wound care where he remains on 3/17/25.
On 3/17/25 at 9:55 AM, V4 (Hospital Social Worker) stated V4 was covering the emergency room (ER) on 3/14/25 and V4 received a phone call from V12 (Nurse Practitioner) that R2 showed up at her office with a wound on his foot and needing medications, so V12 sent R2 to the ER (Emergency Room) because V12 felt R2 couldn't manage at a shelter. V4 stated R2 told V4 he was at a nursing home facility but was told he had to leave. V4 stated R2 told V4 he was interested in going back to the facility. V4 stated V1 (Administrator) told hospital staff R2 signed paperwork to leave AMA but R2 told us he does not read or write, so he did not know what he signed. V4 stated she felt concerned that he is having issues managing his medical care, he is staying at warming center he has no bed there, so he is unable to manage his care. V4 stated R2 takes insulin and needs dressing changes. V4 stated R2 was admitted to hospital on [DATE] and is currently still in the hospital for wound management because the hospital has no way to safely discharge R2.
On 3/17/25 at 3:00 PM, V12 Nurse Practitioner stated that she sent R2 to the emergency room on 3/14/25 from her office. V12 stated that R2 is homeless. V12 stated R2 has diabetes and has developed a pressure ulcer on his right great toe from walking around town and wearing a hole in his shoes. R2 is not able to read and has vision issues due to his diabetes. V12 stated R2 also is not able to manage wound care to his foot. V12 stated she referred R2 to the nursing home facility for wound care. V12 stated the facility discharging R2 the way that they did put R2 at risk for developing an infection or losing his toe as R2 is unable to manage his own wound care. V12 stated R2 is currently in the local hospital after walking to her office. V12 stated it's not safe for R2 to be in the homeless shelter as there is no bed for him to sleep on and his toe is going to get worse without medical care. V12 also stated she was not made aware of R2's discharge from the facility until he walked to her office from the homeless shelter.
Dec 2024
15 deficiencies
CONCERN
(D)
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 of a new pressure ulcer and nausea/stomach pain for two residents (R5, R247) of two residents reviewed for reporting c...
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Based on interview and record review, the facility failed to notify the physician of a new pressure ulcer and nausea/stomach pain for two residents (R5, R247) of two residents reviewed for reporting changes in status in the sample list of 25.
Findings include:
1.) R5's Care Plan dated 12/6/24, documents R5 is high risk for Pressure Ulcers due to Osteoarthritis, Weakness, and Incontinence. This same Care Plan documents if open skin is assessed, report to the doctor and responsible party.
R5's Nursing Notes by V14 (Registered Nurse) dated 12/8/24 at 4:00 AM, documents open area noted to right coccyx, barrier applied and covered bony prominence with (an absorbent foam dressing). No further documentation is in the nursing notes about the area.
On 12/15/24 at 2:29 PM, V3 (Resident Care Coordinator/Licensed Practical Nurse), stated V3 did not know about an open area on R5, and nothing was reported and V3 was not even aware of any orders being documented. V3 stated V14 should have filled out a new skin sheet and notified the doctor and whoever was on call.
2.) R247's undated diagnoses list documents R247's diagnoses as: wound infection of left lower extremity related to tibia/fibula fracture and open distal left tibia/fibula fracture status post open reduction and internal fixation (ORIF).
R247's Nursing Notes dated 12/13/24 at 8:00 PM, document: resident complaining of nausea and stomachache, nurse faxed primary care provider on change and will continue to monitor. There is no further documentation regarding nausea being addressed.
On 12/16/24 at 11:40 AM, V2 (Director of Nursing) stated the nurse should have called the doctor or on-call nurse to get an order.
The facility's Notification for Change in Resident Condition or Status Policy dated Revised 12/7/17, documents the facility staff shall promptly notify the Administrator, Director of Nursing, Physician, Health Care Power of Attorney of changes in the resident's status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility to ensure the least restrictive restraint was used for the least amount of time for one resident (R8) of one resident reviewed for restr...
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Based on observation, interview, and record review the facility to ensure the least restrictive restraint was used for the least amount of time for one resident (R8) of one resident reviewed for restraints in a sample list of 25.
Findings Include:
The facility's Physical Restraint/Enabler policy revised 7/24/18 states Policy: To allow residents to be free of physical restraints which are not required to treat medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience. It is recognized that there may be emergency situations in which restraints may be required. Under the heading Procedures the policy also states Place physical restraint problem on the resident's Care Plan. The Care Plan must address the duration, type, and circumstances under which the restraint can be used. After initial documentation, all physical restraints require quarterly documentation regarding the type of physical restraint used, resident's response to the physical restraint, and if any reduction plan has been attempted. Initiate Restraint Elimination/Reductions Program ninety days after application.
R8's Physician's Order Sheet (POS) for December 1, 2024 to December 31, 2024 included the following diagnoses: Dementia, Anxiety, Depression, Coronary Artery Disease, Atrial Fibrillation, and Pelvic Tilt.
R8's MDS (Minimum Data Set) dated 11/22/24 documents R8 as severely cognitively impaired with two restraints under chair that prevents rising and two restraints under other restraints.
R8's Care plan updated 6/5/24 documents (R8) Least restrictive measure to ensure safety include use of device that limits movement and accessibility (meets definition of physical restraint). Device in place: Self-releasing safety belt and busy tray while up in wheelchair. (R8) has unsafe sitting balance and leans forward and sideways in (R8's) wheelchair. (R8) attempts to pick up off the floor making safety an issue. R8's reclining seat and back wheelchair with bilateral trunk supports is not addressed in the Care Plan.
On 12/16/24 at 11:00AM R8 was observed being transferred to reclining seat lifted wheelchair with bilateral trunk supports in place by V11 (Certified Nursing Assistant/CNA) and V12 (CNA). A sling type mechanical lift was being utilized. R8 was placed in the wheelchair with the seat lifted and the back reclined. The bilateral trunk supports were placed on either side of R8. A seat belt was fastened across R8's lap. A rigid tray was put in place extending outward from R8's waist. When asked if R8 could stand, V11 stated not very well anymore. But (R8) can wiggle forward and fall that is why her (family member) insists we have the seat belt and the tray on when (R8) is up. V12 nodded in agreement stating (R8) can't stand, but she can get out of this chair without the belt and tray. (R8) has fallen that way before and gotten a couple of big lumps on (R8's) head. (R8's) husband had us add the lap tray because (R8) was fiddling with the buckle on the safety belt.
R8's Physical Enabler/Restraint Use/Reduction Evaluation last updated 11/22/24 does not include the lap tray, the reclining raised seat wheelchair, or the trunk supports.
On 12/17/24 at 12:00PM V2 (Director of Nursing) verified R8 is Care Planned for restraints and only the seat belt has been assessed. V2 stated V2 believes these are not restraints but are for positioning.
On 12/17/24 at 2:00PM V1 (Administrator) stated (R8's) husband insists (R8) have these (devices) and I don't think they are restraints. When asked why they are coded on the MDS as restraints V1 indicated V1 did not know.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to consistently maintain good personal and oral hygiene f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to consistently maintain good personal and oral hygiene for one of three residents (R26) reviewed for Activities of Daily Living on the sample list of 25.
Findings Include:
The facility A.M. Care policy dated 3/20/23 documents A.M. Care will be given to all residents daily. Nursing assistants are responsible for providing daily A.M. care to all residents which includes providing oral hygiene including the brushing of teeth, washing of the face, underarms, and perineal areas, applying deodorant, dressing in clean clothing, and providing nail care.
R26's Physician Order Sheet dated December 2024 documents R26 is diagnosed with Epileptic Syndrome with Seizures and Mild Neurocognitive Disorder.
R26's Minimum Data Set, dated [DATE] documents R26 is cognitively intact and is totally dependent on staff for oral care, bathing, dressing, and requires maximal assistance with personal hygiene.
R26's Care Plan Summary dated 10/25/24 documents R26 has a self-care deficit and needs assist to complete Activities of Daily Living. The same care plan documents R26 has his own teeth and is to be set up and assisted with oral care. Staff are to provide hygiene and grooming per Resident's preference. Staff should provide care for R26's fingernails on shower days and as needed.
On 12/15/24 at 10:06 AM R26 stated staff never offer to set him up to brush his teeth, wash his face, put on deodorant, or clean up his beard. He gets a shower on occasion but sometimes he will refuse because they come so early in the morning, and it is freezing cold. R26 stated they don't offer another time or come back later- he just doesn't get one that week. R26 stated he needs help to take care of himself.
On 12/15/24 at 10:06 AM R26's hair appeared dirty and greasy. R26's nails were long and dark, dirt like substance was under his fingernails. R26's beard had food debris throughout it. R26's white shirt was stained with multiple yellow stains up around his neck and chest. R26's face appeared unwashed, and he had dry skin flaking off. R26's teeth and gums appeared coated with debris.
On 12/15/24 at 11:48 AM V2 (Director of Nursing) confirmed R26 does refuse showers sometimes and should be getting showers at least once per week and per his preference. V2 confirmed R26 needs new unstained clothing. V2 confirmed staff should be offering assistance with and encouraging morning care which would include face washing, brushing of teeth, combing hair, and cleaning hands and nails.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain infection control standards for catheter irrigation for one resident (R2) of one resident reviewed for catheter care...
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Based on observation, interview, and record review, the facility failed to maintain infection control standards for catheter irrigation for one resident (R2) of one resident reviewed for catheter care in the sample list of 25.
Findings include:
R2's undated diagnoses report documents R2's diagnoses as: Spastic Quadriplegic Cerebral Palsy, other Obstructive and Reflex Uropathy, Atrophy of Kidney (terminal), Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and personal history of Urinary Tract Infections.
R2's Medication Administration Record (MAR) dated 12/1/24 through 12/31/24, documents and order to flush (indwelling) catheter twice a day with 10 cubic centimeters (cc) of normal saline.
On 12/16/24 at 1:05 PM, V15 (Licensed Practical Nurse) performed irrigation of R2's indwelling catheter. V15 did not wash V15's hands before the procedure. V15 pulled the catheter apart from the drainage tubing to do the irrigation and did not wipe off the catheter before administering the flush or before connecting the catheter back to the drainage tubing.
On 12/16/24 at 1:12 PM, V15 stated she did not wash her hands before the task and stated oh yeah when asked about cleaning off the catheter after taking it apart and putting it back together.
The facility's Irrigation of Indwelling Catheter dated Reviewed 03/2018, documents pull the privacy curtains and close the door to the resident's room, wash your hands, cleanse the connection site between the drainage tubing and the catheter with antiseptic wipes, and reconnect the tubing to the catheter using aseptic technique.
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 change, date and store oxygen tubing and humidifier bottles in a sanitary manner for two of two residents (R3, R14) reviewed f...
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Based on observation, interview, and record review the facility failed to change, date and store oxygen tubing and humidifier bottles in a sanitary manner for two of two residents (R3, R14) reviewed for respiratory care in the sample list of 25.
Findings Include:
1. R3's Medical Diagnoses list dated December 2024 documents R3 is diagnosed with Congestive Heart Failure and Atrial Fibrillation.
R3's Physician Order Sheet (POS) dated December 2024 documents R3 is prescribed oxygen at two liters per nasal cannula continuously. Nursing is to change oxygen tubing weekly.
On 12/15/24 at 10:43 AM R3's oxygen tubing was laying on the ground. The nasal cannula was attached to the concentrator which was running at two liters per minute. The humidifier bottle was empty and both tubing and humidifier bottle were undated. Humidifier bottle was a refillable bottle and appeared to have white dried residue on the bottom of the container.
2. R14's Medical Diagnoses list dated December 2024 documents R14 is diagnosed with Chronic Obstructive Pulmonary Disease.
R14's Physician Order Sheet (POS) dated December 2024 documents R14 is prescribed oxygen at two liters per nasal cannula and nursing should change oxygen tubing and water weekly.
On 12/16/24 at 12:37 PM R14's oxygen tubing was hanging over the oxygen concentrator with the nasal cannula touching the floor.
On 12/16/24 at 3:35 PM V2 (Director of Nurses) confirmed staff should be storing oxygen tubing in plastic bags, refilling humidifier bottles when needed and should be changing tubing and humidifier bottles at least weekly, dating when changed and documenting in the Treatment Administration Record (TAR).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide Trauma Informed Care for one resident (R27) of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide Trauma Informed Care for one resident (R27) of one resident reviewed for Post Traumatic Stress Disorder in a sample of 25.
Findings Include:
The facility's Trauma Informed Care Policy dated [DATE] states Purpose: To ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. The third bullet point under Types of trauma survivors is Survivors of abuse.
This policy also states If a resident is determined to have suffered a traumatic event, the SSD (Social Service Director) will discuss with the resident or the resident's representative regarding potential triggers that may cause re-traumatization and interventions or preferences that eliminate or decrease triggers that may cause re-traumatization. The IDT (Interdisciplinary team) will develop a resident centered Care Plan that will identify the stressors, triggers, clinical manifestations, and interventions to mitigate against Re-traumatization. IDT will monitor the resident's response and adjustment to placement through collaboration and communication and input from the resident or the resident's representative. The trauma informed Care Plan will be updated and revised on an ongoing basis.
R27's Physician's Order Sheet (POS) for [DATE] to [DATE] includes the following diagnoses: Type II Diabetes, Late Onset Alzheimer's without Behavioral Disturbance, Generalized anxiety Disorder, Post Traumatic Stress Disorder (PTSD).
R27's Behavioral Health assessment dated [DATE] documents History of PTSD secondary to decades of Spousal abuse and Generalized Anxiety Disorder with Alzheimer's Dementia. (R27's) abusive spouse is deceased now and (R27) receives visits from one of (R27's) two sons. Visits are generally pleasant and positive interactions. Patient has high anxiety and repeatedly feels (R27) is not doing 'the right thing' and that 'I'm always wrong' and questions self often throughout the day, even with simple tasks like using the toilet.
On [DATE] at 9:00AM R27 was observed in the front common area sitting in a wheelchair picking at a cardboard box on the table in front of her. (R27) appears anxious stating I don't know where I need to go or if I need to lay down. I'm tired. (R27's) voice is tremulous. No staff are observed to attempt to redirect (R27) or intervene to assist (R27).
R27's Care Plan revised [DATE] does not include interventions to implement related to R27's PTSD.
On [DATE] at 11:40AM V19 (Social Service Director) stated (R27) had been abused by (R27's) spouse for years. V19 verified the IDT was aware of R27's diagnosis of PTSD and should have a care plan in place to address this.
On [DATE] at 12:00PM V2 (Director of Nursing) verified R27 has a diagnosis of PTSD and does not but should have a care plan in place with interventions to address identified triggers for PTSD.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to maintain safe and secure bed rail for one of one resident (R14) reviewed for bed rails on the sample list of 25.
Findings Inc...
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Based on observation, interview, and record review the facility failed to maintain safe and secure bed rail for one of one resident (R14) reviewed for bed rails on the sample list of 25.
Findings Include:
R14's Medical Diagnoses list dated December 2024 documents R14 is diagnosed with History of Falling, Mixed Alzheimer's Vascular Dementia with Behavioral Disturbances, Insomnia, Anxiety, Psychotic Disorder, Bipolar Disorder with Psychotic Features, Attention Concentration Deficit, and Chronic Obstructive Pulmonary Disease.
R14's Physician Order Sheet (POS) dated December 2024 documents R14 is prescribed the use of a right 1/2 side transfer bar for physical function of bed mobility.
On 12/15/24 at 10:30 AM R14's side rail was extremely loose and moved from side to side and front and back leaving a big gap between the bed mattress and side rail.
On 12/16/24 at 3:10 PM V16 (Maintenance Director) moved R14's bed rail and stated yes this is very loose and this needs tightened. V16 confirmed R14 has behaviors and can get aggressive and shake the bed rail and is at risk for falls.
On 12/16/24 at 3:15 PM V16 (Maintenance Director) stated he does not routinely check bed rails unless they are new or a resident moves rooms or beds. V16 stated he would expect the staff working with her daily to notify him if a bed rail is loose or needs fixed.
On 12/17/24 at 10:30 AM V1 (Administrator) confirmed R14 does need her bed rail checked often because she will shake the rail when upset and is a safety concern due to cognition, behaviors, and falls.
CONCERN
(D)
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 observation, interview, and record review the facility failed to properly dispose of a medication for one of six reside...
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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 properly dispose of a medication for one of six residents (R197) reviewed for medication administration in a sample of 25.
Findings include:
The facility's Drug release/Destruction Policy revised [DATE] states Discontinued medications or medications belonging to discharged residents should be destroyed as soon as practical and within seven days of resident discharge or drug discontinuation.
On [DATE] at 11:00AM V2 (Director of Nursing) accompanied surveyor to review the medication room for the facility.
During review of the medication refrigerator a zip lock package of Bisacodyl Suppositories were observed in the refrigerator with (R197's) name on the label. V2 stated (R197) expired on [DATE] and those should have been disposed of.
On [DATE] at 9:30AM V2 verified it is the facility's policy to destroy or if appropriate return to the resident all medications upon discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to administer medications as ordered to keep the medication error rate below five percent (5%). There were three medication error...
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Based on observation, interview, and record review the facility failed to administer medications as ordered to keep the medication error rate below five percent (5%). There were three medication errors out of 25 opportunities resulting in a 12% error rate. This failure affected one resident (R19) of six residents reviewed for medications on the sample list of 25.
Findings Include:
The facility's Medication Administration policy revised 11/18/17 states Medications must be prepared and administered within one hour of the designated time or as ordered. (i.e. Medication time is 9:00AM the medication can be administered as early as 8:00AM or as late as 10:00AM.) Medication is ordered Daily then medication can be given during the day at residents preference.
R19's Medication Administration Record for December 2024 lists the following current physician's orders for medications scheduled at 8:00AM.
1. MiraLAX 17 Grams in 8 ounces water Daily
2. Aspirin 325 milligrams (mg) daily
3. Gabapentin 600 mg Three times Daily
4. Multiple vitamin 1 daily
5. Tiotropium Bromide 3% 1 spray in each nostril Daily
6. Tylenol 650 mg Three times Daily
7. Tramadol 650 mg Twice Daily.
On 12/16/24 at 9:20AM V9 (Registered Nurse) was observed to administer all seven of these medications. Although the facility policy stipulates medications ordered daily can be given during the day at the resident's preference R19's Tramadol, Tylenol, and Gabapentin were not administered within one hour of the designated time.
On 12/16/24 at 12:00 V2 (Director of Nursing) verified the acceptable window for medication administration is one hour before and one hour following the ordered time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide dental services for one of two residents (R26)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide dental services for one of two residents (R26) reviewed for Dental Services on the sample list of 25.
Findings Include:
R26's Physician Order Sheet (POS) dated December 2024 documents R26 is diagnosed with Epileptic Syndrome with Seizures and Mild Neurocognitive Disorder. The same POS documents an order for dental services to be provided as needed.
R26's Care Plan Summary dated 10/25/24 does not address R26's need for dental services and broken teeth.
R26's Minimum Data Set (MDS) dated [DATE] documents R26 is cognitively intact.
On 12/15/24 at 10:06 AM R26 stated staff never offer to set him up or assist him with brushing his teeth. R26 stated he has had multiple teeth break off and has not seen a dentist since he has been in the facility. R26 stated although he does not have tooth pain currently, the broken teeth do affect how and what he can eat. R26 stated there are things he enjoys that he can't eat anymore due to his broken teeth.
On 12/15/24 at 10:06 AM R26's teeth and gums appeared coated with debris. R26 had broken teeth.
On 12/16/24 at 10:20 AM V2 (Director of Nursing) stated the facility does not have a dental service that provides regular cleanings and check-ups in the facility. V2 stated a couple residents see a dentist regularly but she does not know if R26 has ever seen a dentist for regular cleanings or to address acute concerns since being admitted to the facility. V2 confirmed residents should get regular dental care, cleanings, and checkups and R26 should get his broken teeth addressed and if he would like dentures, R26 should be able to get that process started.
On 2/17/24 at 10:30 AM V1 (Administrator) confirmed the facility does not currently contract with or provide dental services for resident check-ups, cleaning, and broken teeth on a regular and routine basis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide and/or assist the resident in arranging dental...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide and/or assist the resident in arranging dental services for a resident with broken dentures for one resident (R24) of two residents reviewed for dental issues in a sample list of 25.
Findings Include:
R24's Care Plan dated 4/19/24 Documents R24 requires oral/dental health maintenance related to (R24) is edentulous. Coordinate arrangements for dental care and transportation as needed/as ordered.
On 12/15/24 at 10:00AM V20 (R24's family member) stated (R24) hasn't got any dentures. They were broken at the nursing home (R24) was in before (R24) came to (the facility). I have asked for (R24) to be taken to the dentist over and over to get some new teeth. I have even spoken to the administrator, but they just grind (R24's) food. (R24) does not like the ground food.
R24's Physician's Order Sheet (POS) for December 1, 2024 through December 31,2024 documents R24 was admitted to the facility on [DATE].
On 12/16/24 at 11:00AM V2 (Director of Nursing) stated (R24) should have had arrangements made to see a dentist by this time. (R24) has been at (the facility) for several years. V2 denied knowledge the facility has arrangements with a dental service to provide care for residents at the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to have a communication process in place with the Hospice service provider and failed to have an up to date Hospice Plan of Care for one (R36)...
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Based on interview and record review, the facility failed to have a communication process in place with the Hospice service provider and failed to have an up to date Hospice Plan of Care for one (R36) of one residents reviewed for Hospice Services on the sample list of 25.
Findings include:
R36's Face Sheet (current) documents the following diagnoses: Generalized Anxiety Disorder, Dementia, and Alzheimer's Disease.
R36's Medical Record did not contain a Hospice Plan of Care.
The Hospice service provider communication binder does not contain any nursing entries by V18 Hospice Registered Nurse (RN) for R36.
On 12/17/24 at 8:35am, V3 Resident Care Coordinator stated V18 Hospice RN would write any new orders/changes directly on the Physician Order Sheet and flag the chart. V3 stated V18's only means of communication to the nursing staff of any resident order changes and/or changes in care was to reposition the page in R36's chart. V3 stated the chart would then be placed back on the shelf or left on the nurses station. V3 stated V18 does not write any communication in the communication binder or make nursing staff aware of these changes. V3 stated V18 should be documenting in the Hospice communication binder any visits and pertinent information pertaining to R36 including changes in status, care, and orders.
The Nursing Facility Hospice Services Agreement with R36's Hospice Provider (dated 10/28/24) documents the following: Coordination of Services. Hospice shall: Designate a member of the interdisciplinary group responsible for each Resident. The designated interdisciplinary group member is responsible for providing overall coordination of the hospice care of the Resident with Facility representatives and communicating with Facility representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family. Provide the Facility with the following information: the most recent Hospice Plan of care specific to each Resident.
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 monitor walk-in refrigerator and freezer temperatures and failed to prevent food contamination by storing utensils in bulk fo...
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Based on observation, interview, and record review, the facility failed to monitor walk-in refrigerator and freezer temperatures and failed to prevent food contamination by storing utensils in bulk food containers. These failures have the potential to affect all 44 residents residing in the facility.
Findings Include:
The facility's Storage policy dated October 2020 documents Food should be stored at the proper temperature and utensils or tools should not be left in food containers.
The facility's Equipment Temperatures policy dated September 2008 documents all refrigerators and freezers shall be monitored regularly to ensure that they are working properly and to correct any mechanical difficulties quickly to prevent food spoilage. The temperatures should be recorded on the corresponding Temperature Charts.
On 12/15/24 at 8:30 AM there were scoops and spoons observed in multiple multi-use food containers. A plastic scoop was inside the thickener container with the handle of the scoop in direct contact with the powder. A plastic scoop was inside the oatmeal container with the handle of the scoop in direct contact with the oats. A metal spoon was inside the brown sugar container with the handle in direct contact and partially covered with brown sugar. A metal spoon was inside the hot cocoa container with the handle in direct contact with the powder.
On 12/15/24 the Freezer Temperature Log for December 2024 was only filled out on 12/2/24 for the morning shift and from 12/4-12/8, and 12/11-12/12/24 on the evening shift.
On 12/15/24 the Walk-in Refrigerator Temperature Log for December 2024 was only filled out on 12/2/24 for the morning shift and from 12/4-12/8, and 12/11-12/12/24 on the evening shift.
On 12/16/24 at 3:28 PM V17 (Dietary Manager) confirmed the dietary staff should be completing temperature logs for the walk-in refrigerator and freezers twice per day. V17 also confirmed staff should not be storing scoops or spoons in containers of food products.
The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/16/24 documents 44 residents 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 have the survey results readily accessible to the residents. This failure has the potential to affect all 44 residents residin...
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Based on observation, interview, and record review the facility failed to have the survey results readily accessible to the residents. This failure has the potential to affect all 44 residents residing in the facility.
Findings include:
On 12/16/24 at 10:07 AM, during the resident council meeting, residents stated they have no idea where the State inspection book is located.
On 12/16/24 at 10:40 AM, V1 (Administrator) was asked where the survey book was located. After observation of the survey book location, it was found to be in a room off the front door in a bookshelf on the top shelf, not at wheelchair eye level, with many other books not seemingly in plain sight to take or view.
The State of Illinois, Illinois Department on Aging Residents' Rights pamphlet dated Revised 9/21, documents you have the right to see reports of all facility reviews from the most recent to the last three years.
The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/16/24 documents 44 residents reside in the facility.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0801
(Tag F0801)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review, the facility failed to provide the services of a qualified director of food and nutrition services. This failure affects all 44 residents residing i...
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Based on observation, interview, and record review, the facility failed to provide the services of a qualified director of food and nutrition services. This failure affects all 44 residents residing in the facility.
Findings Include:
On 12/15/24 at 9:15 AM V1 (Administrator) stated the facility has not had a qualified Dietary Manager since the last one quit. The facility hired V17 (Dietary Manager) who is starting work on 12/16/24 and would work on getting V17 trained and qualified.
On 12/16/24 at 11:45 AM V17 was actively supervising and directing the meal service for lunch.
The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/16/24 documents 44 residents reside in the facility.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
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 therapy services were provided for two (R1 and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure therapy services were provided for two (R1 and R3) of three residents reviewed for therapy services on the sample list of 3.
Findings include:
On 3/15/24 from 9:00 AM to 2:00 PM there were no therapists working in the facility, and the therapy room was locked.
1. On 3/15/24 at 11:05 AM R1 stated, I was in a hospital in Florida after having a stroke, and V3 (R1's Power of Attorney/POA) wanted me to receive physical therapy closer to V3's house, so that V3 could help out. The facility told me and V3 the facility would be getting a new physical therapy service provider starting on 3/4/24 and that I would be able to start therapy, and so far, they have not come to the facility, and I have not received any physical therapy. I need to get physical therapy so that I can get stronger on my left side and go back home to Florida.
R1's Social Service Note dated 2/28/24 documents R1 is a [AGE] year-old white female brought today by medical transport from hospital in (name of city) Florida. R1 is friendly and cooperative and extremely tired from 12-13-hour ride. R1 appears alert and oriented x 3, was admitted to room XXX. R1 has a diagnosis of Intracranial Hemorrhage and plans to return home after completing therapy.
V6 (Nurse Practitioner) Note dated 3/6/24 documents R1 is a [AGE] year-old female new admit to facility from Florida. R1 was living at own home in Florida and wants to return home. R1 had stroke and is in the facility for Physical and Occupational therapy (PT/OT). R1 states that R1 is weaker on the left side and tires easily. Came to facility to be closer to V3 (Daughter and Power of Attorney) because V3 wants to help R1.
2. R3's Face Sheet documents R3 was admitted to the facility on [DATE].
R3's Physician Order Sheet (POS) dated 2/21/24 documents Physical/Occupational (PT/OT) therapy, right hip fracture.
R3's Physician Order Sheet dated 2/22/24 documents discontinue therapy services as of 2/24/24.
R3's Social Service admission assessment dated [DATE] documents R3 was admitted to the facility on [DATE] with a Closed Fracture of Rip Hip, and reason for admission to receive Physical and Occupational therapy.
On 3/15/24 at 1:38 PM, V2 (Director of Nursing/DON) said the facility is currently not providing any therapy services to residents. V2 said there are two residents in the facility that were prescribed therapy services, R1 and R3. V2 said on 2/13/24 the facility was sent a letter documenting the termination of the therapy service agreement, with the final day of service was 2/18/24. V2 said the facility has not provided any therapy services since 2/18/24.
Facility assessment dated [DATE] documents Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies. Staff Type: Therapy Services (Rehab Care: Physical Therapy (PT), Occupational Therapy (OT), Speech/Language Therapy (SLP), Physical Therapy Assistant (PTA), Certified Occupational Therapy Assistant (COTA).
Letter from (contracted therapy company) dated 2/13/24 documents: Dear Administrator (Contracted therapy company) is providing a 5-day written notice of termination of Therapy Services with the facility due to failure to maintain payment terms, pursuant to Section 5.2.2 of the Therapy Services Agreement. (Contracted therapy company's) final date of service will be Sunday, February 18, 2024.
Dec 2023
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 44 reside...
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Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 44 residents in the facility.
Findings include:
On 12/20/2023 at 10:09AM, V3 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V3 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V3 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V3 reported the facility dietician only works in the facility one day per month.
On 12/20/2023 at 10:09AM V3 denied:
-being a dietician.
-being a certified dietary manager.
-having an associate's or higher degree in food service management or in hospitality.
-having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting.
-being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition.
-being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician.
-or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course.
On 12/20/2023 at 11:15AM, V1 (Administrator) reported V3 (Dietary Manager) did not meet the qualifications of a Certified Dietary Manager.
The Facility Assessment (11/29/2023) documents a full-time dietician or other clinically qualified nutrition professional is needed to provide competent support and care for the facility's resident population every day and during emergencies.
The facility resident roster (undated) documents 44 residents reside in the facility.
Nov 2023
23 deficiencies
1 IJ
CRITICAL
(J)
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 identify repeated episodes of verbal abuse of R28 by V...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify repeated episodes of verbal abuse of R28 by V11 (R28's Spouse) and failed to protect the resident's right to be free from verbal, mental, and physical abuse by V11. These failures resulted in V11 being allowed unsupervised visits with R28, subjecting R28 to repeated incidents of verbal and mental abuse by V11, and R28 being hit in the mouth by V11 resulting in psychosocial harm. R28 is one of five residents reviewed for abuse in the sample list of 33.
The Immediate Jeopardy began on 10/26/23 at 6:50 PM when V11 was witnessed hitting R28 in the mouth. V1 (Administrator) was notified of the Immediate Jeopardy on 11/8/23 at 9:30 AM. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed on 11/13/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
Findings include:
The facility's Abuse Prevention policy revised 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. The 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 facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, or humiliation and threats of punishment or deprivation. Physical Abuse including hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.
The Facility Reported Incidents report form dated 10/27/23 at 5:27 PM documents on 10/26/23 V9 (Visitor) reported that V11 was feeding R28, R28 refused and pushed V11's hand away, and V11 hit R28 in the mouth. The facility's (State Surveying Agency) Notification Form dated 11/1/23 documents the incident between V11 and R28 occurred on 10/26/23 at 6:50 PM. This form documents the facility found no intentional abuse on V11's part. The facility instructed V11 not to feed R28 again, the staff will feed R28, and V11 was educated on Dementia and R28 not wanting to eat.
The Incident Investigation Form dated 10/26/23 at 10:00 PM documents V2's (Director of Nursing/DON) interview. V2 was approached by V9 who reported that V11 struck R28 in the mouth with V11's hand at the dining room table, and V11 was swearing at R28. V2 immediately approached V11 and R28. V11 stated (R28) won't eat. (R28) don't got a brain in (R28's) head. V11 continued to belittle R28. V11 and R28 were separated. V11 went home. V2 asked R28 where V11 hit R28, and R28 pointed to R28's mouth. R28 had no signs of injury or pain.
The Incident Investigation Form dated 10/27/23 at 9:45 AM documents: V1 interviewed V10 (Visitor), V10 witnessed V11 feeding R28 in the dining room, and R28 kept moving R28's head back not wanting to eat. R28 pushed V11's hand away and V11 hit R28 in the mouth and told R28 if you don't want to (expletive) eat, you (R28) can starve.
The Incident Investigation Form dated 10/30/23 at 12:05 PM documents V1 interviewed V9 regarding the incident, and V9 stated that V9 witnessed V11 trying to force R28 to eat while R28 kept tilting R28's head back. It looked like V11 had food in V11's hand and was holding it up to R28's mouth. R28 said No, no I (R28) don't want it and V11 kept trying to feed R28. V11 then hit R28 in the mouth with V11's fist. V9 yelled out for V11 to stop and V9 sent V17 (Visitor) to get a nurse.
The Incident Investigation Form dated 10/27/23 at 11:30 AM documents: V1 interviewed V11 regarding the incident, V11 denied hitting R28 and V11 said V11 was trying to feed R28 a cookie. V11 stated V11 might have cursed at R28. V11 said R28 is going to starve and V11 just wants R28 to eat, and R28 has not been the same since R28 fell at home and broke R28's hip. V1 tried to explain Dementia to V11 and will provide V11 with additional support. V1 asked for V16 (R28's Power of Attorney) to come to the facility with V11 after the investigation and put a plan in place to keep R28 safe while V11 visits.
The Incident Investigation Form dated 10/27/23 at 2:00 PM documents: R28 was interviewed by V4 (Social Services Director). R28 was asked if R28 could remember V11 visiting the night before. R28 replied yes. R28 was asked if R28 could tell V4 what happened and R28 did not answer. R28 was asked if V11 hollered at R28 and R28 replied yes. R28 was asked if V11 hit R28 and R28 said no, that V11 fell on (R28). R28 was asked if V11 hit R28 at home and R28 replied yes all the time. R28 stated He has been hitting me since I was a little girl.
The Incident Investigation Form dated 10/31/23 at 9:15 AM documents the Interdisciplinary Team reviewed the incident and agreed that V11 can continue to visit, but V11 is not to feed R28 during V11's visits.
R28's admission Minimum Data Set, dated [DATE] documents R28 has severe cognitive impairment. R28's November 2023 Physician Order Summary documents R28 has Dementia. R28's medical record does not contain a comprehensive care plan to address R28's risk for abuse or incidents of abuse from V11. There is no documentation that the facility implemented increased supervision of R28 during V11's visits.
V11 and R28 were in R28's room unsupervised and without staff present on 11/05/23 at 11:00 AM and 11:40 AM, on 11/6/23 at 9:43 AM, 9:58 AM, 10:00 AM, 10:15 AM, 11:03 AM, and on 11/7/23 at 10:48 AM.
On 11/06/23 at 9:15 AM V7 (Certified Nursing Assistant/CNA) stated V11 and R28 are hateful towards each other and this was prior to the incident on 10/26/23. V7 stated V11 is no longer allowed to feed R28, and V11 visits with R28 in R28's room or in the dining room without staff supervision.
On 11/6/23 at 9:22 AM V8 (CNA) stated V11 has been frustrated with R28 while feeding R28. V11 has called R28 stupid, idiot, [NAME] and R28 was tearful. V11 stated this used to happen daily during V11's visits prior to the physical abuse of V11 hitting R28 in the mouth. V8 stated R28 has told V8 that R28 and V11 have been together since R28 was 16 and that V11 has always been that way. V8 stated the incidents have occurred on second shift. V8 stated V8, V18 (CNA), and a few other unidentified CNAs on second shift have reported the incidents to V3 (Assistant DON) on several occasions and was told that V11 had been spoken to. At 10:39 AM V8 stated abuse allegations are reported immediately to V1 and usually V1 is gone in the evenings. V8 stated V3 was working in the facility when the incidents occurred, which is why V8 reported to V3. V8 confirmed V8 specifically told V3 the names that V11 called R28. V8 confirmed V8 did not report the incidents to V1.
On 11/06/23 at 9:48 AM V9 stated during supper on 10/26/23 R28 was sitting at a table that was directly in front of (family member's) table where V9 was sitting, and V9 had a clear view of R28 and V11. V9 stated R28 moved R28's head back multiple times while V11 fed R28. V9 heard R28 say stop, stop, I don't want it. V9 stated V9 then witnessed V11 pull V11's hand back, there was no food in V11's hand, and V11 hit R28 in the mouth with V11's closed fist. V9 stated V9 told V11 to stop and sent V17 to get a nurse. V9 stated V17 did not witness the incident. V10 was also present and may have witnessed the incident. V9 stated there was no staff present in the dining room during the incident. V9 stated V11 said that R28 was worthless, made belittling comments, and said you're stupid to R28. V9 stated it was very mean what (V11) did to (R28). R28 was just quiet and did not say anything back to V11. At 1:03 PM V9 stated V9 did not know R28 or V11 prior to their family member being admitted to the facility. V9 stated V9 does not know V11 and R28 personally.
On 11/06/23 at 10:10 AM V18 (CNA) stated prior to that night (10/26/23) on multiple occasions, almost every night V11 would feed R28, call R28 stupid, yell at R28 and degrade R28. V18 stated R28 would cry or go silent in response to V11's actions. One night V11 asked R28 why R28 was crying and R28 stated because you (V11) yelled at me (R28). V18 stated it was verbal abuse the way (V11) treated (R28). V18 stated V19 (CNA), V25 (CNA), V26 (CNA), and V27 (Unit Aide) have also witnessed these interactions as well. V18 stated V18 reported V11's actions to V3 (Assistant DON). V3 said V3 would talk with V1 (Administrator), and V3 later told V18 that V1 was made aware. V18 stated V18 asked V3 about separating V11 and R28 and was told that V11 is R28's spouse who pays for R28 to live in the facility.
On 11/06/23 at 3:32 PM V19 (CNA) stated when V11 would feed R28, V11 would raise V11's voice at R28 and call R28 ignorant and stupid. V19 stated it happened often, and confirmed the incidents were prior to the 10/26/23 incident. V19 stated R28 would get upset and ask V11 why V11 was talking to R28 like that. V19 confirmed V19 did not report the incidents to V1.
On 11/06/23 at 10:29 AM V3 was asked about V11's interactions with R28. V3 stated there are constant issues and V11 gets frustrated with R28 not wanting to eat. V3 stated unidentified staff mentioned in general to V3 that V11 would get frustrated and general concerns with how V11 would speak to R28. V3 stated V3 reminded V11 to be mindful of how V11 spoke to R28. V3 stated V3 discussed during the morning interdisciplinary team meetings to pay attention to V11's interactions with R28. V3 stated V3 would have reported immediately to V1 if staff told V3 that V11 called R28 names such as idiot, stupid, or [NAME].
On 11/6/23 at 10:44 AM V2 (DON) stated the night of the incident V17 reported to V2 that V11 was trying to force food into R28's mouth, R28 wouldn't eat, and V11 hit R28 in the mouth. V2 witnessed V11 say, with R28 present, that R28 doesn't have a brain, in reference to R28 not eating. V2 described V11 as being really frustrated that R28 would not eat, and R28 was sitting there with R28's eyes closed. V2 stated V2 asked R28 where V11 hit R28, and R28 pointed to R28's mouth. V2 stated V9's family member has only been in the facility for about a week, and V2 has no reason not to believe V9's description of the incident.
On 11/06/23 at 11:06 AM V1 stated during a morning meeting, V3 mentioned that V3 had spoken to V11 about V11 getting overwhelmed with R28 not eating. V1 stated nothing was brought up about V11 being abusive towards R28. V1 confirmed calling a resident an idiot, stupid, [NAME] would be verbal abuse. V1 stated V1 would have initiated investigations into V11's interactions with R28 just like the incident on 10/26/23, suspended V11's visits during the investigations, restricted V11 from feeding R28, and V1 possibly would have implemented supervised visits for V11 and R28. V1 stated V1 interviewed V10 and V10 witnessed V11 trying to make R28 eat, as R28 moved R28's head away (V11) went like this, and V1 demonstrated a close fist touching her mouth. V1 confirmed V10 reported hearing V11 say you (R28) can (expletive) starve then. V1 stated V11 told V1 that V11 may have cursed at R28 but did not hit R28. V11 reported that V11 had a piece of a cookie pushed up against R28's mouth. V1 stated V1 interviewed V9 and V9 told V1 that V11 kept trying to feed R28, R28 did not want to eat, and V11 hit R28 in the mouth. V1 stated abuse was not substantiated; the incident was discussed with the interdisciplinary team, and it was decided that V11 is no longer allowed to feed R28. V1 confirmed the facility has not implemented supervised visits for V11 and R28 after the 10/26/23 incident.
On 11/07/23 at 9:52 AM V16 (R28's Power of Attorney) stated R28 has Dementia, and this has affected R28's ability to recognize hunger. V16 stated V16 has tried to explain that to V11, but V11 thinks R28 will get better and return home. V16 was asked prior to R28's dementia, how would R28 have felt or responded to V11's verbal treatment and being hit in the mouth in front of other residents and visitors. V16 stated R28 would have yelled back at V11. V16 was asked if R28 would have felt humiliated, embarrassed, upset, or tearful and V16 replied R28 would have probably felt all those things.
The Immediate Jeopardy that began on 10/26/23 was removed on 11/13/23 when the facility took the following actions to remove the immediacy:
1.) On 11/9/23 at 8:55 am, V1 (Administrator) confirmed the facility held a care plan meeting with V16 (R28's POA) on 11/8/23 to inform V16 that V11 (R28's spouse) will have to check in with the manager on duty before the start of each visit, only be allowed to visit in common areas, and that staff will check on R28 after each visit to ensure R28's safety.
2.) On 11/9/23 between 8:30 am - 8:55 am, V29 (Licensed Practical Nurse/LPN), V30 (CNA), V31 (Activity Director) and V1 all confirmed that a staff member would be assigned to make visual checks on R28 every 15 minutes while V11 was at the facility visiting. On 11/13/23, these visual checks were provided to the survey team. The visual checks dated 11/9/23, 11/11/23, and 11/12/23 document R28 was checked on every 15 minutes. On 11/13/23 between 9:00 AM and 9:30 AM, V1, V3, and V28 (Licensed Practical Nurse) stated that V11 did not visit on 11/10/23.
3.) On 11/9/23 at 1:10 PM, V1 provided an in-service sheet dated 11/8/23 that documents V41 (Regional Director of Clinical Operations) provided education to V1 and V2 regarding the facility Abuse and Neglect Policy.
4.) On 11/9/23 at 1:10 PM, V1 provided in-service sheets dated 11/8/23 and 11/9/23 that document all but six staff have been in-serviced by V1 and V2 on the facility Abuse Prevention Policy and Procedure. At this time, V1 stated the six staff that are not educated yet will not be allowed to work until they have received the education. On 11/13/23 at 9:15 am, V1 provided a phone listing for in-services completed over the phone for the remaining six staff. Five were provided education on 11/9/23 however one Agency CNA, V37, has not received the abuse in-service training. At this time, V1 explained V37 is an agency staff and has not returned the phone call, but that V37 will not be allowed to work at the facility until V37 has received the training.
5.) On 11/9/23 at 2:00 PM, V1 provided Abuse Risk Assessments for all but two residents. V1 stated V1 was waiting for families to get back with V1 to complete the assessment for these residents. At this time, V1 also stated that any resident who answered yes to any of the questions will have an abuse risk care plan developed with specific interventions however that has not been done yet. On 11/13/23 at 9:00 am, V1 provided the Risk for Abuse Care Plans for all at risk residents and stated the facility is still waiting to complete two assessments. On 11/13/23 between 10:20 - 10:23 am, V1 provided the final two Abuse Risk Assessments dated 11/13/23, to make 100% of the residents now being assessed.
6.) On 11/13/23 between 9:00 am - 9:30 am, V1 stated V1 will continue to in-service staff on abuse monthly and the next in-service is schedule for 11/25/23.
7.) On 11/13/23 between 9:00 am - 9:30 am, V1 stated that no new employees have been hired, but that V1 is responsible for providing Abuse Prevention training for all new employees during their orientation.
SERIOUS
(H)
Actual Harm - a resident was hurt due to facility failures
Report Alleged Abuse
(Tag F0609)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure repetitive allegations of verbal and mental abuse and an inju...
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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 repetitive allegations of verbal and mental abuse and an injury of unknown origin were reported to the administrator, and timely report an allegation of abuse to the state survey agency. These failures affect two (R28, R45) of five residents reviewed for abuse in the sample list of 33. These failures resulted in R28 being subjected to repeated incidents of verbal/mental abuse, and physical abuse by V11 (R28's Spouse) resulting in psychosocial harm for R28.
Findings include:
The facility's Abuse Prevention policy revised 11/28/16 documents: Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, or humiliation and threats of punishment or deprivation. Physical Abuse including hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property to a supervisor and administrator. Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities, or injuries, of unknown origin as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee.
1.) The Facility Reported Incidents report form (initial notification to state survey agency) dated 10/27/23 at 5:27 PM documents on 10/26/23 a visitor (V9 Visitor) reported that V11 was feeding R28, R28 refused and pushed V11's hand away, and V11 hit R28 in the mouth. The facility's Notification Form dated 11/1/23 documents the incident between V11 and R28 occurred on 10/26/23 at 6:50 PM. The Incident Investigation Form dated 10/26/23 at 10:00 PM documents V2's (Director of Nursing/DON) written interview. V2 stated V2 was approached by V17 (Visitor) who reported that V11 struck R28 in the mouth with V11's hand at the dining room table and V11 was swearing at R28. V2 immediately approached V11 and R28 and V11 stated (R28) won't eat, (R28) don't' got a brain in (R28's) head. V11 continued to belittle R28. V11 and R28 were separated. V11 went home. V2 asked R28 where V11 hit R28, and R28 pointed to R28's mouth.
The Incident Investigation Form dated 10/27/23 at 9:45 AM documents V1 interviewed V10 (Visitor) and V10 witnessed V11 feeding R28 in the dining room, and R28 kept moving R28's head back not wanting to eat. R28 pushed V11's hand away and V11 hit R28 in the mouth and told R28 if you don't want to (expletive) eat, you (R28) can starve.
The Incident Investigation Form dated 10/30/23 at 12:05 PM documents V1 (Administrator) interviewed V9 regarding the incident and V9 witnessed V11 trying to force R28 to eat while R28 kept tilting R28's head back. It looked like V11 had food in V11's hand and was holding it up to R28's mouth. R28 said No, no I (R28) don't want it and V11 kept trying to feed R28. V11 then hit R28 in the mouth with V11's fist. V9 yelled out for V11 to stop and V9 sent V17 to get a nurse.
V1 (Administrator) provided the facility's undated abuse log that was requested for September-November 2023. There is no documentation of abuse allegations involving V11 and R28 besides the incident on 10/26/23.
R28's admission Minimum Data Set, dated [DATE] documents R28 has severe cognitive impairment. R28's November 2023 Physician Order Summary documents R28 has Dementia.
On 11/6/23 at 9:22 AM V8 (Certified Nursing Assistant/CNA) stated V11 has been frustrated with R28 while feeding R28. V11 has called R28 stupid, idiot, [NAME] and R28 was tearful. V11 stated this used to happen daily during V11's visits prior to the physical abuse of V11 hitting R28 in the mouth. V8 stated R28 has told V8 that R28 and V11 have been together since R28 was 16 and that V11 has always been that way. V8 stated the incidents have occurred on second shift. V8 stated V8, V18 (CNA), and a few other unidentified CNAs on second shift have reported the incidents to V3 (Assistant DON) on several occasions. At 10:39 AM V8 stated abuse allegations are reported immediately to V1 and usually V1 is gone in the evenings. V8 stated V3 was working in the facility when the incidents occurred, which is why V8 reported to V3. V8 confirmed V8 specifically told V3 the names that V11 called R28. V8 confirmed V8 did not report the incidents to V1.
On 11/06/23 at 9:48 AM V9 stated during supper on 10/26/23 R28 was sitting at a table that was directly in front of (family member's) table where V9 was sitting, and V9 had a clear view of R28 and V11. V9 stated R28 moved R28's head back multiple times while V11 fed R28. V9 heard R28 say stop, stop, I don't want it. V9 stated V9 then witnessed V11 pull V11's hand back, there was no food in V11's hand and V11 hit R28 in the mouth with V11's closed fist. V9 stated V9 told V11 to stop and sent V17 to get a nurse. V9 stated V17 did not witness the incident. V10 was also present and may have witnessed the incident. V9 stated there was no staff present in the dining room during the incident. V9 stated V11 said that R28 was worthless, made belittling comments, and said you're stupid to R28. V9 stated it was very mean what (V11) did to (R28). R28 was just quiet and did not say anything back to V11. At 1:03 PM V9 stated V9 did not know R28 or V11 prior to their family member being admitted to the facility. V9 stated V9 does not know V11 and R28 personally.
On 11/06/23 at 10:10 AM V18 (CNA) stated prior to that night (10/26/23) on multiple occasions, almost every night V11 would feed R28, call R28 stupid, yell at R28 and degrade R28. V18 stated R28 would cry or go silent in response to V11's actions. One night V11 asked R28 why R28 was crying and R28 stated because you (V11) yelled at me (R28). V18 stated it was verbal abuse the way (V11) treated (R28). V18 stated V19 (CNA), V25 (CNA), V26 (CNA), and V27 (Unit Aide) have also witnessed these interactions as well. V18 stated V18 reported V11's actions to V3 (Assistant DON). V3 said V3 would talk with V1 (Administrator), and V3 later told V18 that V1 was made aware. V18 stated V18 never spoke with V1 regarding V11's interactions with R28.
On 11/06/23 at 3:32 PM V19 (CNA) stated when V11 would feed R28, V11 would raise V11's voice at R28 and call R28 ignorant and stupid. V19 stated it happened often, and confirmed the incidents were prior to the 10/26/23 incident. V19 stated R28 would get upset and ask V11 why V11 was talking to R28 like that. V19 confirmed V19 did not report the incidents to V1.
On 11/06/23 at 10:29 AM V3 was asked about V11's interactions with R28. V3 stated there are constant issues and V11 gets frustrated with R28 not wanting to eat. V3 stated staff have mentioned in general that V11 would get frustrated and general concerns with how V11 would speak to R28. V3 stated V3 reminded V11 to be mindful of how V11 spoke to R28. V3 stated that staff did not specifically tell V3 what V11 said to R28. V3 stated V3 did not ask staff what V11 has said to R28. V3 stated V3 would have reported immediately to V1 if staff told V3 that V11 called R28 names such as idiot, stupid, or [NAME]. V3 stated V3 discussed during the morning interdisciplinary team meetings to pay attention to V11's interactions with R28.
On 11/05/23 at 1:45 PM V2 (DON) stated on 10/26/23 around 6:00 PM V17 approached V2 and reported that V9 witnessed V11 hit R28 in the mouth. V2 stated V1 notified the police and sent in the initial report to the state survey agency. On 11/6/23 at 10:44 AM V2 stated on the night of 10/26/23 V2 went to separate V11 and R28 and witnessed V11 say, with R28 present, that R28 doesn't have a brain, in reference to R28 not eating. V2 described V11 as being really frustrated that R28 would not eat, and R28 was sitting there with R28's eyes closed. V2 stated V2 asked R28 where V11 hit R28, and R28 pointed to R28's mouth. V2 stated nothing had been reported previously about V11's treatment of R28. V2 stated V2 has not been attending morning meetings due to working night shift.
On 11/05/23 at 2:40 PM V1 stated the initial report to the state survey agency for the incident on 10/26/23 was not sent in until 10/27/23. V1 stated it was a miscommunication and V1 thought V2 had submitted the report. V1 stated the time frame for reporting abuse allegations to the state survey agency is two hours. On 11/06/23 at 11:06 AM V1 stated during a morning meeting, V3 mentioned that V3 had spoken to V11 about V11 getting overwhelmed with R28 not eating. V1 stated nothing was brought up about V11 being abusive to R28. V1 confirmed calling a resident an idiot, stupid, [NAME] would be considered verbal abuse. V1 stated if staff had reported these prior incidents, V1 would have initiated investigations into V11's interactions with R28 just like the incident on 10/26/23, suspend V11's visits during the investigations, restricted V11 from feeding R28, and V1 possibly would have implemented supervised visits for V11 and R28.
On 11/07/23 at 9:52 AM V16 (R28's Power of Attorney) stated R28 has Dementia, and this has affected R28's ability to recognize feeling hungry. V16 stated V16 has tried to explain that to V11, but V11 thinks R28 will get better and return home. V16 was asked prior to R28's dementia, how would R28 have felt or responded to V11's verbal treatment and being hit in the mouth in front of other residents and visitors. V16 stated R28 would have yelled back at V11. V16 was asked if R28 would have felt humiliated, embarrassed, upset, or tearful and V16 replied R28 would have probably felt all those things.
2. R45's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Dementia with Behavioral Disturbance, Depression, Anxiety, Insomnia, and History of Fall with Hip Fracture.
R45's Minimum Data Set (MDS) dated [DATE] documents R45 is severely cognitively impaired, is wheelchair bound, and requires moderate to maximum staff assistance to complete Activities of Daily Living (ADLs).
R45's skilled nurse's note date 6/18/23 at 7:15AM documents Noted Bruising on (R45's) left hand that extends up to forearm. Area measures 21 centimeters by 14 centimeters. Purple and black in color. (R45) denies pain or discomfort. (R45) is unsure how (R45) obtained bruise. Staff will monitor for changes until resolved. Nurse Practitioner notified and family notified. Power of Attorney voiced understanding.
R45's skilled nurse's note date 6/19/23 at 3:10PM documents CNA advised writer about large hematoma and bruising to left wrist. Writer observed (R45) to have a golf ball sized hematoma to left wrist and bruising covering most of the arm to the elbow. Resident complains of pain to the hematoma. Will advise day nurse to get X-ray orders from Nurse Practitioner. Writer attempted to apply ice pack. (R45) refused and wouldn't leave ice pack on.
On 11/6/23 V1 (Administrator) stated I've checked with (V2) the Director of Nursing and this injury was not reported. We do not have an investigation for an injury of unknown origin.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse. This failure affects ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse. This failure affects one (R28) of five residents reviewed for abuse in the sample list of 33.
Findings include:
The facility's Abuse Prevention policy revised 11/28/16 documents abuse allegation investigative procedures include interviewing staff, residents, visitors/family members who were in the vicinity of the incident, and interviewing staff to determine if they have ever witnessed other incidents of mistreatment.
The Facility Reported Incidents report form (initial notification to state survey agency) dated 10/27/23 at 5:27 PM documents on 10/26/23 V9 (Visitor) reported that V11 (R28's Spouse) was feeding R28, R28 refused and pushed V11's hand away, and V11 hit R28 in the mouth. The facility's Notification Form dated 11/1/23 documents the incident between V11 and R28 occurred on 10/26/23 at 6:50 PM, the investigation was completed, and the facility did not substantiate abuse. The facility's investigative file for this incident was provided by V1 (Administrator). The file contained written interviews conducted with V17 (Visitor), V2 (Director of Nursing), V16 (R28's Power of Attorney), V10 (Visitor and witness of incident), V11, R28, V9 (Visitor and witness of incident), V33 and V34 Certified Nursing Assistants (CNAs) dayshift CNAs. There were no documented interviews with any second shift (shift the incident occurred on) staff or residents to determine if prior similar incidents were witnessed.
R28's admission Minimum Data Set, dated [DATE] documents R28 has severe cognitive impairment. R28's November 2023 Physician Order Summary documents R28 has Dementia.
On 11/6/23 at 9:22 AM V8 (CNA) stated V11 has been frustrated with R28 while feeding R28, and that V11 has called R28 stupid, idiot, moron and R28 was tearful. V11 stated this used to happen daily during V11's visits prior to the physical abuse of V11 hitting R28 in the mouth. V8 stated R28 has told V8 that R28 and V11 have been together since R28 was 16 and that V11 has always been that way. V8 stated the incidents have occurred on second shift and have been witnessed by residents. V8 stated V8, V18 (CNA) and a few other unidentified CNAs on second shift have reported the incidents to V3 (Assistant DON) on several occasions and was told that V11 had been spoken to.
On 11/06/23 at 9:48 AM V9 stated during supper on 10/26/23 V9 was sitting at a table that was directly in front of R28's table, and V9 had a clear view of R28 and V11. V9 stated R28 moved R28's head back multiple times while V11 fed R28. V9 heard R28 say stop, stop, I don't want it. V9 stated V9 then witnessed V11 pull V11's hand back, there was no food in V11's hand and V11 hit R28 in the mouth with V11's closed fist. V9 stated V9 told V11 to stop and sent V17 to get a nurse. V9 stated V17 did not witness the incident. V10 was also present and may have witnessed the incident. V9 stated there was no staff present in the dining room during the incident, and there were a few residents in the dining room with their back to V11. V9 stated their family member was sitting with V9 when the incident happened, but (he/she) did not witness it.
On 11/06/23 at 10:10 AM V18 (CNA) stated prior to that night (10/26/23) on multiple occasions, almost every night V11 would feed R28, call R28 stupid, yell at R28 and degrade R28. V18 stated R28 would cry or go silent in response to V11's actions. One night V11 asked R28 why R28 was crying and R28 stated because you (V11) yelled at me (R28). V18 stated it was verbal abuse the way (V11) treated (R28). V18 stated V19 (CNA), V25 (CNA), V26 (CNA), and V27 (Unit Aide) have also witnessed these interactions as well, and other resident(s) may have witnessed it as well.
On 11/06/23 at 3:32 PM V19 (CNA) stated when V11 would feed R28, V11 would raise V11's voice at R28 and call R28 ignorant and stupid. V19 stated it happened often, and confirmed the incidents were prior to the 10/26/23 incident. V19 stated R28 would get upset and ask V11 why V11 was talking to R28 like that.
On 11/06/23 at 11:06 AM V1 stated V1 conducted the investigation of the 10/26/23 incident. V1 stated V33 and V34 were interviewed as part of the investigation. V1 stated R28 was the only resident besides the resident sitting in the dining room when the incident occurred. V1 confirmed V1 did not interview any second shift staff or other residents including the resident sitting in view of R28's table regarding the incident or prior interactions between V11 and R28. V1 stated the facility did not substantiate abuse, and V1 believes V11 did not intentionally hit R28 in the mouth.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a Level II PASARR (Preadmission Screening and Resident Review...
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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 Level II PASARR (Preadmission Screening and Resident Review) was completed for one of one resident (R35) reviewed for PASARR in the sample list of 33.
Findings include:
R35's November 2023 Physician's Order Summary documents R35 admitted to the facility on [DATE], has a diagnosis of Bipolar and includes orders for Divalproex 250 milligrams (mg) three times daily for Bipolar and Mirtazapine 7.5 mg daily for Bipolar. R35's October and November 2023 Behavior Tracking Records document R35 has manic aggressive outbursts of yelling at staff.
R35's undated Problem Detail documents R35 has an active diagnosis of Bipolar since 5/29/20.
R35's Notice of PASARR Level 1 Screen Outcome dated 5/13/22 documents a Level II screen was not required due to no diagnoses of Serious Mental Illness, Intellectual Disability, or Related Condition.
On 11/05/23 at 1:37 PM V4 (Social Services Director) stated V5 (Business Office Manager) sets up the OBRA (Omnibus Budget Reconciliation Act) screens (a screening form that helps identify reasonable basis to suspect an intellectual/developmental disability or mental illness). V4 stated the OBRA screens are usually completed at the hospital prior to admission and should be in the resident's medical record. V4 confirmed the 5/13/22 PASARR screen is the only documented PASARR in R35's medical record.
On 11/06/23 at 2:28 PM V1 (Administrator) stated R35 admitted in June 2022 and V1 did not see a diagnosis of Bipolar on R35's admission history and physical. V1 stated Bipolar is listed as a diagnosis on R35's August 2022 hospital records. V5 (Business Office Manager) stated V5 does not set up OBRA/PASARR screens to be completed after a diagnosis of mental illness is added after admission.
On 11/06/23 at 3:13 PM V3 (Assistant Director of Nurses) stated R35 has behaviors including yelling, verbal outbursts, and hallucinations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
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 develop a baseline care plan to include fall risk and interventions ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a baseline care plan to include fall risk and interventions for one (R28) of 13 residents reviewed for care plans in the sample list of 33.
Findings include:
On 11/05/23 at 10:54 AM V11 (R28's Spouse) stated R28 admitted to the facility after a fall at home with a hip fracture that required surgical repair. V11 stated R28 fell at the facility a few days after admission.
R28's admission Minimum Data Set, dated [DATE] documents R28 has severe cognitive impairment and requires extensive assistance of one staff person for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing.
R28's Fall Investigations dated 9/28/23 at 7:20 PM, 10/7/23 at 6:25 AM, 10/17/23 at 7:45 PM, and 10/20/23 at 11:15 AM document R28's falls. These investigations document R28's fall interventions include hospital evaluation for stent placement, low bed, fall mat, bedroom furniture rearranged, and a pressure alarm.
R28's Baseline Care Plan dated 9/25/23 documents R28 has Dementia, Cognitive Impairment, Type 1 Diabetes Mellitus, and includes activity interests. This care plan does not include R28's risk for falls, fall history, or fall interventions.
On 11/07/23 at 3:37 PM V2 (Director of Nursing) confirmed R28's baseline care plan does not address R28's fall risk/history or fall interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R28's admission Minimum Data Set (MDS) dated [DATE] documents R28 has severe cognitive impairment and requires extensive ass...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R28's admission Minimum Data Set (MDS) dated [DATE] documents R28 has severe cognitive impairment and requires extensive assistance of one staff person for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing.
R28's November 2023 Physician Orders Summary documents R28 has Type 1 Diabetes Mellitus, orders for scheduled short and long-acting insulin, and has blood glucose checks scheduled four times daily. R28's November 2023 Medication Administration Record documents R28's blood glucose varies, including being in the 400's (milligrams per deciliter), 500's (milligrams per deciliter), and high on 11/2/23.
R28's Fall Investigations dated 9/28/23 at 7:20 PM, 10/7/23 at 6:25 AM, 10/17/23 at 7:45 PM, and 10/20/23 at 11:15 AM document R28's falls. These investigations document R28's fall interventions include hospital evaluation for stent placement, low bed, fall mat, bedroom furniture rearranged, and a pressure alarm.
The Facility Reported Incidents report form dated 10/27/23 at 5:27 PM documents on 10/26/23 a visitor (V9 Visitor) reported that V11 (R28's Spouse) was feeding R28, R28 refused and pushed V11's hand away, and V11 hit R28 in the mouth. The facility's Notification Form dated 11/1/23 documents the incident between V11 and R28 occurred on 10/26/23 at 6:50 PM. This form documents the facility found no intentional abuse on V11's part. The facility instructed V11 not to feed R28 again, the staff will feed R28, and on Dementia and R28 not wanting to eat. The Incident Investigation Form dated 10/27/23 at 9:45 AM documents V1 (Administrator) interviewed V10 (Visitor), V10 witnessed V11 feeding R28 in the dining room, and R28 kept moving R28's head back not wanting to eat. R28 pushed V11's hand away and V11 hit R28 in the mouth and told R28 if you don't want to (expletive) eat, you (R28) can starve. The Incident Investigation Form dated 10/30/23 at 12:05 PM documents V1 interviewed V9, and V9 witnessed V11 trying to force R28 to eat while R28 kept tilting R28's head back. It looked like V11 had food in V11's hand and was holding it up to V11's mouth. R28 said No, no I (R28) don't want it and V11 kept trying to feed R28. V11 then hit R28 in the mouth with V11's fist.
There is no documentation in R28's medical record that a comprehensive care plan with problems, goals, and interventions was developed to address R28's abuse risk/history, Type 1 Diabetes Mellitus with insulin use and falls.
On 11/6/23 at 2:33 PM V3 (Assistant Director of Nursing) stated the facility does not have an MDS/Care Plan Coordinator as of 11/1/23, and both V2 (Director of Nursing) and V3 (Assistant Director of Nursing) have been trying to update and complete care plans.
On 11/7/23 at 9:47 AM V1 confirmed residents with dementia would be considered at risk for abuse. V1 stated I think that is part of the dementia care plan.
On 11/07/23 at 3:37 PM V2 confirmed R28 does not have a comprehensive care plan to address R28's fall and Type 1 Diabetes Mellitus with insulin use.
The facility's Abuse Prevention Program revised 11/28/16 documents As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents. Staff will continue to monitor the goals and approaches on a regular basis.
The facility's Policy Comprehensive Care Plans revised 7/20/22 states The Comprehensive Care Plan (CCP) shall be developed within seven day of the completion of the RAI. a. The CCP shall be reviewed after each Annual, Significant Change, and Quarterly MDS and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs as identified by the IDT (Interdisciplinary Team) 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. c. The IDT may determine a Comprehensive revision of the Plan of Care may warrant a Significant Change MDS (Minimum Data Set). Documentation of such a decision shall be contained in the resident's record.
Based on observation, interview and record the facility failed to initiate care plans to include resident centered problems, goals, and interventions for four residents (R11, R15, R28) of 12 residents reviewed for care plans in a sample list of 33.
Findings include:
1. R11's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Parkinson's Disease, Depression, Anxiety and Chronic Fatigue Syndrome.
R11's Minimum Data Set (MDS) dated [DATE] documents R11 is cognitively intact and requires staff assistance or is dependent on staff for Activities of Daily Living (ADLS).
On 11/05/23 at 11:55 AM R11 was observed lying in her bed. There was a Stop sign on R11's door. R11 spoke in a very faint voice. R11 stated I can't move very much, and I can't talk very loud because I have Parkinson's Disease. I'm pretty weak. That woman (R15) comes in my room, and she has threatened me. That is why they have the stop sign that is on the door. She just takes it off and comes in anyway. She threatens to hit me.
No care plan is documented to address R11's vulnerability to abuse.
2. R15's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Mixed Alzheimer's Disease, Vascular Dementia with behavioral disturbances, Anxiety, and Major Depression.
R15's MDS dated [DATE] documents R15 is moderately cognitively impaired and experiences verbal and physical behaviors directed toward others which put R15 and others at significant risk for physical injury.
No care plan is documented to address R15's vulnerability to abuse or danger to other residents.
On 11/9/23 at 2:24PM V2 (Director of Nursing/DON) confirmed Care Plans for R11's vulnerability to abuse, and R15's vulnerability to abuse and danger to others was not documented on their Care Plans and should have been addressed in the Care Plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) The facility's Monthly Weight Grid dated November 2022-October 2023 documents R26 weighed 134 pounds (lbs.) in February and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) The facility's Monthly Weight Grid dated November 2022-October 2023 documents R26 weighed 134 pounds (lbs.) in February and March, 129 lbs. in May, 122 lbs. in June (8.96% since March and 5.43% loss in 1 month), 120 lbs. in August, and 118 lbs. in September (11.94% loss in 6 months).
R26's Minimum Data Set (MDS) dated [DATE] documents R26 has severe cognitive impairment, requires limited assistance of one staff person for eating, and has had a significant weight loss within the past month or six months.
R26's November 2023 Physician Order Summary documents an order initiated on 9/21/23 for (nutritional supplement) 90 milliliter (ml) three times daily. R26's June 2023 Medication Administration Record (MAR) documents (nutritional supplement) 60 ml three times daily was initiated on 6/26/23.
R26's Care Plan dated 7/5/22 documents R26 is at risk for altered nutritional status and/or weight loss and has not been updated to address R26's significant weight loss and interventions after 7/5/22.
On 11/6/23 at 2:33 PM V3 (Assistant Director of Nursing) confirmed R26's care plan has not been updated to include R26's significant weight loss and nutritional interventions. V3 stated the facility does not have an MDS/Care Plan Coordinator as of 11/1/23, and both V2 (Director of Nursing) and V3 have been trying to update/complete care plans.
The facility's Policy Comprehensive Care Plans revised 7/20/22 states The Comprehensive Care Plan (CCP) shall be developed within seven day of the completion of the RAI. a. The CCP shall be reviewed after each Annual, Significant Change, and Quarterly MDS and revised as necessary to reflect the resident's current medical, nursing and mental and psychosocial needs as identified by the IDT (Intradisciplinary Team) 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. c. The IDT may determine a Comprehensive revision of the Plan of Care may warrant a Significant Change MDS (Minimum Data Set). Documentation of such a decision shall be contained in the resident's record.
Based on observation, interview and record review the facility failed to update a care plan to include a significant weight loss for two residents (R26, R45) of 12 residents reviewed for care plans in a sample list of 30.
Findings Include:
1. R45's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Dementia with Behavioral Disturbance, Depression, Anxiety, Insomnia, and History of Fall with Hip Fracture.
The facility's Weight flow sheet for the preceding 12 months documents on 08/01/2023, R45 weighed 127 pounds (lbs.) and on 10/01/2023 R45 weighed 112 lbs. which is an 11.81 % Loss.
On 11/6/23 from 11:30AM to 12:15PM R45 was observed sitting in the dining room and attempting to leave the table. When table mates were served before R45, R45 attempted to take food and drink off another resident's tray.
R45's Care Plan does not address significant weight loss or interventions to address R45's inattention at meals.
On 11/9/23 at 2:24PM V2 (Director of Nursing/DON) confirmed R45's Care Plan should address the weight loss and R45's inattention during meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide Restorative Nursing Programs for one resident (R24) of one r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide Restorative Nursing Programs for one resident (R24) of one resident reviewed for positioning and mobility in a sample list of 33 residents.
Findings Include:
R24's Physician's Order Sheet (POS) for November includes the following diagnoses: Cerebral Infarct, Emphysema, Chronic Kidney Disease Stage III, Malignant Neoplasm of the Spinal Cord, Type II Diabetes, and Depression.
On 11/6/23 at 11:00AM R24 stated After I finished therapy, they were supposed to start Restorative programs, but I don't get them.
R24's Minimum Data Set (MDS) dated [DATE] documents R24 is to receive Passive Range of Motion, Active Assisted Range of Motion, Bed Mobility, Transfer, dressing, and grooming restorative programs.
On 11/08/23 at 9:09 AM V2 (Director of Nursing/DON) stated the CNAs (Certified Nursing Assistants) are supposed to do restorative programs. We did have a Restorative Aide, but she quit a little while ago. They should be documented in the CNA book.
R24's October and November 2023 restorative CNA documentation includes zero minutes of restorative programs.
On 11/08/23 at 9:15 AM V33 (CNA) stated, We try to do the restorative programs, but with the number of aides we have it isn't always possible.
A policy for restorative Nursing programs was requested numerous times over the course of the survey. No policy was provided.
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 interview and record review the facility failed to complete a fall risk assessment and thoroughly investigate falls for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a fall risk assessment and thoroughly investigate falls for one (R28) of four residents reviewed for accidents in a sample list of 33 residents.
Findings include:
On 11/05/23 at 10:54 AM V11 (R28's Spouse) stated R28 admitted to the facility after a fall at home with a hip fracture that required surgical repair. V11 stated R28 fell at the facility a few days after admission.
R28's Minimum Data Set (MDS) dated [DATE] documents R28 has severe cognitive impairment, requires extensive assistance of one staff person for transfers, bed mobility, dressing and toileting, and requires staff assistance to stabilize balance during transitions and walking. R28's November 2023 Physician Order Summary documents R28 has diagnoses of Dementia and Closed Fracture of Neck of Left Femur.
R28's medical record does not contain a completed Fall Risk Assessment or a comprehensive care plan to address fall risk, history of falls, or interventions to prevent falls. R28's baseline care plan dated 9/25/23 does not identify fall risk, history of falls, or fall interventions.
R28's 9/28/23 Fall Investigation documents at 7:20 PM R28 fell, R28's fall was unwitnessed and R28 was found on the floor of the women's restroom near the nurse's station. The investigation documents R28 was last seen sitting on the toilet 3 minutes prior to the fall and R28 said that R28 was attempting to pull up R28's pants when R28 fell. This investigation documents R28 was sent to the emergency room and diagnosed with a NONSTEMI (non-ST elevated myocardial infarction), and the new intervention was that R28 was admitted for treatment and possible stent placement. V8 (Certified Nursing Assistant's/CNA) written interview dated 9/28/23 documents V8 transferred R28 onto the toilet, gave R28 the call light, and stepped outside the bathroom to allow for privacy. An unidentified resident was yelling in the front dining room so V8 left R28 and went to assist the other unidentified resident onto the toilet. V36 (CNA) then came and told V8 that R28 was on the floor.
R28's 10/7/23 Fall Investigation documents R28 had an unwitnessed fall at 6:25 AM. R28 was last observed at 6:05 AM sleeping and R28 stated R28 was attempting to go to the bathroom when R28 fell. There is no documentation as to the last time R28 was toileted or provided incontinence care. The root cause of the fall is R28 did not use a call light and attempted to transfer without assistance. The post fall intervention was a low bed and fall mat.
R28's 10/17/23 Fall Investigation documents R28 had an unwitnessed fall at 7:45 PM and R28 was last seen lying in bed 15 minutes prior to the fall. There is no documentation as to the last time that R28 was toileted or provided incontinence care. The root cause is R28 attempted to ambulate without assistance or device and R28's bedroom furniture was rearranged as the post fall intervention.
R28's 10/20/23 Fall Investigation documents R28 had an unwitnessed fall at 11:15 AM and R28 was last seen sitting in R28's wheelchair 15 minutes prior to the fall. There is no documentation of when R28 was last toileted or provided incontinence care prior to the fall. The root cause of the fall was R28 attempted to stand up out of wheelchair without assistance or device and a pressure alarm was implemented as a post fall intervention.
On 11/07/23 at 3:37 PM V2 (Director of Nursing) stated the facility uses a fall risk assessment tool that is completed upon admission and quarterly. V2 reviewed R28's chart and was unable to locate a completed Fall Risk Assessment. V2 stated the former MDS/Care Plan Coordinator was responsible for completing the Fall Risk Assessments. V2 reviewed R28's baseline care plan and confirmed it does not address fall risk or interventions and confirmed R28 does not have a comprehensive care plan to address falls. V2 stated R28 requires assistance of one staff person for toileting and R28 fell on 9/28/23 after V8 (CNA) transferred R28 onto the toilet in the employee bathroom. V2 stated V8 left R28 on the toilet because another resident was in the dining room walking without a walker. V2 stated V2 told V8 that V8 should have stayed with R28 and yelled for staff while staying with R28 in the bathroom. V2 confirmed R28's October falls were unwitnessed and confirmed the investigations do not document when R28 was last toileted or provided incontinence care prior to the falls.
The facility's policy Fall Prevention revised 11/10/19 states Policy: 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. Responsibility: All Staff. 1. Conduct fall assessments on the day of admission, quarterly, and with changes in condition. 2. Identify on admission the resident's risk for falls. 3. Assessment of fall risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. This policy also states If residents with a high-risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. This policy also states A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of the fall in the nurse's notes or on a AIMS for wellness form along with any new interventions deemed to be appropriate at the time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to correctly perform incontinence care for one (R6) of fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to correctly perform incontinence care for one (R6) of four residents reviewed for Urinary Tract Infections in the sample list of 33.
Findings include:
The facility's Perineal Cleansing policy dates as revised 9/21/10 documents for female perineal cleansing use long strokes from the most anterior down to the base of the labia (front to back motion), turn resident onto side and wash peri-anal area from the base of the labia up over the buttocks (front to back motion).
On 11/05/23 at 11:30 AM R6 stated R6 has been in the hospital three to four times within the last year, including a few times for Urinary Tract Infections (UTIs). R6 stated R6 is incontinent, and staff provide R6's incontinence cares.
R6's Minimum Data Set, dated [DATE] documents R6 has a Brief Interview for Mental Status score of 12 (the higher end of moderate cognitive impairment), R6 requires extensive assistance of one staff person for toileting, and R6 is frequently incontinent of bowel and bladder.
R6's Urine Culture reported on 9/1/23 documents Escherichia Coli (E. Coli) (a bacteria present in the colon/stool) greater than 100,000 colony forming units per milliliters (cfu/ml), indicating an infection. R6's Urine Culture reported on 9/15/23 documents E. Coli 70-99,000 CFU/ml.
On 11/6/23 at 3:18 PM V19 and V18 (Certified Nursing Assistants/CNAs) entered R6's room to provide incontinence cares. R6's brief was wet with urine. During R6's incontinence care V19 cleansed R6's frontal perineal area, turned R6 onto R6's side, and wiped R6's buttocks moving from R6's rectum to R6's labia twice with disposable wipes.
On 11/6/23 at 3:28 PM V19 stated V19 has received training on incontinence care and UTI prevention. V19 stated we are supposed to wipe front to back to prevent infection. V19 confirmed during R6's incontinence cares V19 wiped from back to front, buttocks to labia.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report significant weight loss to the resident representative and ph...
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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 significant weight loss to the resident representative and physician, timely implement nutritional recommendations, and record amount of intake for nutritional supplements for one (R26) of two residents reviewed for nutrition in the sample list of 33.
Findings include:
The facility's Resident Weight Monitoring policy revised March 2019 documents significant weight changes of 5% or more in one month, 7.5% or more in 3 months, and 10% or more in six months will be reported to the resident, resident representative, and physician. This policy documents the dietitian will make recommendations for nutritional interventions and nursing will convey the recommendations to the physician to obtain orders.
The facility's Monthly Weight Grid dated November 2022-October 2023 documents R26 weighed 134 pounds (lbs.) in February and March, 129 lbs. in May, 122 lbs. in June (8.96% since March and 5.43% loss in 1 month), 120 lbs. in August, and 118 lbs. in September (11.94% loss in 6 months).
R26's Minimum Data Set, dated [DATE] documents R26 has severe cognitive impairment, requires limited assistance of one staff person for eating, and has had a significant weight loss within the past month or six months. R26's Care Plan dated 7/5/22 documents R26 is at risk for altered nutritional status and/or weight loss and has not been updated to address R26's significant weight loss.
R26's Progress Note dated 6/9/23 recorded by V20 (Registered Dietitian) documents R26 has a Body Mass Index (BMI) 19 (low), significant weight loss of 7 lbs./5.4% in one month and 12 lbs./9.1% loss in 3 months. V20 recommended to start (nutritional supplement) 60 milliliters three times daily. R26's Progress Note dated 9/15/23 recorded by V20 documents R26 triggered for 11.9% weight loss in the last six months and V20 recommended to increase (nutritional supplement) to 90 ml three times daily.
R26's November 2023 Physician Order Summary documents an order initiated on 9/21/23 for (nutritional supplement) 90 ml three times daily (six days after V20's recommendation).
R26's June 2023 Medication Administration Record (MAR) documents (nutritional supplement) 60 ml three times daily was initiated on 6/14/23 (5 days after V20's recommendation). R26's June 2023-September 2023 MARs do not document supplement intake amounts.
On 11/06/23 at 2:33 PM V3 (Assistant Director of Nursing) stated V3 is responsible for notifying the physician and resident representative of weight loss and would refer to the facility's policy for reporting weight loss to the physician and representative. V3 stated R26 had COVID-19 and had lost weight. V3 stated V20 sends V20's recommendations to V3 via electronic mail. V3 prints the recommendations and gives them to V24 (Nurse Practitioner) for approval. V3 stated on 9/15/23 V20 recommended increasing the nutritional supplement to 90 ml three times daily, and confirmed this recommendation was not implemented until 9/21/23. V3 stated V24 may not have been in the facility 9/18/23 and therefore V24 didn't sign an order for the recommendation. V3 stated on 6/9/23 V20 recommended changing R26's diet to regular and initiating (nutritional supplement). V3 confirmed R26's medical record does not contain any nursing notes after May 2023 and no documentation that R26's Family (V15) and physician were notified of R26's significant weight loss. At 3:42 PM V3 stated nutritional supplements are recorded on the MAR. V3 confirmed the consumed amount of nutritional supplements are not documented on R26's MAR and should be.
On 11/7/23 at 11:06 AM V20 stated V20 visits the facility monthly and creates a generated report that is emailed to V3, V1 and the Dietary Manager. V20 stated the facility has had issues with not having a Dietary Manager so V3 has been following up on V20's recommendations. V20 stated V20 submits her report on the same day as V20's visits, which is usually Friday. V20 stated V20 expects V20's recommendations to be implemented by the following Monday or Tuesday. V20 stated supplement intakes should be recorded to determine how much is consumed. V20 stated V20 would recommend something else if the resident is not consuming the supplement.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify the risk for entrapment for one (R11) of 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 identify the risk for entrapment for one (R11) of one resident reviewed for bed rails in a sample list of 33 residents.
Findings Include:
R11's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Parkinson's Disease, Depression, Anxiety and Chronic Fatigue Syndrome.
R11's Minimum Data Set, dated [DATE] documents R11 is cognitively intact and requires staff assistance or is dependent on staff for Activities of Daily Living (ADL's).
On 11/05/23 at 11:55 AM R11 was lying in her bed. There is a 1/2 length side rail in place to both sides of R11's bed. On the end of the rail toward R11's legs there is a gap in the rail approximately 5 by 10. R11 is very thin, and her left foot is against the rail. When comparing R11's foot with the rail it could easily fit into the gap.
On 11/06/23 at 2:32 PM V21 (Maintenance Director) stated that is a 10 gap and I see that (R11) could get an arm or leg caught in that. I will change that out today.
The facility's policy Determining for use of bed rails/Transfer Bars dated 5/12/17 states Zone assessments for the enablers will be conducted at the time they are placed on the bed and at least annually.
The facility's Siderail Zone Assessment for R11 (Not dated) states Zone 1-Within the rail gap circular cross section less than 4 3/4 in diameter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide physician visits at least every 60 days alternating with an advanced practice nurse for three of four residents (R11, R15,R45) revie...
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Based on interview and record review the facility failed to provide physician visits at least every 60 days alternating with an advanced practice nurse for three of four residents (R11, R15,R45) reviewed for physician's visits in the sample list of 33.
Findings Include:
The facility's Policy Physician's Services (not dated) documents After the first 90 days a resident must be seen by a physician at least every 60 days. The physician may schedule alternate visits by a Physician's Assistant or a Nurse Practitioner.
1. R11's Nurse Practitioner Progress note dated 8/31/23 documents R11 has been a resident since 2015. V24 (Nurse Practitioner) documented assessments for R11 on 8/31/23. There is no documentation to indicate a physician has evaluated R11 in July, August, September, or October 2023. There is no documentation to indicate R11 has been assessed by a physician so far in November 2023.
2. R15's Face Sheet documents R15 has been a resident since 5/24/23. V24 (Nurse Practitioner) documented assessments for R15 on 9/18/23, and 10/5/23. There is no documentation to indicate a physician has evaluated R15 in July, August, September, or October 2023. There is no documentation to indicate R15 has been assessed by a physician so far in November 2023.
3. R45's Face Sheet documents R45 has been a resident since 4/4/23. V24 documented assessments for R45 on 8/24/23, 9/11/23 and 10/26/23. There is no documentation to indicate a physician has evaluated R45 in July, August, September, or October 2023. There is no documentation to indicate R45 has been assessed by a physician so far in November 2023.
On 11/9/23 at 2:00PM V1 (Administrator) stated, We did have a little trouble getting physician's notes in June and July. We hired V39 (Medical Director) in August 2023 and we are in the process of getting the physician's visits caught up. I'm sorry to say I can't locate physician's notes for (R11, R15, R45) since July.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to track targeted behaviors for one (R15) of five residents reviewed for psychotropic medications in a sample list of 33 resident...
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Based on observation, interview, and record review the facility failed to track targeted behaviors for one (R15) of five residents reviewed for psychotropic medications in a sample list of 33 residents.
Findings Include:
R15's Physician's Order Sheet (POS) for November 2023 includes the following diagnoses: Mixed Alzheimer's Disease, Vascular Dementia with behavioral disturbances, Anxiety, and Major Depression. This POS also documents current physician's orders for the following psychotropic medications: 1. Alprazolam (antianxiety) 0.25 milligrams (MG) in the AM and 0.5 mg at Bedtime. 2. Quetiapine (antipsychotic) 12.5 mg every morning. 3. Buspar (Antianxiety) 15 mg twice daily. 3. Remeron (antidepressant) 7.5 mg at bedtime. 4. Melatonin (sleep aide) 10 mg at bedtime.
The only behavior tracking sheet documented for R15 is for November 2023 and the sheet is blank.
On 11/8/23 V1 (Administrator) stated We are aware our psychotropic medication documentation and care plans are not complete. We lost the Care Plan Coordinator recently and we found that the documentation was not what it should be.
The facility's Psychotropic Medication Policy revised 6/17/22 states, 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. 7. Any resident receiving such medication shall have a psychiatric diagnoses 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.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to administer insulin per orders, have parameters for notifying the physician of blood glucose results, and coordinate times for glucose monito...
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Based on interview and record review the facility failed to administer insulin per orders, have parameters for notifying the physician of blood glucose results, and coordinate times for glucose monitoring and insulin administration. These failures resulted in significant medication errors for one (R28) of five residents reviewed for medications in the sample list of 33.
Findings include:
R28's October 2023 Physician Order Summary (POS) documents R28 has Type 1 Diabetes Mellitus. This POS documents an order dated 10/23/23 for Novolog (insulin) 5 units subcutaneous with meals (8:00 AM, 12:00 PM, and 4:00 PM). R28's November 2023 POS includes the following orders: Novolog give three times daily (8:00 AM, 11:00 AM, and 4:00 PM) per sliding scale, for blood glucose 161-220 give 1 unit, 221-280 give 2 units, 281-340 give 3 units, 341-400 give 4 units, and greater than 400 give 5 units. Notify the physician for blood glucose levels greater than 400, implemented on 11/6/23. R28's blood glucose checks are ordered at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. There is no documentation that prior to 11/6/23 R28 had ordered parameters for notifying the physician of blood glucose results.
R28's November 2023 Medication Administration Record (MAR) documents the following: On 11/2/23 at 6:00 AM R28's blood glucose was 433 and Novolog 4 units was given (not 5 units as ordered per sliding scale). On 11/2/23 at 11:00 AM R28's blood sugar was 540 and Novolog 3 units was given (not 5 units as ordered per sliding scale). On 11/2/23 at 4:00 PM R28's blood glucose was hi. This MAR does not document R28's blood glucose was rechecked at that time, or that Novolog insulin per sliding scale parameters was administered as ordered. R28's 8:00 PM blood glucose on 11/2/23 was 516.
R28's Nursing Note dated 11/2/23 at 5:30 AM documents R28's blood glucose was 433 and was rechecked with a result of 448. Novolog 4 units was given (not 5 units as ordered). V24 (Nurse Practitioner) was called, but V24 did not answer. There are no documented additional attempts to notify V24 or that V39 (Physician) was notified of R28's blood glucose results after 11/2/23 at 5:30 AM until 11/2/23 at 7:30 PM. R28's Nursing Note dated 11/2/23 at 7:30 PM documents R28's blood glucose was 516, it was rechecked with a result of 587. The Nurse Practitioner was notified and gave orders to give (Novolog) 7 units, Basaglar (insulin) 10 units, give protein/carbohydrate snack, recheck blood glucose level in one hour, call if results are greater than 500, and recheck blood glucose again at midnight.
On 11/08/23 at 10:10 AM V2 (Director of Nursing) and V3 (Assistant Director of Nursing) reviewed R28's chart and confirmed R28's Novolog sliding scale order includes to give 5 units for a blood glucose greater than 400. V3 stated 5 units should have been given on 11/2/23 at 8 am, not 4 units, and the nurse (V40 Registered Nurse) should have notified V39 (Physician) since it was before 9:00 AM. V3 stated we contact V24 (Nurse Practitioner) if it is after 9:00 AM. V3 confirmed there is no documentation of follow up with V24 or V39 after 11/2/23 at 5:30 AM until 11/2/23 at 7:30 PM. V3 stated V40 is an agency nurse and it was V40's first night working in the facility. At 10:26 AM V3 stated we have always checked blood glucose at 6:00 AM since the resident will be fasting at that time. V3 stated the Novolog per sliding scale is given at 8:00 AM and is based on the 6:00 AM blood glucose results. On 11/13/23 at 11:20 AM V3 confirmed R28's blood glucose result is recorded as 540 on 11/2/23 at 11:00 AM. V3 stated a high reading is anything over 599, since the blood glucose meter only gives a numerical result up to 599. V3 stated prior to 11/6/23 R28 did not have ordered blood glucose parameters for when to notify V24 or V39. V3 stated on 11/6/23 we added the order to notify for blood glucose over 400.
The facility's Medication Administration policy revised on 11/18/17 documents medications should be administered within one hour before or after the designated time, verify the seven rights of administration including the right dose, and record the date/time/drug/dose/route on the MAR.
The facility's Notification for Change in Resident Condition or Status revised 12/7/17 documents the nurse will notify the attending or on-call physician when there is a change in condition including when signs/symptoms are unrelieved by previously prescribed measures. This policy includes notifying the physician of abnormal laboratory results and when there is a need to alter the resident's medical treatment significantly. This policy documents to record information regarding changes in the resident's condition in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide pneumococcal vaccinations per resident/resident representative request for two of five residents (R27, R31) reviewed for vaccinatio...
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Based on interview and record review, the facility failed to provide pneumococcal vaccinations per resident/resident representative request for two of five residents (R27, R31) reviewed for vaccinations on the sample list of 33.
Findings Include:
1.) R27's Consent for vaccinations dated 12/28/22 documents R27 wishes to have the PPSV23 (Pneumococcal Polysaccharide Vaccination) and/or PCV13 (Pneumococcal Conjugate Vaccination), whichever vaccination R27 is able to receive.
R27's medical record does not document that R27 has historically received a Pneumococcal vaccination or that the facility administered the PPSV23 or PCV13 vaccination as requested.
2.) R31's Consent for vaccinations dated 8/12/22 documents R31 wishes to have the PPSV23 and/or PCV13, whichever vaccination R31 is able to receive.
R31's medical record does not document that R31 has historically received a Pneumococcal vaccination or that the facility administered the PPSV23 or PCV13 vaccination as requested.
On 11/8/23 at 9:31 AM, V2 (Director of Nursing) stated Pneumonia Vaccination requests are only obtained upon admission, and that is why R31 does not have a more recent consent. V2 also stated that V2 is not able to follow the vaccination guide/table so V2 is unsure what type of Pneumococcal vaccination R27 and R31 need therefore the requested Pneumococcal vaccination has not been given. V2 explained that V2 has asked V24 (Nurse Practitioner) to find out which vaccination R27 and R31 need but that V24 has not gotten back to V2 with the information.
The facility Immunization of Residents Policy dated 4/21/22 documents the facility will offer immunizations and vaccinations that aid in the prevention of infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director. Explain to the resident, resident's guardian, or the resident's Durable Power of Attorney of Health Care, at the time of admission and at the start of the recognized mass immunization period, the importance of vaccination against common illnesses such as pneumonia and influenza. Assess all newly admitted residents' Pneumococcal and influenza vaccination status upon admission and record last known immunization on the resident's Immunization Record. Offer the PCV13, PCV15 (Pneumococcal Conjugate Vaccination), PCV20 (Pneumococcal Conjugate Vaccination) or PPSV23 as indicated utilizing the Pneumonia Vaccination Timing Guidelines, unless contraindicated.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
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 have sufficient dietary staff to timely serve meals. T...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have sufficient dietary staff to timely serve meals. This failure has the potential to affect all 44 residents who reside at the facility.
Findings Include:
On 11/5/23 at 10:31 AM, R24 stated the facility food/meals are always served late.
On 11/6/23 at 11:22 AM, V12 (Cook) and V13 (Dietary Aide) were the only two staff working in the kitchen preparing food for lunch.
On 11/6/23 at 12:06 PM, V12 served the first meal tray and stated, lunch is supposed to be served at 11:30 am however, it is hard because of only having two people in the kitchen. V12 explained there is always only two staff in the kitchen, a cook, and the aide and that the facility really needs an extra person. V12 also stated that V12 is taking over as Dietary Manager and as soon as V12 can find someone to take V12's spot as the cook.
On 11/6/23 at 12:19 PM, V12 had to stop serving lunch trays to make gravy to put onto R23's mashed potatoes stating, I can't serve potatoes without gravy, and V12 had not prepared the gravy yet. Serving was halted until 12:24 PM.
On 11/6/23 at 12:40 PM, the last lunch tray was served.
The Facility assessment dated [DATE] documents the facility will have a full time Dietary Manager, and two food/nutrition service staff on first shift.
The facility Matrix for Providers dated 11/5/23 documents 44 residents reside at the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper food storage, cleanliness of the kitchen...
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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 proper food storage, cleanliness of the kitchen and prevent potential food contamination by not ensuring facial hair was covered while preparing and serving food. This failure has the potential to affect all 44 residents who reside at the facility.
Findings Include:
The facility Kitchen Sanitation Policy dated October 2020 documents the Food Service Manager will monitor sanitation of the Dietary Department on a daily basis. The Dietary Sanitation QA (Quality Assurance) Review shall be used as a tool to monitor compliance with sanitation standards and identify which areas need corrective action. The Food Service Manager will develop a cleaning schedule for the department and ensure that dietary employees complete cleaning tasks as scheduled. The Food Service Manager shall provide cleaning instructions for each area and piece of equipment in the kitchen and specify which chemical and personal protective equipment should be used for each task.
The Dietary Sanitation QA Review Sheet dated October 2020 includes areas of evaluation that includes but is not limited to: hair nets being worn by everyone entering the kitchen, including facial hair coverings, ensure food and non-food contact surfaces are easily cleanable including shelves and cart and that they are clean, all food is covered and containers are labeled with contents, dated when opened and dated when to discard, food is stored in airtight containers and labeled if not in original container, ceilings and walls are clean, a cleaning schedule is posted/followed and that staff are knowledgeable about cleaning schedule and duties.
1. On 11/6/23 between 2:00 -2:15 PM, the Dietary Storage Room, which is also the Dietary Manager's Office had a gallon jug of Apple Cider Vinegar with less than 1/4 left in it that was undated and the lid was not closed/sealed. At this time, V12 (Cook/Dietary Manager) stated the lid should be closed and it should have been dated when it was opened. There was also an opened bag of [NAME] powder, undated and unsealed sitting in a plastic container without a lid, on the storage rack. V12 stated, We (facility) don't have lids for the container, it has been like that. Also on the storage rack was an open bag of rice crispy cereal dated 9/21/23 that was not sealed, an open/unsealed bag of cinnamon streusel coffee cake mix dated 11/1/23 that was half used, a bag of complete buttermilk pancake mix dated 11/5/23 that was open and not sealed, two large bags of pasta opened, unsealed and undated. In the kitchen, the prep table had two pull-down built-in cabinets, one with a large tub of flour and the other with a large tub of sugar, neither were covered with lids, the lids were off the tubs and sitting in the cabinet.
The facility Food Safety Policy dated April 2017 documents food or beverages should be labeled and dated to monitor for food safety.
The facility Storage Policy dated October 2020 documents all food shall be stored on shelves in areas that provide the best preservation. When using only a part of a product, the remaining product should be in the original package or an airtight container and be dated and labeled.
2. On 11/6/23 at 11:22 AM, the back of the stove has food splatters up the back of it, including on the pots that are sitting on the shelf above the stove top. The shelf has a yellow substance hanging from the shelf on the right side. Under the counter by the sink and dishwasher, there are dark brown streaks running down the wall. There are brownish colored food splatters all over the wall behind the steam table, from the table extending approximately 3 feet up the wall. On the shelf under the steam table/prep area where the cups are stored, there are circular in shape white rings appearing to be calcium/lime build up. On the bottom shelf of the steam table/prep area where the napkins and cup lids are stored, there is white colored food/drink splatter. The milk machine has white substance splatters covering the front of it. The mixer cart, parked next to the milk machine, has dried white splatters on the top, middle, and bottom shelf.
On 11/6/23 at 12:19 PM, V12 stated the kitchen floors are cleaned daily but the facility does not really have a cleaning schedule they go by. V12 stated, the walls haven't been cleaned since (V12) has been here that (V12) is aware of, and V12 has worked at the facility for one year. V12 explained cleaning the kitchen is just hard with only two of us and no dietary manager.
On 11/6/23 at 2:10 PM, the ice maker, in the kitchen, had yellowish brown residue streaking down the side of the ice maker and a buildup of a white substance on the front/door of the machine.
On 11/6/23 at 2:15 PM, V1 (Administrator) stated V1 has not seen a cleaning schedule for the kitchen but knows that about one month ago, the wall behind the steam table was cleaned.
On 11/7/23 at 1:48 PM, the shelf above the stove continues to have yellowish dried food hanging from the right side, the pots on the shelf continue to have food splatters on it, as does the back of the stove, the same as yesterday (11/6/23). Dried brown food splatter remains on the wall behind the steam table, as do the dark brown streaks on wall by the dishwasher and sink.
The facility Cleaning Schedule Policy dated October 2014 documents the facility will have a system for determining frequency of cleaning and to document the completion of a particular cleaning task. The Food Service Manager shall develop a cleaning rotation form that lists all cleaning tasks required for proper sanitation of the food preparation and serving areas. Tasks should be divided into categories that must be completed daily, weekly, and monthly and each position in the Dietary Department is assigned certain cleaning tasks to be completed at a particular frequency.
3. On 11/6/23 at 12:06 PM, V13 (Dietary Aide), who has a bushy full beard approximately three inches in length, was placing drinks and pears on the trays. V13 did not have a cover over V13's beard. At this time, V13 stated V13 was told V13 didn't need to wear a beard cover if V13's beard was less than one inch. V13 was asked if V13 thought V13's beard was less than one inch and V13 responded, V13 will go get a cover.
The facility's untitled procedure guide dated October 2016 documents hair net or appropriate hair coverings, including facial hair covering, will be used while involved in food production and clean-up activities.
The facility Matrix for Providers dated 11/5/23 documents 44 residents reside at the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to give residents and their representatives an option of not signing an arbitration agreement as a condition of admission. This failure has th...
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Based on interview and record review, the facility failed to give residents and their representatives an option of not signing an arbitration agreement as a condition of admission. This failure has the potential to affect all 44 residents who reside at the facility.
Findings include:
R28's Agreement to Resolve Disputes by Binding Arbitration dated 9/25/23 was signed by V11 (R28's Spouse) and V4 (Social Service Director/SSD).
On 11/6/23 at 10:07 AM, V11 stated upon R28's admission to the facility, V11 does not recall anybody giving V11 the option to not sign the arbitration agreement. V11 explained V11 was just given several papers and was told where V11 needed to sign.
On 11/7/23 at 2:33 PM, V4 stated everybody is required to sign it therefore, V4 does not give residents or resident representative's an option.
On 11/7/23 at 2:49 PM, V5 (Business Office Manager) checked the computer system for Arbitration Agreements and stated all residents that reside at the facility have a signed Arbitration Agreement. At this time, V1 (Administrator), stated residents and/or resident representatives should be given the option to not sign the agreement so if V4 isn't doing that, V4 needs re-educated.
The facility Matrix for Providers dated 11/5/23 documents 44 residents reside at the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to have timely quarterly Quality Assurance (QA) meetings. This failure has the potential to affect all 44 residents residing in the facility.
...
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Based on interview and record review the facility failed to have timely quarterly Quality Assurance (QA) meetings. This failure has the potential to affect all 44 residents residing in the facility.
Findings include:
The facility's Quality Assurance meeting sign in sheets for the last year were requested and were provided by V1 (Administrator). The facility had documented meetings on 1/23/23, 6/5/23, 8/15/23, and 10/25/23. The QA Meeting sign in sheet dated 1/23/23 documents the facility reviewed information from the months of October 2022, November 2022, and December 2022. There is no documented QA meeting sign in sheet for April 2023. The QA Meeting sign in sheet dated 6/5/23 documents the facility reviewed information from the months of January, February, and March 2023. The QA Meeting sign in sheet dated 8/15/23 documents the facility reviewed information from the months of April, May, and June 2023.
On 11/6/23 at 4:10 PM V1 stated we did not have a meeting in April 2023 and the January-March information was reviewed at the June 2023 meeting. V1 stated as long as we have meetings that review information from each quarter we are in compliance. V1 confirmed the facility does not have quarterly QA meetings based on the time frame of every 3 months per calendar year. V1 stated the April meeting had to be rescheduled due to a change in Medical Directors. V1 confirmed the August 2023 meeting reviewed information from April-June 2023.
The facility's CMS (Centers for Medicare & Medicaid Services) Form 802 dated 11/5/23, provided by V1 documents 44 residents reside in the facility.
The facility's QAPI (Quality Insurance Performance Improvement) Plan dated as reviewed 7/20/23 documents: At a minimum on a quarterly basis, data will be collected and reported to the QAPI Committee from the following areas:
-Input from caregivers, residents, families, and others
-Adverse events
-Performance indicators
-Survey findings.
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 interview and record review, the facility failed to implement their Infection Control Surveillance and Monitoring Policy by failing to thoroughly complete infection control logs, analyze the ...
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Based on interview and record review, the facility failed to implement their Infection Control Surveillance and Monitoring Policy by failing to thoroughly complete infection control logs, analyze the data, identify trends, and implement the appropriate isolation precautions for shingles. This failure has the potential to affect all 44 residents who reside at the facility.
Findings Include:
The facility Infection Control Surveillance and Monitoring Policy dated 3/10/22 documents the facility will do routine surveillance and monitoring of the facility to determine if compliance with work practices. Monitoring of the day-to-day operation of the Infection Control Program will be conducted by the DON (Director of Nursing). Included in these duties are investigation and implementation of controls to prevent infections in the facility, determine and direct the correct procedures necessary for the prevention of infections (this should be done on an individual basis, applying the concepts of isolation per infection), and follows up on documentation of and reporting of infection to physicians through direct and random inspections of the clinical record with respect to isolation techniques instituted and followed. The Infection Control Log shall be updated on a daily basis in order to analyze data and identify trends that would indicate the need for additional controls to prevent any further spread of an infection. Maintaining records of surveillance and monitoring will be the DON and/or Administrator and shall reflect: the conditions associated with each incident of mucous membrane or parenteral exposure to blood/body fluids; and an evaluation of those conditions and a description of any corrective measures taken to prevent a recurrence or similar exposure.
1. R27's Progress Notes dated 10/30/23 document R27 has red blisters/spotty redness down R27's neck and right side of chest.
R27's October 2023 Physician Order Sheet documents R27 was started on Acyclovir (Antiviral) 400 mg (milligrams) TID (Three times a day) for 5 days.
R35's November 2023 Physician Order Sheet documents an order for Nitrofurantoin (Antibiotic) 100 mg daily as prophylaxis, received on 7/31/23.
The facility's July - October 2023 Infection Control Logs do not document that R35 is receiving Antibiotics. The October 2023 Infection Control Log also does not document R27's Antiviral.
The facility also did not provide any infection surveillance or data analysis for infections in October 2023.
On 11/8/23 at 10:58 AM, V3 ADON/IP (Assistant Director of Nursing/Infection Preventionist) stated R27's Antiviral is not on the October 2023 Infection Control Log because the log is not completed. V3 also stated V3 has not done any infection surveillance or data analysis because the Infection Control Log isn't completed. V3 explained that V3 does not put any prophylactic antibiotics on the infection control log, including R35's. V3 confirmed that any infection control monitoring, surveillance, and data analysis would not be accurate due to all infections and antibiotic/antiviral usages not being monitored. V3 stated V3 has been in the IP (Infection Preventionist) role since June/July 2023.
2. R27's Progress Notes dated 10/30/23 document R27 has red blisters/spotty redness down R27's neck and right side of chest.
R27's October 2023 Physician Order Sheet documents an order dated 10/30/23 to start Acyclovir (Antiviral) 400 mg (milligrams) TID (Three times a day) for 5 days and to place R27 in contact isolation.
R27's November 2023 Physician Order Sheet documents an order dated 11/3/23 to start Acyclovir 400 mg TID for 2 days along with an order on 11/6/23 to discontinue isolation.
R27's Care Plan dated 10/30/23 documents R27 has Shingles, Blisters/Rash present to the right shoulder and neck.
On 11/7/23 at 3:47 PM, V3 ADON/IP (Assistant Director of Nursing/Infection Preventionist) stated R27 was being treated for suspected shingles and was placed on contact isolation only and was not on droplet/airborne isolation.
On 11/8/23 at 9:40 AM, V22 (Certified Nursing Assistant/CNA) stated R27 was recently on contact isolation for shingles. V22 stated R27's rash/blisters were never covered with a dressing and were only covered by what R27's clothing would cover, which was not the entire area as it was on R27's chest and up on R27's neck.
The CDC (Centers for Disease Control and Prevention) Guidance for Preventing Varicella-Zoster Virus Transmission from Herpes Zoster in Healthcare Settings dated 5/10/23 documents for Immunocompetent residents, the localized lesions should be completely covered, and the resident should be on airborne and contact precautions until the lesions are dry and scabbed.
The facility Matrix for Providers dated 11/5/23 documents 44 residents reside at the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to implement their antibiotic stewardship program. This failure has the potential to affect all 44 residents who reside at the facility.
Find...
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Based on interview and record review, the facility failed to implement their antibiotic stewardship program. This failure has the potential to affect all 44 residents who reside at the facility.
Findings Include:
The facility Antibiotic Stewardship Program dated 11/1/17 documents this program is used to improve the use of antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished utilizing the Core Elements: Leadership Commitment (demonstrates support and commitment for safe and appropriate antibiotic use), Accountability (identify physicians, nursing and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities), Drug Expertise (establish access to consultant pharmacists or other individuals with experience or training in antibiotic stewardship), Action (implement at least one policy or practice to improve antibiotic use), Tracking (monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use), Reporting (Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff), and education (provide resources to clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improving antibiotics).
R35's November 2023 Physician Order Sheet documents an order received on 7/31/23 for Nitrofurantoin (Antibiotic) 100 mg (milligrams) daily as prophylaxis.
On 11/7/23 at 12:54 PM, V3 ADON/IP (Assistant Director of Nursing/Infection Preventionist) stated V3 does not use any kind of assessment tool to ensure or determine the appropriateness for use of the ordered antibiotic. V3 also stated V3 does not have any clinically documented rational for continued use of prophylactic antibiotic use for R35. V3 also stated V3 has not followed up with any medical providers regarding R35's antibiotic use or provided antibiotic stewardship education to them.
On 11/8/23 at 10:58 AM, V3 was not able to provide any assessments for the documented use of antibiotics for any documented infections from June 2023 - November 2023 stating the facility really doesn't do any antibiotic stewardship to make sure the ordered antibiotic is appropriate or not. At this time, V3 also stated a lot of times, when a resident is started on antibiotics outside of the facility, the facility is not able to get the culture results from the hospital therefore the facility has no way to check to ensure the residents are on the appropriate antibiotic.
The facility Matrix for Providers dated 11/5/23 documents 44 residents reside at the facility.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0576
(Tag F0576)
Minor procedural issue · This affected most or all residents
Based on record review and interview the facility failed to deliver unopened mail to all residents. This failure has the potential to affect all 44 residents residing at the facility.
Findings include...
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Based on record review and interview the facility failed to deliver unopened mail to all residents. This failure has the potential to affect all 44 residents residing at the facility.
Findings include:
The current resident roster dated 11/5/23 documents there are 44 residents residing at the facility.
The facility's Resident Rights document states You have the right to privacy.
On 11/6/23 at 10:28AM R29, R39, R30, R24, R37, R5, R6, R42, R9, and R10 attended a resident council meeting. V32 (Long term Care Ombudsman) was also present. R42 asked Should the facility be opening our mail before delivering it to Us? R42 was advised residents have the right to receive their mail unopened. R42 replied well when we get our mail it is opened. All other residents in attendance at the meeting agreed their mail is opened when they get it.
On 11/6/23 at 12:00PM V31 (Activity Director) stated We do open all mail with a mail opener when we get it. We don't take anything out or look at it. We were just doing it for the resident's convenience. We weren't aware we were supposed to give it to them unopened.
Nov 2022
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a physician of abnormal blood glucose and laboratory results ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a physician of abnormal blood glucose and laboratory results for two (R4, R5) of three residents reviewed for change in condition in the sample list of 12.
Findings include:
1.) R4's [DATE] Physician's Orders documents to administer Glipizide (diabetic medication) 2.5 mg (milligrams) by mouth daily at 8:00 AM, and Metformin (diabetic medication) 500 mg by mouth twice daily. The order dated [DATE] documents to check R4's blood glucose every morning and does not include parameters for notifying the physician.
R4's Telehealth Progress Note dated [DATE] recorded by V22 (Nurse Practitioner) documents R4 has a diagnosis of Type 2 Diabetes and to report if R4's blood glucose is greater than 400 or less than 60.
R4's [DATE] Medication Administration Record documents: R4's blood glucose at 6:00 AM was 37 on 10/30 and 36 on [DATE]. R4 received Glipizide 2.5 mg at 8:00 AM on [DATE], and this medication was not administered on [DATE]. R4 received Metformin 500 mg by mouth at 8:00 AM and 4:00 PM on [DATE], and this medication was not administered on [DATE]. There is no documentation in R4's medical record that a physician was notified of R4's low blood glucose on 10/30 or [DATE].
On [DATE] at 10:50 AM V12 (Certified Nursing Assistant) stated R4 started refusing to eat about 3-4 days before R4 died (on [DATE]).
On [DATE] at 12:50 PM V2 (Director of Nursing) confirmed R4's blood glucose at 6:00 AM was 37 on 10/30 and 36 on [DATE]. V2 confirmed R4 received oral diabetic medications on [DATE], and these medications were not given on [DATE]. V2 stated: V2 was R4's nurse on the mornings of 10/30 and [DATE]. R4 was given orange juice after R4's low blood glucose results, and R4's blood glucose was rechecked and in the 90's. V2 did not notify the physician of R4's low blood glucose since R4's blood glucose returned to normal range. We don't have parameters of when to notify for (R4's) blood glucose results. Physicians are notified of changes in condition, and the facility utilizes the Nurse Practitioners between 9:00 AM and 9:00 PM.
On [DATE] at 1:04 PM V21 (Nurse Practitioner) stated: R4 was evaluated by V22 (Nurse Practitioner) and V22's [DATE] note says to notify for blood glucose greater than 400 and less than 60. The facility should have absolutely notified our office of R4's low blood glucose levels and R4's medications could have been adjusted. We have no record in our office of being notified of R4's low blood glucose.
2.) R5's Hospital History and Physical dated [DATE] documents: R5 was treated for Acute Urinary Tract Infection, Acute Encephalopathy, and dehydration. R5's laboratory results included [NAME] Blood Cell Count (WBC) 9.19, Protein 5.9, Albumin 3.4, Hemoglobin 12.7, and Hematocrit 39.2, Absolute Neutrophils 6.96, and Blood Urea Nitrogen (BUN) 19.
R5's [DATE] Physician's Orders documents R5 admitted to the facility on [DATE] and includes an order dated [DATE] for Complete Blood Count, Complete Metabolic Panel, Thyroid Stimulating Hormone, Hemoglobin A1C, Lipid Panel, Vitamin D, Vitamin B12 due on the next laboratory day. R5's laboratory results dated [DATE] document R5's results included: BUN 30 (high), BUN/Creatinine Ratio 38 (high), Albumin 3.1 (low), WBC 15.1 (high), Hemoglobin 11.6 (low), Hematocrit 35.5 (low), and Absolute Neutrophils 13.5 (high). There is no documentation that these laboratory results were reported to a physician.
On [DATE] at 3:00 PM V1 (Administrator) confirmed R5's entire closed medical record was provided.
On [DATE] at 1:04 PM V21 (Nurse Practitioner) stated V21 would expect the facility to notify their office of abnormal laboratory results.
On [DATE] at 12:50 PM V2 (Director of Nursing) obtained R5's [DATE] laboratory results from the computer. At 1:21 PM V2 stated: Usually physician notification is documented on the laboratory result sheet. Since V2 printed R5's results from the computer, there is no documentation of physician notification for the laboratory results.
The facility's Glucose Monitoring policy revised [DATE] documents to check physician's orders and administer insulin as ordered, or notify the physician as indicated.
The facility's Notification for Change in Resident Condition or Status dated as revised [DATE] documents: The resident's physician will be notified when there is a change in the resident's physical/emotional/mental condition including reactions to medications, abnormal lab findings, and a need to alter the resident's medical treatment significantly.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer showers as scheduled for three (R3, R10, R12) of four res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer showers as scheduled for three (R3, R10, R12) of four residents reviewed for showers in the sample list of 12.
Findings include:
1.) R3's Minimum Data Set (MDS) dated [DATE] documents R3 requires physical assistance of one staff person for bathing. R3's Care Plan dated [DATE] documents R3 will receive two showers per week. The facility's Weekly Shower List documents R3's showers are scheduled on Wednesday and Saturday day shift.
On [DATE], V1 (Administrator) provided R3's October and [DATE] shower documentation. There is no documentation that R3 received scheduled showers after [DATE] until [DATE], from [DATE] until [DATE], or after [DATE].
2.) R10's MDS dated [DATE] documents R10 has short and long term memory impairment, and requires dependence on two staff for bathing. R10's Care Plan dated [DATE] documents to provide bathing assistance per R10's/family's preference but does not identify the frequency of R10's showers. The facility's Weekly Shower List documents R10's showers are scheduled on Wednesday and Saturday day shift.
On [DATE] V1 provided R10's October and [DATE] shower documentation. There is no documentation that R10 received scheduled showers/bed baths from [DATE] until [DATE], or after [DATE].
3.) R12's MDS dated [DATE] documents R12 had short and long term memory impairment and required assistance of one staff person for bathing. The facility's Discharge log documents R12 expired on [DATE].
R12's Care Plan dated [DATE] documents hospice and facility Certified Nursing Assistants provide bathing but does not identify the frequency of baths.
On [DATE] V1 provided R12's shower documentation. R12's Shower/Abnormal Skin Reports document R12 received showers on 6/13, 7/15, 7/20, and [DATE]. There are no other documented showers for July and [DATE].
On [DATE] at 1:25 PM V2 (Director of Nursing) stated R12 was hospitalized on [DATE] and returned on [DATE]. R12 was hospitalized on [DATE] and returned on [DATE]. R12 was in the facility for the entire month of [DATE]. V2 did not have any documentation of baths provided by hospice.
On [DATE] at 2:43 PM V6 (Registered Nurse) stated: Showers are scheduled to be given twice weekly. If the resident refuses, then the Certified Nursing Assistant has to notify us and we document the refusal on the shower sheet.
On [DATE] at 3:00 PM V1 confirmed V1 provided all of the requested shower documentation that V1 could locate for R3, R10, and R12.
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 F0691
(Tag F0691)
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 monitor, assess, and treat nephrostomy sites for one (R1) of two res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor, assess, and treat nephrostomy sites for one (R1) of two residents reviewed for indwelling tubes/catheters in the sample list of 12.
Findings include:
R1's Hospital Discharge Transfer Orders dated 8/24/22 document: R1's Discharge Diagnoses included bilateral nephrostomy tubes with concerns for complicated Urinary Tract Infection. R1's nephrostomy tubes were replaced on 8/8/22 and ordered to be flushed twice daily with 10 milliliters (ml) of normal saline.
R1's August 2022 Medication Administration Record (MAR) documents R1's nephrostomy flushes are scheduled twice daily, and do not document the tubes were flushed on 3 scheduled day shifts. V13 (Licensed Practical Nurse) documented V13 flushed R1's nephrostomy tubes at 8:00 AM on 10/31/22. R1's medical record does not contain an August 2022 Treatment Administration Record (TAR).
R1's admission Assessment documents R1 admitted to the facility on [DATE] with bilateral nephrostomy tubes. R1's nursing notes include assessments of R1's nephrostomy tubes on 8/24/22 at 5:00 PM and 8/25/22 at 2:00 AM. There are no documented assessments/monitoring of R1's nephrostomy tubes after 8/25/22, and R1 was transported to the hospital on 8/31/22. There is no documentation in R1's medical record that R1's nephrostomy sites contained sutures, that nephrostomy dressing treatment orders were obtained and implemented, or that urinary output was recorded/monitored.
On 11/15/22 at 11:40 AM V13 (Licensed Practical Nurse/LPN) stated urinary catheter/nephrostomy urine output is monitored and should be recorded on an Intake and Output sheet. On 11/15/22 at 3:58 PM V13 confirmed V13 signed R1's flush administration at 8:00 AM on 8/31/22. V13 stated V13 did not flush R1's tube that day, and that it was signed in error.
On 11/15/22 at 3:11 PM V4 (LPN) stated V4 changed R1's bilateral nephrostomy site dressings at night, and these sites contained sutures.
On 11/15/22 at 11:55 AM V1 (Administrator) stated V1 expects staff to sign out the MARs/TARs for treatments and medication administration. V1 confirmed three of R1's scheduled nephrostomy tube flushes are not signed out as administered. V1 verified R1's entire medical record was provided and confirmed R1's medical record does not contain an August 2022 TAR, recorded urinary output, or assessments after 8/25/22.
On 11/15/22 at 12:42 PM V21 (Nurse Practitioner) stated: Around 1:00 PM on 8/31/22, R1's family (V20) came to the nurse's station saying R1 had increased confusion. R1 was moaning, flushed, and diaphoretic. R1's left nephrostomy tube valve was between the on and off position. There was very little urine output from the left nephrostomy. V20 adjusted the valve to the on position and dark urine returned. Staff should have ensured the valve was open and draining urine, monitored R1's nephrostomy sites and monitored urinary output.
The facility's General Rules of Charting/Documentation dated January 2005 documents: Newly admitted residents will have 3-day documentation on every shift. Daily treatments will be documented on the Treatment Administration Record. Residents' output should be measured and documented, including total output per shift for colostomy/ileostomy, drains, and urine. The intake and output will be recorded when there is a physician's order, when a urinary catheter is in place, or at the discretion of the nurse.
The facility's Flushing Nephrostomy Tubes policy dated 9/10/13 documents: To assist in the proper maintenance and flow of urine flushing of the nephrostomy tube may be ordered by the physician. This policy documents to check the position of the stopcock sidearm and for kinks in the tube when flushing the tube, and check for urine in the bag.
Oct 2022
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain consent from a resident's Healthcare Power of Attorney for o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain consent from a resident's Healthcare Power of Attorney for one resident (R30) of five residents reviewed for informed consent in the sample list of 24.
Findings include:
R30's Minimum Data Set (MDS) dated [DATE] documents R30 was diagnosed with Depression.
R30's Physician Order Sheet (POS) dated 5/27/22 documents R30 was prescribed Sertraline (Antidepressant medication) 75 milligrams, one time per day for Depression.
R30's Physician Order Sheet date 6/24/22 documents R30's prescribed Sertraline 75 milligrams was increased to100 milligrams, one time per day for Depression.
R30's Power of Attorney for Health Care, dated 1/26/16, documents R30 appointed V19 (Health Care Power of Attorney/HPOA), which gives V19 legal authority to act for R30 and make any and all decisions for R30 regarding personal care, medical treatment, hospitalization, and health care and require, withhold, or withdrawal any type of medical treatment or procedure even though death may ensue.
R30's Psychotropic Medication Consent Antidepressant Form, dated 5/27/22, documents V19's telephone consent for R30's Anti-Depressant medication Sertraline 75 milligrams, one time per day. No other signed Psychotropic Medication Consent Antidepressant Form is in R30's chart documenting the facility obtained consent to increase R30's Sertraline from 75 milligrams to100 milligrams, one time per day for Depression.
On 10/4/22 at 1:30 PM V17 (Licensed Practical Nurse/Minimum Data Set Coordinator) said, R30 was sent to the hospital on 5/28/22 and returned on 6/24/22 with new orders to increase R30's Sertraline from 75 milligrams to 100 milligrams. V17 said, since R30 has a legal HPOA, the facility should have obtained V19 (R30's HPOA) consent to increase R30's of Anti-Depressant medication Sertraline from 75 milligrams to 100 milligrams a day. V17 said, there is no documentation in R30's chart that the facility obtained consent to increase R30's Anti-Depressant medication Sertraline from 75 milligrams to 100 milligrams a day. V17 said, V17 is not sure how V17 missed not getting a new consent for R30's increase.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R30's Minimum Data Set (MDS) dated [DATE] documents R30 was diagnosed with Depression.
R30's Physician Order Sheet (POS) da...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R30's Minimum Data Set (MDS) dated [DATE] documents R30 was diagnosed with Depression.
R30's Physician Order Sheet (POS) dated 5/27/22 documents R30 was prescribed Sertraline (Antidepressant medication) 75 milligrams, one time per day for Depression.
R30's Physician Order Sheet date 6/24/22 documents R30's prescribed Sertraline 75 milligrams was increased to 100 milligrams, one time per day for Depression.
R30's Progress Notes do not document V19 (Power of Attorney for Health Care/HPOA) was notified of R30's increase of Sertraline from 75 milligrams to 100 milligrams a day.
On 10/4/22 at 1:30 PM V17 (Licensed Practical Nurse/Minimum Data Set Coordinator) said, R30 was sent to the hospital on 5/28/22 and returned on 6/24/22 with new orders to increase R30's Sertraline from 75 milligrams to 100 milligrams. V17 said, since R30 has a legal HPOA, the facility should have notified V19 (R30's HPOA) that R30's Sertraline was increased from 75 milligrams to 100 milligrams a day. V17 said, there is no documentation in R30's chart that the facility notified V19 of the increase in R30's medication dosage. V17 said, the facility should have informed V19 of this increase when R30 was admitted back into the facility.
Based on interview and record review the facility failed to notify a resident's physician and resident's representative of a new pressure area. The facility also failed to notify a resident's representative of an increase in a psychotropic medication for two of 12 residents (R30, R40) reviewed for notification in the sample list of 24.
Findings include:
The facility's Notification of Change in Resident Condition or Status policy with a revised date of 12/7/17 documents, Policy: The facility and/or facility staff shall promptly notify appropriate individuals (i.e. {for example} Administrator, DON {Director of Nursing}, Physician, Guardian, HCPOA {Health Care Power of Attorney}, etc. {etcetera}) of changes in the resident's medical/mental condition and/or status. Procedure: 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: f. A need to alter the resident's medical treatment significantly; o. Onset of pressure ulcers or stasis ulcers. 3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
1.) R40's Physician Order Sheet (POS) dated 10/1/22 through 10/31/22 documents diagnoses including Vascular Dementia without Behavior Disturbances, Osteoporosis, Cerebral Infarction, Alzheimer's and Bipolar Disorder. This POS documents the only skin orders as a skin check weekly and anti-fungal powder to the left arm pit prophylactically.
R40's Nurse's Notes dated 9/29/22 at 1:00 AM documents a new pressure area to coccyx observed during rounds this shift. 2 cm (centimeters) x (by) 2 cm round pressure wound to coccyx. Newly acquired skin condition report started by writer. Will have next shift notify all parties and obtain orders. Signed by V12 (Licensed Practical Nurse.)
On 10/4/22 at 10:54 AM, V2 (Director of Nursing) stated that V2's expectation of nurses when a new skin area is observed is that they would fill out a newly acquired skin sheet and give it to V2 and notify the resident's family and the physician. V2 confirmed V2 did not receive a new skin sheet for R40's new area.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a resident's room in clean condition. This f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a resident's room in clean condition. This failure affects one (R26) of 16 residents reviewed for a clean environment on the sample list of 24 residents.
Findings include:
R26's Face Sheet (undated) documents R26 was admitted to the facility on [DATE].
On 10/2/22 at 9:17am, a dark black, kidney bean shaped, approximately 24 x 24 inches in size mark was noted on R26's floor.
On 10/3/22 at 11:38am, R26 is currently in isolation but remains in same room. R26's floor observed with the same above noted marking and dark brown food debris noted on floor in front of R26's recliner.
On 10/4/22 at 1:30pm, R26 observed sitting in recliner with bedside table next to recliner. On top of the bedside table was the following: four disposable drinking cups containing various fluids; the remnants of lunch on disposable plates stacked on top of each other and multiple open condiment wrappers. The garbage can next to R26's recliner was observed with no garbage can liner, reddish brown drip marks on the inside of the can, and various tissues/garbage inside. Also observed various food debris on the floor around R26's bedside table and recliner. A full black trash bag was observed next to the inside of R26's room door. The same dark black, kidney bean shaped mark was noted on R26's floor. R26 stated no one has been in here to clean recently. I know it's messy.
On 10/4/22 at 1:58pm, V1 (Administrator) stated V18 (Housekeeping Supervisor) has been off on leave and V16 (Maintenance) has been cleaning also. V1 stated, I will have V16 come down and clean in here, resident rooms should be cleaned daily.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents remain free from physical restraints b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents remain free from physical restraints by failing to obtain an order for restraints and failing to accurately assess the resident's ability to release the safety belt for one of four residents (R21) reviewed for physical restraints in the sample list of 24.
Findings include:
The facility's undated Physical Restraint/Enabler policy documents, Policy: To allow residents to be free of physical restraints which are not required to treat the resident's medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience.
R21's Minimum Data Set (MDS) dated [DATE] documents R21 was admitted to the facility on [DATE]. This MDS documents R21 has severe cognitive impairment and documents R21 has diagnoses including Medically Complex Conditions, Anxiety, Depression, Muscle Weakness and Alzheimer's Disease. This MDS documents that R21 has a Physical Restraint used daily. This MDS also documents that R21 requires extensive assistance of one staff member for transfers.
R21's Physician Order Sheet dated 10/1/22 through 10/31/22 does not have an order documented for the self-releasing safety belt.
R21's Physical Restraint/Enabler Consent form dated 7/15/22 documents the reason for the restraint is Posterior Pelvic Tile and leaning forward unsafely. This form documents the type of restraint as a self-releasing safety belt and documents alternatives tried as a (brand name) cushion, therapy and repositioning.
R21's Physical Enabler/Restraint Use/Reduction Evaluation form documents an evaluation was completed on 7/15/22 and 8/3/22. This form documents the diagnoses used for this restraint as Alzheimer's and this form documents R21 can release the safety belt R21's self.
R21's A.I.M. (Assess, Intercommunicate, Manage) report dated 7/14/22 documents R21 had a fall out of R21's wheelchair. This report documents the self-releasing safety belt was applied as an intervention for this fall.
On 10/2/22 at 9:37 AM, R21 was in R21's room sitting in a recliner, V4 (Certified Nursing Assistant) was in R21's room feeding R21 and R21's roommates.
On 10/2/22 at 12:20 PM R21 was in the dining room sitting at the dining table in R21's wheelchair feeding R21's self. R21 did not appear to be leaning at that time.
On 10/3/22 at 8:31 AM, R21 was in the dining room at the dining table sitting in R21's wheelchair being fed by V5 (Certified Nursing Assistant). R21 was sitting up and not leaning at that time.
On 10/3/22 at 8:42 AM, R21 was in R21's wheelchair sitting in the hallway outside of the dining room. R21 was sitting up and not leaning in the wheelchair. R21 did have the self-release safety on and fastened in front of R21's waist.
On 10/4/22 at 10:54 AM, R21 was in R21's room with V10 and V5 (Certified Nursing Assistants). V10 asked R21 if R21 could remove the self-releasing safety belt. R21 did not acknowledge V10's request. V10 asked another time and told R21 they could remove it and stand up. R21 did not respond. R21 appeared to stare off into the room. At that time V5 approached R21 and pointed to the self-releasing safety belt and asked R21 if R21 could take it off. R21 did not respond. R21 stared off into the room and did not acknowledge their requests.
On 10/4/22 at 2:00 PM, V2 (Director of Nursing) stated that there was one fall in July and then R21 kept standing up out of the wheelchair, so they put the self-releasing seat belt on R21.
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 thoroughly assess, monitor, and obtain a treatment for ...
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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 thoroughly assess, monitor, and obtain a treatment for a newly identified pressure wound for one of four residents (R40) reviewed for pressure ulcers in the sample list of 24.
Findings include:
The facility's Pressure Sore Prevention Guidelines policy with a revised date of 4/2006 documents, Procedure: The nurse will complete a skin assessment on all residents upon admission then weekly for four weeks. After the weekly assessments are completed, they must then be done with the annual and quarterly MDS (Minimum Data Set), with significant change in condition, or if a pressure sore develops. The following guidelines will be implemented for any resident assessed at a Moderate or High skin risk. Turn and reposition every two hours, Range of Motion, Special Mattress, Incontinence Care, Daily Skin Checks, Quarterly Review by the Dietary Manager, Nutritional Supplement and Care Plan Entry. Any resident scoring a High or Moderate risk for skin breakdown will be noted on the Treatment sheet and signed off by the nurse. In addition, a brief weekly narrative will be completed describing the resident's skin condition on the back of the treatment sheet.
The facility's Decubitus Care/Pressure Areas policy with a revised date of 1/2018 documents, Policy: It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Procedure: 1) Upon notification of skin breakdown, the QA (Quality Assurance) form for Newly Acquired Skin Condition will be completed and forwarded to the Director of Nurses. 2) The pressure area will be assessed and documented on the Treatment Administration Record or the Wound Documentation Record. 3) Complete all areas of the Treatment Administration Record or Wound Documentation Record. i) Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from physician). 4) Notify the physician for treatment orders. 5) Documentation of the pressure area must occur upon identification and at least once each week on the TAR (Treatment Administration Record) or Wound Documentation Form. The assessment must include: i) Characteristic (i.e. {for example} size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.) ii) Treatment and response to treatment.
R40's Physician Order Sheet (POS) dated 10/1/22 through 10/31/22 documents diagnoses including Vitamin B deficiency, Vascular Dementia without Behavior Disturbance, Osteoporosis, Cerebral Infarction, Vitamin B12 deficient Anemia, Edema, Alzheimer's, and Congestive Heart Failure. This POS documents orders for skin checks weekly and an order for an antifungal for the left arm pit prophylactically. This POS documents R40 was admitted to the facility on [DATE].
R40's Braden Skin Risk assessment dated [DATE] and 9/21/22 documents R40 is a high risk for skin impairment. There are no further skin risk assessments as the policy documents there will be.
R40's Nurse's Notes dated 9/29/22 at 1:00 AM, documents, new pressure are to the coccyx observed during round this shift 2 cm x 2 cm round, pressure wound to coccyx newly acquired skin condition report started by writer will have next shift notify all parties and obtain tx (treatment) orders. (Transparent) dressing applied as a nursing measure until tx orders can be obtained.
R40's Nurse's Notes do not document any further notes. R40's Treatment Administration Record (TAR) dated 9/14/22 through 9/30/22 documents an order for weekly skin checks (not daily as the policy documents for high risk) and there are no days signed out as completed. 9/21/22 and 9/28/22 are highlighted but there is no signature in any dates for skin checks. There is no treatment order on the TAR for a pressure wound to the coccyx. R40's TAR dated 10/1/22 through 10/31/22 documents an order for weekly skin checks and a treatment order for an antifungal to the left arm pit prophylactically but no other treatments are documented on this TAR. There is no treatment order for a wound on R40's coccyx.
On 10/3/22 at 10:02 AM, R40 was in bed laying on R40's right side with a pillow between R40's knees. On 10/3/22 at 11:17 AM, V4 and V5 (Certified Nursing Assistants) prepared to perform incontinent care on R40. V4 and V5 removed R40's incontinent brief. There was an open area on R40's coccyx approximately 2 cm (centimeters) by 2 cm. V5 stated that V5 has been putting cream on the area. V5 stated that V5 thinks the nurses know about the area. V5 stated V5 would report any new areas to the nurse's if V5 found one.
On 10/4/22 at 10:54 AM, V2 (Director of Nursing) stated that V2's expectation of nurse's when a new skin area is observed is that they would fill out a newly acquired skin sheet and give it to V2 then notify the family and the physician. V2 stated once V2 gets the sheet V2 assesses the area and sends a consult to the wound doctor. V2 confirmed that V2 has not gotten a skin sheet for R40 for the area on R40's coccyx.
On 10/3/22 at 3:13 PM, V21 (Licensed Practical Nurse) stated that V21 did not see any information regarding the wound on R40's coccyx.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a resident's oxygen humidifier bottle and cha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a resident's oxygen humidifier bottle and change oxygen tubing according to physician orders and facility policy. This failure affects one resident (R13) of two residents reviewed for respiratory care on the sample of 24.
Findings include:
On 10/3/22 at 10:24 am, the oxygen being supplied from R13's oxygen concentrator was not bubbling through the prefilled humidifier bottle because the water in the humidifier bottle was depleted. The prefilled humidifier bottle, oxygen extension tubing, and nasal cannula tubing were not labeled with a date for when they were last changed.
On 10/3/22 at 10:26 am, R13 stated, I asked them for humidifier water last night and it looks like I will ask them again. R13 then stated, With me running at 6 liters (per minute), when those run out of water, it is really hard on my nose. R13 also stated, I couldn't tell you when the last time was, they changed my tubing.
R13's Minimum Data Set (MDS) dated [DATE] documents R13 was admitted to the facility 7/4/18. This same MDS documents R13 scored 14 out of a possible 14 on the Brief Interview for Mental Status, rating R13 as cognitively intact with no short term or long-term memory problems and no disorganized thinking.
R13's Physician Order Sheet dated for October 2022 documents physician orders for O2 (oxygen) 6 liters (per minute) nasal cannula continuously and Change O2 tubing and humidifier bottle weekly and PRN (as needed).
On 10/3/22 at 11:28 am, V2 (Director of Nursing), stated The oxygen and tubing should be changed weekly, and the humidifier bottle should be checked and changed as needed. V2 also stated the oxygen tubing and humidifier bottle should be dated when it was changed.
On 10/3/22 at11:35am V2 changed and dated R13's humidifier bottle and oxygen tubing.
On 10/3/22 V2 said, R13's water bottle and tubing weren't dated like they should be, staff must have forgot change and date them or just forgot to date them.
The facility's policy Oxygen Therapy dated 3/19 (March 2019) documents, Change oxygen tubing/mask/cannula/and/or tracheostomy mask on a weekly basis. If using an oxygen tracheostomy mask, wash with warm soap and water daily, and PRN (as needed) in between changing if needed. Date tubing changes and document on the treatment sheet. If humidification is indicated, date prefilled bottles when changed. Humidifier changes and cleaning is to be documented on the treatment sheet at the time of occurrence.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain pharmacy labels and open dates on insulin pens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain pharmacy labels and open dates on insulin pens and failed to discontinue use of eyedrops after the expiration date for two residents (R5, R13) reviewed for medication storage in the sample list of 24.
Findings include:
The facility's Procurement and Storage of Medications policy with a revised date of 10/2006 documents, 5. All medications brought into the Facility shall be labeled with at least the following information: Name, address and phone number of dispensing pharmacy; resident name, physician name, name and strength of medication, directions for administering, last date dispensed and prescription number; both the brand and generic name if substitution is made; appropriate auxiliary labeling. 7. All medication containers shall be labeled with the date opened by the person breaking the container seal. 14. All discontinued/expired non-controlled medications are to be removed from the active medication storage area, and the quantity should be noted on the medication sheet. All medication should then be returned to pharmacy or destroyed per facility policy as soon as practical.
1.) R5's Physician Order Sheet (POS) dated [DATE] through [DATE] documents the diagnosis of Glaucoma. This POS documents an order for Latanoprost (Prostaglandin analog) 0.005% eye drops, instill one drop into both eyes at bedtime for the diagnosis of Glaucoma with a start date of [DATE].
On [DATE] at 2:45 PM, the North Medication cart review took place with V20 (Licensed Practical Nurse). In the top drawer of the medication cart where the eye drops were stored, there was an eye drop bottle with a pharmacy label for R5. This label documented instructions to discard 6 weeks after opening. The open date written on this bottle was [DATE] and the expiration date written on this bottle was [DATE] (6 weeks after opening). V20 confirmed this was the only bottle of eye drops for R5 and was the bottle that R5 was receiving R5's nightly eye drops from. V20 placed the Latanoprost eye drops back in the cart with the other eye drops.
R5's Medication Administration Record (MAR) dated [DATE] through [DATE] documents R5's Latanoprost was signed out as given on [DATE] through [DATE] after the eye drops had expired. R5's MAR dated [DATE] through [DATE] documents R5's Latanoprost was signed out as given on [DATE], [DATE] and [DATE] after the eye drops expiration date.
2.) R13's POS dated [DATE] through [DATE] documents a diagnosis of Type 2 Diabetes Mellitus. This POS documents an order for Tresiba pen (insulin degludec) inject 15 units subcutaneous every morning with an order date of [DATE].
On [DATE] at 2:45 PM, the North Medication cart review took place with V20 (Licensed Practical Nurse). In the top drawer of the medication cart was a Tresiba insulin pen with no pharmacy label on it and no open date written on it. There was no identification on the pen at all. V20 stated that the pen belonged to R13. V20 placed the insulin pen back in the top drawer of the medication cart with the other insulin pens.
R13's MAR dated [DATE] through [DATE] documents R13's Tresiba was signed out as given on [DATE], [DATE] and [DATE].
On [DATE] at 12:26 PM, V2 (Director of Nursing) stated that V2's expectation regarding insulin pens for the nurses is that they label the date on them when they take them out of the refrigerator. V2 stated the insulin pens should have the resident's name on it and open date written on them. V2 stated regarding expired eye drops that the nurses should order a new bottle and dispose of the expired bottle.
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?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 39% turnover. Below Illinois's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 2 harm violation(s), $122,236 in fines, Payment denial on record. Review inspection reports carefully.
- • 52 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $122,236 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (3/100). Below average facility with significant concerns.
Bottom line: Trust Score of 3/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Haven Of Farmer City's CMS Rating?
CMS assigns THE HAVEN OF FARMER CITY 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 The Haven Of Farmer City Staffed?
CMS rates THE HAVEN OF FARMER CITY's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 39%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at The Haven Of Farmer City?
State health inspectors documented 52 deficiencies at THE HAVEN OF FARMER CITY during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 46 with potential for harm, and 3 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 The Haven Of Farmer City?
THE HAVEN OF FARMER CITY 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 HAVEN HEALTHCARE, a chain that manages multiple nursing homes. With 56 certified beds and approximately 45 residents (about 80% occupancy), it is a smaller facility located in FARMER CITY, Illinois.
How Does The Haven Of Farmer City Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, THE HAVEN OF FARMER CITY's overall rating (1 stars) is below the state average of 2.5, staff turnover (39%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting The Haven Of Farmer City?
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?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is The Haven Of Farmer City Safe?
Based on CMS inspection data, THE HAVEN OF FARMER CITY has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Haven Of Farmer City Stick Around?
THE HAVEN OF FARMER CITY has a staff turnover rate of 39%, which is about average for Illinois nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was The Haven Of Farmer City Ever Fined?
THE HAVEN OF FARMER CITY has been fined $122,236 across 1 penalty action. This is 3.6x the Illinois average of $34,301. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is The Haven Of Farmer City on Any Federal Watch List?
THE HAVEN OF FARMER CITY is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.