FRANKFORT TERRACE
For profit - Corporation
120 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
48/100
#236 of 665 in IL
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Frankfort Terrace has received a Trust Grade of D, which means it is below average and raises some concerns about the quality of care provided. It ranks #236 out of 665 nursing homes in Illinois, placing it in the top half, but it is only #6 out of 16 in Will County, indicating that there are five local facilities that may offer better options. The facility is showing improvement, with issues decreasing from 11 in 2024 to just 1 in 2025, which is a positive sign. Staffing is relatively stable, with a turnover rate of 34%, better than the state's average, and there is good RN coverage, as they have more registered nurses than 92% of Illinois facilities. However, there are serious concerns, including an incident where hazardous chemicals were left unsecured, posing a significant risk to residents, as well as failures in food safety and sanitation practices in the kitchen. While the facility has no fines on record, which is a positive aspect, the presence of critical safety issues suggests families should weigh both strengths and weaknesses carefully when considering this nursing home.
- Trust Score
- D
- In Illinois
- #236/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 34% turnover. Near Illinois's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Illinois facilities.
- Skilled Nurses ○ Average
- Each resident gets 39 minutes of Registered Nurse (RN) attention daily — about average for Illinois. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Top 35%
Review needed
11 → 1 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 1 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (34%)
14 points below Illinois average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Illinois average (2.5)
Meets federal standards, typical of most facilities
Staff Turnover: 34%
11pts below Illinois avg (46%)
Typical for the industry
The Ugly 29 deficiencies on record
1 life-threatening
Jul 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
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to maintain a comfortable environment. This applies to 4 of 6 (R1, R2, R4, R6) residents reviewed for elevated environmental tempe...
Read full inspector narrative →
Based on observation, interview and record review the facility failed to maintain a comfortable environment. This applies to 4 of 6 (R1, R2, R4, R6) residents reviewed for elevated environmental temperatures in a sample of 7. Based on observation, interview and record review the facility failed to maintain a comfortable environment. This applies to 4 of 6 (R1, R2, R4, R6) residents reviewed for elevated environmental temperatures in a sample of 7.Findings include.
On 7/9/25 at 12:37 PM, residents were interviewed during lunch service. R1 stated she is hot everywhere she goes, and her room is very warm. R1 stated she was provided with a fan, but it is not sufficiently cooling her room. R1 stated the lobby and staff offices are cool.
R2 stated her room was too hot and she was not provided with a fan.
R4 stated the dining room temperature was comfortable, but her room was too warm.
R6 stated only the dining room was comfortable.
On 7/9/25 at 2:42 PM, room temperatures were taken with V6 (Maintenance Director). R1's room temperature with a fan was 81.8 degrees F (Fahrenheit). R2's room temperature was 82.2 degrees F. R4's room temperature was 82.2 degrees F. R6's room temperature was 81.8 degrees F.
On 7/9/25 at 3:05 PM, the weather app showed outside temperatures for the area at 85 degrees F.
On 7/9/25 at 4:18 PM, V1 Administrator stated she had just been informed of the elevated resident room temperatures. V1 stated she does not follow a hot weather bulletin or receive hot weather alerts.
On 7/9/25 at 4:36 PM, V6 (Maintenance Director) stated environmental temperatures are done three times per day in the front corridor, down each hallway and two or three random resident rooms down each hallway. V6 stated when temperatures are above 80 degrees F he is to report it to his supervisor. V6 that was the first time environmental temperatures were above 80 degrees F.
Review of the environmental temperature logs provided show on 6/26 temperature logs were done three times in the resident halls and dining area. No environmental temperatures were measured in resident rooms.
On 6/26 at 11:40 AM all environmental temperatures logged were over 80 degrees F (Fahrenheit) with the highest being 83.1 degrees F. On 6/26 at 3:30 PM the second environmental temperature done shows all temperatures above 80 degrees F with the highest reading of 85.5 degrees F.
On 6/26 at 8:30 PM, three hallways measured over 80 degrees F with the highest reading of 80.6 degrees F. On 6/27 at 2:54 PM environmental temperatures were only conducted once and all temperatures measured over 80 degrees F with the highest reading at 83.2 degrees F. On 7/3 temperatures were logged twice. At 9PM environmental logged were over 80 degrees with the highest reading of 81.6 degrees F. On 7/4 temperatures were logged twice. At 9PM environmental logged were over 80 degrees with the highest reading of 81.6 degrees F. No hourly temperatures logs were provided for day with temperatures above 80 degrees F.
The facility Hot Weather / Heat Emergencies policy date 11/1/2020 states the administrator will be aware of the weather forecast of extreme temperatures and comfort levels inside the facility. Maintenance Director will monitor the facility's air conditioning to ensure that all are in good working order. The Maintenance Director will monitor temperatures to ensure that air temperatures in the facility maintain comfortable temperature range of 71- 80 degrees F. If temperatures increase reading will be taken every hour.
Jun 2024
11 deficiencies
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** Based on interview and record review the facility failed to invite residents to their interdisciplinary care plan meeting. This ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to invite residents to their interdisciplinary care plan meeting. This applies to 2 of 2 residents (R21 and R76) reviewed for care planning in a sample of 28 residents.
Findings include:
1. R21 admitted to the facility on [DATE]. R21 has diagnoses that includes schizophrenia, venous insufficiency, gastro-esophageal reflux disease, hypertensive heart disease, hyperlipidemia, peripheral vascular disease, osteoarthritis, scoliosis, osteoporosis, and bipolar disorder. R21 MDS (Minimum Data Set) dated 5/1/24 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. R21's care plan dated 5/13/24 states the residents demonstrate strong activity participation as evidence by joining a variety of group programs, actively participating in, and supporting resident council.
On 6/6/24 at 10:45 AM, R21 stated she did not remember the last time she was invited to a care plan meeting.
2. R76 readmitted to the facility on [DATE]. R76 has diagnoses that includes paranoid schizophrenia, obesity, type 2 diabetes, dorsalgia, gastro-esophageal reflux disease and vitamin d deficiency. R76's MDS (Minimum Data Set) dated 4/26/24 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15.
On 6/4/24 at 11:01 AM, R76 stated she did not know anything about care plan meetings and had not been invited to any. R76 stated it would be a good idea to participate in her care plan meetings.
On 6/6/24 at 1:48 PM, V11 MDS Coordinator stated R21 and R76 have not been present during their interdisciplinary care plan meetings. V11 stated there is no documentation of R21 or R76 being invited to their care plan meetings. V11 stated there is no documentation of R21 or R76 declining to participate in their care plan meetings.
On 6/6/24 at 2:09 PM, V1 Administrator stated residents should be invited to their care plan meetings, so they know what is going on with them and their plan of care. V1 stated there should be documentation they were invited to their care plan.
The facility policy Care Plan Development dated 3/2021 states the facility's Interdisciplinary team, in consultation with the resident and his/her representative, develops and implements a person-centered care plan for each resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician's order for 1 resident (R92) in a ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician's order for 1 resident (R92) in a sample of 27.
Findings include:
R92 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including schizophrenia, type 2 diabetes & osteoarthritis.
On 06/04/24 at 11:13 AM, R92 was observed in her room with no braces on her wrist. There were 2 braces observed on her chair in her room at that time. R92 stated she wears braces on her wrists, but no one will come to help her to put it on. R92 stated, I can't put it on myself. The CNAs (Certified Nurse's Assistants) don't come to help put it on. I feel I should get the same help as everyone else, and I don't. R92 was observed crying as she was speaking. R92 said They know I have to wear the braces every day and that they are to put them on me, and they don't come.
R92's 3/7/24 MDS section C showed that R92 cognition is intact & section GG Personal Hygiene showed that R92 needs substantial to maximal assistance. On 6/06/24 at 12:42 PM, R92's progress notes were reviewed for last 30 days and no notes were observed for refusing care. R92's Task ADL care 30 day look back from 5/8/24 to 6/6/24 showed no documentation of refusal for ADL care. R92's 20 day look back for behavior monitoring and interventions from 5/8/24 through 6/6/24 showed no behaviors observed. R92's 5/31/24 physician order showed, Bilateral volar wrist braces for wrist osteoarthritis. May take the brace off for bathing, eating and for breaks as needed. Avoid axial loading and heavy lifting with wrist every shift for Wrist Osteoarthritis.
On 06/06/24 at 02:33 PM, V2 DON (Director of Nursing) stated that if a resident has an order for braces on their wrist and they ask staff to put them on staff should put them on. V2 said that staff should ensure that residents braces are on them. On 06/06/24 at 10:54 AM, V1 (Administrator) said that if a resident has an order for braces on their wrist, they should have them on. V1 stated that if a resident asks staff to put the braces on, the staff should put them on.
The facility's Physician Orders-verbal and Fax (3/2021) showed under Procedure: Follow through with the orders as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adaptive eating utensils to a resident with up...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adaptive eating utensils to a resident with upper extremity impairments.
This applies to 1 of 1 resident (R5) reviewed for adaptive utensils.
The findings include:
R5 a [AGE] year-old admitted to the facility on [DATE] with multiple diagnoses which included dementia with behavioral disturbance, pressure ulcer of right buttock, diabetes, hypertensive heart disease, epilepsy, peripheral vascular disease, intellectual disabilities, schizophrenia, chronic obstructive pulmonary disease, and polyosteoarthritis per the face sheet.
R5's MDS (Minimum Data Set) dated 03/22/24 showed R5 was cognitively impaired. The same MDS showed R5 had impairments to both upper and lower extremities.
On 06/04/24 at 1:05 PM R5 was sitting in the dining room, at the table. R5 was being fed a mechanical soft diet by V16 (Certified Nursing Assistant). R5's meal card provided by the dietary department showed R5 was supposed to have a special spoon with meals. R5 did not have a special spoon during lunch. On 06/06/24 at 9:01 AM R5 was sitting at dining room table eating breakfast. R5 was being fed by V15 (Certified Nursing Assistant). Resident continues to not have the special spoon per the meal card for breakfast.
On 06/04/24 at 1:05 PM V16 said R5 feeds himself at times. V6 stated R5 fed himself this morning for breakfast.
On 06/06/24 at 1:30 PM V9 (Dietary Manager) stated R5 is fed at times but he can feed himself if he is not wound up. V9 stated R5 has a blue divider plate but does not have special utensils. V9 said when R5 feeds himself, he eats with the regular utensils. V9 stated she has no knowledge of R5 using special utensils and there are none in the kitchen for him. V9 stated R5 may have difficulties feeding himself without the proper eating utensils.
On 06/06/24 at 3:22 PM V2 (Director of Nursing) stated he was not aware R5 required the use of an adaptive spoon for meals. V2 said R5 can feed himself. V2 said if the proper utensils are not given to R5, he may not get the proper nutrition and can lose weight. V2 said the kitchen should make sure R5 has the proper eating utensils. V2 said the facility does not have a policy for adaptive utensils, we follow the recommendations of the therapy department.
R5's meal card showed a blue plate and a special spoon. R5's dietary care plan initiated 06/03/24 showed adaptive equipment: blue plate and special spoon as an intervention dated 03/22/24.
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 contain respiratory equipment for 2 residents (R38 & R42) in a sample of 27.
1. On 06/04/24 at 11:00 AM R38's BIPAP (bilevel ...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to contain respiratory equipment for 2 residents (R38 & R42) in a sample of 27.
1. On 06/04/24 at 11:00 AM R38's BIPAP (bilevel positive airway pressure) mask and O2 nasal cannula was observed not covered. R38 said I use my BIPAP ever night and the oxygen as needed.
R38's electronic medical record showed that she has diagnoses including chronic obstructive pulmonary disease with acute exacerbation, asthma & sleep apnea. R38's 2/19/23 physician order showed, oxygen as needed for COPD (chronic obstructive pulmonary disease), & 12/19/23 Physician order showed, BIPAP at night at bedtime for COPD.
2. On 06/04/24 10:36 AM R42's CPAP mask (continuous positive airway pressure) and O2 nasal cannula was observed not covered. R42 stated, I use my CPAP every night at 10pm.
R42's electronic health record showed that R42 has diagnoses including chronic respiratory failure and obstructive sleep apnea. R42's 6/11/23 physician's order showed oxygen as needed via nasal cannula at 2 liters per minute. R42's 6/11/23 physicians order showed O2 while on CPAP every night related to obstructive sleep apnea.
On 06/06/24 at 10:35 AM, V1 (Administrator) stated that the machines should be stored and covered for infection control when not in use. On 06/06/24 at 2:33 PM, V2 DON (Director of Nursing) stated respiratory equipment including masks and nasal cannula should be contained or covered when not in use. V2 stated that the staff are to ensure that they are contained when they do rounds.
The facility's CPAP - BIPAP guideline dated 3/2021 does not show how the equipment should be contained when it is not in use.
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 store and label medications properly.
This applies to...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store and label medications properly.
This applies to 1 of 1 resident (R48) reviewed for medication storage in the sample of 28.
The findings include:
On 06/05/24 at 9:00 AM The medication storage cabinet located inside of the nursing office contained a clear storage bag. R48 had three medications stored in the bag. The medications included: 1) Terconazole Cream 0.4% with directions to insert one applicator vaginally at bedtime until 06/01/24. The cream did not have a cap on it, and there was one applicator left in the box. 2) Ketoconazole shampoo 2% and 3) Albuterol Sulfate 0.083%. The medications were not stored in separate bags. The clear storage bag was not labeled.
On 06/05/24 at 9:15 AM V2 (Director of Nursing) stated R48's vaginal medication was completed on 06/01/24 but the shampoo and nebulizer solution were still an active order. V2 stated the vaginal medication should not be stored with any other medications. V2 stated medications that residents take by mouth or inhalation should be separate from vaginal medications. V2 stated medications stored in bags should be labeled.
R48 was [AGE] years old. R48 was admitted to the facility on [DATE] with multiple diagnoses which included schizophrenia, chronic obstructive pulmonary disease, and candidiasis of skin and nail.
R48's order summary showed R48 was ordered Terconazole Vaginal Cream 0.4% on 05/24/24 and completed on 06/01/24. R48's current physician orders showed Albuterol Sulfate Inhalation Nebulization Solution and Ketoconazole External Shampoo 2%.
The facility's Medication Storage Policy dated 03/2021 showed: Guideline- the facility maintains proper store of a variety of medications in accordance to the pharmacy recommendations and regulatory guidelines. Procedure- 4) Medications that have a different route from oral are kept separated and when appropriate in labeled and dated bags in the cabinets. 8) Discontinued medications are disposed of per facility policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
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 respect residents' right to make choices about their diet. This appl...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to respect residents' right to make choices about their diet. This applies to 3 of 3 residents (R47, R57 and R101) in a sample of 28 residents.
Findings include:
On 6/4/24 at 12:43 PM during lunch resident were observed eating a plain turkey burger with cheese, a few tater tots, and a cup of shredded pineapple.
1. R47 admitted to the facility on [DATE]. R47 has diagnoses that includes schizophrenia, prediabetes, iron deficiency anemia, obesity, hypertensive heart disease and bipolar disorder. R47's current Physician order is no added salt diet regular thin liquids, milk with all meals per resident's request. R47's physician orders do not include a caloric limit or order limiting food intake. R47's MDS (Minimum Data Set) dated 5/21/24 shows he is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15.
On 6/4/24 at12:43 PM, R47 stated he is not given extra food when he asks for it. R47 stated residents aren't allowed extra food unless they have double portions ordered.
2. R57 admitted to the facility on [DATE]. R57 has diagnoses that includes major depressive disorder, hyperlipidemia, type 2 diabetes, obesity, hypokalemia, alcohol abuse, anxiety, migraines, and hypertensive heart disease. R57's physician diet order is no added salt no concentrated sweets regular texture, thin liquids. R57's physician orders do not include a caloric limit or order limiting food intake. R57's MDS (Minimum Data Set) dated 4/1/24 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15.
On 6/4/24 at12:43 PM, R57 stated she can't get second helpings of food if she is still hungry. R57 stated the meals are not filling. R57 stated when you're in a place like this there is usually nothing to look forward to except a good meal.
3. R101 admitted to the facility on [DATE] with diagnoses that includes major depressive disorder, gastro-esophageal reflux disease, basal cell carcinoma, hypertensive heart disease, chronic rhinitis, and suicidal ideations. R101 physician diet order is no added salt regular texture, regular thin liquids. R101's physician orders do not include a caloric limit or an order limiting food intake. R101's MDS (Minimum Data Set) dated 5/7/24 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15.
On 6/4/24 at12:43 PM, R101 stated this isn't enough food for a child. R101 stated residents are not allowed to get second helpings of food. R101 stated she would get food from the vending machine when she gets hungry, but she did not have money for the vending machine,
On 6/04/24 at 1:28 PM, V12 Dietary Aide stated there are no second helpings served to residents even if there is extra. Only resident that are on double portions are given extra food.
On 6/04/24 at 1:28 PM, V9 Dietary Manager stated there are no second helpings for anyone that does not have double portions ordered.
On 6/4/24 at 1:57 PM, V13 CNA (Certified Nursing Assistant) stated only residents that get double portions receive extra food. All other residents receive a single serving of their meal and are not given second helpings.
On 6/6/24 at 2:09 PM, V1 Administrator stated If residents are still hungry, they will be provided a second helping. If there isn't enough for seconds, we can give them something else to eat.
The facility did not provide a policy regarding resident meal choices and restrictions.
CONCERN
(D)
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 provide mental health rehabilitation services to a res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide mental health rehabilitation services to a resident identified with a serious mental health condition.
This applies to 1 of 1 resident (R74) reviewed for mental health rehabilitative services in the sample of 28.
The findings include:
On 06/04/24 at 10:31 AM R74 was lying in bed. R74 stated she does not attend group meetings. R74 stated she doesn't do much since she does not attend group. R74 stated the staff does not try to encourage her to go to group. On 06/05/24 at 4:15 PM R74 was lying in bed. R74 stated she did not attend any group sessions today. R74 said no one invites her to groups, and she does not know the dates or times they are held. R74 said if she was invited to groups, she would attend. On 06/06/24 at 9:14 AM R74 continued to be lying in the bed. R74 said since the facility does not offer her anything to do, she lays in the bed and sleeps all day. R74 said she seldom attends activities, and no staff members comes to talk to her. R74 said she does not talk to social services or counselors.
On 06/06/24 at 9:32 AM V14 (Psychiatric Rehabilitative Services Director) said he just started at the facility two weeks ago. V14 said R74 does not attend any groups. V14 said the last time R74 attended a group session was in February 2024. V14 said he does not have documentation showing R74 refused any programming. V14 said R74 has not been invited to groups or have been seen by the psychologist. V14 said R74 does not receive any outside services. V14 said residents with psychiatric diagnoses should not lay in bed all day and should receive services from the psychologist. All residents should be involved in counseling, programs, or group. V14 said residents in the facility should attend groups or 1:1 counseling. The social services department should invite residents to group and provide 1:1 counseling to residents. V14 said the facility did not have a policy for groups and therapy.
R74 was [AGE] years old. R74 was admitted to the facility on [DATE] with multiple diagnoses which included schizophrenia, generalized anxiety disorder, Alzheimer's Disease with early onset per the face sheet.
R74's MDS (Minimum Data Set) dated 05/03/24 showed R74 was cognitively intact. The same MDS showed R74 required supervision or touching assistance with all ADL's (Activities of Daily Living).
R74's PASRR (Preadmission Screening and Resident Review) II dated 08/29/23 showed R74 was eligible for nursing facility placement. The same screening showed R74 required the following rehabilitative services: 1) Consistent implementation during the resident's daily routine and across settings, of systemic plans which are designed to change inappropriate behaviors. 2) Provision of a structured environment for those individuals who are determined to need such structure (e.g., structured socialization activities to diminish tendencies toward isolation and withdrawal). 3) Development, maintenance, and consistent implementation across settings of those programs designed to teach individuals daily living skills necessary to become more independent and self-determining including, but not limited to, grooming, personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of the living environment. 4) Individual, group, and family psychotherapy.
R74's social services progress notes from 01/29/24-06/06/24 were reviewed. On 02/07/24 and 02/12/24 R74 had 1:1 anger management session provided by the counselor. No other documentation regarding group or 1:1 found in R74's EMR (Electronic Medical Record).
R74's psychosocial care plans initiated 05/02/23 showed interventions: to encourage participation in activities and psychosocial group, re-educate and counsel resident on the benefits of attending/being compliant with psychosocial programming, remind resident of time/dates of programs and provide with a schedule as applicable.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, & record review, the facility failed to provide ADL care (activities of daily living) to 4 0f 4...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, & record review, the facility failed to provide ADL care (activities of daily living) to 4 0f 4 residents dependent of ADL care (R3, R42, R83 & R92) in a sample of 28.
Findings include:
1. On 06/05/24 at 11:07 AM R3 was observed with facial hair on her chin. R3 stated that she did not know the last time she was shaved and that she wanted the staff to shave her.
R3's electronic health record showed that she is an [AGE] year-old female admitted to the facility with diagnoses including paranoid schizophrenia, scoliosis, spinal stenosis, and polyosteoarthritis. R3's 5/1/24 MDS (Minimum Data Set) Section GG - personal hygiene showed that R3 is dependent on staff for care. A review of R3 electronic health records was conducted on 06/06/24 at 1:40 PM and it showed under Task GG- Personal Hygiene - no documentation for the last 6 months. R42's 30 day look back for Behavior Monitoring and Interventions from 5/8/24 - 6/6/24 showed no behaviors observed and the 30 days look back for ADL care for 5/8/24 - 6/6/24, did not show any refusal of ADL care.
2. On 06/04/24 at 10:36 AM R42 was observed with facial hair on her upper lip and chin. 06/05/24 at 12:54 PM R42 was again observed with facial hair on her upper lip and chin. R42 stated It has been over a week or so since anyone shaved me. It bothers me and I have asked them to shave me, and I am going to ask them again today.
R42's electronic health record showed that she is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, type 2 diabetes and polyosteoarthritis. R42's 4/30/24 MDS section GG Personal hygiene showed that R42 needs partial to moderate assistance with personal hygiene. R42's Task GG showed no documentation no progress notes for last 6 months. R42's Progress notes were reviewed with no notes showing any refusal of ADL care. R42's 30 day look back for Behavior Monitoring and Interventions from 5/8/24 - 6/6/24 showed no behaviors observed and the 30 days look back for ADL care for 5/8/24 - 6/6/24, did not show any refusal of ADL care.
3. On 06/04/24 at 1:41 PM, R83 was observed with long jagged toenails, about a half an inch over her toes. R83 stated that it had been about a month since the podiatrist cut them, & that it bothers her that they are so long. R83 said, I told the staff and they said that they will get to it. R83 said that was the day before on 6/5/24.
R83 electronic health record showed that she is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including bipolar disorder & type 2 diabetes. The facility Podiatry list for 5/7/24. R83 was on the list but the list did not indicate if she had been seen or refused as it did for all of the other residents. The facility was asked to produce the podiatrist progress notes for the resident and was unable to produce a note from the Podiatrist for services for R83 on 5/7/24. On 06/06/24 at 1:30 PM a record review for the last 60 days of R83's progress notes did not show any documentation of R83 refusing care including nail care and no progress notes for 5/7/24 podiatry care. R83's 3/21/24 MDS section C showed that R83's cognition is intact and section GG - Personal Hygiene showed that R83 needs supervision or touching assistance with personal hygiene. R83's Task - Behavior Monitoring & Interventions 30 day look back from 5/8/24 - 6/6/24 showed no behaviors observed and the 30 days look back for ADL care for 5/8/24 - 6/6/24 did not show any refusal of ADL care. R83's Task GG- Personal hygiene - showed no progress notes for the last 6 months.
4. On 06/04/24 at 11:13 AM R92 was observed with long jagged toenails. R92 said I can't remember the last time they were cut they reach/touch my shoes. They have a podiatrist here, but I have not seen him. On 06/04/24 at 1:22 PM R92 was observed with short, jagged fingernails. R92 said They need to be filed and I asked the staff, but they won't file them. R92 said that after the staff cut her nails, she asked them to file them, but they wouldn't do it.
R92's electronic health record showed that she is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including schizophrenia, polyosteoarthritis, and type 2 diabetes. R92's 3/7/24 MDS section C showed that R92 cognition is intact & section GG Personal Hygiene showed that R92 needs substantial to maximal assistance. On 6/06/24 at 12:42 PM, R92's progress notes were reviewed for last 30 days and no notes were observed for refusing ADL nail care. R92's Task ADL care 30 day look back from 5/8/24 to 6/6/24 showed no documentation of refusal for ADL care. R92's 20 day look back for behavior monitoring and interventions from 5/8/24 through 6/6/24 showed no behaviors observed.
On 06/04/24 at 2:17 PM, V2 DON (Director of Nursing) stated that as of this day no one is on the list to be seen by podiatry for this month. On 06/04/24 at 2:17 PM, V3 ADON (Assistant Director of Nursing) stated - the podiatrist comes every 6-8 weeks and as needed if we request them to come. V3 stated that the staff have the emery boards to file the nails when it is needed. On 06/06/24 at 2:33 PM V2 DON stated that the staff should be shaving the women and that nail care depends on if the resident is a diabetic or not. V2 stated that staff should notify the nurse so they can put the residents on the podiatry list, or the nurse can cut the nails. V2 state that he usually cuts the nails himself. V2 stated Last week I cut R92's nails and the nails could not be cut down anymore because of calluses on the nails. I told R92 that I would put her on the list to see the podiatrist. I did not put her on the list that was an oversite on me. I looked at her nails today and yes, they are long and jagged, but they are long because of the calluses, and they are jagged, but I did not file them, that is on me. V2 stated that if the residents refuse ADL care, they let the nurse know and we document that they refused. V2 said he had no knowledge of the residents refusing nail care or shaving and there is no documentation for R3, R42, R83 & R92 refusing nail care or shaving. On 06/06/24 at 10:41 AM, V1 (Administrator) said that if a resident asks for assistance with ADL care and requires assistance, staff should provide it. V1 said that staff should observe residents' nails when they give showers and notify the nurse if they need nail care.
The facility's Nail Care policy date 3/2021 showed routine nail care helps reduce the potential for infection, prevents intrusion of the nail into the skin, prevents possible injuries and promotes a feeling of well-being for the residents. The policy showed under, Standard: nail care is a routine part of grooming each day. The policy showed under Procedure: clip one nail at a time and file the fingernails in an oval shape, file toenails straight and do not leave any edges. Determine the resident's preferred nail length.
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 properly label, date, seal, and store food items in t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen and use proper sanitation while checking food temperatures.
This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.
Findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 6/4/24 documents that the total census was 101 residents. On 6/4/24 at 10:49 AM, V9 (Dietary Manager) said there are no NPO (Nothing by Mouth) residents. All 101 residents eat from the facility kitchen.
On 6/4/24 starting at 10:00 AM, the facility kitchen was toured in the presence of V9 (Dietary Manager) and the following was found:
In the dry storage room refrigerators:
1. An opened bag of shredded lettuce, not labeled or dated with browning lettuce and yellow liquid in the bottom of the bag.
2. A bag of unlabeled and undated diced meat with yellow liquid in bottom of bag. V9 said it was diced turkey.
3. A partially sliced yellow onion in a resealable bag dated 5/20.
4. A half empty gallon of 2% reduced fat milk with best by date of May 27th.
5. A full gallon of 2% reduced fat milk with best by date of May 27th.
In the kitchen refrigerators:
6. A resealable bag of salami deli meat that is not labeled or dated.
7. An unlabeled medium sized bin of opened various deli meats dated 5/30/24 with yellow liquid in bottom of bin that meat is sitting in. V9 said the meats were turkey ham, turkey baloney, and turkey salami.
8. Half of a deli ham dated 5/23/24 sitting in pink liquid in a medium sized silver bin.
9. A pork roast dated 5/9/24. V9 said it is defrosting for later in the week, but there is no defrost date on it to show when/if it was moved from freezer to refrigerator.
In the dry storage:
10. The dry storage room is filled with boxes stacked on top of boxes of dry foods. Surveyor unable to reach or see the food on the shelves on one side of the room and unable to fully open the refrigerator doors on the opposite side of the room due to boxed food items that have not been appropriately stocked. V9 said the last delivery came on 6/3/24 in the evening. The boxes have multiple delivery dates, some of the boxes were delivered on 5/23/24, some on 4/22/24, and some on 4/8/24.
11. A 14.5 ounce can of diced green sweet bell peppers with a large dent in can on the circulation rack.
12. A 1 gallon tub of grape jelly with lid not sealed and sticky red residue on the handle and the lid of the tub. When surveyor lifted tub off the shelf, a fly flew off the tub.
13. On 6/5/24 at 12:06 PM during a return to the kitchen tour, a 20-gallon flour bin was found with a Styrofoam cup inside used for scooping and a sticky brown substance under the lid of bin.
14. On 6/5/24 at 12:19 PM, while testing lunch food temperatures, V10 (Cook) wiped the thermometer with the same paper towel between each of the 7 food items, he did not clean/sanitize the thermometer probe.
On 6/6/24 at 1:04 PM, V9 (Dietary Manager) stated all foods in the kitchen should be labeled and dated for food safety and for kitchen staff to be able to follow the first in, first out rule. V9 said all foods should be sealed to prevent pests or debris from contaminating the food. V9 said dented cans should be removed from circulation to prevent the food from being fed to residents and risking the residents getting sick or botulism. V9 said the food items should be stocked/put away after delivery and boxes should not be sitting on the floor because of the risk of contamination. V9 said if foods are not stocked/put away on shelves the FIFO (First In, First Out) rule is not being appropriately followed. V9 said expired foods should be discarded so the foods are not accidentally fed to residents with potential for foodborne illness. V9 said no Styrofoam cup or scooper should be stored in the flour bin because the cup could be contaminated and then contaminate the whole bin of flour. V9 said when V10 (Cook) checked food temperatures, he should have sanitized the thermometer with an alcohol wipe in between each food item to prevent the possibility of contamination and mixing foods.
The facility's undated policy titled, Food Storage states, Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: 1. Label and date foods and put foods away promptly. 2. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of foods. a. old stock is always used first (first in- first out method). b. Supervise the person designated to put stock away to make sure it is rotated properly. c. Food should be dated as it is placed on the shelves if required by state regulation. d. Date marking to indicate the date or day by which a ready-to-eat, time/temperature control for safety food should be consumed, sold, or discarded will be visible on all high-risk food. e. Foods will be stored and handles to maintain the integrity of the packaging until ready for use .
The facility's undated policy titled, Dry Storage Areas states, Policy: Dry storage areas will be kept in a condition which protects stored foods from infestation. Procedure: 1. Foods will be received, checked, and stored properly as soon as possible after delivery. 2. All items must be stored at least 6 inches off the floor .There must be adequate space on all sides of stored items to permit ventilation. 3. Floors, walls, shelves, and other storage areas will be kept clean .5. Dented cans without leaking or compromised seal will be stored separately in designated/labeled area . Care of the Storeroom [ROOM NUMBER]. Staff will maintain the care of the storeroom according to the following directions. a. All food will be arranged in the storeroom logically, with similar food stored together. b . New stock will be placed behind previously delivered items so that older stock will be used first . d. The storeroom will be cleaned on a regular basis. Floors will be swept and mopped at least weekly and more often as needed .
The facility's provided undated document titled, Cold Storage Chart, USDA shows .Luncheon meats in opened package are good in the refrigerator for 3-5 days .
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 and document measure that prevent the waterborne pathogen Legionella and provide an up-to-date infection control policy. \This app...
Read full inspector narrative →
Based on interview and record review the facility failed to implement and document measure that prevent the waterborne pathogen Legionella and provide an up-to-date infection control policy. \This applies to all 101 residents that resided in the facility.
Findings include:
On 6/6/24 at 12:48 PM, V4 Maintenance Director stated corporate is responsible for testing for legionella and would have the reports. V4 stated he never heard of legionella. V4 stated each wing has hot water heater. V4 stated the last time he checked water temperatures was in March 2024. V4 stated he wasn't documenting because there were problems with the water heaters giving accurate temperatures. V4 Maintenance Director stated the resident and staff would tell him when the water temperatures dropped to make sure it was up to par.
On 6/6/24 at 2:09 PM, V1 Administrator stated the facility uses well water and city tests the water for legionella. V1 stated water temperatures should be tested daily so if there is a problem, we know about it.
On 6/6/24 at 3:00 PM V1 Administrator stated there is no infection control policy. V1 stated the facility has an infection control program. V1 stated she did not know when the program was last reviewed. V1 stated we don't have to test for legionnaires according to our corporate. V1 stated we do not have to do water flushing according to the water management program.
On 6/6/24 at 3:17 PM, V4 Maintenance Director stated he does water flushing of the water heaters randomly monthly. V4 stated he does not log the flushing and did not know he was supposed to. V4 stated he called the city, and they test for legionella. The report goes on the bill and the bill goes to corporate.
On 6/6/24 at 01:02 PM, V17 Infection Preventionist confirmed the undated document Infection Control and Surveillance Program was the facilities infection control policy. Documents provide as part of the infection control program includes Antimicrobial / Antibiotic Stewardship program dated 4/2020. Covid and Influenza dated 12/2020. Coronavirus dated 3/21. Care of residents with Covid 19 dated 5/13/20. Flu / Pneumovax Vaccine Dated 7/2022.
The facilities undated Water Management Program for Legionella identifies control measures of temperatures at a variety of points. The program does not indicate the frequency or appropriate temperatures to control Legionella. Examples provided of what to do when controls are not met includes daily flushing of sink and showers, emptying of the ice machines and cleaning per manufactures instructions and testing of water. The last document water temperature check was done 3/21/24. The Village water report provided by the facility dated April / May 2024 does not list Legionella testing.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to have a fully functioning call light system.
This applies to all residents residing at the facility.
Findings include:
The f...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to have a fully functioning call light system.
This applies to all residents residing at the facility.
Findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 6/4/24 documents that the total census was 101 residents.
On 06/04/24 at 11:13 AM, R92 was observed in her room and R92 said that she turned her call light on for staff to come down to put her brace on and nobody came down. At 11:24 AM R92 turned her call light on again. R92 said, I told my case manager that it is hard to get a CNA (Certified Nurse's Assistant) to come down to my room to help me. I feel I should get the same help as everyone else, and I don't. R92 was observed crying as she was speaking. At 11:31 AM the surveyor went to the nurses' station where the call light board was located and saw that R92's call light was on but not alarming. At that time V11 MDS (Minimum Data Set) Coordinator was observed in the nurse's station making the first announcement over the facility's overhead pager system that R92's call light was on.
On 06/04/24 at 11:33 AM, V5 (Nurse) was in the nurse's station and said that sometimes the call light system will sound and sometimes it will not.
On 06/04/24 at 11:35 AM, V6 (Nurse) was in the nurse's station and said that the call light system buzzer is to stay on the whole time the light is on. V6 said that sometimes no one is in the nurse's station to see or hear the call lights come on.
On 06/04/24 at 11:44 AM, V4 (Maintenance Director) was in the nurse's station and said that the call light and buzzer is supposed to stay on until it is answered.
On 06/04/24 at 11:47 AM the State Surveyor and V4 were in the nurse's station while the call light was being tested in a room and the call light showed the room, but it did not sound or buzz. At 11:48 AM the system was tested in another room and the system sounded/buzzed once but the board did not show what room was calling. At 11:48 AM, V4 said, I'm not going to make any excuses it's not working right. The last time I tested it was probably last month. I don't keep a log. V4 continued testing the system, at 11:54 AM the board lit up indicating a room, but it did not buzz/sound. At 11:55 AM the system buzzed once but the board did not light up indicating which room.
On 06/04/24 at 12:54 PM V7 (Nurse) said that since she started in March 2024, she could not recall the call light system sounding a continuous buzzing while the call light was on.
On 06/04/24 at 1:04 PM, V6 (Nurse) said that she has worked at the facility for 18 years and the last time she heard the call light system work properly was at least a month ago. V6 said that now the system will just chirp, or it will chirp and no light will come on. V6 said that she has told V4 about the call light system not working but she is not sure if she told V4 that the system doesn't continue to buzz until the light is turned off like it is supposed to. V6 said she should have reported it because if the call lights are not working someone could need help and they wouldn't know.
On 06/04/24 at 1:11 PM, V5 (Nurse) said that she has worked at the facility for 2 years and she did not recall the system buzzing continuously when the call light is turned on until it is turned off.
On 06/04/24 at 1:15 PM, V8 CNA (Certified Nurse's Assistant) said that they only know that the residents' call lights are on is when the nurses notify them.
On 06/04/24 at 12:40 PM, V1 (Administrator) said that she did not know the last time the facility check the call light system and doesn't know how often it should be checked.
Facility's call light policy dated 3/2021 showed that all defective call lights are to be reported to the nurse supervisor and or maintenance director.
Jul 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure that their environmental temperature was comfortable and within acceptable range.
This applies to 5 of the 5 resident...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure that their environmental temperature was comfortable and within acceptable range.
This applies to 5 of the 5 residents (R1, R2, R3, R4, R5) reviewed for environmental temperature in the sample of 5.
The findings include:
On 7/27/23 from 12:32 PM through 3:21 PM, intermittent observation of the facility's environmental temperature was conducted with V4 (Maintenance Director) and V5 (Housekeeping Manager). The facility was warm all over the residents' area such as the dining/day room, A, B, C, D, and E hallways. During the observation on 7/27/23, the following were noted: At 12:32 PM, majority of the residents were in the day/dining room during lunch time. V4 (Maintenance Director) checked the temperature in the different spots of the dining room. The results came out between 82.7 to 84 degrees Fahrenheit (F) despite having a portable air-conditioning fan in one of the corners of the dining area. At 12:59 PM, V4 stated that the humidity is high. The air conditioner is overworking because it's very hot. It was not pumping adequately. V4 also stated that some residents open their windows which affects the flow of cold air.
From 12:47 through 1:30 PM, the A, B, C, D, E hallways and random bedrooms were checked for the temperature which showed readings within acceptable ranges, however at 1:15 PM, R1 was in her bedroom. The room was warm and humid. The window was closed. R1 stated that her room was very warm, sometimes it really bothers her. R2 (R1's roommate) came in and stated that their room was very warm and uncomfortable. Additional temperatures were taken at 2:25 PM through 3:30 PM with V5 (Housekeeping Manager). V5 and state representative, checked the air vents as well. Multiple bedrooms were observed with faint warm air coming out from the vents which included bedrooms of R1, R2, R3, R4, and R5. R1's and R2's bedroom had 86.4F, R3's bedroom has 83F, R4's bedroom had 89.2F, and R5's bedroom was 85F. These residents all verbalized that their bedrooms were warm and uncomfortable.
At 2:25 PM, R3 was noted coming out of her bedroom. R3 said that there's no air coming out of air conditioning vent. The warm air inside the facility has been going on for the past few days and she was having difficulty sleeping.
At 3:45 PM, V3 (Corporate Maintenance) was at the back patio by the exit door, fixing the facility's air conditioning unit. There were some balls of wet dirt on the ground which was removed from the air-conditioning unit. V3 stated that basically it's hot in the day and cool at night because it was running non-stop, the air-conditioner froze up. The staff should have ensured that all windows were closed. There was ice build-up in the air-conditioning unit which blocks the air from getting inside the building. V4 should have checked it this morning for ice formation or ice build-up. Had V4 seen it this morning, he could have defrosted it, allowing the cold air to flow inside the building before the weather became too hot. V3 also said the last time he cleaned it was spring this year.
On 7/27/23 at 3:27 PM, V5 (Activity) stated that every resident has different feeling about the environmental temperature and added that some resident's complaint that it was too warm, and some has no complaint.
On 7/27/23 at 3:30 PM, V1 (Administrator) stated that there were residents who constantly open their bedroom windows which affects the air temperature circulating inside the building. V3 came to fix the air-conditioner because it was frozen.
R1's, R2's, R3's, R4's, and R5's most recent minimum data set (MDS) indicates that they are alert and oriented.
The facility was not able to present manufacturer's guidelines on how often they should clean the air-conditioning unit. However, there were balls of wet built-up dirt that was removed when V3 cleaned the air-conditioner.
Facility's Daily Air Temperature Policy and Procedure dated 2/2014 indicates:
Purpose: To Assure that air temperatures in the facility must maintain comfortable temperature of 71F to 81F.
Jun 2023
9 deficiencies
1 IJ (1 facility-wide)
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on observation, interview and record review the facility failed to secure hazardous chemicals in a locked storage area in accordance with the facility policy. There were 96 ambulatory residents,...
Read full inspector narrative →
Based on observation, interview and record review the facility failed to secure hazardous chemicals in a locked storage area in accordance with the facility policy. There were 96 ambulatory residents, all with psychiatric illness with access to the hallway where the chemicals were stored. This failure presented a serious health risk to all 96 residents residing in the facility.
This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on June 14, 2023, when hazardous chemicals were observed in an unsecured hallway during the environmental tour. On June 14, 2023, at 12:48 PM with V16 (housekeeping supervisor) hazardous chemicals were observed in an unsecured hallway that leads to the kitchen and laundry room. The hallway has an unsecured door with direct access to the main dining room where ambulatory residents gather for meals and activities. The ambulatory residents can easily access the unlocked door and enter the hallway where the chemicals are being stored. V16 staed that t there was no room in the locked storage area to secure the hazardous chemicals. V1 (Administrator) was notified of the Immediate Jeopardy on June 15, 2023, at 12:32 PM.
The survey team confirmed by observation, interview, and record review the immediate jeopardy was removed on June 15, 2023, at 5:36PM. Noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of the removal plan.
The findings include:
The facility's CMS form 672 (Resident Census and Condition) dated June 12, 2023, showed there are 96 residents who ambulate independently with or without an assistive device and 101 residents with diagnoses of psychiatric illness.
The facility identified 34 residents with suicidal ideation. In the sample of 34 residents, 8 reviewed during the survey (R11, R42, R49, R57, R59, R74, R75, R76) identified with suicidal ideation, and were ambulatory.
On June 14, 2023, at 12:48 PM with V16 (housekeeping supervisor) hazardous chemicals were observed in an unsecured hallway that leads to the kitchen and laundry room. The hallway has an unsecured door with direct access to the main dining room where ambulatory residents gather for meals and activities. The ambulatory residents can easily access the unlocked door and enter the hallway where the chemicals are being stored. In the unsecured hallway, there were twelve, five -gallon containers of cleaning chemicals sitting on the floor and four housekeeping carts with cleaning chemicals unsecured on top of the carts. Three of the four housekeeping carts did not have locks for the closed compartment. V16 was asked why the hazardous chemicals were being stored in the unsecured hallway. V16 stated there was no more room in the locked storage area for the chemical containers in the hallway. V16 acknowledged the door to the hall was a swing away door, had no lock on the door and the door is accessed from the main dining room. The residents use the main dining room for meals and activities. The door is not monitored, and staff are not present in the area when the kitchen is closed. V16 acknowledged three out of four housekeeping carts parked in the same hallway had missing locks to secure chemicals on the carts.
An inventory of the chemical containers on June 14, 2023, at 12:55 PM included:
1. Eight, five-gallon containers of a yellow cleaning solution labeled chlorine additive for laundry and dishwashing. The label had the caution harmful if swallowed. The MSDS (Material Safety Data Sheet) showed the chemical to be corrosive and can cause skin burns and serious eye irritation requires the use of PPE (Personal Protective Equipment) during handling. The chemical is classified as a hazardous chemical as defined by the OSHA (Occupational Safety and Health Administration) hazard communication.
2. Three, five-gallon containers of a dark red cleaning solution labeled as a dish machine cleaning solution. The label had a caution that the chemical was corrosive, can cause skin burns and eye irritation. The MSDS stated keep locked up and harmful if swallowed. The MSDS also showed if direct contact with skin or if ingested could result in severe burns to the skin, mouth and throat, or severe eye irritation.
3. One, five- gallon container of floor cleaner. The label warns of serious eye damage or eye irritation. The MSDS shows keep out of reach of children regarding storage of the chemical. Also cautions the need for using PPE and hand washing when handling.
4. On the top of the housekeeping cart number one, there were two cans of foaming disinfectant spray, a can of glass cleaner and an open, unlabeled container of blue liquid with a brush in the container. V16 (housekeeping supervisor) identified the blue liquid as toilet bowl cleaner.
5. On the top of cart number two, there were two bottles of bleach cleaner and one container of toilet bowl cleaner.
6. On the top of cart number three, there were two cans of foaming disinfectant spray, a container of toilet bowl cleaner and an open, unlabeled container of purple liquid. V17 (housekeeping aide) identified the purple liquid as a cleaner and stated it makes things smell better.
According to the MSDS, the foaming disinfectant spray is flammable and could cause serious eye irritation and cautioned to seek medical attention in case of ingestion. The OSHA hazard communication classified the disinfectant spray as a hazardous chemical. The toilet bowl cleaner contains hydrochloric acid and is corrosive to skin, eyes, and ingestion causes irritation or burns to the mouth and throat. The MSDS for the glass cleaner, shows it can be absorbed through the skin, is flammable and requires the use of PPE when handling. The MSDS for the purple cleaner shows it is to be stored in the original container, use PPE when handling, and it can cause skin and eye irritation if comes in direct contact with the skin or the eyes.
Residents were observed gathering in small groups and walking throughout the dining room area without staff supervision during the entire survey from June 12 through June 14, 2023. The groups of residents were socializing independently and had to walk near the unsecured door (where the hazardous chemicals were stored) to access the A hallway where residents reside. The water cooler and ice container were also placed a few steps away from the unsecured hallway door and multiple residents were observed getting ice and water from the container.
On June 14, 2023, at 2:15 PM, V1 (Administrator) was made aware of the chemicals being stored in the hallway.
On June 14, 2023, at 4:04 PM, the same hallway door remained unlocked and the storage room door was propped open using a five- gallon container of blue chemical used for the dish machine. The label contained a caution statement that the chemical was corrosive and an irritant to skin and may cause eye irritation. There was no staff present in the hallway.
The facility provided a Housekeeping Policy and Procedure, undated and titled, Housekeeping Carts. The Policy stated, All chemicals and other hazardous items will be kept inside the cart with the cart door locked unless attended or stored in a locked utility room, janitor's closet or storage room. The policy stated, Carts and all equipment will be maintained in a clean condition and good repair at all times. Locks will be maintained in functioning order.
The facility presented a plan on June 15, 2023, at 3:49 PM, to remove the immediacy. The survey team reviewed the removal plan and was unable to accept the plan to remove the immediacy. The removal plan was returned to the facility for revisions. The facility presented a revised removal plan on June 15, 2023, at 5:36 PM and the survey team reviewed and accepted the removal plan.
The Immediacy was removed on June 15, 2023, at 5:36PM when the facility took the following actions to remove the immediacy:
- Housekeeping carts fitted with locks on June 14, 2023.
- The chemicals were removed from the hallway and placed in the locked storage room on June 14, 2023. All chemicals/cleaning/toxic agents will be stored in a locked and secure area when not in use.
- The hallway door was locked and a keypad was installed on June 15, 2023.
- The chemical storage room was fitted with a new lock on June 15, 2023
- An Emergency QAPI (Quality Assurance Performance Improvement) meeting with Medical Director and all department heads was held on June 15, 2023, regarding survey findings and plan of correction for Immediate Jeopardy component.
- Re-assessments of all 32 residents currently in house, were identified for suicidal identification risk (including sampled residents R11, R42, R49, R57, R59, R74, R75, R76) were completed on June 15,2023. The 2 other residents will be reassessed upon their return to the facility.
- In-service education and training for the housekeeping supervisor and housekeeping staff was initiated on June 15, 2023. The training included appropriate storage of housekeeping chemicals, locking chemicals in housekeeping carts, keeping unused carts in a locked storage room, and safely storing chemicals. Any staff on vacation will receive their training prior to returning to work.
- In-service education for all staff (including nursing, dietary, activities, social services, medical records) was initiated on June 15, 2023. The in-service training included the appropriate storage of housekeeping chemicals, locking of housekeeping carts, storage of housekeeping carts in locked storeroom and keeping any chemicals away from residents. Any staff on vacation will receive their training prior to their return to work.
- The Administrator/designee will perform the Quality Assurance monitoring activities including daily audits for 3 months to ensure all housekeeping carts are locked while on unit, stored in locked storeroom when not in use and all chemical/cleaning/toxic agents are stored in a locked and secure area when not in use.
- The completed audits will be reviewed by the QA/QI (Quality Assurance /Quality Improvement) committee review and follow up as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's signed POLST (Practitioner Order for Life-Sustai...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's signed POLST (Practitioner Order for Life-Sustaining Treatment) form and physician's order were consistent and reflected the resident's treatment wishes in an event of a medical emergency based on the facility's advance directives guideline. This applies to 1 of 2 residents (R5) reviewed for advance directives in the sample of 28.
The findings include:
R5 has multiple diagnoses which includes dementia with other behavioral disturbance, type 2 Diabetes mellitus and intellectual disabilities, based on R5's face sheet.
R5's admission notification record showed R5 was admitted to hospice care on February 25, 2023, for diagnosis of dementia.
R5's quarterly MDS (minimum data set) dated [DATE], shows R5 is severely impaired with cognitive skills for daily decision making and requires total assistance from the staff with most of his ADLs (activities of daily living).
R5's order summary report showed an active order dated February 25, 2022, for hospice care. The same order summary report showed an active order dated [DATE], for, Full Treatment: Primary goal of sustaining life by medically indicated means. In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, mechanical ventilation and cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated.
R5's electronic record dash board profile showed, Code status: Full Treatment: Primary goal of sustaining life by medically indicated means. In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, mechanical ventilation and cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated.
R5's electronic records showed a scanned POLST form signed on February 17, 2022. The signed POLST form showed if R5 has no pulse and is not breathing, Do Not Attempt Resuscitation/DNR. The same signed POLST showed under medical interventions if patient is found with a pulse and/or is breathing, Selective Treatment: Primary goal of treating medical conditions with selective medical measures. In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV (intravenous) fluids and IV medications (may include antibiotics and vasopressors), as medically appropriate and consistent with patient preference. Do not intubate. May consider less invasive airway support (example CPAP (continuous positive airway pressure), BiPAP (bi-level positive airway pressure)). Transfer to hospital, if indicated. Generally, avoid the intensive care unit.
On [DATE] at 9:59 AM in the presence of V2 (Director of Nursing) while inside the nursing station, V9 (Licensed Practical Nurse) stated she is the assigned nurse to R5 for the day from 7:00 AM through 3:00 PM. According to V9, in case of an emergency related to R5, the first thing she would check is the code status of R5 which is available on the resident's electronic record dash board profile and active physician order. After V9 reviewed R5's electronic record dash board profile and active physician order, V9 stated R5 is a full code status and CPR (cardiopulmonary resuscitation) should be performed on R5 in case of an emergency if the resident has no pulse and is not breathing. V9 was asked to check the signed POLST form for R5. V9 attempted to open and view R5's signed POLST form on the electronic record but was unsuccessful.
On [DATE], at 10:19 AM, V11 (Psychiatric Rehabilitation Service Director) stated R5's code status is unclear based on the signed POLST form and the physician order. V11 added, I do not know why we did not see this earlier because the active order for the code status is from [DATE] and the POLST form was signed on February 2022.
On [DATE], at 1:13 AM, V2 acknowledged R5's code status was not clear, and it does not reflect the wishes on the signed POLST form versus the physician order.
The facility's advance directives guidelines dated [DATE] showed in-part under procedure, 2. The resident's/patient's physician should be informed of advance directives and copies should be placed in the medical record. Physician's orders to support the advance directive should be obtain by nursing personnel, as appropriate. 3. If the Advance Directive is not clear, nursing should contact Social Services for assistance in clarifying the Advanced Directive as soon as possible. 4. Social Services will review the resident/patient's advance directives with the physician and/or compare with the physician's documentation/orders to ensure all documentation is congruent with the resident/patient's wishes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy for hand hygiene during resident ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy for hand hygiene during resident care. This applies to 1 of 28 residents (R3) reviewed for infection control in the sample of 28.
The findings include:
On June 14, 2023, at 1:21 PM, V14 (CNA/Certified Nursing Assistant) and V15 (CNA) provided incontinence care to R3. V14 and V15 applied gloves. V14 said R3's incontinence brief was soiled with urine and stool. V14 used a premoistened wipe and wiped R3's front perineal area. V14 and V15 turned R3 onto her side and V14 wiped stool from R3's buttocks. Wearing the same soiled gloves, V14 touched R3's clothes, clean incontinence brief, applied cream to R3's buttocks, and touched R3's thigh when repositioning R3. V14 removed her gloves and applied new gloves. V14 did not perform hand hygiene. V14 then touched R3's leg, clothes, pillow, linens, and bed controls.
On June 14, 2023, at 2:17 PM, V2 (DON/Director of Nursing) said facility should change their gloves and perform hand hygiene when moving from a dirty site to a clean site. V2 continued to say facility staff should be using clean gloves when applying cream to a resident's buttocks. V2 said V14 should have changed gloves and performed hand hygiene after wiping stool from R3's buttocks and before applying cream to R3's buttocks.
The EMR (Electronic Medical Record) shows R3 was admitted to the facility on [DATE], with multiple diagnoses including urinary incontinence, epilepsy, lymphedema, and spinal stenosis.
The MDS (Minimum Data Set) dated May 19, 2023, shows R3 has severely impaired skills for daily decision making and is totally dependent on facility staff for bed mobility, transfers, dressing, and toilet use. The MDS continues to show R3 is always incontinent of urine and bowel.
The facility's policy titled, Hand Hygiene dated 4/2020, shows, Guideline: All personnel are responsible for hand hygiene. Wash hands with soap and water when hands are visibly soiled or when working with a resident with a spore producing organism. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands. The American Hospital Association and the Center for Disease Control recommend: . after removal of gloves (the use of gloves does not negate the need for hand hygiene). After moving from a contaminated body site to a clean body site during patient care .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to label and date medications after it was opened to determine expiration dates. This applies to 8 of 10 residents (R9, R15, R35,...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to label and date medications after it was opened to determine expiration dates. This applies to 8 of 10 residents (R9, R15, R35, R40, R51, R71, R72, R103) reviewed for labeling and storage of medications.
The findings include:
On 6/13/23 at 2:54 PM, the 3 morning medication carts and refrigerator (used for medication storage) were inspected with V12 (Nurse). The following medications were in the medication carts and observed as follows:
1. R71's Combivent Respimat 20 mcg/100 mcg per actuation was open and not dated.
2. R103's Combivent Respimat 20 mcg/100 mcg per actuation was open and not dated
3. R51's Latanoprost ophthalmic solution 0.005% opened 3/29/23.
4. R40's two bottles of Latanoprost 0.005% was open and not dated.
5. R35's Latanoprost 0.005% 125 mcg/2.5 ml was open and not dated
6. R72's Breo Ellipta 100-25 was open and not dated.
7. R15's Advair Diskus was open and not dated.
8. R9's Spiriva Respimat 2.5 mcg per actuation was open and not dated.
On 6/14/23 at 1:23 PM, V2 (Director of Nursing/DON) stated that the medications should be labeled with the resident's name, and they go by the expiration dates of the inhalers and eye drops that was recommended by the pharmacy.
The expiration guidelines sent by V18 (Facility's pharmacy staff) showed the following.
Advair Diskus (Fluticasone/salmeterol) is to be discarded 30 days after removal from foil overwrap
Breo Ellipta (Fluticasone/Vilanterol) is to be discarded 6 weeks after opening the foil.
Combivent Respimat (Ipratropium/Albuterol), to be discarded 3 months after first use.
Spiriva Respimat (Tiotropium) discard 3 months after cartridge inserted into inhaler base.
Xalatan (Latanoprost) is to be discarded 42 days after it was opened.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to serve portion sizes for regular and pureed diets as s...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to serve portion sizes for regular and pureed diets as shown on the diet extension spreadsheet. This applies to 10 of 10 residents (R38, R50, R55, R72, R74, R85, R90, R96, R99, R103) reviewed for dining in the sample of 28.
The findings include:
1. On June 12, 2023 at 10:13 AM during initial tour of kitchen, V4 (Dietary Manager) stated that the facility is serving breaded fish squares for lunch as that was what was sent by the food vendor. Facility daily spreadsheet for week 4, Monday lunch meal showed [NAME] Montreal (1 portion=3 oz/ounce protein) and the protein portion should be 3 ounces.
On June 12, 2023 at 12:35 PM, during lunch meal service R38, R55, R72, R85, R90, R96, R99 and R103 received the above breaded fish squares served inside a bun.
On June 12, 2023 at 12:57 PM, V4 weighed one piece of breaded fish with breading removed. The amount of editable protein was noted to be 2 oz per fish square leaving residents short 1 ounce of protein. V4 remarked that she was not informed by the food vendor about serving portion size when they substituted the menu item.
2. Facility daily spreadsheet for week 4, Monday included [NAME] Montreal, garden blend rice, green beans, and bread. The same spreadsheet did not list portion sizes for pureed diet consistency diets. V2 stated that she does not know how to print the pureed extension for the menu and that the facility serves the same portions as mechanical soft diets to the residents on pureed diets.
On June 12, 2023 at 1:15 PM, during lunch meal service V8 (Dietary Aide) was observed plating pureed consistency meals. V8 used a 6 oz scoop to serve pureed breaded fish and used an #8 scoop (4 oz/scoop) to serve pureed rice to R50 and R74. When asked why these residents did not receive any vegetables, V8 pointed to the served meal and remarked that the vegetables are all mashed up in there.
On June 12, 2023 at 01:21 PM, V4 was notified that the pureed diets did not receive pureed vegetables and bread. V4 stated that the pureed vegetables were overlooked to be served. V4 also added that the facility did not have pureed bread on hand and needed to be purchased. Later in the day, V4 stated she reached out to the menu provider who was able to give her direction on how to print the pureed extension to the menu and provided the same.
The Pureed extension spreadsheet for Week 4 Monday included pureed peas # 8 scoop and pureed bread #16 scoop.
Facility scoop portion control chart guidance showed that #8=4 oz/scoop and #16=2 oz /scoop.
On June 12, 2023 at V13 (Consultant Dietician) stated the facility should follow the menu spreadsheet to meet required serving portion sizes for the meal.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to follow the recipe to serve consistencies as shown for pureed and mechanical soft rice. This applies to 6 of 6 residents (R3, R...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to follow the recipe to serve consistencies as shown for pureed and mechanical soft rice. This applies to 6 of 6 residents (R3, R5, R48, R50, R74, R97) observed for dining in the sample of 28.
The findings include:
On June 12, 2023, at 12:35 PM, the pureed meal prep of cooked white rice by V7 (Cook) was observed in the facility kitchen. V7 stated he is preparing pureed meals for 2 residents R50 and R74. After pureeing two 1/2 cup portions of rice with 1/2 cup water in a blender, V7 stated it was ready for service. The rim of the blender around the poring spout still had grains of rice that were not pureed. As R7 tilted the blender to pour the mixture into a pan, some of the whole grains of rice got mixed in with the pureed product. When tested with a spoon, the grains of rice could be felt with the fingers. R7 was notified the pureed mixture was not safe to serve.
On June 12, 2023, during lunch meal tray line service, the mechanical soft consistency diets were served white rice along with the meal. The facility spreadsheet for Week 4 Monday lunch showed the mechanical soft diets to be served rice with gravy. R3, R5, R48, and R97 received white rice with no gravy.
On June 14, 2023, at 12:07 PM, V13 (Consultant Dietician) stated the facility should follow the recipe for mechanically altered diets to obtain consistencies or directives as shown.
Facility recipe for rice included to portion with #8 scoop (1/2 cup) plus 1 oz/ounce gravy to keep moist.
Facility recipe for pureed rice included to place portion of prepared white rice in food processor with hot broth and blend to a smooth consistency.
Facility undated policy and procedure titled Pureed -Dysphagia Level 1 included as follows: The pureed consistency is planned according to the Regular consistency, but the texture is modified to a smooth, pudding-like texture for all food items.
Facility diet order list report printed on June 12, 2023 included R50 and R74 were on pureed diets and R3, R5, R48, R97 were on mechanical soft diets.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer residents the pneumococcal vaccine and administer the influen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer residents the pneumococcal vaccine and administer the influenza vaccine to residents. This applies to 6 of 6 residents (R4, R41, R85, R91, R95, R103) reviewed for immunizations in the sample of 28.
The findings include:
1. The EMR (Electronic Medical Record) shows R4 is [AGE] years old and was admitted to the facility on [DATE], with multiple diagnoses including asthma, heart failure, bipolar disorder, and schizophrenia.
The facility's documentation titled Authorization and Release for Influenza Vaccine signed by R4 on October 5, 2022, shows R4 consented to receiving the influenza vaccine.
The facility does not have documentation to show R4 had received the influenza vaccine during the 2022 to 2023 influenza season.
R4's immunization history shows R4 has not received a pneumococcal vaccine.
The facility does not have documentation to show R4 was educated about the pneumococcal vaccine and offered the pneumococcal vaccine since R4 was admitted to the facility on [DATE]. The facility does not have documentation to show R4 refused to receive the pneumococcal vaccine.
2. The EMR shows R41 is [AGE] years old and was admitted to the facility on [DATE], with multiple diagnoses including sickle cell disease, anemia, chronic obstructive pulmonary disease, and psychosis.
R41's immunization history shows R41 has not received a pneumococcal vaccine.
The facility does not have documentation to show R41 was educated about the pneumococcal vaccine and offered the pneumococcal vaccine prior to June 2, 2023. The facility does not have documentation to show R41 previously refused to receive the pneumococcal vaccine.
3. The EMR shows R85 is [AGE] years old and was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, dementia, diabetes, and hyperlipidemia.
R85's immunization history shows R85 has not received a pneumococcal vaccine.
The facility does not have documentation to show R85 was educated about the pneumococcal vaccine and offered the pneumococcal vaccine prior to June 2, 2023. The facility does not have documentation to show R85 previously refused to receive the pneumococcal vaccine.
4. The EMR shows R91 is [AGE] years old and was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease, chronic kidney disease, bipolar, and schizoaffective disorder.
R91's immunization history shows R91 has not received a pneumococcal vaccine.
The facility does not have documentation to show R91 was educated about the pneumococcal vaccine and offered the pneumococcal vaccine since R91's admission on [DATE]. The facility does not have documentation to show R91 refused to receive the pneumococcal vaccine.
5. The EMR shows R95 is [AGE] years old and was admitted to the facility on [DATE], with multiple diagnoses including dementia, bipolar, thrombocytopenia, and hypertensive heart disease.
R95's immunization history shows R95 has not received a pneumococcal vaccine.
The facility does not have documentation to show R95 was educated about the pneumococcal vaccine and offered the pneumococcal vaccine. The facility does not have documentation to show R95 refused to receive the pneumococcal vaccine.
6. The EMR shows R103 is [AGE] years old and was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, alcohol abuse, acute kidney failure, and schizophrenia.
R103's immunization history shows R103 has not received a pneumococcal vaccine.
The facility does not have documentation to show R103 was educated about the pneumococcal vaccine and offered the pneumococcal vaccine. The facility does not have documentation to show R103 refused to receive the pneumococcal vaccine.
On June 13, 2023, at 1:43 PM, V2 (DON/Director of Nursing) said the facility follows the CDC (Center for Disease Control and Prevention) recommendations for influenza and pneumococcal vaccine timing.
The facility's guideline titled Flu/Pneumovax Vaccine, dated 3/2021 shows Guideline: One of the leading causes of death in persons aged 65 or over is pneumonia and influenza. The Centers for Disease Control and Prevention recommend that individuals over the age of 65 years have: an annual flu shot and Prevnar 13 and Pneumococcal 23 vaccine.
CDC Recommendations for Flu Vaccines: 1. Give seasonally; 2. Administer flu vaccine once received; 3. Provide VIS (Vaccine Information Statement) education/information.
CDC Recommendations for Pneumococcal Vaccines: 1. An initial pneumococcal vaccine will be offered to all resident who have never received the vaccine or if not medically contraindicated. This is the PPSV23 (23-valent pneumococcal polysaccharide vaccine). 2. For adults 65 and older who do not have an immunocompromised condition, cerebrospinal fluid leak, or cochlear implant and want to receive the PPSV23 show only receive a dose . 9. For anyone with sickle cell or related disease, anatomic or functional asplenia, congenital or acquired immunodeficiency, HIV (Human Immunodeficiency Virus) infection, chronic renal failure or nephrotic syndrome, leukemia, or lymphoma, Hodgkin disease, generalized and metastatic malignancies, iatrogenic immunosuppression, including radiation therapy or multiple myeloma: CDC recommends one does of PCV13 (13-valent pneumococcal conjugate vaccine) and two doses of PPSV23. Administer PCV13 first, then give the first PPSV23 dose at least eight weeks later. Give the second dose at least five years after the first dose of PPSV23. 10. For anyone who smokes, has alcoholism, chronic heart disease, chronic liver disease, chronic lung disease, including chronic obstructive pulmonary disease, emphysema, asthma, and diabetes mellitus and has not received the vaccine; the CDC recommends one dose of PPSV23.
Standard: The facility encourages residents to receive inoculations, as recommended, upon orders of the attending physician. Influenza vaccinations should be offered to residents each year and for all residents accepting the vaccine, the vaccine should be initiated as soon as the vaccine is made available and continued through flu season. Pneumococcal vaccination should be offered to residents at the time of admission. Resident refusal of vaccines should be documented in the medical record.
Procedure: 1. Upon admission, the admitting nurse should interview the resident and/or responsible party to determine the status of prior inoculations . 4. Each resident will be offered the pneumococcal immunization upon admission, unless the immunization is medically contraindicated or the resident has already been immunized . 8. The resident's medical record will include the following documentation: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunization; and (B) That the resident either received the immunization or did not receive the immunization due to medical contraindication or refusal .
The Pneumococcal Vaccine Timing for Adults on the cdc.gov website, dated April 1, 2022, showed CDC recommends pneumococcal vaccination for: Adults [AGE] years old and older; and Adults 119 through [AGE] years old with certain underlying medical conditions or other risk factors: alcoholism . chronic heart/liver/lung disease, chronic renal failure, cigarette smoking . diabetes . sickle cell disease or other hemoglobinopathies .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure foods are stored and the dishes washed in a sanitary manner. This applies to all 105 residents who receive foods prepar...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure foods are stored and the dishes washed in a sanitary manner. This applies to all 105 residents who receive foods prepared in the facility kitchen.
The findings include:
Facility Resident Census and Conditions of Residents form (CMS Form 672) dated June 12, 2023, showed the facility census is 105. Facility gave verbal confirmation all 105 residents receive oral diets.
On June 12, 2023, at 10:13 AM, during initial tour of facility kitchen, the freezer (#1) inside the kitchen was noted to be packed from floor to ceiling of the freezer with cardboard boxes containing frozen foods allowing no air circulation in between. Some of boxes had condensation on them and the outside temperature gauge showed 50 degrees Fahrenheit. There was no visible temperature gauge inside the freezer. The outside door surface of the freezer had extensive dried drippings. V4 (Dietary Manager) stated the delivery just came in and the door was kept open as they are in the process of stocking and arranging the items came in. V4 also added the facility does not have enough space to store all the frozen foods. The freezer temperature was checked again at around 1:05 PM and showed 10 degrees Fahrenheit.
A cooler container was seen stored on a shelf in kitchen had grayish streaks on the interior sides and brownish deposits on bottom of cooler. V4 stated the cooler is used to store milk for breakfast and supper.
On June 13, 2023, at 9:35 AM, the kitchen was visited again and noted to have another reach in freezer (#2) at the entrance of the kitchen with an outside gauge that showed 10 degrees Fahrenheit. When opened, it was noted to have ice built up on interior top shelf with condensations dripped into the loosely closed boxes containing frozen zucchini and French toast. Extensive ice built up was seen on top of the box that contained zucchini. No visible thermometer was seen on the inside of the freezer. (The inside thermometer which was located under the boxes was checked later in presence of V4 and showed 40 degrees Fahrenheit).
The reach in freezer (#1) inside the kitchen was also observed again and showed the same boxed frozen foods piled one on top of the other from floor to ceiling. A package of ground sausage was on top of the boxes had condensation on it and was soft to touch. The outside gauge of the Freezer showed 10 degrees Fahrenheit. (The inside thermometer was buried in between the boxes was checked later in presence of V4 and showed 10 degrees Fahrenheit). The surface of the door of the freezer had the same dried-up drippings. V7 (Cook) stated the staff has not had the time to clean the door.
The cooler was used to store milk remained on the kitchen shelf with the above mentioned gray and brown streaks and deposits. When the interior of the cooler was wiped with a rag by V7, the brownish gray color came off on the rag. V7 stated, This needs to be washed and put the cooler in the dish washing area. V4 was notified of above findings.
On June 13, 2023, at 10:51 AM, V8 (Dietary Aide) was seen finishing wrapping silverware and then handle his phone and place it back in his pocket. V8 proceeded to pick up washed and sanitized trays and put it away. V8 then put a dirty pan in the 3-compartment sink and started to a put away cleaned and sanitized bowls without washing his hands or putting on gloves. When notified of the same, V8 remarked, I am doing a million things. I put on hand sanitizer in between when I get a chance. V4 who was in the vicinity stated, V8 should not use hand sanitizer and should have washed his hands when going from one task to the next.
Facility Policy and Procedure titled Cleaning dishes/Dish Machine included: Policy: All flatware, serving dishes, and cookware will be cleaned, rinsed and sanitized after each use.
Procedure:
2. The person loading dirty dishes will not handle the clean dishes unless they change into clean apron and wash hands thoroughly before moving from dirty to clean dishes.
10. Inspect for cleanliness and dryness and put dishes away if clean (be sure clean hands or gloves are used).
Facility Policy and Procedure titled Freezers included as follows-
Policy: Freezer units will be kept clean and in good working condition.
Procedure:
1. Frozen foods must be maintained at a temperature to keep the food frozen solid.
2. All foods should be stored to allow adequate air circulation.
MINOR
(C)
Minor Issue - procedural, no safety impact
Antibiotic Stewardship
(Tag F0881)
Minor procedural issue · This affected most or all residents
Based on interview and record review, the facility failed to follow their policy for antibiotic stewardship. This has the potential to affect all 105 residents residing in the facility.
The Resident ...
Read full inspector narrative →
Based on interview and record review, the facility failed to follow their policy for antibiotic stewardship. This has the potential to affect all 105 residents residing in the facility.
The Resident Census and Conditions of Resident report dated June 12, 2023, shows the facility census as 105 residents.
The findings include:
On June 13, 2023, at 1:43 PM, V2 (DON/Director of Nursing) said he is responsible tracking antibiotic use in the facility. V2 continued to say he does not use McGeer's Criteria for collecting infection information because they do not have to in this patient population since there is not a lot of antibiotic use.
Review of the facility's Infection Control Log for the period of January 1, 2023, to May 31, 2023, shows 37 antimicrobials were ordered. The facility does not have documentation to show McGeer's Criteria was used to validate the use of the antimicrobial.
The facility policy titled Antimicrobial/Antibiotic Stewardship Program dated 4/2020 shows, Guideline: The facility antimicrobial stewardship program includes the following elements; a) Antimicrobial/antibiotic policy and procedure . Procedure: 1. The Infection Preventionist will collect the infection information using the McGreer Criteria .
Jul 2022
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow facility's policy and procedure on advance directives.
This...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow facility's policy and procedure on advance directives.
This applies to 1 of 1 residents (R23) reviewed for advance directives in the sample of 19.
The findings include:
R23's face sheet on EMR (Electronic Medical Records) showed that R23 was (re)admitted on [DATE] with diagnoses of schizoaffective disorder, depressive type, personal history of other venous thrombosis and embolism, chronic embolism and thrombosis of left popliteal vein, hypertension secondary to endocrine disorders, unspecified asthma, uncomplicated, nutritional anemia unspecified. R23's admission MDS (minimum data set) dated [DATE] included that R23 was cognitively intact.
On [DATE] at 8:35 AM, the same EMR showed DNR (Do Not Resuscitate) on the dashboard and Physician Order Sheet (revision date [DATE]). R23's POLST/Practitioner Order for Life Sustaining Treatment form effective [DATE] uploaded in EMR showed Attempt Resuscitation/CPR (Cardiopulmonary Resuscitation) and was signed by R23 on [DATE] and by the Practitioner on [DATE].
R23's current Nursing nor Social Service care plan did not have any Advance Directive care plan.
On [DATE] at 09:52 AM, V2 (Director of Nursing) stated Social Services handles Advanced Directives.
On [DATE] at 9:58 AM, the above discrepancy in information was relayed to V12 (Psychiatric Rehabilitation Service Director). V12 stated that the facility's process is that when a resident is admitted , the POLST form is filled out by the resident or Power of Attorney or guardian as applicable and uploaded in the EMR after the resident's Practitioner also signs it. V12 stated that the resident's PSRC (Psychiatric Rehabilitation Service Coordinator) is responsible for this and then informs V3 (MDS Supervisor). V12 stated that the resident's PSRC or V3 will then update the Advance Directive binder which has hard copies of the POLST form and updates the care plan. When this binder was reviewed in presence of V12, it included a copy of R23's POLST form dated/signed on [DATE] by R23 and Practitioner which showed Do not Attempt Resuscitation. V12 remarked that this should have been updated on recent admission.
Facility policy and procedure titled Advanced Directives (effective date 4/2020) included the following:
Standard:
Advance Directive means written instructions, such as a living will or a health care proxy within a durable power of attorney, recognized under State law relating to the provision of healthcare, when the individual is capacitated. This instruction instrument is prepared in advance of the resident's incapacitation, while the resident is able to make health care decisions. The Advance Directive is used to determine the resident/patient's instruction regarding withholding and withdrawing of life sustaining treatments, under certain conditions.
Advance Care Planning is a process used to identify and update the resident/patient's preferences regarding care and treatment at a future time including a situation in which the resident subsequently lacks capacity to do so. For example, when life sustaining treatment are a potential option for care and the resident/patient is unable to make his or her choices known.
Procedure:
1. Upon admission, nursing is to clarify the Advance Directive orders that have accompanied the resident/patient.
2. The resident's/patient's physician should be informed of advance directives and copies should be placed in the medical record. Physician's orders to support the Advance Directive should be obtained by nursing personnel, as appropriate.
4. Social Services will review the resident/patient's advance directives with the physician and/or compare with the physicians' documentation/orders to ensure all documentation is congruent with the resident/patient's wishes.
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 toilet and provide grooming assistance to residents t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to toilet and provide grooming assistance to residents that needed extensive assistance or the same.
This applies to 3 of 3 residents (R10, R29, R63) reviewed for Activities of Daily Living care in the sample of 19.
The findings include:
1. R29's diagnoses in the EMR (electronic medical records) included schizoaffective disorder, depressive type, other mechanical complication of indwelling ureteral stent, sequela, urinary tract infection, site not specified, abnormal uterine and vaginal bleeding, unspecified, Parkinson's disease. R29's Comprehensive MDS (Minimum Data Set) dated 4/28/2022 included that R29 is cognitively intact and needs extensive one-person physical assist with toilet use and personal hygiene.
On 07/11/22 at 1:05 PM, R29 was seated in the dining room and had a strong odor of stale urine. R29 also had multiple long facial/chin hairs (greater than 1/2 inch).
On 07/11/22 at 1:09 PM, V7 (Registered Nurse) stated that she is R29's nurse and that R29 needs help with ADL (Activities of Daily Living care) including grooming, transferring to wheelchair, toileting.
On 07/11/22 at 1:20 PM, R29 was eating lunch and still had a very strong odor of stale urine. R29 stated I wear pull ups. I did not get changed after they got me up in the morning.
07/11/22 1:28 PM, V15 (Certified Nursing Assistant) was notified of the strong urine odor and the facial hairs. V15 stated The night staff get her up and change her clothes and pull ups. She is usually toileted after breakfast and after lunch. V15 could not recall if she changed R29 that morning after breakfast. V15 also stated that grooming of facial hairs are done during showers.
07/12/22 10:47 AM R29 was in the room and appeared clean with no odors and stated, They gave me a shower as I had diarrhea this morning. R29 chin still had long facial hairs.
On 07/13/22 at 1:01 PM, V2 (Director of Nursing) stated that the night staff get the residents ready for the morning and the morning shift should take care of ADL care including toileting and grooming. V2 stated that grooming can be done daily and not just on shower days and that the CNAs have been told multiple times to do so.
2. Face sheet and active care plan shows that R10 is 86 years-old who has multiple medical diagnoses and has generalized weakness and decreased muscle strength. In addition, her Minimum Data Set (MDS) dated [DATE] showed that R10 is totally dependent upon staff with regards to her hygiene/grooming.
On 7/12/22 at 10:42 AM, R10 was in the milieu, sitting in her wheelchair. R10 was observed to be struggling with untangling her hair using her bare hands, which displayed long dirty (with black/brown substances underneath nails), crooked, and uneven nails. R10 stated that she needs somebody to do her nails.
3. Face sheet and active care plan shows that R63 is 72 years-old who has multiple medical diagnoses. She requires assistance from staff with personal grooming related to impaired cognition, poor coordination, and poor sequencing. R63 benefits from being in a grooming restorative program. In addition, R63's MDS dated [DATE] showed that she is alert and oriented and requires extensive assistance with grooming/hygiene.
On 7/12/22 at 10:51 AM, R63 was sitting in the day room. She displayed long uneven, crooked, jagged fingernails, and dirty fingernails with black/brown substance underneath. R63 stated Yes, I would like someone to clean my nails.
On 7/13/22 at 11:17 AM, V7 (Nurse) stated that one of the Activities of Daily Living (ADL) care is hygiene and grooming which includes dressing, shower/bathing, and nail care. There's a podiatrist who comes and does the toenails of the residents. While the fingernails are done by the CNA (Certified Nursing Assistant) staff. This is to be done to prevent scratching, prevent infection, and for cleanliness.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report high blood pressures of a resident to the Phys...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report high blood pressures of a resident to the Physician in a timely manner.
This applies to 1 of 18 residents (R48) reviewed for Nursing Care in the sample of 19.
The Findings Include:
According to the EMR (Electronic Medical Record) R48 has congestive heart failure and hypertensive heart disease. The same record shows R48 was in the hospital from [DATE] to 6/28/22 and several blood pressure medications were discontinued at that time.
On 7/11/22 at 2:30pm, R48 was in a wheelchair. R48 had swollen legs and ankles. R48 stated his ankle did swell every day. R48 stated he had been in the hospital a few weeks earlier and he's ok now.
On 7/12/22 the physician's orders for R48 showed he had prescriptions for 2 blood pressure medications and there was an order to measure blood pressure and record it daily in the morning.
On 7/12/22 the record of R48's vital signs showed as follows:
6/28/22 at 6:01pm: 171/124
6/30/22 at 11:19am: 139/100
6/30/22 at 10:16pm: 126/100
7/3/22 at 9:40am: 171/127
7/7/22 at 1:56pm: 154/102
7/8/22 at 9:23am: 50/98
7/11/22 at 1:38pm: 166/89
As of 7/12/22 at 4:00pm there was no record of a report to the Doctor (V31) or V22 (Physician's Assistant) regarding R48's high pressures.
On 7/12/22 at 1:40pm, V2 (Director of Nursing) stated he is surprised the nurses haven't reported the blood pressures for R48 because V22 comes here frequently.
On 7/14/22 at 9:31am, V31 (Medical Doctor) stated he had not been informed of the high-pressure readings of R48, before yesterday (7/13/22) and he should have been called because R48 has heart disease. V31 stated, he had not been informed of the swelling in R48's legs which needs to be treated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide pureed entrée portions as shown on the menu spreadsheet during the lunch meal.
This applies to 1 of 1 resident ...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to provide pureed entrée portions as shown on the menu spreadsheet during the lunch meal.
This applies to 1 of 1 resident (R29) reviewed for pureed diet in the sample of 19.
The findings include:
On 07/11/22 at 10:27 AM, during initial tour of the kitchen, V13 (Food Service Manager) stated currently the facility only has one resident on pureed diet.
On 7/11/22 at 12:53 PM, the lunch meal service was observed in the facility kitchen. V13 stated that the pureed meal for R29 is already plated into bowls which were noted placed in the steam table. Each bowl appeared half full of pureed beef stroganoff, pureed noodles and pureed peas and V13 stated that each of these bowls contains 4 oz/ounce of these items.
Facility daily menu spreadsheet for Week 4 Monday showed to use #6 scoop for pureed Beef Stroganoff.
On 07/11/22 at 1:03 PM, R29 was seen seated in the dining room and stated I am hypoglycemic, and they don't give me enough food. I eat what they give me. I did not get enough breakfast. They give me a supplement.
On 07/11/22 at 1:15 PM, R29 received the above 3 bowls of food with 4 oz/ounce each of pureed beef stroganoff, pureed noodles and pureed peas along with apple sauce, mildly thick 4 oz health shake, thickened water and yogurt. R29 ate 100% of her food and scraped her bowl clean with a spoon.
On 7/12/22 at 12:30 PM, V14 (Registered Dietitian) stated that menu portion sizes should be served as shown on the menu spreadsheet.
Facility Client List Report of diet orders printed on 7/11/22 included that R29 was on pureed diet with nectar thick liquids.
Facility scoop size guidance titled Scoop and Ladle Equivalents included that #6 scoop =6 ounces.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
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 all staff were fully vaccinated for COVID-19.
This has the p...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all staff were fully vaccinated for COVID-19.
This has the potential to affect all 88 residents in the facility.
The findings include:
On 07/12/22 at 10:55 AM V2 (Director of Nursing/DON) stated not all staff have had COVID-19 boosters.
The facility COVID-19 vaccination staff list provided on 07/13/2022 showed they had 54 direct hire staff members. Eight staff members had religious exemptions and five staff members were not fully vaccinated. The facility's vaccination rate was 90.74 percent vaccinated.
The following staff members had not received a COVID-19 booster shot:
V1 (Administrator).
V18 (Licensed Practical Nurse/LPN).
V5 (Psychiatric Rehabilitation Services Counselor/PRSC) also tested positive for COVID-19 on 06/10/2022 during a recent COVID-19 outbreak in the facility.
V23 (Housekeeping) also tested positive for COVID-19 on 06/13/2022 during a recent COVID-19 outbreak in the facility; and
V24 (Dietary) also tested positive COVID-19 on 06/15/2022 during a recent COVID-19 outbreak in the facility.
On 07/13/22 at 11:35 AM, V2 (DON) stated the guideline from the Centers for Disease Control (CDC) show everyone should be vaccinated for COVID-19 including a booster and people over [AGE] years old should also receive a second booster.
The following contract staff providing direct resident care, not included in the direct hire staff vaccination list, do not have a COVID-19 booster:
V27 (Certified Nursing Assistant/CNA agency);
V29 (CNA agency).
V30 (CNA agency).
V32 (CNA agency).
V33 (CNA agency).
V34 (CNA agency).
V35 (CNA agency).
V36 (CNA agency; and
V37 (Physical Therapist/PT).
On 07/13/22 at 12:10 PM, V27 (CNA agency) stated she could not recall if she has had the COVID-19 booster. V27 stated she tests for COVID-19 depending on which facility she was working at. V27 stated she worked in the facility on 07/12/2022 and 07/13/2022 and had not been tested either day. V27 stated the agency she worked for does not require testing, it was up to each individual facility.
On 07/13/22 at 12:38 PM, V2 (DON) stated all staff members who are not fully vaccinated need to be tested for COVID-19 three times a week or when they arrive for work if they work less than three days a week including agency staff.
The facility's Reopening Plan dated 03/24/2022 included vaccination status as Up to date: An individual has received the primary series of COVID-19 vaccine .and has received all additional and booster doses for which they are eligible as recommended by the CDC.
The CDC shows You are up to date with your COVID-19 vaccines when you have received all doses in the primary series and all boosters recommended for you, when eligible.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who smoke in the facility's gro...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who smoke in the facility's ground/patio were supervised all throughout the smoking period.
This applies to 6 of 19 residents (R5, R11, R27, R40, R70, R84) reviewed for smoking in the sample of 19.
The findings include:
On 7/12/12 at 1:50 PM, V4 (Psychiatric Rehabilitation Service Assistant/PRSA) distributed the cigarettes to the residents while V5 (Psychiatric Rehabilitation Service Councilor/PRSC) watched the residents smoking. At 2:05 PM, there were multiple residents (R5, R11, R27, R40, R70, R84) smoking on the patio without staff's presence. V4 and V5 were nowhere in sight.
1. R5's Face Sheet documents that R5 is a [AGE] year-old who has multiple medical diagnoses which include schizophrenia and schizoaffective disorder. R5's Minimum Data Set (MDS) dated [DATE] showed that R5 is alert and oriented.
On 7/12/22 at 2:08 PM, R5 was smoking in the facility's patio. On 7/13/22 at 10:44 AM, R5 stated some staff stays all throughout the smoking period, and other staff would leave residents on their own after they light the cigarettes.
2. R11's Face Sheet documents that R11 is a [AGE] year-old with multiple diagnoses to include, schizoaffective disorder, depressive type, and recurrent major depressive disorder. R11's smoking assessment dated [DATE] indicates that he requires supervision during smoking time.
3. R27's Face Sheet showed that R27 is a [AGE] year-old with multiple diagnoses including, schizoaffective disorder bipolar type, unspecified psychosis not due to a substance or known psychological condition, and generalized anxiety disorder.
4. R40's Face Sheet documents that R40 is a 27 years-old with multiple diagnoses including, schizoaffective disorder bipolar type, and unspecified psychosis not due to a substance or known psychological condition.
5. R70's Face Sheet documents that R70 is a [AGE] year-old who has multiple medical diagnoses which include schizoaffective disorder.
R70's active care plan indicates that R70 is assessed to be an unsafe smoker due to being unable to smoke according to the facility smoking program. R70 demonstrates non-compliance with safe smoking regulations as evidenced by: Smoking in the rooms, bathrooms, and other non-designated areas. In addition, R70 will be monitored on 1:1 (one on one) basis by staff while smoking.
6. R84's Face Sheet documents that R84 is a [AGE] year-old who has multiple diagnoses which include bipolar disorder, psychotic disorder with hallucinations due to known physiological condition, and delusional disorders.
R84's active care plan indicates that R84 demonstrates non-compliance with safe smoking regulations as evidenced by begging, borrowing, stealing, selling and/or trading for smoking materials. R84 has multiple intervention during smoking time including, R84 will be supervised within the structured smoking program and will not carry any smoking materials, through the next review date.
On 7/12/22 at 2:30 PM, V2 (Director of Nursing/DON) stated that during smoking time there should be 2 staff supervising the residents, one staff is handling the cigarettes and lighters while the other staff is supposed to watch the residents in the backyard while they are smoking. This is for safety measure. To ensure that residents are not sharing or bartering cigarettes and to make sure that residents are disposing the cigarette butts safely.
Facility's Smoking Safety Policy indicates: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. In this effort, all residents will be supervised by staff while smoking in the designated smoking areas designated smoking times.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to label and date medications after they were opened to d...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to label and date medications after they were opened to determine expiration dates.
This applies to 10 of 10 residents (R18, R38, R41, R52, R53, R57, R60, R64, R72, R79) reviewed for labeling and storage of medications.
The Findings Include:
On [DATE] from 11:00 AM through 11:45 AM, the medication carts and refrigerator (used for medication storage) were inspected with V7 and V17 (Both Nurses). The medication carts and refrigerator were all stored inside the nurses' station. The following medications were observed as follows:
1. R64's Breo Ellipta opened and not dated.
2. R72's Basaglar Kwik Pen and Novolog Insulin were opened and not dated. In addition, R72's Basaglar Kwik pen was opened on [DATE] (expires 28 days after it was opened) and is mixed with the active medications.
3. R52's Insulin Glargine was opened and not dated.
4. R41's two bottles of Latanoprost 0.005% solution eye drops were opened and not dated.
5. R60's Lantus Glargine, Novolin R, and Latanoprost Solution 0.005% eye drops were opened and not dated.
6. R53's two (2) multi-dose syringes of Victoza were opened and not dated.
7. R79's seven (7) multi-dose syringes of Victoza were all opened and not dated. On [DATE] at 11:32 AM, V17 stated that it's (Victoza) supposed to be dated.
8. R18's Basaglar Kwik Pen was opened and not dated. While R18's Novolin R vial has a label which showed that it was opened on [DATE] and expired on [DATE]. This Novolin R was mixed with the active medication in the refrigerator.
9. R38's Latanoprost Solution 0.005% eye drops was opened and not dated.
10. R57's Novolog Insulin Aspart vial was opened on [DATE] and expired on [DATE]. This vial was mixed with the active medications in the refrigerator.
11. There was an Insulin Aspart Flex Pen which was opened and not dated with no resident's name, mixed with the active medications in the refrigerator.
12. There was an open vial of Tuberculin Purified Protein Derivatives (PPD/TB test solution vial) multi-dose vial which was opened and not dated.
13. There was an Insulin Aspart Flex Pen which was opened and not dated, and label indicates that it was owned by a discharge resident. This medication was mixed with the active medications in the refrigerator
On [DATE] at 12:15 PM, V2 (Director of Nursing/DON) stated that nursing staff are supposed to label medications with resident's name and the date it was opened. They are also supposed to check medications for expiration dates and remove the expired and inactive medications from the container of active medications.
On [DATE] at 12:32 PM, V21 (Pharmacist) stated that PPD test expires 30 days after it is opened. V21 also stated that she would send the information regarding expiration dates of inquired medications.
Facility presented copy of the (PASS NATIONAL) The Pharmacy Audit Assistance Services which indicates:
The following medications have expiration dates after it was opened:
Basaglar Insulin Glargine expires 28 days after it is opened.
Victoza expires 30 days after it is opened.
Novolog Insulin expires 28 days after it is opened.
Breo Ellipta expires 6 weeks after it is opened.
Novolin R- vial is 42 days and pen are 28 days after it is opened.
Latanoprost Ophthalmic Solution- expires 6 weeks after it is opened.
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
- • No fines on record. Clean compliance history, better than most Illinois facilities.
- • 34% turnover. Below Illinois's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 29 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Frankfort Terrace's CMS Rating?
CMS assigns FRANKFORT TERRACE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Illinois, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Frankfort Terrace Staffed?
CMS rates FRANKFORT TERRACE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 34%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Frankfort Terrace?
State health inspectors documented 29 deficiencies at FRANKFORT TERRACE during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 27 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Frankfort Terrace?
FRANKFORT TERRACE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 120 certified beds and approximately 106 residents (about 88% occupancy), it is a mid-sized facility located in FRANKFORT, Illinois.
How Does Frankfort Terrace Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, FRANKFORT TERRACE's overall rating (3 stars) is above the state average of 2.5, staff turnover (34%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Frankfort Terrace?
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 Frankfort Terrace Safe?
Based on CMS inspection data, FRANKFORT TERRACE 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 3-star overall rating and ranks #1 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 Frankfort Terrace Stick Around?
FRANKFORT TERRACE has a staff turnover rate of 34%, 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 Frankfort Terrace Ever Fined?
FRANKFORT TERRACE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Frankfort Terrace on Any Federal Watch List?
FRANKFORT TERRACE 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.