ALLURE OF GALESBURG
For profit - Limited Liability company
108 Beds
ALLURE HEALTHCARE SERVICES
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#428 of 665 in IL
Photo by Allure of Galesburg
Photo by Allure of Galesburg
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Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Allure of Galesburg has received a Trust Grade of F, indicating significant concerns about the facility's overall quality and care. It ranks #428 out of 665 nursing homes in Illinois, placing it in the bottom half of facilities statewide and #4 out of 6 in Knox County, meaning only two local options are worse. The facility is worsening, with the number of issues increasing from 13 in 2024 to 14 in 2025. Staffing is a weakness, earning only 1 out of 5 stars, with a turnover rate of 53%, which is higher than the state average, suggesting that staff may not stay long enough to build relationships with residents. Notably, there have been alarming incidents, such as a resident receiving the wrong medication and being hospitalized, and another resident being subjected to abuse by a staff member, which underscores significant safety and care failures. While the facility has some good quality measures, these serious issues raise serious red flags for families considering this nursing home.
- Trust Score
- F
- In Illinois
- #428/665
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $220,820 in fines. Higher than 72% of Illinois facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 46 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 36%
Review needed
13 → 14 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 14 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 53%
Near Illinois avg (46%)
Higher turnover may affect care consistency
Federal Fines: $220,820
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: ALLURE HEALTHCARE SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 46 deficiencies on record
2 life-threatening
Sept 2025
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0760
(Tag F0760)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to properly prepare and administer medications to prevent a significant...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to properly prepare and administer medications to prevent a significant medication error for one resident (R4) of three residents (R3, R4, and R5), reviewed for medication administration errors in a total sample of 21. These failures resulted in R4 receiving the wrong medication and being hospitalized for lethargy, heart rate in 40s, difficult to arouse, and subsequently being intubated.These failures resulted in an Immediate Jeopardy.While the immediacy was removed on 9/10/25, the facility remains out of compliance at severity level 2 while the facility continues to educate the nursing staff on proper medication preparation and administration and conduct audits to ensure continued compliance.FINDINGS INCLUDE:The Facility's Medication Administration Policy, not dated, documents: 10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug; c. Right dosage; d. Right route; e. Right time; f. Right documentation; 11. Review MAR to identify medication to be administered; 12. Compare medication source (bubble pack, vial, etc.) with MAR [Medication Administration Record] to verify resident name, medication name, form, dose, route, and time; 14. Remove medication from source, taking care not to touch medication with bare hand; 17. Administer medication as ordered in accordance with manufacturer specifications; and 23. Correct any discrepancies and report to nurse manager.The Facility's Medication Error policy, not dated, documents: 3. Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines: a. The nurse assesses and examines the resident's condition and notifies the physician or care practitioner as soon as possible; b. Monitor and document the resident's condition, including response to medical treatment nursing interventions; c. Document actions taken in the medical record; d. Once the resident is stable, the nurse reports the incident to the appropriate supervisor completes the incident or occurrence report.The facility's Medication Error Report Form, dated 8/15/25, document: Resident Name [R4]; Date/Time Error Occurred: 8/15/25 at 4:24 a.m.; Date/Time Error Discovered: 8/15/25 at 7:15 a.m.; Discovered by [V4/Licensed Practical Nurse-LPN]; Medication(s) involved: Vit[[NAME]] C 500 mg, ASA [aspirin] 81 mg, Claritin 10 mg, clonazepam 1 mg, Plavix 75 mg, fluoxetine 60 mg, Ibuprofen 600 mg, Lyrica 300 mg, MVI [multivitamin], Methocarbamol 750 mg, Seroquel 100 mg, and vitamin D3 5000 IU; Description of Error: Nurse gave another residents medications to wrong resident; and What symptoms, if any did the resident experience: lethargy, decreased BP [Blood Pressure].R4's Electronic Medical Record/EMR document R4's diagnosis to include: Hemiplegia, Poisoning by Unspecified Drugs Accidental, Bradycardia, Parkinson's Disease, Muscle Wasting, Acute Pain due to Trauma, Major Depressive Disorder, Crohn's Disease, and Acute Hepatitis C.R4‘s August 2025 Medication Administration Record/MAR document, on the 15th, V3/Licensed Practical Nurse-LPN, [after administering R5's medication to R4], administered R4's Carbidopa/Levodopa 25/100 two tablets, and Diazepam 5 mg. The MAR also document V4 gave R4 his 7:00 a.m. medications-Lexapro 10 mg, Celebrex 200 mg, Protonix 40 mg, Keppra 1500 mg, Metoprolol 50 mg, Morphine Sulfate Extended Release 15 mg, Carbidopa/Levodopa 25/100 2 tabs, Entacapone 200 mg, and Lacosamide 100 mg. R4's EMR progress notes document: 8/15/25, at 7:15 AM, this nurse [V4] was notified by resident [R5] that he saw the third shift B/E Hall nurse [V3] give his 5 AM medications to this resident. Resident stated he felt unwell this a.m. Resident laying bed and vitals checked, and resident noted to be hard to arouse and lethargic. [V8/medical doctor], 911, Local hospital], and brother notified.On 9/9/25, at 1:25 p.m., V2/Director of Nursing confirmed: On 8/15/25, V3 (3rd Shift Nurse) pre-popped [pre-prepared] and stacked residents' medications. R4 was subsequently administered R5's medications-Ascorbic Acid 500 milligram/mg, Aspirin 81 mg, Claritin 10 mg, Clopidogrel 75 mg, Fluoxetine 60 mg, Multivitamin, Seroquel 100 mg, Vitamin D3 125 ug (micrograms), Lyrica 300 mg, Klonopin 1 mg, ibuprofen 600 mg, Robaxin 750 mg; After realizing the error, V3 then administered R4's correct medication which included-diazepam 5 mg, carbidopa/levodopa 25/100 2 tabs; V3 did not report the error; V4/Licensed Practical Nurse/LPN 1st shift nurse administered R4's 7:00 a.m. medications-Lexapro 10 mg Celebrex 200 mg Protonix 40 mg, Keppra 1500 mg, Metoprolol 50 mg, Morphine Sulfate Extended Release 15 mg, Carbidopa/Levodopa 25/100 2 tabs, Entacapone 200 mg, and Lacosamide 100 mg; R5 then told V4 that V3 had given his medications to R4; and R4 was sent to the emergency room where R4 was admitted .R4's hospital documentation: 8/15/25 Emergency Room-Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: CNS [Central Nervous System] failure or compromise, metabolic crisis and respiratory failure; Hospital admission History & Physical-Admitting diagnosis: Medication overdose; and Discharge Summary, dated 8/18/25, document: [R4] was admitted after unintentional medication overdose given at facility. Patient noted to be lethargic, upon arrival is also bradycardic into 40s. Patient given Narcan x3 in ED and was protecting his airway and brought to ICU [Intensive Care Unit]. ICU attending when rounding on the patient noted that he had gone apneic and was difficult to arouse and patient was then intubated. He was extubated the following day and did well. He was started on a diet and his home medications and was at his baseline mental status.On 9/10/25, at 4:00 a.m., the State Agency entered the facility and found V5/Registered Nurse and V6/LPN had pre-prepared and stacked medicine cups on and in their medicine carts. Among the medicines, pre-popped, five resident med cups contained controlled medicines which were signed out on the narcotic log. V5 and V6 confirmed they should not have pre-prepared/stacked medicine cups.On 9/10/25, at 4:15 a.m., R4 stated, The facility tries to make me feel better by telling me that the nurse is no longer working, but it doesn't make me feel better. If [R5] didn't tell them [facility staff] I got the wrong medicine, I would be dead.On 9/10/25, at 1:55 p.m., V8/Regional Nurse confirmed the medication error should have been immediately reported and all medications held pending the medical doctor's approval.On 9/10/25, at 3:25 p.m., R5 confirmed he saw the nurse give his medicine, with pudding, to R4. He did not know that those were R5's meds at the time. Then the nurse, realizing her mistake, took the empty med cup which had R5's name written on it and said to R5, I suppose this is you? When R5 said, yes, she popped his meds out again and gave them to him. R5 went to the dayshift nurse [V4] and asked her if his meds were double punched, and when she said, yes, he told V4 that his meds had been given to R4.The Immediate Jeopardy began on 8/15/25, at 4:24 a.m., when V3 administered the wrong pre-prepared medications to R4. V1/Administrator was notified of the Immediate Jeopardy on 9/10/25, at 3:09 p.m.The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1. R4's medical record confirms R4 was sent immediately to the emergency room, on 8/15/25, for treatment of lethargy and low blood pressure and remained in the hospital until 8/18/25.2. On 8/18/25, V3's employment, with the facility, was terminated and the incident reported to the State Nursing Board.3. On 9/10/25, An emergency Quality Assurance Performance Improvement (QAPI) meeting was held to review and interpret all audit findings, reviewed all procedures, review investigation, review root cause analysis, review all facts surrounding the incident. Findings will be reported at the monthly QAA meeting for a minimum of 3 months. All applicable facility policies and procedures for medication administration were reviewed/revised by the QAPI team.4. On 9/10/25, V11/Assistant Director of Nursing re-educated licensed nurses on facility policies regarding Medication Administration as well as medication errors and medication administration reconciliation guidelines. All nurses were educated prior to working their next shift including agency nurses. Sign-in sheets were utilized.5. On 9/10/25, an audit of all med carts to ensure no other medications were opened in advance of administering to residents was completed by V11 and continued.6. V8 verified the facility's contracted pharmacy service performed a med cart audit and medication administration audit on 9/10/25.7. The DON or designee will audit med carts on all shifts to ensure medications are being prepped and administered accordingly weekly for 4 weeks then bi-weekly for 2 months. The audits will continue until compliance can be maintained for 3 consecutive months.8. The DON or designee will educate all new hire licensed nurses on medication administration and reconciliation guidelines. 9. On 9/11/25, Education on Medication Administration and Medication Error sign in sheets and course material reviewed with no concerns.10. On 9/11/25, V12/LPN, V13/LPN, and V14/LPN, confirmed they had received education on proper medication preparation and administration procedures on 9/10/25.11. On 9/11/25, Medication Cart Audit was completed by [and observed by the State Agency] V12, V13, and V14's med carts. No concerns.Completion date 9/10/2025
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure nurses do not pre-prepare and stack clear medication cups (with meds) in/on medicine carts for 16 residents (R5-R21) o...
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Based on observation, interview, and record review, the facility failed to ensure nurses do not pre-prepare and stack clear medication cups (with meds) in/on medicine carts for 16 residents (R5-R21) of 16 residents reviewed for medications not being pre-prepared, in a total sample of 21. FINDINGS INCLUDE:Facility Policy, entitled Medication Storage, copyright 2025, document: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls; b. Only authorized personnel will have access to the keys to locked compartments; and c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.On 9/10/25, at 4:00 a.m., the State Agency entered the facility and observed V5/Registered Nurse and V6/LPN had pre-prepared and stacked medicine cups, with resident medication, on and in their medicine carts. Among the medicines, pre-prepared, five resident med cups (R8, R12, R13, R14, R15), along with non-controlled medication, contained controlled medicines which were signed out on the Controlled Drug Received/Record/Disposition Form.On 9/10/25, at 4:00 a.m., V5/Registered Nurse confirmed V5 should not have pre-prepared and stacked the clear med cups, containing residents' morning medication, on top of the medicine cart for R6, R7, and R8-R14. Additionally, V5 stated, I am forced to do that here because the type of residents who get mad when they are not ready and it takes time to pop them out one at a time.On 9/10/25, at 4:05 a.m., V6 confirmed V6 should not have pre-prepared and stacked the clear med cups, containing residents' morning medication for R15-R21, in the top drawer of the medicine cart.The individual medicine carts, Controlled Drug Received/Record/Disposition Form document the following controlled medicine was signed out, as morning medication, by V5 and V6: R8-Clonazepam 0.5 mg, R12-Ativan 0.5 mg, R13 Tylenol with Codeine 300/30 mg, R14-Ativan 1 mg, and R15-Ativan 1 mg.On 9/10/25, V1/Administrator confirmed V5 and V6 should not have pre-prepared resident medication, and they won't be back.
Jul 2025
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
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 assess two residents (R12 and R87) for available walking pass privil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess two residents (R12 and R87) for available walking pass privileges of 24 residents reviewed for choices in a total sample of 42.
Findings include:
The facility's undated Walking Pass Program documents that the program is designed to help you function in healthy ways both inside the facility and out in the community. Your involvement in the Walking Pass Program is a privilege that requires you to meet all referral criteria before you first utilize your walking pass. Your participation in the program will help you develop necessary skills for activities of daily living and successful community life while increasing your independence. The walking pass program requires you to meet.
criteria of each level before advancing to the next level.
1. R12's Medical Record documents he was admitted on [DATE] with diagnoses to include but not limited to depression, schizoaffective disorder, narcissist, and antisocial personality.
On 6/29/25 at 8:00 AM, R12 stated I want a walking pass; I have asked multiple times. I really just want to be able to go for short walks or maybe walk up to dollar general.
On 6/30/25 at 10:30 AM (V5 (Social Service Director) confirmed R12 has asked for a walking pass. I think it was April when he asked me about it. V5 confirmed she has not started any walking pass assessment for R12 I haven't gotten to it; I have been swamped.
2. R87's medical records indicate that R87 was admitted [DATE] with diagnoses to include, but not limited to: Schizoaffective Disorder, Depression, Bipolar Disorder, and Suicidal Ideations.
R87's medical record documents Walking Pass Program Contract signed by R87 on 6/18/25.
On 6/30/25 at 9:30 AM, R87 stated he felt his walking pass took a long time to get. I know (V5/ Social Service Director) has been by herself and now she has some help so it's better for her.
On 7/1/25 at 12:30 PM, V1 (Administrator) stated that a Walking Pass Assessment should be completed no longer than thirty days from time of resident's request. V1 confirmed three months after a resident request is too long to wait.
On 6/29/25 at 10:41 AM, V5 (Social Service Director) stated that after the first walking program violation that a resident would lose walking pass privileges for twenty-four hours, after the 2nd violation a resident would lose privileges for two weeks, and after the third violation a resident would lose privileges for one month.
On 6/30/25 at 10:30 am V5 (Social Service Director) stated that all residents are informed of the availability of the walking pass program upon admission, but it is up to each resident to request a walking pass program assessment.
On 7/1/25 at 12:35 PM, V5 (Social Service Director) confirmed that R87 had requested a walking pass assessment upon admission [DATE]) and was approved 3/12/25. R87's walking pass was rescinded on 3/13/25 due to possession of contraband. V5 confirmed that R87 did not have walking pass privileges from 3/13/25 until 6/18/25 and R87's walking pass was reinstated on 6/18/25.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure one resident (R26) was free from verbal abuse of two residents reviewed for abuse in a total sample of 42.
Findings Include:
The Abu...
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Based on interview and record review the facility failed to ensure one resident (R26) was free from verbal abuse of two residents reviewed for abuse in a total sample of 42.
Findings Include:
The Abuse, Neglect, and Exploitation policy dated 2/3/25 documents It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.
The Facility's Long-Term Care Facility & IID (Individuals with Intellectual Disabilities) Serious Injury Incident Communicable Disease Report dated 5/2/25 documents that V11 (Registered Nurse) and V12 (Certified Nurse Aide) both reported that they overheard V10 (Certified Nurse Aide) tell R26 to Shut the f*ck up. The final investigation documents that R26 stated that he did not like the way that (V10/Certified Nurse Aide) had spoken to him and didn't think it was professional. She shouldn't be allowed to talk to me like that.
The Facility's Long-Term Care Facility & IID (Individuals with Intellectual Disabilities) Serious Injury Incident Communicable Disease Report dated 5/2/25 documents that V10 Certified Nurse Aide was terminated from employment at the facility.
On 7/1/25 at 8:20 AM R26 stated that V10 (Certified Nurse Aide) yelled and cursed at him couple of months ago. R26 stated She shouldn't be able to talk to us (residents) like that.
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**
2. R13's Physicians Orders include the following orders: Cleanse wound to sacrum with normal saline, pat dry and apply hydrocol...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
2. R13's Physicians Orders include the following orders: Cleanse wound to sacrum with normal saline, pat dry and apply hydrocolloid (TTHSA) every day shift, every Tuesday, Thursday and Saturday for pressure wound. R13's physicians Orders also the following wound care: Cleanse open area to right hip with normal saline, pat dry and apply a border form (bordered dressing) until healed one time a day for opening to old incision.
R13's current TAR/Treatment Administration Record includes the task to implement EBP/Enhanced Barrier Precautions every shift.
On 7/1/25 at 11:00am there were no gowns in or outside of R13's room for facility staff to utilize and no signage indicating Enhanced Barrier Precautions were in place.
On 7/1/25 at 11:30am V13 LPN/Licensed Practical Nurse, V21 and V22 CNAs/Certified Nurse's Assistant entered R13's room to perform R13's wound cares. V13 performed wound cares for R13's stage 3 sacral pressure ulcer and right ischial (hip) opened incisional wound area. V21 and V22 CNAs assisted in turning and positioning R13 throughout the wound cares.
V21 and V22 turned R13 onto his left side to expose the dressings covering R13's sacrum and R13's surgical incision wound dressings.
V13 removed the dressing from R13's sacrum, exposing a quarter-size open pressure ulcer with cream-colored wound base. V13 sprayed wound cleansing solution onto the open pressure ulcer and wiped the pressure ulcer with gauze V13 replaced a new hydrocolloid dressing over the pressure ulcer. V13 then removed the bordered dressing from an approximately 3 centimeter long by 1-centimeter-wide open area at the distal end R13's right hip surgical incision. A moderate amount of creamy and light brown drainage was noted on the dressing after it was removed. V13 sprayed wound cleansing solution into the wound, cleaned the wound with a gauze pad and replaced a new bordered dressing over the wound.
V21 and V22 CNAs/Certified Nursing Assistants entered R13's room and did not don protective gowns prior to assisting V13 by turning, positioning, exposing the wound sites and supporting R13 throughout the wound cares. V13 LPN did not don a protective gown prior to performing the wound cares for R13.
On 7/2/25 at approximately 12:45pm V15, the facility's Regional Nurse Consultant verified EBP should have been in place due to R13's pressure ulcer and open wound.
Based on interview and record review the facility failed to implement an antibiotic stewardship program that included assessment and monitoring of residents for signs and symptoms of infections and failed to ensure that the antibiotic usage was appropriate which has the potential to affect all 91 residents that reside in the facility; failed to ensure Enhanced Barrier Precautions (EBP) were utilized per policy for one of two residents (R13) observed on EBP; and failed to follow manufacturer's guidelines for disinfecting blood glucose monitor which has the potential to effect nine residents (R15, R19, R23, R30, R37, R41, R43, R52, R62) that require blood glucose monitoring from that medication cart in a sample of 42.
Findings include:
The Facility Resident Census Roster and Facility Matrix/802, dated 6/29/25, were reviewed. The Census Roster documented 91 Residents resided in the Facility.
The Infection Surveillance policy, not dated, documents McGeer criteria or other nationally recognized surveillance criteria will be used to define infections. Surveillance activities will be monitored facility-wide and may be broke down by department or unit, depending on the measure being observed. The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying a. Data to be collected including how often and the type of data to be documented including: i. The infection site, pathogen, signs and symptoms, and resident location, including summary and analysis of the number of residents (and staff, if applicable) who developed infections: ii. Observations of staff including the identification of ineffective practices, if any; and iii. The identification of unusual or unexpected outcomes, infection trends and patterns. 8. Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparison over time and will be monitored for trends. 9. All resident and infections will be tracked. Separate, site-specific measures may be tracked as prioritized from the infection control risk assessment.
The Facility assessment dated [DATE] documents surveillance of infections is on-going among residents and personnel with documentation to support the evidence. The facility has established an Infection Prevention Committee that meets weekly to discuss trends and patterns. The Quality Assurance Performance Improvement (QAPI) committee meets quarterly and as needed to review and make adjustments to the facility infection prevention plan.
The blood glucose monitor system owner's manual documents to Disinfect the meter between each patient to prevent infection. Disinfecting Procedures: put on non-sterile gloves; take out one disinfecting wipe from the package and squeeze out any excess liquid in order to prevent damage to the meter; wipe all meter's exterior surface display and buttons; hold the meter with the test strip slot pointing down and wipe the area; keep meter wet with disinfection solution contained in wipe for a minimum of 2 minutes for (disinfecting wipe).
The facility's Enhanced Barrier Precautions policy documents the following: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gowns and gloves use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers .unhealed surgical wounds . Make gowns and gloves available immediately near or outside of the resident's room.
1. The Monthly Infection Log had not been completed for February, March, April, May, and June 2025.
The Infection Control Binder included Antimicrobial Days of Therapy Reports dated 2/1/25 through 2/28/25; 3/1/25 through 3/31/25; 4/1/25 through 4/30/25; and 5/1/25 through 5/31/25. The Reports did not include the infection site, pathogen, signs and symptoms, resident location, x-ray/culture report, McGeer criteria or an analysis. The Reports did not include a diagnosis/indication for antibiotic use for the following residents: R29 (2/15/25-2/25/25); R73 (1/28/25-2/11/25); R33 (2/18/25-2/28/25); R7 (1/16/25-3/13/25); R63 (1/30/25-no end date); R47 (2/28/25-3/7/25); R46 (3/24/25-4/3/25); R34 (3/15/25-3/20/25); R20 (3/21/25- 4/4/25); R7 (2/9/25-3/13/25); R47 (2/28/25-3/7/25); R52 (5/15/25-5/25/25); R49 (5/8/25-5/18/25); R24 (5/9/25-5/16/25); R65 (5/10/25-5/14/25); R41 (5/21/25-5/26/25); R22 (5/10/25-5/20/25); R3 (4/16/25-4/26/25); R46 (3/24/25-4/3/25); and R20 (4/2/25-4/4/25).
The Antimicrobial Days of therapy Report documented R72 (2/19/25 -2/26/25); R25 (3/3/25-3/10/25); R92 (5/8/25-5/18/25) were treated with an antibiotic for Urinary Tract Infections.
The UTI (Urinary Tract Infection) Log dated 1/1/25 through 6/29/25 did not include R72, R25 or R92's Urinary Tract Infections.
On 7/1/25 at 12:30 PM, R14 (Chief Nursing Officer) agreed the Monthly Infection Logs had not been completed for February, March, April, May, and June 2025. The Antimicrobial Days of Therapy Reports did not include the infection site, pathogen, signs and symptoms, resident location, x-ray/culture report, McGeer criteria or an analysis. The UTI (Urinary [NAME] Infection) Log dated 1/1/25 through 6/29/25 did not include R72, R25 or R92's Urinary Tract Infections.
On 5/9/25 at 11:30 AM, V2 (Director of Nursing/Infection Preventionist) stated she does review McGeer criteria for infections but does not document the review.
3. On 06/29/25 at 11:45 AM After V13 (Licensed Practical Nurse) performed blood glucose monitoring on R43, V13 wiped blood glucose meter with alcohol wipe and returned meter to the medication cart.
On 07/01/25 at 09:10 AM V2 (Director of Nursing) confirmed that blood glucose meter should not have been cleaned with an alcohol wipe. V2 stated that V13 should have used the disinfectant wipes provided.
On 7/1/25 at 2:30 PM V2 (Director of Nursing) provided a list of residents that require blood glucose monitoring on the B/C medication cart. The list included: R15, R19, R23, R30, R37, R41, R43, R52, R62.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to notify the state mental health authority to reevaluate residents when the Preadmission Screening and Resident Review (PASRR) approval had e...
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Based on interview and record review, the facility failed to notify the state mental health authority to reevaluate residents when the Preadmission Screening and Resident Review (PASRR) approval had ended for six of 26 residents (R26, R41, R79, R81, R87, R498) reviewed for PASRR compliance in a sample of 42 residents.
Findings include:
The Resident Assessment-Coordination with PASARR Program policy, not dated, documents all applicants to this facility will be screened for serious mental disorders (MD) or intellectual disabilities (ID) and related conditions in accordance with the State's Medicaid rules for screening. A PASRR Level II is a comprehensive evaluation by the appropriate state-designated authority that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual and recommends any specialized services and/or rehabilitative services the individual needs.
The PASRR Outcome Explanation Notice of Short-Term Nursing Facility Approval documents short term nursing facility services are approved for the length of time listed on the Notice of PASRR Level II Outcome that came with this letter. The Effective date on the Notice of PASRR Level II Outcome is the first approved day for you to enter a nursing facility.
1. R26's Notice of PASRR Level II Outcome dated 5/8/24 documents the short-term approval ended on 8/4/24. R26's medical record did not include documentation a referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority when the PASRR short-term approval had ended.
2. R41's Notice of PASRR Level II Outcome dated 2/20/25 documents the short-term approval ended on 5/21/25. R41's medical record did not include documentation a referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority when the PASRR short-term approval had ended.
3. R79's Notice of PASRR Level II Outcome dated 10/4/24 documents the short-term approval ended on 1/2/25. R79's medical record did not include documentation a referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority when the PASRR short-term approval had ended.
4. R81's Notice of PASRR Level II Outcome dated 11/21/24 documents the short-term approval ended on 1/20/25. R81's medical record did not include documentation a referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority when the PASRR short-term approval had ended.
5. R87's Notice of PASRR Level II Outcome dated 1/21/25 documents the short-term approval ended on 5/21/25. R87's medical record did not include documentation a referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority when the PASRR short-term approval had ended.
6. R498's Notice of PASRR Level II Outcome dated 4/20/24 documents the short-term approval ended on 10/17/24. R498's medical record did not include documentation a referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority when the PASRR short-term approval had ended.
On 6/30/25 at 10:54 AM, V5 (Social Services Director) stated R26, R41, R79, R81, R87 and R498 were not reevaluated by the state mental health and should have been revaluated when the short-term approval had ended.
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** B. Findings include:
Facility Fall Prevention Program, dated 2024, documents: each Resident will be assessed for fall risk and w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Findings include:
Facility Fall Prevention Program, dated 2024, documents: each Resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls; the nurse will indicate on the Resident's fall risk and initiate interventions on the Resident's base line care plan, accordance with the Resident's level of risk; each Resident's risk factors and environmental hazards will be evaluated when developing the Resident's comprehensive plan of care; and interventions will be monitored for effectiveness and the plan of care revised as needed.
1. R24's Fall Report (#410), dated 12/22/24, document a fall in R24's bathroom hitting head on tub. The Report or R24's Care Plan does not document fall interventions.
R24's Fall Report (#411), dated 12/26/24, documents a fall in R24's bathroom (communal bathroom). R24 was ambulating without assistance and got up from the toilet, went to sit in wheelchair, feet slipped on wet floor and sat himself down. The intervention was to place non-skid strips in front of toilets in communal bathroom.
R24's Fall Report (#412), dated 12/30/24, documents R24 slipped out of bed, mattress to bed noted to be displaced, bed in lowest position. The Report documents an intervention of non-adhesive pad to the bed frame.
R24's Fall Report (#493), dated 6/13/25, documents R24 attempted to transfer self to bed and slipped out of the chair. The Report documents that non-skid strips to left side of the bed/opposite side of bed from the bathroom.
2. R25's Fall Report (#427), dated 3/2/25, documents R25 was found sitting on the floor in front of recliner and the intervention was for non-skid strips in front of recliner.
3. R72's Fall Report (#428), dated 2/14/25, documents R72 had fallen out of bed and needed assistance and the intervention was a perimeter/scooped edge mattress.
On 7/1/25 at 11:45 am, V2 (Director of Nursing/DON) did a tour of R24's R25's and R72's rooms and communal bathroom, and verified that no fall interventions were in place. R24's non-skid strips in bathroom, non-skid strips by bed and non-adhesive to R24's bed frame were not in place. R25's non-skid strips in front of the recliner were not in place. R72's perimeter/scooped edge mattress were not in place. V2 stated, I just came here not long ago to work and I do not know why none of these interventions are in place. I have not had a chance to review all of the falls here yet, that is on my list of things to do so these things do not happen.
Facility failures resulted in two deficinct practices.
A. Based on interview and record review the facility failed to accurately assess one resident (R87) for smoking safety and the facility failed to follow facility smoking policy for one resident (R87) of two residents reviewed for smoking in a total sample of 42.
B. Based on observation, record review and interview the Facility failed to implement documented fall interventions for three of four Residents (R24, R25 and R72) reviewed for Falls in a sample of 99.
A. Findings include:
R87's Resident Smoking Contract/Agreement dated 1/22/25 documents: You must first be evaluated for smoking safety skills before you obtain your smoking privileges. Marijuana/cannabis/gummies/THC/edibles are not allowed in (the facility) building. There is absolutely no use of vapes or any kind of tobacco product inside (the facility) or in any (facility) vehicle. All smoking materials must remain locked in a secure designated location when not in use.
R87's medical record documents R87 was admitted [DATE] with diagnosis to include, but not limited to: Schizoaffective Disorder, Bipolar Disorder, Depression, and Suicidal Ideations.
R87's progress notes dated 02/14/2025 at 9:37 PM documents: This nurse was doing med pass and smelled marijuana in the hall, checked rooms, the smell was the strongest in this resident's room. The resident admitted that he had a marijuana vape and turned (it) over to the nurse and was very sorry for what he did.
R87's progress notes dated 02/15/2025 at 2:52 am documents: Checking on resident, had another vape in his hand while sleeping, this nurse woke resident up with aide in room and asked for the vape that was in his hand, handed it over to the nurse and went back to sleep.
R87's progress notes dated 02/27/2025 at 1:50 PM documents: Resident was informed it is against facility policy for him to have a lighter in his room. He explained he wanted to hold on to it due to sentimental value. He was informed his lighter would be labeled with his name and put in the social services file cabinet.
R87's progress notes dated 03/12/2025 at 11:17 PM documents that Nicotine vape juice, a
lighter, (and) (marijuana) edibles found in resident's room (and) placed in (medication) room. Administrator notified.
R87's progress notes dated 03/28/2025 at 2:54 am documents: CNA (Certified Nurse's Aide) was doing 15 (minute) checks, and resident had obtained a vape, which was in his bed. CNA came and got the nurse; Nurse woke resident up and requested that he hand it to her. Resident handed this nurse the vape with no altercation. Resident then went back to sleep.
R87's Smoking and Safety assessment dated [DATE] documents: follows facility's policy on smoking times and location.
On 7/1/25 at 12:30 PM V14 (Chief Nursing Officer) stated that Smoking and Safety Assessments should be done on admission and quarterly. V14 confirmed that R87's Smoking and Safety assessment dated [DATE] was not marked correctly because R87 had multiple documented incidents of noncompliance with smoking policy.
On 7/1/25 at 12:35pm V5 (Social Service Director) confirmed R87's noncompliance with the facility's Smoking Policy. V5 confirmed there was not any documentation to confirm that facility followed Resident Smoking Policy to ensure R87's safety.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure safe handling of oxygen humidification vessels and change oxygen supplies (oxygen tubing and humidification bottles) fo...
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Based on observation, interview, and record review the facility failed to ensure safe handling of oxygen humidification vessels and change oxygen supplies (oxygen tubing and humidification bottles) for four of four residents (R15, R23, R24 and R37) reviewed for oxygen therapy in a sample of 42.
Findings include:
The facility's undated Oxygen Administration policy documents the following: Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Change humidifier bottle when empty, every 72 hours or per facility policy.
1. R23's correct physicians Order sheet documents Oxygen at 2L (liters) per minute per nasal cannula via O2 (Oxygen) concentrator and/or tank PRN (as needed) to maintain pulse ox (oximetry above 90%.
On 6/29/25 at 9:12am R23 was seated in her room with humidified oxygen in place via nasal cannula at 2 liters per minute connected to the oxygen concentrator at her bedside. R23's oxygen humidification bottle was dated 6/9/25 and the oxygen tubing was not dated.
2. R15's medical record documents R15 has a diagnosis of COPD/Chronic Obstructive Pulmonary Disease.
R15's Physicians Order Sheet includes the following order: Oxygen at 2 liters per nasal cannula at HS (bedtime) for shortness of breath related to Chronic Obstructive Pulmonary Disease.
On 6/29/25 at 9:15am R15 was sitting in her room with humidified oxygen in place via nasal cannula at 2 liters per minute connected to an oxygen concentrator at her bedside. R15's oxygen humidification bottle was dated 6/9/25 and the oxygen tubing was not dated.
On 7/2/25 at 3:10pm V15 Regional Nurse Consultant stated the facility's policy is to change oxygen humidification bottles and oxygen tubing weekly, every Sunday by the night shift.
3. R24's Phsysician Order Sheet, dated 6/30/25, does not document an order for oxygen or tubing/humidifcation bottle changes.
R24's Progress Note, dated 6/23/25 at 12:57 am, documents oxygen via nasal cannula.
On 6/29/25 at 9:48 am (laying in bed) and 6/20/25 at 10:00 am (sitting in wheelchair), R24 was wearing oxygen tubing and oxygen was running at two liters per nasal cannula (2LNC) and R24's oxygen tubing and humidifcation bottle was not dated.
4. R37's Physician Order Sheet, dated 6/30/25, documents an order to change oxygen tubing/cannula/mask/water bottle every week on Sunday.
On 6/29/25 at 9:45 am and 6/30/25 at 9:48 am, R27 was laying in bed with oxygen at two liters per nasal cannula (2LNC) running and R37's oxygen tubing was not dated and R37's humidification bottle was dated 6/22/25.
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 ensure Influenza and Pneumococcal immunizations were offered to fou...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Influenza and Pneumococcal immunizations were offered to four of five residents (R26, R87, R81, R498) reviewed for immunization compliance in a sample of 42.
Findings include:
The Influenza Vaccination, no date, documents the influenza vaccination will be routinely offered annually from October 1st through March 31st.
The Pneumococcal Vaccine (Series), no date, documents each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted.
R26 was admitted on [DATE]. The Immunization Audit Report sheet did not include a pneumococcal immunization history or evidence the vaccine was offered, declined, or administered.
R81 was admitted on [DATE]. The Immunization Audit Report sheet did not include a pneumococcal immunization history or evidence the vaccine was offered, declined, or administered.
R87 was admitted on [DATE]. The Immunization Audit Report sheet did not include an influenza or a pneumococcal immunization history or evidence the vaccines was offered, declined, or administered.
R498 was admitted on [DATE]. The Immunization Audit Report sheet did not include a Pneumococcal immunization history or evidence the vaccine was offered, declined, or administered.
On 7/1/25 at 12:30 PM, V15 (Regional Nurse Consultant) agreed R26, R81, R87 and R498's Immunization Audit Report sheets did not include an influenza and/or a pneumococcal immunization history or evidence the vaccine was offered, declined, or administered.
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 store food in accordance with professional standards for food service safety. This failure has the potential to affect all 91 ...
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Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety. This failure has the potential to affect all 91 residents in the facility.
Findings include:
The facility's Food Safety Requirements policy dated 2025 documents the following: Practices to maintain safe refrigerated food storage include: iv. Labeling, dating and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) discarded; d and v. Keeping foods covered or in tight containers.
On 6/29/25 at 7:35am 11 individual servings of mixed fruit and two individual cups of applesauce were uncovered and undated on a shelf in one of the refrigeration units at the front of the kitchen. In the back refrigerated unit six cooked chicken breast servings were undated and wrapped in foil with open areas exposing the chicken breasts.
On 6/29/25 at 8:10am V16 Dietary Manager verified refrigerated foods should not be stored undated or uncovered.
On 6/29/25 the facility's Matrix documents 91 residents are currently residing in the facility.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure their nurse staffing information was posted and accessible to residents and visitors. This has the potential to affect ...
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Based on observation, interview and record review, the facility failed to ensure their nurse staffing information was posted and accessible to residents and visitors. This has the potential to affect all 91 residents in the facility.
Findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 6/29/25, documents 91 residents currently reside in the facility.
On 6/30/25 at 10:00 AM, the facility's nurse staffing sheet dated 6/9/25, 21 days prior, was posted on a board in the dining area behind a document titled Summary for Filing Year 2022 Injury Tracking Application and was not viewable.
On 6/30/25, at 10:00 AM, V1 (Administrator) confirmed the nurse staffing sheet was not posted daily at the beginning of each shift nor was the posting visible.
Feb 2025
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to prevent staff to resident sexual abuse and mental abuse for one of t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to prevent staff to resident sexual abuse and mental abuse for one of three residents (R1) reviewed for abuse in the sample of four. These findings resulted in R1 being subjected to bribery with alcohol and drugs and sexual abuse by V3 (CNA/Certified Nursing Assistant) on more than 100 occasions, R1 suffering fear and depression, and R1 requiring prophylaxis for prevention of STDs (Sexually Transmitted Diseases).
These failures resulted in an Immediate Jeopardy.
The Immediate Jeopardy started on 6-1-24 when V3 started bribing R1 with alcohol and drugs and started sexual abusing R1 within the facility.
V1 (Administrator), V15 (Regional Director of Operations), V17 (Corporate Nurse) were notified of the Immediate Jeopardy on 2-3-25 at 11:00 AM.
While the immediacy was removed on 2-3-25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.
Findings include:
The facility's Abuse, Neglect, and Exploitation dated 2024 documents, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.
The facility's Agreement with the Employees International Union Healthcare Illinois/Indiana dated 5-1-22 through 5-30-25 documents, These work and safety rules and regulation shall be applicable to each facility and its employee in the bargaining unit. It is essential to the successful operation of the facility's business and the welfare of its patients and employees that fairly established standards of discipline, health, safety, attendance, workmanship, and honesty be maintained. Employees shall have an opportunity to sign formal warning, acknowledging that such warning has been given and to comment on such warning. Maintaining or attempting to maintain a relationship (whether or not consensual) with a resident that is sexual or romantic in nature unless the resident is the employee's spouse. First offense-Discharge.
R1's Pre-admission Hospital History and Physical dated 5-1-24 documents, Chief Complaint: Suicidal Ideation. (R1) is a [AGE] year-old with past reported psychiatric history of Bipolar I Disorder with Psychotic Features, stimulant use disorder (methamphetamine), and alcohol use disorder admitted voluntarily for suicidal ideation in the context of methamphetamine use. (R1) has been non-adherent with medication and utilizing methamphetamine which is likely a significant exacerbating factor. The patient warrants inpatient level of care for safety and stabilization.
R1's admission Record documents R1 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Bipolar Disorder Severe with Psychotic Features, Suicidal Ideation's, Major Depressive Disorder, Persistent Mood Affective Disorder, Hallucinations, and Psychotic Disorder not due to a substance or know Psychotic Condition.
R1's current Physician's Orders document, 24-hour nursing care. Mirtazapine 30 mg (milligrams) one daily at bedtime for the Major Depressive Disorder. Hydroxyzine HCL (Hydrochloride) 50 mg twice daily for Anxiety. Alprazolam one mg three times daily for Anxiety. Aripiprazole 15 mg one time daily for Bipolar with Severe Psychotic Features.
R1's Brief Interview for Mental Status dated 1-8-25 documents R1 is cognitively intact.
The facility's Serious Injury Incident and Communicable Disease Report dated 1-29-25 documents (R1) reported that (V3/CNA) has been having inappropriate sexual encounters with (R1). (V3) previously resigned from her position. Last day to work was 1-7-25. (Local) police department notified. (Primary Care Physician) notified. Investigation initiated. Final to follow.
R1's Hospital Emergency Department Notes dated 1-29-25 and signed by V16 (Hospital Physician) document, Primary diagnosis: Sexual assault of adult. (R1) reports he is here for a rape kit. (R1) reports for something that happened three weeks ago. (R1) reports he has showered and changed his clothing. (R1) reports police have been notified and wanted him to have a rape kit. (R1) reports he just showed them the video. (R1) is from a nursing facility and reports the person was a worker but no longer is employed at the facility. RN (Registered Nurse) spoke with the charge nurse at (the hospital). Due to (R1) reporting this happened three weeks ago, (R1) wouldn't be in the time frame for a rape kit. Medical Decision Making: I (V16) have evaluated (R1) and performed medical screening exam. Evidence was not collected. I have discussed all information regarding the risk of contracting sexually transmitted infections as well as the possibility of pregnancy, as applicable, Prophylaxis for gonorrhea, chlamydia, and trichomonas was given. (R1) declined baseline HIV (Human Immunodeficiency Virus) test, (R1) declined other STD testing as noted in orders. Counseling: You (R1) are a survivor of sexual assault. You may have trouble sleeping. You may have anxiety, irritability, depression, and other symptoms. This is normal. They are reactions to trauma. You can get help. Rape crisis centers have free counseling services.
R1's Police Report Incident Number 25-003634 dated 1-29-25 at 3:44 PM and signed by V5 (Local Police Officer) documents, On January 29, 2025, at 3:44 PM I (V5) was dispatched to (the facility) in reference to a Criminal Sexual Assault. During the investigation, the victim (R1), also admitted to sending video of the sexual encounters to other people who work at (the facility). (R1) and (V3), an ex-employee, have been having sexual intercourse for the past six months and just recently stopped having sexual encounters after (V3) quit on January 7, 2025. (R1) would also state they (R1 and V3) have had sex approximately 50 times or more. (R1) stated he felt threatened by (V3) and that (V3) has said on several occasions that (V3) could get (R1) kicked out of (the facility) if (R1) did not do what (V3) wanted him to do. (R1) stated (V3) would come into his bedroom, while he was sleeping, and started giving him blow***s. (R1) would wake up and push (V3) away and she would continue to give (R1) a blow**b. (R1) advised that (V3) would also help him with his showers due to him not being able to reach his right side with how badly his left arm is injured. (V3) would help him in the shower and while helping him in the shower (V3) would get naked and bend over so (V3 and R1) could have sex. (R1) stated (V3) would take him to her friend's residence who lived close to the nursing home when (R1) was able to leave on his own time. (R1) and (V3) would go to her friend's residence and have sex, along with (R1) recording some of these sexual encounters happening. (R1) stated the last time (R1) had a blow**b or sex with (V3) was before (V3) quit on January 7, 2025. When (R1) was asked about the recordings he stated he advised (V3) about the recordings and (V3) was okay with him recording the two of them. (R1) showed (V5) one of the videos of (V3) giving (R1) a blow**b in (R1's) room inside (the facility). (R1) stated (V3) would send pictures and videos back and forth of the two masturbating on several occasions. (R1) advised he would like to go to the hospital and have a sex assault kit done.(V1/Administrator) and (V15/Regional Director of Operations) stated they would arrange transportation for (R1) to get to the hospital. (R1) advised he was supposed to leave and spend time with (V3) on January 27th, 2025, but (V3) had canceled plans. (R1) advised he was upset with (V3) due to her not being able to spend time with him. (R1) advised he was feeling down and upset on January 28, 2025. While feeling like this (R1) finally told an employee about the sexual encounters between him and (V3). (R1) stated he recorded the two (R1 and V3) having sexual encounters several times with (V3's) permission. (V3) sent the videos via (social media). Once (R1) sent the video to one employee, other employees started to ask (R1) for the video to be sent via (social media). (R1) stated he sent the videos to several employees including (V11/CNA), (V12/CNA), (V13/LPN/Licensed Practical Nurse), and (V14/LPN).
R1's updated Care Plan dated 6-4-24 to current documents, Focus: I am at risk for abuse/neglect/exploitation related to my SMI (Serious Mental Illness) diagnoses of Bipolar Disorder with Psychotic Features, Major Depressive Disorder, and Anxiety. Goal: I will verbalize to staff any instanced of abuse/neglect/exploitation through the next review period. Interventions/Task Provide care in a manner consistent with training and (facility) policies and procedures as appropriate to responsibilities and job tasks. Provide re-assurance if negative feelings occur. Provide regular opportunity for me to communicate my choices, preferences, needs/wants, related to my care and opportunity for me to express my concerns about care. Report any verbalization of abuse/neglect/exploitation to administrator immediately. Focus: Due to personal report of trauma history, I benefit from trauma informed care. I shared that my three-month-old daughter accidentally suffocated after my ex-wife put her in bed with her after coming home from work near Christmas of 2016. Goal: I will share my trauma related history and the challenges it presents to the degree I am comfortable in order to begin the healing and recovery process through the next review. Interventions/Tasks: Encourage me to participate in group/individual psychotherapy/counseling. Monitor of signs/symptoms of PTSD (Post Traumatic Stress Disorder), document, and notify my IDT (Inter-Disciplinary Team) including therapist as applicable, psychiatrist, and Primary Care Provider. Respect my choices/wishes. Offer care and assistance in a way that promotes re-assurance, comfort, choice, dignity, and safety.
On 1-31-25 at 1:30 PM R1 stated, Around six months ago (June 2024) V3 (CNA) would bring me in alcohol, gummies, and vapes (electronic cigarettes) in to trade for sex. We would have sex in my room with other residents in the room. (R2) caught us several times. We have had sex almost every time (V3) has worked, over 100 times. I would have to have sex when she wanted to, or she would cut me off from vapes or anything else I wanted. It was a threat over my head. I have not had sex with any other residents here. A couple times I woke up to her giving me h**d. I told her to knock it off and she continued to give me h**d. She would say she is union, and they can't fire her, and the facility would never believe anything she said. I recorded with my phone when she would give me oral sex. I felt like she was the one in power. She initiated the sex the first time and the last time. She would bribe me with home visits and would sign me out. She would meet me at the corner of the building so staff would not see us. I went to her house twice and had sex and sex at a hotel once. We would have normal sex and oral sex. She even told me she was pregnant with my child and had a miscarriage. That caused me severe depression as I have had a child of mine die in the past. I have not spoken to her in the last three days. I have blocked her on all accounts. I lived at an apartment prior to here. The police officer said it was the best thing to do was to go to the hospital for a rape kit. The hospital said it had been over three weeks so there was really no reason to do a rape kit since I have showered, and all the evidence would be gone. She would bring me in alcohol and vapes as a bribe for sex. Once in a while she would bring me in THC (Tetrahydro-Cannabinol) gummies. I am not aware of her having sexual relations with any other residents. I showed some staff the videos because the staff asked me to send them to them. I sent videos to staff on Monday.
On 1-31-25 at 12:55 PM V1 (Administrator) stated, On Wednesday (R1) reported to me that he felt coerced and raped by (V3). When (R1) reported it on Monday to me, (R1) did not report feeling coerced or raped by (V3). As soon as (R1) reported sex with (V3) as not being consensual, I notified the police and the physician. (R1) was interviewed by the police for three and a half hours. We (the facility) sent (R1) to the hospital to have a rape kit done. A rape kit could not be done since it had been over three weeks since (R1 and V3) had sex. Staff having sex with residents is against company policy and against the employees' union agreement. (V3) had not worked here since January 3, 2025, as (V3) quit after I had suspended her after having reports that (V3) was bringing in CBD (Cannabidiol) gummies to the residents.
On 1-31-25 at 2:10 PM R2 (R1's roommate) stated, I would hear or see (V3) and (R1) having sex almost every time (V3) worked. I would tell (V3) that it was going to catch up with her and (V3) was going to get fired. I would see (V3) bring in alcohol, vape pens, and weed to (R1). A couple times I heard (R1) say he did not want to have sex and (V3) told (R1) if he didn't want to have sex anymore she was not going to bring him in any more alcohol or vapes. It really bothered me that (R1 and V3) would have sex in my room.
On 1-31-25 at 2:20 PM V6 (LPN) stated, On Saturday night (R1) showed me a video of (V3) performing oral sex on (R1). I was not sure if it was consensual. It is not ethical and against company policy for a staff member to have sex with a resident. (R1) said (V3) had been having sex with him for months.
On 1-31-25 at 2:30 PM V7 (R1's Primary Physician) stated, (R1) should not be subjected to sex from a staff member. That is unethical and abuse. Staff should not be bringing in drugs or alcohol to the residents.
On 1-31-25 at 4:40 PM V12 (CNA) stated, Either last Saturday or Sunday (R1) told me (V3) was having sex with (R1) while (V3) was working within the facility. (R1) sent a video on Monday to my (social media) and I saw (V3's) face plain as day, in (R1's) bed, performing oral sex on (R1). That is not okay.
On 1-31-25 at 5:10 PM V14 (CNA) stated, (R1) told me Sunday night that (V3) was having sex with (R1) in his room with (R1's) roommates in the room. (R1) said for the past six months (V3) would bring him alcohol and THC edibles and have sex with (R1) while (V3) was supposed to be working. (R1) said (V3) had told him she (V3) was pregnant with his child and then told (R1) she had a miscarriage. That was terrible as (R1) has lost a child in the past and was very upset. It is not appropriate for staff to be bringing in drugs and alcohol to the residents or have sex with the residents. (R1) sent me a video on my (social media) and the video was (V3's) face and (V3) was giving (R1) a blow**b while in (R1's) bed. There was also a picture of (V3) in the facility's shower room. (V3) had her shirt raised, exposing her breasts to (R1). (V3) was manipulating (R1).
On 2-1-25 at 12:00 PM V13 (LPN) stated, (R1) showed me a video on Monday night of (V3) performing oral sex on (R1). It was disgusting. I could see (R1's) face in the video and could tell by the surrounding they (R1 and V3) were in (R1's) bed. (R1) said (V3) would bring (R1) in alcohol and drugs for sex. (R1) said (V3) would have sex with him almost every night she worked. (R1) seemed upset while telling me about it. That is so inappropriate. Staff should never have sex with residents.
On 2-1-25 at 1:00 PM V11 (CNA) stated, (R1) sent me a video on (social media) of (V3) giving (R1) a blow**b. I could tell it was (V3) on the video. Staff should not have sex with residents.
On 2-4-25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:
1. The Administrator (V1) or designee immediately ensured the safety and well-being of the (R1). V3 was no longer employed with the facility as of 1-7-25.
2. On 1-29-25 V1 initiated and abuse investigation into R1's abuse allegation.
3. On Upon notification of the allegation on 1-29-25, police were notified and R1 was sent to the emergency room for evaluation and examination.
4. As of 02-03-25 V1 or designee educated all staff on what constitutes all forms of abuse and bribery.
5. As of 02-03-25 V4 (Social Service Director) completed an Abuse/Neglect/Trauma screening on all residents and any resident who triggered at risk for abuse neglect, or trauma was educated on what to report and who to report to.
6. On 02-02-25 the quality assessment and assurance committee developed and implemented plans to ensure further abuse and bribery of the residents does not continue within the facility.
7. On 02-03-25 the abuse policies were reviewed and revised by the quality assurance committee prior to educating staff.
8. On 02-03-25 a root cause analysis was completed for the alleged sexual relationship that occurred between R1 and V3.
9. V1 received education on 2-1-25 from V15 (Regional Director of Operations reporting abuse timely and thoroughly investigating all abuse allegations.
10. All newly hired staff and agency staff will be educated by V1 (Administrator), V20 (Director of Nursing), or designee prior to the start of their shift on abuse prevention and reporting as well as what constitutes bribery, prohibiting staff from providing contraband to residents, and maintaining professional boundaries with residents, staff not having a physical relationship with residents, and for staff to not request or view photos or videos of residents.
Completion date: 2-3-25
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to implement their Abuse Policy to immediately report an allegation of staff-to-resident sexual abuse to the State Agency for one of three resi...
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Based on record review and interview the facility failed to implement their Abuse Policy to immediately report an allegation of staff-to-resident sexual abuse to the State Agency for one of three residents (R1) reviewed for Abuse in the sample of four.
Findings include:
The facility's Abuse, Neglect, and Exploitation policy dated 2024 documents, Reporting/Response: 1. The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within the specified timeframes: a. Immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.
The facility's Serious Injury Incident and Communicable Disease Report dated 1-29-25 documents (R1) reported that (V3/CNA/Certified Nursing Assistant) has been having inappropriate sexual encounters with (R1). (V3) previously resigned from her position. Last day to work was 1-7-25. (Local) police department notified. (Primary Care Physician) notified. Investigation initiated. Final to follow.
On 1-31-25 at 12:55 PM V1 (Administrator) stated, I was informed by (V6/Licensed Practical Nurse) on 1-27-25 about (R1) stating (R1) and (V3/CNA) were having sexual encounters. I did not report the sexual encounters to the State Agency until 1-29-25 when (R1) said the sexual encounters were not consensual.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0944
(Tag F0944)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to ensure all staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to...
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Based on record review and interview the facility failed to ensure all staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 93 residents residing within the facility.
Findings include:
The facility's Resident Roster dated 1-31-25 documents the resident in-house census as 93 residents.
The facility's Staff Training and Staff In-Service Logs dated 1-1-24 through 2-3-25 do not include documentation of facility staff receiving annual QAPI training.
On 2-4-25 at 10:30 AM V17 (Corporate Nurse) stated, No staff at this facility have received annual QAPI training. Our training program did not list this as one of the trainings that needs completed yearly.
Jul 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to develop a skin care Plan of Care for one resident (R30); and failed to develop a foot wound Care Plan for one resident (R13), of 18 residen...
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Based on record review and interview, the facility failed to develop a skin care Plan of Care for one resident (R30); and failed to develop a foot wound Care Plan for one resident (R13), of 18 residents reviewed for Care Plans in a sample of 53.
Findings includes:
The facility's Comprehensive Care Plans Policy, Undated, documents: It is the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS/Minimum Data Set assessments.
1. On 7/9/24 at 9:45 am, R30's bilateral upper extremities present with discoloration and lesions, with right upper arm more affected than left. R30 stated that the staff had not provided treatment or sleeve skin protectors to protect the skin on her arms.
R30's Skin Monitoring: Comprehensive CNA/Certified Nursing Assistant Shower Sheet dated 7/2/24 indicated Discoloration at R30's bilateral forearms.
R30's current Care Plan does not include focus, goals or interventions for care of R30's skin discoloration/lesions on R30's bilateral upper extremities.
On 7/10/24 at 9:25 am, V3 Assistant Director of Nursing/ADON stated that (V15 Wound Physician) saw R30 this morning and stated that the reddish scar lesion on R30's right upper forearm was pre-cancerous, and will have a new treatment for that; stated that V15 said the discoloration on R30's upper extremities resulted from (R30's) Plavix medication. V3 ADON stated, We got the order for a sleeve for her forearms yesterday.
At this same time, V1 Administrator and V3 ADON stated that R30's skin issues did not have to be on R30's Care Plan. V3 ADON stated that the discoloration on R30's bilateral upper extremities was nothing new for (R30), and that R30 has had the discoloration for a while.
2. Current Physician Orders indicate orders for antifungal cream to R13's lower back, groin and sacrum twice daily and as needed.
On 7/9/24 at 2:00pm R13 noted with bright red, shiny area covering skin over entire buttocks, upper buttocks and lower buttocks and into groin. Also noted were various scattered satellite areas of redness surrounding solid red areas.
On 7/9/24 at 11:15am and 1:45pm R13 was in bed on his back and both feet/heels were in contact with the vinyl mattress extender at the bottom of the mattress/footboard. At that time, it was noted that R13 had an oval brownish scabbed area right lateral foot and a circular dark brown scabbed are on left heel. V11, CNA (Certified Nurse Assistant) stated that R13's heels should be offloaded and placed a pillow under R13's lower lower legs.
On 7/11/24 at 10:00am V8, LPN (Licensed Practical Nurse) assisted in assessment of R13's feet. R13 was noted to have an approximate 50-cent piece sized, dark brown/grey/deep purple scabbed area on left outer lateral heel and an oval brown/grey scabbed area on right outer lateral mid foot - directly over a bony prominence of R13's foot.
V8, LPN stated that R13 has boots for his feet to keep his feet offloaded, however V8 did not find them in R13's room. V8 stated (R13) doesn't like to turn, has a lot of pain. He does like to lay more toward his right side.
On 7/11/24 11:15am V3, ADON (Assistant Director of Nursing/Wound Nurse) stated I didn't know anything about the wounds on (R13's) feet. I'll check with Hospice.
R13's care plan did not include a care plan or interventions for the fungal/reddened areas on R13's buttocks or for either of the wounds on R13's feet.
On 7/12/24 at 12:20pm V2, DON (Director of Nursing) acknowledged there should have been care plans for R13's current skin conditions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record reviews, and interview, the facility failed to ensure skin care concerns were addressed, failed to provide skin treatments, and failed to notify physician about skin conce...
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Based on observation, record reviews, and interview, the facility failed to ensure skin care concerns were addressed, failed to provide skin treatments, and failed to notify physician about skin concern for one resident (R30) of 18 residents reviewed for quality of care in a sample of 53.
Findings Include:
Facility's Skin Assessment Policy, Undated, documents: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission, daily for three days, and weekly thereafter. Consider the general status of the resident's skin. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions.
Facility's Resident Rights Policy, Undated, documents: The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
The (State) Ombudsman Program Resident Rights for People in Long Term Care Facilities, Ombudsman Program, Revised 11/2018, documents: Your facility must provide services to keep your physical and mental health, at their highest practical levels.
On 7/9/24 at 9:45am, noted that both upper extremities of R30 showed discoloration and lesions, with right upper arm more affected than left. R30 stated that the staff had not provided treatment or sleeve protectors to protect the skin on her arms.
At this same time, R30 smiled and stated, No one beat me. I just don't like the appearance of how they look.
R30's current Treatment Administration Record (TAR) dated 7/9/24 does not document skin treatments to R30's bilateral upper extremities; there were no physician orders for treatment of R30's bilateral upper extremities; and R30's current Care Plan does not provide focus, goals or interventions for care of R30's skin discoloration/lesions on bilateral upper extremities. R30's Weekly Skin Assessments (Dated 7/5/24, 6/28/24, 6/21/24, and 6/14/24) document: No issues noted/No skin issues.
On 7/9/24 at 1:10pm, V13 Licensed Practical Nurse/LPN stated that she has observed the skin redness and discoloration on R30's bilateral upper extremities, and there had been no treatments. V13 LPN stated, I have done skin assessments for her; we have no treatment order, did not think to get protection sleeves for her to protect her skin.
On 7/9/24 at 1:12pm, V14 Licensed Practical Nurse/LPN stated that Weekly Skin Assessments were done for R30. V14 LPN stated, (R30) has fragile skin.
On 7/9/24 at 1:16pm,V3 Assistant Director of Nursing/ADON stated that she is the facility's Wound Care Nurse; stated that there was no treatment order for (R30's) bilateral upper extremities; and stated that (R30) would benefit from (arm skin protectors). V3 ADON stated, We will get an order for her arms.
R30's 7/10/24 Progress Note documents: Narrative: (R30) seen by (V15 Wound Physician) during rounds today. (V15) performed a pinch biopsy after reviewing risks with (R30) and (Power of Attorney/POA).
On 7/10/24 at 10:05am, R30 stated that (V15 Wound Physician) saw her today and told her that that one reddish lesion on her right upper arm was cancerous.
R30's 7/10/24 Wound Evaluation and Management Summary, signed by V15 Wound Physician, documents: Diagnosis: Actinic Keratosis/AK's: Multiple AK's both arms with purpura resulting from anticoagulant usage with capillary fragility; using (arm skin protectors) to protect arms; however, expect she will continue to have purpura regardless but may not be as extensive with (arm skin protectors). (Internet definition of Actinic Keratosis/AK's: A rough, scaly, pink or white growth that occurs on the surface of the skin in areas (such as the face, neck, and back of the hands) frequently exposed to sunlight and that may develop into squamous cell carcinoma. Excessive exposure to sunlight causes skin cancer, but a pre-cancerous lesion called an actinic keratosis appears long before the cancer.)
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 provide physician orders for the administration of oxygen and failed to change oxygen tubing/humidifier bottles per facility po...
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Based on observation, interview and record review the facility failed to provide physician orders for the administration of oxygen and failed to change oxygen tubing/humidifier bottles per facility policy for one resident (R13) of three residents reviewed for oxygen therapy in the sample of 53.
Findings include:
Facility Policy/Oxygen Concentrator dated 2023 documents:
The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators.
Oxygen is administered under the orders of the attending physician, except in case of an emergency.
The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc).
Facility Policy/Oxygen Administration dated 2024 documents:
Oxygen is administered under orders of a physician, except in cases of an emergency.
Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.
On 7/9/24, 7/10/24 and 7/11/24 R13 was in bed with an oxygen cannula administering oxygen at 3.5L (liters) during multiple observations on all three days.
On 7/9/24 and 7/10/24 R13's oxygen tubing noted to be dated 6/30/24 and non-disposable humidification bottle not dated.
On 7/11/24 at 9:30am V8, LPN (Licensed Practical Nurse) stated that oxygen tubing should be changed weekly along with non-disposable humidification bottles.
On 7/11/24 at 10:12am V3, ADON (Assistant Director of Nursing) stated she was not aware R13 was receiving continuous oxygen and he should have a physician order.
No physician order was found or presented indicating R13 should be receiving oxygen until 7/11/24 at 3pm.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to identify an appropriate indication for use and identify...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to identify an appropriate indication for use and identify target behaviors for the use of an antipsychotic medication for one resident (R13) of five residents reviewed for unnecessary medications in the sample of 53.
Findings include:
Facility Policy/Use of Psychotropic Medication dated 2024:
Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).
Enduring Conditions (non-acute, chronic, prolonged):
The resident's symptoms and therapeutic goals shall be clearly and specifically identified and documented.
Current Physician Orders indicate order for Seroquel (antipsychotic) 25mg (milligrams) at bedtime related to anxiety disorder and Major Depressive Disorder (date initiated 3/19/24). Physician Orders also indicate R13 is [AGE] years old, on Hospice Care with diagnoses that include Chronic Viral Hepatitis, Cirrhosis of Liver, Chronic Pain Syndrome and Emphysema.
Current Care Plan/Pharmacotherapy: The resident (R13) uses psychotropic medications related to anxiety and depression dated 12/27/23. Care Plan does not indicate R13 receives an antipsychotic medication or target behaviors requiring the use of an antipsychotic medication.
Behavior Monitoring and Tracking reviewed times three months (July, June, May/2024) with no behaviors identified.
Psychiatric Evaluation dated 6/18/24 indicates No Audio/Visual hallucinations, delusions or Suicidal Ideation.
Consent for Psychotropic Medications dated 3/19/24 indicates consent obtained for Seroquel 25mg on that date without documentation of diagnosis or indication for use.
On 7/9/24, 7/10/24 and 7/11/24 R13 was seen in bed and able to answer questions appropriately. R13 did not display any inappropriate behaviors or signs/symptoms of psychosis.
On 7/11/24 at 1:15pm V2, DON (Director of Nursing) stated she was unsure of the reason for R13 receiving Seroquel and redirected to the Psychiatric Evaluation dated 6/18/24.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure the women's shower room was clean, functional and protected the resident's privacy. This failure potentially affects all sixteen femal...
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Based on observation and interview, the facility failed to ensure the women's shower room was clean, functional and protected the resident's privacy. This failure potentially affects all sixteen females residing on the E Wing (R3, R5, R9, R11, R16, R22, R27, R33, R54, R50, R55, R58, R70, R78, R90, R394) that utilize the women's shower room.
Findings include:
1. On 7/9/24 at 9:45 AM, R16 stated The shower heads are broken (in the women's shower room). There is hardly a stream of water that comes out (of the shower head).
2. On 7/9/24 at 10:00 AM, R394 stated The showers don't work and there is no water. Even the toilets don't flush.
3. On 7/9/24 at 10:15 AM, R27 stated They need to clean up the shower room.
4. On 7/9/24 at 10:20 AM, R54 stated The bathrooms have mold, there is no soap, showers suck, bathroom sinks don't work and they keep saying they are going to fix it but they don't. The bathroom had poop in the toilet and I had to flush the toilet like five times to get it down.
5. On 7/9/24 at 2:00 PM, R58 stated The bathrooms have been like that since I got here probably three years ago.
6. On 7/9/24 at 10:35 AM, in the women's shower room, the following was observed:
a) Shower #1 has no faucets and no water;
b) Shower #2 has minimal water pressure with a non-continuous stream of water from the shower head and black stains around the inside walls of shower;
c) The bathtub has no faucets and no water;
d) Two of three sinks have no faucets and no water and the sink has black smudges and debris on the inside;
e) Three of three soap dispensers have no soap, two have broken handles and one was lying on top of the paper towel machine;
f) Toilet #1 does not flush and the shower curtain was pulled off multiple shower hooks and falling down;
g) Toilet #2 does not have a privacy curtain;
e) Toilet #3 had poop sitting in it and the shower curtain was pulled off multiple shower hooks and falling down;
f) A cabinet labeled towels and wash clothes contains broken pieces of PVC pipe (polyvinyl chloride/plastic plumbing), two shower curtain hangers, pieces of toilet paper and a gait belt.
6. On 7/11/24 at 10:00 AM, V6 (Maintenance Director) stated Corporate came in a few months ago and plans on doing a full remodel. It (bathroom) is hard to maintain because it is so old.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure the women's shower room was free from hazards. This failure potentially affects all sixteen female residents on the E-Wing (R3, R5, R9...
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Based on observation and interview, the facility failed to ensure the women's shower room was free from hazards. This failure potentially affects all sixteen female residents on the E-Wing (R3, R5, R9, R11, R16, R22, R27, R33, R54, R50, R55, R58, R70, R78, R90, R394) that utilize the women's shower room.
Findings include:
1. 07/09/24 01:55 PM, a 2-blade disposable razor was observed on the counter in the women's shower room which is utilized by the E Wing residents.
2. On 7/9/24 at 1:45 PM, V13 (Licensed Practical Nurse) stated That (disposable razor) should absolutely not be in here. The only way they (residents) even have access to them (disposable razors) are if staff give them (razors) to them (residents). They (razors) are kept locked up.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure kitchen waste/trash was secured by leaving the lids left open on the trash receptacle located outside. This failure ha...
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Based on observation, interview, and record review, the facility failed to ensure kitchen waste/trash was secured by leaving the lids left open on the trash receptacle located outside. This failure has the potential to affect all 90 residents residing in the facility.
FINDINGS INCLUDE:
The Centers for Medicare & Medicaid Service/CMS Form 671, entitled Long Term Care Facility Application for Medicare and Medicaid, dated 7/9/2024, document 90 residents reside in the facility.
The facility policy, entitled Disposal of Garbage and Refuse, not dated, document: Policy: The facility shall properly dispose of kitchen garbage and refuse. 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.
On 7/9/2024, at 9:00 a.m., during the initial kitchen tour, with V7/Head Cook, the outside trash dumpster/receptacle lids were observed to be left open.
On 7/9/2024, at 9:00 a.m., V7 confirmed the lids to the trash dumpster should be closed to keep animals from getting into the trash.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure food service areas and equipment was free of pests/insects, in that gnats were observed on and flying around the juice...
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Based on observation, interview, and record review, the facility failed to ensure food service areas and equipment was free of pests/insects, in that gnats were observed on and flying around the juice dispenser spigot/handle located in the facility kitchen. This failure has the potential to affect all 90 residents residing in the facility.
FINDINGS INCLUDE:
The Centers for Medicare & Medicaid Service/CMS Form 671, entitled Long Term Care Facility Application for Medicare and Medicaid, dated 7/9/2024, document 90 residents reside in the facility.
The facility policy, entitled Sanitation Inspection, not dated, document: Policy Explanation and Compliance Guidelines: 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.
On 07/9/2024, at 8:50 a.m., during the initial kitchen tour, with V7/Head Cook, the juice dispenser spigot/handle was observed to have gnats flying around and on the dispensing end.
On 7/9/2024, at 8:50 a.m., V7 confirmed the gnats were present and they shouldn't be present as the facility has attempted to exterminate them.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure greater than 80 square feet per resident in multiple resident rooms. This failure affects fourteen residents (R2,R17,R21...
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Based on observation, interview and record review the facility failed to ensure greater than 80 square feet per resident in multiple resident rooms. This failure affects fourteen residents (R2,R17,R21,R28,R31,R44,R48,R53,R56,R68,R72,R832,R84 and R85) in the total sample of 53.
.
Findings Include:
On 7/10/24 at 9:00 AM V6 (Maintenance Director) confirmed that the facility does have some rooms that do not meet the 80 square foot per resident requirement. l
On 7/11/24 (R2,R17,R21,R28,R31,R44,R48,R53,R56,R68,R72,R83,R84 and R85) were noted to occupy the rooms identified as less than 80 square feet per resident according to the facility floor plan.
A letter signed by V9 (Previous Administrator) dated 1/29/2019 indicates that the facility has submitted a waiver to the State Agency regarding the square footage of their resident rooms as they are slightly under 80 square foot per resident requirement.
On 7/12/24 at 10:30AM V1 (Administrator) stated that waiver dated 1/29/2019 was the last waiver sent in to the State Agency as far as he was aware.
A letter from the State Agency sent to the facility and dated 4/3/2019 indicated that rooms A1, A4, A8, B1, B3, B7, D5, and D10 were waivered for not providing at least 80 square feet per bed.
May 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure two residents (R1 and R3) was free from verbal abuse by an employee of three resident reviewed for abuse.
Findings include:
Facility ...
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Based on interview and record review the facility failed to ensure two residents (R1 and R3) was free from verbal abuse by an employee of three resident reviewed for abuse.
Findings include:
Facility Policy/Abuse, Neglect and Exploitation dated 2023 documents:
Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.
Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability.
Final Incident Investigation Report dated 5/16/24 indicates On 5/10/24 V5, RN (Registered Nurse) was overheard being verbally inappropriate with R3. Report indicates V5 was immediately separated from all residents and suspended.
Witness V6, LPN (Licensed Practical Nurse) statement indicates V5 asked R3 to step away from the nurses' station and cussed back at (R3). Report also indicates V5 then turned to R1 and yelled See, look what you've caused.
Report Conclusion of the investigation determined that V5 had been verbally inappropriate with R1 and R3.
Report indicates V5 was terminated from employment.
On 5/14/24 at 10:30am R3 stated that V5 did cuss and yell at him/R3 when he was trying to help R1.
On 5/16/24 at 10:45am V4, Regional Nurse stated, We concluded our investigation and found the allegation was substantiated.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to revise care plans for three residents (R1, R3, R4) who smoke of three residents reviewed for care plan revision.
Findings include:
Facility ...
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Based on interview and record review the facility failed to revise care plans for three residents (R1, R3, R4) who smoke of three residents reviewed for care plan revision.
Findings include:
Facility Policy/Comprehensive Care Plans dated 2023 documents:
It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
On 5/14/24 at 2:30pm V2, DON (Director of Nursing) stated R1, R3 and R4 have all had their smoking privileges taken away due to repeatedly breaking the smoking rules.
On 5/16/24 at 3:00pm V2, DON stated that R1's smoking privileges have been revoked since 12/5/23.
NP (Nurse Practitioner) note dated 5/7/24 indicates R1 has lost all smoking privileges due to not following facility smoking rules.
On 5/14/24 V1, Administrator and V2, DON (Director of Nursing) stated that R1 continues to obtain contraband, possibly smoking in the bathroom and receiving smoking materials from other residents.
On 5/14/24 R1 stated that she's in trouble for having a vape and has been banned from cigarettes since then. R1 stated I have broken the rules since then. R1 identified R3 and R4 as also breaking the smoking rules and having their smoking privileges revoked.
Current Care Plan indicates:
Due to symptoms of Serious Mental Illness R1 can be an unreliable reporter. R1 may indicate she does not remember information communicated to her and may make statements that are not based in reality.
R1 is a smoker and have expressed that she does not have funds to purchase smoking materials. R1 was provided smoking cessation materials and provided nicotine gum. R1 did not follow smoking policy and was observed smoking while also using nicotine gum. R1 was educated on the risks of using smoking cessation and expectation was told to R1 to either use smoking cessation or smoke but not both. Smoking cessation resumed on 11/3/22.
R1's care plan does not include revocation of smoking privileges.
2) On 5/14/24 R3 stated he is currently on smoking restriction because he gave cigarettes to R1 (who is also on restriction).
On 5/16/24 at 3:00pm V2, DON stated that R3's smoking privileges have been revoked since 4/8/24.
NP Note dated 4/17/24 R3 lost walking day pass and smoking privileges due to not following rules-Ordered gum for smoking cessation.
R3's care plan indicates R3 is a smoker and requires supervised smoking.
R3's care plan does not address non-compliance with smoking rules, specific incidence of non-compliance, revised interventions or current revocation of smoking privileges.
3) Progress Note Text dated 5/2/24 indicates: at last smoke break R4 was noted to be outside taking drags off of other resident cigarettes; R4 was educated and brought back inside the facility.
On 5/16/24 at 3:00pm V2, DON stated that R4's smoking privileges have been revoked since 4/15/24.
R4's care plan indicates R4 is a smoker and is able to carry smoking materials into the community and keep smoking materials in a secured location.
R4's care plan does not address non-compliance with smoking rules, specific incidence of non-compliance, revised interventions or current revocation of smoking privileges.
On 5/16/24 at 310pm V2, DON stated the Social Service Director was responsible for revising the smoking care plans. They just didn't get done.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to prevent staff verbal abuse for one (R1) and failed to prevent resident-to-resident physical abuse for two of two (R5 and R6) r...
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Based on observation, interview, and record review the facility failed to prevent staff verbal abuse for one (R1) and failed to prevent resident-to-resident physical abuse for two of two (R5 and R6) residents reviewed for abuse in the sample of three.
Findings include:
The facility's undated Abuse, Neglect and Exploitation policy and procedure documents: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Mistreatment means inappropriate treatment or exploitation of a resident.
1. The facility's Final Incident Investigation Report for R1, dated 2/9/24, documents On 2/3/24, a verbal incident occurred between (V5 Former CNA/Certified Nursing Assistant) and (R1). It was reported to this administrator that (V5 Former CNA) had been verbally inappropriate. (V5) was immediately separated from all residents and subsequently suspended. Upon conclusion of investigation, it was determined that (V5) had been verbally inappropriate with (R1). (V5 Former CNA) has been terminated. (R1) has been scheduled to meet with psychologist.
The Face Sheet for R1, includes the following diagnoses: Major Depressive Disorder, Dementia, Delusional disorders, Schizophrenia, Anxiety Disorder, Parkinson's Disease, Anoxic Brain Damage, and Cognitive Communication Deficit. The Quarterly MDS (minimum data set) assessment, dated 1/4/24, documents R1 with moderately impaired cognition and requires assist with activities of daily living and transferring.
On 2/28/24 R2 and R3 resided next door to R1 with a shared bathroom. On 2/28/24, 3/5/24, and 3/6/24 there were no identified behaviors noted.
On 3/6/24 at 10:23 am, R1 stated I don't think so. I can't remember that when asked if anyone has yelled at her or refused to brush her hair. R1 stated she feels safe at the facility.
On 3/5/23 at 2:00pm, R2 stated she was lying in bed and heard V5 Former CNA yell out F**k and got up and went to the bathroom and could hear V5 yelling at R1. R2 stated R1 just wanted (V5) to brush her hair and V5 told R1 Your fault you lost it, going to just be wearing a hat. R2 stated she reported it to the Nurse.
On 3/5/24 at 2:42 pm, R3 stated she lives next door and shares a bathroom with R1. R3 stated (V5 Former CNA), the boy CNA was not very nice. I was in my room, next to (R1's) room. I heard him yelling, loudly at (R1). I could tell he wasn't being nice. This wasn't the only time I had heard him yelling at (R1). R3 stated even with the bathroom doors shut between the rooms I could still hear him yelling at her. Shouldn't have been.
A signed statement from V17 LPN/Licensed Practical Nurse, dated 2/3/24, documents during medication pass, (R2) reported to her that (V5 Former CNA) was yelling and being mean to (R1) and heard the interaction while going to the conjoining bathroom. (R2) stated (V5) was yelling at (R1) for her room being messy and (R1) asking for her hair to be combed and (V5) couldn't find the hairbrush and yelled at (R1) to just wear a hat. R3 (R2's roommate) denied hearing the interaction but has heard (V5 Former CNA) be mean in the past to R1. Administrator was notified, V5 was removed from the hall and then sent home.
Signed statements from R1, dated 2/3/24, documenting (V5 Former CNA) started yelling at (R1) because (V5) is impatient and was furious and kept saying do you want to miss breakfast. A second signed, undated interview from R1, documents R1 stated (V5) yelled at me and spun me around in my chair. (V5) wouldn't brush my hair.
Signed witness statement from R2 documents she was awakened by loud voices and heard V5 Former CNA saying F**k something and heard R1 wanting her hair combed and (V5) yelling No your just going to wear this hat. V5 Former CNA sounded mean and (R2) felt bad for (R1). When (R1) asked for hair to be brushed (V5) said Well you lost your brush and (R2) stated it seemed like (V5) had no patience for (R1).
Signed statement from V5 Former CNA, dated 2/3/24, documents he was trying to assist (R1) in getting up for the day and (R1) was not focused, almost fell during transfer, and (V5) tried to explain that (R1) needed to tell him if she needed something. V5 stated he did not know that (R1) did not like male CNA's but we was short and I was asked to get her up.
On 2/28/24 at 11:38 am, V1 Administrator stated he does all the abuse investigations for the facility and he did the investigation regarding V5 Former CNA verbal altercation with R1. V1 Administrator stated he interviewed R1, R2 and R3 the day of the allegation and had V2 DON/Director of Nursing interview R1 again a few days later because R1 had a UTI (urinary tract infection) at the time of the initial interview and was on antibiotics. R1 had the same story when V2 DON interviewed her. V1 Administrator stated V5 Former CNA stated (V5) was trying to help R1 get up and R1 was being resistive. V1 Administrator stated (R2) does have a history of making false allegations but when R3 (R2's roommate) said she was in the bathroom and heard V5 Former CNA yelling at (R1) I decided that we just didn't need to take any chances. V1 Administrator stated V5 was suspended during the investigation, DNR'd (do not return) from the facility and later terminated. V1 stated he did not have any other complaints from the residents about (V5) but did have some staff issues and problems so after this incident I decided to just be done. V1 stated he took the full allotted time to do the investigation which was substantiated and he notified the float pool (company staffing agency) and the float pool terminated V5 Former CNA. V1 Administrator stated he did not terminate V5; the float pool did so all of that paperwork is with the company's agency.
2. The facility's Final Incident Investigation Report, dated 1/11/24, documents On 1/3/24 R5 and R6 were in a physical altercation. R5 said R6 walked from R6's room, through the adjoining bathroom, into R5's room. R6 attempted to exit R5's room into the hallway through R5's room. R5 became upset and threw his cup of coffee on R6. Per camera review, R6 exited R5's room with coffee on his shirt. Staff observed R6 with the coffee on his shirt and this admin questioned R5 about the situation. R5 stated he was upset R6 walked into his room and threw the coffee. (V2) DON/Director of Nursing did a skin assessment and no injuries noted to R6. Residents were separated and R5 was sent in for a psychiatric evaluation.
The Face Sheet for R5, includes the following diagnoses: Major Depressive Disorder, Traumatic Brain Injury, and Cognitive Communication Deficit. The Quarterly MDS for R5, dated 12/13/23, documents R5 is cognitively intact, requires partial to supervision assist with activities of daily living and supervision for transfers and walking.
The Face Sheet for R6, includes the following diagnoses: Schizophrenia, Unspecified Psychosis, Altered Mental Status, and Catatonic Disorder. The Quarterly MDS for R6, dated 12/12/23, documents R6 with moderately impaired cognition and requires partial to supervision assist with all activities of daily living and supervision for transfers and walking.
The facility abuse investigation includes R5 and R6's statements. R5 stated R6 was in the bathroom and exited the shared bathroom into R6's room. This upset R5 who then threw his cup of coffee on R6. Interview was attempted with R6 but V1 Administrator was unable to get a clear response from R6. V2 DON did a skin assessment with no injuries noted.
The Progress Notes for R5, dated 1/3/24 at 6:24 pm, documents (R5) admitted to throwing coffee on another resident that lives in room next to him. Other resident gets confused and goes into (R5's) room. (R6) does grab (R5's) walker and other personal items when he goes through there. (R5) passed resident in hallway and hit (R6) in the stomach with back of his hand. (R5) tried to grab (R6's) cup of water (Nurse) had given meds (medications) with. (R5) was taken to ER (emergency room) via facility van for evaluation d/t (due to) behaviors.
The Progress Note for R6, dated 1/3/24 at 7:06 pm, documents Late Entry Nurse came to DON door to inform of (R6) getting coffee thrown on him. DON went to main core to assess resident. Skin assessment revealed no redness or injury to resident. Resident not complaining of any pain or showing any signs of discomfort. Will continue to monitor (R6).
On 2/28/24, 3/5/24, and 3/6/24 R5 and R6 were residing on different hallways with no behaviors identified.
On 2/28/24 at 12:40 pm, R6 was sitting in a stationary chair in his room. On 3/5/24 at 11:30 am, R6 was sitting in a stationary chair on the left side of the dining room. There were no behaviors noted. On 2/28/24 at 12:40 pm, R6 stated his name and said I'm calmed down. R6 would not engage in any other conversation however, did say Yes when asked if he feels safe in the facility.
On 2/28/24 at 11:52 am, R5 was sitting on the side of his bed. On 3/5/24 at 11:29 am, R5
was lying in bed. There were no identified behaviors. On 2/28/24 R5 stated he has no complaints, feels safe in the facility and hasn't had any problems with anyone and is unaware of anyone being mean to the residents.
On 3/5/24 at 3:15 pm, V1 Administrator stated he did the investigation regarding the altercation between R5 and R6. V1 Administrated stated V5 and V6 shared a bathroom and V6 exited the bathroom into R5's room. R5 got upset and threw his coffee on R6. V1 confirmed that R5 hit R6 in the belly, in the hallway and he forgot to add that detail to the final abuse report. V1 stated there were no injuries and room moves were made and there have been no further problems.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to prevent abuse for two of five residents (R1 and R5) reviewed for abuse in the sample of five .
Findings include:
The Facility's undated poli...
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Based on record review and interview the facility failed to prevent abuse for two of five residents (R1 and R5) reviewed for abuse in the sample of five .
Findings include:
The Facility's undated policy Abuse, Neglect and Exploitation documents It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.
The Facility's Abuse policy documents the definition of abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.
The Facility's Abuse policy documents the definition of verbal abuse as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.
1) The Facility's Final Incident Investigation Report dated 01/03/24 documents On 12/27/23 around 8:15 PM, a verbal incident occurred between V5 CNA (Certified Nursing Assistant) and R1. It was reported to (V1/Administrator) that V5 had been verbally inappropriate. V5 was immediately removed from resident contact to the nurse's desk area with V7 (RN) and other staff stayed with R1 until (V1) arrived at facility to suspend (V5).
R6's undated written statement documents I heard the end of what (V5) said. She called (R1) a rapist and (pedophile).
V6 CNA written statement dated 12/27/23 was I heard (R1) and (V5) get into an argument. I didn't catch the beginning but heard (V5) say 'damn' then (R1) said 'Don't cuss at me'.
V7 RN (Registered Nurse) written statement dated 12/27/23 documents (V6/CNA) and (V5/CNA) were passing snacks at 8:10 PM. (R1) asked (V6) for coffee and after getting coffee (R1) asked for juice. (V5) raised pitcher with juice and yelled at resident, 'I have only enough juice for like 3 god damn rooms.' (R1) yelled back, 'Shut up you stupid B**ch. You are always a c**t'. (V5) yelled back, 'F**k you'.
V7 (Licensed Practical Nurse)'s written statement documents I was doing my (medication) pass and heard someone yelling, looked up and saw (V5) passing snacks and yelled at (R1) 'F**k you'.
On 01/23/24 at 12:50 PM V3 (Corporate Nurse) confirmed the allegation of abuse against V5 was founded and V5's employment was terminated for same.
2) The Facility's Final Incident Investigation Report dated 01/11/24 documents On 01/03/24, (R4 and R5) were in a physical altercation. (R4 stated (R5) had walked from his room, through the bathroom, and attempted to exit into the hallway through (R4's) room. At this point (R4) became upset and threw his cup of coffee on (R5). Per camera review, (R5) exited the room with coffee on his shirt. Staff observed (R5) with the coffee on his shirt and this (administrator) questioned (R4) about the situation. He stated he was upset he had walked into his room and threw the coffee.
On 01/23/24 at 3:31pm, R4 stated during interview that he threw the coffee on R5 because he was mad at him for always coming through his room.
On 01/24/24 at 9:00 AM V3 (Corporate Nurse) confirmed that it was substantiated that R4 threw his coffee on R5 because he was mad.
Nov 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent mistreatment and verbal abuse of one resident (R2) of four r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent mistreatment and verbal abuse of one resident (R2) of four residents reviewed for abuse.
Findings include:
Facility Policy/Abuse, Neglect and Exploitation dated 2022 documents:
Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
Verbal abuse means the oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend or disability.
Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.
Mistreatment means inappropriate treatment or exploitation of a resident.
Alleged Violation: is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.
Current Care Plan indicates R2 was admitted to the facility on [DATE] and has diagnoses that include Schizoaffective Disorder, Major Depressive Disorder, Generalized Anxiety Disorder and Pseudobulbar Affect.
Care Plan indicates R2 is dependent on staff for meeting emotional, intellectual and social needs related to cognitive deficits; at risk for abuse/neglect/exploitation related to diagnosis of depression.
Current Comprehensive assessment dated [DATE] indicates R2 is mildly cognitively impaired and exhibits both delusions and hallucinations.
Final Incident Investigation Report dated 10/13/23 indicates that on 10/7/23 at 9:12pm V9, CNA (Certified Nurse Assistant) reported to V10, Nurse that V8, CNA had inappropriately spoken to R2 the last time they worked together on C-Hall. Report indicates V8 was mad about a pair of missing scissors and was yelling at R2 at the C-Hall nurses station, dumping R2's belongings over the desk, followed R2 to her room and continued to speak poorly to her. Review of staff schedules found this incident occurred 9/29/23. Report indicates V11, RN (Registered Nurse) was nurse on duty on C-Hall on 9/29/23 and witnessed the incident.
Incident Investigation Signed Witness Statement dated 10/7/23 indicates V9, CNA documented the following:
(R2) went to the nurses station to get her medications and was confronted by (V8, CNA) for scissors that (V8) had loaned to (R2). (V8) got mad and was screaming at (R2) for the scissors and started throwing and dumping (R2's) bags for these scissors and made (R2) cry. (V8) then followed (R2) back to (R2's) room screaming at (R2) calling her names. (R2) was screaming back at (V8) and upon entering (R2's) room, overheard (V8) say I'll go break all your things Mother fucker as R2 was telling (V8) to get out of her room. Once the screaming match was done (V8) proceeded to slam (R2's) door saying something and calling (R2) a b**ch. I had not reported because I was not sure who to talk to and was scared of (V8) because she can become very confrontational.
On 11/30/23 at 2:10pm V9, CNA stated that she did not immediately report the incident between R2 and V8 because V11, RN was present during the altercation and assumed she would report. V9 stated that she told another CNA a few nights after the incident and was told by the CNA that she has to report the incident to V1, Administrator but since V1 was not there at that time, she should tell V10, Nurse. V9 stated that she then told V10 (on 10/7/23) about what had occurred between V8 and R2 a few nights earlier. V9 stated that V11 was also working the night she reported the incident to V10. V9 stated at that time V11 denied the incident occurred because V11 was worried she would be in trouble for not reporting the incident (on 9/29/23), but later V11 actually helped V9 write her witness statement.
On 11/30/23 at 2:15pm V9, CNA stated that she stood by all the statements she made in the written investigation statement.
Incident Investigation Signed Witness Statement dated 10/11/23 indicates V11, RN documented the following:
On an unknown date - about a week or two ago, V8 was at the nurses station where R2 had just received her medications. V8 kept asking R2 where V8's scissors were that she loaned to R2 and R2 never returned. V8 then began to look through R2's bags looking for the scissors and V8 followed R2 to her room to continue to look for the scissors.
On 11/30/23 at 2:25pm V11, RN stated that (on 9/29/23) V8, CNA dumped all of R2's belongings onto the floor at the nurses station in front of the medication cart - in front of R2 - looking for scissors that V8 stated she loaned to R2. V11 stated that R2 did not like that V11 was going through her things or that she had dumped them on the floor. V11 told V8 to put R2's belongings back into R2's bag and that it was inappropriate to dump them out. V11 stated that after V8 put R2's belongings back into R2's bag, she locked them in the closet in the medication room where they are kept at night. V11 stated she should have reported V8's behavior to V1, Administrator. V11 stated that she then gave R2 her medications and R2 went back to her room and she then went on her lunch break and was unaware V8 continued to follow R2 to her room or any further altercation between R2 and V8.
Incident Investigation Signed Witness Statement dated 10/9/23 indicates V8, CNA documented the following:
I, (V8) admit to joking around with (R2). No harm was intended. (R2) knows I was playing about her stuff. Me and (R2) always play around.
On 11/29/23 at 2:50pm V8, CNA stated (R2) and I have a mutual friendship. We are always laughing and joking with each other. V8 stated that R2 had borrowed scissors from V8 for an art project and she forgot to get them back from R2. V8 denied dumping R2's belongings out and stated I said I would throw her stuff away. I never said I would break them. V8 stated (V9) is new and took it the wrong way. I wasn't angry - just kidding.
On 11/30/23 at 1:00pm V10, Nurse stated that (on 10/7/23) V9, CNA came to her and reported the incident that occurred between R2 and V8. V10 stated that V9 reported that V8 had yelled at R2 over missing scissors and had dumped out R2's belongings and followed R2 to her room.
On 11/29/23 at 1:30pm R2 stated All the CNA's are back R2 stated there was no disagreement about scissors or with V8 (when directly asked). R2 stated There is one nurse who puts rats heads, marbles and rock salt down my throat and it is really hard to have a bowel movement. R2 was unable to stay focused on questions asked and was preoccupied with getting back to previous activity.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to immediately report an allegation of verbal abuse to the Abuse Coordinator for one resident (R2) of four residents reviewed for abuse.
Findin...
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Based on interview and record review the facility failed to immediately report an allegation of verbal abuse to the Abuse Coordinator for one resident (R2) of four residents reviewed for abuse.
Findings include:
Facility Policy/Abuse, Neglect and Exploitation dated 2022 documents:
Alleged Violation: is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.
Reporting of all alleged violations to the Administrator, the state agency, adult protective services and to all other required agencies within specific timeframe's:
Immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.
Final Incident Investigation Report dated 10/13/23 indicates that on 10/7/23 at 9:12pm V9, CNA (Certified Nurse Assistant) reported to V10, Nurse that V8, CNA had inappropriately spoken to R2 the last time they worked together on C-Hall. Report indicates V8 was mad about a pair of missing scissors and was yelling at R2 at the C-Hall nurses station, dumping R2's belongings over the desk, followed R2 to her room and continued to speak poorly to her. Review of staff schedules found this incident occurred 9/29/23. Report indicates V11, RN (Registered Nurse) was nurse on duty on C-Hall on 9/29/23 and witnessed the incident.
Incident Investigation Signed Witness Statement dated 10/7/23 indicates V9, CNA documented the following:
(R2) went to the nurses station to get her medications and was confronted by (V8, CNA) for scissors that (V8) had loaned to (R2). (V8) got mad and was screaming at (R2) for the scissors and started throwing and dumping (R2's) bags for these scissors and made (R2) cry. (V8) then followed (R2) back to (R2's) room screaming at (R2) calling her names. (R2) was screaming back at (V8) and upon entering (R2's) room, overheard (V8) say I'll go break all your things Mother fucker as R2 was telling (V8) to get out of her room. Once the screaming match was done (V8) proceeded to slam (R2's) door saying something and calling (R2) a bitch. I had not reported because I was not sure who to talk to and was scared of (V8) because she can become very confrontational.
On 11/30/23 at 2:10pm V9, CNA stated that she did not immediately report the incident between R2 and V8 because V11, RN was present during the altercation and assumed she would report. V9 stated that she told another CNA a few nights after the incident and was told by the CNA that she has to report the incident to V1, Administrator but since V1 was not there at that time, she should tell V10, Nurse. V9 stated that she then told V10 (on 10/7/23) about what had occurred between V8 and R2 a few nights earlier. V9 stated that V11 was also working the night she reported the incident to V10. V9 stated at that time V11 denied the incident occurred because V11 was worried she would be in trouble for not reporting the incident (on 9/29/23), but later V11 actually helped V9 write her witness statement. On 11/30/23 at 2:15pm V9, CNA stated that she stood by all the statements she made in the investigation written statement and now knows she needs to report immediately to V1, Administrator.
On 11/30/23 at 2:25pm V11, RN stated that (on 9/29/23) V8, CNA dumped all of R2's belongings onto the floor at the nurses station in front of the medication cart - in front of R2 - looking for scissors that V8 stated she loaned to R2. V11 stated that R2 did not like that V11 was going through her things or that she had dumped them on the floor. V11 told V8 to put R2's belongings back into R2's bag and that it was inappropriate to dump them out. V11 stated that after V8 put R2's belongings back into R2's bag, she locked them in the closet in the medication room where they are kept at night. V11 stated she should have reported V8's behavior to V1, Administrator. V11 stated that she then gave R2 her medications and R2 went back to her room and she then went on her lunch break and was unaware V8 continued to follow R2 to her room or any further altercation between R2 and V8.
On 11/30/23 at 1:00pm V10, Nurse stated that (on 10/7/23) V9, CNA came to her and reported the incident that occurred between R2 and V8. V10 stated that V8 had confirmed that the incident did not happen that day but had occurred a week or so prior. V10 stated that V9 reported that V8 had yelled at R2 over missing scissors and had dumped out R2's belongings and followed R2 to her room. V10 stated that she immediately reported the allegation to V1, Administrator and educated V9 on reporting abuse allegations immediately.
Sept 2023
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident to resident physical abuse for two of three reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident to resident physical abuse for two of three residents (R1, R2) reviewed for abuse in the sample of three.
Findings include:
The facility's Abuse, Neglect and Exploitation policy dated 2022, states It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.
R1 is a [AGE] year-old resident that was admitted to the facility on [DATE] and has diagnoses which include, Paranoid Schizophrenia, Psychotic Disorder with Delusions, and COVID-19 (8/16/23).
R1's Minimum Data Set assessment dated [DATE], documents R1 is cognitively intact and ambulates with supervision.
R2 is a [AGE] year-old resident that was admitted to the facility on [DATE] and has diagnoses which include Schizophrenia, Dementia, and Major Depressive Disorder.
R2's Minimum Data Set assessment dated [DATE], documents R2 has moderately impaired cognition and uses a wheelchair that he is able to propel independently.
A Final Incident Investigation Report dated 8/23/23, states On August 16, 2023 (R1 and R2) were in a physical altercation. (R1 and R2) had been roommates up until this incident. (R1) tested positive for COVID-19 (8/16/23). At the same time, (R2) tested negative. (R2) was asked to stay in the dining room while (R1) was moved, but (R2 refused to stay put). (R2) went back to their room and began to 'nag' at (R1) due to positive COVID-19 result. (R2) stated that (R2) would have to wear a mask all night while he sleeps now because (R1) caught COVID. (R1) asked (R2) to stop, but (R2) continued to be upset. Staff heard the altercation and began to move toward (R1 and R2's room). When staff (V10/Housekeeper) arrived, (R1) was witnessed placing hands on (R2's) neck and was visibly upset. Staff immediately intervened and separated (R1 an R2). (The ambulance service) was contacted to transport (R1) to the local hospital for psychiatric evaluation. (R2) had no complaints of pain during assessment. (R1) returned from the hospital with no new orders. An x-ray was done on (R2's) neck, and no problems were noted. (R1 and R2) have been separated and are no longer roommates. (R1) has been placed on frequent visuals to monitor any changes in behaviors.
On 9/8/23 at 11:00 a.m., V10 (Housekeeper) stated On 8/16/23 around 3:30-3:45 p.m., I was cleaning D Hall and (R3/Witness) stated 'Hey what's with the choke hold.' (R2) was yelling 'help me, help me'! I ran down to (R1 and R2's) room and saw (R1) had hold of (R2) with one arm bent around (R2's) neck and then he placed both hands around (R2's) neck in a choking manner. (R1) immediately let go of (R2) when I walked in. I yelled for help and (R2) was removed from the room. (V3/Licensed Practical Nurse) took over the situation.
On 9/8/23 at 11:30 a.m., R3 stated on the afternoon of 8/16/23, R3 witnessed R1 and R2 in their room. R3 stated R1 had R2 in a choke hold and R3 thought they were joking around. R3 stated R2 started saying 'help me!' and R3 yelled at V10 to come help. R3 stated staff immediately intervened and R1 and R2 were separated. R3 stated he is not aware of R1 or R2 ever having altercations prior to 8/16/23.
On 9/8/23 at 10:00 a.m., V1 (Administrator) stated it is the policy of the facility that residents will be free from abuse.
Apr 2023
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
2. R16's Progress Notes document R16 had a fall at 8:00am on 2/5/23, was sent to the hospital on 2/6/23; and returned to the facility on 2/10/23.
The facility's Ombudsman Notification Log for February...
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2. R16's Progress Notes document R16 had a fall at 8:00am on 2/5/23, was sent to the hospital on 2/6/23; and returned to the facility on 2/10/23.
The facility's Ombudsman Notification Log for February 2023 does not document R16's name or indicate transfer notification for R16 was given to the Ombudsman.
The facility's Admission/Discharge To/From Report, dated 2/1/23 to 2/28/23, does not document R16's name to indicate R16 was discharged to the (local Hospital).
On 4/13/23 at 10:45am, V5 Regional Nurse Consultant stated that the facility's resident transfers to hospitals have not been sent to the Ombudsman. V5 stated, We only send transfers of residents to the Ombudsman if they (residents) discharged to the community, home, or left against medical advice, but not names of residents who discharged to the hospital.
Based on interview and record review, the facility failed to provide written notice to the Ombudsman for two (R3 and R16) of two residents reviewed for transfers in a sample of 25.
Findings include:
1. R3's medical record documents R3 went to the hospital on 1/11/23 and 1/29/23.
R3's medical record has no documentation the Ombudsman was notified of R3's transfer.
On 4/13/23 at 10:47 AM, V5 Regional Nurse Consultant stated We don't notify the ombudsman of any discharges to the hospital, so I don't have any notification for (R3 or R16's) transfers. At that same time V5 Verified R3's medical record had no documentation the ombudsman was notified of a transfer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide written notice of a bed hold for one (R3) of two residents reviewed for bed holds in a sample of 25.
Findings include:
R3's medical...
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Based on interview and record review, the facility failed to provide written notice of a bed hold for one (R3) of two residents reviewed for bed holds in a sample of 25.
Findings include:
R3's medical record documents R3 went to the hospital on 1/11/23 and 1/29/23.
R3's medical record documents R3 is Medicare and Medicaid certified.
R3's medical record has no documentation a bed hold was given to R3 or R3's representative.
On 4/13/23 at 10:47 AM, V5 Regional Nurse Consultant stated We don't have a bed hold paper that was sent with (R3) when she went to the hospital on 1/11 and 1/29/23. At that same time, V5 Verified R3's medical record had no documentation a bed hold was given with the transfers on 1/11/23 and 1/29/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to obtain a second required screening for one resident (R58) of four reviewed for PASARR (Preadmission Screening and Resident Review) in a tota...
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Based on record review and interview the facility failed to obtain a second required screening for one resident (R58) of four reviewed for PASARR (Preadmission Screening and Resident Review) in a total sample of 25.
Findings Include:
R58's Interagency Certification of Screening Results dated 1/17/2017 documents Screening indicated nursing facility services are agree appropriate and NOTE: Screening is valid for 90 days from the date of the screening: 01/17/2017
R58's Current (April 2023) Physician Order Sheet documents R58's Diagnosis as muscle weakness, hypertension, seizures, hypokalemia, hyperosmolality and hypernatremia, unspecified sequelae of unspecified cerebrovascular disease, unspecified bacterial pneumonia, streptococcal sepsis, anemia, selective mutism, chronic embolism, and thrombosis of unspecified vein, gastro-esophageal reflux disease without esophagitis fatigues, reduced mobility, dysphasia, anxiety, pseudobulbar affect, bipolar disorder and exposure to COVID.
R58's Medical Record did not have any other PASARR or Interagency Certification Screening Results noted in her medical record.
On 4/12/23 V4 (Regional Nurse) stated According to this PASARR dated 1/17/2017, this PASARR is incomplete. We missed it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan to include Post Traumatic Stress ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan to include Post Traumatic Stress Disorder (PTSD) for two resident (R78, R88) out of 22 residents revived for care plans in a sample of 25.
Findings include:
The facility's Trauma Informed Care policy dated 2023, documents 4. The facility will collaborate with resident trauma survivors and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as physiologists and mental health professionals) to develop and implement individualized care plan interventions. 10. In situations where trauma and survivor is reluctant to share their story, the facility will try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the rigger on the resident.
1. R88's medical record documents R88 admitted to the facility on [DATE] with a diagnosis of PTSD.
R88's current care plan does not include PTSD or triggers that can cause re-traumatization of the experience.
R88's Abuse/Neglect/Trauma assessment form dated [DATE] documents 1. History of abuse and/or neglect (including physical, sexual, verbal, emotional, financial) and/or unexplained injuries prior to admission? A. Yes. The form also documents that R88's risk measure for likelihood of a history of previous/recent mistreatment and/or future problems/symptoms related to mistreatment is high.
On [DATE] at 2:00 PM V2, Director of Nursing (DON), verified R88's care plan does not address his PTSD or triggers of PTSD and stated (R88) comes in here and talks to me a lot. As soon as I come in the door, he follows me to my office and talks to me. He's made comments that leads me to believe his PTSD is from child abuse. I never actually found out what the root cause of his trauma was or what his triggers are.
On [DATE] 2:34 PM, V13, Social Services Director (SSD), verified R88 and R78 did not have PTSD or triggers listed on their care plan and stated, Unfortunately, (R88) and (R78) were two residents that slipped through the cracks. I didn't add their PTSD or triggers to the care plan. It should be on the care plan because that's how the information of the PTSD history and what the triggers are get conveyed to the staff.
2) Current Physician Order Report Summary indicates R78 was admitted to the facility on [DATE] with a diagnosis of PTSD (Post Traumatic Stress Disorder).
Current Care Plan did not include an individualized plan of care to address R78's PTSD, triggers, or any plan to provide trauma informed care.
On [DATE] at 2:15pm R78 was quiet, guarded, and superficial.
On [DATE] at 3:09pm V13, SSD (Social Service Director) stated that R78's care plan should have included a comprehensive care plan for PTSD. V13 stated I don't know what his trauma was. It got missed. The care plan is where information gets conveyed to staff - would convey triggers to staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to revise the pain management care plan for one resident (R47) of 17 residents reviewed for care plans in the sample of 25.
Findin...
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Based on observation, interview and record review the facility failed to revise the pain management care plan for one resident (R47) of 17 residents reviewed for care plans in the sample of 25.
Findings include:
Facility Policy/Pain Management dated 2022 documents:
In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will:
Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission.
The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal.
On 4/11/23 at 11:00am R47 was in bed and stated her left leg hurts when she stretches it out. R47 stated There's nothing to look at. It's not red or anything, and I didn't fall.
On 4/12/23 at 9:45am R47 stated that her leg still hurts when she moves it and when she stands on it. R47 Pulled up both pants legs and stated that her left knee is where most of the pain is located. At that time, R47's left knee appeared slightly larger than right knee and both knees appeared to have enlarged knee joints. R47 stated that she receives Tylenol when she asks for it but it doesn't really help with the pain.
Last physician visit on 2/7/23 indicates R47 is followed for pain management.
Progress Note dated 3/30/23 at 10:47am indicates (R47) requested scheduled Tylenol. Current order for prn (as needed) Tylenol only and physician notified.
On 4/13/23 at 9:45am V15, LPN (Licensed Practical Nurse) stated (R47) just said the pain was in her legs so I notified the physician. V15 stated that she re-faxed the physician when she didn't hear back. V15 stated that she didn't document that she sent another fax to the physician. V15 stated that R47 didn't tell her until today that the Tylenol wasn't working. V15 stated that R47's physician is coming today.
Current Care Plan (date initiated 12/9/21) indicates plan of care for chronic left shoulder pain only.
Care Plan was not revised to include R47's complaints of leg/knee pain and increased requests for Tylenol since March 30, 2023.
On 3/14/23 at 11:45am V2, DON (Director of Nursing) stated R47's care plan should have been revised to include re-assessment of R47's pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to conduct ongoing scheduled pain assessments and re-evalu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to conduct ongoing scheduled pain assessments and re-evaluate one resident (R47) after increased complaints of pain of four residents reviewed for pain management in the sample of 25.
Findings include:
Facility Policy/Pain Management dated 2022 documents:
In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will:
Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain)
Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission.
The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal.
Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen.
If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised.
On 4/11/23 at 11:00am R47 was In bed and stated her left leg hurts when she stretches it out. R47 stated There's nothing to look at. It's not red or anything, and I didn't fall.
On 4/12/23 at 9:45am R47 stated that her leg still hurts when she moves it and when she stands on it. R47 Pulled up both pants legs and stated that her left knee is where most of the pain is located. At that time, R47's left knee appeared slightly larger than right knee and both knees appeared to have enlarged knee joints. R47 stated that she receives Tylenol when she asks for it but it doesn't really help with the pain.
Last physician visit on 2/7/23 indicates R47 is followed for pain management.
Current MAR (Medication Administration Record) indicates R47 had orders for Extra Strength Tylenol
500mg (milligrams) as needed for pain.
(MAR) dated March 2023 indicates R47 started requesting Tylenol for pain on 3/29, 3/30 and 3/31 with pain level documented from 6/10 to 8/10 receiving Tylenol four times in three days.
MAR dated April 2023 indicates R47 requested and received Tylenol eleven times between 4/1/and 4/13 with pain level documented between 4/10 and 8/10.
Prior to March 3/29/23, R47 had no documented pain and not requested or received Tylenol. MAR documentation shows a change in level of pain as reported by R47.
Progress Note dated 3/30/23 at 10:47am indicates (R47) requested scheduled Tylenol. Current order for prn (as needed) Tylenol only and physician notified.
On 4/13/23 at 9:45am V15, LPN (Licensed Practical Nurse) stated (R47) just said the pain was in her legs so I notified the physician. V15 stated that she re-faxed the physician when she didn't hear back. V15 stated that she didn't document that she sent another fax to the physician. V15 stated that R47 didn't tell her until today that the Tylenol wasn't working. V15 stated that R47's physician is coming today.
Progress Note dated 4:52pm indicates R47 was seen by physician and order consult with physiologist and also ordered scheduled antinflammatory medication to be administered twice daily.
Pain assessment dated [DATE] indicates pain score NA (not applicable. No other or more recent pain assessment was found or presented.
Current Care Plan (date initiated 12/9/21) indicates plan of care for chronic left shoulder pain only
On 3/14/23 at 11:45am V2, DON (Director of Nursing) stated R47's care plan should have been revised to include re-assessment of R47's pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess and identify the root cause, potential triggers...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess and identify the root cause, potential triggers and implement trauma-informed care for two residents (R78, R88) with a diagnosis of Post-Traumatic Stress Disorder (PTSD) out of three residents reviewed for mood and behavior in a sample of 25.
Findings include:
The facility's Trauma Informed Care policy dated 2023, documents Trauma-Informed Care: is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization .2. The facility will use a multi-pronged approach to identify a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others. 4. The facility will collaborate with resident trauma survivors and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as physiologists and mental health professionals) to develop and implement individualized care plan interventions. 10. In situations where trauma a survivor is reluctant to share their story, the facility will try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the rigger on the resident.
1. R88's medical record documents R88 admitted to the facility on [DATE] with a diagnosis of PTSD.
R88's current care plan does not document the root cause of R88's PTSD or triggers that can cause the resident to relive the traumatized experience.
R88's medical record does not document a PTSD Screening Tool or PTSD Assessments to identify the specific trauma and triggers for R88's diagnosis of PTSD.
R88's Abuse/Neglect/Trauma assessment form dated 12/1/22 documents 1. History of abuse and/or neglect (including physical, sexual, verbal, emotional, financial) and/or unexplained injuries prior to admission? A. Yes. The form also documents that R88's risk measure for likelihood of a history of previous/recent mistreatment and/or future problems/symptoms related to mistreatment is high.
R88's medical record dated 11/21/22 through 4/11/23 documents several occurrences of verbal outbursts to staff and peers and on 12/10/23 punching a tree resulting in R88 being sent to the hospital for evaluation for his hand.
On 04/11/23 at 10:00 AM, R88 Stated I'm so sick of this place. They don't do anything for you. The doctor is a complete joke. I'm not getting the care I need. I'm leaving today because they don't do anything here to address your needs. During the interview with R88, R88 became increasingly upset talking in a loud voice, hitting the bed with his fist and cussing. R88 then stated They haven't done anything here to help me. I've been through more in my life than anyone should ever have to go through.
On 4/12/23 at 2:00 PM V2, Director of Nursing (DON), verified R88's care plan does not address his PTSD and stated (R88) comes in here and talked to me a lot. As soon as I come in the door, he follows me to my office and talks to me. He's made comments that leads me to believe his PTSD is from child abuse. I never actually found out what the root cause of his trauma was or what his triggers are. He would get upset very easily and there was a situation where he got upset and punched a tree outside, but it was never directed at anyone. We had to send him to the hospital to evaluate his hand. He's one that gets worked up pretty easily.
On 4/12/23 2:34 PM, V13, Social Services Director (SSD), verified the facility did not develop a trauma-informed plan of care for R78 and R88 and stated, The screening for PTSD is done on admission intake. I would also look at the hospital admission paperwork, psychiatric notes and talk to family members, if available, to gather the necessary information to establish a plan for a resident's PTSD. Unfortunately, (R88) and (R78) were two residents that slipped through the cracks. (R88) did allude to abuse from his family as a child, but I never established what his PTSD was from and what his triggers are. We also didn't add their PTSD or triggers to the care plan. It should be on the care plan because that's how the information of the PTSD history and what the triggers are gets conveyed to the staff. I did the intake evaluation for both (R78 and R88), but I see what you're saying now that I'm looking at it. The assessment only identifies they have a history of trauma, but it doesn't assess the specific trauma/abuse they experienced and there's no questions to indicate their PTSD triggers.
2) Current Physician Order Report Summary indicates R78 was admitted to the facility on [DATE] with a diagnosis of PTSD (Post Traumatic Stress Disorder).
admission Assessment and most recent Assessment indicates R78 had been exposed to some form of past trauma. Assessment did not indicate what type of trauma or any further assessment including possible triggers for re-traumatization.
Current Care Plan did not include an individualized plan of care to address R78's PTSD, triggers, or any plan to provide trauma informed care.
On 4/12/23 at 2:15pm R78 was quiet, guarded, and superficial.
On 4/12/23 at 3:09pm V13, SSD (Social Service Director) stated that R78's care plan should have included a comprehensive care plan for PTSD. V13 stated I don't know what his trauma was. It got missed. We complete an assessment on admission but didn't expand on it after that. We need to because that is how we communicate information to the staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide an appropriate indication for use of antipsycho...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide an appropriate indication for use of antipsychotic medications for one resident (R33) with a diagnosis of dementia of five residents reviewed for unnecessary medications in the sample of 25.
Findings include:
Facility Policy/Use of Psychotropic Medication dated 2022 documents:
The indications for use of any psychotropic drug will be documented in the medical record.
For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician.
The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as:
During the pharmacist's monthly medication regimen review;
In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications and the resident's comprehensive plan of care.
Use of psychotropic medications in specific circumstances:
Enduring conditions:
The resident's symptoms and therapeutic goals shall be clearly and specifically identified and documented.
An evaluation shall be documented to determine that the resident's expressions or indications of distress are:
Not due to a medical condition or problems that can be expected to improve or resolve as the underlying condition is treated or the offending medications are discontinued;
Not due to environmental stressors alone, that can be addressed to improve the symptoms or maintain safety;
Not due to psychological stressors, anxiety, or fear stemming from misunderstanding related to his or her cognitive impairment that can be expected to improve or resolve as the situation is addressed: and
Persistent, and negatively affect his/her quality of life.
Current Physician's Order Report Summary indicates R47 is [AGE] years old, was admitted to the facility 12/02/20 and has a diagnosis of Alzheimer's Disease with Early Onset.
Current Physician's Order Report Summary indicates R33 has current orders for Olanzapine (antipsychotic) 2.5mg (milligrams) (date initiated 4/1/23) every evening related to visual hallucinations and Haldol 0.5mg three times per day for agitation (date initiated 11/21/22) related to Unspecified Dementia with Behavioral Disturbance.
Consent for Psychotropic Medications dated 1/29/21 indicates consent was given for R33 to receive Zyprexa/Olanzapine 2.5mg twice daily.
Consent for Psychotropic Medications dated 11/21/22 indicates consent was given for R33 to receive Haldol 0.25mg three times per day.
Both consents indicate Indicators and Side Effects Antipsychotics indicators:
Schizophrenia, Delusional, Psychotic Episodes, Tourette's Disorder, Huntington's, Dementia/Alzheimer's with Psychotic and/or Agitated Behavior.
No specific indications or behaviors are identified on these consents.
Psychiatric Evaluation dated 2/17/23 indicates Staff reports sundowning, really bad in the evening. (R33) becomes agitated. Son reports (R33) calls and reports people are in her room, deny's living at facility. Otherwise cooperative with care.
On 4/11/23, 4/12/23, 4/13/23 and 4/14/23 R33 was observed in the dining room on multiple occasions - interacting with peers, actively participating in activities and accepting of care. R33 was easily engaged with appropriate responses to questions.
Medication Regimen Review Prescriber Recommendations dated 4/7/23 indicates recommendations made on that date include GDR (Gradual Dose Reductions) for Olanzapine and Haldol.
On 4/14/23 at 11:45am V2 stated that the pharmacy recommendations (from 4/07/23) have not yet been sent to the physician. V2 stated that R47's main behaviors are sundowning in the evening and acknowledge R33's behaviors are associated with Dementia.
Current Care Plan indicates a problem of Pharmacotherapy was initiated on 12/14/20 related to use of psychotropic medications for hallucinations and depression.
Care plan does not specifically address the use of antipsychotic mediations, specific individualized behaviors or sundowning.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to safely dispose of medications during medication pass. This failure had the potential to affect three residents (R36, R69, R95) ...
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Based on observation, interview and record review the facility failed to safely dispose of medications during medication pass. This failure had the potential to affect three residents (R36, R69, R95) reviewed during medication pass.
Findings include:
Facility Policy/Destruction of Unused Drugs documents:
All unused, contaminated, or expired drugs shall be disposed of in accordance with state laws and regulations.
Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements.
Unused and unwanted medications should be removed from the storage area and secured until destroyed.
A Non-Controlled Medication Destruction Record must be maintained for all non-controlled drugs destroyed and such a record must be verified by the consultant pharmacist.
The sealed container must be maintained in a secure area in the pharmacy or in a locked cabinet in the medication room until transferred to the waste disposal service or the reverse distributor.
On 4/12/23 at 11:25am V11, LPN (Licensed Practical Nurse) removed three Valproic Acid (anticonvulsant) 250mg (milligrams) capsules from a medication card and threw all three capsules into the open/uncovered, full garbage container on the side of the medication cart. V11 then proceeded to pass medications to three residents who were in their rooms, leaving the medication cart and the capsules in the exposed garbage container unattended.
R36, R69 and R95 were all observed either walking past or standing near medication cart while V11 was away from the medication cart.
On 4/12/23 at 12:05pm V11 stated I didn't know what to do with them. I didn't want to leave them in the card. I should have thrown them away in the sharps container so residents couldn't have access to them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0917
(Tag F0917)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident had a bedside table for one (R77) o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident had a bedside table for one (R77) of 25 residents reviewed for resident needs in a sample of 25.
Findings include:
R77's medical record documents she was admitted on [DATE].
On 4/11/23 at 11:55 AM, R77 was alert and oriented and had no overbed table in her room. R77 stated I have been here for a few weeks, I don't have an overbed table and would like one, I eat all three meals in my room per my request, I eat my meals off the chair (stationary chair pulled up next to side of bed), the meals aren't real comfortable to eat off the chair but that is all I have. I was told they do not have any other overbed tables for me to use.
On 4/11/23 at 12:40pm, (R77) was eating her meal off her chair.
On 4/11/23, 4/12/23, 4/13/23, and 4/14/23 CNA's/Certified Nurse Aides were observed charting in the hallway and dining room on over bed tables, and three over bed tables were in the physical therapy room on the same hallway as R77.
On 4/14/23 at 11:58 AM, V5 Regional Nurse Consultant verified R77 did not have an overbed table and needed one. At that same time, V4 verified their were overbed tables available in the hallway, and physical therapy room. V5 stated This is unacceptable.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to provide an ongoing Activity Program for 3 residents (R68, R74, R12), this failure has the potential to affect all 94 residents ...
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Based on observation, interview and record review the facility failed to provide an ongoing Activity Program for 3 residents (R68, R74, R12), this failure has the potential to affect all 94 residents who currently reside in the facility.
Findings Include:
The Facility's undated Activity Policy documents It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community.
Activity Staff Schedule for March 2023 documents no staff members on the schedule at all for activities on 3/10/23, 3/11/23, 3/12/23, 3/15/23, 3/18/23, 3/20/23, 3/24/23, 3/25/23, 3/26/23 and 3/29/23.
Activity Staff Schedule for April 2023 documents no staff members on the schedule at all for activities on 4/03/23, 4/08/23 and 4/09/23 so far into April.
The April Activity Calendar documents on 4/03/23, 04/07/23, 4/08/23, 4/09/23, 4/12/23, 4/17/23, 4/21/23, 4/22/23, 4/23/23 and 4/26/23 11:00 AM-3:00 PM: Residents Choice.
On 4/13/23 at 9:00 AM R68 stated All there is to do is color, and that gets old.
On 4/13/23 at 9:05 AM R74 stated There is nothing to do around here.
On 4/13/23 at 11:00 AM R12 stated If you don't have things to keep yourself busy then you will get bored around here. They (facility) gets someone to work and then they leave. We never have enough activities
On 4/23/23 at 9:30 AM V16 (Activity Director) stated Resident's Choice is where they can come out and do whatever they choose of the games and things we have available. I just had an activity aide quit and those are the days that I don't have enough staff to do structured activities. If I have one person, I can get some of it done, but they have more to do than the structured calendar. Things don't get done on the days I have one or no one at all. It gets missed.
Facility census report provided by V3, Minimum Data Set (MDS) Coordinator, dated 4/11/23 documents 94 residents currently residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide the services of a registered nurse (RN) for eight hours in a 24-hour period. This failure has the potential to affect all 94 reside...
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Based on interview and record review, the facility failed to provide the services of a registered nurse (RN) for eight hours in a 24-hour period. This failure has the potential to affect all 94 residents residing in the facility.
Findings Include:
The facility's nursing schedule dated 3/9/23 through 4/5/23 does not have an RN scheduled for eight hours a day on 3/22/23 and 3/25/23.
4/12/23 1:04 PM, V2, Director of Nursing (DON), verified there was no RN coverage for 3/22 and 3/25 and stated, That would be correct, we had an issue of not having enough RN's to cover all the days.
Facility census report provided by V3, Minimum Data Set (MDS) Coordinator, dated 4/11/23 documents 94 residents currently residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to complete annual performance reviews and education based on the performance review of the Certified Nursing Assistants (CNA) working in the ...
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Based on interview and record review, the facility failed to complete annual performance reviews and education based on the performance review of the Certified Nursing Assistants (CNA) working in the facility. This failure has the potential to affect all 94 residents residing in the facility.
Findings include:
V4's, CNA, personnel file documents V4's start date of 4/18/21 and does not include a performance review at least every 12 months or the in-service education provided to the CNA based on his/her performance review.
V9's, CNA, personnel file documents V9's start date of 12/3/19 and does not include a performance review at least every 12 months or the in-service education provided to the CNA based on his/her performance review.
On 4/13/23 at 10:23 AM, V5, Regional Nurse Consultant, verified V4 and V9's, CNA, annual performance reviews and in-services based on the performance were not completed and stated I'll be honest with you, our communities haven't been the best at completing the CNAs annual competency evaluations. We don't have any completed on any of the CNAs. here.
Facility census report provided by V3, Minimum Data Set (MDS) Coordinator, dated 4/11/23 documents 94 residents currently residing in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to double lock refrigerated liquid controlled medications, failed to document and reconcile controlled medications after administr...
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Based on observation, interview and record review the facility failed to double lock refrigerated liquid controlled medications, failed to document and reconcile controlled medications after administration and failed to ensure shift to shift controlled medication reconciliation was completed. This failure has the potential to affect all 48 residents in the facility who receive controlled medications.
Findings include:
Facility Policy/Controlled Substance Administration and Accountability dated 2022 documents:
The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure.
Controlled substances are stored in a separate compartment of an automated dispensing system or other locked storage unit with access limited to approved personnel.
All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form.
The Controlled Drug record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration.
Areas without automated dispensing systems utilize a substantially-constructed storage unit with two locks and a paper system for 24-hour recording of controlled substance use.
Patient-specific controlled substances are stored under double lock until administered to the patient.
For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift.
On 4/13/23 at 11:25am V12, LPN (Licensed Practical Nurse) administered Tramadol 50mg (opioid analgesic) - a controlled medication - to R76 then put the multi-dose medication card immediately back into the controlled medication box on the medication cart.
On 4/13/23 at 11:47am V12 administered Oxycodone (opioid) 2.5mg and Ativan (antianxiety) 1mg to R54 and immediately returned the multi-dose medication card back into the controlled medication box on the medication cart.
At that time, V12 was asked when she reconciles the controlled medications card she administered with the Controlled Drug/Receipt/Record/Disposition Form. V12 responded I was nervous. I thought I already did. V12 then opened the Controlled Medication binder and compared R76's card of Tramadol to the Tramadol control drug receipt. The Tramadol card had 34 tablets remaining and the control sheet had 33 tablets as the amount remaining. The last entry on the sheet was documented as administered on 4/13/23 at 12pm. V12 then confirmed the initials for that date and time were hers and that she had signed out the medication earlier. V12 could not explain why the count was incorrect.
V12 then reconciled R54's card of Oxycodone and card of Ativan with the controlled medication receipts. Both matched at that time. V12 stated that she is supposed to reconcile the amount on the card and on the control receipt after the medication is prepared.
Shift Change Controlled Substance Inventory Sheet indicates:
Nurse oncoming to shift must verify count of all controlled substances with nurse coming off shift or anytime the medication cart keys are exchanged.
Nurses must count the number of cards/containers and total number of count sheets, both for individual residents and applicable contingency supplies with controlled drugs.
Nurses must verify actual drug counts against each individual resident count sheet.
Shift Change Controlled Substance Inventory Sheet's for all three medication carts reviewed on 4/13/23 found incomplete signature documentation for oncoming nurses and off-going nurses from 4/1/23 through 4/13/23.
Control Sheets for Units A/E, B/D and C signatures incomplete or missing for all days.
On 4/13/23 at 12:10pm V15, LPN stated that she always signs, but Only one nurse signs (the shift-to-shift narcotic count) but both count. It's always been that way. I didn't know both had to sign.
On 4/13/23 at 12:30pm both V2, DON (Director of Nursing) and V5, Nurse Consultant stated that both nurses are required to sign the shift count and that has always been the facility policy.
On 4/13/23 at 11:42am V12, LPN was looking through the medication room for a resident's insulin and looked through the unlocked medication refrigerator in the medication room. V12 then closed the refrigerator door without locking. At 2:00pm the medication refrigerator remained unlocked in the medication room. At that time, six bottles of liquid Ativan (antianxiety), 2 bottles of Morphine Sulfate (opioid)and one bottle of Hydromorphone (opioid) was being stored in the unlocked refrigerator. V12 acknowledged that the refrigerator should be locked but she didn't have the key. V12 acknowledged the refrigerator had been unlocked all day.
On 4/14/23 at 11am V2, DON stated that the lock on the medication refrigerator was not locking properly and should have been reported to maintenance. V2 stated the refrigerator should be locked at all times. V2 stated that Ativan, Morphine and Hydromorphone are all controlled drugs and should be double locked.
Facility census report provided by V3, Minimum Data Set (MDS) Coordinator, dated 4/11/23 documents 94 residents currently residing in the facility.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0576
(Tag F0576)
Minor procedural issue · This affected most or all residents
Based on interview and record review, the facility failed to provide mail on Saturdays for all 94 residents residing in the facility.
Findings include:
The facility's Resident Rights policy dated 20...
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Based on interview and record review, the facility failed to provide mail on Saturdays for all 94 residents residing in the facility.
Findings include:
The facility's Resident Rights policy dated 2023, documents 6) i. The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility.
On 4/12/23 at 11:05 AM, R68 stated The facility doesn't give us our mail on Saturdays. R74 responded stating The administration told me they can't hand out mail on Saturday because there's no management here on the weekends to pass it out.
On 4/12/23 at 10:04 AM, V14, Business Office Manager (BOM), stated The mail doesn't get delivered on Saturday because the facility asked the post office not to deliver mail on the weekends. We asked them not to deliver mail on the weekends because we don't have management here to sort the facility mail from the resident's mail. Every Monday I have a stack of mail that I have to sort through from the weekend and distribute it to the resident.
Facility census report provided by V3, Minimum Data Set (MDS) Coordinator, dated 4/11/23 documents 94 residents currently residing in the facility.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review the facility failed to post where the survey results book was located and failed to have the survey results in the binder. This has the potential to ...
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Based on observation, interview, and record review the facility failed to post where the survey results book was located and failed to have the survey results in the binder. This has the potential to affect all 94 residents living in the facility.
Findings include:
Facility Resident Rights, copyright 2023, documents The resident has a right to examine the results of the most recent survey of the facility and any plan of correction in effect with respect to the facility.
On 4/11/23 at 9:20am and 4/12/23 at 2:49pm the survey results book was located in the front foyer area in a drawer. A door separates the foyer area from the entrance to the building where the staff and residents reside.
No posting was noted to be inside the building identifying where the survey results book was located.
On 4/12/23 at 2:50 PM, V1 Administrator verified there was no posting in the building on where the survey results book was located, verified their was no state reports with respect to any surveys, certifications, and complaint investigations for the facility during the three preceding years (last report put in the survey results book was from 2020), and no plan of correction was available for any individual to review. At that time V1 stated If residents don't know where it is located, they can ask, and I did not know I needed to put the report in the book, or the plan of correction.
Facility census report provided by V3, Minimum Data Set (MDS) Coordinator, dated 4/11/23 documents 94 residents currently residing in the facility.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), $220,820 in fines. Review inspection reports carefully.
- • 46 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $220,820 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Allure Of Galesburg's CMS Rating?
CMS assigns ALLURE OF GALESBURG an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Allure Of Galesburg Staffed?
CMS rates ALLURE OF GALESBURG's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 53%, compared to the Illinois average of 46%. RN turnover specifically is 83%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Allure Of Galesburg?
State health inspectors documented 46 deficiencies at ALLURE OF GALESBURG during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 40 with potential for harm, and 4 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 Allure Of Galesburg?
ALLURE OF GALESBURG is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ALLURE HEALTHCARE SERVICES, a chain that manages multiple nursing homes. With 108 certified beds and approximately 96 residents (about 89% occupancy), it is a mid-sized facility located in GALESBURG, Illinois.
How Does Allure Of Galesburg Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, ALLURE OF GALESBURG's overall rating (1 stars) is below the state average of 2.5, staff turnover (53%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Allure Of Galesburg?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Allure Of Galesburg Safe?
Based on CMS inspection data, ALLURE OF GALESBURG has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Allure Of Galesburg Stick Around?
ALLURE OF GALESBURG has a staff turnover rate of 53%, which is 7 percentage points above the Illinois average of 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 Allure Of Galesburg Ever Fined?
ALLURE OF GALESBURG has been fined $220,820 across 1 penalty action. This is 6.3x the Illinois average of $35,287. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Allure Of Galesburg on Any Federal Watch List?
ALLURE OF GALESBURG 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.