GOLDWATER CARE GIBSON CITY
For profit - Corporation
60 Beds
GOLDWATER CARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#531 of 665 in IL
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Goldwater Care in Gibson City, Illinois, has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #531 out of 665 facilities in Illinois, placing it in the bottom half, and #4 out of 4 in Ford County, meaning there are no better local options available. Though the facility is reportedly improving, with issues decreasing from 20 in 2024 to 8 in 2025, it still faces serious challenges. Staffing is rated at 2 out of 5 stars, suggesting below-average conditions, and there is a concerning $82,059 in fines, indicating compliance issues. Serious incidents include a resident who suffered from Warfarin toxicity leading to hospitalization and death, as well as failures in fall risk assessments that resulted in injuries for multiple residents. Overall, while there are some signs of improvement, the facility's history and current issues raise significant red flags for families considering it for their loved ones.
- Trust Score
- F
- In Illinois
- #531/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $82,059 in fines. Higher than 64% of Illinois facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 35 minutes of Registered Nurse (RN) attention daily — about average for Illinois. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 56 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 21%
Review needed
20 → 8 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 20 issues
2025: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 48%
Near Illinois avg (46%)
Higher turnover may affect care consistency
Federal Fines: $82,059
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: GOLDWATER CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 56 deficiencies on record
1 life-threatening 2 actual harm
Sept 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accurate documentation of medications that was administered f...
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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 accurate documentation of medications that was administered for 2 of 3 residents (R1,R2) reviewed for medication administration.Findings include: 1.R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses; Fibromyalgia, Morbid Obesity, Complex Regional Pain Syndrome, Major Depressive Disorder, HTN, Hypothyroidism, GERD, Anxiety Disorder and Barrett's Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 15 cognitively intact and receives an opioid.R1's Physician Orders Sheet (POS) date documents Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams, give 1 tablet by mouth every 8 hours as needed for severe pain.R1's Controlled Drug Receipt Record/Disposition Form dated August 29, 2025, no time given, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.R1's Medication Administration Record (MAR) dated August 29, 2025, does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.2. R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnoses; Primary Osteoarthritis Right Knee, Type 2 Diabetes, Cellulitis of Left Lower Limb, Non-Pressure Ulcer Right Lower Leg, Ataxia, Difficulty in Walking, Pulmonary Hypertension, Non-ST Elevation Myocardial Infarction, Heart Disease, Venous Insufficiency, Chronic Embolism and Thrombosis of Deep Veins of Lower Extremity. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 15 cognitively intact and receives an opioid.R2's Physician Orders Sheet (POS) date documents Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams, give 1 tablet by mouth every 4 hours as needed for severe pain. R2's Controlled Drug Receipt Record/Disposition Form dated September 8, 2025, at 5:00am, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.R2's Medication Administration Record (MAR) dated September 8, 2025, does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.The Facilities Medication Administration General Guidelines not dated documents: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after the have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). Documentation (including electronic) 1. The individual who administers the medication dose records the administration on the residents Medication Administration Record (MAR) directly after the medication was given. 3. When as needed (PRN) medications are administered the following documentation is provided: a) Date and time of administration, dose, route of administration and if applicable the injection site. d) signature or initials of person recording administration and signature or initials of person recording effect, if different from the person administering the medication. On 9/13/25 at 10:15 AM V4 Licensed Practical Nurse stated that when V4 administers a residents opioid, V4 will open the lock box, obtain the medication and sign out for the medication on the Controlled Drug Receipt Record/Disposition Form. V4 stated after administering the medication, V4 will then sign that the medication was administered in the residents Electronic Health Record (EHR). On 9/13/25 at V1 Administrator confirmed that R1's Controlled Drug Receipt Record/Disposition Form dated August 29th, 2025, no time given, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams and R1's Medication Administration Record (MAR) does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams. V1 also confirmed that R2's Controlled Drug Receipt Record/Disposition Form dated September 8th, 2025, at 5:00am, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams and R2's Medication Administration Record (MAR) dated September 8th, 2025, does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams. V1 stated that V3 should first sign out for the residents narcotic on the Controlled Drug Receipt Record/Disposition Form, and then after administering the medication to the resident, V3 should document that the medication was administered to the resident in the residents Electronic Health Record.
May 2025
5 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the residents right to be free from physical and verbal abus...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the residents right to be free from physical and verbal abuse by another resident. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample list of 13. This failure resulted in R1 abusing R2 causing R2 to experience psychosocial harm as evidenced by crying.
Findings include:
The facility's Abuse Prevention and Reporting Policy (revised 10/24/22) documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.
R1's Face Sheet dated 5/8/25 documents the following diagnoses: Dementia with agitation and behaviors and Alzheimer's Disease.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired.
R1's Care Plan (current) documents R1 has a behavior problem and screams/curses at staff. This same record documents R1 is frequently verbally aggressive towards others and can have aggressive behaviors.
A Progress Note dated 5/7/25 documents R1 still wearing the same clothing as the day before and R1 resistive to cares and very aggressive physically and verbally.
R2's Face Sheet dated 5/8/25 documents the following diagnoses: Alzheimer's Disease.
R2's MDS dated [DATE] documents R2 is severely cognitively impaired.
A typed, undated incident narrative documents a physical and verbal altercation between R1 and R2. This same record documents R1 was witnessed by V4 Certified Nursing Assistant (CNA) hitting R2 in the back and yelling at R2 stating R2 needed a good smacking.
On 5/7/25 at 12:38pm, V9 Registered Nurse stated R1 can be aggressive towards other residents. V9 stated R1 does not like other residents to be around R1.
On 5/7/25 at 1:21pm, V4 CNA stated on 4/26/25, R1 was in the lobby sitting area near the table by the front window and R2 was near the front door yelling I want to go home. V4 stated this is not unusual for R2. V4 stated V4 was sitting at the nurses station charting when V4 heard R1 yelling at R2, 'I'm tired of listening to you. Why don't you shut up.' V4 stated V4 then heard what sounded like R1 smacking R2 in the back and R2 posturing like R2 had been hit in the back.
On 5/8/25 at 10:45am, R8 stated R1 cusses residents out.
On 5/8/25 at 12:21pm, V16 CNA stated the last weekend V16 worked, either Saturday or Sunday (4/26/25 or 4/27/25), V16 was told by V4 CNA that R1 hit R2. V16 stated V16 came upon R1 and R2 shortly after the incident. V16 stated R2 was crying and rubbing R2's arm and R2 said R1 hit R2.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement their Abuse Prevention and Reporting Policy. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sampl...
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Based on interview and record review, the facility failed to implement their Abuse Prevention and Reporting Policy. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample list of 13.
Findings include:
On 5/7/25 at 9:49am, V1 Administrator stated V1 was notified on 4/26/25 by V4 Certified Nursing Assistant (CNA) of R1 hitting and yelling at R2 but did not report the incident to the State Agency or do an investigation.
On 5/7/25 at 10:59am, V6 R1's Representative stated V6 was not notified of the altercation between R1 and R2.
On 5/7/25 at 1:21pm, V4 CNA stated V4 notified V1 Administrator on 4/26/25 of R1 yelling at R2 and hitting R2 in the back.
There is no documentation in R1's medical record of the state survey agency or V6 being notified of the incident.
There is no documentation in R2's medical record of the state survey agency or V10 R2's Representative being notified of the incident.
The facility's Abuse Prevention and Reporting Policy (revised 10/24/22) documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Implementing systems to promptly and aggressively investigate all reports and allegations of abuse. Filing accurate and timely investigative reports. All incidents will be documented, whether or not abuse was alleged or suspected. Any incident or allegation involving abuse will result in an investigation. When an allegation of abuse has occurred, the resident's representative and the State Agency shall be informed by telephone or fax. The State Agency shall be informed that an occurrence of potential abuse has been reported and is being investigated.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely report an allegation of resident to resident physical and ve...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely report an allegation of resident to resident physical and verbal abuse to the state survey agency. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample list of 13.
Findings include:
R1's Face Sheet dated 5/8/25 documents the following diagnoses: Dementia with agitation and behaviors and Alzheimer's Disease.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired.
R1's Care Plan (current) documents R1 has a behavior problem and screams/curses at staff. This same record documents R1 is frequently verbally aggressive towards others and can have aggressive behaviors.
A Progress Note dated 5/7/25 documents R1 still wearing the same clothing as the day before and R1 resistive to cares and very aggressive physically and verbally.
R2's Face Sheet dated 5/8/25 documents the following diagnoses: Alzheimer's Disease.
R2's MDS dated [DATE] documents R2 is severely cognitively impaired.
A typed, undated incident narrative documents a physical and verbal altercation between R1 and R2. This same record documents R1 was witnessed by V4 Certified Nursing Assistant (CNA) hitting R2 in the back and yelling at R2 stating R2 needed a good smacking.
There was no abuse investigative file for the altercation between R1 and R2 and no documentation of the incident in R1 or R2's medical record.
There is no documentation that the facility reported this altercation to the state survey agency.
On 5/7/25 at 9:49am, V1 Administrator stated V1 was notified on 4/26/25 by V4 Certified Nursing Assistant (CNA) of R1 hitting and yelling at R2 but did not report the incident to the state survey agency or do an investigation.
On 5/7/25 at 12:38pm, V9 Registered Nurse stated R1 can be aggressive towards other residents. V9 stated R1 does not like other residents to be around R1.
On 5/7/25 at 1:21pm, V4 CNA stated on 4/26/25, R1 was in the lobby sitting area near the table by the front window and R2 was near the front door yelling I want to go home. V4 stated this is not unusual for R2. V4 stated V4 was sitting at the nurses station charting when V4 heard R1 yelling at R2, 'I'm tired of listening to you. Why don't you shut up.' V4 stated V4 then heard what sounded like R1 smacking R2 in the back and R2 posturing like R2 had been hit in the back. V4 stated V4 notified V1 Administrator on 4/26/25 of R1 yelling at R2 and hitting R2 in the back.
On 5/8/25 at 10:45am, R8 stated R1 cusses residents out.
On 5/8/25 at 12:21pm, V16 CNA stated the last weekend V16 worked, either Saturday or Sunday (4/26/25 or 4/27/25), V16 was told by V4 CNA that R1 hit R2. V16 stated V16 came upon R1 and R2 shortly after the incident. V16 stated R2 was crying and rubbing R2's arm and R2 said R1 hit R2.
The facility's Abuse Prevention and Reporting Policy (revised 10/24/22) documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Implementing systems to promptly and aggressively investigate all reports and allegations of abuse. Filing accurate and timely investigative reports. All incidents will be documented, whether or not abuse was alleged or suspected. Any incident or allegation involving abuse will result in an investigation. When an allegation of abuse has occurred, the resident's representative and the State Agency shall be informed by telephone or fax. The State Agency shall be informed that an occurrence of potential abuse has been reported and is being investigated.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to thoroughly investigate and document an allegation of resident-to-resident physical and verbal abuse. This failure affects two (R1 and R2) o...
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Based on interview and record review, the facility failed to thoroughly investigate and document an allegation of resident-to-resident physical and verbal abuse. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample of 13.
Findings include:
The facility Abuse, Neglect and Exploitation Policy dated 12/5/22 documents the following: when suspicion of abuse or reports of abuse occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members and visitors in the area. Obtain witness statements. Document the entire investigation chronologically. Notify the attending physician and the resident's family/legal representative. Monitor and document the resident's condition, including the response to medical treatment or nursing interventions.
A typed, undated incident narrative documents V1 Administrator notified by V4 Certified Nursing Assistant (CNA) of a physical and verbal altercation between R1 and R2. This same record documents R1 was witnessed by V4 hitting R2 in the back and yelling at R2 stating R2 needed a good smacking. Further documents R1 and R2 separated by nursing staff and R2 assessed for injury by V5 Licensed Practical Nurse.
On 5/7/25, the above incident narrative failed to document the time of the incident between R1 and R2, failed to document the date and time of required notifications, failed to document what staff and residents were interviewed, the results of those interviews, and the date/time of those interviews. The same record failed to document the investigation chronologically and failed to document any subsequent monitoring or assessment of potential resident psychosocial outcomes following R1 and R2's incident on 4/26/25.
On 5/7/25 at 9:49am, V1 stated the typed, undated incident narrative was the complete investigation for the incident between R1 and R2.
The facility's Abuse Prevention and Reporting Policy (revised 10/24/22) documents the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Implementing systems to promptly and aggressively investigate all reports and allegations of abuse. Filing accurate and timely investigative reports. All incidents will be documented, whether or not abuse was alleged or suspected. Any incident or allegation involving abuse will result in an investigation. When an allegation of abuse has occurred, the resident's representative and the State Agency shall be informed by telephone or fax. The State Agency shall be informed that an occurrence of potential abuse has been reported and is being investigated.
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
Resident Rights
(Tag F0550)
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 residents' right to be treated in a dignified manner for thre...
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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 residents' right to be treated in a dignified manner for three (R8, R9, and R10) of 12 residents reviewed for abuse in the sample list of 13.
Findings include:
The facility's Resident Rights policy dated 8/23/17 documents Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. The facility will not hamper, compel, treat differentially, or retaliate against a resident for exercising his/her rights
On 5/8/25 at 10:45 AM R8 stated V3 Certified Nursing Assistant (CNA) is a b**** (expletive), she's just mean. R8 stated about six months or so ago V3 hit R8 in the stomach while rolling R8 in bed. R8 felt this was done intentionally and described V3 as being mean about it. V3 stated V1 Administrator and V2 Director of Nursing were notified. R8 stated V3 also left R8's former room mate, R10, to take herself to the bathroom. R8 stated V3 knew R10 needed the bathroom, but left her on her own. R8 stated R10 waited an hour for V3 to return prior to taking herself to the bathroom.
R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. The facility's daily assignment sheets dated 4/30/25-5/7/25 documents V3 worked on R8's hallway five days during this time frame.
V3's employee file was reviewed on 5/8/25. This file contained Employee Disciplinary Action Form dated 11/7/24, which documents a written warning and three day suspension was given to V3 regarding being unprofessional in language and actions with resident (identified as R9) and family (identified as V16 CNA) present. V3 was educated on Abuse and Neglect and Customer Service. This file contained Employee Disciplinary Action Form dated 2/27/25, which documents it was reported to V1 Administrator that V3 did not assist a resident (R10) with toileting assistance and walked out of the room. V3 was issued a written warning and three day suspension, and provided education on the facility's Customer Service Policy. The attached undated Customer Service policy documents the facility is dedicated in serving others to create a positive experience, and this includes responding promptly and in a positive/professional manner and being polite, interested, and respectful. This policy documents to smile, convey friendliness, avoid raising your voice in frustration or anger, have an open/friendly posture, be respectful and empathize and apologize where required.
R9's Census documents R9 discharged from the facility on 2/10/25. R9's MDS dated [DATE] documents R9 has severe cognitive impairment. R10's Census documents R10 discharged from the facility on 3/17/25. R10's MDS dated [DATE] documents R10 as cognitively intact. R10's Care Plan initiated 2/12/25 documents R10 has Activities of Daily Living self care deficit with varying levels of assistance needed due to right distal femur fracture.
On 5/8/25 between 10:35 AM and 1:13 PM the following staff were interviewed: V19 Licensed Practical Nurse stated V3 has a history of problems with R8, including R8 saying V3 was rough with R8. V19 stated V1 Administrator was aware and V3 was placed on suspension. V16 CNA stated V16 was R9's Power of Attorney and V3 has a history of not doing things. In regards to V3's 117/24 Disciplinary Action , V16 stated V16 entered R9's room and noted an odor. V3 entered R9's room to give V16 report and V16 told V3 that R9 needed to be checked/changed. V16 stated V3 huffed and said V3 did not have time for this while standing near R9. V16 stated V1 was notified and V16 was upset to find out that V3 continues to be employed by the facility despite having similar situations. V16 stated V3 had poked R8 in the chest causing R8 to cry. V18 Human Resources, in regards to the 11/7/24 Disciplinary Action, stated it was reported by V16 that while assisting V3 to change R9, V3 did not sound very professional, it was V3's tone of voice. V3 was placed on suspension and educated on customer service.
On 5/8/25 at 11:54 AM V3 stated R8 does not like V3 and described R8 as being rude to V3, even though V3 is not rude to R8. V3 confirmed V3 still provides cares for R8. V3 confirmed receipt of abuse and resident rights training. In regards to V3's 11/7/24 Disciplinary Action, V3 stated V3 went in to provide care for R9 who was dirty/incontinent. V3 stated V3 told R9 that R9 was dirty and V3 needed to change her. V3 stated V16 was also in the room providing care for R9's unidentified room mate, and V16 told V3 that V3 shouldn't talk to R9 that way. V3 stated management talked to V3 about the situation, but didn't recall what was said or reviewed. In regards to the 2/27/25 Disciplinary Action, V3 stated R10 called to request the bathroom, V3 told R10 that V3 was in the middle of providing cares to another unidentified resident and would return. V3 stated V3 did not return to R10's room since R10's call light was no longer on.
On 5/8/25 at 10:40 AM V2 Director of Nursing stated R10 was R8's room mate on 2/27/25. V1 and V2 confirmed V3's 2/27/25 Disciplinary Action form was for R10. V1 stated the concern was reported by R10 and this was addressed with V3. At 10:52 AM V1 stated R8 says a lot of people are rough with her and R8 likes to make up things. V1 stated R8 has said V3 was rough with her and we have talked to V3 about it. At 1:27 PM V1 confirmed that V3 has been allowed to continue to provide R8's cares, despite a history of abuse allegation between R8 and V3 in June 2024.
Mar 2025
2 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to provide timely call light response for four (R17, R38, R45, R20...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to provide timely call light response for four (R17, R38, R45, R206) of nine residents reviewed for call light response times in the sample list of 27.
Findings include:
On 3/25/25 at 9:00 am, R206 stated that R206 needed assistance from staff, and R206 was unsure why they took so long to come to R206's room. R206 stated sometimes R45 (R206's roommate) has to wait 45 minutes or more for staff to come and put R45 into bed. R206 stated that sometimes R206 will wheel down the hall to get staff to come and help R45.
Facility Census documents R206 was admitted to the facility on [DATE] and has the following medical diagnoses: Acute Respiratory Failure with Hypoxia, Difficulty in Walking, Lack of coordination, Abnormal Posture, and Muscle Wasting and Atrophy.
R206's Minimum Data Set (MDS) dated [DATE] documents R206's Brief Interview for Mental Status (BIMS) score of 8, moderate cognitive impairment, and needs moderate assistance with showers/bathing.
On 3/25/25 at 9:15 am, R45 stated that sometimes R45 has to wait 45 minutes or more for staff to come and help R45 into bed. R45 stated that R206, R45's roommate, will get staff to help R45.
R45's Minimum Data Set (MDS) dated [DATE] documents R45's Brief Interview for Mental Status (BIMS) score of 15, cognitively intact and needs substantial/maximum assistance with showers/bathing.
On 3/25/25 at 11:24am R38 stated that it takes staff to long to answer call lights sometimes. R38 stated that R38 needed assistance from staff to get transferred to the toilet. R38 stated that in more than one instance R38 has had an incontinent episode, due to waiting on staff to come toilet R38. R38 stated, R38 sometimes has to wait 30-40 minutes for staffs' assistance.
Facility Census documents R38 was admitted to the facility on [DATE] and has the following medical diagnoses: Parkinson's Disease, Major Depressive Disorder, and Post-Traumatic Stress Disorder.
R38's Minimum Data Set (MDS) dated [DATE] documents R38's Brief Interview for Mental Status (BIMS) score 15, cognitively intact and needs substantial/maximum assistance with showers/bathe.
On 3/26/25 at 9:00am, a resident council meeting was held. During the meeting R206 stated it takes a long time for call lights to be answered, R206's roommate (R45) calls out, so R206 turns the call light on for R45. R206 stated R206 has had to go looking for staff because no one responds to the call light. R206 stated R206's/R45's room gets overlooked because it is at the end of the hallway. R17 stated R17 has waited for over an hour for R17's call light to be answered, especially during the afternoon and midnight shifts. R17 stated R17 waits a long time for the call light to be answered and often ends up getting out of bed by herself, but R17 is supposed to have assistance from staff. These residents stated that call light wait times have been an ongoing issue brought up in the resident council meetings that haven't been resolved.
On 3/26/25 at 9:15am R17 stated that staff take a long time to answer call lights and R17 needs help to get to the toilet. R17 stated we have been bringing it up at the monthly resident council meeting and nothing seems to get done, it's not getting any better.
Facility Census documents R17 was admitted to the facility on [DATE] and has the following medical diagnoses: Parkinson's Disease, Major Depressive Disorder, and Post-Traumatic Stress Disorder.
R17's Minimum Data Set (MDS) dated [DATE] documents R17's Brief Interview for Mental Status (BIMS) score 15, cognitively intact and needs Partial/moderate assistance with showers/bathe.
On 3/26/25 at 9:20am V5 Activity Director confirmed call lights have been an ongoing concern brought up in the resident council meetings. V5 stated that for the past two monthly Resident Council meetings residents have been complaining on waiting a long time for call lights to be answered.
On 3/26/25 at 10:30 a.m., the V1 Administrator stated that V1 is aware of the delay in answering residents' call lights. V1 stated that the facility has been educating staff on answering call lights in a timely manner, but residents are still complaining that the staff is taking too long to answer them. V1 stated that some residents are taking themselves to the toilet due to staff not responding in a timely manner.
The Resident Council Minutes dated 1/27/25 and 2/24/25 document concerns with call light response times taking too long.
Facility Call Light Policy dated 2/2/18 documents Purpose: To respond to resident's requests and needs in a timely and courteous manner. Guidelines: Residents' call lights will be answered in a timely manner. 1. All residents who can use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at bedside or other reasonable accessible location. 2. All staff should assist in answering call lights. Nursing staff members shall go to a room to respond to call system and promptly cancel the call light when the room is entered. 5. Hand bells will be provided for alert dependent resident's when positioned out of reach of permanent call light when needed. 6. Call bell system defects will be reported promptly to Maintenance Department for servicing. Check room frequently until system is repaired.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to provide numerous showers as scheduled for two (R45, R206) of th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to provide numerous showers as scheduled for two (R45, R206) of three residents who were reviewed for showers in the sample list of 27.
Findings include:
1. On 3/25/25 at 9:00am R206 was sitting in the wheelchair in R206's room, nails not trimmed and face not shaven.
On 3/25/25 at 9:00 am R206 stated that R206 was admitted a couple of weeks ago and has only gotten one shower last week. R206 stated that staff do not cut R206's nails on that day or any other day; they are very long and need trimming.
The Facility Census documents that R206 was admitted to the facility on [DATE] and has the following medical diagnoses: Acute Respiratory Failure with Hypoxia,
Difficulty in Walking, Lack of coordination, Abnormal Posture and Muscle Wasting and Atrophy.
R206's Minimum Data Set (MDS) dated [DATE] documents R206's Brief Interview for Mental Status (BIMS) score 8, moderate cognitive impairment and needs moderate assistance with showers/bathe.
The Facility's East Evening Showers schedule documents R206 is scheduled to receive showers on Tuesdays and Fridays.
R206's Shower Day Skin Inspection report documents R206 received showers on 3/21/25 and has no documented refusals or bed baths. The same report documents R206's nails were never cut or trimmed.
2. On 2/25/25 at 9:15am R45 was sitting in the wheelchair in R45's room, nails not trimmed.
On 2/25/25 at 9:15am R45 stated that R45 never gets two showers a week. R45 stated that staff never cut or trim R45's nails, and they are long and need trimming.
R45's Minimum Data Set (MDS) dated [DATE] documents R45's Brief Interview for Mental Status (BIMS) score of 15, cognitively intact and needs substantial/maximum assistance with showers/bathing.
The Facility's East Evening Showers schedule documents R45 is scheduled to receive showers on Tuesdays and Fridays.
R45's Shower Day Skin Inspection report documents R45 received showers on 2/11/25, 2/18/25, 2/28/25 and 3/21/25, refused showers on 2/25/25, 3/11/25 and 3/14/25 and was not offered a bed bath. The same report documents that R45's nails were never cut or trimmed.
On 2/26/25 at 1:30 p.m., V2, the Director of Nursing, stated that all residents are scheduled two showers a week and should be getting them. V2 stated that after a resident receives a shower, bed bath, or refuses a shower, the Certified Nursing Assistant is required to complete a Shower Day Skin Inspection Form. V2 confirmed that R45 and R206 are not receiving two showers a week and will have staff cut their nails today.
The Facility's Shower Documentation documents showers should always include washing hair, oral care, fingernails, toenails (except diabetic residents), shaving, stripping and remaking the bed, cleaning the shower room. Please make sure you're performing each of these when giving a shower. Shower reminders: refusals or N/A's require a shower sheet be completed with reason (showered on AM shift, showered yesterday by hospice, res states does not feel like it).
Sept 2024
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 interview and record review the facility failed to follow physician orders for a resident's anticoagulant medication (W...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow physician orders for a resident's anticoagulant medication (Warfarin/Coumadin) resulting in the resident receiving an increased anticoagulant dosage for 24 days. The facility also failed to monitor the resident's anticoagulant medication as recommended by the drug manufacturer guidelines. These failures affect one (R1) resident reviewed for anticoagulation therapy on a sample list of three residents. These failures resulted in R1 experiencing internal bleeding and dying.
Findings include:
The Immediate Jeopardy began on [DATE] when the facility failed to follow the physician orders to decrease R1's Warfarin dosage from 3mg to 2.5mg and failed to obtain a PT/INR (Prothrombin Time/International Normalized Ratio (measures blood clotting time)). Twenty four days later, R1's PT/INR were at critical levels, R1 was bleeding internally and was sent to the hospital for Warfarin toxicity where he subsequently died. V1 Administrator was notified of the immediate jeopardy on [DATE] at 3:37PM.
The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE] but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.
The undated Warfarin package insert documents, The dosage and administration of warfarin sodium tables must be individualize for each patient according to the patient's (International Normalized Ratio) INR response to the drug. Adjust the dose based on the patient INR and the condition being treated. Monitoring: Obtain daily INR determinations upon initiation until stable in the therapeutic range. Obtain subsequent INR determination every 1-4 weeks.
The National Institute of Health (NIH) report on Warfarin (Coumadin) anticoagulant dated [DATE] documents, Close monitoring of a patient's INR is a strong recommendation when initiating Warfarin. The INR requires more frequent monitoring when starting Warfarin. More frequent monitoring is necessary for patients with supratherapeutic or subtherapeutic INR to evaluate safety and efficacy. Also, the INR requires assessment when initiating, discontinuing, or changing doses of medications known to interact with Warfarin. Patients also require close monitoring for signs and symptoms of active bleeding throughout their treatment. Close monitoring for signs and symptoms of bleeding, such as dark tarry stools, nosebleeds, and hematomas, is necessary.
R1's census report dated [DATE] documents admission to the facility.
R1's undated diagnoses sheet includes the following diagnoses: Transient Cerebral Ischemic Attack, Non-Rheumatic Aortic Valve Stenosis, Hypothyroidism, Hypertension, Chronic Respiratory Failure, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Aneurysm of the Ascending Aorta Without Rupture, Depression, Dementia, Anxiety, and the Presence of a Prosthetic Heart Valve.
R1's January, February and [DATE] physician order sheet documents Plavix (antiplatelet) 75 milligrams (mg) to be given daily.
R1's [DATE] medication administration record documents R1's Plavix was discontinued and Warfarin (anticoagulant), 4mg daily was started.
R1's Anticoagulant Monitoring Flow Sheets do not document target INRs.
R1's Prothrombin Time (PT) and International normalized ratio (INR) results sheet dated [DATE] documents a target range PT of 9.1-10.7 and a target range INR of 2.0-3.0.
R1's first documented PT/INR in the medical record is dated [DATE] with PT results of 16.4 and INR results of 1.7 (Both out of range).
R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 14.3 and INR results of 1.5 (Both out of range).
R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 15 and INR results of 1.5 (Both out of range).
R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 19.4 and INR results of 2.0 (PT results out of range).
R1's [DATE] physician orders document to administer Warfarin 2mg from [DATE]-[DATE] and to administer Warfarin 3mg from [DATE]-[DATE].
R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 24.8 and INR results of 2.6 (PT results out of range).
R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 51.3 and INR results of 5.4 (Both out of range).
R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 35.8 and INR results of 3.7 (Both out of range).
R1's [DATE] physician orders document Warfarin 3mg to administer from [DATE]-[DATE], [DATE]-[DATE] and from [DATE]-[DATE].
R1's next documented PT/INR in the medical record is dated [DATE] with PT results of 116 and an INR greater than 10 (Both critically out of range high results).
R1's physician orders dated [DATE] document to hold the Warfarin for three days, obtain two PT and INRs, the first on [DATE] and the second on [DATE] and to restart Warfarin at 2.5mg on [DATE].
R1's June and [DATE] medication administration records document that the facility continued to administer 3mg of Warfarin from [DATE] until discharge on [DATE] (24 days) and that a PT/INR was not completed until [DATE], rather than as ordered on [DATE] and [DATE].
After the critical PT/INR value on [DATE] and the recheck on [DATE]; the facility, the physician, nor the pharmacy requested another PT/INR until [DATE] when the results are documented as a PT of 120 and an INR of greater than 10 (critically high results). At this time R1 was sent to the local hospital.
R1's local hospital notes dated [DATE] document that R1 was sent to the local hospital with Warfarin toxicity and was admitted with lethal bleeding requiring frozen fresh plasma to reverse his INR and then R1 was sent to a tertiary care center for critical care.
R1's tertiary care center notes dated [DATE] document a left hemothorax, right lung with alveolar hemorrhage, increased size of the ascending aortic aneurysm, and a subcutaneous right gluteal hematoma measuring 7.8 centimeters (cm) x 5.7cm x 7.9cm.
R1's death certificate dated [DATE] documents R1's cause of death as cardiopulmonary arrest with acute respiratory failure and a left hemothorax.
On [DATE] at 10:30AM, V2 Director of Nursing (DON) said that the facility was not administering the Warfarin as ordered and not monitoring R1's labs as they should have done.
On [DATE] at 9:10AM, V13 Medical Director said that the facility should have followed the correct Warfarin order and that R1 was at risk for increased bleeding and that R1 clearly died from the hemothorax.
On [DATE] at 10:30AM, V12 Consultant Pharmacist said that she was unaware that R1 had out of target range or critical Prothrombin (PT) and International normalized ratio (INR) times.
On [DATE] at 1:15PM, V3 Pharmacist stated that collaboration with the pharmacy when PT/INRs are inconsistent is the standard of care and that given R1's inconsistent results, closer laboratory monitoring should have been done. Failure to do so could result in increased bleeding and possibly death.
The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy:
1.
All licensed and direct care staff was educated on Administration Procedures for All Medications including but not limited to: medications are administered in accordance with physician order, and physician notification including monitoring and adverse reactions by the Director of Nursing (DON) and the Administrator on [DATE]. Licensed staff and Direct Care Staff who are on leave or vacation and all agency staff will be inserviced prior to returning to the facility by the Director of Nursing/Designee or the Administrator.
2.
All licensed and direct care staff was educated on referencing and following drug manufacturing guidelines for monitoring of drug side effects, labs, and possible adverse reactions by the Director of Nursing and the Administrator on [DATE]. Licensed staff and Direct Care Staff who are on leave or vacation and all agency staff will be inserviced prior to returning to the facility by the Director of Nursing/Designee or the Administrator.
3.
All licensed staff was educated on utilizing the Coumadin Tracking Log to ensure medication dosage, order, and follow-up PT/INR are reviewed and to ensure physician's orders are carried out by the Director of Nursing and the Administrator on [DATE]. Licensed staff who are on leave or vacation and all agency staff will be inserviced prior to returning to the facility by the Director of Nursing/Designee or the Administrator.
4.
All licensed and direct care staff was educated on anticoagulant administration, effects, precautions, and monitoring by the Director of Nursing and the Administrator on [DATE]. Licensed staff and Direct Care Staff who are on leave or vacation and all agency staff will be inserviced prior to returning to the facility by the Director of Nursing/Designee or the Administrator.
5.
All licensed staff was educated on the facility process to monitor/review/follow-up/coordinate and administer safe use of anticoagulant medications by the Director of Nursing and the Administrator on [DATE]. Licensed staff who are on leave or vacation and all agency staff will be inserviced prior to returning to the facility by the Director of Nursing/Designee or the Administrator.
6.
An impromptu QAPI (Quality Assurance Performance Improvement) meeting was held with the medical director and staff IDT (Interdisciplinary Team) to discuss deficiency and facility action plan.
7.
The facility will audit the Coumadin Tracking Log and review resident charts to ensure anticoagulant medication orders were followed, monitoring for anticoagulant side effects, the physician was notified of changes in condition(s) of residents, and that abnormal lab results were reported to the physician within a timely manner. A QA (Quality Assurance) tool -will be completed to verify this practice has occurred. The QA tool will be completed by the DON or designee, daily for 6 weeks. There will be oversight of the QA tool by the RNC (Registered Nurse Certified).
8.
The facility will audit all residents currently receiving an anticoagulant to ensure physician orders are being followed, and monitoring is in place including monitoring side effects, labs, and adverse reactions. A QA tool will be completed to verify this practice has occurred. The QA tool will be completed by the DON or designee, daily for 6 weeks. There will be oversight of the QA tool by the RNC.
9.
Nursing Management will audit all newly admitted and readmitted residents within 24 hours of admission to ensure residents receiving anticoagulant medication are being monitored for side effects and adverse reactions, laboratory orders are in place, and the physician is notified of any change in condition. A QA tool -will be completed to verify this practice has occurred. The QA tool will be completed by the DON or designee, daily for 6 weeks. There will be oversight of the QA tool by the RNC.
The facility presented an abatement plan to remove the immediacy on [DATE]. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility on [DATE] for revisions. The facility presented a revised abatement plan on [DATE] and the survey team accepted the abatement plan on [DATE].
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
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to utilize data to put a quality improvement program in place that woul...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to utilize data to put a quality improvement program in place that would identify, intervene, and improve resident outcomes to address significant medication errors after learning of a significant medication error that resulted in resident harm. This failure has the potential to all 51 residents who reside in the facility.
Findings include:
The facility provided census dated [DATE] documents 51 residents reside in the facility.
The facility Quality Assurance Performance Improvement Program Policy dated [DATE] documents that quality of care will be monitored and evaluated in areas of resident care and services at each quality meeting including but not limited to adverse resident events and medication errors.
R1's census report dated [DATE] documents admission to the facility.
R1's [DATE] physician order sheet documents Plavix (anticoagulant) 75 milligrams (mg) to be given daily.
R1's [DATE] medication administration record documents that R1 was started on Warfarin (anticoagulant) 4mg on [DATE].
On [DATE], R1's laboratory results documents a PT of 116 and an INR of greater than 10 (critical levels) with physician orders to repeat the PT and INR on [DATE] and again on [DATE] and to begin Warfarin 2.5mg on [DATE].
R1's June and [DATE] medication administration records document that the facility continued to administer 3mg of Warfarin from [DATE] until discharge on [DATE] (24 days) and a PT/INR was not completed until [DATE], rather than as ordered on [DATE] and [DATE]. Subsequently, the facility, nor a physician, nor the pharmacy requested another PT/INR until [DATE] when the results documented as a PT of 120 and an INR of greater than 10 (critical levels).
R1's local hospital notes dated [DATE] document that R1 was transferred to the local hospital at approximately 10:00PM for hypoxia and Warfarin toxicity with dried blood in and around the mouth. Upon admission to the local hospital, R1 was determined to be bleeding internally and was given fresh frozen plasma to reverse the anticoagulant effect. R1 was then sent to a tertiary care center for critical care where he died as a result of Warfarin toxicity, causing a left hemothorax.
The facility provided quality committee minutes dated [DATE] document attendees including: V1 Administrator, V2 Director of Nursing, V12 Pharmacy Consultant and V13 Medical Director. The [DATE] quality minutes do not reflect any discussion of medication errors.
On [DATE] at 9:10AM, V13 Medical Director said that he was not made aware of the Warfarin errors at the quality meeting in September and that [DATE] was the first time he had been apprised of the whole picture of what happened with R1.
On [DATE] at 11:14AM, V12 Consulting Pharmacist said that she did not know about R1's medication error or concerns with the management of R1's anticoagulant therapy until just now.
On [DATE] at 9:05AM, V1 stated, We had a quality meeting on [DATE] and our pharmacy (representative) attended but we didn't discuss Coumadin (Warfarin) or medication errors. In the future, I would expect that this will be a part of the quality process and discussed weekly.
Jul 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers as scheduled for one (R10) of seven residents review...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers as scheduled for one (R10) of seven residents reviewed for Activities of Daily Living in the sample list of 17.
Findings:
On 7/9/24 from 10:35 AM-10:50 AM, R10 stated residents are suppose to get showers/bed baths twice per week, but sometimes that doesn't happen. R10 stated the staff get too busy and forget, usually because they don't have enough staff. R10 stated R10's showers are scheduled for Mondays and Thursdays, and R10 did not get a shower yesterday (Monday).
R10's Minimum Data Set, dated [DATE] documents R10 is cognitively intact and is dependent on staff for bathing/showers.
The undated East Evening Showers list documents R10's showers are scheduled on Monday and Thursday evenings. R10's Shower Day Skin Inspections for June and July 2024 were requested. R10's shower documentation, provided by V2 Director of Nursing, documents showers on 6/6/24, 6/10/24, 6/13/24, 6/20/24 (refused), and 6/27/24. There are no documented showers for July 2024 and no other documented showers for June 2024.
On 7/9/24 at 1:20 PM, V2 Director of Nursing stated V2 could not find documentation that R10 received showers in July 2024. V2 confirmed there are no documented showers for R10 from 6/14-6/19/24 and 6/21/24-6/26/24. V2 stated when a resident refuses a shower staff should offer a shower the next day, but V2 could not find documentation that R10 was offered a shower after 6/20/24 until 6/27/24.
The facility's Bathing-Shower and Tub Bath policy dated 1/31/18 documents showers/bathing will be offered twice weekly or according to resident's preferred frequency, and will be documented in the resident's electronic record.
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to respond to call lights timely for five (R6, R7, R10, R9, R12) of 12 residents reviewed for call lights in the sample list of 17.
Findings in...
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Based on interview and record review the facility failed to respond to call lights timely for five (R6, R7, R10, R9, R12) of 12 residents reviewed for call lights in the sample list of 17.
Findings include:
The facility's Resident Council Meetings dated 4/29/24, 5/28/24, and 6/24/24 document concerns of call light wait times on all shifts, including wait times of almost an hour on second shift.
On 7/9/24 at 10:00 AM, R6 stated sometimes R6 waits awhile for R6's call light to be answered.
On 7/9/24 at 10:25 AM, R7 stated R7 waits awhile for call lights to be answered due to the facility being short of staff.
On 7/9/24 between 10:35 AM and 10:50 AM, R10 stated it takes a long time for staff to answer R10's call light, because staff are too busy, and this happens on any day and shift.
On 7/9/24 at 10:44 AM, R9 stated R9 waits awhile with R9's call light on before staff provide help.
On 7/9/24 at 12:58 PM, R12 stated R12 is the Resident Council President and long call light wait times is frequently mentioned in the council meetings.
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 F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview and Record Review the facility failed to serve meals at an appropriate or palatable temperature....
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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 serve meals at an appropriate or palatable temperature. This failure effects nine (R6, R7, R9, R10, R13, R14, R15, R16, and R17) of 17 residents reviewed for food on the sample list of 12.
Findings include:
The Policy titled In-Room Dining dated 2020 states Meals served in rooms may be periodically checked at the point of service for Palatable food temperatures. Food temperatures of hot foods on room trays the point of service are preferred to be at 120 degrees Fahrenheit or greater to promote palatability for the resident. If there is concern about the temperature or palatability of a meal, a new meal should be ordered from dining services.
On 7/9/24 at 1:55 PM, there was a sign with posted meal times on dining room door that documented Breakfast at 7:00 AM, Lunch at 11:45 AM, and Dinner at 5:00 PM.
On 7/9/24 at 12:00 PM, V17 Dietary Aide pushed a cart of uncovered meal trays to the assisted dining room and distributed the trays to half of the residents. V12 and V20 Certified Nurse's Assistants (CNAs) were in the room with 14 residents. The meal trays sat uncovered in front of residents and there was no staff assisting these residents to eat. On 7/9/24 at 12:04 PM, a second cart of uncovered meal trays was delivered to the assisted dining room. Dietary staff passed the trays and residents R13-R17 sat in the dining with uncovered meals and no staff assistance.
On 7/9/24 at 12:06 PM, there were two Certified Nursing Assistants (V20,V12 ) in the assisted dining room. Residents R13-R17 sitting with food in front of them uncovered and no staff assisting. V17 did unwrap silverware and instructed R15 to start eating. R15 took a drink of water. R17 told V17 that her and R16 can't feed themselves. At 12:09 PM, V11(Certified Nursing Assistant) entered dining room and started feeding R16 and R17.
On 7/9/24 at 11:47 AM, V17 (Dietary aide) stated we serve room trays then assisted dinning room then dinning room. V17 stated she can take food carts to hallway and they may sit for 20 min waiting for a CNA to pass them. V17 stated on 7/8/24 we didn't start serving breakfast until late because staff didn't have residents in the dining room. V17 stated we often have to wait to serve assisted dining room because we wait on CNAs. V17 stated I don't think there is enough CNAs to cover all the people who need help.
On 7/9/24 at 12:06 PM, V20 (Certified Nursing Assistant) stated normally we pass the room trays and hurry back to assisted dining room to feed residents. V20 stated we try and run and pass trays, then assist with feeding, however depends on staffing how long that takes. Some of the CNAs stay on the floor to answer lights. V20 stated CNAs also have to go pick trays up after residents are finished with meal.
On 7/9/24 at 10:00 AM, R6 stated sometimes he receives cold food; it depends on how fast they move the cart down the hall. On 7/9/24 at 1:10 PM electronic record review shows R6's MDS dated [DATE] documents R6 is cognitively intact.
On 7/9/24 at 10:25 AM, R7 stated sometimes she gets cold food at mealtimes. R7 states residents complain at Resident Council meetings, but she feels nothing ever gets done. On 7/9/24 at 1:20 PM, electronic record review of MDS dated [DATE] documents R7 is cognitively intact.
On 7/9/24 at 10:44 AM, R9 stated that sometimes he waits awhile with call light on before staff come help. R9 stated that the food is often cold when served at mealtimes and sometimes residents wait over an hour once getting to dining room to be served. R9's MDS dated [DATE] was reviewed and was still in progress. R9 was alert and oriented and answered questions appropriately during interview
On 7/9/24 between 10:35 AM and 10:50 AM, R10 stated the facility doesn't serve the meals on time, the meals are usually late. R10 stated it is all meals, they just don't have enough staff. R10's Minimum Data Set, dated [DATE] documents R10 is cognitively intact.
On 7/9/24 at 1:30 PM, V22 (Dietary Manager) stated that kitchen staff start plating room trays for breakfast at 7:00 AM, Lunch at 11:45 AM and Supper at 5:00 PM. V22 stated we don't have set meal times to eat because each day is different. V22 stated there could be times that food sits if staff are not ready to serve yet, however I try and communicate with them if they are running behind. When asked about plates going to dining room uncovered, V22 stated I was always taught they didn't need covered. V22 stated that if the food is left uncovered and not served right away then the resident's food would be cold. V22 stated that there has been multiple cold food complaints in the past.
Mar 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain informed consent for surgical debridement of wounds from a re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain informed consent for surgical debridement of wounds from a resident's representative for one of three residents (R1) reviewed for wounds on the sample list of five.
Findings include:
R1's Order Summary Report dated 3/18/24 documents diagnoses including Age-Related Cognitive Decline, Atherosclerotic Heart Disease, Unspecified Osteoarthritis, Presence of Automatic (Implantable) Cardiac Defibrillator, Polyneuropathy, Difficulty in Walking, Heart Failure, Chronic Kidney Disease Stage 3, Chronic Atrial Fibrillation, Flaccid Neuropathic Bladder, Benign Prostatic Hyperplasia, Repeated Falls and Weakness. This Order Summary documents R1 was admitted to the facility on [DATE].
R1's admission Minimum Data Set, dated [DATE] documents R1 was moderately cognitively impaired.
R1's Wound Physician Initial Wound Evaluation and Management Summary dated 1/19/24 documents wounds on R1's right buttock and sacrum. This Wound Evaluation documents R1 received Surgical Excisional Debridement Procedure to remove necrotic tissue and establish the margins of viable tissue of site number two a Stage 3 Pressure Wound on the Right Buttock. There is no documentation that R1's Representative was notified or gave consent for this bedside surgical procedure.
R1's Wound Physician Wound Evaluation and Management Summary dated 1/31/24 documents two separate wounds, one Stage 3 pressure wound on the Sacrum and one Stage 3 pressure wound of the Right Buttock. This Wound Evaluation documents R1 received Surgical Excisional Debridement Procedure to site 1 the Stage 3 pressure wound to the Sacrum. There is no documentation that R1's Representative was notified or gave consent for this bedside surgical procedure.
R1's Wound Physician Wound Evaluation and Management Summary dated 2/7/24 documents two separate wounds, one Stage 3 pressure wound of the Inferior Sacrum and one Unstageable Deep Tissue Injury to the Sacrum. This Wound Evaluation documents R1 received Surgical Excisional Debridement Procedure to site 1 the Stage 3 pressure wound of the Inferior Sacrum. There is no documentation that R1's Representative was notified or gave consent for this bedside surgical procedure.
R1's Wound Physician Wound Evaluation and Management Summary dated 2/14/24 documents one Stage 3 pressure wound of the Inferior Sacrum, an Unstageable wound of the Right Heel and an Unstageable Deep Tissue Injury to the Left, Medial Heel. This Wound Evaluation documents R1 received Surgical Excisional Debridement Procedure to site 1 the Stage 3 pressure wound of the Inferior Sacrum. There is no documentation that R1's Representative was notified or gave consent for this bedside surgical procedure.
R1's Wound Physician Wound Evaluation and Management Summary dated 3/1/24 documents one Stage 4 pressure wound of the Inferior Sacrum, one Stage 3 pressure wound of the Left Medial Heel and an Unstageable wound of the Right Heel. This Wound Evaluation documents R1 received Surgical Excisional Debridement Procedure to site 1 the Stage 4 pressure wound of the Inferior Sacrum and to the Stage 3 pressure wound of the Left Medial Heel. There is no documentation that R1's Representative was notified or gave consent for this bedside surgical procedure.
On 3/19/24 at 11:47 AM, V2 Director of Nursing confirmed that there is no documentation in R1's medical record of R1's Representative being notified of the wounds or any documentation of consent being given for the surgical debridement of the pressure wounds.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the resident's representative of wounds for one of three resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the resident's representative of wounds for one of three residents (R1) reviewed for wounds in the sample list of five.
Findings include:
The facility's Pressure Injury and Skin Condition Assessment policy with a Revised date of 1/17/18 documents, At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified.
R1's Order Summary Report dated 3/18/24 documents diagnoses including Age-Related Cognitive Decline, Atherosclerotic Heart Disease, Unspecified Osteoarthritis, Presence of Automatic (Implantable) Cardiac Defibrillator, Polyneuropathy, Difficulty in Walking, Heart Failure, Chronic Kidney Disease Stage 3, Chronic Atrial Fibrillation, Flaccid Neuropathic Bladder, Benign Prostatic Hyperplasia, Repeated Falls and Weakness. This Order Summary documents R1 was admitted to the facility on [DATE].
R1's Admission/re-admission Observation GG dated 1/12/23 at 3:25 PM by V3 Licensed Practical Nurse documents under the section Skin Integrity that R1 has a Stage 2 wound on the buttocks.
R1's Wound Physician Initial Wound Evaluation and Management Summary dated 1/19/24 documents wounds on R1's right buttock and sacrum. This Summary documents Site 1 as a Stage 2 pressure wound on Sacrum measuring 1.2 cm (centimeters) x (by) 2 cm x 0.01 cm and as an open area/open ulceration. This Summary documents Site 2 as a Stage 3 pressure wound of the right buttock measuring 4 cm x 1 cm x 0.1 cm as an open ulceration.
There is no documentation that R1's Power of Attorney (POA) was notified of the new pressure area.
On 3/18/24 at 10:58 AM, V8 R1's POA confirmed that V8 was not notified of any pressure areas that R1 had.
On 3/19/24 at 11:47 AM, V2 Director of Nursing confirmed that there is no documentation of notification of R1's POA of the pressure areas.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete an initial wound assessment on admission and obtain treatme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete an initial wound assessment on admission and obtain treatment orders, failed to complete wound treatments as ordered and failed to complete pressure ulcer interventions as ordered and as stated in the facility policy for one of three residents (R1) reviewed for pressure ulcers in the sample list of five.
Findings include:
The facility's Pressure Ulcer Prevention policy with a Revision date of 1/15/18 documents, Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. (etcetera) may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds.
The facility's Pressure Injury and Skin Condition Assessment policy with a Revision date of 1/17/18 documents, A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. A wound assessment for each identified open area will be completed and will include: a. Site location b. Size (length x {by} width x depth) c. Stage of Pressure ulcer d. Odor e. Drainage f. Description g. Date and initials of the individual performing the assessment. Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. Other nursing measures not involving medication shall be documented in the weekly wound assessment or nurses note.
R1's Order Summary Report dated 3/18/24 documents diagnoses including Age-Related Cognitive Decline, Atherosclerotic Heart Disease, Unspecified Osteoarthritis, Presence of Automatic (Implantable) Cardiac Defibrillator, Polyneuropathy, Difficulty in Walking, Heart Failure, Chronic Kidney Disease Stage 3, Chronic Atrial Fibrillation, Flaccid Neuropathic Bladder, Benign Prostatic Hyperplasia, Repeated Falls and Weakness. This Order Summary documents R1 was admitted to the facility on [DATE].
R1's hospital referral information dated 1/4/24 documents R1 had a Stage 2 pressure ulcer on the coccyx.
R1's Admission/re-admission Observation GG dated 1/12/23 at 3:25 PM by V3 Licensed Practical Nurse documents under the section Skin Integrity that R1 has a Stage 2 wound on the buttocks. There is no assessment of the wound documented. There is no size or description of the wound documented.
R1's Nursing Progress Notes dated 1/12/24 at 11:09 PM by V6 Registered Nurse documents R1's evening vital signs were already completed and at 11:10 PM the note documents the admission charting was also completed on this evening shift for R1. There is no documentation regarding a wound or any skin issues in the Nurse's Progress notes.
R1's Treatment Administration Record dated 1/1/24 through 1/31/24 does not document a treatment for the pressure ulcer on the sacrum/buttocks until 1/14/24, two days after admission.
On 3/19/24 at 8:45 AM, V1 Administrator confirmed there is no initial assessment of R1's wound on admission. V1 confirmed the Wound Summary dated 1/18/24 is the first assessment of R1's wounds and confirmed R1 was admitted on [DATE] with a Stage 2 on the buttocks.
On 3/19/24 at 9:20 AM, V3 Licensed Practical Nurse confirmed that V3 saw R1 upon admission on [DATE] and confirmed that R1 had a pressure wound on the buttocks area.
R1's Wound Physician Initial Wound Evaluation and Management Summary dated 1/19/24 documents wounds on R1's right buttock and sacrum. This Summary documents Site 1 as a Stage 2 pressure wound on Sacrum measuring 1.2 cm (centimeters) x (by) 2 cm x 0.01 cm and as an open area/open ulceration and a treatment of alginate calcium once daily, a non bordered foam (cut to size) dressing over the top secured with retention tape and reposition R1 per facility protocol. This Summary documents Site 2 as a Stage 3 pressure wound of the right buttock measuring 4 cm x 1 cm x 0.1 cm as an open ulceration with a treatment of alginate calcium once daily, a non bordered foam (cut to size) dressing over the top and secured with retention tape and also reposition R1 per facility policy.
R1's Treatment Administration Record (TAR) dated 1/1/24 through 1/31/24 documents one order for the sacrum/right buttocks with a start date of 1/22/24 to cleanse with wound cleanser, pat dry, apply calcium alginate cut to size, cover with bordered foam cut to size and secure with retention tape every day shift. This TAR does not document separate orders as ordered by V7 Wound Physician for site 1 sacrum and site 2 right buttock.
R1's Wound Physician Wound Evaluation and Management Summary dated 1/31/24 documents two separate areas and two separate orders for site 1 a Stage 3 pressure wound to the Sacrum measuring 2.5 cm x 3 cm x 0.1 cm with orders for treatment of calcium alginate with a non bordered foam dressing and a transparent film dressing over the top once a day. This Summary documents a site 2 of a Stage 3 pressure wound of the Right Buttock measuring 3 cm x 0.6 cm x 0.1 cm with orders for a treatment of calcium alginate with a non bordered foam dressing and a transparent film dressing over the top once a day.
R1's TAR dated 2/1/24 through 2/29/24 documents one treatment for the sacrum/right buttock to cleanse with wound cleanser, pat dry, apply calcium alginate cut to size and cover with a non bordered foam dressing and a transparent film dressing every day shift. There were not two separate areas being treated with two separate orders.
R1's TAR dated 2/1/24 through 2/29/24 documents that the treatments to the sacrum/right buttock was not signed off as completed on 2/1/24 and 2/8/24. This TAR documents an order for pressure relieving boots on R1 while R1 is in bed with a start date of 2/2/24 and this order was not signed off as completed on 2/5/24 evening shift, 2/14/24 day and evening shift, 2/21/24 night shift and 2/22/24 on the evening shift.
On 3/19/24 at 11:47 AM, V2 Director of Nursing stated that nurses are expected to sign the TAR when the treatments are completed. V2 confirmed that the two separate areas are combined into one area on the TAR and V2 is not sure why it is that way. V2 stated that they should have placed an alternating air mattress on R1's bed sooner.
On 3/19/24 at 1:18 PM, V2 stated that upon admission for R1 they had a pressure reducing mattress, a cushion in a reclining wheel chair and R1 was being turned and repositioned every two hours to try to prevent any new pressure areas.
On 3/19/24 at 1:46 PM, V7 Wound Physician stated that R1's pressure areas were not avoidable. V7 stated that R1 should have been placed on hospice after admission due to all of the comorbidities R1 had.
Feb 2024
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide a written, Notice of Medicare Non-Coverage notice, (NOMNC) for three (R51, R257, R258) of three residents reviewed for Medicare Non-...
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Based on interview and record review the facility failed to provide a written, Notice of Medicare Non-Coverage notice, (NOMNC) for three (R51, R257, R258) of three residents reviewed for Medicare Non-Coverage notices from a total sample list of 37 residents.
Findings include:
The facility Skilled Nursing Facility Notices for Medicare/Medicare Advantage/Medicaid MCO Admissions-NOMNC policy dated 7/28/23 documents that the designated staff shall ensure that the required procedures are followed to remain compliant with the rules and regulations of distribution, follow-up and completion of the required skilled nursing facility notices as advised by Medicare/Medicare Advantage/MMAI plans. The facility social services designee will contact the patient/representative and review the Medicare (Part A) / Medicare advantage/MMAI letters no later than 48 hours before the last Medicare covered day with them. Additionally, the deadline to request a review, as well as what to do if the deadline is missed, and the telephone number of the (Quality Improvement Organization) QIO to request the appeal.
On 2/6/24 at 11:00AM, V1 Administrator stated that R51, R257 and R258 were admitted to the facility on Medicare Part A stays and discharged from the facility to the community, with Medicare days remaining.
During this survey, the facility was unable to provide documentation of NOMNC notices given to R51, R257 or R258.
On 2/6/24 at 12:00PM, V1 Administrator stated that the facility had only been providing NOMNCs or Advanced Beneficiary Notifications (ABN) to residents on Medicare Advantage Plans. We will start using the pathway so that the residents who should get them do get them. Next year this will all be correct.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 Minimum Data Sets (MDS) were accurate to includ...
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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 Minimum Data Sets (MDS) were accurate to include oxygen use for two (R20, R38) of five residents reviewed for respiratory care in the sample list of 37.
Findings include:
1.) On 2/4/24 at 9:12 AM and 11:55 AM R20 was lying in bed wearing oxygen at 3 liters per minute (l/min) per nasal cannula.
R20's Physician Order dated 9/1/23 documents to administer oxygen at 2 l/min continuously per nasal cannula. R20's January and February 2024 Medication/Treatment Administration Records (MARs/TARs) document daily use of oxygen and weekly changing of oxygen tubing and humidification bottles. R20's MDS dated [DATE] documents R20 does not use oxygen.
2.) On 2/04/24 at 8:59 AM R38 was wearing oxygen at 3 l/min per nasal cannula.
R38's Physician Order dated 11/24/23 documents to administer oxygen at 3 l/min continuously. R38's December 2023 MAR documents daily use of oxygen and weekly changing of oxygen tubing and humidification bottles. R38's MDS dated [DATE] documents R38 does not use oxygen.
On 2/05/24 at 2:14 PM V3 MDS Coordinator stated V3 observes the residents and reviews orders when coding oxygen use on the MDS. V3 verified R20's and R38's oxygen orders and confirmed R20's and R38's MDSs are not coded accurately to reflect oxygen use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have quarterly care plan meetings for two (R20, R42) of two resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have quarterly care plan meetings for two (R20, R42) of two residents reviewed for care plan meetings in the sample list of 37.
Findings include:
1.) On 2/04/24 at 11:52 AM R20 stated the facility doesn't have any meetings with R20 about R20's care. R20's Minimum Data Set (MDS) dated [DATE] documents R20 is cognitively intact and admitted on [DATE]. There are no documented care plan meetings in R20's medical record.
2.) On 2/04/24 at 8:50 AM R42 stated the facility doesn't have care plan meetings with R42. R42's MDS dated [DATE] documents R42 is cognitively intact and admitted on [DATE]. There are no documented care plan meetings in R42's medical record.
On 2/06/24 at 9:41 AM V16 Social Services Director (SSD) stated V16 is responsible for scheduling care plan meetings and residents and their families are invited to attend the meetings. V16 stated care plans are documented in a plan of care note in the resident's record. V16 was unsure the frequency of care plan meetings and would have to refer to the facility's policy. V16 stated V16 has been the SSD for a month and is trying to get caught up on care plan meetings. At 9:50 AM V16 stated V16 was unable to locate documentation of care plan meetings for R20 and R42.
The facility's Comprehensive Care Plan policy revised 11/17/17 documents the care plan directs the care team and includes resident goals, preferences, and services to attain/maintain the resident's highest practicable physical, mental, and psychosocial well-being. This policy documents care plans are developed seven days after the comprehensive assessment is completed, and should be prepared by the interdisciplinary team (IDT) which includes the resident and/or resident representative. This policy documents to invite the resident and/or resident representative to review the care plan with the IDT at least quarterly and within five days of admission, and document in the resident's medical record if their participation is determined not practicable.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide grooming per resident preference for one (R42)...
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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 grooming per resident preference for one (R42) of one resident reviewed for activities of daily living in the sample list of 37.
Findings include:
On 2/04/24 at 12:02 PM R42's hair was long down to R42's shoulders and R42's beard was long down to R42's chest. R42 stated R42 does not like to have long hair/facial hair, and prefers to keep it short/trimmed. R42 stated R42 has asked to have R42's hair cut/trimmed, but the facility doesn't have anyone here to cut R42's hair.
R42's Minimum Data Set, dated [DATE] documents R42 is cognitively intact. R42's care plan dated 11/1/23 documents R42 requires substantial assistance of one staff person with personal hygiene.
On 2/06/24 at 9:31 AM V15 Certified Nursing Assistant stated residents should be shaved twice weekly during showers and R42 is currently getting a shower. V15 stated we have straight razors available in the shower room to use. V15 was not sure if R42 has an electric razor and stated we can get one for R42.
On 2/04/24 at 12:39 PM V2 Director of Nursing stated the facility has not had anyone to consistently give resident hair cuts. V2 stated we are in the process of getting one of our nurses to cut hair, but she has to go through the licensing process. V2 stated some of the residents' families have been giving hair cuts, but R42 doesn't have family that visits often. On 2/06/24 at 9:36 AM V2 stated R42's hair and beard will be cut/trimmed today.
The facility's undated Shaving Male & Female Residents policy documents the purpose of the policy is to provide cleanliness, comfort, and improve morale. This policy documents male residents will be assessed daily for shaving needs and assisted as needs indicate.
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 interview and record review the facility failed to follow physician's orders for insulin and notify the physician that insulin was held for one (R38) of five residents reviewed for unnecessar...
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Based on interview and record review the facility failed to follow physician's orders for insulin and notify the physician that insulin was held for one (R38) of five residents reviewed for unnecessary medications in the sample list of 37.
Findings include:
On 2/04/24 at 9:02 AM R38 stated the other day my blood sugar was 100 so the nurse did not administer R38's insulin. R38 stated last night R38's blood sugar was 168, the nurse was worried that R38's blood sugar would bottom out and so R38's insulin was not given.
R38's Care Plan dated 10/12/23 documents R38 has Diabetes Mellitus, receives insulin, and includes interventions for medication as ordered and to monitor/report any symptoms/signs of hypoglycemia (low blood sugar).
R38's Physician Order dated 12/8/23 documents to give Novolog (short acting insulin) 30 units subcutaneously before meals. There are no ordered parameters to hold R38's insulin based on blood sugar results. R38's February 2024 Medication Administration Record (MAR) documents an entry to refer to the nursing notes on 2/2/24 at 5:00 PM, and R38's blood sugar was 168 on 2/3/24 at 5:00 PM and insulin was held. R38's Nursing Note dated 2/2/24 at 5:44 PM documents R38's blood sugar was 100 prior to dinner and 167 after dinner. There is no documentation that R38's physician was notified and consulted about R38's blood sugars and insulin administration on 2/2/24 and 2/3/24.
On 2/4/24 at 3:45 PM V10 Registered Nurse stated last evening V10 checked R38's blood sugar and held R38's insulin since R38 only ate ice cream. V10 stated R38 gets 30 units of insulin and V10 did not want R38's blood sugar to drop. V10 stated V10 rechecked R38's blood sugar after supper which was 211 and R38's insulin was not given. V10 stated R38's blood sugars have been running lower the last few days and R38's blood sugar is usually in the 300s. V10 stated V10 told the oncoming shift nurse that V10 held R38's insulin, but V10 did not notify the physician or nurse practitioner.
On 2/05/24 at 12:22 PM V2 Director of Nursing stated V2 encourages the nurses to have ordered parameters to hold insulin and the nurse should notify the physician if they withhold insulin without ordered parameters. V2 confirmed R38 does not have physician ordered parameters to hold scheduled insulin.
The facility's undated Medication Administration and Record policy documents to compare the prescription label to the MAR when administering medications and record on the MAR when medication is refused or withheld and the reason why.
The facility's Physician-Family Notification-Change in Condition policy revised 11/13/18 documents to notify the physician or nurse practitioner when there is a need to alter treatment significantly such as discontinuing a form of treatment due to adverse consequences or to start a new form of treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to provide wound care as ordered for one (R23) of two residents reviewed for wound care from a total sample list of 37 residents.
...
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Based on observation, interview and record review the facility failed to provide wound care as ordered for one (R23) of two residents reviewed for wound care from a total sample list of 37 residents.
Findings include:
The facility Pressure Skin Condition Assessment & Monitoring- Pressure and Non-Pressure policy dated 6/8/18 documents that dressings will be performed based on physician orders.
R23's physician order dated 2/5/23 documents that the treatment to the left and right buttocks will include packing the wounds with gauze soaked in antiseptic solution, covered with an abdominal dressing and a clear adhesive dressing over that and a skin protective wipe to the periwound twice daily.
On 2/5/24 at 11:45AM, V7 Licensed Practical Nurse (LPN) provided R23's wound care treatments. Both left and right coccyx wounds were packed with antiseptic soaked gauze and a clear adhesive dressing was placed over the packing. No abdominal pad was used to cover the wounds and no skin protective wipe was used on the periwound, as ordered.
On 2/6/24 at 2:25PM, V2 Director of Nursing stated, I would absolutely expect the wound care to be done as ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide restorative range of motion services for one (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide restorative range of motion services for one (R42) of one resident reviewed for restorative services in the sample list of 37.
Findings include:
On 2/04/24 at 8:47 AM R42 stated R42 had a stroke that affected R42's left side and R42 received therapy, but after that the exercises stopped. R42 stated the Certified Nursing Assistants (CNAs) are too busy to provide range of motion exercises. R42 was lying in bed and had impaired movement of his left leg and arm.
R42's Diagnoses dated 6/7/23 documents hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side. R42's Minimum Data Set (MDS) dated [DATE] documents R42 is cognitively intact, has one sided impaired range of motion to upper and lower extremity, and does not receive any range of motion restorative services. There is no documentation in R42's medical record that R42 receives range of motion services.
R42's Occupational Therapy Discharge summary dated [DATE]-[DATE] documents R42 received passive range of motion to left upper extremity and includes a discharge recommendation for staff to provide hygiene and range of motion to R42's left hand.
On 02/04/24 at 1:11 PM V3 MDS Coordinator stated V3 oversees restorative programs and these programs are documented in the tasks section of the resident's electronic medical record. V3 stated R42 should have a program for upper and lower extremity range of motion. V3 confirmed R42 does not have documented restorative programs for range of motion.
On 2/06/24 at 9:59 AM V5 Director of Rehab stated therapy communicates discharge planning with V3 to develop restorative programs. V5 stated the facility has three CNAs who provide restorative services, and that is something that was added recently. V5 confirmed range of motion exercises would be beneficial for residents with impairment related to a stroke, in order to maintain range of motion and prevent contractures.
The facility's Restorative Nursing Program revised 1/4/19 documents: Purpose: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Each resident will be screened for restorative nursing upon admission, annually, quarterly, and with any significant change in function. Appropriateness for a restorative program will be determined by the interdisciplinary team as needed and/or may be determined as a continuation of care following a course of physical, occupational, and/or speech therapy. Each resident involved in a restorative program will have an individualized program with individualized goals and measurable objectives documented on the plan of care. Documentation of the interventions and the resident's response will be completed with each implementation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
2.) On 2/5/24 at 11:05AM, V11 and V12 Certified Nursing Assistants (CNA) provided catheter care for R23. When V11 removed R23's brief it was soaked with urine and smelled of urine. R23's catheter was ...
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2.) On 2/5/24 at 11:05AM, V11 and V12 Certified Nursing Assistants (CNA) provided catheter care for R23. When V11 removed R23's brief it was soaked with urine and smelled of urine. R23's catheter was leaking around the tubing.
On 2/5/24 11:06AM, V12 wiped the front of the perineum, but did not wipe down the catheter tubing. V12 also did not wash hands or change gloves between dirty and clean cares.
On 2/5/24 at 11:10AM, V11 and V12 CNA's and V7 Licensed Practical Nurse said that R23's catheter had been leaking for months.
On 2/5/24 at 11:11AM, V12 CNA stated that she realized after the fact that she did not perform hand hygiene during catheter care.
On 2/5/24 at 2:00PM, V2 Director of Nursing (DON) stated, We don't have any documentation of intervening in this leaking catheter. We changed it monthly as ordered but it has been leaking for months and we didn't contact the doctor and ask to put a larger catheter in to see if that would help. I'm sure the leaking isn't helping with her wounds. We should have intervened sooner. I would expect them to wash their hand and or change gloves between care.
On 2/6/24 at 10:00AM, V2 DON stated, Last night we changed the catheter from a 16 gauge to an 18 gauge and to my knowledge, it isn't leaking now.
On 2/6/24 at 2:30PM, V7 LPN stated, When I did my treatment earlier, there was no leakage around the catheter and no smell of urine.
Based on observation, interview, and record review, the facility failed to properly secure urinary catheter tubing and drainage bags to ensure hygenic storage (R306, R256), intervene for a leaking urinary catheter, and provide hygenic catheter care (R23). R306, R256, and R23 are three of three residents reviewed for catheters in the sample list of 35.
Findings include:
1.) On 2/4/24 at 9:24am, R306 was seated in a recliner in R306's room sleeping. R306's urinary catheter tubing and collection bag were resting on the floor next to R306's recliner. V4 Certified Nursing Assistant (CNA) entered R306's room and asked R306 if R306 needed anything, and left the room, leaving the catheter bag and tubing on the floor.
On 2/5/24 at 9:26am, V4 Certified Nursing Assistant (CNA) acknowledge that R306's urinary catheter bag and tubing should not be on the floor, and should be secured inside a dignity bag.
On 2/5/24 at 9:40am, V1 Administrator stated, R306's catheter bag should be in a dignity bag, and the bag and tubing should not be laying on the floor. V1 said, staff should of secured it on R306's recliner, and had it placed in a dignity bag
On 2/6/24 at 9:49am, V3 Infection Preventionist stated no residents urinary catheter tubing and collection bag should be resting on the floor, it absolutely is an infection control issue having the bag and tubing resting on the floor.
3.) On 2/04/24 at 9:44 AM and 12:01 PM, and on 2/5/24 at 8:50 AM R256 was sitting in a recliner in R256's room. R256's urinary catheter was secured to R256's bed frame with the catheter tubing on the floor. The tubing contained dark yellow cloudy urine.
On 2/6/24 at 9:49am V3 Infection Preventionist stated no residents urinary catheter tubing and collection bag should be resting on the floor, it absolutely is an infection control issue having the bag and tubing resting on the floor.
The facility Urinary Catheter Care Policy dated 2/14/19 documents the following: Purpose: To establish guidelines to reduce the risk of or prevent infections in residents with an indwelling catheter. 2. Hand hygiene shall be performed before and after touching any part of the urinary catheter drainage system. 4. Ideally a sterile, closed drainage system shall be maintained at all times. 5. Indwelling catheters may be secured to prevent trauma and tension. 7. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor. May place drainage bag and excess tubing in a secondary vinyl bag or other similar device to prevent primary contact with floor or other surfaces. Urinary catheter and tubing may be removed and reinserted when any of the following are observed: d. Upon Physician's Orders. 16. Routine hygiene (e.g. (example) cleaning of the meatal surface during daily bathing or showering) is appropriate. Encrustations on the (brand name) catheter should be removed from the meatus outward with clean wash cloth, rinsed with clean water on an as needed basis.
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 ensure medications were labeled with resident's name and opened date for two (R29, R43) of two residents reviewed for medicati...
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Based on observation, interview, and record review the facility failed to ensure medications were labeled with resident's name and opened date for two (R29, R43) of two residents reviewed for medication storage in the sample list of 37.
Findings include:
On 2/05/24 at 10:02 AM, the 200 medication cart was reviewed with V7 Licensed Practical Nurse (LPN). There were two bottles of Dorzolamide Timolol Maleate 22.3 milligrams (mg)/6.8 mg per milliliter eye drops. These bottles were not in boxes and did not contain a pharmacy label with a resident name. V7 stated R29 is the only resident on this medication cart who has an order for this medication. V7 confirmed the bottles were not labeled with a resident's name and opened date. This cart contained R43's Budesonide Formoterol Fumarate 160-4.5 MCG/ACT (microgram per actuation) inhaler that contained a label with a dispensed date of 10/27/23. There was no opened date on the medication box or inhaler and this was confirmed with V7.
R29's Physician Order dated 1/9/24 documents Dorzolamide Hydrochloride Ophthalmic Solution give one drop to each eye twice daily.
R43's Physician Order dated 9/14/23 documents Budesonide-Formoterol Fumarate 160-4.5 MCG/ACT inhale two puffs twice daily.
On 2/05/24 at 11:10 AM V2 Director of Nursing confirmed resident medications should be labeled with resident's name and open dates for eye drops and inhalers. At 12:10 PM V2 provided the facility's pharmacy guidelines Medications with Beyond Use Dates, and confirmed Budesonide-Formoterol inhalers should be discarded 90 days after opening.
The pharmacy guidelines Medications with Beyond Use Dates updated December 2023 documents the medications listed must be used within a specific timeframe to avoid reduced stability, sterility, and efficacy and the beyond use date should be attached to the medication package and not discarded. These guidelines includes Budesonide/Formoterol in list of medications and documents to discard this medication three months after opening.
The facility's Medication Storage policy revised 7/2/19 documents the facility should record the opened date on the medication container for medications that have shortened expiration dates once opened and follow the manufacturer's guidelines for expiration dates for opened medications. This policy documents to store medications in the original containers in which they were received.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer pneumococcal vaccines for two (R36 and R38) of five resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer pneumococcal vaccines for two (R36 and R38) of five residents reviewed for vaccines in a sample list of 37 residents.
Findings include:
The facility Influenza and Pneumococcal Policy dated 4/21/22 documents that each resident or the resident's representative will be provided education regarding the benefits and potential side effects of the immunization. Each resident is offered a pneumococcal immunization per Centers for Disease Control (CDC) recommendations unless the immunization is medically contraindicated or the resident has already been immunized and a second pneumococcal vaccine will be offered only when necessary according to the CDC guidelines. The medical record will include documentation that indicates that the resident either received or did not receive the pneumococcal immunization due to medical contraindications or refusal.
1. The facility provided authorization and release for Pneumococcal Vaccine documents that on 11/10/23, R38's family member signed the consent for R38 to receive the pneumococcal vaccine, however on 2/6/24, R38 had not yet received the vaccination.
R38's immunization record did not document R38 receiving any pneumococcal vaccinations.
R38's undated census sheet documents admission to the facility on 8/4/23.
2. The facility provided authorization and release for Pneumococcal Vaccine documents that on 11/14/23, R36's family member provided verbal consent for R36 to receive the pneumococcal vaccine, however on 2/6/24, R36 had not yet received the vaccination.
R36's immunization record documents R36 receiving Prevnar 13 on 3/10/21 (prior to admission).
Based on CDC guidelines, R36 is due for a pneumoccal conjugate vaccine 20 or 23.
R36's undated census sheet documents admission to the facility on [DATE].
On 2/6/24, at 11:24AM, V2 Director of Nursing (DON) said that their (R36 and R38's vaccines) should have been given sooner. We've just been trying to get caught up.
On 2/6/24 at 2:20PM, V2 DON stated, Moving forward, we will look at the CDC guidelines and the application so that we can easily figure out what pneumonia vaccines are due and get them done in a timely manner.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to change and label oxygen tubing and humidifier bottles ...
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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 change and label oxygen tubing and humidifier bottles (R43, R45, R306), failed to properly maintain Continuous Positive Airway Pressure (CPAP) mask (R20) and failed to properly maintain and store nebulizer mask/tubing (R38). These failures affect five (R43, R45, R306, R20, R38) of five residents reviewed for respiratory care in the sample list of 37.
Findings include:
1). On 2/4/24/23 at 9:06 AM, R43 had oxygen on at 4 liters per minute (LPM) via a nasal cannula and an oxygen concentrator in R43's room. The oxygen tubing was not dated as to indicate when it was changed, and the humidification container was not dated as to when it was applied.
R43's Order Summary Report dated 2/6/24 documents diagnoses including Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Dependence on Supplemental Oxygen, and Chronic Atrial Fibrillation.
R43's Physician Order Sheet (POS) dated 9/14/23 documents Oxygen at 4 liters per minute per nasal cannula, every shift related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Change Oxygen/Nebulizer humidifier bottle/tubing weekly and as needed. Date/initial, every night shift every Sunday.
2.) On 2/4/24 at 9:24 AM, R306 had oxygen on at 4 liters per minute (LPM) via a nasal cannula and an oxygen concentrator in R306's room. The oxygen tubing was not dated as to indicate when it was changed, and the humidification container was not dated as to when it was applied.
R306's Order Summary Report dated 2/6/24 documents diagnoses including Dependence on Supplemental Oxygen, Chronic Respiratory Failure with Hypoxia, Acute and Chronic Respiratory Failure, Chronic Diastolic (Congestive) Heart Failure and Chronic Obstructive Pulmonary Disease.
R306s Physician Order Sheet (POS) dated 1/25/24 documents Oxygen at 4 liters per minute per nasal cannula and Change Oxygen bottle/tubing weekly and as needed. Date/initial, every night shift every Sunday.
On 2/5/24 at 9:40am V1 Administrator stated staff changes oxygen and humidifier bottles every Sunday night. V1 stated they should be dating and initialing the tubing and humidifier bottles to when they were changed. V1 said, V1 expects all nurses to be doing this. V1 said, V1 does not know why R43 and R306's tubing and humidifier bottles were not dated and initialed.
3.) On 2/04/24 at 9:12 AM and 11:55 AM, and on 2/5/24 at 8:48 AM R20's CPAP mask was uncovered and lying on top of R20's night stand. There was a cloudy substance on the mask. On 2/4/24 at 9:15 AM R20 stated R20 uses the CPAP every night and the staff does not clean the mask/tubing.
R20's Minimum Data Set, dated [DATE] documents R20 is cognitively intact. R20's Care Plan dated 10/6/23 documents CPAP use, but does not include interventions for care and cleaning.
R20's Physician Order dated 8/31/23 documents the use of a CPAP, but there are no orders for routine care/cleaning of this CPAP. R20's January and February 2024 Treatment Administration Records (TAR) do not document R20's CPAP use or routine care/cleaning.
On 2/05/24 at 9:06 AM V2 Director of Nursing (DON) stated the nurses should be cleaning the CPAP mask/tubing and this would be documented on the TAR. V2 stated the CPAP mask and tubing should be stored in a bag when not in use, and confirmed R20's CPAP mask/tubing was uncovered.
4.) On 2/04/24 at 8:59 AM R38's nebulizer mask and tubing was lying on top of R38's dresser, uncovered. The mask was dated 1/29/24. At 12:34 PM R38's nebulizer mask and tubing was uncovered on top of R38's dresser. R38 stated R38's last nebulizer treatment was given prior to lunch. On 2/05/24 at 12:05 PM R38's nebulizer mask and tubing was uncovered on top of R38's night stand.
R38's January and February 2024 TARs document R38 receives Pulmicort 0.5 milligrams per 2 milliliters nebulizer treatments every 12 hours at 10:00 AM and 10:00 PM since 11/24/23. These TARs do not document that R38's nebulizer mask and tubing are routinely changed or cleaned.
On 2/04/24 at 1:07 PM V14 Licensed Practical Nurse stated V14 administered R38's nebulizer treatment around 10:00 AM and R38 has another treatment scheduled on evening shift. V14 stated nebulizer mask cleaning is done by night shift who is also responsible for changing the mask and tubing weekly. V14 confirmed V14 did not clean R38's nebulizer mask after R38's treatment.
On 2/5/24 at 12:22 PM V2 DON stated the nurses should be cleaning the nebulizer mask after each treatment/use and the mask/tubing should be stored in a bag once it is clean/dry. At 2:04 PM V2 stated the nurses should be changing the nebulizer mask/tubing and oxygen tubing weekly, and this should be documented on the TAR.
5.) On 2/04/24 at 8:33 AM R45 was lying in bed wearing oxygen at 2 liters per minute (l/min) per nasal cannula. There was no date on the humidification bottle or oxygen tubing.
R45's Physician Order dated 1/5/24 documents Oxygen continuously at 2 l/min per nasal cannula. R45's Physician Order dated 1/7/24 documents to change/date/label oxygen humidification bottle and tubing weekly on Sundays and as needed.
The facility's Oxygen & Respiratory Equipment Changing/Cleaning policy dated 1/17/19 documents: Purpose: 1. To provide guidelines to employees for changing all disposable respiratory supplies. 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. 3. To minimize the risk of infection transmission. 1. Hand Held Nebulizer (HHN) and Mask, if applicable: a. The Hand held nebulizer should be changed weekly and PRN (as needed). b. A clean plastic bag with a zip loc or draw string etc. (etcetera) will be provided with each new setup, and will be marked with the date the set up was changed. 2. Nasal Cannula: a. Nasal cannula's are to be changed once a week and as needed (PRN).
The facility's Nebulizer- Medication Administration policy revised 10/9/18 documents after administering a nebulizer treatment disconnect the T-piece, mouthpiece, and medication cup. This policy documents to rinse/disinfect the nebulizer equipment per manufacturer's recommendations or with warm soapy water daily, and once dry store the tubing/mask in a plastic bag.
The facility's undated CPAP policy documents to gently wash the mask and nasal pillows with warm water and a mild clear liquid detergent, rinse thoroughly, allow to air dry, and wash the tubing as necessary.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to administer medications in accordance with manufacturer's instructions and physician's orders for three (R37, R42, R256) of sev...
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Based on observation, interview, and record review the facility failed to administer medications in accordance with manufacturer's instructions and physician's orders for three (R37, R42, R256) of seven residents reviewed for medication administration in the sample list of 37. This failure resulted in four medication errors out of 31 opportunities, resulting in a 12.9 % medication error rate.
Findings include:
1.) On 2/04/24 at 3:18 PM V8 Registered Nurse (RN) administered R37's Naproxen Sodium 220 milligrams (mg). The medication card contained a label to take this medication with meals. There was no food at R37's bedside when V8 administered the medication. At 3:23 PM V8 stated supper is served at 5:00 PM (over an hour after R37's medication administration.)
R37's Physician's Order dated 12/31/23 documents Aleve (Naproxen Sodium) give 220 mg by mouth twice daily. R37's February 2024 Medication Administration Record (MAR) documents Aleve is scheduled twice daily at 8:00 AM and 4:00 PM.
The Naproxen Sodium Manufacturer's Instructions revised July 2014 documents this medication may cause severe stomach bleeding and to take this medication with food or milk to avoid causing stomach upset.
2.) The Lispro Insulin Manufacturer's Instructions revised September 2023 documents Lispro is a rapid acting insulin and should be given within 15 minutes of a meal or immediately following a meal. Hypoglycemia (low blood sugar) is listed as a potential adverse reaction of this medication.
R42's Physician Order dated 11/20/23 documents administer Lispro insulin 100 units/ml (units per milliliters) give 5 units subcutaneously (sub q) three times daily with meals in addition to sliding scale insulin. R42's February MAR documents Lispro 5 units sub q is scheduled at 8:00 AM, 12:00 PM, and 4:00 PM.
On 2/4/24 at 3:47 PM V10 RN obtained R42's blood sugar of 148. V10 stated R42 gets scheduled insulin at this time and R42 will administer the insulin now since R42 has a good appetite. V10 administered Lispro 5 units sub q into R42's abdomen. There was no food at R42's bedside when R42's insulin was administered.
3.) The Levothyroxine Manufacturer's Instructions revised April 2019 documents Administer Levothyroxine Sodium Tablets as a single daily dose, on an empty stomach, one-half to one hour before breakfast. The Omeprazole Manufacturer's Instructions revised September 2012 documents to take the medication before meals and this medication suppresses gastric acid secretion.
R256's Physician Order dated 1/20/24 documents Omeprazole Delayed Release 20 mg give one capsule by mouth in the morning. R256's Physician Order dated 1/20/24 documents Levothyroxine Sodium 125 micrograms (mcg) give one tablet in the morning. R256's February 2023 MAR documents Omeprazole and Levothyroxine are scheduled to be given at 8:00 AM.
On 2/06/24 at 8:41 AM V9 RN administered Levothyroxine 125 mcg and Omeprazole 20 mg to R256 in R256's room. The medication card for Levothyroxine contained a label to take 30 minutes before meals.
On 2/06/24 at 8:51 AM V9 stated they start serving breakfast at 7:30 AM and they are done serving by 8:00 AM.
On 2/06/24 at 9:02 AM V9 stated Omeprazole and Levothyroxine are usually scheduled to be given by the night nurse at 6:00 AM, but V9 has noticed there are a few residents that have them scheduled at 8:00 AM. V9 stated it is close to 9:00 AM by the time V9 administers some of those medications. V9 confirmed R256 already ate breakfast and these medications are to be given before meals.
On 2/6/24 at 9:10 AM V2 Director of Nursing stated the nurses should follow manufacturer's instructions for medications, and Omeprazole and Levothyroxine should be given before meals.
The facility's undated list of meal times documents the following: Breakfast hall trays are scheduled at 7:00 AM followed by the small and main dining rooms. Supper hall trays are scheduled at 5:00 PM followed by the small and main dining rooms.
Oct 2023
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately complete fall risk assessments, thoroughly ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately complete fall risk assessments, thoroughly investigate a fall, and implement fall interventions for three (R1, R2, R6) of three residents reviewed for falls in the sample list of six. The facility also failed to safely transfer R1, resulting in R1 falling and sustaining a right ear laceration requiring sutures to close.
Findings include:
1.) R1's undated Diagnoses List documents R1's diagnoses include Cerebral Infarction (stroke), hemiplegia and hemiparesis following Cerebral Infarction affecting right dominant side, aphasia (difficulty communicating), epilepsy (seizures) and lack of coordination.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 requires extensive assistance of two staff for transfers. This MDS documents R1 has impaired balance requiring staff assistance to stabilize when moving from sitting to standing, walking, turning, transferring on/off of the toilet, and during surface to surface transfers. from R1's Care Plan dated as revised 10/2/23 documents R1 fell and includes an intervention dated 10/2/23 that staff was educated to use a gait belt with R1's transfers. R1's Care Plan dated 10/1/23 documents R1 has an Activities of Daily Living self care deficit related to impaired mobility and includes interventions that R1 is usually provided substantial assistance of one staff person for chair/bed transfers and when moving from sitting to standing.
R1's September 2023 Medication Administration Record (MAR) documents R1 received the following medications from 9/15/23 through 9/30/23: Furosemide (diuretic) 40 milligrams (mg), Losartan Potassium (antihypertensive) 25 mg, Carvedilol (antihypertensive) 6.25 mg, and Levetiracetam (antiseizure) 500 mg,
R1's Fall Risk assessment dated [DATE] documents a score of 11, indicating R1 is at risk for falls. This assessment is inaccurate. The section for gait/balance does not document R1's impaired balance with standing and walking. This assessment documents R1 takes 1-2 of the types of medications listed (Anesthetics, Antihistamines,Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics,Psychotropics, Sedative/Hypnotics). This assessment documents R1 does not have any predisposing diseases, and CVA (Cerebrovascular Accident) and seizures are listed as examples of predisposing diseases.
R1's Physical Therapy Progress Report dated 9/29/23 and signed by V14 Physical Therapist/Director of Rehab documents as of 9/28/23 R1 requires partial/moderate assistance with chair/bed transfers and R1 has right sided hemiparesis.
R1's Fall Report dated 10/1/23 at 6:00 AM documents: Resident (R1) had witnessed fall this AM during transfer at approximately 0600 (6:00 AM). Staff states they were attempting to transfer resident and resident got weak and lost balance and fell. Staff states resident hit his head on the night stand as he fell. Laceration noted to his R (right) ear. MD (Medical Doctor) notified and stated to monitor bleeding and if needed, can be glued. VS WNL (vital signs within normal limits). Resident had no visible s/s of fx (signs/symptoms of fracture). Called POA (Power of Attorney) at approximately 0900 (9:00 AM) to inform her of fall. POA states she would like resident to be seen in hospital to rule out any bleeding or fractures just to be safe. Called 911 and EMTs (Emergency Medical Technicians) arrived at 0940 (9:40 AM) to take resident to (Emergency Room).
R1's Hospital Oral & Maxillofacial Surgery Consult Note dated 10/1/23 documents R1 presented to the emergency room for a witnessed fall during a staff assisted transfer from the bed to the wheelchair. R1 fell and hit R1's right ear on the night stand and has a 2 centimeter partial thickness laceration to the right ear. This note documents R1's laceration required sutures to close the wound.
R1's Fall Interdisciplinary Team Note dated 10/2/2023 at 10:43 AM documents a summary of R1's fall (10/1/23) and the root cause was that R1 lost R1's balance. The post fall intervention is documented as staff education provided on use of gait belt.
The facility's fall investigation for R1's 10/1/23 fall, provided by V2 Director of Nursing (DON), included V4 Certified Nursing Assistant (CNA) interview dated 10/1/23 that documents V4 was transferring R1, R1 lost balance and fell forward hitting R1's ear on the nightstand. V4's Employee Disciplinary Action Form dated 10/5/23 documents V4 was given a 3rd and Final Written Warning for failing to follow safe transfer instructions resulting in a resident injury after a fall.
On 10/17/23 at 3:08 PM, V4 CNA stated on 10/1/23 V4 assisted R1 with transferring out of bed and into the wheelchair. V4 stated R1 was using a quad cane,V4 was standing behind R1's wheelchair with the wheelchair positioned between R1 and V4, and R1 was transferring towards R1's bad side (right side). V4 stated R1 had right sided weakness, and R1's prior room was set up to where R1 would transfer out of bed towards R1's left side. V4 stated V4 did not use a gait belt during the transfer. V4 stated R1 lost R1's balance and fell to the floor, hitting R1's right ear on the corner of the night stand. V4 stated V4 received a written warning for not using a gait belt during R1's transfer, and gait belts should be used for any transfers that are not mechanical lifts. V4 stated using a gait belt may have lessened R1's impact.
On 10/17/23 at 2:45 PM, V2 Director of Nursing (DON) stated fall risk assessments are completed by the nursing staff. V2 reviewed R1's fall risk assessment dated [DATE] and confirmed the assessment does not accurately document R1's impaired balance, diagnoses, and medication use which affects the fall risk score. V2 stated V4 CNA was assisting R1 with transferring out of bed on 10/1/23, R1 lost balance and fell, and R1 had a laceration to the right ear from hitting the night stand. V2 stated the root cause of R1's fall was that R1 lost R1's balance and V2 stated V4 was not using a gait belt during R1's transfer. V2 stated after R1's fall, V4 was educated to use a gait belt and was given disciplinary action. V2 stated a gait belt should be used for all resident transfers that is not a mechanical lift transfer.
On 10/17/23 at 3:48 PM, V16 Physician confirmed R1's right ear laceration would be consistent with R1 falling and hitting R1's head on the night stand. V16 stated V16 would defer to physical therapy in regards to whether a gait belt should have been used for R1's transfer. V16 stated if therapy recommends a gait belt be used, then one should have been used for R1's transfer.
On 10/18/23 at 8:45 AM, V15 Certified Occupational Therapy Assistant stated R1 was evaluated for therapy services on 9/14/23 and was receiving physical and occupational therapy until R1's discharge on [DATE]. V15 stated R1 transferred with assistance of two staff, hemiwalker, and gait belt. V14 Physical Therapist/Director of Rehab stated R1 had fair balance and confirmed R1 required hands on assistance with gait belt during transfers to maintain balance.
2.) R2's MDS dated [DATE] documents R2 requires extensive assistance with transfers and ambulation, has impaired range of motion to one upper and lower extremity, and has impaired balance during transfers/walking and requires staff assistance to stabilize. R2's Care Plan dated 10/5/21 documents R2 has impaired physical mobility and includes an intervention dated 7/14/23 to transfer with two assist and use of gait belt.
R2's October 2023 MAR documents R2 receives the following medications: Atenolol (antihypertensive) 50 mg, Bupropion Hydrochloride (antidepressant) Extended Release 100 mg, Enalapril Maleate (antihypertensive) 2.5 mg, Furosemide (diuretic) 10 mg, Norvasc (antihypertensive) 2.5 mg, Sertraline Hydrochloride (antidepressant) 100 mg, Lantus insulin (hypoglycemic) 44 units, and Insulin Aspart (hypoglycemic) 10 units.
R2's Fall Risk assessment dated [DATE] documents a score of 9 and indicates R2 is not at risk for falls. This assessment is inaccurate. The section for gait/balance does not document R2's impaired balance with standing and walking. This assessment incorrectly documents R2 takes 1-2 of the types of medications listed (Anesthetics, Antihistamines,Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics,Psychotropics, Sedative/Hypnotics).
On 10/18/23 at 11:17 AM, V2 DON reviewed R2's Fall Risk assessment dated [DATE] and confirmed this assessment was not completed accurately to reflect medication use and impaired balance, which would create a higher score and higher risk for falls.
3.) R6's MDS dated [DATE] documents R6 has severe cognitive impairment, is dependent on two staff for transfers, is dependent on one staff for toileting assistance, and is frequently incontinent of bowel and bladder. This MDS documents R6 has impaired balance during surface to surface transfers and requires staff assistance to stabilize.
R6's Care Plan with revised date 9/28/21 documents R6 is at risk for falls related to spinal stenosis, osteoporosis, osteoarthritis and weakness, and includes interventions for a low bed, use of floor mat beside R6's bed (initiated 8/30/23), and staff were educated to ensure the floor mat is in place (9/15/23).
R6's October 2023 MAR documents R6 receives the following medications: Furosemide 20 mg, Loratadine (antihistamine) 10 mg, Spironolactone (diuretic) 12.5 mg, Metoprolol Tartrate (antihypertensive) 12.5 mg, and Norco (narcotic) 5-325 mg
R6's Fall Risk assessment dated [DATE] documents a score of 15 indicating R6 is at risk for falls. This assessment is inaccurate and documents R6 takes 1-2 of the types of medications listed.
R6's Nursing Note dated 10/8/2023 at 11:11 PM documents nurse (V8 Registered Nurse (RN)) heard R6 yelling, upon entering R6's room there were two nurses (V18 RN and V19 Licensed Practical Nurse) assisting R6 who was lying on the floor. This note documents R6 was found holding onto R6's bedrail yelling, with R6's lower body on the floor. The nurses assisted R6 to the floor and R6 had no injuries. This note documents R6's floor mat was not in place when R6 was assisted into bed.
R6's 10/8/23 Fall Investigation, provided by V2, includes staff witness statements but there is no documentation as to what time R6 was last checked on or toileted prior to R8's fall. The documented root cause of R6's fall was that R6 was trying to get out of bed without assistance.
On 10/17/23 at 12:49 PM, R6 was sitting in a wheelchair in R6's room and there was a full mechanical lift sling positioned underneath of R6. At 1:48 PM and 1:53 PM R6 was lying in a bed that was low to the floor. There was no fall mat positioned besides R6's bed. R6's fall mat was standing up next to the closet.
On 10/17/23 at 2:13 PM, V9 CNA stated R6 uses a fall mat when R6 is in bed. V9 stated hospice staff laid R6 down earlier and did not put the floor mat down.
On 10/17/23 at 3:35 PM, V8 RN stated on the evening of 10/8/23 V8 heard R6 yelling and other nurses were already in R6's room when V8 entered. V8 stated R6 was lying on the floor and had no injuries. V8 stated there were two nurses (V18 and V19) in R6's room assisting R6. V8 stated R6's fall mat was not beside R6's bed when R6 fell. V8 stated the CNA forgot to put the fall mat down when R6 was assisted to bed. V8 stated It is a large mat and obvious to see in (R6's) room.
On 10/17/23 at 2:45 PM, V2 DON referenced R6's 10/8/23 fall investigation and stated R6 tried to crawl out of R6's bed which was in low position. V2 stated R6's fall mat was not placed beside R6's bed. V2 stated following R6's fall we obtained a concave mattress from hospice and increased frequent checks on R6 to ensure R6's fall mat is down and check R6 for positioning needs. On 10/18/23 at 11:17 AM, V2 reviewed R6's Fall Risk assessment dated [DATE] and confirmed this assessment was not completed accurately to reflect medication use which affects the total score. V2 confirmed all of the documentation for R6's fall investigation was provided, and confirmed there is no documentation to indicate when R6 was last checked on or toileted prior to R6's fall.
The facility's Fall Prevention Program dated as revised 11/21/17 documents: The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall. Safety interventions will be implemented for each resident identified at risk. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. Transfer conveyances shall be used to transfer residents in accordance with the plan of care. The fall risk interventions will be identified on the plan of care. Residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care. Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair and provide care as assigned in accordance with the plan of care.
The facility's Transfers-Manual Gait Belt and Mechanical Lifts policy revised 1/19/18 documents a gait belt will be used for one and two person assisted transfers.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report a resident fall to the physician and resident representative ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report a resident fall to the physician and resident representative for one (R6) of three residents reviewed for falls in the sample list six.
Findings include:
R6's Minimum Data Set, dated [DATE] documents R6 has severe cognitive impairment.
R6's Nursing Note dated 10/8/2023 at 11:11 PM documents nurse (V8 Registered Nurse (RN)) heard R6 yelling out and found two nurses (V18 RN and V19 Licensed Practical Nurses) in R6's room helping R6 who was lying on the floor. This note documents R6 was found holding onto R6's bedrail yelling, with R6's lower body on the floor. The nurses assisted R6 to the floor and R6 had no injuries. R6's nursing notes do not document that R6's Power of Attorney (V17) and physician were notified of R6's fall.
R6's Witnessed Fall Report dated 10/8/23 at 10:00 PM documents R6's fall. The section titled Agencies / People Notified is blank and this report does not document the physician and R6's representative were notified of R6's fall.
On 10/17/23 at 3:35 PM V8 RN stated on the evening of 10/8/23 V8 heard R6 yelling and other nurses were already in R6's room when V8 entered. V8 stated R6 was lying on the floor and had no injuries. V8 was asked if R6's fall was reported to anyone. V8 stated V8 reported R6's fall to hospice.
On 10/18/23 at 11:17 AM V2 Director of Nursing stated the floor nurses notify the physician and resident representative of resident falls and this is documented on the incident report or in a nursing note. V2 stated sometimes hospice notifies the family and physician. At 12:15 PM V2 stated V2 was unable to locate documentation that R6's fall was reported to R6's representative and physician. V2 stated V2 spoke with V8 RN and V8 only notified hospice.
The facility's Fall Prevention Program revised 11/21/17 includes notifying the physician and resident representative.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers as scheduled for three (R1, R3, R4) of four resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers as scheduled for three (R1, R3, R4) of four residents reviewed for showers in the sample list of six.
Findings include:
1.) R1's undated census documents R1 admitted to the facility on [DATE] and discharged on 10/1/23. R1's Minimum Data Set (MDS) dated [DATE] documents R1 requires extensive assistance of two staff for transfers, and bathing did not occur during the review period.
R1's Care Plan dated 10/1/23 documents R1 has an activity of daily living self performance deficit related to impaired mobility and includes an intervention that R1 is usually dependent on staff for bathing transfers.
R1's electronic documentation for bathing dated 10/17/23 documents showers were given on 9/23/23 and 9/27/23, and R1 refused shower on 9/30/23.
On 10/17/23 at 4:04 PM, V2 Director of Nursing stated showers are scheduled to be given at least twice weekly for all residents and are documented in the resident's electronic medical record and on paper forms. V2 provided one paper shower sheet for R1 that is undated and documents R1 was given a shower. V2 confirmed the shower sheet was not dated. On 10/18/23 at 11:17 AM V2 confirmed all of R1's shower documentation was provided.
2.) On 10/17/23 at 11:35 AM, R3 stated R3 is suppose to have showers on Tuesdays and Fridays, and sometimes Friday showers are missed due to the facility not having enough staff. R3 stated the staff try to make up missed showers on Saturdays, but sometimes that doesn't get done due to not having enough staff on the weekends.
R3's MDS dated [DATE] documents R3 is cognitively intact and requires staff supervision and setup assistance with bathing.
R3's electronic documentation report for bathing dated 10/18/23 does not document R3 received a shower after 9/19/23 until 9/29/23. R3's paper shower sheets provided by V2, do not document R3 was given a shower after 9/19/23 until 10/3/23.
On 10/18/23 at 11:17 AM, V2 confirmed all of R3's shower documentation for September 2023 and October 2023 was provided. V2 stated staff are suppose to make up missed Friday showers on Saturdays.
3.) On 10/17/23 at 11:35 AM, R4 stated R4's shower days are on Tuesdays and Fridays and R4 does not always receive showers twice per week as scheduled. R4 stated it has been a week since R4's last shower.
R4's MDS dated [DATE] documents R4 has moderate cognitive impairment and requires assistance of one staff for bathing assistance.
R4's Care Plan dated as revised 3/22/21 documents R4 has a self care deficit for activities of daily living related to impaired mobility and includes an intervention dated 7/14/23 that R4 requires one staff person for bathing assistance.
R4's electronic documentation report for bathing dated 10/18/23 does not document R4 received a shower after 9/19/23 until 9/29/23, and documents Not Applicable for R4's shower scheduled on 10/13/23 (Friday). R4's paper shower sheets, provided by V2, do not document R4 received a shower after 9/19/23 until 10/3/23, and there are no documented showers after 10/6/23.
On 10/17/23 at 3:08 PM, V4 Certified Nursing Assistant (CNA) stated V4 usually works dayshift and when there are only 4 CNAs, it makes it difficult to get showers done. V4 stated the CNAs used to get a list of showers to make up the next day, but they don't get a list anymore.
On 10/18/23 at 9:54 AM, V3 CNA stated V3 gave showers last week and confirmed R4 was not given a shower on 10/13/23. V3 stated Not Applicable is marked when showers are unable to be given. V3 stated sometimes R3 and R4 are told they can't have a shower due to not having enough staff.
On 10/18/23 at 11:17 AM, V2 confirmed all of R4's shower documentation for September 2023 and October 2023 was provided.
The facility's Bathing-Shower and Tub Bath policy dated as revised 1/31/18 documents bathing/showers will be offered twice weekly and as needed/requested or per resident's preferred frequency. This policy documents to document bathing in the resident's electronic medical record.
Sept 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain and implement urinary catheter orders and document urinary output for one (R1) of two residents reviewed for urinary catheters in th...
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Based on interview and record review, the facility failed to obtain and implement urinary catheter orders and document urinary output for one (R1) of two residents reviewed for urinary catheters in the sample list of five.
Findings include:
The facility's Urinary Catheter Care policy with a revision date of 2/14/19 documents the following: Catheter drainage bags will be emptied one time on each shift or as needed. This policy does not discuss documenting urinary output.
R1's Electronic Medical Records (EMR) document R1 resided at the facility from 8/19/23 through 8/29/23.
R1's Progress Note dated 8/26/23 documents R1 had an indwelling urinary catheter placed in the emergency department on 8/26/23.
R1's August Physician Orders does not document an order for an indwelling urinary catheter.
R1's EMR does not contain any documentation of R1's urinary output.
On 9/1/23 at 10:08 am, V5 R1's Representative stated R1 was sent to the hospital on 8/26/23 for abdominal pain and a urinary catheter was placed. V5 stated V5 visited R1 on 8/27/23 at 8:30 am and R1's urinary collection bag was full and contained approximately 3000 milliliters of urine. V5 stated, V4 Certified Nursing Assistant (CNA) emptied R1's urinary catheter bag at that time stating 'this is way too full.'
On 9/1/23 at 11:19 am, V3 Medical Director stated R1 was assessed and treated by V3 in the local emergency department for urinary retention and an indwelling urinary catheter was placed. V3 stated R1 does not have a history of urinary retention and urinary output is expected to be documented.
On 9/1/23 at 1:25 pm, V6 Registered Nurse (RN) stated V6 sent R1 out to the local emergency department for evaluation and treatment on 8/26/23 for abdominal pain/distension. V6 stated R1 returned to the facility with an indwelling urinary catheter in place. V6 stated, unsure if a Physician Order was received. V6 stated CNA's chart urinary output under the Tasks tab in the EMR. V6 stated, there doesn't appear to be any output under tasks documented for [R1] or an order for the catheter.
On 9/1/23 at 2:22 pm, V4 CNA stated family came out of R1's room on 8/27/23 stating R1's urinary collection bag was full. V4 stated V4 emptied R1's urinary collection bag at that time and recalls it being quite full. V4 stated unable to recall if V4 charted R1's output in R1's EMR. V4 confirmed urinary output is charted in resident EMR's under the Tasks tab.
On 9/1/23 at 12:52 pm, V2 Director of Nursing stated the facility does not have standing orders for indwelling urinary catheters. V2 stated the nurse should have obtained an order for R1's urinary catheter including the size of the catheter. V2 stated urinary output is documented in the resident EMR under the Tasks tab and all residents with urinary catheters are to have urinary output documented every shift.
Feb 2023
24 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately record a resident's preference for life-sustaining treatm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately record a resident's preference for life-sustaining treatment in the medical record for one resident (R6) and failed to obtain a Qualified Practitioner's signature for a resident's POLST (Practitioner Order for Life-Sustaining Treatment) form for one resident (R49). This failure affects two (R6, R49) of three residents reviewed for advance directives in the sample list of 46.
Findings include:
The facility's Advance Directive policy with a revised date of 11/2022 documents, All residents will be given information regarding Advance Directives upon admission, in accordance with the Self Determination Act. Advance Directives include but are not limited to: Power of Attorney for Health Care, Living Will, IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life-Sustaining Treatment (POLST), Medically Administered Nutrition including feeding tubes. The IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) is an individual's signed and dated document that reflects an individual's wishes about receiving cardiopulmonary resuscitation (CPR) in the event the individual has no pulse and is not breathing. To formulate a valid Practitioner Order for Life-Sustaining Treatment, the signature of a Qualified Practitioner (physician, licensed resident (second year or higher), advanced practice nurse, or physician assistant, is required, so you should consult with your health care professional.
1.) R6's Order Summary dated [DATE] documents diagnoses including Dementia, Unspecified Severity with Agitation, Hypothyroidism, Hypertension and Depression. This Order Summary documents an order for a Full Code dated [DATE]. R6's Electronic Face Sheet documents Full Code status.
R6's POLST form dated [DATE] documents R6 does not want CPR (Cardio Pulmonary Resuscitation) attempted if R6 is in Cardiac Arrest.
On [DATE] at 9:40 AM, V7 Corporate Field Nurse confirmed R6's code status in the electronic record does not match the POLST form and stated that they should match.
2.) R49's Order Summary dated [DATE] documents diagnoses including Anxiety, Major Depressive Disorder, Hypertension, Personal History of COVID-19 (Human Coronavirus) and Body Mass Index 45.0-49.9, Adult. This Order Summary documents an order for a DNR (Do Not Resuscitate) dated [DATE].
R49's POLST form in the electronic medical record is dated [DATE] has R49's signature but does not have a Qualified Practitioner's signature.
On [DATE] at 10:38 AM, V7 stated the POLST form is still at the doctor's office. V7 stated they have contacted the V26 Physician and V26's office is supposed to fax it over.
On [DATE] at 9:40 AM, V7 confirmed they do not have a signed POLST for R49 and confirmed if they do not have a POLST form signed by the Physician the person is to be treated as a Full Code.
On [DATE] at 2:19 AM, V12 Social Services Director stated they do not have a signed POLST form for R49. V12 stated that it is hard to get V26 to get things done and back to them.
On [DATE] at 2:49 PM, V14 Registered Nurse says if a resident is coding the nurses can look in the computer on the resident's face sheet to see the code status and it is also on the resident's Physician's orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
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 document written notification/acknowledgement of the Skilled Nursin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document written notification/acknowledgement of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage for three of three residents (R18, R24, R52) and failed to document acknowledgement of Notice of Medicare Non-Coverage for one of three residents (R18) reviewed for beneficiary protection notification on the sample list of 46.
Findings include:
1. R18's Notice of Medicare Non-Coverage (NOMNC) dated 2/9/23 does not document a signature of acknowledgement of the notice by R18 or V28, R18's Family.
R18's Skilled Nursing Advance Beneficiary Notice of Non-coverage (SNFABN) dated 2/9/23 does not document R18 or V28's signature of acknowledgement of the notice.
2. R24's Census documents R24 admitted to the facility on [DATE] with Medicare Part A benefits and a payor change on 2/2/23. This Census documents R24 remains in the facility.
R24's NOMNC documents R24's skilled services end date of 2/1/23.
The facility was unable to find documentation of R24's SNFABN upon request on 2/16/23.
3. R52's Census documents R52 admitted to the facility on [DATE] with Medicare Part A benefits and R52 discharged from the facility on 2/3/23.
R52's NOMNC documents R52's skilled services end date of 2/3/23.
The facility was unable to find documentation of R52's SNFABN upon request on 2/16/23.
On 2/16/23 at 1:20pm, V12, Social Services Director (SSD) stated V12 provides notification for the NOMNC and SNFABN notices. V12 stated V12 was unable to find documentation that R24 and R52 received a SNFABN and was unsure of if it was provided. V12 stated V12 only verbally notified V28, R18's family but did not have a signature verifying R18 received the written notification.
The facility's undated Medicare Letters and Forms educational sheets documents if a resident is competent, the resident is issued the NOMNC and signs the letter. If the resident is not competent, then the Power of Attorney (POA) signs the letter. If the POA is unavailable to sign, then the facility would issue the NOMNC verbally to the POA and have to issue the letter in full to the POA. Mail a copy of the letter to the POA on the same day of the conversation. A Certified Copy of the letter must be sent to the POA. When the letter is received and signed for is when the 48 hour notice starts. These sheets document the facility is to keep a copy in facility records. These sheets doucment the Advanced Beneficiary Notice (SNFABN) is delivered to a capable beneficiary that can comprehend and given in person and in advance of the services with sufficient time to the beneficiary. These sheets document the SNFABN is signed by the beneficiary or representative.
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, interview and record review, the facility failed to complete skin assessments and assess and document a blood filled blister to the left hand little finger for one of one residen...
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Based on observation, interview and record review, the facility failed to complete skin assessments and assess and document a blood filled blister to the left hand little finger for one of one resident (R15) reviewed for skin alterations/edema on the sample of 46.
Findings include:
R15's Order Summary Report documents an order dated 1/4/23 to complete weekly skin checks and document if a wound is present. This order documents to document in R15's Progress Notes after completing the wound assessment.
On 2/15/23 at 3:30pm, R15 was observed in the hall in R15's wheelchair and noted to have a dark, fluid filled circular skin alteration to R15's left hand little finger.
R15's Electronic Medical Records (EMR) do not document R15 has this skin alteration. R15's EMR does not document an evaluation/assessment/measurements of this skin alteration. R15's Electronic Medical Records do not document weekly skin assessments as ordered.
On 2/16/23 at 12:30pm, V2, Director of Nursing (DON) stated the facility does not have documentation of skin assessments weekly as ordered. V2 stated the facility should be completing the skin assessments weekly as ordered and documenting them in R15's medical records.
On 2/16/23 at 2:35pm, V3, Care Plan Coordinator/Assistant Director of Nursing (ADON) stated R15 had a fall and V3 feels R15 may have sustained this dark fluid filled skin alteration during the fall. V3 stated V3 may have been the staff who should have documented an assessment of this alteration as V3 worked the night of the fall V3 thinks it may have occurred from, but V3 could not remember.
The facility's Physician Orders policy dated May 2022 documents it is the policy of the facility to maintain current physician orders to provide treatment according to the attending physician for each resident of the facility.
The facility's Wound and Ulcer Policy and Procedure dated 1/10/2018 documents the facility is to provide nursing standards for assessment, prevention, treatment and protocols to manage residents at any level of risk for skin breakdown and for wound management. This policy documents a weekly skin check is to be completed by direct care staff and changes in condition are promptly reported. This policy documents when a resident is found to have a wound, a licensed nurse will complete documentation of an assessment of the wound/ulcer in the residents medical record, initiate appropriate treatment protocol and notify the physician and document in the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to complete weekly pressure ulcer assessments, ensure a wound dressing was dated and intact, perform hand hygiene and prevent cro...
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Based on observation, interview, and record review the facility failed to complete weekly pressure ulcer assessments, ensure a wound dressing was dated and intact, perform hand hygiene and prevent cross contamination during a pressure ulcer treatment for one resident (R26) reviewed for pressure ulcers in the sample list of 46.
Findings include:
R26's Diagnoses List dated 2/15/23 documents R26 has Paraplegia, Moderate Protein-Calorie Malnutrition, and Stage IV Pressure Ulcer of the Left Buttock (5/10/22). R26's Hospice Plan of Care dated 1/25/23 documents R26 has a diagnosis of Stage IV Pressure Ulcer of the Right Buttock as of 10/21/22.
R26's February 2023 Treatment Administration Record (TAR) documents an order to cleanse left and right gluteal wounds with Wound Cleanser, pack with Sodium Chloride 0.9 % moistened 4 x 4 sterile gauze or gauze roll, cover with abdominal dressing and a transparent adhesive dressing twice daily on dayshift and evening shift and as needed. This TAR documents orders to check to ensure the dressing is intact and not saturated every shift/three times per day, and administer the as needed treatment order when the dressing is saturated or not intact. The as needed order has not been signed out as administered in February.
R26's Ulcer/Wound Documentation dated 12/22/22 documents R26 admitted with the right gluteal pressure ulcer on 4/17/22, the wound measured 5.5 cm (centimeters) long by 5 cm wide by 3.8 cm deep, and does not document the stage of the wound. R26's left gluteal pressure ulcer was facility acquired on 7/1/22, the wound measured 4 cm by 3.5 cm by 1 cm, and the assessment does not document the stage of the wound. There are no measurements/assessments of these wounds until 1/24/23. R26's Ulcer/Wound Documentation dated 1/24/23 documents R26's left gluteal wound described as Stage III, measured 3.4 cm by 2.4 cm by 1.8 cm with pink and firm undermining at 2 clock. The unstaged right gluteal wound measured 5.6 cm by 5 cm by 4.3 cm, and the bottom perimeter was firm, red and flakey that measured 4.9 cm. The wound had tunneling of 4.9 cm at 2 o'clock, 3.7 cm at 7 o'clock, and 5.2 cm at 3 o'clock. There are no documented assessments until 2/3/23 when the left gluteal wound described as stage III, measured 3.4 cm by 3.3 cm by 1.9 cm, had 2 cm tunneling at 11 o'clock, and a pink, excoriated, superficial open area that measured 1 cm by 0.8 cm off of the 7 o'clock area. The unstaged right gluteal wound measured 5.4 cm by 3.4 cm by 3.5 cm, with tunneling 4.3 cm tunneling at 2 o'clock and 2 cm undermining at 7 o'clock . The periwound was pink/firm at 6-7 o'clock with a black/firm edge. There are no documented assessments of these wounds after 2/3/23.
On 2/15/23 at 12:21 PM V3 Assistant Director of Nursing (ADON) administered R26's gluteal wound treatments. R26 was lying on R26's side in bed. The transparent dressing on R26's gluteal wounds was not intact, edges were loose, the right gluteal wound did not contain gauze, and both wounds were not covered with an abdominal pad underneath of the transparent adhesive dressing. The dressing was not labeled with a date. V3 removed the dressing. V3 confirmed the wounds were not covered with abdominal pads, the dressing was no longer intact and the right wound did not contain packed gauze. V18 and V27 Certified Nursing Assistants confirmed the dressing had looked the same when they provided R26's morning care at the beginning of dayshift. The left gluteal wound was red and had depth and the right gluteal wound was deep with areas of tunneling and contained red/yellow tissue. V3 cleansed each wound and did not change gloves or perform hand hygiene between cleansing each wound. V3 measured the left gluteal wound as 2.2 cm by 1.8 cm by 2.8 cm, and the right as 3.5 cm by 3.2 cm by 3.5 cm with 1.6 cm of tunneling at 11 o'clock. V3 stated the right gluteal wound looked worse. V3 changed V3's gloves, did not perform hand hygiene, packed the left wound with 4 x 4 gauze soaked with Sodium Chloride 0.9 %, and covered with an abdominal pad and transparent adhesive dressing. Without changing gloves V3 packed 4 x 4 gauze soaked with Sodium Chloride into the right wound, and covered with an abdominal wound and transparent dressing. V3 dated the dressing and stated it is standard practice for dressings to be labeled with a date.
On 02/15/23 at 8:52 AM V3 stated V2 DON is responsible for completing weekly wound assessments that are documented under the assessments section of the resident's Electronic Medical Record. On 02/15/23 at 12:55 PM V3 confirmed R26's wound treatments should be administered separately. V3 confirmed gloves should be changed and hand hygiene performed when moving from soiled to clean during wound treatments, after cleansing wounds, and between each wound treatment.
On 2/15/23 at 1:09 PM V2 DON stated the hospice nurse completes R26's wound assessments and was not sure how often the wounds are assessed or where the information is documented. On 2/15/23 at 2:59 PM V2 stated V2 had no documentation to provide for R26's wound assessments.
The facility's Hand Hygiene Protocol dated 7/26/21 documents hand hygiene should be performed when moving from soiled to clean body sites, after contact with blood/body fluids, and after glove removal.
The facility's Wound And Ulcer Policy and Procedure revised 1/10/18 documents pressure ulcers will be assessed weekly and documented in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide a frozen nutritional supplement as ordered for two residents (R2, R12) reviewed for nutrition in the sample list of 46...
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Based on observation, interview, and record review the facility failed to provide a frozen nutritional supplement as ordered for two residents (R2, R12) reviewed for nutrition in the sample list of 46.
Findings include:
1. R2's undated weight log documents R2 weighed 120.2 lbs (pounds) on 10/13/22, 110.4 lbs on 11/10/23 (8.15% loss in one month), 109.6 lbs on 12/6/22, 108.2 lbs on 1/2/23, and 107.4 lbs on 2/1/23 (10.65% loss in 4 months.)
R2's February 2023 Medication Administration Record (MAR) documents a frozen nutritional supplement is ordered to be given three times daily at 8:00 AM, 12:00 PM, and 4:00 PM.
R2's Nursing Notes dated 12/26/22 at 12:45 PM documents R2's physician was notified of R2's weight and gave orders to increase R2's nutritional supplement to three times daily. R2's Nursing Note dated 1/10/23 at 10:08 AM documents R2's physician was notified of R2's weights and new orders given to increase the frozen nutritional supplement to three times daily. R2's Nutrition Notes document on 1/24/2023 at 3:58 PM documents R2 was evaluated by a registered dietitian and triggered for a significant weight loss of 13.4 % since August 2022. R2 has decreased oral intakes and receives a frozen nutritional supplement three times daily and a nutritional supplement 90 milliliters three times daily.
R2's Care Plan revised on 11/22/22 documents a problem area for nutrition, but has not been updated to reflect R2's significant weight loss or updated with new interventions after 11/22/22.
On 2/14/23 at 11:55 AM R2 was served lunch in the dining room and R2's meal did not include a frozen nutritional supplement. R2's meal ticket listed a frozen nutritional supplement as part of R2's noon meal. At 12:16 PM and 12:31 PM R2's lunch did not include a frozen nutritional supplement.
2.) R12's February 2023 MAR documents a frozen nutritional supplement is ordered to be given twice daily at 12:00 PM and 4:00 PM.
On 2/14/23 at 12:20 PM R12 was served lunch in the dining room and R12's meal did not include a frozen nutritional supplement. R12's meal ticket listed a frozen nutritional supplement as part of R2's noon meal. At 12:29 PM and 12:36 PM R2's noon meal did not include frozen nutritional supplement.
On 2/14/23 at 3:51 PM V27 Certified Nursing Assistant stated frozen nutritional supplements are distributed by dietary staff and served with meals.
On 2/16/23 at 2:10 PM, V4, Dietary Manager stated the kitchen staff are responsible for providing/ensuring residents with orders for a frozen nutritional supplement and the supplements are served with meals to residents with orders for them. V4 stated they are on the diet menus so they are served.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
2.) R26's Census dated 2/15/23 documents R26's payor status is hospice as of 10/21/22.
R26's Hospice Comprehensive Assessment and Plan of Care dated 1/25/23 documents: R26's diagnoses related to term...
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2.) R26's Census dated 2/15/23 documents R26's payor status is hospice as of 10/21/22.
R26's Hospice Comprehensive Assessment and Plan of Care dated 1/25/23 documents: R26's diagnoses related to terminal prognosis include Moderate Protein-Calorie Malnutrition, Anxiety, and Stage IV Pressure Ulcer of the Right Buttock. The skilled nursing facility is responsible for administering medications and wound treatments. R26's orders include Hyoscyamine 0.125 mg (milligrams) tablet sublingually every 4 hours as needed for tracheal secretions, Lorazepam 2 mg/ml (milliliter) give 0.25 ml every 4 hours as needed for anxiety, and Morphine Sulfate Solution 20 mg/ml give 0.25 ml by mouth every 2 hours as needed for shortness of breath/pain.
R26's Physician's Orders dated 2/15/23 documents hospice oversees R26's wound care. R26's Physician's Orders and Care Plan (last reviewed 7/19/22) does not document R26's hospice company and contact information. R26's Care Plan does not address R26's hospice/terminal diagnoses, targeted symptoms, coordination of hospice services, and symptom management including hospice ordered medications.
On 2/15/23 at 10:52 AM V3 Assistant Director of Nursing stated the resident's hospice company is listed on the nurse report sheets, which we are currently out of. The hospice company/contact information and order should be listed on the physician's orders. V3 stated the resident's hospice information should be included in the care plan. V3 confirmed R26's orders do not include a hospice order and the hospice company/contact information.
Based on interview and record review, the facility failed to ensure orders for hospice services were transcribed to residents Physician's Orders in the Electronic Medical Record and failed to ensure facility care plans were comprehensive for hospice services. These failures affect two of five residents (R26, R44) reviewed for hospice on the sample list of 46.
Findings include:
1. R44's Hospice admission Orders/Initial Plan of Care documents R44 was admitted to hospice care on 1/4/23.
R44's Physician's Orders dated do not document an order for hospice in R44's Physician's Orders.
R44's Care Plans dated 2/14/23 document the hospice company used, but no details on how to contact them or to see R44's hospice plan of care. R44's Care Plans do not document resident specific interventions related to R44's hospice/facility coordination of cares.
On 2/15/23 at 10:52 AM V3 Assistant Director of Nursing stated the resident's hospice company is listed on the nurse report sheets, which we are currently out of. The hospice company/contact information and order should be listed on the physician's orders. V3 stated the resident's hospice information should be included in the care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review the facility failed to act, follow-up, and resolve concerns discussed in the resident council meetings for four of four residents (R8, R50, R49, an...
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Based on observations, interviews, and record review the facility failed to act, follow-up, and resolve concerns discussed in the resident council meetings for four of four residents (R8, R50, R49, and R42) reviewed for resident council on the sample list of 46.
Findings include:
On 2/15/23 at 10:00 AM, during the group meeting, R8, R50, R49, and R42 stated the resident council meets once a month. When asked about concerns brought forth during the resident council meetings, R8, R50, R49, and R42 stated the snack cart is still a problem. They stated the staff are supposed to take it around and offer a snack and they don't do it. They stated at 2:00 PM, the staff don't always come to the activity room to offer a snack which they are supposed to do. They stated there is never a CNA (Certified Nursing Assistant) in the big dining room to help them. The dietary staff pass the trays and the CNAs are supposed to help them after the trays are passed. They stated call lights are a huge problem. R42 stated it took 62 minutes for the staff to answer R42's light. R50 stated it has taken an hour before to get someone to answer my call light. They stated it doesn't do any good to complain. They stated water is not always passed and is still a concern.
The facility's 9/26/22 Resident Advisory Council meeting minutes documents the snack cart is rarely passed. Ice water is not passed most of the time. The Resident Council Referral Form for 9/26/22 does not address the snack cart or the ice water concerns.
The facility's Resident Advisory Council meeting minutes dated 7/2022 through 2/2023 does not contain meeting minutes for October of 2022.
The facility's 11/28/22 Resident Advisory Council meeting minutes documents the snack cart has not been passed and there are no drinks on the snack cart to pass. Call lights are not being answered on time some are waiting 45 to 50 minutes at a time. Certified Nurse's Aides (CNA) are not in the dining room when trays are ready to be passed. The Resident Council Referral Form dated 11/28/22 does not address the snack cart, drinks, or call lights.
The facility's 12/26/22 Resident Council Meeting minutes documents CNAs should be handing out trays instead of talking, call lights are not being answered in a timely manner, and the snack cart is not being passed. The Resident Council Referral Form does documents the concerns of CNAs handing out trays, call lights not being answered and the snack cart not being passed. This form documents the CNAs were educated.
The facility's 1/30/23 Resident council Meeting minutes documents CNAs are not in the dining room, ice water is not being passed, and the snack cart is not being passed. The Resident Council Referral Form dated 1/30/23 documents the residents concerns but does not document the action taken. This form is signed by V2 Director of Nursing on 2/12/23.
On 2/14/23 at 12:30 PM and on 2/15/23 at 12:15 PM, there was not a CNA in the main dining room to assist the residents.
On 2/15/23 at 12:31 PM, V1 Administrator stated he did not find follow up responses to all of the resident council meetings held from July of 2022 to January of 2023.
On 2/16/23 at 12:00 PM V1 Administrator and V2 Director of Nursing stated the complaints about the call lights, the ice water, and snacks are not resolved. V2 stated snacks should be passed at 2:00 PM and at bedtime and everyone should be offered a snack.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) On 2/14/23 at 10:29 AM R2's bed contained bilateral C shaped siderails.
R2's Bed Rail assessment dated [DATE] documents R2 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) On 2/14/23 at 10:29 AM R2's bed contained bilateral C shaped siderails.
R2's Bed Rail assessment dated [DATE] documents R2 uses bilateral siderails. R2's Care Plan with a reviewed date of 1/31/23 does not include the use of bilateral siderails.
On 2/16/23 at 1:20 PM V7 Corporate Field Nurse stated siderails should be including in the resident's care plan.
5.) R26's Census dated 2/15/23 documents R26's payor status as hospice as of 10/21/22.
R26's Hospice Comprehensive Assessment and Plan of Care dated 1/25/23 documents: R26's diagnoses related to terminal prognosis include Moderate Protein-Calorie Malnutrition, Anxiety, and Stage IV Pressure Ulcer of the Right Buttock. The skilled nursing facility is responsible for administering medications and wound treatments. R26's orders include Hyoscyamine 0.125 mg (milligrams) tablet sublingually every 4 hours as needed for tracheal secretions, Lorazepam 2 mg/ml (milliliter) give 0.25 ml every 4 hours as needed for anxiety, and Morphine Sulfate Solution 20 mg/ml give 0.25 ml by mouth every 2 hours as needed for shortness of breath/pain.
R26's Care Plan dated 11/9/22 documents R26 receives hospice care and has a terminal prognosis, and includes interventions to assess R26's coping strategies, respect R26's wishes, encourage a support system including family and friends, orders for pain, administer pain medications as ordered, notify the physician of breakthrough pain, review and follow R26's living will, work with the hospice team to ensure spiritual, emotional, intellectual, physical and social needs are met. This care plan is not person centered to identify R26's specific terminal diagnosis to warrant hospice care, the hospice company and contact information, hospice services provided, symptom management including the use of hospice medications listed in the hospice plan of care.
On 2/15/23 at 10:52 AM V3 Assistant Director of Nursing stated the resident's hospice information should be included in the care plan. V3 stated V3 has been behind in updating care plans.
Based on observation, interview and record review, the facility failed to ensure comprehensive care plans were developed and implemented for five residents (R2, R12, R26, R35, R44) reviewed for care plans on the sample list of 46.
Findings include:
The facility's Resident Assessment and Care Planning policy dated November 2017 documents the facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs as well as preferences for care and goals. This polciy documents this comprehensive care plan is person centered.
1. R35's Face Sheet dated 2/16/23 documents R35's diagnoses including Dementia.
R35's Progress Notes dated as follows document:
1/18/23 at 11:02am, R35 was yelling at staff and made R35's roommate upset.
1/20/23 at 10:43pm, R35 displayed multiple aggresive and threatening behaviors throughout the nightshift anytime staff and residents talked with R35.
1/24/23 at 11:12am, R35 struck another resident.
1/25/23 at 3:23pm, R35 wandered into an unidentified resident's room and scared the unidentified resident by yelling get out of my house. R35 had a curtain rod and was holding it (curtain rod) as if (R35) was going to hit someone with it.
1/25/23 at 9:00pm, R35 refused to have vital signs taken, refused to have an assessment performed and refused medication.
1/26/23 10:46pm, Assistance with R35 was requested in the dayroom due to R35 yelling at staff. R35 entered a room occupied by unidentified residents and approached two unidentified residents beds with those residents in those beds. R35 was yelling and screaming and swung at staff, making contact.
2/7/23 at 8:53am, R35 had a bowel movement and smeared feces on the walls of R35's room, bathroom, tray table, towel dispenser and bed.
2/7/23 at 8:43pm, R35 was in the hall screaming.
02/14/23 02:32 PM R35 wanders in and out of resident room with a recent history of attempting to be physical with other residents.
2/15/23 at 6:00am, R35 wandering the hallways, yelling and lunging at other unidentified residents, trying to bite staff members.
R35's Care Plans dated 2/16/23 do not document R35's history of wandering with resident specific interventions to attempt when R35 is wandering. These care plans do not document R35's history of physical abuse towards other residents and staff or R35's history of yelling and threatening other residents and staff or R35's history of smearing stool throughout room and bathroom.
2. R44's Hospital Discharge Instructions dated 12/24/22 document R44's diagnoses including Pneumonia. These orders document R44's medication orders including Ipratropium-Albuterol Solution (nebulizer) 0.5-2.5 (3) MG (milligrams)/3ML (milliliter).
R44's Care Plans do not document R44's history of Pneumonia or R44's use of respiratory nebulizer equipment. These Care Plans do not document R44's use of side/bed rails.
3. On 2/14/23 at 9:53 AM, R23 was lying in bed and wearing oxygen. There was a BIPAP (Bilevel positive airway pressure) mask and tubing lying on table.
R13's care plan dated 1/13/23 does not contain an oxygen or BIPAP plan of care.
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** 3. On 2/14/23 at 9:54 AM, R13 was sitting in R13's room in a wheel chair asleep. R13's call light was not within reach.
On 2/15...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 2/14/23 at 9:54 AM, R13 was sitting in R13's room in a wheel chair asleep. R13's call light was not within reach.
On 2/15/23 at 1:00 PM, R13 was sitting in a wheel chair in the hallway outside of R13's room sleeping. R13 did not have a call light within reach.
R13's Fall Prevention care plan dated 1/28/22 documents an intervention that states, Be sure my call light is within reach and encourage me to use it for assistance as needed.
R13's Fall Details report dated 12/1/22 at 3:25 AM documents R13 had a fall in R13's room. The follow up report for this fall documents a recommendation that states, Staff and resident education to use call light for assistance with transfers early in the morning.
4. R24's Fall Detail Report dated 1/8/23 at 3:30 PM documents R24 fell in R24's room. R24's fall report does not document a root cause for this fall. This report documents an intervention for a mat beside the bed. R24's care plan was not updated with this intervention until 1/11/23.
R24's Fall Detail Report dated 1/13/23 at 10:00 PM, documents R24 fell in R24's room. R24's fall report does not document a root cause for this fall. This report documents a recommendation to toilet R24 every two hours. This interventions was not added to the care plan until 1/30/23.
R24's Fall Detail Report dated 2/4/23 at 4:15 AM, documents R24 fell in the hallway. R24's fall report does not document a root cause for this fall. This report documents a recommendation for nonskid pad in the seat of R24's wheelchair.
On 2/16/23 at 11:00 AM V2 DON, stated that after a resident falls there should be a root cause identified, a new intervention put into place, and then the intervention added to the care plan.
Based on observation, interview and record review the facility failed to investigate falls, determine the root cause of falls, implement interventions add interventions to resident's care plans for four of four residents (R6, R47, R13, R24) reviewed for falls in the sample list of 46.
Findings include:
The facility's Fall Assessment and Management Policy with a revised dated 4/2019 documents, The potential for falls will be care planned when appropriate, based on the results of the Fall Risk Assessment. The interdisciplinary care plan will be person centered to reflect the specific needs and risk factors of the resident. Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall. Post fall assessment - immediately after fall: A licensed nurse will immediately assess the resident after a fall. Risk Watch Occurrence report (facility's investigation) is initiated within the shift that the fall occurred. Care planning after a fall. 1. A licensed nurse will consult with the resident's care givers and other interdisciplinary team members in regards to future intervention, and resident specific risk factors.
The facility's Fall Mitigation policy dated 4/2015 documents, Post Fall, What was the resident doing? Adjust ADL (Activities of Daily Living) schedule to address. (Nursing/Restorative/MDS {Minimum Data Set}). Implement fall intervention. The F.I.T. (Fall Interdisciplinary Team) will meet at designated intervals throughout each week to: discuss any fall events, to conduct Root Cause Analysis specific to individual residents, to review current fall prevention measures, to develop and implement new and/or additional measures of prevention, and to communicate changes. The care plan will be adjusted to reflect any change.
1.) R6's Order Summary dated 2/15/23 documents R6 was admitted on [DATE] and documents R6's diagnoses including Dementia with Agitation, Spondylosis, Systemic Lupus Erythematosus, Essential Hypertension and Depression.
R6's Fall Risk Assessments dated 1/16/23 and 2/6/23 document R6 is at High Risk for falling. R6's Minimum Data Set (MDS) dated [DATE] documents R6 is severely cognitively impaired. This MDS documents R6 requires extensive physical assistance of two staff for bed mobility, transfers and toileting.
R6's Care Plan dated 2/6/23 documents R6 had a fall. Interventions documented on this Care Plan are assist me to keep non-skid foot wear on at all times while I am up dated 2/8/23, non skid material added to recliner dated 2/4/23, make sure my call light is always within reach dated 2/8/23, make sure to keep a clear path to my bathroom dated 2/8/23.
R6's Nurse's Progress Notes document a fall on 1/19/23 in R6's spouse's room. This note documents R6 was found on the floor in front of the recliner.
R6's Occurrence Report dated 1/20/23 documents the root cause determined was, Due to resident action or internal risk factors. This report documents an intervention put into place was non skid material in the seat of the recliner in spouse's room.
R6's Nurse's Progress Notes dated 2/4/23 documents R6 was found on R6's spouse's floor in front of the recliner.
R6's Occurrence Report dated 2/4/23 documents R6 slid out of the recliner and documents the root cause for the fall on 2/4/23 as no fault. There is no new intervention documented on this occurrence report.
On 2/16/23 at 9:40 AM, V7 Corporate Field Nurse confirmed the investigation did not determine a root cause for the falls on 1/19/23 and 2/4/23.
2.) R47's Electronic Diagnosis list documents diagnoses including Atherosclerotic Heart Disease, Paroxysmal Atrial Fibrillation, Dementia, Anxiety Disorder, Scoliosis and Depression.
R47's Fall Risk assessment dated [DATE] documents R47 is at High Risk for falling. This assessment documents R47 was admitted to the facility on [DATE]. R47's MDS dated [DATE] documents R47 is severely cognitively impaired. This MDS documents R47 requires extensive physical assistance of two staff for bed mobility, transfers and toileting.
R47's Care Plan dated 4/26/23 documents R47 is at risk for fall and had an actual fall with interventions to assist me to keep non-skid foot wear on at all times while I am up dated 4/26/22, body pillow for positioning dated 8/1/22, reclining geriatric chair dated 6/15/22, educate staff to follow care plan for toileting every two hours dated 11/21/22, every two hours toileting while awake dated 6/21/22, make sure my call light is always within my reach 4/26/22, provide me with a low bed dated 4/26/22 and staff educated for positioning of chair and resident dated 1/11/23.
R47's Nurse's Progress Notes document R47 was found on the floor in R47's room on 7/29/22, 12/15/22 and on 12/24/22.
R47's Occurrence Report dated 7/29/22 documents R47 rolled out of bed and the root cause is documented as no fault. The intervention documented is to request a body pillow from hospice for positioning.
R47's Medical record does not contain an investigation of the 12/15/22 fall.
R47's Occurrence Report dated 12/24/22 does not document any conclusion or root cause or an intervention developed. This investigation is incomplete.
On 2/16/23 at 9:40 AM, V7 confirmed there is no fall investigation for R47's 12/15/22, confirmed the investigation of R47's fall on 12/24/22 is incomplete and confirmed the root cause was not determined for the falls on 7/29/22, 12/15/22 and 12/24/22.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R44's Hospital Discharge Instructions dated 12/24/22 document R44's diagnoses including Pneumonia. These orders document R44'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R44's Hospital Discharge Instructions dated 12/24/22 document R44's diagnoses including Pneumonia. These orders document R44's medication orders including Ipratropium-Albuterol Solution (nebulizer medication) 0.5-2.5 (3) MG (milligrams)/3ML (milliliter).
On 02/14/23 10:59 AM R44's nebulizer mask was laying uncovered on R44's bedside table.
On 02/15/23 09:00 AM R44's nebulizer mask was laying uncovered on R44's bedside table with nebulizer tubing attached and hanging from the nebulizer machine.
On 2/16/23 at 11:00 AM V2 DON, stated all respiratory tubing and appliances should be bagged when not in use.
Based on observation, interview, and record review the facility failed to store respiratory tubing and equipment in a sanitary manner, failed to obtain a physician's order for oxygen, and failed to date tubing and humidification bottle for four of four (R23, R43, R44, and R18) residents reviewed for respiratory equipment on the sample list of 46.
Findings include:
1. On 2/14/23 at 9:53 AM, R23's BIPAP (Bilevel positive airway pressure) tubing and mask were not bagged and lying on a table in the room.
On 2/16/23 at 1:00 PM, V2 Director of Nursing stated that all respiratory tubing and equipment should be bagged when not in use.
2. On 2/14/23 at 9:53 AM, R43's oxygen tubing and nasal cannula was laying on the floor unbagged.
On 2/16/23 at 1:00 PM, V2 Director of Nursing (DON) stated that all respiratory tubing and equipment should be bagged when not in use.
4.) R18's Order Summary dated 2/16/23 documents R18 was admitted to the facility on [DATE]. This Order Summary documents R18's diagnoses including Acute Pulmonary Edema, Recurrent Depressive Disorders, Hypertension, Presence of Cardiac Pacemaker and Atrial Fibrillation. This Order Summary does not document an order for oxygen administration.
R18's Progress Notes dated 2/7/23 at 6:55 AM documents R18 complained of not being able to use R18's left arm or left leg. R18's Progress Notes dated 2/7/23 at 6:58 AM documents staff spoke to Physician and awaiting ambulance. R18's Progress Notes dated 2/7/23 at 10:32 AM documents R18 was sent to a local hospital and then transferred to another hospital for further evaluation.
R18's Progress Notes dated 2/9/23 at 8:00 PM documents R18 was admitted back to the facility from the hospital with oxygen on at 1 liter. This note documents R18's oxygen desaturates on room air to 87% (percent). This note documents oxygen condenser and oxygen via nasal cannula was provided.
R18's Progress Notes dated 2/10/23 at 5:51 AM, documents oxygen in place.
On 2/14/23 at 9:15 AM, there was an oxygen concentrator in R18's room. There was oxygen tubing laying on top of the concentrator and draped onto the floor. The oxygen tubing and humidification bottle were not dated as to indicate when put into place.
On 2/16/23 at 9:40 AM, V7 Corporate Field Nurse confirmed R18 was in the hospital from [DATE] to 2/9/23 and confirmed the Nurse's Progress Notes document that R18 returned to the facility on oxygen. V7 stated that there should be an order for the oxygen in the computer and confirmed there was no order for the oxygen in R18's electronic medical record. V7 confirmed that the oxygen tubing should not be laying on the floor either.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5.) On 2/14/23 at 10:29 AM, R2's bed contained bilateral C shaped siderails (bed rails).
R2's Minimum Data Set, dated [DATE] do...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5.) On 2/14/23 at 10:29 AM, R2's bed contained bilateral C shaped siderails (bed rails).
R2's Minimum Data Set, dated [DATE] documents R2 has moderate cognitive impairment.
R2's Bed Rail Evaluation dated 11/18/22 documents R2 uses 1/4 bilateral siderails and no alternatives were attempted prior to use of the siderails.
On 2/16/23 at 10:13 AM V2 Director of Nursing stated siderails should have prior alternative interventions that were attempted and documented on the bed rail assessment.
4. R44's Bed Rail assessment dated [DATE] is incomplete for R44's use of Bed rails. This assessment documents alternatives were not attempted prior to installation of bed rails for R44.
On 2/14/23, R44's bed had a metal bed rail bar very loosely attached to the bed frame.
On 2/16/23 at 10:13 AM V2 Director of Nursing stated siderails should have prior alternative interventions that were attempted and documented on the bed rail assessment.Based on observation, interview, and record review the facility failed to attempt alternatives prior to the use of bed rails and accurately complete a side rail assessment for five of five residents (R23, R24, R38, R44, and R2) reviewed for bed rails on the sample list of 46.
Findings include:
The facility's side rail policy with a revision date of 1/10/2018 documents, Prior to the use of bed rails the facility will document assessment of use.
1. On 2/14/23 at 9:53 AM, R23 was lying in bed, there were bed rails up on both sides of the bed. R23's bed rail assessment dated [DATE] does not document interventions attempted prior to the use of the bed rails.
On 2/16/23 at 10:13 AM V2 Director of Nursing stated siderails should have prior alternative interventions that were attempted and documented on the bed rail assessment.
2. On 2/15/23 at 9:25 AM, R24 was lying in bed. A bed rail was up on both sides of the bed.
R24's bed rail assessment dated [DATE] documents R24 does not have bed rails on the bed.
On 2/16/23 at 10:13 AM V2 Director of Nursing stated siderails should have prior alternative interventions that were attempted and documented on the bed rail assessment.
3. On 2/15/23 at 9:30 AM, R38 was lying in bed. R38's bed rails were elevated on both sides of the bed. R38's bed rail assessment dated [DATE] does not documents interventions attempted prior to the use of the bed rails.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify targeted behaviors and nonpharmacological interventions att...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify targeted behaviors and nonpharmacological interventions attempt psychotropic medication reductions, document a rationale for not attempting medication reductions, develop a psychotropic medications care plan, and complete timely psychotropic assessments for five of five residents (R8, R38, R45, R6, and R49) on the sample list of 46.
Findings include:
1. R8's Medications Administration Record for 2/1/23 through 2/28/23 documents an order with a start date of 8/5/22 for 2.5 milligrams (mg) of Abilify (antipsychotic) everyday at 8:00 AM, an order with a start date of 6/11/21 for 20 milligrams of Celexa (antidepressant), an order with a start date of 5/25/22 for 10 milligrams of Buspar (anxiolytic) three times a day.
R8's psychotropic medication assessment dated [DATE] documents R8 has a diagnosis of Bipolar Disease and is receiving Abilify 2.5 mg every am, Celexa 20 mg every am and Buspar 10 mg twice a day. This assessment does not document which targeted symptoms R8 is being treated for. This assessment documents that a medication was attempted on 7/23/21 for medications #1. This assessment does not document which medication is medication #1. This assessment documents no medication reduction have been attempted for Medication #2 or #3 and does not provide a rationale as to why a reduction has not been attempted.
2. R38's Medication Administration Record dated 2/1/23 through 2/28/23 documents an order dated 10/15/22 for Mirtazapine Tablet 30 milligrams one tablet in the evening for Other Recurrent Depressive Disorders.
R38's Psychotropic assessment dated [DATE] documents a symptom of being depressed/withdrawn and documents an intervention to provide activities. R38's care plan does not include any nonpharmacological interventions or the intervention to provide activities.
3. R45's Medication Administration Record dated 2/1/23 through 2/28/23 documents an order dated 1/27/23 for Ativan 1 milligram every evening, an order dated 2/13/23 for Ativan 2 mg/milliliter (ml) give 0.25 ml 7:00 AM and 1:00 PM and 0.5 ml at 6:00 PM, an order dated 7/19/22 for Buspar 5 MG, 1 tablet by mouth two times a day for anxiety, and an order dated 2/13/22 for Seroquel 25 milligrams twice a day.
R45's psychotropic medication assessment dated [DATE] does not document which symptoms R45 is experiencing or which nonpharmacological interventions are being used.
R45's care plan with a review date of 2/8/23 does not include a psychotropic care plan.
On 2/16/23 at 10:50 AM, V2 Director of Nursing stated psychotropic assessments should be completed quarterly, targeted behaviors and nonpharmacological interventions identified and documented on the assessments, and behavior tracking should match what is on the assessment. V2 stated the care plan should also match the psychotropic assessment and targeted behaviors and nonpharmacological interventions should be on the care plan.
4.) R6's Order Summary dated 2/15/23 documents diagnoses including Dementia, Unspecified Severity with Agitation, Hypothyroidism, Hypertension and Depression. This Order Summary documents R6 was admitted to the facility on [DATE].
R6's Medication Administration Record (MAR) dated 1/1/23 through 1/31/23 documents an order for Quetiapine Fumarate ER (Extended Release) (Antipsychotic) 150 mg (milligrams) at bedtime with a start date of 1/16/23.
R6's Psychoactive Medication Initial and Quarterly Evaluation is dated 1/25/23 and documents it is the initial assessment for the antipsychotic medication Quetiapine.
5.) R49's Order Summary dated 2/16/23 documents diagnoses including Anxiety Disorder and Major Depressive Disorder, Recurrent. This Order Summary documents R49 was admitted to the facility on [DATE]. This Order Summary documents an order for Buspirone HCL (hydrochloride) 5 mg (antianxiety) by mouth two times a day for anxiety with a start date of 11/4/22 and an order for Venlafaxine HCL ER 150 mg (antidepressant) by mouth in the morning for depression with a start date of 11/5/22.
R49's Psychoactive Medication Initial and Quarterly Evaluation is dated 1/26/23 and documents it is a quarterly assessment for the antianxiety medication Buspirone and the antidepressant medication Venlafaxine.
On 2/16/23 at 9:40 AM, V7 Corporate Field Nurse stated that they recently completed audits for the psychotropic medications. V7 stated that V7 is aware that the residents did not have the initial and quarterly assessments as required for psychotropic medications but they have started to complete them with the MDS (Minimum Data Set) assessments quarterly.
0
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to administer medications in accordance with Physician's Orders and manufacturer's recommendations for two of three residents (R1...
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Based on observation, interview, and record review the facility failed to administer medications in accordance with Physician's Orders and manufacturer's recommendations for two of three residents (R105, R22) reviewed for medication administration in the sample list of 46. The facility had 4 medication errors out of 26 opportunities resulting in a 15.38% (percent) medication error rate.
Findings include:
The Medication Administration policy dated 1/11/10 documents, Policy: It is the policy of this facility to accurately administer medication following physician's orders. Missed doses of medication may occur at points in time related to lack of availability by suppliers, drug recalls, etc. In such cases, the facility will notify the contracted back up pharmacy or resident family (in cases where the family is the provider of these medications, such as is common with some insurance and VA {Veterans Administration} medications) for provision to the facility.
1.) R105's Order Summary dated 2/15/23 documents an order for Sucralfate oral tablet 1 GM (Gram), give one tablet by mouth two times a day for supplement with a start date of 2/15/23 and an order for Hydrochlorothiazide oral tablet 25 mg (milligrams), give one tablet by mouth in the morning for Hypertension with a start date of 2/15/23.
On 2/15/23 at 7:45 AM, V8 Registered Nurse (RN) administered R105's morning medications. V8 stated that there was no Sucralfate or Hydrochlorothiazide for R105 and V8 stated these two medications were not in the convenience box and V8 would have to get them from the back up pharmacy.
2.) R22's Order Summary Report dated 2/15/23 documents an order for Aspirin tablet 81 mg, give one tablet by mouth in the morning related to Essential Hypertension with a start date of 7/11/22 and an order for an order for Vitamin D Capsule, give 5,000 units by mouth in the morning for Vitamin D level low with a start date of 3/16/19.
On 2/15/23 at 8:18 AM, V3 RN administered R22's morning medications. V3 administered one Aspirin chewable 81 mg and stated there was no Vitamin D 5,000 units. V3 confirmed there was no Vitamin D 5,000 units in the convenience box. V3 stated V3 ordered R22's Vitamin D 5,000 units at this time.
On 2/15/23 at 12;57 PM, V2 Director of Nursing stated V2 expects the nurse's to call the pharmacy if they do not have a resident's medications and pull the medications from the convenience box. V2 stated if they do not have the medication in the convenience box they have a back up pharmacy in town that they can get the medications from.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to store medications separately from food. This failure affects 20 residents (R26, R1, R12, R44, R47, R43, R19, R28, R5, R22, R30,...
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Based on observation, interview and record review the facility failed to store medications separately from food. This failure affects 20 residents (R26, R1, R12, R44, R47, R43, R19, R28, R5, R22, R30, R10, R25, R50, R46, R17, R45, R33, R35, R51) with medications in the refrigerator.
Findings include:
On 2/15/23 at 3:46 PM, V15 Registered Nurse completed the medication storage room tour. At this time there was pudding, applesauce, gelatin, individual thickened water, nutritional shakes, beer, wine, juice and whiskey in the medication refrigerator. In this same refrigerator were medications for specific residents and stock medications for back up supply. There was also Influenza vaccine vials and Tubersol vials in this same refrigerator with the food and drinks.
On 2/16/23 at 8:58 AM, V7 Corporate Field Nurse supplied a list of items in the medications refrigerator. This list documents the refrigerator contains Lorazepam (antianxiety) concentrate for R26, R1, R12, R44, R47 and R43, Levemir (insulin) and Novolog (insulin) for R19, Latanoprost eye drops for R28 and R5, Trulicity (antidiabetic injection) for R5, Humalog (insulin) and Lantus (insulin) for R22, Tresiba (insulin) for R30, Lispro (insulin) and Lantus (insulin) for R10, Dulcolax suppositories for R1, R25, R50, R43, R46, R17, R45, R44, R33, R47, R12, R35, R26, R51, Tylenol Suppositories for R44, R1, R43, R12, R47, R45 and R26. This list documents that the medication refrigerator also contains stock supply of Tubersol solution, Influenza vaccine, High dose Influenza vaccine, stock Novolog 70/30, Basaglar (insulin), Novolog, Humalog, Lantus and Levemir. This list documents that the medication refrigerator contains beer, wine, applesauce, juices, nutritional shakes, whiskey, gelatin and thickened water.
On 2/16/23 at 9:40 AM, V7 confirmed that food and drinks should not be stored in the same refrigerator as medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to serve residents meals as per the dietary spreadsheet. This failure affects seven residents (R9, R15, R21, R28, R48, R51, R255)...
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Based on observation, interview and record review, the facility failed to serve residents meals as per the dietary spreadsheet. This failure affects seven residents (R9, R15, R21, R28, R48, R51, R255) reviewed for dietary food service on the sample list of 46.
Findings include:
The facility's Week 2 Wednesday Diet Spreadsheet documents residents requiring Low Concentrated Sweets (LCS) diets portion sizes to be served at the noon/lunch meal including the following:
1 square piece of Lasagna
8 ounce scoop of tossed salad with dressing
1/2 slice of Garlic Bread
1/2 square Chocolate Peanut Butter Cake.
The facility's Diet Type Report dated 2/14/23 documents R9, R15, R21, R28, R48, R51 and R255's current diet types which include LCS.
On 2/15/23 starting at 12:00pm, the facility served R9, R15, R21, R28, R48, R51 and R255's lunch meals which included a full slice of Garlic Bread and a full square of cake to each resident listed.
On 2/16/23 at 2:10pm, V4, Dietary Manager (DM) stated the facility is to follow the dietary spreadsheets for each diet type, including serving sizes. V4 stated V4 was unaware the facility did not serve the half portions of the garlic bread and cake to residents who received the LCS diet with those items.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer influenza and pneumococcal vaccinations, obtain/track resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer influenza and pneumococcal vaccinations, obtain/track resident influenza and pneumococcal vaccination information and document the information in the resident's medical record for four (R255, R50, R48, R6) of five residents reviewed for immunizations in the sample list of 46.
Findings include:
The facility's undated list of resident influenza and pneumonia vaccine status documents the following: R255's and R6's influenza and pneumococcal vaccine information is blank and does not document if they have received influenza or pneumococcal vaccines, or that they were offered and refused. R50 and R48 refused the influenza vaccine and there is no documentation listed for the pneumococcal vaccine.
1.) R255's Census dated 2/15/23 documents R255 admitted to the facility on [DATE]. R255's medical record does not document that R255 was offered the influenza and pneumococcal vaccines or R255's vaccine history/information.
2.) R50's Census dated 2/15/23 documents R50 admitted to the facility in November 2022. R50's Diagnoses List dated 2/15/23 documents R50 has Multiple Sclerosis.
There is no documentation in R50's medical record that R50 was offered the influenza and pneumococcal vaccines or that R50 declined the vaccines. There is no documentation in R50's medical record regarding R50's pneumococcal and influenza vaccine history/information.
3.) R48's Medical Record does not document that the influenza and pneumococcal vaccines were offered or that R48 declined the vaccines. There is no documentation in R48's medical record regarding R48's pneumococcal and influenza vaccine history/information.
R48's Diagnoses List dated 2/16/23 documents R48 has Chronic Obstructive Pulmonary Disease, Asthma, and a history of Legionnaire's Disease.
4.) R6's Census dated 2/16/23 documents R6 admitted to the facility on [DATE]. There is no documentation in R6's medical record that the influenza and pneumococcal vaccines were offered or R6's vaccine history/information.
On 2/15/23 at 9:53 AM V2 Director of Nursing provided the facility's list of resident immunizations. V2 stated there are some residents that we are waiting for them to provide documentation of their immunization information/history. On 2/15/23 at 12:05 PM V2 stated if a resident refuses an immunization there would be documentation of the refusal in the resident's medical record. V2 stated R48 and R50 refused the influenza vaccine. V2 confirmed the facility's list of resident immunizations does not document pneumococcal vaccine information and influenza information for R6 and R255. On 2/15/23 at 12:40 PM V2 stated the facility does not have documentation to provide for R6's, R48's, R50's, an R255's influenza and pneumococcal vaccination status. V2 stated V10 Medical Records was to obtain resident vaccination information, but has not.
The facility's Pneumococcal Pneumonia Vaccination Policy dated as revised April 2022 documents: All residents admitted will be screened to determine eligibility for the pneumococcal pneumonia vaccines (Prevnar 20, Pneumococcal Conjugate Vaccine - PCV13 and Pneumococcal Polysaccaride Vaccine- PPSV23). A physician's order is required for administration of any of the vaccines to current residents and new admissions at high risk for the disease (e.g. (for example), those 65 years and older, those with chronic illness such as lung, heart, or kidney disease, sickle cell anemia, or diabetes, those recovering from acute illness, those in nursing homes or other chronic care facilities, those with a weekend immune system). The resident or legal representative is provided education (copies of vaccine information statements) regarding the benefits and potential side effects of the vaccinations and a signed consent is obtained. The resident or legal representative has the opportunity to refuse these vaccinations. This will be documented on the Vaccination Consent.
The facility's undated Influenza Vaccination Policy documents: All residents will be screened to determine risk factors prior to giving the vaccination. The resident and or power of attorney for health care will be educated as to the benefits and risks of receiving the vaccination (given copies of vaccine information statement). A Vaccination Consent will be completed prior to giving the vaccination. Each resident is offered the vaccination annually, which is usually between October 1st and March 31st (unless other factors such as regulatory agencies or the CDC extend the flu season), unless the vaccination is medically contraindicated, or the resident has already received the vaccination, during this same time period. Each resident and/or the residents' power of attorney for health care have the opportunity to refuse the vaccination. This choice will be documented on the Vaccination Consent. The Vaccination Consents will be added to the chart of the resident and the vaccine will be administered per the physician's order if not contraindicated or refused.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to offer a COVID-19 (Human Coronavirus 2019) primary and b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to offer a COVID-19 (Human Coronavirus 2019) primary and booster vaccines, and obtain resident COVID-19 immunization information for four of (R255, R50, R48, R6) of five residents reviewed for immunizations in the sample list of 46.
Findings include:
On 2/14/23 at 8:35 AM there was a sign dated 2/8/23 posted at the entrance of the facility documenting the facility currently has COVID-19 positive cases and is considered to be in outbreak status.
The facility's list of resident COVID-19 vaccination status documents R255, R50, R48, and R6 are not up to date on COVID-19 vaccination, and R48 and R50 declined the COVID-19 vaccine. This list does not document COVID-19 vaccination information for R255.
1.) R255's Census dated 2/15/23 documents R255 admitted to the facility on [DATE]. R255's medical record does not document that R255 was offered the COVID-19 vaccine or R255's COVID-19 vaccine history/information.
2.) R50's Census dated 2/15/23 documents R50 admitted to the facility in November 2022. R50's Diagnoses List dated 2/15/23 documents R50 has Multiple Sclerosis. R50's medical record does not document that R255 was offered/declined the COVID-19 vaccine or R50's COVID-19 vaccine history/information.
3.) R48's Medical Record does not document that R48 was offered/declined the COVID-19 vaccine or R48's COVID-19 vaccine history/information. R48's Diagnoses List dated 2/16/23 documents R48 has Chronic Obstructive Pulmonary Disease, Asthma, a history of COVID-19 in August 2022, and a history of Legionnaire's Disease.
4.) R6's Census dated 2/16/23 documents R6 admitted to the facility on [DATE]. R6's COVID-19 Vaccination Record Card documents R6 received a primary dose of a one step series in April 2021. There are no other documented COVID-19 Vaccines. R6's Medical Record does not document R6's COVID-19 Vaccine history/information or that R6 was offered/declined a COVID-19 booster vaccine.
On 2/15/23 at 9:53 AM V2 Director of Nursing provided the facility's list of resident immunizations. V2 stated there are some residents that we are waiting for them to provide documentation of their immunization information/history. On 2/15/23 at 12:05 PM V2 stated if a resident refuses an immunization there would be documentation of the refusal in the resident's medical record. V2 stated R48 and R50 refused the COVID-19 vaccine. V2 confirmed the facility's list of resident immunizations does not document COVID-19 vaccine information for R255. V2 confirmed R6 is not up to date on COVID-19 Vaccination, and the list does not document a COVID-19 was offered/declined/given. V2 stated the facility had a COVID-19 booster clinic in October 2022, and has not offered a booster clinic since then. V2 stated the COVID-19 vaccines are available to be ordered from the pharmacy and administered. On 2/15/23 at 12:40 PM V2 stated the facility does not have documentation to provide for R6's, R48's, R50's, an R55's COVID-19 vaccination status, including vaccination refusals/consent forms. V2 stated V10 Medical Records was to obtain resident vaccination information, but has not.
The facility's COVID-19 Testing and Response Plan dated as revised 1/5/23 documents: Vaccination remains a critical piece of COVID-19 Prevention & is important in reducing hospitalizations & death from COVID-19. Community will continue to promote and provide vaccination and boosters for all residents and staff. Community will continue to encourage residents, staff, and families to remain up to ate with COVID-19 vaccination, including all eligible booster doses. Community will maintain a record of the vaccination status of residents and staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected multiple residents
5.) On 2/14/23 at 2:00 PM, R2's bed contained bilateral C shaped siderails that were loose, and moved side to side, parallel with R2's bed. On 2/15/23 at 8:42 AM R2 was lying in bed and R2's bed had b...
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5.) On 2/14/23 at 2:00 PM, R2's bed contained bilateral C shaped siderails that were loose, and moved side to side, parallel with R2's bed. On 2/15/23 at 8:42 AM R2 was lying in bed and R2's bed had bilateral siderails.
On 2/16/23 at 11:34 AM V25 Maintenance Assistant stated the Certified Nursing Assistants are to notify maintenance if the siderails are loose. V25 stated we try to assess the siderails for stability on a quarterly basis. At 11:40 AM V25 stated the C shaped siderails have a bolt and pin latch, and these type of siderails are always loose. At 11:48 AM V25 inspected R2's siderails and confirmed R2's siderails were loose, and able to be moved from side to side, parallel with R2's bed. V25 checked the bolt and stated the bolt was already tight, and could not be tightened.
4. On 2/14/23, R44's bed had a metal side rail bar very loosely attached to the bed frame.
On 2/16/23 at 11:08 AM V24, Maintenance Director stated the facility uses a test kit that is sent from corporate once per year to assess side rails for risk for entrapment and these assessments are kept in a binder. V24 stated the facility does not have access to the kit until the kit is provided by corporate. V24 provided documentation these were last done in October 2022.
On 2/16/23 at 11:34 AM, V25, Maintenance Assistant stated the Certified Nursing Assistants are to tell maintenance staff if the side-rails are loose so they can be tightened. V25 stated the facility tries to assess side rails quarterly to see if they are loose. At 11:45 AM V25 entered R44's room and R44's bed had metal C shaped side rails attached to R44's bed. V25 tested and confirmed the side rail was loose. V25 checked the bolt under R44's bed and stated the bolt was loose and needed to be tightened.
Based on observation, interview, and record review the facility failed to inspect bed rails to identify areas of entrapment, failed to ensure bed rails were secured to the bed frame, and failed to ensure the mattress fit securely against the side rails for five of five residents (R23, R24, R38, R44, and R2) reviewed for bed rails on the sample list of 46.
Findings include:
1. On 2/14/23 at 9:53 AM, R23's was lying in bed. There were side rails up on both sides of the bed.
On 2/16/23 at 11:18 AM, V25 Maintenance Assistance stated R23's bed and rails have not been inspected for areas of entrapment.
2. On 2/15/23 at 9:25 AM, R24 was lying in bed. A Side rail was up on both sides of the bed. The side rails are loose and move freely when shook back and forth. There is a six inch gap between the mattress and the side rails.
On 2/16/23 at 12:05 PM, V25 Maintenance Assistant inspected R24's bedrails. At that time, V25 confirmed the side rails were loose and not tightly secured to the bed frame. V25 the gap between the rail and mattress was 3 inches.
3. On 2/15/23 at 9:30 AM, R38 was lying in bed. R38's side rails were elevated on both side of the bed. The side rails moved freely when shook. There was at least a six inch gap between the side rail and the bed. The mattress was moving.
On 2/16/23 at 11:18 AM, V25 Maintenance Assistant stated R38's bed and rails have not been inspected for areas of entrapment. At 11:40 AM, V25 entered R38's room to inspect R38's bed and rails. There was 16 inches between the head board and rail. V25 said the bed rails were loose and V25 was unable to tighten the bed rails.
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 properly store raw poultry to prevent cross contamination. The facility also failed to ensure food preparation equipment was d...
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Based on observation, interview and record review, the facility failed to properly store raw poultry to prevent cross contamination. The facility also failed to ensure food preparation equipment was disposed of/replaced when worn, cracked or broken and failed to ensure hand hygiene was performed after removing gloves and donning new gloves during food preparation. These failures have the potential to affect all 54 residents residing in the facility.
Findings include:
On 2/14/23 at 9:15am, the kitchen equipment storage shelving contained a green cutting board that was extremely worn with deep marks.
On 2/14/23 at 9:35am, the cooler in the main area of the kitchen had a laminated undated Proper Food Storage sheet that documents raw poultry is to be placed on the bottom shelf and that raw foods which require higher cooking temperatures must be stored below or separately from foods requiring lower cooking temperatures to prevent cross contamination. This sheet documents the cooking temperature of raw poultry of 165 degrees Fahrenheit (F) and ground beef and pork products cooking temperature of 155 degrees F. This cooler contained two pans of raw, uncooked chicken thighs. This cooler also contained a pan of ground beef patties covered with a white paper like sheet, and two trays of two five pound packages of ground beef all located/stored under the raw, uncooked chicken thighs. At this time, V4, Dietary Manager stated V5, [NAME] would be educated on the proper storage of raw poultry/chicken and moved the trays of raw chicken to the bottom of the cooler, below all other foods in the cooler.
On 2/15/23 at 10:14am, the facility's kitchen equipment storage shelving contained an extremely worn green cutting board, two extremely worn red cutting boards and a blue colander that had a broken/cracked edge. At this time, V4, Dietary Manager was notified and confirmed they were extremely worn/broken and V4 took these items and disposed of them in the trash.
On 2/15/23 at 10:44am, V4, Dietary Manager stated the three cutting boards and the blue colander needed replaced and V4 has not looked at the condition of those items lately. V4 stated V4 tries to replace them on a regular basis.
On 2/15/23 at 10:32am, V13, [NAME] was preparing the noon/lunch meal for the residents. V13 donned gloves and placed a total of 50 pieces of white Texas bread on three different different metal pans. V13 removed V13's gloves, touched V13's top/shirt, did not wash V13's hands and obtained a small metal pan. V13 placed a piece of parchment paper on the bottom of this pan. V13 then donned one glove to V13's left hand without washing V13's hands/performing hand hygiene and placed one slice of gluten free bread in the pan.
On 2/16/23 at 2:10pm, V4, Dietary Manager stated V13 should have washed V13's hands after removing the gloves from V13's hands and before preparing the gluten free bread but did not. V4 stated V4 has already began to inservice dietary staff regarding hand hygiene and gluten free food preparation after observing the lack/absence of hand hygiene on 2/15/23 at 10:32am.
The facility's Hand Washing and Glove Use policy dated February 2022 documents proper handwashing is cleaning hands and exposed arms by applying soap and warm water, rubbing them together vigorously and rinsing and drying them thoroughly. Hand washing is important to get rid of dirt and reduce germs that can cause illness. This policy documents hands should be washed when changing food preparation tasks and before putting on new, single use gloves and between glove changes. This policy documents hand sanitizers are not to be used in place of proper hand washing in food preparation areas. This policy also documents gloves are effective in preventing contamination only if used properly.
The facility's Resident Census and Conditions of Residents Report dated 2/15/23 documents 54 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to maintain an infection control surveillance program that tracks/analyzes/monitors resident and employee illnesses to identify a...
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Based on observation, interview, and record review the facility failed to maintain an infection control surveillance program that tracks/analyzes/monitors resident and employee illnesses to identify any trends and patterns, and failed to conduct surveillance of staff and resident COVID-19 (Human Coronavirus Infection) infections during an outbreak. This failure has the potential to affect all 54 residents residing in the facility. The facility also failed to ensure staff removed or disinfected personal protective equipment after the care of a COVID-19 positive resident (R15) and prior to caring for COVID-19 negative resident (R25), failed to conduct symptom monitoring and vital signs every four hours for COVID-19 positive resident (R28), and failed to ensure staff wore eye protection during a COVID-19 outbreak for R12.
Findings include:
On 2/14/23 at 8:35 AM there was a sign dated 2/8/23 posted at the facility entrance that documented the facility currently had COVID-19 positive cases and was in outbreak status.
The undated COVID-19 positive staff list documents V11 Certified Occupational Therapist (COTA) tested positive on 2/8/23 and V22 Director of Rehab (DOR) tested positive on 2/13/23.
The facility's COVID-19 testing logs document R28 and R15 tested positive on 2/13/23, and R32, R42, R2, and R24 tested positive on 2/16/23.
1.) The facility's Resident Infection Control Logs dated September 2022-January 2023 do not document the facility completed the monthly process surveillance forms (which includes outcome of surveillance data analysis, action taken, and that the employee infection record was reviewed) until January 2023. October and November logs do not document a cumulative total of infections by type or the facility's infection rate of in house infections. The facility did not have a current resident/staff Infection Control Log for February 2023 as of 2/16/23, and the facility has been in COVID-19 outbreak status as of 2/1/23. There was no documentation that V2 Director of Nursing/Infection Preventionist monitors employee illnesses for any trends/patterns in comparison with resident illnesses.
On 2/15/23 at 1:31 PM V2 stated prior to January 2023 the monthly process surveillance infection control forms were not being completed. At 3:13 PM V2 stated V20 Human Resources (HR) tracks employee illnesses. On 2/16/23 at 10:13 AM V2 stated V23 Certified Occupational Therapy Assistant (COTA) tested positive for COVID-19 on 2/2/23, V11 COTA tested positive on 2/8/23, and V22 Director of Rehabilitation tested positive on 2/13/23. R34 was the first resident to test positive on 2/12/23. V2 stated R28 and R15 tested positive on 2/13/23, V17 Certified Nursing Assistant (CNA) tested positive on 2/15/23, and R32, R42, R2, and R24 tested positive on 2/16/23. V2 confirmed the facility did not have an infection control log for February 2023 or a log for COVID-19 positive staff/residents to monitor/track infections and identify any trends/patterns. V2 stated V2 does not complete the infection logs until the end of each month. V2 stated V2 does not conduct surveillance regarding employee illnesses or compare employee illnesses to resident illnesses to identify any trends/patterns.
On 2/15/23 at 3:14 PM V20 HR stated employee call offs are reviewed as part of the morning management team meetings. V20 stated V20 only logs employee illnesses related to COVID-19/respiratory symptoms.
The facility's Resident Census & Condition of Residents dated 2/15/23 documents 54 residents reside in the facility.
The facility's Surveillance policy revised April 2022 documents: The Infection Preventionist is responsible for gathering infection surveillance information, and this should be done routinely on an ongoing basis. Data collected is recorded on the monthly infection logs. These logs are utilized to identify infection trends and the facility determines if any changes in practice is necessary to minimize the spread of infections and improve infection prevention. Process surveillance includes reviewing compliance in practices that relate to resident care such as transmission based precautions, hand hygiene, and the use of personal protective equipment.
2.) R28's medical record documents R28's vitals and COVID-19 symptom monitoring was conducted 1-2 times per day between 2/13/23 and 2/16/23, after R28 tested positive for COVID-19 on 2/13/23.
On 2/14/23 at 9:35 AM R28 stated R28 tested positive for COVID-19 and R28's symptoms included cough and runny nose. R28 stated staff are checking R28's vitals 1-2 times per day.
On 2/16/23 at 10:13 AM V2 confirmed vital sign and symptom monitoring for COVID-19 positive residents should be done every 4 hours and documented in the resident's electronic medical record.
3.) On 2/14/23 at 8:40 AM there was a sign posted at the nurse's station that stated as of 2/9/23 all staff must wear a mask and eye protection.
On 2/14/23 at 9:11 AM V21 Hospice CNA was sitting near R12 in R12's room. V21 was wearing a surgical mask and was not wearing eye protection.
On 2/16/23 at 10:13 AM V2 stated currently all staff, including hospice staff, should be wearing eye protection while in the facility.
4.) On 2/14/23 between 9:00 AM and 10:00 AM V18 and V19 CNAs were working the 200 hall and entering COVID-19 negative rooms. R28's and R15's (COVID-19 positive) rooms are also located on the 200 hall.
On 2/14/23 at 12:03 PM V18 applied an N95 respirator, gown, gloves and wore eye protection that V18 already had on, and entered R15's room. V18 then left R15's room, removed V18's gown, gloves, and disposed of V18's N95 mask. V18 did not change or disinfect V18's eye protection.
On 2/14/23 at 12:09 PM V18 stated eye protection should be disinfected upon leaving a COVID-19 positive room. V18 confirmed V18 did not disinfect V18's goggles upon leaving R15's room. V18 stated the disinfectant spray should be kept in the cart that contains personal protective equipment (PPE) located outside of the resident room. V18 confirmed the PPE carts located outside of R15's and R28's rooms did not contain a disinfectant. V18 stated COVID-19 positive residents do not have dedicated vital sign equipment, the equipment is shared and should be sprayed with the same disinfectant (that is used for the eye protection) between each resident use.
On 2/14/23 at 12:41 PM V19 CNA entered R15's room wearing gown, gloves, N95 respirator, and eye protection. V19 delivered R15's meal tray, setup R15's meal and touched R15's overbed table. V19 then delivered and prepared R25's (R15's COVID-19 negative room mate) meal touching R25's overbed table and eating utensils. At 12:46 PM V19 left R25's/R15's room and did not change/disinfect V19's eye protection.
On 2/14/23 at 1:30 PM V19 CNA stated PPE is changed between the care of COVID-19 positive and negative residents including room mates, or we are to provide care for the negative room mate prior to caring for the positive room mate. V19 stated eye protection is to be disinfected when leaving a COVID-19 positive room. V19 confirmed V19 did not disinfect V19's eye protection upon leaving R15'/R25's room and confirmed V19 did not change V19's PPE between delivering and setting up meals for R15 and R25.
On 2/16/23 at 10:13 AM V2 stated: Staff should change PPE between the care of COVID-19 positive and negative room mates. Staff should disinfect goggles when leaving a COVID-19 room and then place the goggles into the PPE cart located outside of the resident's room.
The Facility's COVID-19 Testing & Response Plan dated as revised 1/5/23 documents: Monitor symptoms and vital signs every 4 hours for COVID-19 positive residents in order to identify and treat serious infections. Staff should wear eye protection and a well fitted face mask when the COVID-19 Community Transmission Level is high.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to ensure urine and wound cultures were obtained to ensure appropriate use of antibiotics. This failure has the potential to affect all 54 resi...
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Based on interview and record review the facility failed to ensure urine and wound cultures were obtained to ensure appropriate use of antibiotics. This failure has the potential to affect all 54 residents residing in the facility.
Findings include:
The facility's undated Antibiotic Stewardship Protocol documents: Antibiotic Stewardship is part of the Infection Prevention and Control Program and includes a committee consisting of the Medical Director, Director of Nursing, Infection Preventionist, and consulting pharmacist. The committee will review/monitor infections, antibiotic usage, hospital antibiograms, and patterns of antibiotic resistant organisms. Diagnostic testing will be used in accordance with physician's orders. The antibiotic risk management tools include to review the appropriateness of antibiotic administration and review of cultures and laboratory results. The Infection Preventionist will review whether tests, including cultures, were completed and whether the antibiotic ordered was appropriate based on the sensitivity report.
The facility's Infection Control Logs from September 2022- January 2023 document: In September R34 received an antibiotic for a urinary tract infection (UTI). The culture/sensitivity was obtained at the hospital, and the organism is listed as not applicable. R34 is also listed as having Clostridium Difficile. R41 and R21 received antibiotics for UTIs. The organisms from the culture results are not identified and lists Bacteremia. In November R39 received an antibiotic for a UTI and a urine culture was not completed. R7 received Doxycycline (no dose documented) for ten days for a wound infection. Methicillin-Resistant Staphylococcus Aureas (multidrug resistant organism) is listed as the organism, but a culture was not done. In December R26 received an antibiotic for a UTI and a culture was not completed. R7 continued to receive Doxycycline 100 mg for a wound infection and Ciprofloxacin 250 mg twice daily for 14 days beginning on 12/20/22 for a wound infection. There was no culture completed to identify the organism and antibiotic sensitivity. R33 received an antibiotic for a wound infection and there was no culture completed. In January R33 and R7 received antibiotics for wound infections, and R305 received an antibiotic for a UTI. There were no cultures completed for R33, R7, and R305 .
On 2/16/23 at 10:13 AM V2 Director of Nursing/Infection Preventionist stated cultures are done if ordered by the physician, and cultures are used to determine the antibiotic prescribed is appropriate. V2 reviewed the facility's infection control binder and confirmed urine and wound infections are being treated with antibiotics without cultures being completed.
The facility's Resident Census and Conditions of Residents dated 2/15/23 documents 54 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to notify residents and resident representatives after two COVID-19 confirmed cases and provide cumulative updates. This failure ...
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Based on observation, interview, and record review the facility failed to notify residents and resident representatives after two COVID-19 confirmed cases and provide cumulative updates. This failure has the potential to affect all 54 residents residing in the facility.
Findings include:
On 2/14/23 at 8:35 AM there was a sign dated 2/8/23 posted at the facility entrance that indicated the facility had COVID-19 positive staff cases and was in outbreak status. This sign did not document a cumulative total of COVID-19 positive staff/residents. This same sign remained posted on 2/15/23 and 2/16/23 at 8:20 AM.
On 2/14/23 at 9:35 AM R28 stated R28 recently tested positive for COVID-19, and R28 has not received any communication from the facility regarding the total number of positive staff or residents. On 2/14/23 at 9:40 AM R22 stated the facility has not provided information to R22 regarding the number of COVID-19 positive cases.
There is no documentation in R28's and R22's medical records that the facility informed them or their representatives of COVID-19 positive cases prior to 2/13/23.
The undated COVID-19 positive staff list documents V11 Certified Occupational Therapy Assistant tested positive on 2/8/23 and V22 Director of Rehabilitation tested positive on 2/13/23. The COVID-19 Testing Logs document 3 residents tested positive on 2/13/23.
The letter signed by V1 Administrator dated 2/8/23, documents the facility has additional COVID-19 staff member(s). The letters dated 2/12/23 and 2/13/23 document the facility has additional positive COVID-19 resident(s). These letters do not provide a cumulative total number of COVID-19 positive cases for the current outbreak.
On 2/14/23 at 3:06 PM V23 COTA stated V23 had been working at another facility that had an active COVID-19 outbreak. V23 tested positive on 2/1/23 when V23's COVID-19 symptoms started. V23 had provided therapy services to residents and worked in the facility for a few hours on 1/30/23.
On 2/15/23 at 12:10 PM V12 Social Services Director stated V12 and V16 Activity Director are responsible for notifying residents/representatives of COVID-19 cases during an outbreak. V12 stated a letter is given to each resident. V16 stated V16 notified resident representatives by phone on 2/13/23. Both V12 and V16 stated the total number of positive cases during an outbreak is not provided to the residents/representatives unless requested. On 2/15/23 at 2:13 PM V12 stated notification of COVID-19 cases is documented in the resident's progress notes. V12 stated we made calls when the one employee tested positive and it should be documented in the progress notes. V12 confirmed there is no documentation in the nursing notes of resident/representative notification of COVID-19 cases prior to 2/13/23. On 2/15/23 at 4:30 PM V12 provided a copy of an electronic mail dated 2/9/23 that documents a list of residents (R34, R35, R51, R39, R30, R8, R29, R255, R45, and R19 who were determined to have close contact exposure to COVID-19), a request to notify their families of the COVID-19 positive employee, and record the notification in the resident's electronic record. V12 stated they only notified the residents/representatives who had COVID-19 exposure from V11, and did not notify all residents/representatives of the confirmed COVID-19 positive case on 2/9/23. V12 confirmed the facility did not notify residents/representatives of the outbreak prior to 2/9/23.
On 2/16/23 at 10:13 AM V2 Director of Nursing/Infection Preventionist stated: The outbreak began on 2/8/23 when V11 tested positive. V23 tested positive on 2/2/23. V22 Director of Rehabilitation provided V2 with a list of four residents that V23 had provided care for within the 48 hours prior to testing positive. We tested these residents three times and they were negative. We didn't consider V23 as the start of the outbreak since V23 had worn a mask and worked in the facility such a short time prior to testing positive.
The Resident Census & Condition of Residents dated 2/15/23 documents 54 residents reside in the facility.
The facility's COVID-19 Testing & Response Plan dated as revised 1/5/23 documents: The Community informs residents/legally authorized representatives, staff, and families of the number of cases in the community by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19 using social media, written letters, telephone communications. Communications are recorded.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents (R35, R38, R51, R23, R50, R255, R4, R18, R19, R39, ...
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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 residents (R35, R38, R51, R23, R50, R255, R4, R18, R19, R39, R48, R42, R34, R30, R8, R29, R45) who had close contact exposure to COVID-19 (Human Coronavirus Infection) and employees were tested for COVID-19 during an outbreak in accordance with facility policy. This failure has the potential to affect all 54 residents residing in the facility.
Findings include:
The facility's COVID-19 Testing & Response Plan revised 1/5/23 documents: Asymptomatic residents and HCP (Health Care Personnel) with a close contact or higher-risk exposure with someone with SARS-CoV-2 (COVID-19) should have a series of three viral tests for SARS-CoV-2 infection unless they have recovered from COVID-19 in the prior 30 days. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If no additional cases are identified during contact tracing (testing only those residents or staff with a close contact or higher risk exposure) no further testing is indicated. If additional cases are identified from testing close contacts or higher-risk exposures, communities should expand testing as determined by the distribution and number of cases throughout the community and ability to identify close contacts. This is considered a broad-based approach. When using the broad-based approach a community should continue to test every 3-7 days until there are no more positive cases identified for 14 days. If additional cases are identified after testing a unit, floor, or specific area of the community, the community may expand testing to community-wide testing if testing and implementation of infection control measures have failed to halt transmission.
On 2/14/23 at 8:35 AM there was a sign dated 2/8/23 posted at the entrance of the facility that documented the facility had positive cases of COVID-19 and was currently in outbreak status.
On 2/15/23 at 3:33 PM V11 Certified Occupational Therapy Assistant (COTA) stated: V11 developed COVID-19 symptoms on 2/7/23 after V11 had left work. V11 had worked in the facility providing therapy services on 2/6/23 and 2/7/23. V11 worked with V22 Director of Rehabilitation (DOR) and had lunch with V22. V11 tested positive for COVID-19 on 2/8/23 and V11 provided the facility with a list of residents who had received therapy services from V11.
On 2/15/23 at 3:39 PM V22 DOR stated: V22 had congestion, sneezing, and body aches that started on 2/11/23. V22 had last worked in the facility on 2/10/23. V22 self tested on [DATE] and tested positive for COVID-19. V22 provided the facility with a list of residents that V22 had worked with prior to testing positive.
The facility's undated COVID-19 positive employee list documents V11 COTA tested positive on 2/8/23 and V22 DOR tested positive on 2/13/23.
The undated list of residents who received therapy services and identified to be a close contact, documents the following: V11 provided therapy services to R35, R38, R51, R23, R39, R48, R50, R255, R4, R18, and R19 between 2/6/23 and 2/7/23 prior to testing positive on 2/8/23. V22 provided therapy services to R35, R38, R51, R48, R255, R18, R42, R39, R4, and R19 between 2/9/23 and 2/10/23 prior to developing COVID-19 symptoms on 2/11/23 and testing positive for COVID-19 on 2/13/23.
The facility's Resident List Report dated 2/14/23 documents R34 resides with R19. R30 resides with R51. R8 resides with R39. R29 resides with R48. R45 resides with R255.
The facility's COVID-19 testing logs document the following: On 2/9/23 R23, R50, R255, R4 and R18 are not listed as being tested for COVID-19. There is no documentation that these close contact residents were tested again until all residents were tested on [DATE] (when R34, R28, and R15 tested positive). Residents were not tested again until 2/16/23, and R32, R42, R2, and R24 tested positive.
The facility's Employee Time Detail reports document the following employees worked between 2/9/23 and 2/16/23: V29, V30, V31, V32, V27, V34, V17, V36 Certified Nursing Assistants (CNAs), V33 Dietary, and V35 Housekeeper. These employees are not documented on the COVID-19 Testing Logs from 2/13/23-2/16/23.
On 2/16/23 at 10:13 AM V2 Director of Nursing (DON) stated V11 tested positive on 2/8/23 and the facility conducted contact tracing and identified residents receiving therapy services and their room mates as close contacts. V2 stated close contact residents are tested three times per facility policy. These residents were tested on [DATE] and 2/13/23. V2 stated V2 was not in the facility on 2/11/23 and had left a note for the nurses to conduct COVID-19 testing for the close contact residents on 2/11/23. V2 was unable to provide additional documentation of COVID-19 resident testing, besides the COVID-19 test logs. V2 stated R34 tested positive on 2/12/23 and V22, R28 and R15 tested positive on 2/13/23. V2 stated facility conducted community wide COVID-19 testing of all staff and residents on 2/13/23 and 2/16/23. All staff should have been tested by V20 Human Resources (HR) on 2/13/23, and V20 keeps the employee testing logs. V2 stated V17 CNA tested positive on 2/15/23, and R32, R42, R2, and R24 tested positive on 2/16/23. V2 stated the facility will continue community wide testing of staff and residents twice weekly and if symptomatic, until there are no new positive cases for 14 days.
On 02/16/23 at 10:51 AM V20 HR stated all staff that worked on 2/13/23 tested and some staff come in to test on their day off. If employees are not tested on routine testing days, then they should test at the beginning of their next scheduled shift. V20 stated V20 was not aware that V20 was responsible for overseeing staff COVID-19 testing. V20 stated V20 does not have a check list to verify that all staff are being tested routinely. V20 provided the COVID-19 testing logs for staff between 2/13/23-2/16/23. At 1:13 PM V20 stated V20 was unable to locate additional COVID-19 testing for staff between 2/13/23 and 2/16/23.
On 2/16/23 at 1:15 PM V2 DON stated V2 was unable to provide additional documentation of employee COVID-19 testing between 2/13/23 and 2/16/23. V2 stated V17 showed V2 V17's positive COVID-19 test on 2/15/23. V2 was unsure who conducted the test, and stated V17's test results are not documented anywhere. V2 stated V17 worked in the facility for about an hour on 2/14/23. V2 confirmed CNAs are assigned to halls within the facility but they do cross over to assist on the unassigned hallway and assist in the dining rooms.
The facility's Resident Census & Conditions of Residents dated 2/15/23 documents 54 residents reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to ensure an employee was fully vaccinated for COVID-19 (Human Coronavirus Infection), and develop a policy for employee COVID-19...
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Based on observation, interview, and record review the facility failed to ensure an employee was fully vaccinated for COVID-19 (Human Coronavirus Infection), and develop a policy for employee COVID-19 vaccination that includes a process for medical and religious exemptions, and additional precautions to mitigate the spread of COVID-19 for unvaccinated staff. This failure has the potential to affect all 54 residents residing in the facility.
Findings include:
The facility's COVID-19 Vaccination Policy dated 11/14/22 documents staff can work if they have received at least the first dose of a two dose series, and they must receive the second dose on schedule in order to be allowed to continue to work. Staff are exempt from this requirement if they have an approved medical or religious exemption, or if COVID-19 vaccination is temporary delayed when recommended by the Centers for Disease Control and Prevention (CDC). A line list should be used to ensure all staff and newly hired staff COVID-19 vaccination status is accounted for.
The facility's Employee COVID-19 Vaccination spreadsheet and V5's COVID-19 Vaccination Card document V5 [NAME] only received the first dose of a two step COVID-19 vaccine series on 10/4/22.
The facility's Dietary February 2023 Schedule documents V5 worked on 2/8, 2/13, and 2/14.
On 2/14/23 at 8:35 AM there was a sign posted at the entrance of the facility indicating the facility had positive cases of COVID-19 and was in outbreak status.
On 2/15/23 at 9:46 AM V2 Director of Nursing/Infection Preventionist stated V20 Human Resources tracks employee COVID-19 vaccinations. On 2/16/23 at 10:13 AM V2 stated the facility uses the CDC guidance regarding the time frame of COVID-19 vaccine administrations. V2 stated V2 was not aware until 2/15/23 that V5 had not received V5's 2nd dose of the primary COVID-19 vaccine. V2 stated V2 has not been following up with staff to ensure they are vaccinated for COVID-19 since V2 thought V20 was doing that.
On 2/15/23 at 10:21 AM V20 stated the former Administrator was updating the employee COVID-19 spreadsheet, and V20 has been updating the logs since. The facility offers/provides the COVID-19 vaccines and boosters, as well as the local pharmacies and hospital. V20 stated V5 has only had the first dose of the two step primary COVID-19 vaccination series and is eligible for the 2nd dose. V20 was not sure who follows up with employees to ensure they receive the 2nd dose timely.
On 2/15/23 at 3:24 PM V5 [NAME] stated: V5 has only received the 1st dose of the primary COVID-19 vaccine in October 2022. V5 has not had time to get the 2nd dose. The facility told V5 that V5 had to get the vaccine from a local pharmacy. V5 works primarily as a cook preparing food, but also assists as a dietary aide prepping and serving meal trays in the dining room.
The facility's Resident Census & Conditions of Residents dated 2/15/23 documents 54 residents reside 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, 1 life-threatening violation(s), 2 harm violation(s), $82,059 in fines, Payment denial on record. Review inspection reports carefully.
- • 56 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $82,059 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 Goldwater Care Gibson City's CMS Rating?
CMS assigns GOLDWATER CARE GIBSON CITY an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Goldwater Care Gibson City Staffed?
CMS rates GOLDWATER CARE GIBSON CITY's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 48%, compared to the Illinois average of 46%.
What Have Inspectors Found at Goldwater Care Gibson City?
State health inspectors documented 56 deficiencies at GOLDWATER CARE GIBSON CITY during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 53 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Goldwater Care Gibson City?
GOLDWATER CARE GIBSON CITY is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GOLDWATER CARE, a chain that manages multiple nursing homes. With 60 certified beds and approximately 54 residents (about 90% occupancy), it is a smaller facility located in GIBSON CITY, Illinois.
How Does Goldwater Care Gibson City Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, GOLDWATER CARE GIBSON CITY's overall rating (1 stars) is below the state average of 2.5, staff turnover (48%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Goldwater Care Gibson City?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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 Goldwater Care Gibson City Safe?
Based on CMS inspection data, GOLDWATER CARE GIBSON CITY 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 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Goldwater Care Gibson City Stick Around?
GOLDWATER CARE GIBSON CITY has a staff turnover rate of 48%, which is about average for Illinois nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Goldwater Care Gibson City Ever Fined?
GOLDWATER CARE GIBSON CITY has been fined $82,059 across 5 penalty actions. This is above the Illinois average of $33,899. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Goldwater Care Gibson City on Any Federal Watch List?
GOLDWATER CARE GIBSON CITY is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.