GLENVIEW TERRACE
For profit - Limited Liability company
314 Beds
LEGACY HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
58/100
#147 of 665 in IL
Photo by Glenview Terrace
Photo by Glenview Terrace
Photo by Glenview Terrace
1 / 10 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Glenview Terrace has received a Trust Grade of C, indicating it is average compared to other nursing homes, so families might want to weigh their options carefully. It ranks #147 out of 665 facilities in Illinois, placing it in the top half, and #50 out of 201 in Cook County, meaning there are only a few local options rated higher. However, the facility's trend is worsening, as the number of issues identified increased from 5 in 2024 to 6 in 2025. Staffing is a relative strength, with a rating of 3 out of 5 stars and a turnover rate of 40%, which is below the state average. On the positive side, there have been no fines, and the facility has more RN coverage than 87% of Illinois facilities, ensuring better monitoring of residents. On the downside, a critical incident involved two residents who were physically and verbally abused by a staff member, leading to hospitalization for both. Another serious issue resulted in a resident sustaining multiple facial and skull fractures due to inadequate supervision, which is alarming. There were also concerns about the facility failing to adhere to its abuse policy, which could potentially affect all 234 residents. Families should consider both the strengths and weaknesses when evaluating Glenview Terrace for their loved ones.
- Trust Score
- C
- In Illinois
- #147/665
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 40% turnover. Near Illinois's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Illinois facilities.
- Skilled Nurses ✓ Good
- Each resident gets 68 minutes of Registered Nurse (RN) attention daily — more than 97% of Illinois nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 14 deficiencies on record. Higher than average. Multiple issues found across inspections.
58/100
Top 22%
Review needed
5 → 6 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 6 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below Illinois average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 40%
Near Illinois avg (46%)
Typical for the industry
Chain: LEGACY HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 14 deficiencies on record
1 life-threatening 1 actual harm
Jun 2025
5 deficiencies
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 ensure ongoing monitoring and assessment to identify suprapubic stoma site drainage and skin impairment and obtain appropriate...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to ensure ongoing monitoring and assessment to identify suprapubic stoma site drainage and skin impairment and obtain appropriate treatment from the Physician. This deficiency affects one (R195) of three residents in the sample of 35 reviewed for Suprapubic catheter care management and quality of care.
Findings include:
On 6/11/25 at 9:27AM, observed R195 lying in bed with low air loss mattress. V19 CNA (Certified Nurse Assistant) lifted the top sheet and observed R195's disposable brief soaked with serosanguineous drainage on suprapubic area. V19 opened his brief and observed no dressing on suprapubic catheter site with moderate amount of serosanguineous drainage. The stoma site and surrounding skin noted with redness and irritation. The suprapubic catheter is not secured to the abdomen. The catheter is connected to the urinary drainage bag covered with privacy bag. R195 denied any pain. He said that he had a shower yesterday and did not have dressing after it was removed for the shower. R195 said that the nurses usually do his dressing twice a day. Called V7 (Agency Nurse) and showed observation made. V7 said that they do dressing to R195's suprapubic site every shift due to his drainage. V7 said that no one informed him that R195 does not have dressing on his suprapubic site. V7 called for V21 WCN (Wound Care Nurse).
On 6/11/25 at 9:31AM, V20 Agency CNA said that she is the assigned CNA for R195, but she is not aware that he did not have his supra pubic catheter dressing on. She has not yet provided him with morning care.
On 6/11/25 at 9:40AM, called V21 WCN and showed observation made. V21 opened his brief and observed no dressing on suprapubic catheter site with moderate amount of serosanguineous drainage. The stoma site and surrounding skin with redness and irritation. V21 said that he will assess, document and call physician for treatment orders.
R195 is admitted on 5/2024 with diagnosis listed in part but not limited to Obstructive and reflux uropathy, Benign prostatic hyperplasia, Limitation of activities due to disability, need for assistance with personal care. Active physician order sheet indicated: Zinc oxide to urinary meatus topically two times a day for skin irritation/rashes. Indwelling catheter type: Suprapubic catheter, catheter size 16F, 10cc balloon reason for use: Obstructive and Reflux uropathy ordered 6/11/25 after surveyor asked for his medical records. Suprapubic catheters care every shift. Change catheter drainage bag PRN (as needed). Change foley bag, tubing, and tube holder every night shift weekly. Monitor drainage around the stoma every shift. Monitor skin integrity around the stoma every shift. Suprapubic catheter: catheter care every shift. Cleanse area with NS (normal saline) pat dry leave open to air. Apply dressing only if site is observed with drainage and sign and symptoms of infection ordered date 6/12/25 after surveyor interviewed with V21 on 6/12/25. R195's skin/wound evaluation dated 6/11/25 documented by V21 WCN indicated seen patient today for skin assessment. Staff cleaned the area and upon assessment, skin surrounding the suprapubic catheter is intact, no redness, no drainage, and no s/s of infection. Patient is not in pain. Catheter is patent and draining clear colored urine. Dressing applied as ordered. Patient tolerated the procedure well. Patient made comfortable in bed. Call light within reach. Preventive measures in place.
On 6/12/25 at 9:33AM, Reviewed R195's medical records with V21WCN. Informed V21 of discrepancy with his documentation from what was observed yesterday with R195's suprapubic catheter site. V21 said that he observed R195's disposable brief on his suprapubic area was soaked with serosanguineous drainage. He said that he opened R195's brief and observed no dressing on suprapubic catheter site with moderate amount of serosanguineous drainage. The stoma site and surrounding skin with redness and irritation. He said that after he cleansed it, it did not look so bad and took picture. V21 took his phone and showed to 2 surveyors the picture he took of R195's suprapubic site. Surveyor asked V21 to describe the suprapubic site in the picture. V21 said that there is redness on the site and surrounding area. V21 said he was asked by his supervisor to take picture of R195's suprapubic site and sent the picture to her. Surveyor informed V21 that this is an invasion of resident privacy of taking picture from his personal phone. V21 said that he did not call the physician for treatment because they are putting barrier cream - Zinc oxide to the suprapubic site and they don't need physician order because it's a barrier cream. Informed V21 that R195's physician order sheet indicated Zinc oxide ointment to be applied to urinary meatus twice a day for skin irritation/rashes not for suprapubic site. Informed V21 that R195's reason for suprapubic catheter usage ordered date 6/11/25 was changed to Obstructive and reflux uropathy from BPH (Benign Prostatic Hypertrophy) after observation made with R195 and requested for documents yesterday.
On 6/12/25 at 10:40AM, Informed V8 WCC (Wound Care Coordinator) of above observations and concerns. V8 said that they cannot use their own personal cell phone to take picture of resident's suprapubic catheter site. Informed V8 that the nurses are not documenting drainage and changes in suprapubic site. Informed V8 that they failed to ensure ongoing monitoring and assessment to identify suprapubic stoma site drainage and skin impairment and obtained appropriate treatment from the Physician.
Facility's policy on Suprapubic Catheter reviewed 7/31/24 indicated:
Policy statement: The facility shall follow nursing guidelines for safe, aseptic care, removal and change of a suprapubic catheter in order to prevent infection and help maintain catheter patency.
Care guidelines:
2. Dressing around the stoma shall be changed daily and PRN. Monitor stoma site for any redness or maceration.
3. All suprapubic catheters must be secured to abdomen with an appropriate anchor device to prevent accidental dislodgement or removal.
Facility's policy on Skin regimen and Treatment formulary reviewed 3/24/25 indicated:
Policy statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown.
Procedures:
1. Charge nurses must document in the electronic health record any skin breakdown upon assessment and identification.
2. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician
c. other skin condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 6/10/25 at 10:45AM, observed R186 lying in bed with LAL (Low air loss) mattress. V7 Agency LPN (Licensed Practical Nurse) ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 6/10/25 at 10:45AM, observed R186 lying in bed with LAL (Low air loss) mattress. V7 Agency LPN (Licensed Practical Nurse) checked the linens over the mattress. Observed linen folded in quarters and flat sheet over the mattress. R186 is wearing disposable adult brief. Surveyor asked V7 of what the setting for R186's LAL mattress. V7 said he does not know. He said that the wound care team is responsible for setting and monitoring of resident's LAL mattress. Surveyor requested for the V8 WCC (Wound Care Coordinator) and requested to observe wound care.
On 6/10/25 at 10:46AM, informed V8 WCC of above observation. V8 said that resident on LAL mattress should only be on a flat sheet unless indicated in resident's care plan.
On 6/10/25 at 11:10AM, observed V8 adjusting R186's LAL mattress control panel. V8 said that R186 is not on appropriate setting as manufacturer recommendation. V8 said R186 weighs 84lbs and her setting was at 110lbs. V8 said that V10 Wound Tech usually make rounds to checks all the residents in the unit with LAL mattress for appropriate setting.
On 6/10/25 at 11:55AM, observed V8 WCC, V9 WCN (Wound Care Nurse) and V10 Wound Tech provide wound care to R186. During wound care, V8 WCC giving instruction and cuing V9 WCN during wound care.
On 6/11/25 at 3:02PM, Informed V2 DON (Director of Nursing) of above observations and concerns.
R186 is initially admitted on [DATE] with admission diagnosis listed in part but not limited to Sequelae of Cerebral Infarction, Atherosclerosis of native arteries of right leg with ulceration of other part of foot, non-pressure chronic ulcer of other part of left foot, Altered mental status, Palliative care, Diaper dermatitis, Type 2 Diabetes Mellitus. Most recent Braden scale assessment dated [DATE] indicated she is at high risk for skin impairment. Active physician order sheet indicated: Alternating pressure mattress: diagnosis vascular wound and prevention care. Treatment: Left medial ankle-Cleanse wound with normal saline solution (NSS). Xeroform secondary dressings-ABD, rolled gauze every MWF and PRN (as needed). Mid vertebrae -Cleanse wound with NSS. Skin prep. Bordered foam. Report to MD for any abnormalities, continue offloading the areas. Keep area clean and dry as needed for skin protection every TTH and PRN. Right dorsal foot- Cleanse wound with NSS. Xeroform dressings- ABD, rolled gauze every TTHS and PRN. Right hip-Cleanse wound with NSS. Apply foam dressing for protection every TTHS and PRN. Right lower back- Cleanse wound NSS. Xeroform dressing- bordered foam every TTHS and PRN. Sacrum-Cleanse wound with NSS. Calcium alginate, bordered foam dressing every day and PRN. Wound care physician visit dated 6/3/25 indicated sudden onset of pear-shaped skin breakdown and discoloration in the sacral area and right lower back area indicating a Kennedy terminal ulcer. The staff report the patient is declining in health overall, with decreased appetite and weight loss. The patient is also being seen for chronic venous wounds on the BLE. The patient was awake and resting in bed, prevalon boots in place. The patient has thin and fragile skin with history of wounds. Foley catheter in place. Comprehensive care plan indicated that she has an actual and a potential for further impairment to skin integrity due to present of comorbidities, limited mobility, fragile skin, and fracture status post fall.
R186's Low air loss mattress manufacture's functions guide indicated: Pressure adjust knob adjustable by patient's weight. Turn the pressure adjust knob to see a comfortable pressure level by using the weight scale as guide.
Facility's policy on Specialized mattress and appropriate layers of padding revised 8/19/23 indicated: 1. Limit the amount layers on top of specialized air mattress such as low air loss mattress according to the resident's needs and individual's condition in order to manage comfort, positioning, and moisture . 3. Use specialized air mattresses like low air loss mattress on the resident with stage 3 or 4 pressure sores to ensure moisture, heat, and friction control.
Based on observation, interview and record review, the facility failed to ensure low air loss mattress devices were on the correct weight setting for residents who are at risk for developing pressure injuries. This failure has the potential to affect three (R61, R186 and R200) out of four residents reviewed for pressure injury prevention and treatment in a final sample of 35 residents.
Findings Include:
1. On 6/10/25 at 12:50PM, observed R61 in bed with low air loss mattress in use. Air loss mattress is set to 7. Confirmed with V25 (Unit Nurse Manager) that the setting is on 7. V25 looked at a paper with R61's weight record and reset the mattress to 4.
R61 is 116.0 lbs. dated 6/10/25. R61 Braden Scale and Clinical Evaluation dated 6/5/25, reads: High Risk 7.0 and R61 with history of healed pressure injuries to left and right buttocks and coccyx.
On 6/12/25 at 10:30AM, V8 (Wound Care Coordinator) stated that R61 does not have any active pressure injury at this time, however R61 has a history of pressure injury. R61 is high risk for skin alteration and specialty mattress is being used as a preventative measure.
V8 stated that they use a specialty mattress such as low air loss mattress for residents who are high risk for skin alteration, resident with multiple stage 2 pressure injuries and resident with stage 3 or higher.
2. On 6/10/25 at 10:28AM, observed R200 in bed with low air loss mattress in use. Air loss mattress is set to 150 lbs. V24 (LPN) confirmed that the setting is set to 150 lbs. V24 mentioned that R200 is 98 lbs. and needs to be set to 90 Lbs. V24 reset the specialty mattress on 90 lbs.
Record reviewed. R200 is 98.0 lbs. dated 6/2/25. R200 Braden Scale and Clinical Evaluation dated 5/19/25, reads: High Risk 9.0 and R200 with a history of left elbow unstageable pressure injury healed 4/16/25.
Braden Scale and Clinical Evaluation shows that above 20 is low risk and below 20 is high risk.
On 6/12/25 at 10:30AM, V8 (Wound Care Coordinator) stated that the setting for the specialty mattress such as the low air loss mattress is based on resident's weight. The setting should be closer to resident weight if the increment is 30 lbs. (pounds) per dial. If resident is 98 lbs., then it should be set to 120, closer to resident's weight but not under, due to the bed will be too soft and the purpose of the bed will not be effective.
V8 also stated that R200 is a hospice resident and assessed as high risk for skin alteration. R200 has history of pressure injury in which it was healed. The mattress is for comfort and preventative measures.
Proactive Manual states that Weight/Pressure set up: User can adjust air mattress to a desired firmness according to patient's weight or the suggestion from health care professional.
Wound Care Guidelines with a revised date of 1/24/24, reads in part: The goal of this care guidelines is to achieve compliance to regulatory requirements and provide evidence-based recommendations for the prevention and treatment of pressure injuries that can be used by the health professionals in the facility. The purpose of the prevention recommendations is to guide evidence-based care to prevent development of pressure injuries and the purpose of the treatment focused recommendations is to provide evidenced-based guidance of the most effective strategies to promote pressure injury/ulcer healing.
The score from the Braden Scale and Clinical Evaluation should be interpreted/calculated to determined level of risk: Low Risk and High Risk. Each risk factor and potential cause(s) identified be reviewed individually and addressed into the resident's care plan. Facility shall develop a plan of care and implement intervention according to the resident's Braden Scale and Clinical Evaluation of identified risk factors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/10/25 at 10:45AM, observed R186 lying in bed with LAL (Low air loss) mattress. V7 Agency LPN (Licensed Practical Nurse) ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/10/25 at 10:45AM, observed R186 lying in bed with LAL (Low air loss) mattress. V7 Agency LPN (Licensed Practical Nurse) said that R186 has multiple chronic wounds on BLE and has Kennedy terminal ulcer to sacral area. She is on hospice care. She is non-verbal, may open eyes when called. She needs total care with ADLs (Activity of Daily Living) and transfers. V7 said that they monitor her for pain every shift.
R186 is initially admitted on [DATE] with admission diagnosis listed in part but not limited to Sequelae of Cerebral Infarction, Atherosclerosis of native arteries of right leg with ulceration of other part of foot, non-pressure chronic ulcer of other part of left foot, Altered mental status, Palliative care, Diaper dermatitis, Type 2 Diabetes Mellitus. Active Physician order sheet indicated she is on Acetaminophen rectal suppository 650mg insert 1 suppository rectally every 4 hours as needed (PRN) for pain/fever. Hydromorphone HCl solution 2mg/ml give 0.2ml by mouth every 2 hours PRN for dyspnea/pain. Comprehensive care plan indicated she is at risk for pain due to history of femur fracture from fall. Pain tool assessment used for R186 every shift indicated numerical pain scale assessment from 5/25/25 to 6/9/25 which is coded from 0-2.
On 6/11/25 at 3:02PM, V2 DON (Director of Nursing) said that they utilized PAINAD (Pain Assessment in Advanced Dementia) for residents with advanced dementia who may be unable to verbally express their pain. Informed V2 that R186's every shift pain assessment record from 5/25/25 to 6/9/25 indicated that the nurses were using the numeric pain scale pain assessment tool. The numeric pain scale is a tool used to assess and quantify pain intensity. It is typically ranges from 0-10 with 0 representing no pain and 10 representing the worst pain. Residents are asked to select the number that best reflects their current level of pain. This pain assessment tool is typically used for resident who is alert and oriented not for cognitively impaired and nonverbal like R186. Informed V2 that the facility failed to ensure to utilize appropriate pain assessment tool for resident with cognitive impairment or non-verbal resident for pain management. Informed V2 that the nurses stated using the PAINAD tool assessment when surveyor asked for it on 6/10/25.
Facility's PAINAD (Pain Assessment in Advanced Dementia) tool assessment form indicated: observation of 5 key behaviors: Breathing, Negative vocalization, Facial expression, Body language, and consolability. By observing these behaviors, the nurses can assess the severity of pain in individual with advance dementia.
Facility's policy on Pain revised 1/30/25 indicated: Policy statement: It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain.
Based on observation, interview, and record review, the facility failed to have an ordered narcotic pain medication available for five and a half hours for a resident (R330) with severe pain and the facility failed to utilize a pain assessment tool for a cognitively impaired/non-verbal resident (R186) for pain management for two out of four residents reviewed for pain in a total sample of 35.
Findings Include:
1. R330 is a [AGE] year old with the following diagnosis: lupus erythematosus; fibromyalgia; fracture of the right humerus, right tibia, and right fibula; and wedge compression fracture of the T11-T12 vertebra.
On 6/11/25 at 11:10 AM, R330 stated R330 was hit by a car which fractured R330's right arm and lower right leg. R330 reported they live with chronic pain due to R330's lupus diagnosis. R330 stated R330 normally lives at a pain level of seven out of ten with scheduled pain medication. R330 reported the best pain relief is the narcotic pain medication which is ordered as needed so R330 has been requesting it about every four hours. R330 stated R330 also receives scheduled Tylenol but that does nothing to bring down R330's pain.
On 6/12/25 at 10:02 AM, V26 (LPN) stated R330 last received the narcotic pain medication around 4AM. V26 reported R330 requested the narcotic pain medication around 8:30AM but the medication was not available. V26 stated the medication should be reordered from pharmacy before the last dose is given. V26 reported the medication card will tell the nurse when to order it from pharmacy. V26 was not able to answer why the medication was not delivered but stated the previous shift nurse should have reordered the medication at the time it was administered so pharmacy would have time to deliver the pain medication. V26 reported the medication was reordered about an hour ago STAT so it is expected to be delivered in about an hour. V26 stated the narcotic medication is usually stocked in the pyxis system but is currently out of stock. V26 reported R330 stated R330's current pain level was ten out of ten.
On 6/12/25 at 10:08 AM, R330 stated V26 told R330 that the facility did not have the narcotic pain medication in stock. R330 reported a fentanyl patch was put on this morning but has not been on long enough to give any pain relief. R330 stated pain was a ten out of ten in R330's right arm, right leg, and lower back. R330 described the pain as sharp in the upper and lower extremities and aching in the lower back. R330 reported refusing to work with therapy when asked earlier this morning due to R330's uncontrolled pain.
On 6/12/25 at 12:21 PM, V5 (ADON) stated V5 called pharmacy to get an update and the medication will be delivered in about 30 minutes. V5 reported the narcotic pain medication still has not been given yet. V5 was unable to give a number on the pain scale for R330 at this time.
On 6/12/25 at 12:27 PM, V27 (Physical Therapist) stated V27 worked with R330 today around 11AM. V27 reported R330 constantly complained of pain throughout the entire session. V27 stated the nurse told V27 that the medication was not in stock, and they needed to wait for it to be ordered. V27 reported R330 was able to participate in therapy but wasn't able to complete all the planned exercises because of R330's pain level. V27 stated R330 rated the pain a ten out of ten at the beginning of the session and a fourteen out of ten at the end of the session.
On 6/12/15 at 12:32 PM, V2 (DON) stated the nurse is responsible for reordering the medication from pharmacy when the medication card is running low. V2 reported each medication card will indicate when pharmacy needs to be called for more medication to be sent. V2 stated the nurse should order the medication at this time so it is available for the next dose. When asked why the pyxis system wasn't accessed to give the narcotic medication, V2 said, I don't know. I will have to check.
On 6/12/25 at 1:47 PM, V5 stated the staff did not access the pyxis system to get the narcotic medication out because that medication was out in the pyxis as well.
The Physician Order Summary documents to offer pain medication 30-60 minutes prior to treatment which was dated 6/10/25. The following scheduled pain medication was ordered on 6/9/25: Tylenol 325 mg two tablets every six hours, a transdermal fentanyl patch 100mcg/hour that started on 6/12/25, and a lidocaine patch 4% to the left knee and right shoulder every morning. The narcotic pain medication (oxycodone) is ordered as needed only. Oxycodone 15 mg three tablets every four hours as needed was ordered on 6/9/25.
The Medication Administration Record dated 06/2025 documents pain scores are documented once a shift and range from a zero (no pain) to a ten (severe pain). On 6/12/25, the scheduled Tylenol was administered at 6AM and 12PM. Oxycodone was administered at 4:17 AM and was not administered again until 1:42 PM.
The Physical Therapy Treatment note dated 6/12/25 documents R330 rated pain a ten out of ten that was on the right upper and lower extremity and back. R330 was able to walk 15 feet to the bathroom and back but refused to walk more due to pain. R330 presented with excruciating pain during the session. The therapist spoke with the nurse that reported they are waiting for the pain medication to arrive.
The Nursing admission dated 6/9/25 documents R330 had complaints of pain upon admission to the right lower extremity and right shoulder. At this time, R330 rated the pain a three out of ten and described it as an intermittent ache. R330 reported medication, rest, and ice relieve the pain.
A Physician note dated 6/12/25 documents due to lupus and musculoskeletal changes R330 is on medication for chronic pain.
The Care Plan dated 6/9/25 documents R330 is at risk for pain (chronic) related to lupus. Interventions include to medicate prior to therapy/treatment and provide analgesic as ordered.
The policy titled, Pain, dated 1/30/25 documents, Policy Statement: It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain .Procedures 1. Upon admission and readmission, the nurse will assess the resident for pain. For those identified with pain upon admission/readmission assessment, an order for pain medication will be obtained from the physician. If available in the convenience box or facility house stock, the pain medication ordered will be administered to the resident as soon as possible.
A policy on reordering medication was requested but was not given by the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure an accurate count of controlled medication on the controlled drug administration record sheet. This deficiency affects ...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to ensure an accurate count of controlled medication on the controlled drug administration record sheet. This deficiency affects 1 of 3 medication carts reviewed for Controlled Medication count Management. The facility also failed to follow its policy on medication administration on prohibiting pre-pouring of medications. This deficiency affects two (R110 and R525) of twelve residents in the sample of 35 reviewed for administration of medication.
Findings include:
On 6/10/25 at 9:10AM, checked medication cart with V4 LPN (Licensed Practical Nurse). Observed pre-poured medications in plastic medication cup inside the top drawer and controlled/narcotic drawer. V4 said that she prepared the medication for R525 and R110. V4 said that she is about to give the medication, but she answered another resident's call light. V4 said that she should not pre-pour the medications. Medications prepared should be given to the resident immediately. Reviewed and counted controlled/narcotic medications with V4. Observed discrepancies for R525's Controlled medication bingo card of Tramadol 50mg indicated 15 tablets medications left while the Controlled drug administration record documented 17 left medications and Alprazolam 0.25mg indicated 5 tablets medication left while the controlled drug administration record documented 6 left. V4 LPN said that she forgot to sign the date, time, and amount the controlled medication that she took at controlled administration record.
On 6/10/25 at 9:19AM, informed V5 ADON (Assistant Director of Nursing) of above observations. V5 said that medications prepared by the nurse should be administrated immediately. The nurse (V4 LPN) should not be pre- pouring medication for the residents. V5 said that after removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken.
On 6/11/25 at 3:02PM, informed V2 DON (Director of Nursing) of above observations and concerns. V2 said that it is not their facility's practice to pre-pour medications of residents for medication administration.
Facility unable to provide medication policy specific for prohibiting pre-pouring of resident's medications.
Facility's policy on Controlled Medication Count revised 7/26/24.
Policy statement: It is the policy of the facility to maintain an accurate count of schedule II-controlled medications.
Procedure:
1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken.
Facility's policy on Medication Administration revised 8/16/24 indicated:
Policy statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedure.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to use appropriate infection control practices when taking blood pressure during medication administration. This deficiency affec...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to use appropriate infection control practices when taking blood pressure during medication administration. This deficiency affects one (R526) of one resident observed taking blood pressure during medication administration observation in the sample of 35 reviewed for Infection Prevention and Control Program.
Findings include:
On 6/10/25 at 12:28PM, V7 Agency LPN (Licensed Practical Nurse) said that he has to take BP (blood pressure) of R526 before administering her medications. V7 placed the BP cuff on upper arm of R526 without disinfecting the BP monitor portable machine prior to use. V7 obtained 110/75mmHg. After taking the BP, he placed the BP portable machine on top of the medication cart without disinfecting it after using. V7 prepared medication for R526 and administered the medication orally.
On 6/10/25 at 12:34PM, V7 Agency LPN said that he is done with his noon time scheduled medications administration. V7 pushed his medication cart in front of the nursing station. V7 still did not disinfect the BP portable machine that he placed on top of the medication cart. At 12:45pm, informed V7 of observation made that he did not disinfect the BP portable machine before and after he used it to take BP of R526. V7 said that he forgot to disinfect the BP portable machine including BP cuff before and after using it with R526.
On 6/11/25 at 3:02PM, Informed V2 DON (Director of Nursing) of above observations and concerns.
On 6/11/25 at 8:25AM, Informed V17 Infection Coordinator of above observation and concern. V17 said that BP portable machine- including BP cuff should be disinfected before and after using it with resident.
Facility's policy on medical equipment, instruments and Health IT Devices Infection Control Plan revised 8/16/24 indicates:
Policy Statement: it is the policy of this facility to prevent infection and create/maintain a safe environment for the residents, their visitors and staff thru proper handling, cleaning, and sanitizing of medical care equipment, instruments and or other related health IT devices.
Procedures:
7. Nursing personnel shall wipe down/clean reusable equipment between residents using a facility approved cleaner/disinfect
12. Some medical care equipment items shall be cleaned and or sanitized with facility approved disinfectant agent between each resident use.
Apr 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent serious injur...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent serious injury to a resident. This failure affects one of three residents (R1) reviewed for falls in a total sample of six residents. This failure resulted in injuries to R1. R1 sustained facial fractures and skull fractures, acute nondisplaced fractures of bilateral sphenoid sinuses, non-displaced fractures of basilar portion of the occipital bone bilaterally, and acute nondisplaced fractures involving the postero-lateral walls of bilateral maxillary sinuses. R1 also had a small possible C6 fracture requiring a neck collar.
R1 is a [AGE] year-old male. R1's diagnoses are but not limited to fracture at the base of the skull, eye bone fracture, Parkinsonism, heart disease, atrial fibrillation, history of falling, diabetes, high blood pressure, dementia, and hypothyroidism. R1's BIMS (Brief Interview for Mental Status) dated 3/18/2025, notes R1 is not very alert.
R1's care plan notes R1 is at high risk for falls related to current medication use, poor safety awareness, unsteady gait, disease process: fall history, wedge compression fracture L4, paroxysmal AFIB (Atrial Fibrillation), Hypertension, Diabetes Mellitus, Dementia, Hypothyroidism, BPH (Benign Prostate Hypertrophy), and Peripheral Venous Insufficiency. R1 requires total assistance of two-person assistance using the mechanical lift with transfers due to generalized weakness, immobility, impaired mobility, and poor weight bearing control due to compression fracture superior L4, dementia & Parkinson's.
On 04/05/2025, at 11:09 AM, R1 was upright in wheelchair, with a mechanical lift pad underneath him. R1 was sleeping. R1 moaned when spoken to but is not able to talk. R1 has a neck brace around his neck. There was bruising to the left lower eye. There were purple, green, and yellow colors. There were two steri-strips to the left forehead.
Progress note dated 3/19/2025, notes R1 had a fall.
readmission note dated 3/22/2025, notes R1 has neck collar, and leg boots on. R1 has scattered echymotic areas, and stitches to his head. He is not in distress and does not seem to be in a lot of pain. He has black/blue discoloration to left eye, and multiple old dark blue spots. R1 is unable to verbalize pain, due to being non- verbal, but groans which is normal for him. He groans, and slow to response, but with good eye contact. Vitals are stable.
Medical professional note dated 03/27/2025, notes R1 readmitted from 3/19/25-3/22/25 after fall. Imaging shows multiple facial fractures and skull fractures, acute nondisplaced fractures of bilateral sphenoid sinuses, non-displaced fractures of basilar portion of the occipital bone bilaterally, acute nondisplaced fractures involving the postero-lateral walls of bilateral maxillary sinuses. No intracranial hemorrhage. Small possible C6 fracture. Neurosurgery was consulted. Recommended Aspen collar (neck collar) for 4 weeks. R1 remains weak and was transferred back to the facility. Left peri-orbital area with purplish discoloration, stitches on left forehead intact. Aspen collar in-place. No neuro deficit.
On 4/05/2025, at 11:06 AM, V1 (Certified Nursing Assistant) stated, R1 is not alert. He is a mechanical lift transfer. We are supposed to use two aides. I was told that he fell, that is why he has the neck brace.
On 4/05/2025, at 11:35 AM, R2 (R1's Roommate) stated, I was getting off the elevator. I heard a page for staff to our room. I think she (Former Aide) might have pulled the pad too hard, and he fell out of bed. But I did not see it.
On 4/05/2025, at 12:39 PM, V2 (Director of Nursing) stated, I believe the date was 3/19/2025, on the 3:00 PM to 11:00 PM shift. I initiated an investigation and spoke with the aide and the nurses. R1 is not alert or oriented. He is confused and wheelchair bound. He uses the mechanical lift. The aide was V4 (Former Certified Nursing Assistant) at the time. I believe the nurse was V5 (Agency Registered Nurse). The aide told me she was planning to transfer the resident from the wheelchair to the bed. She brought the patient into the room. She told the other aide that she needs help to transfer with mechanical lift. She waited. She was in front of the patient and there was a little bit of a distance away from R1. R1 had a jerky movement. He fell face down on the floor. V4 called everyone. V5 called a rapid response. Immediately, he was taken care of. There was a cut on his head. They immobilized him and sent him out. R1 has Parkinson's. He has been seen by a neurologist. He had falls at home multiple times. He is on a tapering dose by the neurologist. I believe that is why he had a jerky movement. I made them aware that he had a fall. The medication was discontinued, and he has a follow up appointment. A care plan meeting was held with the family.
On 04/05/2025, at 1:09 PM, V5 stated, I was passing medication. I heard yelling from the aide. I ran into the room. The patient was on the floor. I checked the patient. He usually moans and he does not speak. I called his name. I saw he was bleeding from his head. I do not know how he fell. I immobilized him. I called a rapid response, and everyone rushed in. The ambulance came and he went to the hospital. Before he left, I gave him something for pain. R1 was laying on his side. He was on left side. I saw bleeding from his head and there was blood on his face. The aide was in there. Eventually, she said when she was trying to transfer the patient from the wheelchair to the bed; R1 had a jerky movement and he fell. The wheelchair was in the corner. To be honest, I did not go to check the wheelchair because my focus was on the patient. The aide had worked with him before and was pretty good. The wife was there before the event occurred.
On 4/05/2025, at 1:33 PM, V6 (Fall Coordinator/LPN) stated, I coordinate with admissions for high fall risk patients. R1 was identified as a high fall risk before the incident occurred. Prior to admission he had already sustained a fracture. According to the aide, she was preparing R1 to be assisted to bed. I believe he requires the mechanical lift for transfers. That requires two aides. While waiting for another staff to assist her, R1 had an involuntary movement that caused the fall. There was a bed and chair alarm in place, I did not ask her the question if the wheelchair was locked. I am not aware if the wheelchair was locked but it should be to prevent it from rolling backwards, forwards, and the resident falling out. She (the aide) did not mention if the wheelchair was locked, she just stated that he had a jerky movement. According to the nurse, she was passing medication at the time. Her attention was called due to the fall. The aide was alone in the room with the resident. The root cause of the fall was tapering his medication for Parkinson's, and he had a tremor. He had sustained a fracture before and may have had poor trunk control. There should always be two aides even before preparing to transfer a resident. I would stay with the resident while waiting for assistance. I would have that patient visible and if anything happens. I would to try to prevent the fall. If there was a jerky movement, I would try to prevent the resident from hitting any hard surfaces by moving away or staying beside him or in front of him to prevent him from falling; that can cause skin breakdown and fracture. That is my opinion as a nurse. When I interviewed the aide, she was crying. This was her first time dealing with this fall. I would expect my staff to have two people when transferring. The nurse stated that she did not see anything.
On 4/05/2025, at 2:01 PM, V7 (Certified Nursing Assistant) stated, I was in another room with another resident. V4 asked me if I could come help her. Usually, we transfer people with two people assisting. I told her as soon as I was done, I will join her. She went back to the room and the rapid response was called. I saw her in front of the resident. She was trying to explain to the nurse, while she was waiting, R1 had a jerky movement in the wheelchair. I heard her say that she was trying to hold him, and he had a jerky movement. He fell out of the wheelchair. He fell face down. I think I saw the wheelchair locked. The nurse called for rapid response and people rushed in.
On 4/05/2025, at 2:24 PM, V9 (Nurse Practitioner) stated, the facility notified me and told me R1 had a fall. The aide was there. R1 fell forward I think; that is what they said. If there were enough people there, the injuries could have been preventable.
On 4/05/2025, at 3:10 PM, V10 (R1's Wife) stated, I was not here when R1 had the fall. I usually leave here around 6:30 PM. The facility told me that he had fallen, had a bloody nose and was sent to the hospital. I went to the hospital, and I was shocked. He had the neck collar on, was bleeding from the head, but his nose was not bleeding. The hospital stated he has multiple fractures to the skull, orbital bones, C6/C7 fractures and his sinuses on the roof of his mouth. He had stitches on his head. V2 told me the following: she was so sorry this happened, it was totally our fault. V4 had R1 in the mechanical lift alone and R1 slipped out. That person no longer works for us, and we are sorry that happened. Their incident report notes that V4 was not properly trained. We have retrained and gone over proper procedures. V10 continued, V2 told the neurologist that R1 had a tremor and fell out of his wheelchair. I have gotten three different stories from V2. R2 told me that V4 was still working two weeks ago. R4, the resident council president, told me that the aide was wiping blood off the floor and was angry about it. R4 saw R1 lying on his side.
On 04/05/2025, at 4:16 PM in an interview with R4 and R5, R4 stated, I am the resident council president. The facility did not notify me when R1 fell. They are supposed to. R6 told me she heard the fall. There is supposed to be two people that transfer the residents with the mechanical lift. There was only one person. No one will say if she messed up or if R1 was wiggling around and fell. R1 was on the floor and there was a lot of blood on the floor and on his head. He has several fractures: a broken neck, and stitches on his head. The aide wiped up blood off the floor. I saw her folding the mechanical lift pad. The wheelchair was away from his body, and he was laying on the floor sideways. R5 stated, I heard he was in a mechanical lift wiggling and bending and he fell out. That is what I heard.
On 04/05/2025, at 4:55 PM, R6 stated, I was here in my room getting ready for bed. I went outside of my room and the door was closed. The aide opened the door and yelled for the nurse. There is no way R1 could make that loud of a thump from a wheelchair. He had to be up in the air; it was a loud crashing noise. Most of the time two people transfer residents with the mechanical lift. Agency staff try to do it on their own. If he would have fallen the distance from a wheelchair, he would not have hurt himself that bad. I saw the mechanical lift that night at the end of his bed. I'm going to tell the truth. The man was already in bad condition. I really feel bad for the man; I really do.
Facility policy titled Mechanical Lift Transfers, dated 8/16/2024, notes there will always be two staff to assist the resident. One staff will control the lift as the other will guide resident and support back and neck to transfer surface.
May 2024
4 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to protect cognitively impaired residents from physica...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to protect cognitively impaired residents from physical and verbal abuse; and failed to follow the facility abuse policy for two (R1 and R2) of three residents reviewed for abuse. These failures resulted in R1 and R2 being physically and verbally abused during provision of care. R1 and R2 were sent to the hospital for further evaluation and treatment and R2 sustained a right frontal hematoma and abrasion, left lateral periorbital ecchymosis and lower lip abrasion.
These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE] when R1 and R2 were physically and verbally abused by V5 (Certified Nurse Aide) during provision of care.
V1 (Administrator), V2 (Executive Director) and V3 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 12:00 PM. The survey team confirmed by observation, interviews and record reviews 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.
Findings include:
R1 is an [AGE] year old male, admitted in the facility on [DATE] with diagnoses of Delusional Disorders; Dementia In Other Diseases, Classified Elsewhere, Severe, with Psychotic Disturbance and Alzheimer's Disease, Unspecified. R1's MDS (Minimum Data Set) dated [DATE] recorded a BIMS (Brief Interview for Mental Status) score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R1 is at risk for abuse.
R1's care plans documented in part but not limited to the following:
Abuse (initiated [DATE]): Interventions - Provide reassurance to R1 remind him that he is safe and secure.
Cognitive Loss (initiated [DATE]): Intervention - Cue, reorient and supervise him as needed.
Behavior (initiated [DATE]): Interventions: Approach in a calm manner; Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.
According to initial incident report dated [DATE], V16 (Family Member) notified V2 (Executive Director) that V5 (CNA Agency) assigned was verbally and physically aggressive towards R1 during care.
On [DATE] at 12:25 PM, V16 was interviewed regarding R1's alleged abuse allegation. V16 stated, We installed a camera here in this room for him (R1). A camera was observed installed by the television facing R1's bed. V16 continued, I worked in healthcare management, and I know how it is if you live in a nursing home. V2 contacted me last Friday night ([DATE]) around 11:00 PM and asked if we could help her get video footage she needed. I emailed the footage at 12:14 AM, that was Saturday, and one minute later she responded that she received it. I called her back and informed her that there was an incident with R1 when a staff member brought him back to bed, that was around 9:31 PM. The staff was verbally abusive. It was caught on the video. She (V2) said she will do the investigation. During interview with V16, it was observed that a sign stated that there is an audio and video recording in R1's room posted at the door. Same sign was also posted at bedside visible to all staff and visitors.
Electronic Monitoring Notification and Consent Form stipulated that V16 was permitted to conduct authorized electronic monitoring in R1's room through the use of an electronic monitoring device. It was signed and dated [DATE].
Video footage dated [DATE], time stamped 9:31 PM was seen, showing V5 was yelling, intimidating and aggressive with R1 while putting him back to bed. R1 was heard saying You stop, stop, I said I'm not stopping while V5 continued to yell telling him (R1) to lay down in bed. Video also showed R1 was pushed by V5 as she (V5) tried to make him (R1) lie down in bed.
On [DATE] at 1:55 PM, V6 (Registered Nurse, RN Supervisor) was asked regarding R1. V6 stated, On [DATE] incident with V5, I was only told about the incident after V2 saw the video in the room.
On [DATE] at 10:58 AM, V4 (RN) was interviewed regarding knowledge of R1's abuse allegation involving V5. V4 replied, Last [DATE], I was at the nurses' station and didn't hear V5 yelling or anything. I am not aware of any abuse incident on R1 with V5 who worked under me that night. That was my first time working with her (V5).
On [DATE] at 10:17 AM, V2 was asked regarding R1's incident on [DATE]. V2 replied, When the police came in to investigate R2's abuse incident; and make a report after we called, they (police) attempted to interview R2. They noticed the sign that says video surveillance on R1. The police asked for us to contact the family of R1 to see if they are comfortable in providing them the clips related to care provided. I contacted V16 on [DATE] around 11:45 PM, to request video clips which she then provided at 12:15 AM on [DATE]. She sent the clips via email. She called me the same time regarding a concern related to care provided by a staff member to R1. The CNA in R1's video footage was identified as V5, per V2. V2 also verbalized, V16 stated, V5 appeared verbally and physically aggressive towards him (R1). At that point, I got off the phone, started the investigation. I immediately suspended her (V5). She is from staffing agency. That was the first time she (V5) picked up a shift for us. She (V5) was made aware that she is immediately suspended and will not be coming back to the facility. She (V5) was escorted out of the building and was deleted from the system. I also informed the agency to let them know that we had a serious abuse allegation on her (V5). I have had no contact with her (V5) afterwards. I attempted to interview him (R1), but he was confused and unable to provide details of what happened. He (R1) was sent to the hospital and came back with no injuries noted.
Hospital records dated [DATE] recorded that R1 was brought to the emergency department for alleged physical assault. That a staff member at nursing facility was allegedly caught on camera assaulting R1. R1 stated, I hurt all over unable to point to exact location of pain. R1 was complaining of right-hand pain. There were no visible injuries noted including bruising, abrasion or lacerations; and no fractures or dislocation found.
Progress notes dated [DATE] documented R1 came back to facility from the hospital.
On [DATE] at 12:30 PM, R1 was observed in his room, in bed. He is alert and oriented to self, and verbal. R1 was asked regarding incident on [DATE] involving a staff member. R1 stated he does not remember any incident and has no issues with staff in the facility.
On [DATE] at 2:32 PM, V19 (Unit Care Assistant) was asked regarding R1 and V5. V19 verbalized, On [DATE] around 9:32 PM, I saw V5 bringing R1 to room. I told her (V5) to handle R1 with care because there is a camera in his room. Since she (V5) does not know him, she walked him (R1) back to room, without letting him (R1) use the walker. She stood in front of him (R1), took both of his hands and guided him back to his room. She (V5) does not know R1, that he gets agitated easily, so she needs to be careful when she approached him.
Police Report dated [DATE] recorded an offense Aggravated Battery on R1 by V5. The incident was dated [DATE]; and was reported to police [DATE]. In the said police report, it was documented that R1 in this case is an additional victim from the same room at the facility and two incidents took place about 15 minutes apart. V2, apparently after seeing the video provided by V16, advised police that V5 was seen pushing R1 in the chest three times while telling him to lay back in his bed; R1 was sitting up in bed when he was pushed.
On [DATE] at 11:06 AM, V2 was asked regarding police report on R1. V2 replied, I called police the night of the incident, on [DATE]. They did not make the second trip because he (R1) was sent to the hospital.
On [DATE] at 12:35 PM, surveyor called V22 (Local Law Enforcement Agency) to clarify R1's abuse report. V22 stated, the police report states it was reported on [DATE]. Surveyor informed V22 that facility staff stated it was reported on [DATE] with the other allegation. V22 checked records, and stated, the abuse for R1 was only reported on [DATE].
R2 is an [AGE] year old, male, admitted in the facility on [DATE] with diagnosis of Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with other Behavioral Disturbance and Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations. MDS dated [DATE] recorded that R2 has BIMS score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R2 is at risk for abuse.
R2's care plans documented in part but not limited to the following:
Abuse (initiated [DATE]): Interventions - Recognize that the resident (R2) is an adult living with chronic, debilitating comorbidities in a skilled care setting and may experience feelings of lack of control and powerless; Work with the resident (R2) to overcome these feelings; advocate for expression of resident rights, autonomy and encourage independent decision making; Provide positive encouragement, support and kindness.
Parkinson's Disease and is at risk for possible complications (initiated [DATE]): Intervention - Allow sufficient time for speech/communication.
Cognitive loss (initiated [DATE]): Intervention - Offer cues, direction and redirection as needed.
Behavior symptoms (initiated [DATE]): Interventions - Behavior-Communication. Try to ascertain what the behavior is communicating. Why is it being displayed here/now? Why in front of these people? What is the resident trying to tell us? What motivates the person to act this way? Is the behavior related to modesty/possible embarrassment? Is it related to a possible history of trauma? What message or secondary gain is the resident seeking? What message is the person sending by rejecting care? Assure the resident that safety, security and dignity are paramount. What does the resident mean by statements that blame staff for personal poor choices?
Care rejection. Avoid Power Struggles. Build a relationship, rapport. Do not argue. If the present is not a good time for the resident, revisit the care situation later. It is ok to back off.
Episode of increase restlessness, anxiety, impulsive, short attention (initiated [DATE]): Intervention - Monitor/record occurrence of behavior symptoms and document per facility protocol. Notify physician, family, nurse any changes.
On antipsychotic medications (initiated [DATE]): Intervention - Care in pairs. Provide calm approach, explain in simple words task to be given. Allow time to understand.
Initial incident report dated [DATE] documented V2 was notified that V5 reported R2 was aggressive and combative during care. R2 represented confused and unable to recall.
Progress notes dated [DATE] time stamped 9:55 PM recorded that R2 was assessed, observed bleeding on the lips, bump, and scratches on forehead area.
On [DATE] at 1:55 PM, V6 was interviewed regarding R2's incident on [DATE]. V6 stated, I was initially called at 9:55 PM by V4 regarding R2. V4 noted that there were scratches on his (R2) forehead, bumps on both sides of forehead and bleeding on the lips. V4 said, V5 asked for a band aid at 9:52 PM for her injured finger, like a scratch. She (V4) provided the band aid and checked on R2 and noticed the injuries. She (V4) did his (R2) initial assessment and called me right away. I went into his (R2) room, V4 and V5 were at the nurses' station. I went directly to assess R2. I also noted the injuries. I instructed V4 to supervise V5 while I do my investigation. With my investigation, there was a possible abuse on him (R2), so I called V2. I was told that she (V2) is going to come. I assigned a different CNA on R2, first aid provided, instructed V4 to inform Hospice. V2 came around 10:30 PM so she did her investigation as well. She (V2) also called local police. She (V5) was also interviewed by V2. She (V5) was supervised and took her off from the schedule. When the police arrived, they did their track on R2, interviewed me, and V4. After that, they noticed that there was a camera in R1's bed, they requested surveillance. Police interviewed V5; took pictures of R2, and injuries of V5's hand. Police cannot arrest her (V5) at the time because R2 was confused and unable to narrate the incident. He (R2) is alert and oriented to self; unable to verbalize needs and dependent on staff for all care. He (R2) is also a hospice resident.
On [DATE] at 2:20pm V4 was asked regarding R2's incident on [DATE]. V4 replied, Around 9:30 PM, all residents were getting situated. CNAs are getting residents ready for bed. He (R2) was in his bed, in his room. I was at the nurses' station when V5 asked me for a band aid, said she had a scratch in her hand. I did not inspect her hand, but I gave her the band aid. I noticed that she was walking towards R2's room. I followed her and that was the time when I noticed that he (R2) had bleeding in his lips, saw bumps on his (R2) head and scratches that were starting to swell. I asked her (V5) on what happened, said he (R2) was resisting, and she (V5) was trying to get him dressed and ready when he started to kick and swung his arms and ended up hitting his head on the side rails. I told her (V5) to give me a second and will be back and that is when I contacted V6. In between that, I assessed him (R2), I cleaned his lips and forehead, assessed his range of motion and did neuro checks. V6 asked me to contact Hospice. Personally, when I worked with him (R2), he did not display any refusal to care or aggressive behavior. If a resident is refusing care at the moment, let them be, they have the right to refuse. Then come back at a later time, maybe after an hour and try to do the care. She (V5) did not tell me what happened. No, she didn't tell me about the behavior during care. She only told me when I went to the room and checked on him (R2). She (V5) should report the incident to me at the time, so I could assign another CNA to R2.
Electronic Monitoring Notification and Consent Form stipulated that V20 (Family Member) signed a consent form for R2's video and audio surveillance in the room. The consent was signed on [DATE].
R2 shared the same room with R1. R1 and R2 are residents in the facility's Dementia Unit. V5 was the assigned CNA for R1 and R2 on [DATE], from 3:00 PM to 11:00 PM.
In a video footage dated [DATE], time stamped 9:38 PM, it was seen in a partial angle view that R2 was sitting in the wheelchair. V5 was heard yelling, intimidating and verbally threatening R1, saying, Stop, you need to, I'll punch your face like that. Stop. In another video footage dated [DATE], time stamped 9:39 PM, V5 was seen as she aggressively pulled R2's clothing. V5 was then heard saying Stop.
On [DATE] at 12:10 PM, R2 was observed in bed, alert, oriented to self, verbal. R2 was observed with multiple scratches on the forehead and a scratch on the left eye. A purplish discoloration was noted on the left eye and greenish to yellow discoloration above right eye. An abrasion was also noted to his lower lip. R2 was asked regarding injuries, stated, I don't remember what happened. R2 was also asked if he went to the hospital, stated he does not remember.
On [DATE] at 10:17 AM, V2 was asked regarding R2. V2 stated, As soon as V6 notified me at 10:04 PM to report concern regarding R2's injuries, I came to facility within 20 minutes. I advised him (V6) to keep an eye on V5. She (V5) was immediately separated from the residents and another CNA was reassigned to R2. When I interviewed her (V5) that night, she received a scratch from her middle finger from R2 as he (R2) was combative and aggressive during care by kicking and scratching. I saw the scratch from her (V5) middle finger. She (V5) said she was trying to remove his (R2) shirt and he was scratching and kicking her. He was still combative when he was in bed and sustained the injuries from the side rails and headboard. I told her (V5) that if a resident says no, she is supposed to give them time and report to the nurse and that maybe a different staff or CNA should be assigned. She (V5) should have reported his (R2) behavior to the nurse. He (R2) was sent to the hospital for further evaluation and management. She (V5) was made aware that she is immediately suspended and will not be coming back to the facility. She (V5) was escorted out of the building and was deleted from the system. I contacted V15 (Staffing/Schedule Coordinator) not to schedule her (V5). I also informed the agency to let them know that we had a serious abuse allegation on her (V5). I have had no contact with her (V5) afterwards. She (V5) is from s******* agency. That was the first time she (V5) picked up a shift for us. V2 was also asked regarding police involvement during investigation. V2 continued, When the police came in to investigate and make a report after we called, they attempted to interview R2. They noticed the sign that says video surveillance on R1. The police asked for us to contact the family of R1 to see if they are comfortable in providing them the clips related to care provided. I contacted V16 last [DATE] around 11:45 PM, spoke and requested the video clips which she (V16) then provided at 12:15 AM. She sent the clips via email.
R2's Hospital Records dated [DATE] recorded in part but not limited to the following:
Chief complaint: Alleged Assault
Visit Diagnosis: Traumatic injury of Head, Initial Encounter
History of Present Illness: Presents to the emergency room brought in due to an assault. Patient (R2) was reportedly assaulted by a CNA at the nursing home prior to arrival. Patient (R2) suffered multiple head injuries after being hit in the head and face. On questioning the patient (R2), he does not recall what happened and is oriented to name only which is his baseline.
Physical Exam:
Head: Right frontal hematoma and abrasion, left lateral periorbital ecchymosis.
ENT: lower lip outer abrasion.
Emergency Department Diagnosis: Assault; Traumatic Injury of Head, Initial Encounter
Police report dated [DATE] recorded an offense Battery Aggravated to Senior Citizen. Victim was R2 and V5 was the offender. Police report stated in part but not limited to the following: The incident occurred on [DATE] and was reported to police. Police responded, observed R2 with cuts on his head and lip. There was a blood stain on the wall above R2's bed and on his bed sheet. R2's hands were checked for blood or signs of injury. R2's right thumb nail appeared to have a crack in it with dried blood. Spoke with V5 who related she was preparing R2 for bed and transferring him out of his wheelchair and into bed. While doing so, V5 said R2 became agitated and flailed his arms and legs, causing a cut to her (V5) finger. V5 said she does not know how R2 got the cuts on his head and lip. V5 said he could have hit his head and lip on the bed board while he was refusing her care.
The police report also documented that three video clips were uploaded from R1's camera, narrating, The first video shows V5 being aggressive with R2's roommate (R1). V5 tells him (R1) to lay his head down and she (V5) pushes him (R1) into the bed. The second video shows V5 partially out of frame and she says stop and appears to pull something out of R2's hands. The third video shows V5 partially out of frame and she says stop.
On [DATE] at 1:00pm V2 was asked regarding screening and abuse orientation among agency staff working in the facility. V2 verbalized, Agency staffing is ongoing. We make sure that agency provided us background checks. Prescreening is done through agency. Agency staff picked up a shift and we do onboarding orientation with Scheduler and Nurse Manager. We also have the checklist that we go through during orientation. With agency staff - as soon as they physically come into the building, they are checked in at the front desk. The receptionist will check in with them to make sure they are on the schedule. They show photo identification. Receptionist will have them read and sign the form onboarding checklist. From there, the staff check in with Scheduler. If the Scheduler is not here, there is a designee or Nurse Manager to check where they are going. Nurse Supervisor will escort the agency staff to the assigned unit and introduced to the other staff. Regarding V5, she came in 3 PM to 11 PM shift. She should have been checked in with V6 (Nurse Supervisor). He (V6) was the one who signed her onboarding checklist.
On [DATE] at 1:55pm V6, stated during interview, Usually, the agency CNA checks in at the front desk. Then they go to their assigned floor. That time, she (V5) did not look for me or Scheduler, but I saw her at 2 West. I asked her (V5) and told her that she is assigned to 3 East and should go there; and get directions from her nurse, V4. I did not do any orientation/checklist on V5 at the time. V4 was the one who gave the orientation. I only ask about password and if there are any issues to call me.
On [DATE] at 2:20pm V4 was asked if she did an orientation on patients and policies with V5. V4 mentioned, V5, that was my first time working with her. When she came, I did not do any orientation regarding patient care or policies. Patient care is discussed among CNAs during shift change. On my end, I don't do any policies orientation. Management does that.
Agency Nurse Onboarding Checklist showed V5 signed and dated the form [DATE]. The form was verified and signed by V6. V6 denied any knowledge on completing her (V5) onboard checklist. The date was marked wrong when it was signed.
V5's Agency Orientation Checklist also showed V5 signed the form with a wrong date as [DATE]. The form was completed by V6, which he (V6) also denied that he provided the orientation to V5. In this orientation checklist, items that should be provided by agency such as dementia care training, references, background check (to name a few) were not initialed. Facility orientation items that facility should complete such as Dementia training; abuse policy (to name a few) were also not initialed. V2 stated in an interview that all items should be initialed by the one providing the orientation.
On [DATE] at 12:48 PM, V10 (Special Care Unit Director) was interviewed regarding Dementia unit in the facility. V10 stated, This is the Dementia Unit, third floor. All staff assigned here are certified Dementia trained. Agency staff are not trained because they don't work full time here. When they come to the floor to work for the shift, they will be oriented to look at the Kardex, plan of care, behavior monitor and interventions. They will be able to see the plan of care for each resident they were assigned to. V10 also stated in a follow up interview, R1 is kind of stubborn and has his own way to do things. When we do care, we have to explain it to him more than five times. If not, he will not allow staff to touch him and he gets agitated. R2 does not have much behavior. During care, he becomes resistive, he will hold other staff hand. When he does that, we will give him sometimes, leave him alone for 5-10 minutes and come back.
On [DATE] at 10:16 AM, V15 (Staffing/Schedule Co-Ordinator) was asked regarding background checks on agency staffing in the facility. V15 replied, We use agency staff for like 40% most of the time particularly evening and night shifts and on weekends. When they come to the facility, agency staff will check in at the front lobby and I will be directed to my Supervisor, V6, who will guide the assignment. For agency staff, I don't do the background check, it is the agency who does their own background checks. For new agency staff, I don't check the background or any paperwork because agency does that, and we trust the agency. I don't do any screening prior to agency staff working in the facility. We know for sure that the staff these agencies are giving are qualified to work. We trust the agency that their staff are screened prior to their shift.
On [DATE] at 11:03 AM, V2 also mentioned during interview, For V5, I have to call agency Human Resource to verify background on or before shift starts. I have to receive those documentation. I received her (V5) papers last Friday [DATE] prior to start of shift. Facility presented V5's local state agency's health care worker registry paperwork. There were no other background or screening documentation on V5. V2 continued, They wouldn't be in the agency if they are not eligible or appropriately screened. We rely on the agencies for their staff that we use with the background check that they conduct. Everybody is screened and checked out. Agency staffing abuse knowledge and training is automatic, someone who had been working in the healthcare setting should receive training on elder abuse. For us, once they (agency staff) physically come into the facility, they are orientated verbally by Nurse Supervisor or designated Nurse. We also provide them (staff agency) with a badge with abuse emergency. On the badge, it indicates who the abuse coordinator is and the types of abuse. For our regular staff, we do abuse training upon hire, new hire orientation, quarterly and as needed, if abuse is triggered. We also have online training annually. Agency staff are included if they are in the building working, they are invited to attend. When we do abuse training, we do it per shift, normally through verbal and giving of handouts. We like to do demonstration by creating a scene and ask them to identify abuse. We reiterate that any suspicion of abuse should be reported. We have an open door policy making sure that staff continue to work comfortably with residents and other staff. V4 and V7 (RN) are agency staff and have been working with us for quite a while now. Human Resources should have their papers.
V2 presented the following documents on V5 sent by agency electronically prior to start of her shift:
Passport
Local health agency healthcare worker registry
Pre-employment physical form
Tuberculosis skin test
CPR (Cardiopulmonary Resuscitation) card certificate
COVID (Coronavirus) vaccination card
On [DATE] at 11:37 AM, V8 (Medical Director) was interviewed regarding prevention of abuse in the facility. V8 replied, Education and communication to make sure abuse would not happen again. I don't have any input on the hiring, I don't know how these staff are vetted. Nursing Supervisors need to be aware of what is going on. My role is dealing with medical issues. I can't speak to the requirements for this agency hiring. Nurses need to be educated, supervisors need to go over with nurses making sure they are comfortable in handling or dealing with this kind of population with Dementia. All patients should be protected. The fact that they have Dementia they need to be protected.
On [DATE] at 12:20 PM, V17 (Human Resources Director) was asked regarding background checks and personnel files of agency staff. V17 verbalized, I don't keep the background checks and personnel files in a physical file. I saved it in the computer. For Agency staff, V15 takes care of the background checks, obtaining identification and COVID cards. She is the point person that gets the file, and she will just transfer it to me. Surveyor asked V17 to pull personnel files of V4 and V7. V4 and V7 are agency staff and are still working in the facility. During interviews, V4 stated she had been working in the facility for eight months now, while V7 is assigned to work in the facility multiple times. V17 stated, V4 and V7 are agency staff. I don't see their background checks. I believe V15 has a binder that she keeps for all background checks. V5 is new, I don't have her files.
On [DATE] at 1:10 PM, after reviewing video footage provided by V2 from facility's camera, V5 arrived in the third floor Dementia Unit at 3:20 PM on [DATE]. V5 went directly to the nurses' station where V13 (Agency CNA) showed her the schedule, went over the orientation binder. V5 was just seen flipping the pages of the binder, signed a form, then went directly to get her cart in the hallway. Video time stamped 3:20 PM to 3:26 PM showed it took six minutes for V5 to do all the necessary orientation she was provided before the start of her shift.
On [DATE] at 4:37 PM, surveyor was able to contact V5 after several attempts, however, V5 stated she already discussed everything related to the incident on [DATE] with the Supervisor and refused to talk further. She stated she is busy and at work.
On [DATE] at 1:59 PM, V3 (Director of Nursing) was asked regarding abuse and care of residents with Dementia in the facility. V3 mentioned, We have guidelines, policies and procedures to follow regarding abuse. We do abuse in services on our staff upon hiring, orientation before they go to the unit. We do it annually, and as needed - when there is occurrence of abuse incident. For agency staff, expectation is they are being screened by the agency. When they come in here, we provide them with education about abuse, falls, like a general orientation. The orientation is given one on one with them by myself, Assistant Director of Nursing or Nurse Supervisors. The nurse on the floor provides education too. Our staff and the Supervisors are trained and aware of our guidelines when it comes to agency staff. And because the Supervisors would know the agency staff assignments, training in the care of demented residents would be included in their orientation. And floor nurses should also be educating the agency staff in the Dementia related care.
On [DATE] at 2:20 PM, V1 (Administrator) stated during interview, Facility should be free from abuse. Whenever there is suspicion of abuse, residents should be safe, needs to be separated from staff if it is a staff abuse on resident or from resident if it is a resident to resident abuse. Staff has to follow abuse protocol to do what they are supposed to do. All agency staff background checks are done before they start to work and other documents were provided to facility. We need to verify that their background checks are done and prior to working here in the facility and that facility is provided with copies. Agency staffing should have 4-hour Dementia behavior training prior to work and if they don't have, then they will not be assigned to the Dementia care unit. Third floor is Dementia certified unit and staff should be trained regarding dementia.
Facility's policy: Abuse and Neglect, dated [DATE].
Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations.
Types of Abuse and Examples:
1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling
2. Verbal: Verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc.
7 Steps in Abuse Prevention:
This facility follows the federal[TRUNCATED]
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for abuse for two (R1 and R2) of three residents reviewed for abuse.
Findings include:
R1 is an [AGE] year-old resident admitted to facility on 02/19/2024 with medical diagnoses including but not limited to: Dementia, Major Depressive Disorder, Generalized Anxiety, Alzheimer's Disease, and Delusional Disorder. R1's MDS (Minimum Data Set) dated 02/22/24 recorded a BIMS (Brief Interview for Mental Status) score of 2 which means severe cognitive impairment. Social Service user defined assessment (UDA) with effective date of 04/18/2024 scores resident a 2+ for abuse/neglect which means at risk for abuse/neglect. R1's care plan for abuse/neglect was initiated 04/29/24 which was three days after an abuse allegation.
R2 is an [AGE] year-old resident admitted to facility on 02/14/2023 with diagnoses including but not limited to: Dementia, Generalized Anxiety and Parkinson's Disease. MDS dated [DATE] recorded that R2 has BIMS score of 2 which means severe cognitive impairment. Social Service UDA assessment with effective date of 02/28/24 scores resident a 2+ for abuse/neglect which means at risk for abuse/neglect. R2's care plan for abuse/neglect was initiated on 04/27/2024 which is one day after an abuse allegation.
On 05/06/24 at 1:59 PM, V3 (Director of Nursing, DON) was interviewed regarding abuse care plan. V3 stated, I have been the DON here for almost two years. All residents should have abuse care plans. All dementia residents should have an abuse/neglect care plan initiated on admission due to cognitive impairment. Social Services does the abuse assessment upon admission. If a resident is at risk for abuse, a care plan should be developed. For R1: Abuse care plan was initiated 04/29/24. For R2: Abuse care plan was initiated 04/27/24.
On 05/07/2024 at 2:13 PM, V21 (Social Services Director) was interviewed regarding abuse care plan. V21 stated, If residents are at risk for abuse, an abuse care plan should be developed. For Dementia residents, they are at risk for abuse. Its V10's (Special Care Unit Director) responsibility, the Dementia Unit Director.
Interview with V10 (Special Unit Care Director) on 05/06/2024 at 2:22 PM was conducted about abuse care plans. V10 stated All Dementia residents should have abuse care plans upon admission. R2 and R1: I don't know why we don't have it. It's the responsibility of social service to develop an initial abuse care plan. In the abuse risk assessment, my responsibility is the BIMS and PHQ9.
On 05/07/2024 at 2:26 PM V21 stated: Social Service does the risk assessment; the development of the abuse care plan is my responsibility. I guess, we don't have R1 and R2 initial abuse care plans.
Facility's Care Plan Policy dated 11/28/2017 revised 07/27/2023 states in part but not limited to the following:
Policy Statement
It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations.
Based on (name of regulation) a comprehensive care plan must be developed after the comprehensive assessment of the resident.
Based on (name of regulation) a baseline care plan will be completed within 48 hours of admission.
Procedures
1. During admission, the facility may put in place baseline care plans within 48 hours to address resident's care.
4. After the comprehensive assessment (state/federal-required MDS) is completed, the facility will put in place person-centered care plan outlining care for the resident within 7 days.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to follow its abuse policy related to prevention, prot...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to follow its abuse policy related to prevention, protection, screening, training and reporting for two (R1 and R2) of three residents reviewed for abuse. This deficiency also has the potential to affect the 234 residents currently residing in the facility.
Findings include:
Per census report, there are 234 residents currently residing in the facility.
According to initial incident report dated [DATE], V16 (Family Member) notified V2 (Executive Director) that V5 (Agency Certified Nursing Aide, CNA) was verbally and physically aggressive towards R1 during care.
R1 is an [AGE] year-old, male, admitted in the facility on [DATE] with diagnoses of Delusional Disorders; Dementia in other Diseases, Classified Elsewhere, Severe, with Psychotic Disturbance and Alzheimer's Disease, Unspecified. R1's MDS (Minimum Data Set) dated [DATE] recorded a BIMS (Brief Interview for Mental Status) score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R1 is at risk for abuse.
On [DATE] at 12:25 PM, V16 was interviewed regarding R1's alleged abuse allegation. V16 stated, We installed a camera here in this room for him (R1). A camera was observed installed by the television facing R1's bed. V16 continued, I worked in healthcare management, and I know how it is if you live in a nursing home. V2 contacted me last Friday night ([DATE]) around 11:00 PM to see if we could help her get a video footage she needed. I emailed the footage at 12:14 AM, that was Saturday, and one minute later she responded that she received it. I called her back and informed her that there was an incident with R1 when a staff member brought him back to bed, that was around 9:31 PM. The staff was verbally abusive. It was caught on the video. She (V2) said she will do the investigation. During interview with V16, it was observed that a sign stated that there is an audio and video recording in R1's room that was posted at the door. Same sign was also posted at bedside visible to all staff and visitors.
Electronic Monitoring Notification and Consent Form stipulated that V16 was permitted to conduct authorized electronic monitoring in R1's room through the use of an electronic monitoring device. It was signed and dated [DATE].
Video footage dated [DATE], time stamped 9:31 PM was seen, showing that V5 was yelling and intimidating and aggressive on R1 while putting him back to bed. R1 was heard saying You stop, stop, I said I'm not stopping while V5 continued to yell telling him (R1) to lay down in bed. V5 was also observed pushing R1 as she (V5) tried to make him (R1) lie down in bed.
On [DATE] at 10:17 AM, V2 was asked regarding R1's incident on [DATE]. V2 replied, When the police came in to investigate R2's abuse incident; and make a report after we called, they (police) attempted to interview R2. They noticed the sign that says video surveillance on R1. The police asked for us to contact the family of R1 to see if they are comfortable in providing them the clips related to care provided. I contacted V16 on [DATE] around 11:45 PM, to request video clips which she then provided at 12:15 AM. She sent the clips via email. She called me the same time regarding a concern related to care provided by a staff member to R1. The CNA in the video footage was identified as V5, per V2. V2 also verbalized, V16 stated that V5 appeared verbally and physically aggressive towards him (R1). At that point, I got off the phone, started the investigation. I immediately suspend her (V5). She is from staffing agency. That was the first time she (V5) picked up a shift for us. She (V5) was made aware that she is immediately suspended and will not be coming back to the facility. She (V5) was escorted out of the building and was deleted from the system. I also informed the agency to let them know that we had a serious abuse allegation on her (V5). I have had no contact with her (V5) afterwards. I attempted to interview him (R1), but he was confused and unable to provide details of what happened. He (R1) was sent to the hospital and came back with no injuries noted.
Hospital records dated [DATE] recorded that R1 was brought to the emergency department for alleged physical assault. Per emergency medical services, staff member at nursing facility was allegedly caught on camera assaulting R1. R1 stated, I hurt all over unable to point to exact location of pain. R1 was complaining of right-hand pain. There were no visible injuries noted including bruising, abrasion or lacerations; and no fractures or dislocation found.
Progress notes dated [DATE] documented R1 came back to facility from the hospital.
On [DATE] at 12:30 PM, R1 was observed in his room, in bed. He is alert and oriented to self, and verbal. R1 was asked regarding incident on [DATE] involving a staff member. R1 stated he does not remember any incident. He further stated that he has no issues with staff in the facility.
On [DATE] at 2:32 PM V19 (Unit Care Assistant) was asked regarding R1 and V5. V19 verbalized, On [DATE] around 9:32 PM, I saw V5 bringing R1 to room. I told her (V5) to handle R1 with care because there is a camera in his room. Since she (V5) does not know him, she walked him (R1) back to room, without letting him (R1) use the walker. She stood in front of him (R1), took both of his hands and guided him back to his room. She (V5) does not know R1, that he gets agitated easily, so she needs to be careful when she approached him.
R1's care plans documented in part but not limited to the following: Abuse (initiated [DATE]): Interventions - Provide reassurance to R1 reminded him that he is safe and secure.
Police Report dated [DATE] recorded an offense Aggravated Battery on R1 by V5. The incident was dated [DATE]; and was reported to police on [DATE]. In the police report, it was documented that R1 in this case is an additional victim from the same room at the facility and two incidents took place about 15 minutes apart. V2, apparently after seeing the video provided by V16, advised police that V5 was seen pushing R1 in the chest three times while telling him to lay back in his bed; R1 was sitting up in bed when he was pushed.
On [DATE] at 11:06 AM, V2 was asked regarding police report on R1. V2 replied, I called police the night of the incident, on [DATE]. They did not make the second trip because he (R1) was sent to the hospital.
On [DATE] at 12:35 PM, V22 (Local Law Enforcement Agency) was called to clarify R1's abuse report. V22 stated, the police report states it was reported on [DATE]. Surveyor informed V22 that facility staff stated it was reported on [DATE] with the other allegation. V22 checked records then stated, the abuse for R1 was only reported on [DATE].
Progress notes dated [DATE] time stamped 9:55 PM documented that R2 was assessed, observed bleeding on the lips, bump, and scratches on forehead area.
According to initial incident report dated [DATE], V2 was notified that V5 reported R2 was aggressive and combative during care. R2 represented confused and unable to recall.
R2 is an [AGE] year-old, male, admitted in the facility on [DATE] with diagnosis of Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with other Behavioral Disturbance and Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations. MDS dated [DATE] recorded that R2 has BIMS score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R2 is at risk for abuse.
R2's care plans documented in part but not limited to the following: Abuse (initiated [DATE]): Interventions - Recognize that the resident (R2) is an adult living with chronic, debilitating comorbidities in a skilled care setting and may experience feelings of lack of control and powerless. Work with the resident (R2) to overcome these feelings; advocate for expression of resident rights, autonomy and encourage independent decision making; Provide positive encouragement, support and kindness.
On [DATE] at 1:55 PM, V6 was interviewed regarding R2's incident on [DATE]. V6 stated, I was initially called at 9:55 PM by V4 regarding R2. V4 noted that there were scratches on his (R2) forehead, bumps on both sides of forehead and bleeding on the lips. V4 said that V5 asked for a band aid at 9:52 PM for her injured finger, like a scratch. She (V4) provided the band aid and checked on R2 and noticed the injuries. She (V4) did his (R2) initial assessment and called me right away. I went into his (R2) room, V4 and V5 were at the nurses' station. I went directly to assess R2. I also noted the injuries. I instructed V4 to supervise V5 while I do my investigation. With my investigation, there was a possible abuse on him (R2), so I called V2. I was told that she (V2) is going to come. I assigned a different CNA on R2, first aid provided, instructed V4 to inform Hospice. V2 came around 10:30 PM so she did her investigation as well. She (V2) also called local police. She (V5) was also interviewed by V2. She (V5) was supervised and took her off from the schedule. When the police arrived, they did their track on R2, interviewed me, and V4. After that, they noticed that there was a camera in R1's bed, they requested surveillance. Police interviewed V5; took pictures of R2 and injuries in V5's hand. Police cannot arrest her (V5) at the time because R2 was confused and unable to narrate the incident. He (R2) is alert and oriented to self; unable to verbalize needs and dependent on staff for all care. He (R2) is also a hospice resident.
On [DATE] at 2:20 PM, V4 was also asked regarding R2's incident on [DATE]. V4 replied, Around 9:30 PM, all residents were getting situated. CNAs are getting residents ready for bed. He (R2) was in his bed, in his room. I was at the nurses' station when V5 asked me for a band aid, said she had a scratch in her hand. I did not inspect her hand, but I gave her the band aid. I noticed that she was walking towards R2's room. I followed her and that was the time when I noticed that he (R2) had bleeding in his lips, saw bumps on his (R2) head and scratches that were starting to swell. I asked her (V5) on what happened, V5 said he (R2) was resisting, and she (V5) was trying to get him dressed and ready when he started to kick and swung his arms and ended up hitting his head on the side rails. I told her (V5) to give me a second and I will be back and that is when I contacted V6. In between that, I assessed him (R2), I cleaned his lips and forehead, assessed his range of motion and did neuro checks. V6 asked me to contact Hospice. Personally, when I worked with him (R2), he did not display any refusal to care or aggressive behavior. If a resident is refusing care at the moment, let them be, they have the right to refuse. Then come back at a later time, maybe after an hour and try to do the care. She (V5) did not tell me what happened. No, she didn't tell me about the behavior during care. She only told me when I went to the room and checked on him (R2). She (V5) should report the incident to me at the time, so I could assign another CNA to R2.
R2 shared the same room with R1. R1 and R2 are residents in the facility's Dementia Unit. V5 was the assigned CNA for R1 and R2 on [DATE], from 3:00 PM to 11:00 PM.
On [DATE] at 12:10 PM, R2 was observed in bed, alert, oriented to self, verbal. R2 was observed with multiple scratches on the forehead and a scratch on the left eye. A purplish discoloration was noted on the left eye and greenish to yellow discoloration above right eye. An abrasion was also noted to his lower lip. R2 was asked regarding injuries, stated, I don't remember what happened. R2 was also asked if he went to the hospital, stated he don't remember.
Police report dated [DATE] recorded an offense Battery Aggravated to Senior Citizen. Victim was R2 and V5 was the offender. There was no Police report for R1 provided for [DATE].
On [DATE] at 1:00 PM, V2 was asked regarding screening and abuse orientation among agency staff working in the facility. V2 verbalized, Agency staffing is ongoing. We make sure that agency provided us background checks. Prescreening is done through agency. Agency staff picked up a shift and we do onboarding orientation with Scheduler and Nurse Manager. We also have the checklist that we go through during orientation. With agency staff - as soon as they physically come into the building, they check in at the front desk. The receptionist will check in with them to make sure they are on the schedule. They show photo identification. Receptionist will have them read and sign the form onboarding checklist. From there, the staff check in with Scheduler. If the Scheduler is not here, there is a designee or Nurse Manager to check where they are going. Nurse Supervisor will escort the agency staff to the assigned unit and introduce to the other staff. Regarding V5, she came in 3 PM to 11 PM shift. She should have been checked in with V6 (Nurse Supervisor). He (V6) was the one who signed her onboarding checklist.
On [DATE] at 1:55 PM, V6, stated during interview, Usually, the agency CNA check in at the front desk. Then they go to their assigned floor. That time, she (V5) did not look for me or Scheduler, but I saw her at 2 West. I asked her (V5) and told her that she is assigned to 3 East and should go there; and get directions from her nurse, V4. I did not do any orientation/checklist on V5 at the time. V4 was the one who gave the orientation. I only ask about password and if there are any issues to call me.
On [DATE] at 2:20 PM, V4 was asked if she did an orientation on patients and policies on V5. V4 mentioned, V5, that was my first time working with her. When she came, I did not do any orientation regarding patient care or policies. Patient care is discussed among CNAs during shift change. On my end, I don't do any policies orientation. Management does that.
Agency Nurse Onboarding Checklist showed V5 signed and dated the form [DATE]. The form was verified and signed by V6. V6 denied any knowledge on completing her (V5) onboard checklist. The date was marked wrong when it was signed.
Review of V5's Agency Orientation Checklist showed V5 signed the form with an incorrect date of [DATE]. The form was completed by V6, which he (V6) denied providing the orientation to V5. Orientation checklist, items provided by agency such as dementia care training, references, background check (to name a few) were not initialed. Facility orientation items that facility should complete such as Dementia training; abuse policy (to name a few) were not initialed. V2 stated in an interview that all items should be initialed by the one providing the orientation.
On [DATE] at 12:48 PM, V10 (Special Care Unit Director) was interviewed regarding Dementia unit in the facility. V10 stated, This is the Dementia Unit, third floor. All staff assigned here are certified Dementia trained. Agency staff are not trained because they don't work full time here. When they come to the floor to work for the shift, they will be oriented to look at the [NAME], plan of care, behavior monitor and interventions. They will be able to see the plan of care for each resident they were assigned to. V10 also stated in a follow up interview, R1 is kind of stubborn and has his own way to do things. When we do care, we have to explain it to him more than five times. If not, he will not allow staff to touch him and he gets agitated. R2 does not have much behavior. During care, he becomes resistive, he will hold other staff hand. When he does that, we will give him some time, leave him alone for 5-10 minutes and come back.
On [DATE] at 10:16 AM, V15 (Staffing/Scheduling Co-Ordinator) was asked regarding background checks on agency staffing in the facility. V15 replied, We use agency staff for like 40% most of the time particularly evening and night shifts and on weekends. When they come to the facility, agency staff will be checked in at the front lobby and I will direct them to my Supervisor, V6, who will guide the assignment. For agency staff, I don't do the background check, it is the agency who does their own background checks. For new agency staff, I don't check the background or any paperwork because agency does that, and we trust the agency. I don't do any screening prior to agency staff working in the facility. We know for sure that the staff these agencies are giving are qualified to work. We trust the agency that their staff are screened prior to their shift.
On [DATE] at 11:03 AM V2 stated during interview, For V5, I have to call agency Human Resource to verify background on or before shift starts. I have to receive those documentation. I received her (V5) papers last Friday [DATE] prior to start of shift. Facility presented V5's local state agency's health care worker registry paperwork. There were no other background or screening documentation on V5. V2 continued, They wouldn't be in the agency if they are not eligible or appropriately screened. We rely on the agencies for their staff that we use with the background check that they conducted. Everybody is screened and checked out. Agency staffing abuse knowledge and training is automatic, someone who had been working in the healthcare setting should receive training on elder abuse. For us, once they (agency staff) physically come into the facility, they are orientated verbally by Nurse Supervisor or designated Nurse. We also provide them (staff agency) with a badge with abuse emergency. On the badge, it indicates who the abuse coordinator is and the types of abuse. For our regular staff, we do abuse training upon hire, new hire orientation, quarterly and as needed, if abuse is triggered. We also have online training annually. Agency staff are included if they are in the building working, they are invited to attend. When we do abuse training, we do it per shift, normally through verbal and giving of handouts. We like to do demonstration by creating a scene and asked them to identify abuse. We reiterate that any suspicion of abuse should be reported. We have an open door policy making sure that staff continue to work comfortably with residents and other staff. V4 and V7 (RN) are agency staff and have been working with us for quite a while now. Human Resources should have their papers.
V2 presented the following documents on V5 sent by agency electronically prior to start of her shift:
Passport
Local health agency healthcare worker registry
Pre-employment physical form
Tuberculosis skin test
CPR (Cardiopulmonary Resuscitation) card certificate
COVID (Coronavirus) vaccination card
On [DATE] at 12:20 PM, V17 (Human Resources Director) was also asked regarding background checks and personnel files of agency staff. V17 verbalized, I don't keep the background checks and personnel files in a physical file. I save it in the computer. For Agency staff, V15 takes care of the background checks, obtaining identification and COVID cards. She is the point person that gets the file, and she will just transfer it to me. Surveyor asked V17 to pull personnel files of V4 and V7 (RN). V4 and V7 are agency staff and are still working in the facility. During interviews, V4 stated she had been working in the facility for eight months now, while V7 is assigned to work in the facility multiple times. V17 stated, V4 and V7 are agency staff. I don't see their background checks. I believe V15 has a binder that she keeps for all background checks. V5 is new, I don't have her files.
On [DATE] at 1:10 PM, after reviewing video footage provided by V2 from facility's camera, V5 arrived in the third floor Dementia Unit at 3:20 PM on [DATE]. V5 went directly to the nurses' station where V13 (Agency CNA) showed her the schedule, went over the orientation binder. V5 was seen flipping the pages of the binder, signed a form, then went directly to get her cart in the hallway. Video time stamped 3:20 PM to 3:26 PM showed it took six minutes for V5 to do all the necessary orientation she was provided before the start of her shift.
On [DATE] at 11:37 AM, V8 (Medical Director) was interviewed regarding prevention of abuse in the facility. V8 replied, My role is dealing with medical issues. I can't speak with the requirements for this agency hiring. Nurses need to be educated, supervisors need to go over with nurses making sure they are comfortable in handling or dealing with this kind of population with Dementia. All patients should be protected. The fact that they have Dementia they need to be protected.
On [DATE] at 4:37 PM after several attempts, surveyor made contact via telephone with V5. V5 stated, she already discussed everything related to the incident on [DATE] with the Supervisor and refused to talk further. She stated she is busy and at work.
On [DATE] at 1:59 PM, V3 (Director of Nursing) was asked regarding abuse and care of residents with Dementia in the facility. V3 mentioned, We have guidelines, policies and procedures to follow regarding abuse. We do abuse in-services on our staff upon hiring, orientation before they go to the unit. We do it annually, and as needed - when there is occurrence of abuse incident. For agency staff, expectation is they are being screened by the agency. When they come in here, we provide them with education about abuse, falls, like a general orientation. The orientation is given one on one with them by myself, Assistant Director of Nursing or Nurse Supervisors. The nurse on the floor provides education too. Our staff and the Supervisors are trained and aware of our guidelines when it comes to agency staff. And because the Supervisors would know the agency staff assignments, training in the care of demented residents would be included in their orientation. And floor nurses should also be educating the agency staff in the Dementia related care.
On [DATE] at 2:20 PM, V1 (Administrator) stated during interview, Facility should be free from abuse. Whenever there is suspicion of abuse, residents should be safe, needs to be separated from staff if it is a staff abuse on resident or from resident if it is a resident-to-resident abuse. Staff has to follow abuse protocol to what they are supposed to do. All agency staff background checks are done before they start to work and other documents were provided to facility. We need to verify that their background checks are done and prior to working here in the facility and that facility is provided with copies. Agency staffing should have 4-hour Dementia behavior training prior to work and if they don't have, then they will not be assigned to the Dementia care unit. Third floor is Dementia certified unit and staff should be trained regarding dementia.
Facility's policy: Abuse and Neglect, dated [DATE].
Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations.
Types of Abuse and Examples:
1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling
2. Verbal: Verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc.
7 Steps in Abuse Prevention:
This facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven federal components of prevention and investigation. The seven elements of prevention and investigation include:
I. Screening: Have procedures to:
Screen potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries. The facility will also not allow contracted or temporary staff from working in the facility if the contracted or temporary staff was found by the contracting agency to be with disqualifying findings from the registry if registry check is required for the contracted staff. Similarly, prior to placement in the facility, the facility will require background check of prospective consultants, contractors, volunteers, caregivers working on behalf of the facility, and students in its nurse aide training program and students from affiliated academic institutions including therapy, social, and activity programs to care for residents to be done either the facility itself, the third-party agency or academic institution.
1. Initiate a reference from the applicant's previous employer.
2. Obtain a copy of professional licenses. The facility will check annually to ensure professional licenses are current and not expired.
3. Check with the Illinois Nurse Aide Registry now known as Healthcare Worker Registry upon hire, to determine reports of abuse, neglect and theft if staff is not a licensed staff.
4. Initiate Illinois State Police fingerprint check for non-licensed applicants or new hires within 10 days of hiring, unless the applicant had been previously finger-printed in accordance to the Illinois Background Check Act. The Illinois State Police Web Portal will automatically update convictions of those previously fingerprinted.
II. Training: Have procedures to: Train employees, through orientation and on-going sessions on issues related to abuse prohibition, neglect, exploitation, misappropriation of property such as:
Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents.
Abuse identification and recognizing signs of abuse.
How staff should report their knowledge related to allegation without fear of reprisal.
How to recognize signs of burnout, frustration and stress that may lead to abuse; and to what constitutes abuse, neglect, exploitation, and misappropriation of resident property.
Understanding of behavior that has an increased risk of abuse.
III. Prevention: have procedures to:
Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property.
Deployment of sufficient and trained staff to deal with behaviors in the units.
The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their bed.
VII. Reporting/Response: Have procedures to:
If the event that results in allegation of abuse also causes the individual to suspect a crime, the facility will also report to the local law enforcement agency.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of quality by a) failing to protect residents to be free from physical and verbal abuse; and failing to follow abuse policies and procedures. These failures affected two (R1 and R2) of three residents reviewed for abuse and has the potential to affect all 234 residents currently residing in the facility.
Findings include:
Per facility census, there are 234 residents currently residing in the facility.
R1 is an [AGE] year-old, male, admitted in the facility on 02/19/24 with diagnoses of Delusional Disorders; Dementia in other Diseases, Classified Elsewhere, Severe, with Psychotic Disturbance and Alzheimer's Disease, Unspecified. R1's MDS (Minimum Data Set) dated 02/22/24 recorded a BIMS (Brief Interview for Mental Status) score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R1 is at risk for abuse.
On 04/30/24 at 10:58 AM, V4 (RN) was interviewed regarding knowledge of R1's abuse allegation involving V5. V4 replied, Last 04/26/24, I was at the nurses' station and didn't hear V5 yelling or anything. I am not aware of any abuse incident on R1 with V5 who worked under me that night. That was my first time working with her (V5 CNA Agency).
Hospital records dated 04/27/24 recorded that R1 was brought to the emergency department for alleged physical assault. That a staff member at nursing facility was allegedly caught on camera assaulting R1. R1 stated, I hurt all over unable to point to exact location of pain. R1 was complaining of right-hand pain. There were no visible injuries noted including bruising, abrasion or lacerations; and no fractures or dislocation found.
On 04/30/24 at 12:30 PM, R1 was observed in his room, in bed. He is alert and oriented to self, and verbal. R1 was asked regarding incident last 04/26/24 involving a staff member. R1 stated he does not remember any incident and has no issues with staff in the facility.
R2 is an [AGE] year-old, male, admitted in the facility on 02/14/23 with diagnosis of Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with other Behavioral Disturbance and Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations. MDS dated [DATE] recorded that R2 has BIMS score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R2 is at risk for abuse.
Initial incident report dated 04/27/24 documented V2 was notified that V5 reported R2 was aggressive and combative during care. R2 represented confused and unable to recall.
Progress notes dated 04/26/24 time stamped 9:55 PM recorded R2 was assessed, observed bleeding on the lips, bump, and scratches on forehead area.
R2 shared the same room with R1. R1 and R2 are residents in the facility's Dementia Unit. V5 was the assigned CNA for R1 and R2 on 04/26/24, from 3:00 PM to 11:00 PM.
On 04/29/24 at 12:10 PM, R2 was observed in bed, alert, oriented to self, verbal. R2 was observed with multiple scratches on the forehead and a scratch on the left eye. A purplish discoloration was noted on the left eye and greenish to yellow discoloration above right eye. An abrasion was also noted to his lower lip. R2 was asked regarding injuries and stated, I don't remember what happened. R2 was also asked if he went to the hospital, and stated, he don't remember.
On 4/29/24 at 1:00pm V2 (Executive Director) was asked regarding screening and abuse orientation among agency staff working in the facility. V2 verbalized, Agency staffing is ongoing. We make sure that agency provided us background checks. Prescreening is done through agency. Agency staff picked up a shift and we do onboarding orientation with Scheduler and Nurse Manager. We also have the checklist that we go through during orientation. With agency staff - as soon as they physically come into the building, they check in at the front desk. The receptionist will check in with them to make sure they are on the schedule. They show photo identification. Receptionist will have them read and sign the form onboarding checklist. From there, the staff check in with Scheduler. If the Scheduler is not here, there is a designee or Nurse Manager to check where they are going. Nurse Supervisor will escort the agency staff to the assigned unit and introduced to the other staff. Regarding V5, she came in 3 PM to 11 PM shift. She should have been checked in with V6 (Nurse Supervisor). He (V6) was the one who signed her onboarding checklist.
On 4/29/24 at 1:55pm V6, stated during interview, Usually, the agency CNA checked in at the front desk. Then they go to their assigned floor. That time, she (V5) did not look for me or Scheduler, but I saw her at 2 West. I asked her (V5) and told her that she is assigned to 3 East and should go there; and get directions from her nurse, V4. I did not do any orientation/checklist on V5 at the time. V4 was the one who gave the orientation. I only ask about password and if there are any issues to call me.
On 4/29/24 at 2:20pm V4 was asked if she did an orientation on patients and policies with V5. V4 mentioned, V5, that was my first time working with her. When she came, I did not do any orientation regarding patient care or policies. Patient care is discussed among CNAs during shift change. On my end, I don't do any policies orientation. Management does that.
Agency Nurse Onboarding Checklist showed V5 signed and dated the form 4/26/2026. The form was verified and signed by V6. V6 denied any knowledge on completing her (V5) onboard checklist. The date was marked wrong when it was signed.
Review of V5's Agency Orientation Checklist showed V5 signed the form with an incorrect date of 4/26/2026. The form was completed by V6, which he (V6) denied providing the orientation to V5. Orientation checklist, items provided by agency such as dementia care training, references, background check (to name a few) were not initialed. Facility orientation items that facility should complete such as Dementia training; abuse policy (to name a few) were not initialed. V2 stated in an interview that all items should be initialed by the one providing the orientation.
On 05/01/24 at 11:03 AM, V2 stated (in part), For us, once they (agency staff) physically come into the facility, they are orientated verbally by Nurse Supervisor or designated Nurse.
On 05/01/24 at 1:10 PM, after reviewing video footage provided by V2 from facility's camera, V5 arrived to the third floor Dementia Unit at 3:20 PM on 04/26/24. V5 went directly to the nurses' station where V13 (Agency CNA) showed her the schedule, went over the orientation binder. V5 was just seen flipping the pages of the binder, signed a form, then went directly to get her cart in the hallway. Video time stamped 3:20 PM to 3:26 PM showed it took six minutes for V5 to do all the necessary orientation she was provided before the start of her shift.
On 05/06/24 at 1:59 PM, V3 (Director of Nursing) was asked regarding abuse and care of residents with Dementia in the facility. V3 mentioned, We have guidelines, policies and procedures to follow regarding abuse. We do abuse in-services on our staff upon hiring, orientation before they go to the unit. We do it annually, and as needed - when there is occurrence of abuse incident. For agency staff, expectation is they are being screened by the agency. When they come in here, we provide them with education about abuse, falls, like a general orientation. The orientation is given one on one with them by myself, Assistant Director of Nursing or Nurse Supervisors. The nurses on the floor provide education too. Our staff and the Supervisors are trained and aware of our guidelines when it comes to agency staff. And because the Supervisors would know the agency staff assignments, training in the care of demented residents would be included in their orientation. And floor nurses should also be educating the agency staff in the Dementia related care.
Facility's policy: Abuse and Neglect, dated 07/14/23 (in part)
Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations.
Types of Abuse and Examples:
1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling
2. Verbal: Verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc.
7 Steps in Abuse Prevention:
This facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven federal components of prevention and investigation. The seven elements of prevention and investigation include:
How to recognize signs of burnout, frustration and stress that may lead to abuse; and to what constitutes abuse, neglect, exploitation, and misappropriation of resident property.
Understanding of behavior that has an increase risk of abuse.
III. Prevention: have procedures to:
Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property.
Deployment of sufficient and trained staff to deal with behaviors in the units.
The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their bed.
Feb 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to administer medications in a timely manner for 1 of 3 residents (R4) reviewed for medication administration in the sample of 27.
The findings...
Read full inspector narrative →
Based on interview and record review the facility failed to administer medications in a timely manner for 1 of 3 residents (R4) reviewed for medication administration in the sample of 27.
The findings include:
R4's Physician Order Sheet dated 11/23 showed R4 has an order of Atorvastatin (cholesterol medications), Tylenol and Tramadol (both pain medications.)
R4's electronic medication administration record showed that R4 has an order of Atorvastatin 20 milligram (mg) to be given at 2100 (9 PM). R4's Tylenol order of 325 mg 2 tabs every 6 hours to be given at midnight, 6 AM, 12 PM and 6 PM. R4's Tramadol order of 60 mg, 1 tab four times a day to be given at midnight, 6 AM, 12 PM and 6 PM.
On 2/23/24 at 10:15 AM, V14 (R4's granddaughter) said that on 11/6/23, R4's 6 PM medications were given very late or were not given at all. V14 said she looked for the nurse who told her he was busy taking care of so many residents and was not sure when he would be able to give R4's 6 PM medications.
R4's Medication Audit Report dated 11/6/23 showed R4 got her Atorvastatin 9 PM dose at (2345) 11:45 PM which was 2 hours and 45 minutes late. R4's Tylenol 325 mg 2 tabs 6 PM dose was given at (2345) 11:45 PM which was 5 hours and 45 minutes late. R4's Tramadol 50 mg 1 tab 6 PM dose was given at (2345) 11:45 PM which was 5 hours and 45 minutes late.
On 2/23/24 at 11:47 AM, V11 (LPN) said he was the nurse on 11/6/23. V11 said he was very busy that day and gave R4's PM medications late. V11 said he did not realize that R4 was on his assigned unit.
On 2/23/24 at 1 PM, V10 (Nurse Supervisor) said resident's medications should be administered as ordered or an hour before or an hour after their due time.
On 2/23/24 at 2:30 PM both V2 (Director of Nursing) and V20 (Asst Administrator) said the facility did not have a policy on Medication Administration.
Oct 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
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to follow their Privacy, Dignity and Discharge Planning and Instruction policy when a resident was discharged ; and another resident's medic...
Read full inspector narrative →
Based on interviews and record reviews, the facility failed to follow their Privacy, Dignity and Discharge Planning and Instruction policy when a resident was discharged ; and another resident's medication was found in the discharge medication pile. This deficient practice affects one resident (R3) of three residents reviewed for privacy and confidentiality and discharge medication.
Findings Include:
R2 discharged from the facility on 9/29/23.
On 10/5/23 at 11:00 AM, V6 (Complainant) reported that R2 received R3's one medication upon review of medication when already home. V6 was able to give the information from the medication label, such as R3's full name, medication name, direction, and prescription number (Rx # XXXXXXXX). V6 also reported that she informed the facility of this incident on 10/2/23 (Monday).
Concern form dated 10/3/23, reads in part: R2 was discharged on 9/29/23 and was sent home with a medication which does not belong to R2. Action taken: Spoke with Nurse and education one to one was given regarding medication reconciliation during discharge. Resident/Responsible Party informed of outcome on 10/4/23.
On 10/5/23 11:25AM V8 (Discharge Planner) stated that V8 received an email from V6 regarding medication that belonged to another patient (R3). I forwarded the information to V3 (DON) and V7 (Unit Nurse Manager). V8 also provided a copy of an email along with attachment of Medication (Bingo Card) pictures sent to V8 by V6. In there, the label contains the full name of R3, room number, medication name, directions and indication of use and Prescription number.
On 10/5/23 at 11:15AM V7 (Unit Nurse Manager) stated that on Monday (10/2/23) she was informed by V8 because the family called and informed V8 about medication of another resident in R2's discharged medication.
Pharmacy provided information of R3's one medication (Sodium Bicarbonate 650mg) for antacids with prescription number Rx # XXXXXXXX.
On 10/5/23 at 11:45AM (V3) DON When I found out what happened, I talked to V10 right away and re-educated V10. V10 was busy that day and I told V10 it is not an excuse. My expectation is for the nurse is to review the list of medication and reconcile it in with the medication on hand, pack the medication and send it with resident who is being discharged .
On 10/5/23 at 12:00 PM, V10 (RN) stated that he was the nurse that discharged R2. Reviewed the medication with the family and R2. One by one, handed the bingo card. However, there was a pile of bingo cards for extra medication not yet used. I just handed it to the family and did not see R3's medication was somewhere in the pile. I know I should have done better and checked all the bingo cards, but I was so busy that day.
Physician order sheet reviewed and R3 has an order for Sodium Bicarbonate 650mg tablet to give 2 tablets twice a day for antacid.
Privacy and Dignity policy with a revised date of 7/28/23, reads in part: It is the facility policy to ensure the resident's privacy and dignity is respected by the staff at all times. Resident health information will not be shared to anyone who is not involved in resident's care and to anyone whom the alert and oriented resident does not wish to share his and her information with.
Discharge Planning and Instruction policy with the revised date of 7/26/23, reads in part: It is the policy of this facility to conduct proper discharge planning for all residents and provide appropriate discharge instructions in preparation for discharge on ce a discharge order is obtained from the resident attending physician. Medication will be sent with the resident being discharged to the community.
Mar 2023
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide documentation of administering a narcotic med...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide documentation of administering a narcotic medication that was in use. This failure applied to one resident (R121) whom was reviewed during medication storage and labeling.
Findings include:
R121 is an [AGE] year old male who was admitted to the facility 7/1/22 with diagnoses that include Alzheimer's, Dementia. According to R121's MDS (Minimum Data Set) he exhibits severe cognitive impairments scoring a BIMS (Brief Interview of Mental Status) of 2 out of 15. According to Physicians Order Sheet (POS) dated 2/17/23 R121 has been receiving hospice services while living in the facility.
On 03/08/23 3:50 PM, during medication and storage review with V19 LPN, lorazepam 1mg/ml gel narcotic sheet for this resident was found in the narcotic control book and the medication was not on the cart. V19 said that they did not know where the medication was located at that time. Surveyor and V19 checked the medication cart and the refrigerator. At 4:10PM V17 Nursing Supervisor presented the missing medication with resident label and said that it was open and had been used. V17 said, the nurses should sign out the medication immediately after the medication has been administered and it should have been on the cart.
3/9/23 at 10:13AM V17 presented with V20 LPN with the lorazepam medication and a modified control sheet which indicated 2ml were wasted on 3/8/23. This was not signed by any nurse or practitioner. V17 said this medication was discontinued on 2/8/23 and should have been removed as well as the sheet. V17 said usually, we take it and give it to the DON to destroy, but V20 LPN forgot to tell me that it was wasted, and she forgot to record it on the sheet. It was in the refrigerator, but I didn't recognize it as the medication because it is a new form of medication that we are not accustomed to using. V20 said, I noticed that the medication was discontinued and was opened after I counted with the nurse in the morning, but I forgot to sign it out before I left the facility yesterday.
On 3/9/23 at 10:40AM V3 Director of Nursing said, when a medication is wasted, two nurses have to sign out and verify that the medication was wasted.
R121 Physician Order Sheet was reviewed which included an order for lorazepam gel dated 2/9/23 and discontinued 2/23/23.
Facility Policy titled Controlled Medications Count revised 7/27/22 states; Statement: It is the policy of the facility to maintain an accurate count of Scheduled II controlled medications. Procedure: 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken. 2. After administration of the controlled medication, the nurse will sign off the eMAR. 3. If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based interviews and record reviews, the facility failed to follow their policy and procedures for providing care and services in a timely manner by not ensuring nursing staff respond to call lights i...
Read full inspector narrative →
Based interviews and record reviews, the facility failed to follow their policy and procedures for providing care and services in a timely manner by not ensuring nursing staff respond to call lights in a timely manner. This failure applied to four (R343, R443, R445, R446) of four residents reviewed for assistance with activities of daily living.
Findings include:
On 03/06/23 at 10:44 AM R343 stated she has been at the facility with diarrhea for 3 days. R343 stated sometimes it takes 40 minutes for someone to respond to her call light when she uses it for incontinence care.
On 03/06/23 at 12:50 PM R443 stated no one ever gets her out of bed other than for therapy and she stopped using her call light because no one ever responds.
On 03/06/23 at 12:03 PM R445 stated he threw up on himself after eating lunch one day and pressed his call light for assistance. R445 stated it took 20-30 minutes for someone to respond to clean him up. R445 stated sometimes it takes this long for a response to his call light.
On 03/06/23 at 11:00 AM R446 stated, this morning it took an hour for someone to respond to the call light. R446 stated during a shift change you can't get anyone to respond to the call light. R446 stated the night before her roommate rang the call light and she did as well, however the staff responded to her roommate but did not acknowledge that she pressed the call light for assistance as well. R446 stated she had to yell out and remind them that she needed to be changed. R446 stated she had already been waiting soiled for more than an hour but then had to wait another 30-45 minutes before being changed.
On 03/07/23 at 11:17 AM R446 stated a lot of times she has to wait for assistance possibly because she's larger and needs two person assistance.
On 03/08/23 at 01:44 PM V13 (Ombudsman) stated she has received multiple concerns from residents about staffing, including call light response time.
Resident council meeting report dated 11/08/22 and 02/14/23 documents nursing concerns include: resident stated that sometimes their call lights at night are being answered late. Will inform night nurses and supervisor to take frequent rounds. Stand up meeting was held with staff.
On 03/09/23 at 11:17 AM V3 (Director of Nursing) stated it is all nursing staff's responsibility to respond to the call lights and they should always be answered. V3 stated she is not sure what is a reasonable amount of time the call light should be responded to, however as soon as staff become aware of them.
The facility's Call Light Policy reviewed 03/09/23 states:
It is the policy of this facility to ensure that there is prompt response to the resident's call for assistance.
Facility shall answer call lights in timely manner.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Illinois facilities.
- • 40% turnover. Below Illinois's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 14 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade C (58/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 58/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Glenview Terrace's CMS Rating?
CMS assigns GLENVIEW TERRACE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Illinois, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Glenview Terrace Staffed?
CMS rates GLENVIEW TERRACE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 40%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Glenview Terrace?
State health inspectors documented 14 deficiencies at GLENVIEW TERRACE during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 12 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 Glenview Terrace?
GLENVIEW TERRACE 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 LEGACY HEALTHCARE, a chain that manages multiple nursing homes. With 314 certified beds and approximately 232 residents (about 74% occupancy), it is a large facility located in GLENVIEW, Illinois.
How Does Glenview Terrace Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, GLENVIEW TERRACE's overall rating (4 stars) is above the state average of 2.5, staff turnover (40%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Glenview Terrace?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Glenview Terrace Safe?
Based on CMS inspection data, GLENVIEW TERRACE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Glenview Terrace Stick Around?
GLENVIEW TERRACE has a staff turnover rate of 40%, 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 Glenview Terrace Ever Fined?
GLENVIEW TERRACE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Glenview Terrace on Any Federal Watch List?
GLENVIEW TERRACE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.