STEARNS NURSING & REHAB CENTER
For profit - Limited Liability company
109 Beds
NORBERT BENNETT & DONALD DENZ
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#407 of 665 in IL
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Stearns Nursing & Rehab Center has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. They rank #407 out of 665 nursing homes in Illinois, placing them in the bottom half of facilities statewide, and #8 out of 17 in Madison County, meaning only seven local options are worse. The facility's performance is worsening, with the number of issues increasing from 7 to 12 over the past year. Staffing is a major concern, with a low rating of 2 out of 5 stars and a troubling turnover rate of 69%, far above the state average. Additionally, the facility has incurred $213,909 in fines, which is higher than 86% of Illinois nursing homes, suggesting ongoing compliance problems. RN coverage is also inadequate, being lower than 89% of facilities statewide, which can affect the quality of care. Specific incidents include a resident who became unresponsive after failing to receive timely medical treatment for a decline in their condition, and failures to maintain resident privacy during toileting, exposing them to their roommates. Moreover, there have been multiple instances of abuse among residents, highlighting serious safety concerns. While there are some positive quality measures, overall, families should carefully consider these issues when researching this facility.
- Trust Score
- F
- In Illinois
- #407/665
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 69% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $213,909 in fines. Higher than 58% of Illinois facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 19 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 27 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 39%
Review needed
7 → 12 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 12 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Illinois average (2.5)
Below average - review inspection findings carefully
Staff Turnover: 69%
23pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $213,909
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: NORBERT BENNETT & DONALD DENZ
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (69%)
21 points above Illinois average of 48%
The Ugly 27 deficiencies on record
1 life-threatening 10 actual harm
Apr 2025
12 deficiencies
4 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Resident Rights
(Tag F0550)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R38's Care Plan, dated 1/23/2025, documents that R38 has an ADL self-care performance deficit r/t Aggressive Behavior, Confus...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R38's Care Plan, dated 1/23/2025, documents that R38 has an ADL self-care performance deficit r/t Aggressive Behavior, Confusion, Hemiplegia, Impaired balance, Cerebral Infarction, aphasia. It also documents TOILET USE: (R38) requires a 1 person assist toileting.
04/24/25 12:47 PM entered open room door and observed V17, CNA, assisting R38 with toileting. V17 was in bathroom, door open with R38 in a standing position, pants down exposing R38's buttocks and scrotum to R38's roommate.
On 4/24/2025 at 1:00 PM R36 stated that he does not like watching his roommate going to the bathroom and does not want to look at his genitals.
On 4/24/2025 at 12:45 PM V45, R38's sister in law, stated that R38 would not like to be exposed to others and would want the door closed when going to the bathroom.
Based on Interview, Observation, and Record Review, the Facility failed to maintain a resident's privacy and dignity for 4 of 6 residents (R18, R38, R56, R63) reviewed for resident privacy and dignity in the sample of 79. This failure resulted in R18 and R63 feeling embarrassed and uncomfortable. A reasonable person would expect to have privacy in their home and would experience anxiety, humiliation, and embarrassment if their privates were exposed.
The Findings Include:
1. R18's admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity.
R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: R18 is not toileted, she is frequently incontinent, unable to transfer to toilet, use of bedpan encouraged, incontinent care per staff. It continues (4/7/25) R18 has potential for impairment to skin integrity related to impaired mobility, current medications, incontinence of B&B (bowel and bladder). Interventions: Complete pressure ulcer risk assessment quarterly and PRN (as needed), observe skin daily with care, notify MD (medical doctor)/NP (nurse practitioner) of any abnormal findings, pressure redistribution mattress to bed, provide diet as ordered, RD (registered dietitian) to follow related to wound care and nutrition, refer to Specialized Wound Management, staff to assist with turning and repositioning as tolerated, staff to provide incontinent care after each incontinent episode, weekly skin assessment.
R18's Minimum Data Set (MDS), dated [DATE], documents R18 has severe cognitive impairment and is dependent on staff for toileting and bathing. R18 is always incontinent of both bowel and bladder.
On 4/22/25 at 10:00 AM, V12, Certified Nursing Assistant (CNA), provided incontinence care on R18. The window blinds were left open with R18 lying in the bed by the door with the curtain between the beds not pulled to obstruct the view from the window. There is a patio where residents can sit outside, as well as cars seen parked in a parking lot outside her window.
On 4/23/2025 at 9:57 AM R18 stated that she doesn't really pay attention to the CNAs if they pull the curtain or not. R18 stated that she would not feel comfortable if she was exposed to other people. R18 stated that with the staff she must be ok, but with other people she would be embarrassed and would not like it.
On 4/24/25 at 9:40 AM, V14, CNA, stated Any time I am providing care to a resident in their room, I make sure the blinds are closed, the curtains are pulled, and the door is shut.
2. R63's admission Record, dated 4/22/25, documents R63 was admitted to the facility on [DATE] with diagnosis of Cerebral Vascular Accident (CVA) affecting dominant side, Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Generalized Anxiety Disorder, Polyneuropathy, Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen, Overactive Bladder, Chronic Kidney Disease-stage 4, Morbid Obesity, and Type 2 Diabetes Mellitus (DM).
R63's Care Plan, dated 11/13/24, documents R63 requires assistance with ADLs related to impaired mobility. Diagnosis Cerebrovascular Accident (CVA)/hemiplegia. R63 has shortness of breath (SOB) with exertion, when lying flat R63 uses oxygen. Interventions: Assist with all ADLs as needed, provide setup assist and encouragement for those task that resident can perform independently, observe for signs/symptoms or complaint of shortness of breath, elevate head of bed as needed/requested, administer oxygen as ordered per MD (Medical Doctor). It continues (1/13/25) R63 is at risk for skin issues related to impaired mobility. Interventions: Staff to provide incontinent care after each incontinent episode, weekly skin assessment, staff to assist with turning and repositioning as tolerated, pressure redistribution mattress to bed.
R63's MDS, dated [DATE], documents R63 is cognitively intact and is dependent on staff for toileting.
On 4/22/25 at 9:25 AM, V12, CNA, was seen providing incontinence care for R63. The window blinds were left open with R63 lying in the bed by the window. There is a patio where residents can sit outside, as well as cars seen parked in the parking lot outside the window.
On 4/22/2025 at 1:20 PM, R63 stated that she did not pay attention to the CNA and if she closed the blinds or not. R63 stated that she would expect them to close the blinds, and she assumed that they do. R63 stated that her window is facing the patio and there are people out there at times. R63 stated at night with the light on, and during the day with the sun, you can see directly in her room. R63 stated that she would not want her privates to be exposed to the outside. R63 stated that this would be a problem for her. R63 stated that it would be embarrassing.
On 4/28/25 at 11:00 AM, V2, Director of Nursing (DON), stated I would expect staff to provide privacy for the resident at all times, including closing the blinds and curtains during care.
The Facility's Incontinent Care Policy, dated 1/2015, documents in part Procedure: 6. Provide Privacy. 9. Avoid unnecessary exposure of the resident during the procedure.
4.R56's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, rhabdomyolysis, Alzheimer's disease and dementia.
R56's Minimum Data Set (MDS) dated [DATE] documented he was severely cognitively impaired and requires partial/moderate assistance for toileting hygiene and shower/bathing self and is frequently incontinent of bladder.
On 4/23/25 at 10:45 AM, V26, CNA, and V24, CNA, left the blinds to R56's room and curtain open while having his peri-region exposed during peri care. V26 stated he forgot to close the blinds. V24 then went over to the blinds and closed them.
The Residents' Rights for People in Long-term Care Facilities brochure, undated, documented that residents have the right to privacy, including medical and personal care.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent abuse for 4 of 4 (R36, R38, R88, R90) resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent abuse for 4 of 4 (R36, R38, R88, R90) residents reviewed for abuse in the sample of 79. This failure resulted in R36 suffering psychosocial harm and feeling scared, unsafe, unable to protect himself and less of a man. This failure also resulted in R90 suffering harm and being hit in the face, stomach and leg by another resident and R88 having a scratch to upper lip.
1. R36's Care Plan, not dated, does not document R36's risk for or interventions to prevent abuse.
R36's Minimum Data Set (MDS), dated [DATE], moderately cognitively impaired.
On 4/21/2025 at 9:27 AM observed R36 and R38 striking each other with closed fist. R38 yelled out and struck R36 repeatedly, with closed fist on the arm, hand and shoulder. R36 then grabbed R38's arm and swung closed fist at R38, making contact with R38's chest. R38 continued to yell out and push the door into R36's wheelchair and R36's arm. V29, Safety Aide, intervened and attempted to calm the residents. V29 instructed the residents to stop then removed R38's hand from R36's arm. R38 was then taken from room.
On 4/21/2025 at 3:50 PM reviewed R36's medical record. No documentation of the resident to resident altercation.
On 4/22/2025 at 11:30 AM R36's medical record reviewed. No documentation of the resident to resident altercation.
The facility's Midnight Census report dated 4/24/2025 at 9:54 AM documents that R38 and R36 remain roommates.
On 4/23/2025 at 1:30 PM the facility provided documentation of resident to resident abuse reported to IDPH.
On 4/22/2025 at 1:10 PM R36 stated that his roommate is still in the room. R36 stated that his roommate is mean. R36 stated that R38 has been mean and hitting him since moving to the room. R36 stated that he is scared and does not feel safe in the room. R36 stated that he feels that he can't protect himself. R36 stated that he feels less of a man because he can't really defend himself. R36 stated that he has notified V31, Social Services Director (SSD), about he and his roommate not getting along and feeling scared.
On 4/22/2025 at 1:14 PM V4, Registered Nurse (RN), stated that she was not aware of a resident to resident altercation that occurred between R36 and R38. V4 stated that R38 does have aggressive and combative behaviors. V4 stated that R38 is usually the aggressor. V4 stated that R36 is quiet and doesn't bother anyone. V4 stated that R36 has not had any behaviors of aggression towards staff and or resident.
On 4/23/2025 at 11:45 AM V4, RN, stated that she notified V2, DON, of the resident to resident altercation that was reported to her yesterday.
On 4/23/2025 at approximately at 12:30 PM V1, Administrator, stated that she was not aware of a resident to resident altercation that occurred between R36 and R38 until today. V1 stated that when the state surveyor reported it; V1 that is the time it was reported to the state. V1 stated that she was not notified by the staff that were present. V1 stated that V29 is not a CNA. V1 stated that V29 is a safety aide and here to help monitor the residents to keep them safe. V1 stated that V29 did not report the abuse.
On 4/28/2025 at 11:00 AM V4 stated that R36 is alert and oriented and able to voice needs. V4 stated that he can answer questions appropriately.
R38's Care Plan, dated 12/30/2024, documents that R38 BEHAVIOR: (R38) has a hx (history) of physical aggression towards peers. i.e. (for example) on 12/1/24 (R38) grabbed another resident's arm causing him to bleed.
2. R88's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, osteoarthritis, degenerative disease of nervous system, and psychosis not due to a substance or known physiological condition.
R88's MDS, dated [DATE], documented he is severely cognitively impaired.
R88's Care Plan does not include him to be at risk for abuse.
R90's face sheeting documented he was admitted on [DATE] with diagnosis of, in part, osteoarthritis, dementia with moderate agitation, and psychosis.
R90's MDS, dated [DATE], documented he is severely cognitively impaired.
R90's Care Plan dated 12/12/24 documented he is at risk for abuse and/or neglect related to impaired cognitive skills, diagnosis of Alzheimer's and Dementia.
The facility's Initial Event Reporting dated 2/7/25, documented, Please find this as the initial reporting related to an allegation of a resident to resident physical altercation. R90 and R88, two cognitively impaired male residents of the facility locked dementia care unit, were reported to have had an altercation resulting in a small scratch to R88's upper lip. Staff intervened to ensure safety with assessments and notifications completed. R90 was transferred for evaluation related to his behaviors and remains at the ER (emergency room) at this time.
The facility's final report regarding the allegation of resident-resident physical altercation occurring on 2/7/25 documented, On 2/7/25 at approx. (approximately) 1830 (6:30 PM), memory unit staff heard a commotion from the room of R88. Staff responded to the room urgently. As they were approaching R88 was exiting his room reporting R90 had entered his room and became agitated when he was asked to leave. R88 states that R90 had entered his room and became agitated when he was asked to leave. R88 states that R90 hit him three time(sic). R88 reports that R90 hit his face, stomach, and leg. Staff separated resident's immediately.
The facility's interview statement with V42, CNA, dated 2/8/25 documented, R88 was wandering said looking for his wife last I saw by shower room. We heard some yelling, rushed to them. R90 said he hit him. We got R88 away and watched him until he went out. He thought they were sleeping with his wife or something. V42 documented that R90 was last seen wandering.
The facility's interview statement with V43, LPN, dated 2/8/25, documented, R90 was wandering looking for his wife. When we heard the commotion and got to the room they were just yelling. R88 said R90 hit him. We got them away, did assessments and notified and sent R90 out. R88 was okay. He said he thinks he was looking for his wife and he didn't have her. V43 documented R88 was last seen wondering.
The facility's interview statement with R90 dated 2/8/25, documented he had no recollection of the event.
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
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview, Observation, and Record Review, the facility failed to identify and treat a resident's wounds for 1 of 4 res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview, Observation, and Record Review, the facility failed to identify and treat a resident's wounds for 1 of 4 residents (R18) reviewed for wound care in the sample of 79. This resulted in R18 experiencing severe excoriation, including skin breakdown and pain.
The Findings Include:
R18's admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity.
R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: R18 is not toileted, she is frequently incontinent, unable to transfer to toilet, use of bedpan encouraged, incontinent care per staff. It continues (4/7/25) R18 has potential for impairment to skin integrity related to impaired mobility, current medications, incontinence of B&B (bowel and bladder). Interventions: Complete pressure ulcer risk assessment quarterly and PRN (as needed), observe skin daily with care, notify MD (medical doctor)/NP (nurse practitioner) of any abnormal findings, pressure redistribution mattress to bed, provide diet as ordered, RD (registered dietitian) to follow related to wound care and nutrition, refer to Specialized Wound Management, staff to assist with turning and repositioning as tolerated, staff to provide incontinent care after each incontinent episode, weekly skin assessment.
R18's Minimum Data Set (MDS), dated [DATE], documents R18 has a severe cognitive impairment and is dependent on staff for toileting and bathing. R18 is always incontinent of both bowel and bladder.
R18's Physician Order, dated 2/10/25, documents Skin assessment weekly every Tuesday day shift. Every day shift every Tuesday for weekly skin check. Please complete skin checks in (computer system).
R18's Physician Order, dated 4/22/25, documents Cleanse bilateral buttocks with NS (normal saline) or WC (wound cleaner), apply barrier cream daily and PRN (as needed). Every Day shift for incontinence dermatitis.
R18's Physician Order, dated 7/19/24, documents Cleanse peri area with mild soap and water or facility wipes, pat dry, apply Calazinc cream to buttocks, peri area, and inner thighs PRN.
R18's Weekly Skin Assessment, dated 4/15/25, documents Incontinence Dermatitis to left buttock, right thigh, and left thigh.
R18's Weekly Wound Assessment, dated 3/11/25, documents R18 had a Pressure Ulcer to left buttock that was healed. There is no further wound notes completed.
R18's (Wound Management Specialist) Note, dated 3/18/25, documents in part Visit Date: 3/18/25, DC (discontinue) (Wound Management Specialist) services, Nursing to continue to monitor and notify me of changes.
On 4/22/25 at 10:00 AM, V12, Certified Nursing Assistant (CNA), in to do peri-care on R18, and during incontinent care, R18 was rolled to her right side, and her buttocks appeared very reddened with open sores that appear like skin tears with slight bleeding from areas. V12 continued to wipe R18, causing even more bleeding. A clean brief was applied with no moisture barrier cream applied to R18 and no drying seen done.
On 4/22/25 at 10:18 AM, V12, CNA, stated (R18) did not have these sores on her bottom the last time I was working here. It looks like it is from sitting in wetness, especially when sitting her in her wheelchair.
On 4/23/25 at 9:10 AM, V19, Wound Nurse, stated (R18) did have sores on her buttock before and the (Wound Management Specialist) was working with her, but that was all healed. The CNAs are supposed to be putting moisture barrier on her with each incontinence care. When told that R18's buttocks were excoriated and bleeding, V19 stated No one has told me about that, I was not aware of it. I will check her out this morning and probably have (Wound Management Specialist) look at her again.
On 4/23/25 at 9:48 AM, V15, CNA, stated If I'm doing incontinent care and the resident has redness or open sores, I would use a barrier cream and will tell the nurse about it.
On 4/23/25 10:50 AM, V19 gathered supplies to assess R18's wounds with V22, CNA, assisting. V19 opened R18's legs to expose her inner thighs and perineum area which were very bright red and excoriated. V22 turned R18 to her right side exposing her buttocks which showed three open wounds to her back side with the entire buttocks, anal area, gluteal creases all red and excoriated. V19 stated I was not aware of any of these wounds. R18 has been red for quite a while, and we were supposed to be using moisture barrier cream for it because she is a heavy wetter and is always saturated. I will have to call the physician now and get some orders for wound treatment. This looks very painful, and she should be in pain the way it looks. V19 measured R18's wounds which was the right buttock 2 CM (centimeters) X 5 CM X 1.0 CM, the left inner thigh 1.0 CM X 4.3 CM, and the right gluteal fold 0.4 CM X 3.7 CM.
On 4/23/25 at 10:55 AM, V22 stated I just did peri-care on (R18), and she was yelling that it hurt every time I would wipe her. She was definitely in pain.
On 4/28/25 at 11:00 AM, V2, Director of Nursing (DON), stated I would expect the CNAs to report any resident's change in skin condition to the nurse and I would expect the nurses to perform skin and wound assessments and provide appropriate treatments as ordered by the physician.
On 4/23/25 at 11:30 AM, V19 stated I just spoke with the physician and (R18) will be followed up with (Wound Management Specialist) again and he gave me orders to take care of her wounds.
On 4/23/25 at 11:35 AM, V19 gathered her supplies for wound care. V19 sprayed 4X4 gauze with wound cleaner and right buttock wound wiped, then Collagen and Calcium Alginate and foam dressing applied. R19 started to have a loose bowel movement so the wound care paused for peri-care.
On 4/23/25 at 11:53 AM, V19 continued wound care on R18. Previous dressing was replaced due to feces on it. Wound cleanser sprayed on 4X4, wound wiped, then patted dry. Cavalon wiped on left inner thigh and right gluteal fold wounds, allowed to dry, then V19 wiped barrier cream all over R18's buttock/anal area. The previous dressing on R18's right buttock was falling off, V19 removed the old dressing, recleaned site, applied Collagen and Calcium Alginate and foam dressing again. While R18 was turned to her right, a small thin open slit was noticed on R18's gluteal cleft, V19 made aware and wiped barrier cream on it. R18 rolled back to her back side and covered up. There was no cleaning, or wound care provided to R18's front inner thighs or peri-area.
R18's New Physician Order, dated 4/23/25, documents Cleanse bilateral buttocks with NS or WC, apply barrier cream Q shift and PRN. Every shift for incontinence dermatitis/excoriation/ MASD (moisture associated skin dermatitis).
R18's New Physician Order, dated 4/23/25, documents Cleanse wound to right buttock NS or WC, apply Collagen, Calcium Alginate, and cover with a foam dressing daily and PRN. Every Day shift for open area to right buttock.
R18's New Physician Order, dated 4/23/25, documents Cleanse anterior inner things with NS or WC and apply barrier cream Q shift and PRN. Every shift for excoriation/MASD to BIL (bilateral) inner thighs.
R18's New Physician Order, dated 4/23/25, documents Cleanse BIL posterior inner thighs with NS or WC and apply barrier cream Q shift and PRN. Every shift for excoriation/MASD to inner thighs.
R18's New Physician Order, dated 4/23/25, documents Cleanse BIL posterior inner thighs/gluteal folds with NS or WC, pat dry, and apply Cavilon once weekly and PRN. Every day shift every Wed (Wednesday) for excoriation/MASD to BIL thighs.
The Facility's Guide for Wound Evaluation, undated, documents in part Procedure: 1. Upon identification of a pressure ulcer/injury (arterial, venous, or neuropathic), regardless if developed in-house or upon admission, the area is to be documented on the Wound Evaluation Form or in the electronic format. 2. Non-Ulcers are to be documented weekly on a Skin Condition Form or in electronic format. 3. Contact physician, interdisciplinary team, family members, and significant others as indicated. 4. Initiate appropriate treatment per treatment protocol and physician order. 5. Evaluate further interventions that may be indicated to promote healing and prevent infection. 6. Documentation of wound status will occur at least once a week. This weekly evaluation will be documented electronically or on the Wound Evaluation Form / Skin Condition Form as appropriate. 7. The physician is to be notified if there is no improvement in area, signs and symptoms of infection or signs of deterioration. 10. The Director of Nursing Services and/or designated Licensed Nurses will make pressure ulcer rounds on a weekly basis. Documentation of the area will be addressed. Resident lack of progress will be evaluated. Directives may be given for further interventions and changes in plan of care.
The Facility's Wound Care Treatment Protocol, dated 11/2012, documents in part Evaluate the wound daily for signs and symptoms of infection and for signs of healing. Document / Report findings. Provide treatment as per physician's order.
SERIOUS
(G)
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** 3. R17's admission Record, dated 4/24/25, documents R17 was admitted to the facility on [DATE], with diagnosis of Alzheimer's Di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R17's admission Record, dated 4/24/25, documents R17 was admitted to the facility on [DATE], with diagnosis of Alzheimer's Disease, Dementia, Major Depressive Disorder, Anxiety Disorder, HTN, Encephalopathy, Spinal Stenosis, Thoracolumbar and Lumbar Region, Low Back Pain, Radiculopathy Lumbar Region.
R17's Care Plan, dated 1/13/25, documents R17 has potential for acute risk for falls related to Confusion, Deconditioning, Psychoactive drug use. Interventions: Anticipate and meet R17's needs, educate R17/family/caregivers about safety reminders and what to do if a fall occurs, encourage R17 to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure that R17is wearing appropriate footwear i.e. brown leather shoes, tartan bedroom slippers, black non-skid socks when ambulating or mobilizing in wheelchair, follow facility fall protocol, PT (physical therapy) evaluate and treat as ordered or PRN (as needed), review information on past falls and attempt to determine cause of falls, record possible root causes, alter/remove any potential causes if possible, educate R17/family/caregivers/IDT (interdisciplinary team) as to causes.
R17's MDS, 3/19/25, documents R17 has a moderate cognitive impairment and requires supervision/touching assistance for toileting, and supervision/touching assistance for sit-to-stand and toilet transfers.
R17's Fall Risk Assessment, dated 3/20/25, documents R17 is a High Fall Risk.
R17's EZ Move Assessment, dated 3/21/25, documents in part Device Required: Gait Belt.
On 4/21/25 at 9:02 AM, R17 put her call light on with V12, CNA, entering to assist. R17 stated she needed to use the restroom and V12 assisted R17 to side of her bed, R17 stood and pivoted into her wheelchair with V12 holding onto R17 by under her arm and down into the wheelchair, then pushed R17 into restroom. R17 stood and pivoted to the toilet again with V12 holding onto under R17's arm. V12 had a gait belt around her waist, and it dropped to the floor with V12 picking it back up and putting it around her waist again, but never used it on assisting R17 in her transfers.
4. R11's admission Record, dated 4/23/25, documents R11 was admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease, Dementia, Major Depressive Disorder, Psychosis, Generalized Osteoarthritis, and Vertigo.
R11's Care Plan, dated 1/20/25, documents R11 is at moderate risk for falls related to gait/balance problems, incontinence, psychoactive drug use, behaviors. Interventions: Follow facility fall protocol.
R11's MDS, dated [DATE], documents R11 has a severe cognitive impairment and requires partial/moderate assistance for sit-to-stand and bed to chair transfers.
R11's EZ Move Assessment, dated 1/24/25, documents in part Lifting/Mobility Required: one-person, Device Required: Gait Belt.
R11's Fall Risk Assessment, dated 1/24/25, documents R11 is a High Fall Risk.
The Facility's Fall Log, documents R11 had a fall on 3/21/25, and 3/26/25.
On 4/23/25 at 8:55 AM, R11 was seen in bed with V20, CNA, assisting to get her out of bed. V20 had R11 sit up on side of bed, held R11 under her right arm, while R11 stood up and pivoted to her wheelchair. V20 had a gait belt wrapped around herself and did not use on R11.
On 4/24/25 at 9:40 AM, V14, CNA, stated Any time I am assisting a resident with a transfer, I always carry a gait belt around my waist and will use it while assisting the resident.
On 4/28/25 10:35 AM, V25, CNA, stated that she uses a gait belt on residents during transfers.
On 4/28/25 10:40 AM, V12, CNA, stated that she uses her gait belt when transferring residents.
On 4/28/25 at 11:00 AM, V2, DON, stated I would expect all staff to maintain resident safety and perform safe resident transfers by using the gait belt for high fall risk residents.
The Facility's Transfer Belts/Gait Belts Policy, dated 4/2014, documents in part To promote safety in transferring residents, a gait belt is utilized when deemed appropriate.
The Facility's Fall Prevention Strategies and Interventions undated in part Transfer Assistive Devices: Ensure staff uses gait belt, transfer resident with gait belt.
The Facility's Elopement Guidelines, dated 8/2017, documents in part The Elopement Risk Evaluation is to be done upon admission and quarterly and as needed with exit seeking behaviors. At the beginning and end of each shift the charge nurse is to make visual rounds on each high risk resident to ensure that they can be located in the facility. When exit seeking activity occurs consider 1:1 supervision or 15-minute checks.
Based on interview, observation, and record review the facility failed to ensure safety as indicated per plan of care for 4 of 4 (R11, R17, R53, R72) residents reviewed for accidents and hazards in the sample of 79. This failure resulted in R72 suffering multiple falls and receiving a skin tear to her right knee.
Findings include:
1. R72's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, neoplasm of brain, dementia, and neoplasm of lung.
R72's MDS dated [DATE] documented she is moderately cognitively impaired and required supervision or touching assistance for all transfers, walking, and going from a sitting to a standing position.
R72's Care Plan dated 1/7/25 documented she has high risk for falls related to confusion, gait/balance problems, psychoactive drug use, mood adjustment disorder and anxiety. Fall risk interventions put in place included: for 2/25 0900: provide sign on walker to remind resident to use walker when ambulating added on 3/4/25, for 2/25 1200: place in-room signage to remind resident to request help from staff when feeling tired/weak added on 3/4/25, anticipate and meet R72's needs added on 1/7/25, ensure that she is wearing appropriate footwear i.e. shoes/non-skid socks) when ambulating with wheeled walker added on 11/19/24, evaluate the effectiveness and side effects of psychoactive drugs for possible decrease in dosage/elimination of drug on 11/19/24, follow facility fall protocol added on 11/19/24, hospice to provide Bolstered mattress for increased safety and to avoid rolling out of bed when resting added on 4/15/25, increase safety observations: staff to check room during routine rounding and PRN for environment safety, ensure no clothing are left on the floor added on 3/4/25, observe for removal of shoes when sitting in chair, re-direct resident to ensure shoes remain in place when OOB (out of bed) added on 4/15/25, Pt (physical therapy) evaluate and treat as ordered or PRN (as needed) added on 11/19/24, review information on past falls and attempt to determine cause of falls, record possible root causes, alter remove any potential causes if possible, educate resident/family/caregivers/IDT (interdisciplinary team) as to causes added on 11/19/24, and R72 needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach added on 1/7/25. R72's fall care plan had interventions added on the following dates: 11/19/24, 1/7/25, 2/25/25, 3/4/25, and 4/15/25.
R72's Morse Fall Risk assessment dated [DATE] documented she is a high fall risk and to implement high fall risk interventions.
The Facility's Incidents by Type Report from 1/21/25 to 4/21/25 documented R72 had 8 total falls on 2/25/25 (twice), 3/9/25, 4/13/25, 2/23/25, 2/27/25, 3/31/25, and 4/4/25.
R72's Progress Notes documented her having a total of 12 falls on the following dates: 1/10/25, 1/16/25, 2/23/25, 2/25/25 (twice), 3/10/25, 3/12/25, 3/17/25, 4/4/25, 4/13/25, 4/19/25, and 4/23/25.
R72's Progress Note dated 4/19/25 at 2:59 PM, documented R72 obtained a skin tear to her right knee after being found laying on the floor next to her bed on the left side of her face.
R72's Progress Note dated 4/19/25 at 6:27 PM, documented she returned from the hospital with diagnosis of pneumonia and a urinary tract infection.
On 4/21/25 at 8:59 AM, on 4/22/25 at 9:23 AM, 11:39 AM and at 2:55 PM R72 was observed not wearing non-slip socks or shoes.
On 4/21/25 at 8:59 AM, R72 had a bruised left eye with bloody sclera. R72 does not remember what from; she did not have non-slip sock on and was sitting in her wheelchair.
On 4/22/25 at 9:04 AM R72's door was closed, this surveyor knocked, and walked in. R72 was lying in bed awake, call light on floor, fall mat on left side, no mat on right side, bed in low position, and no footwear on and her bed did not have a bolster mattress in place.
On 4/22/25 at 9:23 AM, R72 was in wheelchair at dining area in front of nurse's station with a snack after her morning medications; R72 was not wearing non-slip socks or shoes.
On 4/22/25 at 2:55 PM, V23, R72's daughter, stated her mother came here with lung cancer and it has since metastasized to her brain. Since the metastasis, V23 stated she thinks R72 has had increased falls. V23 stated her mother doesn't have non-slip socks on and she is supposed to. V23 stated she requested the facility try to utilize an alarm system for R72 but was told they couldn't. V23 stated she does not feel like R72 has enough supervision to prevent falls and would like to know if the bolster mattress will be put in place soon. V23 stated she does like the fall mats in place.
On 4/23/25 at 10:26 AM, V24, CNA, stated fall interventions for R72 include floor mats, frequent checks, and assistance to the bathroom, as well as offering the restroom often.
On 4/23/25 at 10:28 AM V25, CNA, stated fall interventions for R72 include floor mats by bed, providing assistance.
On 4/23/25 at 10:29 AM V5, LPN, stated fall interventions for R72 include having the bed in low position, use of fall mats, observation, keep closer to nurse's station, non-slip socks, and fall interventions for R10 include bed in low position, reminders for safety, offering help fast. V5 stated she is new to the facility and since working here for about 2 weeks she has not seen any concerns between R88 and R90. V5 stated interventions for wandering include offering lots of activities, keeping the residents busy, toileting them and providing naps with frequent assistance of needs.
On 4/23/25 at 2:24 PM, V2 DON (director of nursing) stated there was no fall for R72 on 4/19/25 after a fall investigation was requested for that date and would have to check back after this surveyor mentioned there was one documented in the progress notes.
On 4/23/2025 at approximately 2:40 PM V2, Director of Nursing, stated that initially she did not remember what fall that occurred on 4/19/2025 until she read the note in the computer. V2 stated that R72 was sent to the hospital for a change in condition. V2 stated that she remembered at that time R72 was on the floor. V2 stated that they thought R72 had a stroke. V2 stated that the hospital determined that R72 did not have a stroke and was diagnosed with pneumonia.
2.R53's face sheet documented he was admitted to the facility on [DATE] with diagnosis of dementia with severe agitation and psychotic disturbance, and schizoaffective disorder.
R53's MDS dated [DATE] documented he was severely cognitively impaired and exhibits wandering behavior daily.
R53's Care Plan dated 1/13/2025, documented he is an elopement risk due to the following behaviors: exit seeking, confusion, wandering aimlessly and he resides on a secured unit. Interventions for this care plan included encourage R53 to verbalize through one-to-one interaction added on 1/8/2025, place R53 in area where observation is possible added on 1/8/2025, and provide diversional activities for resident when anxious, offer resident a snack added on 12/4/2024.
On 4/21/25 at 9:30 AM, R69 stated R53 wanders into his room and takes things so they keep his door closed, he needs to be watched.
On 4/22/25 at 9:00 AM, R53 was observed walking up and down the hallway. At 9:07 AM, R53 walked into R90's room then came back out and walked into R80 and R33's room, closed the door and came back out within a couple minutes. This surveyor observed no staff intervene while R53 walked into other resident's room.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed maintain a clean, homelike environment for 2 of 3 (R13, R27) residents re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed maintain a clean, homelike environment for 2 of 3 (R13, R27) residents reviewed for housekeeping in the sample of 79.
1. R13's MDS, dated [DATE], documents that R13 is cognitively intact.
On 4/23/2025 at 1:29 PM R13 stated that the facility is filthy. R13 stated that the odor in the building is overwhelming. R13 stated that it's so many people that live here and not enough staff to take care of the building. R13 stated that the staff won't help each other and housekeeping only mop the floor. R13 stated they don't scrub it they only light run the mop that's it.
2. R27's MDS, dated [DATE], documents that R27 is cognitively intact.
04/23/25 at 02:28 PM R27 stated that the facility smells of urine and poop all the time. R27's BIMS is 15. R27 stated that there was a leak last time it rained heavy.
04/28/25 at 10:30 AM V14, CNA stated that she would let housekeeping know if a resident's room needs cleaned or if there are any foul odors so they can clean it and take care of it. V14, CNA stated that if 2 residents are fighting, she would try and to diffuse the situation and report it to V1, Administrator.
04/28/25 at 10:35 AM, V25, CNA, stated that she lets housekeeping know if there is anything that needs cleaned up or if there are strong odors.
04/28/25 at 10:40 AM, V12, CNA stated that she carries her own air freshener if there are any odors and would let housekeeping know if a resident's room needs cleaned.
On 4/21/25 at 8:15 AM, upon entrance to the facility and while walking through the dining room to get to the conference room, the dining room floor appeared dirty with food particles on the floor and was very sticky to walk on. A strong smell of urine was noticed while walking through the facility.
On 4/22/25 at 7:45 AM, while walking through the facility, a strong smell of urine was noticed, residents were seen sitting in the dining room for breakfast with the floor appearing dirty and sticky to walk on.
On 4/23/25 at 12:00 PM, the 100-hall had a strong smell of urine upon walking down the hall, even with the housekeeper mopping resident rooms. While walking back to the conference room, the dining room floor was dirty and sticky to walk on.
04/28/25 at 10:25AM V44, Housekeeping Supervisor, stated that residents' rooms are cleaned every day and that they use air freshener when there are odors.
The facility's Job Card, not dated, documents Resident Room Cleaning (occupied) Daily Tasks: Prepare supplies & wash/sanitize hands/don gloves & applicable PPE. Check for additional signs and follow precautions as indicated. Knock/enter room /close door/ greet patient/ ask if any concerns. Survey room/remove used items /trash/ dispose of needles/ sharps. Remove infectious waste/soiled linen/personal items/loose equipment. Use EPA Registered disinfectant on room surfaces & BLUE microfiber cloth. Disinfect high touch surfaces main room using BLUE microfiber cloth -Bed rails/ controls / tray table I call box / phone/bedside table handle. Chairs/room sink/room light switch / room inner doer knob/tv remote Clean window glass. Spot clean walls/ damp wipe vertical surfaces/ counters/ledges/ sills. Disinfect high touch surfaces restroom using RED microfiber cloth - Bathroom inner doorknob & plate /bathroom light switch/handrails. Restroom sink / toilet seat I toilet flush handle I toilet bed pan cleaner / Disinfect tub and shower (10 min. dwell time) Dust mop and damp mop floor (using BLUE microfiber flat mop Damp mop restroom floor using BLUE microfiber flat mop.)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report allegations of abuse for 4 of 4 (R36, R38, R49, R358) residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report allegations of abuse for 4 of 4 (R36, R38, R49, R358) residents reviewed for Abuse in the sample of 79.
1. R36's Care Plan, not dated, does not document R36's risk for or interventions to prevent abuse.
R36's Minimum Data Set (MDS), dated [DATE], documents moderately cognitively impaired.
On [DATE] at 9:27 AM observed R36 and R38 striking each other with closed fist. R38 yelled out and struck R36 repeatedly, with closed fist on the arm, hand and shoulder. R36 then grabbed R38's arm and swung closed fist at R38, making contact with R38's chest. R38 continued to yell out and push the door into R36's wheelchair and R36's arm. V29, Safety Aide, intervened and attempted to calm the residents. V29 instructed the residents to stop then removed R38's hand from R36's arm. R38 was then taken from room.
On [DATE] at 3:50 PM reviewed R36's medical record. No documentation of the resident to resident altercation.
On [DATE] at 11:30 AM R36's medical record reviewed. No documentation of the resident to resident altercation.
The facility's Midnight Census report dated [DATE] at 9:54 AM documents that R38 and R36 remain roommates.
On [DATE] at 1:30 PM the facility provided No documentation of resident to resident altercation reported to IDPH.
On [DATE] at 1:14 PM V4, Registered Nurse (RN), stated that she was not aware of a resident to resident altercation that occurred between R36 and R38. V4 stated that R38 does have aggressive and combative behaviors. V4 stated that R38 is usually the aggressor. V4 stated that R36 is quiet and doesn't bother anyone. V4 stated that R36 has not had any behaviors of aggression towards staff and or resident.
On [DATE] at 11:45 AM V4, RN, stated that she notified V2, DON, of the resident to resident altercation that was reported to her yesterday.
On [DATE] at approximately at 12:30 PM V1, Administrator, stated that she was not aware of a resident to resident altercation that occurred between R36 and R38 until today. V1 stated that when the state surveyor reported it, at that time it was reported to the state. V1 stated that she was not notified by the staff that was present. V1 stated that V29 is not a CNA. V1 stated that V29 is a safety aide and here to help monitor the residents to keep them safe. V1 stated that V29 did not report the abuse.
On [DATE] at 12:05 PM V29, Safety Aide, stated that (R36) and (R38) were not hitting each other but they were cussing at each other and that he let a CNA know.
2. R38's Care Plan, dated [DATE], documents that R38's BEHAVIOR: (R38) has a hx (history) of physical aggression towards peers. i.e. (for example) on [DATE] (R38) grabbed another resident's arm causing him to bleed. [DATE] [NAME] had aggressive behaviors including attempting to pull his roommate from his bed.
R38's MDS, dated [DATE], documents that R38's daily decision making skills are moderately impaired, has verbal and physical behaviors affecting others.
R38's Progress Note, dated [DATE] at 4:45 PM, documents Resident has been agitated this shift. Has been yelling and cursing at other Residents and staff. He pushed on the back of another Resident's w/c. He was re-directed and explained his behavior is not appropriate. Re-directed him back to his room to lay down in bed.
R38's Progress Note, [DATE] at 5:05 PM, documents that Resident has been angry and agitated this shift. He has been yelling and cursing at other Residents and staff. Re-directed him and explained that his behavior is not appropriate. Resident finally calmed down and allowed staff to help him with his ADL's. Will continue to monitor.
On [DATE] at 1:15 PM V4, RN, stated that there was an incident that happened last week when R38 was cursing at other residents. V4 stated that she notified the Director of Nursing.
On [DATE] at 12:25 PM V2, Director of Nursing, stated that incidents on [DATE] and [DATE] were reported to IDPH on [DATE]. V2 stated that they were made aware of the incidents at that time. V2 stated that the incidents had not been previously reported or investigated. V2 stated that the nurse documented the progress notes as late entry on [DATE]. V2 stated that she would expect the staff to report abuse immediately.
3. R49's admission Record, dated [DATE], documents R49 was originally admitted to the facility on [DATE] with diagnosis of Huntington's Disease, Major Depressive Disorder, and Anxiety Disorder.
R49's Care Plan, dated [DATE], documents R49 has potential for psychosocial well-being problem related to history of physical and sexual abuse. Interventions: Consult with: Social services, Psych services, increase communication between (R49)/family/caregivers about care and living environment: Explain all procedures and treatments, medications, results of labs/tests, condition, all changes, rules, options, provide opportunities for the resident and family to participate in care. It continues R49 has an alteration in neurological status related to diagnosis of Huntington's Disease. Interventions: Assess for effects of psychotropic meds; dystonia, akathisia, akinesia, rigidity, tremors, etc., cueing, reorientation as needed, educate R49 to use scanning (move eyes across affected side) to prevent neglect/injury to affected side, give medications as ordered, monitor/document for side effects and effectiveness.
R49's Minimum Data Set (MDS), dated [DATE], documents R49 has a moderate cognitive impairment and requires supervision/touching assistance for eating, setup/cleanup for toileting, partial/moderate assistance for bathing, and is independent on transfers.
R49's Nurse Practitioner (NP) Note, dated [DATE], documents in part White female nursing home resident since [DATE]. Pt (patient) up in wheelchair, reports doing ok, random jerking and tremors present from neurological issue Huntington's disease psychosis. Staff observed roommate (R358) standing by her bed with pillow, pt woke up and began yelling, no physical contact made, peer has memory issues. Care conference with staff, behavioral tracking active, staff reports no concerns. Continue to use nonpharmacological interventions for behavioral management.
4. R358's admission Record, dated [DATE], documents R358 was admitted to the facility on [DATE] and was discharged /deceased on [DATE]. R358's diagnosis include: Depression, Anxiety Disorder, Disorientation, Cerebral Aneurysm-non-ruptured.
R358's Baseline Care Plan, dated [DATE], documents Cognition: Confused, Communication: Verbal, Vision: Adequate, Bowel and Bladder: Incontinence care, Safety: History of Falls, Smoking.
R358's MDS, dated [DATE], documents R358 had a severe cognitive impairment and was independent for all transfers and ambulation.
R358's Nurses Note, dated [DATE] at 1:38 AM, documents Resident remains on Hospice Care. She is resting comfortably in bed with no signs of acute distress or pain. Lorazepam given as ordered and Fentanyl patch confirmed to be in place to left side of chest. CNA remains at bedside for monitoring. Plan of care ongoing including monitoring for changes in condition, needs, and safety. Care coordination with the Hospice team is ongoing.
R358's NP Note, dated [DATE], documents in part White female nursing home resident since [DATE]. Pt. (patient) is being followed by Hospice, pt up in wheelchair, on one-to-one staff supervision, was standing by roommate's (R49) bed last night holding a pillow, no ill intent or physical contact between patients, peer was yelling out for staff scared, today patient does not remember event reporting she went home last night. Care conference with staff, behavior tracking active, electronic record from last month reviewed, continue to use nonpharmacological interventions for behavior management.
V1, Administrator's Investigation includes the following:
The Facility's Supervisor Investigation Summary Form, dated [DATE], documents How and when was event discovered: CNA (Certified Nursing Assistant) passing room reported to nurse a concern of (R358) attempts to do something with (R49) pillow and was concerned. Briefly describe event: Notified, DNS (Director of Nursing Supervisor) spoke to CNAs on phone. CNA states (R358) was standing by (R49) bed holding the pillow. (R358) did not touch her. Follow-Up Actions: Psych NP (Nurse Practitioner) evaluates to ensure safety without concerns. Contacted VP (Vice President) to review at time reported. Based on statement of concern no evidence of concern. (R358) was assisting (R49) with pillow positioning per (R49) reports/statements. Conclusion: No alleged issue - CNA observation concerned her. No Reportable per interviews immediate on eve of [DATE].
V2, Director of Nursing (DON), Interview/Investigation Record, dated [DATE], documents V27, CNA, stated per phone call I saw her (R358) standing by (R49) bed with her pillow in her hands. That's all. She didn't touch her.
V2, DON, Interview/Investigation Record, dated [DATE], documents When asked did anything happen last night? (R358) stated I wasn't here. I just got here this morning with my husband.
V2, DON, Interview/Investigation Record, dated [DATE], documents Asked did something happen with your roommate last night? (R49) stated No No Did your roommate try to hurt you? (R49) stated No No Help Help Happy Happy she good.
On [DATE] at 2:05 PM, V1, Administrator, stated In our eyes it did not happen, therefore it was not reportable.
There was no separation of residents pending investigation, and nothing reported to Illinois Department of Public Health (IDPH).
The Facility's Abuse Prevention - Illinois Only, dated 1/2025, documents in part a) Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident. d) Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. e) Mental Abuse: The use of verbal or non-verbal conduct which cause or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation including staff taking or using photograph or records in any manner that wound demean or humiliate a resident. Reporting: Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24-hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency, APS, and local law enforcement as required). Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to investigate allegations of abuse for 1 of 4 (R38) residents reviewed for allegations of abuse in the sample of 79.
Findings include:
1. R3...
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Based on interview and record review the facility failed to investigate allegations of abuse for 1 of 4 (R38) residents reviewed for allegations of abuse in the sample of 79.
Findings include:
1. R38's Progress Note, dated 4/18/2025 at 5:05 PM, documents that Resident has been angry and agitated this shift. He has been yelling and cursing at other Residents and staff. Re-directed him and explained that his behavior is not appropriate. Resident finally calmed down and allowed staff to help him with his ADL's. Will continue to monitor.
On 4/22/2025 at 10:00 AM request abuse investigations. As of 4/28/2025 at 2:00 PM the facility had not provided an investigation for verbal altercations occurring on 4/15/2025 and 4/18/2025.
On 4/22/2025 at 1:15 PM V4, RN, stated that there was an incident that happened last week when R38 was cursing at other residents. V4 stated that she notified the Director of Nursing.
On 4/28/2025 at 12:25 PM V2, Director of Nursing, stated that incidents on 4/15/2025 and 4/18/2025 were reported to IDPH on 4/22/2025. V2 stated that they were made aware of the incidents at that time. V2 stated that the incidents have not been investigated. V2 stated that the nurse documented the progress notes as late entry on 4/22/2025. V2 stated that she would expect the staff to report abuse immediately.
The facility's Abuse Prevention policy dated 1/2025 documented, the facility is committed to protecting the residents form abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteer and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. It also documents Invesyigation: The facility will initiate at the time of any finding of abuse or neglect and injuries of unknown origin an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to refer a resident to the appropriate state-designate...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to refer a resident to the appropriate state-designated mental health or intellectual disability authority for review after being diagnosed with a serious mental disorder, intellectual disability or related condition for 1 out of 1 resident, (R53); reviewed for Coordination of PASARR (pre-admission screening and resident review) in a sample of 79.
Findings include:
R53's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, heart valve replacement, atrial fibrillation and congestive heart failure. R53's face sheet documented he was diagnosed with severe dementia with agitation on 11/8/24, dementia with psychotic disturbance on 11/6/24 and schizoaffective disorder, depressive type on 12/29/23.
R53's Minimum Data Set (MDS) dated [DATE] documented he was severely cognitively impaired, had non-Alzheimer's dementia, schizophrenia and had not received psychological therapy in the last 7 days.
R53's Care Plan dated 12/5/24 documented he is at risk for abuse and/or neglect related to impaired cognitive skills, diagnosis of schizoaffective disorder depressive type and dementia; R53 experienced an episode of resident-resident physical aggression on 4/27/24. R53's care plan dated 1/13/25 documented he is an elopement risk due to the following behaviors: exit seeking, confusion, wandering aimlessly; R53 resides on a secured unit.
R53's PASRR Level I Review dated September 21, 2022, documented, Your Level I screen does not show that you have a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IDD and experience a significant change in treatment needs.
On 4/23/25 at 9:50 AM V31 (Social Worker) stated she missed having R53 re-evaluated with a PASARR after his new diagnoses and is getting together all the documentation to have it completed today.
The facility's PASRR Screening for Mental Disorder or Intellectual Disability dated 7/2024 documented, Facility must notify the state-designated mental health or intellectual disability authority promptly when a resident with MD (mental disorder) or ID (intellectual disability), or related condition experiences a significant change (residents that exhibit behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder, where dementia is not the primary diagnosis or previously identified and evaluated through PASRR) unless exemption criteria is met.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to perform hand hygiene and removal of dirty gloves fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to perform hand hygiene and removal of dirty gloves for 1 out of 1 resident, (R56); reviewed for infection control in a sample of 79.
Findings include:
R56's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, rhabdomyolysis, Alzheimer's disease and dementia.
R56's Minimum Data Set (MDS) dated [DATE] documented he was severely cognitively impaired and requires partial/moderate assistance for toileting hygiene and shower/bathing self and is frequently incontinent of bladder.
On 4/23/25 at 10:45 AM, R56 had saturated his incontinence brief and his pants with urine and had a small amount of stool present. V26, CNA, did not perform hand hygiene after peri care on R56 and removing his gloves. V24, CNA, did not removed her gloves and perform hand hygiene after touching R56's soiled clothing and placing them in a trash bag. V24 then touched R56's wheelchair handles and R56's hands, body and gait belt while helping him up from the bed to his wheelchair. Both V26 and V24 touched R56's door handle without performing hand hygiene after leaving the room.
On 4/28/25 at 10:30 AM, V14, Certified Nurse Assistant (CNA) stated that she washes her hands before putting gloves on and after she takes them off. V14 stated that she changes her gloves and wash her hands after handling soiled linen and before touching a resident's wheelchair or anything else.
On 4/28/25 at 10:40 AM, V12, CNA stated that she washes her hands before putting gloves on and after she takes them off. V12 stated that she changes her gloves and wash her hands after handling soiled linen and before touching a resident's wheelchair or anything else.
The facility's Proper Hand Washing and Glove Use policy dated 2016 documented under the procedure section, 6. Hands are washed before donning gloves and after removing gloves. 8.Staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hands again.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R41's Care Plan, dated 1/27/2025, documents that (R41) has an ADL (activity of daily living) self-care performance deficit r/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R41's Care Plan, dated 1/27/2025, documents that (R41) has an ADL (activity of daily living) self-care performance deficit r/t (related to) Hemiplegia, Impaired balance, Musculoskeletal impairment, CVA affecting right side. It also documents TOILET USE: (R41) is not toileted due CVA (Stroke) affecting right dominate side, (R41) is inc (incontinent) of B & B (bowel and bladder), Peri care is provided q 2 hours and as needed.
R41's Minimum Data Set (MDS), dated [DATE], documents that R41 is cognitively intact, always incontinent of bowel and bladder and dependent on staff for toileting.
On 4/22/2024 at 9:25 AM observed V14, Certified Nurse's Assistant (CNA) perform incontinent care. R41 was incontinent of urine and stool. Using a wet wipe V14 cleansed R41's peri and groin area. V14 assisted R41 onto her right side. Using wet wipes V14 then cleansed R41's entire left buttock and partial right buttock. V14 then applied R41's incontinent brief. V14 did not cleanse R41's entire buttock.
4. R42's Care Plan, dated 1/28/25, documents that (R42) has an ADL self-care performance deficit r/t Hemiplegia, Impaired balance. It also documents TOILET USE: (R42) is incontinent of bowel and bladder and is dependent on staff for toileting. Staff to provide peri care q 2 hours and as needed.
R42's MDS, dated [DATE], documents that R41 is cognitively intact, always incontinent of bowel and bladder and dependent on staff for toileting.
On 4/22/2025 at 9:27 AM Observed V17, CNA, perform incontinent care. R42 was incontinent of urine and bowel. V17 pulled back covers and revealing an incontinent brief dated 4/22 4:53. V17 opened R42's incontinent brief and using wet wipes cleansed R42 peri and groin area. V17 then assisted R42 onto her right side and cleansed R42's entire left buttock and partial right buttock. R42 V17 then applied R42's clean incontinent brief with stool remaining on R42's buttock. V17 did not cleanse R42's entire right buttock and inner thighs.
The facility's Incontinent Care policy, dated 1/15, documents that the POLICY: To provide routine, preventive skin, perineal care to residents after an incontinent episode. PROCEDURE: 10. Wash the resident's entire perineal area, and all areas affected by incontinence with a washcloth, soap, warm water, peri-wash or wipes. 11. When washing perineal area, wash the entire area moving from front to back.
Based on Interview, Observation, and Record Review the Facility failed to provide timely and complete incontinent care for 4 of 5 residents (R18, R41, R42, R63) reviewed for incontinent care in the sample of 79.
The Findings Include:
1. R18's admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity.
R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: R18 is not toileted, she is frequently incontinent, unable to transfer to toilet, use of bedpan encouraged, incontinent care per staff. It continues (4/7/25) R18 has potential for impairment to skin integrity related to impaired mobility, current medications, incontinence of B&B (bowel and bladder). Interventions: Complete pressure ulcer risk assessment quarterly and PRN (as needed), observe skin daily with care, notify MD (medical doctor)/NP (nurse practitioner) of any abnormal findings, pressure redistribution mattress to bed, provide diet as ordered, RD (registered dietitian) to follow related to wound care and nutrition, refer to Specialized Wound Management, staff to assist with turning and repositioning as tolerated, staff to provide incontinent care after each incontinent episode, weekly skin assessment.
R18's Minimum Data Set (MDS), dated [DATE], documents has severe cognitive impairment and is dependent on staff for toileting and bathing. R18 is always incontinent of both bowel and bladder.
R18's Physician Order, dated 7/19/24, documents Cleanse abdominal fold with soap and water. Pat dry Apply Antifungal powder PRN (as needed).
R18's Physician Order, dated 7/19/24, documents Cleanse peri area with mild soap and water or facility wipes, pat dry, apply Calazinc cream to buttocks, peri area, and inner thighs PRN.
On 4/21/25 at 9:25 AM, R18 stated they have not gotten her up yet today, has not been cleaned up yet, and is currently wet from the night.
On 4/22/25 at 8:13 AM, R18 stated she was unsure when the last time she was cleaned up. R63, R18's roommate, stated that both of them (R18 and R63) were last cleaned up between 4:00 AM -5:00 AM this morning. R63 stated they will come in and clean them both up again after breakfast. R18 complained of her butt hurting.
On 4/22/25 at 10:00 AM, V12, Certified Nursing Assistant (CNA), entered to do incontinence care on R18. Feces was seen in R18's incontinent brief from the front side and it also appeared saturated. R18's incontinent brief was unfastened and tucked between her legs. V12 wiped R18's right groin three times, left groin twice, down both thighs, and then wiped twice down the middle of R18's vagina with feces showing on the cloth on the last wipe. There was no further wiping of R18's vagina or abdominal fold and no drying of R18. R18 was rolled to her right side, and her buttocks appeared very reddened with open sores that appeared like skin tears with slight bleeding from areas. V12 continued to wipe off some white cream on R18, causing more bleeding. A clean brief was applied with no moisture barrier cream applied to R18 and no drying seen done.
On 4/22/25 at 10:15 AM, V12, CNA, stated I checked (R18) at 6:00 AM when I got here, and she was dry at that time. We don't get (R18) up until after breakfast.
2. R63's admission Record, dated 4/22/25, documents R63 was admitted to the facility on [DATE] with diagnosis of Cerebral Vascular Accident (CVA) affecting dominant side, Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Generalized Anxiety Disorder, Polyneuropathy, Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen, Overactive Bladder, Chronic Kidney Disease-stage 4, Morbid Obesity, and Type 2 Diabetes Mellitus (DM).
R63's Care Plan, dated 11/13/24, documents R63 requires assistance with ADLs (activities of daily living) related to impaired mobility. Diagnosis CVA/hemiplegia. Interventions: Assist with all ADLs as needed, provide setup assist and encouragement for those task that resident can perform independently. It continues (1/13/25) R63 is at risk for skin issues related to impaired mobility. Interventions: Staff to provide incontinent care after each incontinent episode, weekly skin assessment, staff to assist with turning and repositioning as tolerated, pressure redistribution mattress to bed.
R63's MDS, dated [DATE], documents R63 is cognitively intact and is dependent on staff for toileting.
On 4/21/25 at 9:30 AM, R63 stated I have not been out of my bed or cleaned up yet today. I am currently wet from the night. I am usually in bed until around lunch time. There was a urine smell coming from R63.
On 4/22/25 at 8:13 AM, R63 stated I was last checked and cleaned up between 4:00 and 5:00 AM this morning. I am wet now and they will come in and clean me up again after breakfast.
On 4/22/25 at 9:00 AM, V11, Licensed Practical Nurse (LPN), answered R63's call light with R63 stating that she was wet and needed changed. V11 told R63 that she will let a CNA know.
On 4/22/25 at 9:25 AM, V12, CNA, brought in supplies, which included a pack of wet wipes and two trash bags. The window blinds were left open with R63 lying in the bed by the window. There were cars seen parked in a parking lot outside her window. R63 was laid flat in bed for care with her oxygen cannula removed to wash her face and was never put back on. V12 unfastened R63's incontinence brief and tucked it between R63's legs with a strong urine smell filling the room. V12 wiped once to left groin, once to right groin, and once down the middle of R63's vagina. There was no further cleaning of R63's peri-area or vaginal area and there was no drying of R63.
On 4/24/25 at 9:40 AM, V14, CNA, stated The CNAs should be checking on every resident at least every two hours and should provide peri-care at that time if needed. When I do peri-care, I gather all my supplies, which are two basins of water, one with soap and one for rinse or sometimes will use wipes depending on the situation. I will then clean the resident's groins, then the right side, left side, and down the middle of a female's vagina, then roll them over and completely wipe the back side. I will then dry them. Any time I am providing care to a resident in their room, I make sure the blinds are closed, the curtains are pulled, and the door is shut. Any time I am assisting a resident with a transfer, I always carry a gait belt around my waist and will use it while assisting the resident.
On 4/28/25 10:35 AM, V25, CNA, stated that during incontinent care, all areas are washed and dried. V25 stated that during resident care, doors, blinds, and curtains are pulled for privacy.
On 4/28/25 at 11:00 AM, V2, Director of Nursing (DON), stated I would expect staff to perform timely and complete incontinent care and to provide privacy for the resident at all times, including closing the blinds and curtains during care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R13's Care Plan, not dated, does not address R13's oxygen use.
R13's MDS, dated [DATE], documents that R13 is cognitively in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R13's Care Plan, not dated, does not address R13's oxygen use.
R13's MDS, dated [DATE], documents that R13 is cognitively intact.
On 4/21/2025 at approximately 9:15 AM observed oxygen concentrator in room with oxygen tubing on the floor. The concentrator did not have humidified water bottle in place. The oxygen tubing was not dated.
On 4/24/2025 at 1:25 PM observed oxygen concentrator in room with oxygen tubing on the floor. The concentrator did not have humidified water bottle in place. The oxygen tubing was not dated.
On 4/24/2025 at 1:29 PM R13 stated that she uses the oxygen when she is short of breath. R13 stated that it's not all the time but when she needs it it's there. R13 stated that they do not change the oxygen tubing. R13 stated that she doesn't remember ever having a water bottle on the concentrator.
On 4/28/2025 at 10:48 AM V2, Director of Nursing stated that R13 had a change in condition and went out to the hospital. V2 stated that when R13 returned she had an order for oxygen.
On 4/28/25 at 11:00 AM, V2, Director of Nursing (DON), stated I would expect the nurses to attach humidified water bottles and to date the nasal cannulas for those residents on oxygen. I would expect the staff to use the portable oxygen stands for all portable oxygen tanks and not to leave them free standing.
The facility's Oxygen Therapy policy, dated 8/14, document that the OXYGEN THERAPY POLICY: Oxygen (02) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. EQUIPMENT: Cannula - used for oxygen flow of 1-4 liters per minute (LPM). Humidification is not necessary for flow rates of 1-2 LPM or less and should only be used as clinically required. PROCEDURE: I. Oxygen therapy is to be provide under the direction of a written physician's order. A Physician's Order for 02 therapy is to contain liter flow per minute via mask or cannula/timeframe. On an emergency basis, 02 may be used at 2L/minute until the physician is notified. 8. Change tubing weekly. 9. Date tube when changed (weekly).
Based on Interview, Observation, and Record Review, the Facility failed to provide a humidified bottle of water and to date the nasal cannula for 4 of 5 residents (R63, R65, R43, R13) reviewed for residents on Oxygen (O2) in the sample of 79.
The Findings Include:
1. R63's admission Record, dated 4/22/25, documents R63 was admitted to the facility on [DATE] with diagnosis of Cerebral Vascular Accident (CVA) affecting dominant side, Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease (COPD), Major Depressive Disorder, Generalized Anxiety Disorder, Polyneuropathy, Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen (O2), Morbid Obesity, and Type 2 Diabetes Mellitus (DM).
R63's Care Plan, dated 11/13/24, documents R63 requires assistance with ADLs (activities of daily living) related to impaired mobility. Diagnosis CVA/hemiplegia. R63 has SOB (shortness of breath) with excretion, when lying flat R63 uses oxygen. Interventions: Assist with all ADLs as needed, observe for signs/symptoms or complaint of shortness of breath, elevate head of bed as needed/requested, administer oxygen as ordered per MD (Medical Doctor).
R63's Minimum Data Set (MDS), dated [DATE], documents Section C: R63 is cognitively intact and is dependent on staff for toileting. Section I: Pulmonary - Asthma Yes, Respiratory Failure Yes, Other: Dependence on Supplemental Oxygen Yes. Section J: Other Health Conditions: A. Shortness of Breath or trouble breathing with exertion Yes, B. Shortness of breath or trouble breathing when sitting at rest Yes, C. Shortness of breath or trouble breathing when lying flat Yes.
R63's Physician Order, dated 10/31/24, documents Oxygen: Tubing and Humidifier Change. Every night shift, every Sun (Sunday) for oxygen use, please label tubing with date changed.
R63's Physician Order, dated 10/31/24, documents Oxygen: Obtain SPO2 (measure of the percentage of oxygen in the blood). Every shift for SOB (shortness of breath).
R63's Physician Order, dated 10/31/24, documents Oxygen: Obtain SPO2. As needed for SOB.
R63's Physician Order, dated 9/17/24, documents Check O2 Sats Q Shift and if SPO2% is <90% Notify MD Immediately. Every shift related to Dependence on supplemental oxygen.
R63's Physician Order, dated 9/17/24, documents Oxygen 3 Liters Per Nasal Cannula Continuous.
On 4/21/25 at 9:30 AM, R63 seen lying in bed on O2 at 3 Liters (L)/Nasal Cannula (NC) per O2 concentrator. There was no humidified water bottle attached to the concentrator and the NC was not dated. There was also a portable O2 tank free standing in front of the concentrator with no stand or container.
On 4/22/25 at 8:13 AM, R63 lying in bed with 3 L/NC on per oxygen concentrator with no humidified water bottle and the NC not dated. The portable O2 tank remains free standing and now by the door.
On 4/22/25 at 9:25 AM, while providing incontinent care to R63, V12, CNA, laid R63 flat with her NC removed from her nose and placed on the concentrator during care. R63 was transferred from her bed to her wheelchair via (full body mechanical lift device) without her oxygen. After care and the transfer of R63, V12 gave R63 her O2 NC with R63 putting it in her nose, then V12 told V13, CNA, to take R63 to the nurse to get her oxygen turned on. R63 appeared to be slightly short of breath without her oxygen on.
On 4/23/2025 at 10:50 R63 stated that she has COPD and always wears her oxygen because she can't breathe without it. R63 stated that she has to have her head up. R63 stated that she can't lay flat. R63 stated that when lying flat she has trouble breathing. R63 stated that she struggles to breathe and feels like she is suffocating when lying flat. R63 stated that she wears the oxygen and can't breathe without it.
2. R65's admission Record, dated 4/24/25, documents R65 was admitted to the facility on [DATE] with diagnosis of Congested Heart Failure (CHF), Hypertension (HTN), Atherosclerotic Heart Disease (ASHD), Morbid Obesity, Major Depressive Disorder, and Anxiety Disorder.
R65's Care Plan, dated 1/17/25, documents R65 has altered cardiovascular status related to diagnosis of Systolic and Diastolic Heart Disease and Atherosclerotic Heart Disease. Intervention: Monitor/document/report PRN (as needed) any changes in lung sounds on auscultation (i.e. crackles), edema and changes in weight.
R65's MDS, dated [DATE], documents R65 is cognitively intact and is independent for ADLs.
R65 does not have a Physician Order for O2.
On 4/21/25 at 10:05 AM, R65 was on an O2 concentrator with 2 L/NC. The NC was seen lying in the resident's bed, there was no water bottle attached to the concentrator and the NC was not dated.
3. R43's admission Record, dated 4/24/25, documents R43 was admitted to the facility on [DATE], with the diagnosis of Acute Respiratory Failure, CHF, Pneumonia, HTN, Generalized Anxiety Disorder, and Major Depressive Disorder.
R43's Care Plan, dated 1/16/25, documents R43 has altered respiratory status/difficulty breathing related to diagnosis of acute respiratory failure. Interventions: Administer medication/puffers as ordered, monitor for effectiveness and side effects, encourage sustained deep breaths by: Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation); Using incentive spirometer (place close for convenient resident use); Asking resident to yawn, maintain a clear airway by encouraging resident to clear own secretions with effective coughing, if secretions cannot be cleared, suction as ordered/required to clear secretions, monitor/document changes in orientation, increased restlessness, anxiety, and air hunger, Oxygen Settings: O2 via NC at 2L continuous.
R43's MDS, dated [DATE], documents R43 is cognitively intact and is independent on some ADLs.
R43's Physician Order, dated 6/10/24, documents Continuous O2 2 L/NC Check SPO2 Q Shift if SPO2 is < 90 Then Notify MD. Every shift related to Acute respiratory failure, with hypoxia or hypercapnia.
On 4/21/25 at 10:00 AM, R43 stated she is on O2 at 2 L/NC. There was no humidified water bottle attached to the concentrator and the NC was not dated.
On 4/24/25 at 9:35 AM, V30, Licensed Practical Nurse (LPN), stated The Nurses are responsible for taking care of the resident's oxygen needs. The Nurses should add a water bottle to the concentrator and should be changing the nasal cannula once a week. The Nurses should date each one when they put a new bottle or cannula on.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly store and discard expired medications for 30...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly store and discard expired medications for 30 of 32 residents (R11, R15, R18, R23, R27, R29, R30, R31, R32, R35, R39, R40, R41, R43, R44, R45, R46, R48, R58, R60, R63, R65, R81, R82, R86, R94, R96, R97, R101, R357) reviewed for medication storage in the sample of 79.
Findings include:
On 4/21/2025 at 9:55 AM the facility's 100 Hall North Back Medication Cart was inspected. The medication cart contained the following:
R41's opened multi dose Lantus insulin Pen. The multi-dose vial was labeled with no open date.
On 4/21/2025 at 9:59 AM V4, Registered Nurse (RN), verified that the multi dose vial was open, in use and did not have an open date.
On 4/21/2025 at 10:07 AM the facility 100 hall medication room was inspected. The unlocked refrigerator located in the medication room contained the following:
R29's plastic sealable bag with 1 sealed 1ml vial of Lorazepam and 1 open and partially used 1ml vial of Lorazepam.
1 unlabeled plastic sealable bag with R46's sealed 1ml vial of Lorazepam and 1 open and partially used 1ml vial of Lorazepam. The unlabeled plastic sealable bag also contained 2 sealed 1ml vials with no name.
R23's plastic sealable bag with 1 opened and partially used 1ml vial of Lorazepam and 1 sealed 1ml vial of Lorazepam. Both vials manufacturer expiration date was documented on vial 1/2025.
On 4/21/2025 at 10:15 AM the 100 Hall North front medication cart was inspected. Facing the 10-drawer medication cart there are 4 narrow drawers to the right side. The second drawer from the top is missing creating a large hole and gap between the first and third drawer. This hole in the cart exposes the narcotic lock box to anyone in the facility.
On 4/21/2025 at 10:20 AM V8, LPN, stated that the vials of Lorazepam should be under a double lock and with the refrigerator not having a lock it's not. V8 stated that R23's Lorazepam is expired and should have been destroyed. V8 stated that she is agency and has been coming to the facility for some time and the medication cart has been this way. V8 stated that she asked about it and was told to keep it in the medication room. V8 stated that she must take the cart out of the medication room to pass medications. V8 stated that she can reach in the opening and access the narcotics.
On 4/21/2025 at 12:02 AM observed V8 access the narcotic drawer through the opening above. V8 was able to unlock the box and obtain R48's Clonazepam medication.
On 4/21/2025 at approximately 1:40 PM V4 stated that she has worked at the facility for about 6 weeks. V4 stated that she has passed medication using the 100-hall front cart. V4 stated that the cart has had a missing drawer and opening since she has worked at the facility.
On 4/21/2025 approximately 1:50 PM V2, Director of Nursing, verified that the Lorazepam was a controlled substance and should be under a double lock system. V2 stated that currently this is not the case but that they are working to correct this. V2 stated that they do not have a narcotic count sheet for R23's expired lorazepam located in the unlocked refrigerator. V2 stated that she was aware of the condition of the cart and the access to the narcotics and not being under a double lock system. V2 stated that she requested a new cart 2 weeks ago and that V1, Administrator was on it.
On 4/21/2025 observed medication cart in the hallway, with the front of the cart facing outward with narcotic drawer accessible, unattended by staff.
On 4/22/2024 the Medication Cart observed sitting in hallway from 9:57 AM to 11:00 AM unattended. The medication cart front facing to hallway with access to Narcotic drawer accessible to persons walking past.
On 4/22/2025 at 10:00 AM observed R32 propelling self in wheelchair next to unattended medication cart. The opening of medication cart was eye level and in R32's reach.
On 4/22/2025 at 10:04 AM observed R65 propelling self in wheelchair next to unattended medication cart. The opening of medication cart was eye level and in R65's reach. Observed R65 bump into cart and pushed off cart.
On 4/22/2025 at 10:05 AM observed R39 propelling self in wheelchair next to unattended medication cart. The opening of medication cart was eye level and in R39's reach. Observed R39 propelling back and forth past the unattended medication cart.
On 4/22/2025 at 10:14 AM observed R30 ambulating passed the unattended medication cart. The medication cart was within R30's reach.
On 4/22/2025 at 2:35 PM V18, LPN, stated that the cart has been this way for at least 2 years. V18 stated that she has asked about it and was told it has been ordered but has it never shown up.
This failure has the potential to affect independent, mobile residents (R11, R15, R18, R23, R27, R29, R31, R35, R40, R43, R44, R45, R46, R48, R58, R60, R63, R81, R82, R86, R94, R96, R97, R101, R357), which were identified by V2, Director of Nursing as residing in the facility.
The facility's Medication Storage policy, dated 1/15, documents that POLICY: Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. Procedure: 12. The following medications must be removed from stock and disposed of properly on a continuing basis: outdated, contaminated, recalled, deteriorated, unlabeled medications, or those with soiled or broken/ cracked containers.
On 4/21/25 at 1:13 PM, the medication cart located on the 200-Hall was seen unlocked and unattended sitting by the nurse's desk, with R75 sitting in her wheelchair next to the desk and cart.
R75's Minimum Date Set (MDS), dated [DATE], documents R75 has a severe cognitive impairment.
On 4/28/25 at 11:00 AM, V2, Director of Nursing (DON), stated I would expect the nurses to keep the medication carts locked at all times when not administering medications.
Stat-box Check-In (South E-kit Contents) inventory sheet, undated, documented the following medications and amounts as follows: Adrenaline x 2, Amlodipine x 10, Amoxicillin x 10, Amox/Clav x 10, Atorvastatin x 10, Azithromycin x 10, Carvedilol x 10, Cefdinir x 10, Ceftriaxone x 4, Cefuroxime x 10, Cephalexin x 10, Ciprofloxacin x 10, Clindamycin x 10, Clonidine x 5, Clopidogrel x 10, Digoxin x 10, Diphenhydramine x 1, Doxycycline x 10, Donepezil x 10, Furosemide 20 mg (milligrams) x 10, Furosemide 10mg x 2, Gabapentin x 20, Baqsimi (glucagon nasal spray) x 1, Haloperidol x 4, Heparin x 4, Levofloxacin x 10, Lisinopril x 10, Memantine x 10, Mephyton x 3, Methylprednisolone x 1, Metoprolol tartrate x 10, Metoprolol succinate x 10, Metronidazole x 10, Mirtazapine x 10, Naloxone x 1, Nitrofurantoin x 10, Nitroglycerin x 1, Ondansetron x 10, Pantoprazole x 10, Phenytoin x 10, Phytonadione x 2, Potassium ER x 10, Prednisone x 20, Prochlorperazine 5mg x 10, Prochlorperazine 10mg x 2, Spironolactone x 10, Sulfamethoxazole x 10, SPS (sodium polystyrene sulfonate) x 4, Trazodone x 10, Warfarin 1mg x 10, and Warfarin 2mg x 10.
On 4/21/25 at 12:17 PM, the Medication Storage Room in Memory Care Unit contained the following:
At 12:20 PM, located in a refrigerator, R10's Aspart (insulin) box dated 12/17/24 had 4 pens in it. One pen does not have a pharmacy label and has the name (name) written on it, expire date 2/28/27. V5 LPN stated we don't have any resident named (name) on this unit right now. R10 had pharmacy labels on the other 3 pens in her box unopened.
At 12:30 PM, E-Kit (Emergency Kit) labelled Facility South, did not have a sealed tag/lock on it and had a slip for use of it dated 4/20/25 for R92 to be administered doxycycline, the box that is not sealed did not contain doxycycline. The box that contains Doxycycline was sealed/locked with a tag. Unsealed/unlocked box contained: epinephrine, diphenhydramine furosemide, heparin, nitroglycerin, vitamin k, prochlorperazine, and coumadin. V5 stated she does not know why it was not tagged or the process the procedure does when it is used, thinks there should be a booklet with it. The top compartment of the E-kit had medications freely accessible and included Narcan, lidocaine x 4, ceftriaxone, sodium polystyrene sulfonate x4, glucagon nasal spray, and methylprednisolone which.
On 4/21/25 at 12:39 PM, V6 LPN/Unit manager stated the emergency kit with a box not tagged was never reported to her, she is unsure what was used or how much medication should be in it because there is no booklet here with the box. V6 stated the box should be retagged immediately after use to know the correct count. V5 tagged the open box without counting the medications in front of V6. V6 stated there should also be a book with the box.
On 4/22/25 at 9:35 AM, V6, LPN Unit Manager, stated the E-kit not being tagged/sealed/locked appropriately is a concern as well as not having the book that is supposed to be filled out each time the kit is used unavailable. V6 stated she was unable to find the book for the E-kit and does not know why the box was not locked or why there was a box within the kit that was not tagged/locked either. V6 stated she thinks it was an agency nurse that used it over the weekend and was not familiar with the facility's protocols for using the E-kit. V6 stated she has no idea what medications were taken out. V6 stated she did not know where the inventory list was for the E-kit either when asked for a printout of it. This surveyor located it on the side of the box and V6 confirmed that was it. The insulin pen box for R10 should not have contained any other patient's medications and all should have a pharmacy label, not handwritten.
On 4/24/25 at 8:24 AM, V28, LPN, stated the emergency kit has slips of paper we document what we need to use it for each time, and we record the amount we take out on there as well as what drug we needed, and the numbers of the lock tags used. V28 stated the E-kit is supposed to be locked/tabbed at all times as a security measure so no one can get into it. V28 stated the E-kit needs to have new lock tags placed right after use.
Dec 2024
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess, monitor, and provide timely treatment for 1 of 3 (R3) reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess, monitor, and provide timely treatment for 1 of 3 (R3) residents reviewed for change in condition. This failure resulted in R3 experiencing a decline in Activities of Daily Living (ADLs) from 11/30 through 12/4 and subsequently becoming unresponsive on 12/4/24 at 9:00 AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, and intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock.
This failure resulted in an Immediate Jeopardy, which was identified to have begun on 11/30/24 when the facility failed to: 1. assess, monitor, and provide timely treatment for a change in R3's condition. 2. Notify the physician of R3's decline in ADLs from 11/30 through 12/4 and being unresponsive on 12/4/24 at 9:00 AM. 3. Obtain medical treatment for R3's change of condition from 9:00 AM to 4:00 PM at the time of ambulance transfer with R3 experiencing cardiac arrest with Cardiac Pulmonary Resuscitation performed, intubation and hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock.
V2, Director of Nursing, and V3, Regional Clinical Consultant, were notified of the Immediate Jeopardy on 12/19/24 at 1:17 PM. The surveyor confirmed by observations, interview, and record review, the Immediate Jeopardy was removed on 12/23/2024, but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training.
Findings include:
R3's Care Plan, dated 11/5/2024, documents Advance Directives: R3 is a full code and requests life sustaining measures.
R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of urine and always continent of bowel and requires assistance with activities of daily living (ADL).
R3's POLST (Physician Orders for Life-Sustaining Treatment,) dated 8/5/2024, documents that R3 indicated Yes to attempt CPR if in cardiac arrest and if not in cardiac arrest: Full treatment.
R3's Progress Notes, dated 12/4/2024 at 2:23 PM, documents Nurses Note Late Entry: Note Text: Resident received new med order per (V4) for the following: Send resident to ER (emergency room) for evaluation and treatment R/T (related to) refusal of meds and refusal of meals. Resident POA (power of attorney) notified. Writer contacted (Local) ambulance rep who stated that a unit would be sent in 1 hour. Writer verbally notified pm nurse and told her after an hour to check back with (local ambulance company).
R3's Progress Notes, dated 12/4/2024 at 5:23 PM, documents Nurses Note Text: 1632: This DNS (Director of Nursing Services) was called to resident room per emergency response due to resident noted with rapid condition decline. Crash cart requested and reported to resident room with Code called for assistance. 1634: Upon entering resident noted with 2 nurses at bedside. Crash cart and oxygen had been requested and enroute. 911 call already placed by staff nurse. This DNS took over lead duties. 1635: Resident noted in bed with HOB (head of bed) elevated, staff providing airway safety as able awaiting further equipment. Resident tachypneic with evidence of respiratory depression. Pulse present, weak and thready. Unable to obtain accurate reading on Pulse oximeter. Resident known to this nurse to have history of seizures with evidence of postictal s/s (signs/symptoms) noted. Resident diaphoretic, bilateral pupil dilation, increased oral/nasal secretions. [NAME] in color with thick frothy consistency. Resident unresponsive to verbal stimuli, tactile stimuli notes no response. Crash cart arrived. Suction set up and this DNS initiated suctioning, O2 (oxygen) initiated 5L (liters) via mask with continued intermittent suctioning to maintain airway. No gag reflex noted during suction, slight secretions removed from oral cavity, no evidence of food or other particles noted to indicate aspiration. LS (lung sounds) forced but clear bilateral. Care continued until arrival of EMS (Emergency Medical Service). This DNS gave reports while care transitioned to EMS. Facility provided medical equipment transitioned to EMS medical devices (suctioning, oxygen) without further distress noted. Resident remains tachypneic, with weak thready pulse present. Unable to obtain BP (blood pressure). This DNS along with facility staff assisted EMS to transfer resident to stretcher for continued care and transfer. EMT (emergency medical technicians) reports concerns of cardiac arrest during transport. States they were having difficulty obtaining a second rig for assistance due to shortages today. This DNS along with second nurse assisted EMS with resident move to ambulance with no loss of pulse or decreased respiration enroute to ambulance. 1700: Resident placed into ambulance with EMTs, and staff return to facility. 1708: EMTs now noted with second rig finally arrived and assistance being provided. Resident to be transfer to closest hospital due to critical status. Staff nurse contacted POA (power of attorney) and made aware of condition rapid decline and transfer status.
R3's Progress Note, dated 12/4/2024 at 5:57 PM, documents Nurses Note, Note Text: Time error inverted number 1632 should read 1623. Error in consecutive times caused by initial inversion: should read as follows, 1624, 1625, 1630, 1637.
R3's Progress Note, dated 12/4/2024 at 6:59 PM, documents Nurses Note, Note Text: upon writer's arrival to give resident her meds writer observed resident was foaming at the mouth writer immediately notified staff for help and called paramedics staff applied oxygen and suctioning to resident and elevated her head to keep her stable till paramedics arrived resident was still breathing and had a pulse, but it was faint and light paramedics arrived and suctioned resident and applied oxygen and removed resident from bed to stretcher writer sent resident out to hospital resident currently being transported to hospital by paramedics writer will continue to follow up.
R3's Progress Note, dated 12/4/2024 at 9:33 PM, documents Nurses Note, Note Text: error in time the correct time of incident was 16:23.
R3's Therapy Communication Form, documents 11/25/2024 report of change of status to NP, blood work ordered 11/26/2024 change diet to puree, 12/4/2024 educate staff re: not to feed in bed laying flat. Max (assist) without any response from patient.
R3's Local Fire Department Patient Care Records, dated 12/4/2024, documents that they received a call from local facility due to patient being unresponsive and foaming. Upon arrival patient was unresponsive and clammy surrounded by nursing staff. Nursing staff suctioning patient. Fire department took over and continued suctioning with contents of vomit. Staff not sure how long-ago patient had aspirated. Patient was agonal breathing. Faint Pulse, unable to obtain oxygen level and blood pressure. During transport to local hospital pulse was not palpable and CPR initiated.
R3's Local Hospital History and Physical, dated 12/4/2024, documents that This [AGE] year [NAME] Female presents to, ED (emergency department) via Unassigned with complaints of Cardiac Arrest. 12/04 Preceding the arrest, the patient was choking, was found down by nursing home staff. The arrest 17:03 occurred at nursing home. Pre-hospital course: EMS care prior to arrival: initiation of ACLS (Advanced Cardiovascular Life Support), oxygen. Per [NAME] patient was found FOAMING AT THE MOUTH BY NH (nursing home) Staff. Patient arrested upon EMS intervention en route. Patient receiving CPR upon arrival and had an IG EL (airway device) in place. It continues Exam: 12/04 17:08 Eyes: Pupils: constricted, bilaterally. Cardiovascular: Rate: tachycardic, Rhythm: Edema: pedal edema, that is very mild, ankle edema, that is very mild. Respiratory: no spontaneous respirations are appreciated, Respirations: no spontaneous respirations appreciated, Breath sounds: Unable to obtain exam due to obtunded state, patient being intubated. It also documents Procedures: 12/04 Intubation: A time-out was completed verifying correct patient, procedure, site, positioning, and intubation 16:59 set-up. The patient was pre-oxygenated using an Ambu bag and placed in a supine position. Sedation was obtained 100MG SUC. The MAC 3 blade was used and inserted into the oropharynx at which time there was a Grade 1 view of the vocal cords. A 7.5 French endotracheal tube was inserted and visualized going through the vocal cords. The stylet was removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were heard in both lung fields equally. The endotracheal tube was placed at 23cm, measured at the teeth. A chest x-ray was ordered to assess for pneumothorax and verify endotracheal tube placement. Disposition Summary, dated 12/4/2024, documents diagnosis: Cardiac Arrest and Severe Septic Shock.
On 12/19/2024 the facility provided a 5 ways Root Cause Analysis Template, dated 12/19/2024, that documents: Clearly state the problem: Facility failed to Assess, monitor, and provide timely treatment. Nurse failed to follow up, assess resident and call MD. Nurse thought this was resident behavior. Poor assessment skills by nurse.
On 12/12/2024 at 8:46 AM V20, R3's Power of Attorney (POA), stated that she was very concerned with the care that R3 received at the facility. V20 stated she spoke with R3's roommate and was notified that R3 received CPR at the facility when being transported from the facility. V20 stated that she was notified by V5, License Practical Nurse (LPN), around 1:30 -2:00 PM that R3 was being sent out to the hospital because she was not doing well. V20 stated that she received a phone call from the facility 3 hours later telling her that the ambulance is here and R3 is being sent out. V20 stated that she didn't understand why it took so long. V20 stated that the (local) hospital called and told her that CPR had to be performed in the ambulance during transport and in the emergency room. V20 stated that she was informed that R3 was on a vent and would be transported to outlying hospital. V20 stated that she is very upset and concerned because she was told that R3 was not doing well and needed to go to the hospital 3 hours before R3 did. Why didn't they send her? V20 stated that for 2 weeks R3 refused to get up and laid in urine for long periods of time sitting in her own waste. V20 stated that she was informed by the hospital that R3 had an impaction the size of her hip socket. V20 stated that it's clear that R3 was having changes before the day she was sent out and they did not do anything.
On 12/12/2024 at 1:50 PM V7, Certified Nurse's Assistant, CNA, stated that he was not here when R3 went out to the hospital. V7 stated that he had worked with R3 the days and nights before. V7 stated that R3 had taken to the bed and would not get out. V7 stated that R3 was totally incontinent and did not eat. V7 stated that R3 would refuse to allow care but this was different from the norm. V7 stated that R3 was alert and verbal, able to stand and help with transfers, continent for the most part. V7 stated that the day before R3 went he again told the nurse that R3 was different and that something was not right. V7 stated that R3 was not able to stand, and he had to use a full mechanical lift. V7 stated that she was taken to the dining room, and she was not right. V7 stated that he informed the nurse passing pills that R3 was shaking like she had Parkinson's. V7 stated that R3 was different. V7 stated that he told the nurses and V2, DON, that there was something wrong with R3. V7 stated that the changes in R3 started 12/1/2024 and this is when he started notifying the nurses and the Director of Nursing.
On 12/12/2024 at 12:27 PM V5, Licensed Practical Nurse (LPN), stated that he was here the day that R3's change in condition occurred. V5 stated that R3 has a history of behaviors as far as refusing care and refusing to perform self-care but this was different. V5 stated that between 10:30 AM and 12:00 PM R3 was not herself and not responding to verbal stimuli and would not take her medication. V5 stated that he notified the Nurse Practitioner and got an order to send R3 out. V5 stated that he notified the power of attorney and called the ambulance. V5 stated that he was informed that it would be an hour before the ambulance would arrive. V5 stated that he told the oncoming nurse of this and that if the ambulance does not show after 30 to 45 minutes to call them back. V5 stated that he got the paperwork ready. V5 stated that he was not at the facility when R3 went out as he had left after completion of his shift.
On 12/12/2024 at 12:30 PM R1 stated that she and R3 were roommates. R1 stated that R3 was not herself for most of the week. R1 stated that R3 did not eat and stayed in the bed and did not eat or drink. R1 stated that the day before R3 went out to the hospital, V7, CNA, got R3 up. R1 stated that R3 didn't help much at all. R1 stated that when they put R3 to bed she was talking and that was the last time she was ok. R1 stated that R3 yells when they clean R3 but nothing during the night or following day.
On 12/17/2024 at 8:30 AM V6, LPN, stated that she was running late and got to the facility after 2:00 PM. V6 stated that she received shift report and was informed in shift report that R3 was going to the hospital and that the ambulance should be at the facility in 30 minutes, if not call the service. V6 stated that she was not informed of R3's condition and did not think it was an emergency. V6 stated that she went about, did her rounds, and started prepping for her shift and getting herself ready to pass her medications. V6 stated that around 4 to 4:30 PM the therapist (V9) reported to her that R3 needed a nurse now. V6 stated that when she entered the room R3 was in a state of distress. V6 stated that R3 was pale, not responding, shallow breathing and foam coming from R3's nose and mouth. V6 stated that she called 911 and called a code. V6 stated at that time she received help from other staff while she was on the phone with 911.
On 12/17/2024 at 10:21 AM V14, CNA, stated that she was not assigned to R3. V14 stated that R3 did have some changes. V14 stated that R3 was not herself. She would not talk and was spaced out, she (R3) was out of it. V14 stated that R3 does have behaviors but this was different. V14 stated that she reported it to the nurse. V14 stated that she wasn't right. V14 stated this was days before she went out.
On 12/17/2024 at 10:28 AM V17, CNA, stated that she got to the facility between 3:30 to 4:00 PM. V17 stated that she was not assigned to R3 that day and maybe saw her in passing as V17 walked past R3's room but did not look at her. V17 stated that she let the ambulance in and got the oxygen when told to do so. V17 stated that R3 has been having some changes and requiring more assistance than normal. V17 is normally alert and able to make her needs known. V17 stated that R3 hadn't been doing that and the other CNAs were needing help with her which is unusual.
On 12/17/2024 at 10:32 AM V15, CNA, stated that she did not have R3 the day she went out. V15 stated that she helped transfer R3 onto the gurney and got the oxygen tanks and things to help R3 breathe. V15 stated that R3 has behaviors and refuses care. V15 stated that prior to this R3 was not herself and stayed in the bed, went from standing and verbalizing her needs to dependent on staff, not eating and increase incontinence. V15 stated that the nurse was notified.
On 12/17/2024 at 10:39 AM V18, CNA, stated R3 was having changes days before she went out. V18 stated that R3 was crying a lot and not eating. V18 stated that R3 wouldn't stand up. V18 stated that this was different for R3 and that R3 was alert and able to stand and help. V18 stated that R3 did have behaviors and would refuse care. V18 stated that this was different.
On 12/17/2024 at 10:50 AM V9, Speech Therapist, stated that Speech Therapy was seeing R3 due to cognitive changes and eating. V9 stated that R3 did not have any difficulty with swallowing but did have some changes in her ADLs within the last week or so. V9 stated that because of this she went in to see R3 at 9:00 AM to see if she had eaten. V9 stated that she entered R3's room and R3 was lying flat in the bed with food tray on table next to the bed. V9 stated that she called out to R3 and there was
no response. V9 stated that she went to raise the head of the bed and it did not work and R3 did not respond to movement. V9 stated that she noticed at that time that R3 was unresponsive. V9 stated that she performed a sternal rub and R3 did not respond. V9 stated that she notified the nurse and was informed that this was a behavior and no to worry about it. V9 stated at that time she did some in servicing with the staff about feeding R3 with bed being flat and raise the head of the bed. V9 stated that at about an hour later she again noticed that R3 was unresponsive and notified the nurse asking for vitals. V9 stated that she was informed that the vitals could not be taken because the battery was dead in the machine. V9 stated that at about 4 PM she entered R3's room and it was the scariest thing she has seen. V9 stated that R3 was lying in bed unresponsive with foam coming out of her nose. V9 stated that she told the nurse and was informed that the nurse on days said R3 was going out but was waiting on an ambulance. V9 stated that she informed the nurse that R3 needed help now.
On 12/18/2024 at 10:46 AM V10, CNA, stated that she took care of R3 on 12/4/2024. V10, CNA, stated that she came in and went to R3's room and she didn't look herself. V10 stated that she asked what's going on with R3, she doesn't look right. V10 stated that she was informed that R3 was having some problems and to leave her in for breakfast and so she did. V10 stated that she went back in R3's room around 10:00 AM and provided incontinent care. V10 stated that R3 was not responding and was incontinent of a small amount of liquid stool but not wet with urine. V10 stated that R3 does have behaviors when she refuses care and not wanting to get up. V10 stated that this was different. V10 stated that this was not like R3 at all. V10 stated that she left the room and let V5 the nurse know. V10 stated that she provided incontinent care at 1:30 PM and R3 was unresponsive. V10 stated that R3 again had a small amount of liquid stool. V10 stated that this was different, this was a big change for R3. V10 stated that R3 was alert and able to tell you when she needed to toilet. V10 stated that R3 was continent in the day and incontinent at night. V10 stated that R3's change in condition started about 3 to 4 days prior to the unresponsive episode. V10 stated that R3 went from standing and taking steps to using a sit to stand and then not transferring at all and not eating at all. V10 stated that she let the nurse know.
On 12/18/2024 at 4:00 PM V3, Regional Clinical Nurse, stated that the Change in Condition and Physician Notification Policy was all in one and had been provided.
On 12/18/2024 at 9:26 AM V2, Director of Nursing, stated that she was up in front of the building and was called to R3's room. V2 stated that she ran down to R3's room. V2 stated that when she entered the room it looked like R3 had a seizure. V2 stated that R3's pupils were dilated and R3 was foaming at mouth and nose. V2 stated that there were nurses at the bedside. V2 stated that R3 had slow shallow breathing and a weak pulse. V2 stated that the foam was frothy, and she was almost post ictal. V2 stated that they were unable to obtain a pulse ox and O2 applied. V2 stated that 911 had been called. V2 stated that they were keeping R3's airway safe. V2 stated that EMTs came and took over and R3 was transferred to the stretcher and left facility. V2 stated that she had not seen R3 that day. V2 stated that she passed R3's room but did not actually see R3 prior to this event.
On 12/18/2024 at 1:35 PM V4, Nurse Practitioner, stated that on 12/4/2024 at 10:30 AM she received a message that R3 was refusing medication and food, facility attempted to get a urine and was not successful and R3 was shaking. V4 stated that at 12:30 PM she responded to send to R3 to the ER for eval. V4 stated that she was not notified of R3 being unresponsive with sternal rub being performed at 9:00 AM. V4 stated that if she would have been notified, she would have expected them to send R3 to hospital immediately. V4 stated that they know that this would be an emergency and with nursing judgement R3 should be sent out with 911 called. V4 stated if the nurse thought this was a behavior, then there still should have been an assessment. V4 stated that she was not aware of R3's change of condition and decline days before.
On 12/19/2024 at approximately 11:15 AM V5 stated that he was notified of R3's change of conditions prior to R3 being unresponsive and thought it was behavioral. V5 stated that R3 would refuse care and have behaviors in dining room.
On 12/19/2024 at 3:10 PM V21, Physician, stated that he was not notified of R3's change of condition. V21 stated that he was not aware that R3 was found unresponsive at 9:00 AM and then foaming from nose at 4:23 PM and went out to hospital in an ambulance. V21 stated that he was not aware that R3 went into cardiac arrest and received CPR. V21 stated that if he was notified that R3 was unresponsive to a sternal rub, attempts to arouse R3 had failed; he would have considered that an emergency and would have sent R3 to the hospital with lights and sirens. V21 stated that he would expect an assessment to be done and vitals. V21 stated that these are things he would have wanted to know. V21 stated that he was not aware that R3 was having change in condition prior to the event, not eating, taking to the bed and not allowing staff to care for her for days. V21 stated that these are red flags and V21 would have wanted to look further. V21 stated that he would have wanted to know what the assessment was. V21 stated that a resident needing minimal help to dependent, alert and then not is an emergency and V21 would have wanted R3 to be seen at the emergency room. V21 stated that he would expect to be notified of the changes of condition prior to the unresponsive episode with assessment including vitals.
On 12/23/2024 at approximately 11:30 AM V2 stated that they had a QA meeting on 12/19/2024 concerning the change of condition to try to find out what was the cause of the delay in treatment. V2 stated this was transcribed to the 5 ways Root Cause Analysis Template. V2 stated that their findings were transcribed to the form. V2 stated that the Facility failed to Assess, monitor, and provide timely treatment, Nurse failed to follow up, assess resident and call MD, Nurse thought this was resident behavior and Poor assessment skills by nurse was the root cause of the delay in treatment.
On 12/23/2024 at 1:19 PM V36, Restorative Nurse, stated that she is a part of Quality assurance team (QA). V36 stated that there was QA meeting, and they went over the deficiency and tried to figure out what happened. V36 stated that they found that they did not respond timely and appropriately with R3's change in condition. V36 stated that they have been in servicing staff related to the Change in Condition policy and if they feel the nurse is not responding then to go above them.
The facility's Notification of a Change in a Status Change in Condition policy, dated 11/17, documents PROCEDURE: 1. Guideline for notification of physician/ responsible party (not all inclusive): a. Significant change in /or unstable vital signs (Temperature, B/P, Pu Ise, Respiration) . h. Repeated refusals to take prescribed medication (for two days). i. Change in level of consciousness. k. Unusual behavior. 2. Document in the Interdisciplinary Team (IDT) notes: a. Resident change in condition. b. Physician/physician extender notification. c. Notification of responsible party.
The facility presented an Abatement plan to remove the immediacy on 12/19/24. The survey team reviewed the Abatement plan and was unable to accept the plan to remove the immediacy. The Abatement plan was returned to the facility on [DATE] and 12/20/24 for revisions. The facility presented a revised Abatement plan on 12/20/24 and the survey team accepted the Abatement plan on 12/20/24.
On 12/23/24, during the validation of the abatement plan by the survey team, it was noted that several staff members had not been in serviced prior to working their shift, and vital sign equipment was not operational at the time of observation. On 12/23/24, at 11:30 AM, V1, V2, and V3 were notified the abatement was not validated as multiple staff persons working had not received the in-service prior to their shift and vital sign equipment was not functioning. All staff who had not previously received in serviced were completed and vital sign equipment was in working order by end of day on 12/23/24.
The Immediate Jeopardy that began on 11/30/24 was removed on 12/23/2024 when the facility took the following actions to remove the immediacy.
1. Emergency QA held 12/19/24 at 2:45pm with interdisciplinary team which consisted of the Medical Director, [NAME] President/Governing body (V51), Executive Director (V1), Director of Nursing Services (V2), Regional Nurse (V3), Memory Care Manager (V52), Wound Care Nurse ( V35), and Social Service Director (V53), to establish a system that addresses any resident in distress and or unresponsive will be treated timely and without delay. Charge nurse will notify the MD (The resident MD), DNS (V2) and or Administrator (V1) to ensure immediate action is taken to ensure the health and wellbeing of the resident. A Root Cause analysis completed on 12/19/24 related to staff failure to immediately notify and transfer resident to hospital when change in condition arose. Due to the fact of this occurrence, there was also a failure to report R3's non-responsiveness status and seriousness of R3's current status to the oncoming shift. This will be addressed to ensure compliance. The DNS (V2) and or Designee performed Inservice to Licensed Nurses to ensure that shift to shift report is done. This was performed on 12-19-24.
2. Facility immediately suspended on 12/19/2024 V5 (LPN) and V9 Speech Therapist, for not responding or making any effort to assist R3 when unresponsive. This suspension will be on-going until a complete investigation of all actions taken by V5 LPN and V9 Speech Therapist on 12/4/24 is thoroughly investigated by the Administrator, V1.
3. DNS (V2) and Regional Clinical Operations Nurse (V3) will immediately begin in-servicing All Staff in person or by phone. This in-service to include notification of any change in condition to charge nurse and Director of Nursing. Then licensed nurses will notify physician immediately. If resident is unresponsive or acute distress to call 911 immediately and notify physician, DNS (V2) and or Administrator (V1) and resident's responsible party. This in-service completed 12/19/24 by 11pm. Staff will not be allowed to work unit until in-service completed.
4. DNS (V2) and or designee will do 100% visual assessment to ensure all current residents are in stable condition and not in acute distress. Completed 12/19/24 at 3:30pm.
5. DNS (V2) and or designee will do 100% audit of vital sign equipment (Blood pressure cuff, pulse oximetry, and thermometer) to ensure each unit has a working vital sign equipment readily available. These will be accounted for daily and stored in the med cart.
Monitoring:
-DNS (V2) and Unit Managers (V2, Memory Care, V27 LPN - SDC, V37 LPN - MDS, V36 LPN - Restorative and V35 LPN- Wound Care) will visually monitor every resident daily to ensure residents are not in distress and in stable condition.
-DNS and Unit Managers will monitor daily that each unit has vital sign equipment, and it is in working condition.
-Policy (Change in Condition) regarding this IJ related to F684 was reviewed at the Emergency QA meeting on 12-19-24 at 3:30pm. There was no change in the Policy. There were system changes related to assessing, monitoring, and providing timely treatment for R3's change in condition. The discussion will continue to occur monthly, and any trends and concerns will be address immediately to ensure compliance.
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
Notification of Changes
(Tag F0580)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the physician of R3's change in condition and unresponsive ep...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the physician of R3's change in condition and unresponsive episode for 1 of 3 (R3) residents reviewed for change in condition. This failure resulted in R3 experiencing a decline in Activities of Daily Living (ADLs) from 11/30 through 12/4 and subsequently becoming unresponsive on 12/4/24 at 9:00 AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock.
Findings include:
R3's Care Plan, dated 11/5/2024, documents Advance Directives: R3 is a full code and requests life sustaining measures.
R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of urine and always continent of bowel and requires assistance with activities of daily living (ADL).
R3's POLST (Physician Orders for Life-Sustaining Treatment), dated 8/5/2024, documents that R3 indicated Yes to attempt CPR if in cardiac arrest and if not in cardiac arrest: Full treatment.
R3's Progress Notes, dated 12/4/2024 at 2:23 PM, documents Nurses Note Late Entry: Note Text: Resident received new med order per (V4, Nurse Practitioner) for the following: Send resident to ER (emergency room) for evaluation and treatment R/T (related to) refusal of meds and refusal of meals. Resident POA (power of attorney) notified. Writer contacted (Local) ambulance rep who stated that a unit would be sent in 1 hour. Writer verbally notified pm nurse and told her after an hour to check back with ambulance company.
R3's Progress Notes, dated 12/4/2024 at 5:23 PM, documents Nurses Note Text: 1632: This DNS (Director of Nursing Services) was called to resident room per emergency response due to resident noted with rapid condition decline. Crash cart requested and reported to resident room with Code called for assistance. 1634: Upon entering resident noted with 2 nurses at bedside. Crash cart and oxygen had been requested and enroute. 911 call already placed by staff nurse. This DNS took over lead duties. 1635: Resident noted in bed with HOB (head of bed) elevated, staff providing airway safety as able awaiting further equipment. Resident tachypneic with evidence of respiratory depression. Pulse present, weak and thready. Unable to obtain accurate reading on Pulse oximeter. Resident known to this nurse to have history of seizures with evidence of postictal s/s (signs/symptoms) noted. Resident diaphoretic, bilateral pupil dilation, increased oral/nasal secretions. [NAME] in color with thick frothy consistency. Resident unresponsive to verbal stimuli, tactile stimuli notes no response. Crash cart arrived. Suction set up and this DNS initiated suctioning, O2 (oxygen) initiated 5L (liters) via mask with continued intermittent suctioning to maintain airway. No gag reflex noted during suction, slight secretions removed from oral cavity, no evidence of food or other particles noted to indicate aspiration. LS (lung sounds) forced but clear bilateral. Care continued until arrival of EMS (Emergency Medical Service). This DNS gave reports while care transitioned to EMS. Facility provided medical equipment transitioned to EMS medical devices (suctioning, oxygen) without further distress noted. Resident remains tachypneic, with weak thready pulse present. Unable to obtain BP (blood pressure). This DNS along with facility staff assisted EMS to transfer resident to stretcher for continued care and transfer. EMT (emergency medical technicians) reports concerns of cardiac arrest during transport. States they were having difficulty obtaining a second rig for assistance due to shortages today. This DNS along with second nurse assisted EMS with resident move to ambulance with no loss of pulse or decreased respiration enroute to ambulance. 1700: Resident placed into ambulance with EMTs, and staff return to facility. 1708: EMTs now noted with second rig finally arrived and assistance being provided. Resident to be transfer to closest hospital due to critical status. Staff nurse contacted POA (power of attorney) and made aware of condition rapid decline and transfer status.
R3's Progress Note, dated 12/4/2024 at 5:57 PM, documents Nurses Note, Note Text: Time error inverted number 1632 should read 1623. Error in consecutive times caused by initial inversion: should read as follows, 1624, 1625, 1630, 1637.
R3's Progress Note, dated 12/4/2024 at 6:59 PM, documents Nurses Note, Note Text: upon writer's arrival to give resident her meds writer observed resident was foaming at the mouth writer immediately notified staff for help and called paramedics, staff applied oxygen and suctioning to resident and elevated her head to keep her stable till paramedics arrived, resident was still breathing and had a pulse, but it was faint and light, paramedics arrived and suctioned resident and applied oxygen and removed resident from bed to stretcher, writer sent resident out to hospital, resident currently being transported to hospital by paramedic,s writer will continue to follow up.
R3's Progress Note, dated 12/4/2024 at 9:33 PM, documents Nurses Note, Note Text: error in time the correct time of incident was 16:23.
R3's Therapy Communication Form, documents 11/25/2024 report of change of status to NP, blood work ordered 11/26/2024, change diet to puree, 12/4/2024 educate staff re: not to feed in bed laying flat. Max (assist) without any response from patient.
R3's Local Fire Department Patient Care Records, dated 12/4/2024, documents that they received a call from local facility due to patient being unresponsive and foaming. Upon arrival patient was unresponsive and clammy surrounded by nursing staff. Nursing staff suctioning patient. Fire department took over and continued suctioning with contents of vomit. Staff not sure how long-ago patient had aspirated. Patient was agonal breathing. Faint Pulse, unable to obtain oxygen level and blood pressure. During transport to local hospital pulse was not palpable and CPR initiated.
R3's Local Hospital History and Physical, dated 12/4/2024, documents that this [AGE] year [NAME] Female presents to, ED (emergency department) via Unassigned with complaints of Cardiac Arrest. 12/04 Preceding the arrest, the patient was choking, was found down by nursing home staff. The arrest 17:03 occurred at nursing home. Pre-hospital course: EMS care prior to arrival: initiation of ACLS (Advanced Cardiovascular Life Support), oxygen. Per EMS patient was found FOAMING AT THE MOUTH BY NH (nursing home) Staff. Patient arrested upon EMS intervention en route. Patient receiving CPR upon arrival and had an IG EL (airway device) in place. It continues Exam: 12/04 17:08 Eyes: Pupils: constricted, bilaterally. Cardiovascular: Rate: tachycardic, Rhythm: Edema: pedal edema, that is very mild, ankle edema, that is very mild. Respiratory: no spontaneous respirations are appreciated, Respirations: no spontaneous respirations appreciated, Breath sounds: Unable to obtain exam due to obtunded state, patient being intubated. It also documents Procedures: 12/04 Intubation: A time-out was completed verifying correct patient, procedure, site, positioning and intubation 16:59 set-up. The patient was pre-oxygenated using an Ambu bag and placed in a supine position. Sedation was obtained 100MG SUC. The MAC 3 blade was used and inserted into the oropharynx at which time there was a Grade 1 view of the vocal cords. A 7.5 French endotracheal tube was inserted and visualized going through the vocal cords. The stylet was removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were heard in both lung fields equally. The endotracheal tube was placed at 23cm, measured at the teeth. A chest x-ray was ordered to assess for pneumothorax and verify endotracheal tube placement. Disposition Summary, dated 12/4/2024, documents diagnosis: Cardiac Arrest and Severe Septic Shock
On 12/19/2024 the facility provided a 5 ways Root Cause Analysis Template, dated 12/19/2024, that documents: Clearly state the problem: Facility failed to Assess, monitor, and provide timely treatment. Nurse failed to follow up, assess resident and call MD. Nurse thought this was resident behavior. Poor assessment skills by nurse.
On 12/12/2024 at 8:46 AM V20, R3's Power of Attorney (POA), stated that she was very concerned with the care that R3 received at the facility. V20 stated she spoke with R3's roommate and was notified that R3 received CPR at the facility when being transported from the facility. V20 stated that she was notified by V5, License Practical Nurse (LPN), around 1:30 -2:00 PM that R3 was being sent out to the hospital because she was not doing well. V20 stated that she received a phone call from the facility 3 hours later telling her that the ambulance is here and R3 is being sent out. V20 stated that she didn't understand why it took so long. V20 stated that the (local) hospital called and told her that CPR had to be performed in the ambulance during transport and in the emergency room. V20 stated that she was informed that R3 was on a vent and would be transported to outlying hospital. V20 stated that she is very upset and concerned because she was told that R3 was not doing well and needed to go to the hospital 3 hours before R3 did. Why didn't they send her? V20 stated that for 2 weeks R3 refused to get up and laid in urine for long periods of time sitting in her own waste. V20 stated that she was informed by the hospital that R3 had an impaction the size of her hip socket. V20 stated that it's clear that R3 was having changes before the day she was sent out and they did not do anything.
On 12/12/2024 at 1:50 PM V7, CNA, stated that he was not here when R3 went out to the hospital. V7 stated that he had worked with R3 the days and nights before. V7 stated that R3 had taken to the bed and would not get out. V7 stated that R3 was totally incontinent and did not eat. V7 stated that R3 would refuse to allow care but this was different from the norm. V7 stated that R3 was alert and verbal, able to stand and help with transfers, continent for the most part. V7 stated that the day before R3 went he again told the nurse that R3 was different and that something was not right. V7 stated that R3 was not able to stand, and he had to use a full mechanical lift. V7 stated that she was taken to the dining room, and she was not right. V7 stated that he informed the nurse passing pills that R3 was shaking like she had Parkinson's. V7 stated that R3 was different. V7 stated that he told the nurses and V2, DON, that there was something wrong with R3. V7 stated that the changes in R3 started 12/1/2024 and this is when he started notifying the nurses and the Director of Nursing.
On 12/12/2024 at 12:27 PM V5, Licensed Practical Nurse (LPN), stated that he was here the day that R3's change in condition occurred. V5 stated that R3 has a history of behaviors as far as refusing care and refusing to perform self-care but this was different. V5 stated that between 10:30 AM and 12:00 PM R3 was not herself and not responding to verbal stimuli and would not take her medication. V5 stated that he notified the Nurse Practitioner and got an order to send R3 out. V5 stated that he notified the power of attorney and called the ambulance. V5 stated that he was informed that it would be an hour before the ambulance would arrive. V5 stated that he told the oncoming nurse of this and that if the ambulance does not show after 30 to 45 minutes to call them back. V5 stated that he got the paperwork ready. V5 stated that he was not at the facility when R3 went out as he had left after completion of his shift.
On 12/12/2024 at 12:30 PM R1 stated that she and R3 were roommates. R1 stated that R3 was not herself for most of the week. R1 stated that R3 did not eat and stayed in the bed and did not eat or drink. R1 stated that the day before R3 went out to the hospital, V7, CNA, got R3 up. R1 stated that R3 didn't help much at all. R1 stated that when they put R3 to bed she was talking and that was the last time she was ok. R1 stated that R3 yells when they clean R3 but nothing during the night or following day.
On 12/17/2024 at 8:30 AM V6, LPN, stated that she was running late and got there after 2:00 PM. V6 stated that she received shift report and was informed in shift report that R3 was going to the hospital and that the ambulance should be at the facility in 30 minutes if not call the service. V6 stated that she was not informed of R3's condition and did not think it was an emergency. V6 stated that she went about, did her rounds, and started prepping for her shift and getting herself ready to pass her medications. V6 stated that around 4 to 4:30 PM the therapist (V9) reported to her that R3 needed a nurse now. V6 stated that when she entered the room R3 was in a state of distress. V6 stated that R3 was pale, not responding, shallow breathing and foam coming from R3's nose and mouth. V6 stated that she called 911 and called a code. V6 stated at that time she received help from other staff while she was on the phone with 911.
On 12/17/2024 at 10:21 AM V14, CNA, stated that she was not assigned to R3. V14 stated that R3 did have some changes. V14 stated that R3 was not herself. She would not talk and was spaced out, she (R3) was out of it. V14 stated that R3 does have behaviors but this was different. V14 stated that she reported it to the nurse. V14 stated that she wasn't right. V14 stated this was days before she went out.
On 12/17/2024 at 10:28 AM V17, CNA, stated that she got to the facility between 3:30 to 4:00 PM. V17 stated that she was not assigned to R3 that day and maybe saw her in passing as V17 walked past R3's room but did not a look at her. V17 stated that she let the ambulance in and got the oxygen when told to do so. V17 stated that R3 has been having some changes and requiring more assistance than normal. V17 is normally alert and able to make her needs known. V17 stated that R3 hadn't been doing that and the other CNAs were needing help with her which is unusual.
On 12/17/2024 at 10:32 AM V15, CNA, stated that she did not have R3 the day she went out. V15 stated that she helped transfer R3 onto the gurney and got the oxygen tanks and things to help R3 breathe. V15 stated that R3 has behaviors and refuses care. V15 stated that prior to this R3 was not herself and stayed in the bed, went from standing and verbalizing her needs to dependent on staff, not eating and increase incontinence. V15 stated that the nurse was notified.
On 12/17/2024 at 10:39 AM V18, CNA, stated R3 was having changes days before she went out. V18 stated that R3 was crying a lot and not eating. V18 stated that R3 wouldn't stand up. V18 stated that this was different for R3 and that R3 was alert and able to stand and help. V18 stated that R3 did have behaviors and would refuse care. V18 stated that this was different.
On 12/17/2024 at 10:50 AM V9, Speech Therapist, stated that Speech Therapy was seeing R3 due to cognitive changes and eating. V9 stated that R3 did not have any difficulty with swallowing but did have some changes in her ADLs within the last week or so. V9 stated that because of this she went in to see R3 at 9:00 AM to see if she had eaten. V9 stated that she entered R3's room and R3 was lying flat in the bed with food tray on table next to the bed. V9 stated that she called out to R3 and no response. V9 stated that she went to raise the head of the bed and it did not work and R3 did not respond to movement. V9 stated that she noticed at that time that R3 was unresponsive. V9 stated that she performed a sternal rub and R3 did not respond. V9 stated that she notified the nurse and was informed that this was a behavior and not to worry about it. V9 stated at that time she did some in servicing with the staff about feeding R3 with bed being flat and to raise the head of the bed. V9 stated that at about an hour later she again noticed that R3 was unresponsive and notified the nurse asking for vitals. V9 stated that she was informed that the vitals could not be taken because the battery was dead in the machine. V9 stated that at about 4 PM she entered R3's room and it was the scariest thing she has seen. V9 stated that R3 was lying in bed unresponsive with foam coming out of her nose. V9 stated that she told the nurse and was informed that the nurse on days said R3 was going out but was waiting on an ambulance. V9 stated that she informed the nurse that R3 needed help now.
On 12/18/2024 at 10:46 AM V10, CNA, stated that she took care of R3 on 12/4/2024. V10, CNA, stated that she came in and went to R3's room and she didn't look herself. V10 stated that she asked what's going on with R3, she doesn't look right. V10 stated that she was informed that R3 was having some problems and to leave her in for breakfast and so she did. V10 stated that she went back in R3's room around 10:00 AM and provided incontinent care. V10 stated that R3 was not responding and was incontinent of a small amount of liquid stool but not wet with urine. V10 stated that R3 does have behaviors when she refuses care and not wanting to get up. V10 stated that this was different. V10 stated that this was not like R3 at all. V10 stated that she left the room and let V5 the nurse know. V10 stated that she provided incontinent care at 1:30 PM and R3 was unresponsive. V10 stated that R3 again had a small amount of liquid stool. V10 stated that this was different, this was a big change for R3. V10 stated that R3 was alert and able to tell you when she needed to toilet. V10 stated that R3 was continent in the day and incontinent at night. V10 stated that R3's change in condition started about 3 to 4 days prior to the unresponsive episode. V10 stated that R3 went from standing and taking steps to using a sit to stand and then not transferring at all and not eating at all. V10 stated that she let the nurse know.
On 12/18/2024 at 4:00 PM V3, Regional Clinical Nurse, stated that the Change in Condition and Physician Notification Policy was all in one and had been provided.
On 12/18/2024 at 9:26 AM V2, Director of Nursing, stated that she was up in front of the building and was called to R3's room. V2 stated that she ran down to R3's room. V2 stated that when she entered the room it looked like R3 had a seizure. V2 stated that R3's pupils were dilated and R3 was foaming at mouth and nose. V2 stated that there were nurses at the bedside. V2 stated that R3 had slow shallow breathing and a weak pulse. V2 stated that the foam was frothy she was almost post ictal. V2 stated that they were unable to obtain a pulse ox and O2 applied. V2 stated that 911 had been called. V2 stated that they were keeping R3's airway safe. V2 stated that EMTs came and took over and R3 was transferred to the stretcher and left facility. V2 stated that she had not seen R3 that day. V2 stated that she passed R3's room but did not actually see R3 prior to this event.
On 12/18/2024 at 1:35 PM V4, Nurse Practitioner, stated that on 12/4/2024 at 10:30 AM she received a message that R3 was refusing medication and food, facility attempted to get a urine and was not successful and R3 was shaking. V4 stated that at 12:30 PM she responded to send R3 to ER for eval. V4 stated that she was not notified of R3 being unresponsive with sternal rub being performed at 9:00 AM. V4 stated that if she would have been notified, she would have expected them to send R3 to hospital immediately. V4 stated that they know that this would be an emergency and with nursing judgement R3 should be sent out with 911 called. V4 stated if the nurse thought this was a behavior, then there still should have been an assessment. V4 stated that she was not aware of R3's change of condition and decline days before.
On 12/19/2024 at 3:10 PM V21, Physician, stated that he was not notified of R3's change of condition. V21 stated that he was not aware that R3 was found unresponsive at 9:00 AM and then foaming from nose at 4:23 PM and went out to hospital in an ambulance. V21 stated that he was not aware that R3 went into cardiac arrest and received CPR. V21 stated that if he was notified that R3 was unresponsive to a sternal rub and attempts to arouse R3 had failed he would consider that an emergency and would have sent R3 to the hospital with lights and sirens. V21 stated that he would expect an assessment to be done and vitals. V21 stated that these are things he would have wanted to know. V21 stated that he was not aware that R3 was having change in condition prior to the event, not eating, taking to the bed and not allow staff to care for her for days. V21 stated that these are red flags and would have wanted to look further. V21 stated that he would have wanted to know what the assessment was. V21 stated that a resident needing minimal help to dependent, alert and then not is an emergency and V21 would have wanted R3 to be seen at the emergency room. V21 stated that he would expect to be notified of the changes of condition prior to the unresponsive episode with assessment including vitals.
On 12/23/2024 at 1:19 PM V36, Restorative Nurse, stated that she is a part of Quality Assurance team (QA). V36 stated that there was QA meeting, and they went over the deficiency and tried to figure out what happened. V36 stated that they found that they did not respond timely and appropriately with R3's change in condition. V36 stated that they have been in servicing staff related to the Change in Condition policy and if they feel the nurse is not responding then to go above them.
The facility's Notification of a Change in a Status Change in Condition policy, dated 11/17, documents PROCEDURE: 1. Guideline for notification of physician/ responsible party (not all inclusive): a. Significant change in /or unstable vital signs (Temperature, B/P, Pu Ise, Respiration) . h. Repeated refusals to take prescribed medication (for two days). i. Change in level of consciousness. k. Unusual behavior. 2. Document in the Interdisciplinary Team (IDT) notes: a. Resident change in condition. b. Physician/physician extender notification. c. Notification of responsible party.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility neglected to provide necessary medical services including assessing a change ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility neglected to provide necessary medical services including assessing a change in resident's condition and recognizing when a resident needs emergent medical intervention. This failure resulted in the medical neglect of R3, who did not receive needed emergency medical treatment in a timely manner despite, over the course of five and a half hours, R3 exhibiting a significant decline in condition and subsequently becoming unresponsive on 12/4/24 at 9:00 AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock.
Findings include:
R3's Care Plan, dated 11/5/2024, documents Advance Directives: R3 is a full code and requests life sustaining measures.
R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of urine and always continent of bowel and requires assistance with activities of daily living (ADL).
R3's POLST (Physician Orders for Life-Sustaining Treatment,) dated 8/5/2024, documents that R3 indicated Yes to attempt CPR if in cardiac arrest and if not in cardiac arrest: Full treatment.
R3's Progress Notes, dated 12/4/2024 at 2:23 PM, documents Nurses Note Late Entry: Note Text: Resident received new med order per (V4 Nurse Practitioner) for the following: Send resident to ER (emergency room) for evaluation and treatment R/T (related to) refusal of meds and refusal of meals. Resident POA (power of attorney) notified. Writer contacted (Local) ambulance rep who stated that a unit would be sent in 1 hour. Writer verbally notified pm nurse and told her after an hour to check back with the ambulance company.
R3's Progress Notes, dated 12/4/2024 at 5:23 PM, documents Nurses Note Text: 1632: This DNS (Director of Nursing Services) was called to resident room per emergency response due to resident noted with rapid condition decline. Crash cart requested and reported to resident room with Code called for assistance. 1634: Upon entering resident noted with 2 nurses at bedside. Crash cart and oxygen had been requested and enroute. 911 call already placed by staff nurse. This DNS took over lead duties. 1635: Resident noted in bed with HOB (head of bed) elevated, staff providing airway safety as able awaiting further equipment. Resident tachypneic with evidence of respiratory depression. Pulse present, weak and thready. Unable to obtain accurate reading on Pulse oximeter. Resident known to this nurse to have history of seizures with evidence of postictal s/s (signs/symptoms) noted. Resident diaphoretic, bilateral pupil dilation, increased oral/nasal secretions. [NAME] in color with thick frothy consistency. Resident unresponsive to verbal stimuli, tactile stimuli notes no response. Crash cart arrived. Suction set up and this DNS initiated suctioning, O2 (oxygen) initiated 5L (liters) via mask with continued intermittent suctioning to maintain airway. No gag reflex noted during suction, slight secretions removed from oral cavity, no evidence of food or other particles noted to indicate aspiration. LS (lung sounds) forced but clear bilateral. Care continued until arrival of EMS (Emergency Medical Service). This DNS gave reports while care transitioned to EMS. Facility provided medical equipment transitioned to EMS medical devices (suctioning, oxygen) without further distress noted. Resident remains tachypneic, with weak thready pulse present. Unable to obtain BP (blood pressure). This DNS along with facility staff assisted EMS to transfer resident to stretcher for continued care and transfer. EMT (emergency medical technicians) reports concerns of cardiac arrest during transport. States they were having difficulty obtaining a second rig for assistance due to shortages today. This DNS along with second nurse assisted EMS with resident move to ambulance with no loss of pulse or decreased respiration enroute to ambulance. 1700: Resident placed into ambulance with EMTs, and staff return to facility. 1708 EMTs now noted with second rig finally arrived and assistance being provided. Resident to be transfer to closest hospital due to critical status. Staff nurse contacted POA (power of attorney) and made aware of condition rapid decline and transfer status.
R3's Progress Note, dated 12/4/2024 at 5:57 PM, documents Nurses Note, Note Text: Time error inverted number 1632 should read 1623. Error in consecutive times caused by initial inversion: should read as follows, 1624, 1625, 1630, 1637.
R3's Progress Note, dated 12/4/2024 at 6:59 PM, documents Nurses Note, Note Text: upon writer's arrival to give resident her meds writer observed resident was foaming at the mouth writer immediately notified staff for help and called paramedics staff applied oxygen and suctioning to resident and elevated her head to keep her stable till paramedics arrived resident was still breathing and had a pulse, but it was faint and light paramedics arrived and suctioned resident and applied oxygen and removed resident from bed to stretcher writer sent resident out to hospital resident currently being transported to hospital by paramedics writer will continue to follow up.
R3's Progress Note, dated 12/4/2024 at 9:33 PM, documents Nurses Note, Note Text: error in time the correct time of incident was 16:23.
R3's Therapy Communication Form, documents 11/25/2024 report of change of status to NP, blood work ordered 11/26/2024 change diet to puree, 12/4/2024 educate staff re: not to feed in bed laying flat. Max (assist) without any response from patient.
R3's Local Fire Department Patient Care Records, dated 12/4/2024, documents that they received a call from local facility due to patient being unresponsive and foaming. Upon arrival patient was unresponsive and clammy surrounded by nursing staff. Nursing staff suctioning patient. Fire department took over and continued suctioning with contents of vomit. Staff not sure how long-ago patient had aspirated. Patient was agonal breathing. Faint Pulse, unable to obtain oxygen level and blood pressure. During transport to local hospital pulse was not palpable and CPR initiated.
R3's Local Hospital History and Physical, dated 12/4/2024, documents that This 63 yrs (years) old [NAME] Female presents to, ED (emergency department) via Unassigned with complaints of Cardiac Arrest. 12/04 Preceding the arrest, the patient was choking, was found down by nursing home staff. The arrest
17:03 occurred at nursing home. Pre-hospital course: EMS care prior to arrival: initiation of ACLS (Advanced Cardiovascular Life Support), oxygen. Per [NAME] patient was found FOAMING AT THE MOUTH BY NH (nursing home) Staff. Patient arrested upon EMS intervention en route. Patient receiving CPR upon arrival and had an IG EL (airway device) in place. It continues Exam: 12/04 17:08 Eyes: Pupils: constricted, bilaterally. Cardiovascular: Rate: tachycardic, Rhythm: Edema: pedal edema, that is very mild, ankle edema, that is very mild. Respiratory: no spontaneous respirations are appreciated, Respirations: no spontaneous respirations appreciated, Breath sounds: Unable to obtain exam due to obtunded state, patient being intubated. It also documents Procedures: 12/04 Intubation: A time-out was completed verifying correct patient, procedure, site, positioning, and intubation 16:59 set-up. The patient was pre-oxygenated using an Ambu bag and placed in a supine position. Sedation was obtained 100MG SUC. The MAC 3 blade was used and inserted into the oropharynx at which time there was a Grade 1 view of the vocal cords. A 7.5 French endotracheal tube was inserted and visualized going through the vocal cords. The stylet was removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were heard in both lung fields equally. The endotracheal tube was placed at 23cm, measured at the teeth. A chest x-ray was ordered to assess for pneumothorax and verify endotracheal tube placement. Disposition Summary, dated 12/4/2024, documents diagnosis: Cardiac Arrest and Severe Septic Shock
On 12/19/2024 the facility provided a 5 ways Root Cause Analysis Template, dated 12/19/2024, that documents: Clearly state the problem: Facility failed to Assess, monitor, and provide timely treatment. Nurse failed to follow up, assess resident and call MD. Nurse thought this was resident behavior. Poor assessment skills by nurse.
On 12/12/2024 at 8:46 AM V20, R3's Power of Attorney (POA), stated that she was very concerned with the care that R3 received at the facility. V20 stated she spoke with R3's roommate and was notified that R3 received CPR at the facility when being transported from the facility. V20 stated that she was notified by V5, License Practical Nurse (LPN), around 1:30 -2:00 PM that R3 was being sent out to the hospital because she was not doing well. V20 stated that she received a phone call from the facility 3 hours later telling her that the ambulance is here and R3 is being sent out. V20 stated that she didn't understand why it took so long. V20 stated that the (local) hospital called and told her that CPR had to be performed in the ambulance during transport and in the emergency room. V20 stated that she was informed that R3 was on a vent and would be transported to outlying hospital. V20 stated that she is very upset and concerned because she was told that R3 was not doing well and needed to go to the hospital 3 hours before R3 did. Why didn't they send her? V20 stated that for 2 weeks R3 refused to get up and laid in urine for long periods of time sitting in her own waste. V20 stated that she was informed by the hospital that R3 had an impaction the size of her hip socket. V20 stated that it's clear that R3 was having changes before the day she was sent out and they did not do anything.
On 12/12/2024 at 1:50 PM V7, CNA, stated that he was not here when R3 went out to the hospital. V7 stated that he had worked with R3 the days and nights before. V7 stated that R3 had taken to the bed and would not get out. V7 stated that R3 was totally incontinent and did not eat. V7 stated that R3 would refuse to allow care but this was different from the norm. V7 stated that R3 was alert and verbal, able to stand and help with transfers, continent for the most part. V7 stated that the day before R3 went, he again told the nurse that R3 was different and that something was not right. V7 stated that R3 was not able to stand, and he had to use a full mechanical lift. V7 stated that she was taken to the dining room, and she was not right. V7 stated that he informed the nurse passing pills that R3 was shaking like she had Parkinson's. V7 stated that R3 was different. V7 stated that he told the nurses and V2, DON, that there was something wrong with R3. V7 stated that the changes in R3 started 12/1/2024 and this is when he started notifying the nurses and the Director of Nursing.
On 12/12/2024 at 12:27 PM V5, Licensed Practical Nurse (LPN), stated that he was here the day that R3's change in condition occurred. V5 stated that R3 has a history of behaviors as far as refusing care and refusing to perform self-care but this was different. V5 stated that between 10:30 AM and 12:00 PM R3 was not herself and not responding to verbal stimuli and would not take her medication. V5 stated that he notified the Nurse Practitioner and got an order to send R3 out. V5 stated that he notified the power of attorney and called the ambulance. V5 stated that he was informed that it would be an hour before the ambulance would arrive. V5 stated that he told the oncoming nurse of this and that if the ambulance does not show after 30 to 45 minutes to call them back. V5 stated that he got the paperwork ready. V5 stated that he was not at the facility when R3 went out as he had left after completion of his shift.
On 12/12/2024 at 12:30 PM R1 stated that she and R3 were roommates. R1 stated that R3 was not herself for most of the week. R1 stated that R3 did not eat and stayed in the bed and did not eat or drink. R1 stated that the day before R3 went out to the hospital, V7, CNA, got R3 up. R1 stated that R3 didn't help much at all. R1 stated that when they put R3 to bed she was talking and that was the last time she was ok. R1 stated that R3 yells when they clean R3 but nothing during the night or following day.
On 12/17/2024 at 8:30 AM V6, LPN, stated that she was running late and got to the facility after 2:00 PM. V6 stated that she received shift report, was informed in shift report that R3 was going to the hospital and that the ambulance should be at the facility in 30 minutes and if not, call the service. V6 stated that she was not informed of R3's condition and did not think it was an emergency. V6 stated that she went about, did her rounds, and started prepping for her shift and getting herself ready to pass her medications. V6 stated that around 4 to 4:30 PM the therapist (V9) reported to her that R3 needed a nurse now. V6 stated that when she entered the room R3 was in a state of distress. V6 stated that R3 was pale, not responding, shallow breathing and foam coming from R3's nose and mouth. V6 stated that she called 911 and called a code. V6 stated at that time she received help from other staff while she was on the phone with 911.
On 12/17/2024 at 10:21 AM V14, CNA, stated that she was not assigned to R3. V14 stated that R3 did have some changes. V14 stated that R3 was not herself. She would not talk and was spaced out. She (R3) was out of it. V14 stated that R3 does have behaviors but this was different. V14 stated that she reported it to the nurse. V14 stated that she wasn't right. V14 stated this was days before she went out.
On 12/17/2024 at 10:28 AM V17, CNA, stated that she got to the facility between 3:30 to 4:00 PM. V17 stated that she was not assigned to R3 that day and maybe saw her in passing as V17 walked past R3's room but V17 did not look at her. V17 stated that she let the ambulance in and got the oxygen when told to do so. V17 stated that R3 has been having some changes and requiring more assistance than normal. V17 is normally alert and able to make her needs known. V17 stated that R3 hadn't been doing that and the other CNAs were needing help with her which is unusual.
On 12/17/2024 at 10:32 AM V15, CNA, stated that she did not have R3 the day she went out. V15 stated that she helped transfer R3 onto the gurney and got the oxygen tanks and things to help R3 breathe. V15 stated that R3 has behaviors and refuses care. V15 stated that prior to this R3 was not herself and stayed in the bed, went from standing and verbalizing her needs to dependent on staff, not eating and increased incontinence. V15 stated that the nurse was notified.
On 12/17/2024 at 10:39 AM V18, CNA, stated R3 was having changes days before she went out. V18 stated that R3 was crying a lot and not eating. V18 stated that R3 wouldn't stand up. V18 stated that this was different for R3 and that R3 was alert and able to stand and help. V18 stated that R3 did have behaviors and would refuse care. V18 stated that this was different.
On 12/17/2024 at 10:50 AM V9, Speech Therapist, stated that Speech Therapy was seeing R3 due to cognitive changes and eating. V9 stated that R3 did not have any difficulty with swallowing but did have some changes in her ADLs within the last week or so. V9 stated that because of this she went in to see R3 at 9:00 AM to see if she had eaten. V9 stated that she entered R3's room and R3 was lying flat in the bed with food tray on table next to the bed. V9 stated that she called out to R3 and there was no response. V9 stated that she went to raise the head of the bed and it did not work and R3 did not respond to movement. V9 stated that she noticed at that time that R3 was unresponsive. V9 stated that she performed a sternal rub and R3 did not respond. V9 stated that she notified the nurse and was informed that this was a behavior and not to worry about it. V9 stated at that time she did some in servicing with the staff about feeding R3 with bed being flat and to raise the head of the bed. V9 stated that about an hour later she again noticed that R3 was unresponsive and notified the nurse asking for vitals. V9 stated that she was informed that the vitals could not be taken because the battery was dead in the machine. V9 stated that at about 4 PM she entered R3's room and it was the scariest thing she has seen. V9 stated that R3 was lying in bed unresponsive with foam coming out of her nose. V9 stated that she told the nurse and was informed that the nurse on days said R3 was going out but was waiting on an ambulance. V9 stated that she informed the nurse that R3 needed help now.
On 12/18/2024 at 10:46 AM V10, CNA, stated that she took care of R3 on 12/4/2024. V10, CNA, stated that she came in and went to R3's room and she didn't look herself. V10 stated that she asked what's going on with R3, she doesn't look right. V10 stated that she was informed that R3 was having some problems and to leave her in for breakfast and so she did. V10 stated that she went back in R3's room around 10:00 AM and provided incontinent care. V10 stated that R3 was not responding and was incontinent of a small amount of liquid stool but not wet with urine. V10 stated that R3 does have behaviors when she refuses care and not wanting to get up. V10 stated that this was different. V10 stated that this was not like R3 at all. V10 stated that she left the room and let V5 the nurse know. V10 stated that she provided incontinent care at 1:30 PM and R3 was unresponsive. V10 stated that R3 again had a small amount of liquid stool. V10 stated that this was different, this was a big change for R3. V10 stated that R3 was alert and able to tell you when she needed to toilet. V10 stated that R3 was continent in the day and incontinent at night. V10 stated that R3's change in condition started about 3 to 4 days prior to the unresponsive episode. V10 stated that R3 went from standing and taking steps to using a sit to stand and then not transferring at all and not eating at all. V10 stated that she let the nurse know.
On 12/18/2024 at 4:00 PM V3, Regional Clinical Nurse, stated that the Change in Condition and Physician Notification Policy was all in one and had been provided.
On 12/18/2024 at 9:26 AM V2, Director of Nursing, stated that she was up in front of the building and was called to R3's room. V2 stated that she ran down to R3's room. V2 stated that when she entered the room it looked like R3 had a seizure. V2 stated that R3's pupils were dilated and R3 was foaming at mouth and nose. V2 stated that there were nurses at the bedside. V2 stated that R3 had slow shallow breathing and a weak pulse. V2 stated that the foam was frothy, she was almost post ictal. V2 stated that they were unable to obtain a pulse ox and O2 applied. V2 stated that 911 had been called. V2 stated that they were keeping R3's airway safe. V2 stated that EMTs came and took over and R3 was transferred to the stretcher and left facility. V2 stated that she had not seen R3 that day. V2 stated that she passed R3's room but had not actually seen R3 prior to this event.
On 12/18/2024 at 1:35 PM V4, Nurse Practitioner, stated that on 12/4/2024 at 10:30 AM she received a message that R3 was refusing medication and food, facility attempted to get a urine and was not successful and R3 was shaking. V4 stated that at 12:30 PM she responded to send to ER for eval. V4 stated that she was not notified of R3 being unresponsive with sternal rub being performed at 9:00 AM. V4 stated that if she would have been notified, she would have expected them to send R3 to hospital immediately. V4 stated that they know that this would be an emergency and with nursing judgement R3 should be sent out with 911 called. V4 stated if the nurse thought this was a behavior, then there still should have been an assessment. V4 stated that she was not aware of R3's change of condition and decline days before.
On 12/19/2024 at 3:10 PM V21, Physician, stated that he was not notified of R3's change of condition. V21 stated that he was not aware that R3 was found unresponsive at 9:00 AM and then foaming from nose at 4:23 PM and went out to hospital in an ambulance. V21 stated that he was not aware that R3 went into cardiac arrest and received CPR. V21 stated that if he was notified that R3 was unresponsive to a sternal rub andd attempts to arouse R3 had failed. He would have consideresd that an emergency and would have sent R3 to the hospital with lights and sirens. V21 stated that he would expect an assessment to be done and vitals. V21 stated that these are things he would have wanted to know. V21 stated that he was not aware that R3 was having change in condition prior to the event, not eating, taking to the bed and not allowing staff to care for her for days. V21 stated that these are red flags and V21 would have wanted to look further. V21 stated that he would have wanted to know what the assessment was. V21 stated that a resident needing minimal help to dependent, alert and then not is an emergency and V21 would have wanted R3 to be seen at the emergency room. V21 stated that he would expect to be notified of the changes of condition prior to and the unresponsive episode with assessment including vitals.
On 12/23/2024 at 1:19 PM V36, Restorative Nurse, stated that she is a part of Quality Assurance team (QA). V36 stated that there was QA meeting, and they went over the deficiency and tried to figure out what happened. V36 stated that they found that they did not respond timely and appropriately with R3's change in condition. V36 stated that they have been in servicing staff related to the Change in Condition policy and if they feel the nurse is not responding then to go above them.
The facility's Notification of a Change in a Status Change in Condition policy, dated 11/17, documents PROCEDURE: 1. Guideline for notification of physician/ responsible party (not all inclusive): a. Significant change in /or unstable vital signs (Temperature, B/P, Pu Ise, Respiration) . h. Repeated refusals to take prescribed medication (for two days). i. Change in level of consciousness. k. Unusual behavior. 2. Document in the Interdisciplinary Team (IDT) notes: a. Resident change in condition. b. Physician/physician extender notification. c. Notification of responsible party.
The facility's Abuse Prevention Policy, revised 10/22/24, documented Neglect: A failure of the facility, its employees, or service providers to price goods and services necessary to avoid physical harm, mental anguish, emotional distress or pain.
Jun 2024
3 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 interview and record review, the facility failed to administer medications as ordered for 1 of 5 residents (R46) review...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer medications as ordered for 1 of 5 residents (R46) reviewed for pharmacy services in the sample of 45.
Findings include:
On 6/12/24 at 10:44 AM, R46 stated he is supposed to get Tylenol 500 milligrams (mg) three times daily (TID) at 6:00 AM, 2:00 PM and 10:00 PM because he has chronic pain. He stated the regular nurses are very good about getting his medications timely but when the agency nurses are here, he doesn't always get his Tylenol as ordered. He stated his pain is pretty well controlled, but he just wished the agency nurses would pay closer attention.
R46's Diagnoses/ History dated 11/7/23 documents his diagnoses to include Other Chronic Pain and Wedge Compression Fracture Fourth Lumbar Vertebra, Subsequent for fracture with routine healing.
R46's Physician Orders dated May 2024 documents the order dated 3/13/23: Tylenol Extra Strength 500 milligram (mg) caplet-give 2 tabs by mouth (po) TID (three times a day) at 6:00 AM, 2:00 PM and 10:00 PM***Do not change administration times*** diagnosis: pain.
R46's Medication Administration Records (MARs) reviewed for April, May and June 2024 were reviewed with missed doses of Tylenol 500 mg 2 tabs noted in April: 4/10 at 2:00 PM, 4/19/24 6:00 AM, and April 30 at 10:00 PM; No missed doses noted in May and missed doses in June 2024 on 6/2 at 10:00 PM and 6/4/24 at 10:00 PM.
R46's Minimum Data Set (MDS) dated [DATE] documents he has a BIMS (Brief Interview for Mental Status Score) of 15, indicating he is alert and oriented to person, place, time, and situation.
R46's Care Plan, undated, documents, (R46) has the potential for pain related to L-4 compression fracture and my diagnosis of Osteoarthritis. The goal for this care plan documents, I will maintain adequate level of comfort as evidenced by no signs/symptoms of unrelieved pain or distress, verbalizing satisfaction or expressing relief and comfort through next review. Interventions for this care plan include, Observe me for signs and symptoms of pain such as moaning, yelling, crying, favoring a body part, rocking, rubbing a body part, wringing hands, or facial grimacing; Offer non-pharmacological interventions such as relaxation, deep breathing, massages, or repositioning; Use pain scale to identify pain level and intensity; Administer medications as per MD (Medical Doctor). Notify MD/NP (Nurse Practitioner) if pain medication is not effective; Assess location, duration, intensity, and frequency of pain; Evaluate pain using 1-10 pain scale every shift and as needed; Reposition me for comfort.
On 6/18/24 at 10:05 AM, V2, Director of Nursing, stated she specifically changed R46's times for when he receives his Tylenol because when she worked the floor as a nurse and would take his Tylenol to him at 9:00 PM he would refuse to take it before 10:00 PM, so she would have to go back later and give him his Tylenol. V2 stated she changed the times to meet his preferences and would expect any other nurse, agency or not, to follow his physician orders and administer his Tylenol as ordered. V2 acknowledged the missed doses of R46's Tylenol on his April 2024 MAR and June 2024 MAR but stated she could not find the copy of R46's April MAR. She stated she looked at it last week, but it is no longer in his chart, and she is looking for it.
The facility's policy, Medication Administration-General Guidelines dated 1/15, documents, Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedures: 2. Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications, and professional standards of practice. The policy documents 11. The resident's MAR/TAR (Treatment Administration Record) is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose following medication administration. Initials on each MAR/TAR are verified with a full signature in the space provided or on the signature log.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent resident to resident abuse for 4 of 6 resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent resident to resident abuse for 4 of 6 residents (R3, R5, R35, and R259) reviewed for abuse in the sample of 45.
Findings include:
1. R35's Physician Order Sheets (POS) dated June 2024 documents R35's diagnoses of Hyperlipidemia, type 2 diabetes mellitus without complications, hypertension, benign prostatic hyperplasia without lower urinary tract symptom, patient noncompliant with other medical treatment and regimen related unspecified. Muscle weakness, and unspecified dementia.
R35's Minimum Data Set, MDS, dated [DATE] documents R35 was severely impaired for cognition for activities of daily living.
R35's Care Plan with a Problem Onset date of 10/31/2023 documents, (R35) is at risk for psych-social concerns . on 10/31/2023 in which he was reported to have hit another resident with his walker (upon review this was noted to be unintentional, unfounded abuse).
R35's Progress Notes dated 10/31/2023 at 9:20 PM, This shift at 3:45 resident became upset with another resident because she grabbed his walker. He picked his walker up hitting another resident with it on her right hand and wrist. Resident was redirected and separated from others.
Resident Incident Report 10/31/2023 at 3:45 PM, Resident reported to have hit (R259) in the hand/wrist with his walker while the two were moving up the hallway. Reported that (R259) pushed at the resident's walker at which time he became upset and hit her with the walker.
R35's Initial Report dated 10/31/2023 at 4:00 PM, Re: allegation of resident-resident physical abuse. On this date 10/31/2023 at 3:45 PM, (R35) 66 y.o. {year old} male) and (R259) {76 y.o. female} were in the common area of the facility memory care unit when due to crowding both residents were attempting to move in the same direction at which time (R259) pushed (R35's) walker out of her way upsetting (R35). (R35) then proceeded to hit (R259) with his walker making contact with the top of her hand. (R259) c/o (complained of) pain to her hand and x-rays are being obtained to rule out fracture. The residents were immediately separated, and assessment completed with no obvious major injuries observed. Notifications to families and MD were completed. Facility DNS and administrator were notified, and an investigation was initiated per protocol. Due to the poor cognitive condition of both residents at this time, approximately 30 minutes after the event occurred, follow-up interviews were completed with neither resident voicing recollection of the event. Upon review of facility camera monitoring, it was observed when (R259) pushed the walker (R35) picked it up quickly and at that time hit (R259) in the hand. No intention to hit or harm (R259) was observed. X-rays were completed precautionary with no injuries noted. No s/s (signs symptoms) of pain or acute distress or injury at this time. No founded abuse.
R35's Final Incident Report, incident date 10/31/2023 documents, 'Resident to resident physical contact occurred in the facility memory care unit between (R35), a 66 y.o. male, and (R259), a [AGE] year old female. Due to crowding in the area the residents were attempting to move in the same direction at which time (R259) pushed (R35's) with his walker. The walker made contact with the top of the female resident's hand. (R259) c/o (complained of) pain to her hand following the incident and an x-ray has been ordered to rule out fracture. There are no obvious s/s signs/symptoms of injuries. Approximately 30 min (minutes) after the event this DNS attempted to interview both residents involved with no recollection noted by either individual. All notifications and reporting completed. Final report to following completion of full investigation into the event.
R259's Physician Order Sheet (POS) dated June 2024, Alzheimer disease, osteoarthrosis, unspecified psychosis not due to a substance or known physical condition, and restlessness and agitation.
R259's MDS dated [DATE] documents she uses a wheelchair. The MDS does not document her cognition level.
R259's Care Plan with a problem onset date of 4/27/2022 documents, (R259) needs assistance with ADL's (activities of daily living). She has impaired mobility and impaired cognitive skill. Diagnosis of osteoarthritis, Alzheimer dementia with behavioral disturbances, paranoid schizophrenia, COPD, Bipolar affective disorder, and dyspnea with exertion. (R259) is at risk for abuse neglect related to diagnosis of Alzheimer dementia with behavioral disturbance, paranoid schizophrenia, bipolar affective disorder, has impaired cognitive skills and needs assistance with ADL's, (Activities of daily living). Goal and Target Date: I will be free of abuse and/or neglect at all times.
R259's Nurse's Notes dated 10/31/2024 at 9:08 PM, This shift resident was trying to maneuver through the table and chairs in the dining room, grabbing another resident's walker moving it out of the way. Resident who the walker belonged to, picked up the walker slamming it up against her right hand and wrist. Resident yelled out 'it hurt', grabbing her hand.
R259's Incident Report Follow Up Report, resident to resident physical on 10/31/2023 at 3:45 PM, Resident was reaching and propelling herself in her wheelchair when she grabbed another resident's walker. The other resident became upset and hit resident on her hand and wrist with his walker.
R259's Post Incident Actions, Resident to resident physical, date 10/31/2024 at 3:45 PM, Resident was reaching and propelling herself in her wheelchair when she grabbed another resident's walker. The other resident became upset and hit resident on her hand and wrist with his walker.
On 6/14/2024 at 12:55 PM, V2, Director of Nursing stated, (V22) Licensed Practical Nurse (LPN) no longer works here and we do not have a working number for her. This incident happened so long ago. I did not witness the altercation but was told there was an incident between (R259 and R35). I believe (R35) hit her with the walker and she was going past him. I would not expect any resident to be hitting any other resident.
On 6/14/2024 at 1:22 PM, V2 stated, I did the investigation for it and felt both residents were confused and there was no intent to hurt each other, that's why it was not substantiated.
2. R5's Face sheet dated 3/8/24 documents he was admitted to the facility on [DATE].
R5's MDS dated [DATE] documents R5 is severely cognitively impaired.
R5's Baseline Care Plan dated 3/9/24 documents Behaviors inpatient Pysch (psychiatric) at (Local Hospital) 1 to 1 upon return. Physical altercation with male resident place stop sign on door.
R5's Nurse's note dated 3/9/24 documents resident noted standing outside another resident's door, when the resident tried to enter his own room, the resident began attacking him.
R5's Interdisciplinary Progress Note dated 3/9/24 documents resident (R5) noted standing outside another resident's door. When the resident (R3) tried to enter his room. This resident (R5) began attacking him. This resident (R5) banged the residents head on the wall. Staff rushed to both residents and was able to break the two apart. This resident (R5) was sent out for a Psych evaluation. Management advised staff upon return resident will be on one to one.
R5's Final Abuse Investigation titled Departmental Note dated 3/9/24 documents on 3/9/24 at 10:30 (AM or PM was not documented) a physical altercation occurred between 2 male residents on the facility memory care unit. Staff intervened and immediately separated the individuals. Both residents suffer from severe cognitive impairment requiring long term care on the facility MCU (Memory Care Unit). Both residents were assessed (at a local hospital) ER (Emergency Room). The Facility administrator and this DNS (Director of Nursing Services) were notified immediately. Follow-up and interventions were placed immediately, and an investigation initiated. R5 was admitted to inpatient psychiatric services for medication adjustment and stabilization. While R3 returned to the facility, with no needed follow-up, monitoring and care to continue per protocol.
V24's Incident Witness Statement dated 3/9/24 documents (R5) noted in doorway. (R3) noted approaching the door and attempting to push past (R5) to enter the room startling (R5) when he swung his hand and hit (R3) in the side of his head. (R3) fell into the door frame hitting his head onto the frame.
V25's Incident Witness Statement undated documents (R5) was standing in the door when (R3) pushed past him. I think he scared him because (R5) swung at him and hit him in the head. Then (R3) hit the door frame. We ran up and got them away from each other.
R3's MDS dated [DATE] documents R3 is severely Cognitively impaired.
R3's Care Plan dated 3/7/22 with next review date of July 2024 documents (R3) is usually understood and he usually understands others diagnosis of Unspecified Dementia with Behavioral Disturbances. R3's goal is my needs will be anticipated and met by staff through the review date. Intervention Report changes in his ability to communicate to the MD/NP (Medical Doctor/Nurse Practitioner)). (R3) is at risk for abuse and neglect related to impaired cognitive skills and requires assistance with ADL's (Activity of Daily Living). Diagnosis Unspecified Dementia with Behavioral Disturbances I will be free of abuse and neglect through the review date of 7/2024. (R3) intervention Keep him safe from harm at all times.
R3's Interdisciplinary Note dated 3/9/24 documents this resident was noted to be attempting to enter his room at which time a second male resident with confusion whom had been admitted less than 24 HR (Hours) prior became aggressive thinking that this resident was entering the wrong room. The second resident swung his fist hitting (R3) in the side of his face at which time R3 fell to the side noted to bouncy his head back and forth between the sides of the door frame in which he fell. Staff heard the commotion immediately and separated them.
R3's Interdisciplinary Note dated 3/10/24 documents resident continues on incident follow up for resident to resident altercation incident. Resident right eye remains blackened. Skin tear to right arm remains and bruising to left ear. Resident alert and able to make needs known denies pain/discomfort at present moment. no S/S (signs and symptoms) of distress noted.
On 6/18/24 at 1:30PM V2 stated, Based on what we saw (R5) had been in the facility less than 24 hours. We received him from another facility because he continued to elope from that facility. We had no issues with him. (R5) was standing in the doorway to (R3) room. His room (R5) was halfway down the hallway at the other facility he thought that was his room so when (R3) tried to enter the room (R5) hit him.
The Abuse Prevention Ploicy with a history date of 10/22 documents, The facility is committed to protecting the resident from abuse by anyone including, but not necessarily limited to facility, staff, other residents, consultant, volunteer, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse may be resident to resident, staff to resident, family to resident or visitor to resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
4. R16's POS for June 2024 documents a diagnosis of Type 2 Diabetes Mellitus with diabetic neuropathy.
R16's Care Plan documents, at risk for hypo/hyperglycemia related to diabetes diagnosis.
R16's J...
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4. R16's POS for June 2024 documents a diagnosis of Type 2 Diabetes Mellitus with diabetic neuropathy.
R16's Care Plan documents, at risk for hypo/hyperglycemia related to diabetes diagnosis.
R16's June 2024 MAR does not document the number of insulins given to R16. The MAR does not document any units given for 9 of 18 doses for the 6:00 AM, dose, for 15 of 17 doses for the 11:00 AM dose, for 11 of 17 doses for the 4:00PM and 13 out of 17 doses for the 9:00 PM dose.
The Insulin Injection Policy with a history date of 8/16 documents, Daily insulin injections are given with a physician's order. Injection sites will be rotated. Insulin will be given before meals unless otherwise ordered by the physician. Record type, amount, time and site of injection on the MAR/eMAR (electronic medication administration record).
Based on interview and record review the facility failed to prevent significant medications errors regarding insulin administration for 4 of 6 residents (R16, R41, R42 and R104) reviewed for significant medication errors in the sample of 45.
Findings include:
1.R41's Physician's Order Sheet (POS), dated June 2024, documents, diagnoses of long-term use of insulin, other lack of coordination, tremor, cerebral ataxia in disease classified elsewhere, type 1 diabetes mellites with hypoglycemia without coma. R41 has an order for NovoLog 100 unit/ML Flexpen Administer 8 units prior to meals with the correctional scale following 70-200= none, 201-250 = 2 units, 251-300= 3 units, 301-350- 4 units, 351-400= 5 units, 401-450= 6 units, 451 or higher 7 units DO not hold insulin.
R41's Care Plan Problem with onset date of 1/26/2020 documents, (R41) is at risk for falls and has a history of actual falls related to balance issues and diagnosis of cerebral ataxia, hypertension which being treated, pain in right knee tremor unspecified, other lack of coordination, pain, insomnia and diabetes with low blood sugar at time, I have a history of unspecified fracture of left patella with routine healing.
R41's Minimum Data Set, MDS, documents she is alert and orientated for cognition and activities of daily living.
R41's Nurse's Notes dated 5/7/2024 at 4:39 PM, Was alerted by housekeeping that resident fell while walking down the hall. This writer observed resident on the floor sitting on her buttocks with back against the wall. Asked resident what happened, resident stated that her blood sugar was low, and she got dizzy. Blood sugar checked; it was 67. Resident stated she just went down to her buttocks. All extrem (extremities) WNL (within normal limits) for resident. Proper footwear attire worn. Resident assisted off floor and back up onto feet. Resident assisted to room and body assessment performed. No injuries noted.
R41's Incident Report dated 5/7/2024 at 2:38 PM, Was alerted by housekeeping that resident fell while walking down the hall. This writer observed resident on the floor sitting on her buttocks with back against the wall. Asked resident what happened resident stated that her blood sugar was low, and she got dizzy. Resident stated she was just went down to her buttocks. BLGL noted 58 upon check. No obvious s/s of hypoglycemia noted. No injuries noted. Body assessment and pain assessments. Provided snack. Slow increase of BLGL (blood glucose level) noted with results at dinner time. No s/s (signs and symptoms) of hypoglycemia are present. Resident states that she feels fine. Immediate Post Incident Action: Encouraged resident to eat snacks when she feels blood sugar was low and to ask for assistance when she is feeling weak. IDT (Interdisciplinary Team) completed, and resident encouraged to use wheelchair when BLGL is low if short acting insulin is given.
R41's Medication Administration Record, MAR, dated 5/7/2024 documents 7:30 AM, has initials and three numbers, 3, 4, 6, with the time, 11:30 AM. The MAR does not document the units of insulin given to R41 on 5/7/2024 at 11:30 AM.
R41's May 2024 Mar documents on 5/7/24 at 5:30 PM, R41's blood sugar level was 67 (slightly low). A normal blood glucose level of 70-100 mg (milligram per decimeter). R41's MAR does not document how many units of insulin were given at 11:30 AM.
R41's May 2024 MAR documents for the 7:30 AM, sliding scale insulin 21 out of 31 days does not document how many units of sliding scale insulin were given. For the 11:30 AM, dose 23 of 32 doses does not document how many units of sliding scale insulin were given. For the 5:30 PM, dose sliding scale insulin only 23 of 32 units were not documented.
On 6/13/2024 at 11:34 AM, V2, Director of Nursing stated, Every nurse charts differently. It's hard, because we have a lot of agency nurses and not everyone is charting the same way. Not everyone is charting how many units of insulin were given. I do not have a flow sheet or anything documenting how many units of insulin were given. I would expect the units to be documented of how many were given based on the sliding scale. There is no way to know how many units were given to (R41) on 5/7/2024.
2.R42's POS dated June 2024 documents a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease.
R42's Care Plan with a problem onset date of 9/15/2024 documents diabetes mellitus: I require healthcare monitoring related to my diagnosis of diabetes mellitus, I receive oral anti-diabetic mediations daily to help manage my symptoms, I am at risk for episodes of hypo/hyperglycemic reactions.
On 6/18/2024 at 8:14 AM, R42's June MAR only documents three numbers, initials, but does not document how many units of sliding scale insulin were given on 6/18/2024 at 8:00 AM dosage.
R42's MAR for June 2024 for the 8 AM, dose documents 11 out of 18 units were not documented for the 8 AM dose, 7 out 18 units were not documented for the 12:00 PM dose, 8 out of 18 doses for the 4:00 PM, and 9 out of 17 doses for the 8:00 PM.
On 6/18/2024 at 8:12 AM, V4, Licensed Practical Nurse (LPN) stated, I work here full time and when I chart in the MAR, I write down the three numbers in each of the blank boxes. I do not see any place to write the number of units given. Different people do it different ways. I did not write down any units. I gave insulin this morning to (R42).
3. R104's POS dated June 2024 documents a diagnosis of type 2 diabetes mellitus without complications. Type 2 diabetes mellitus without complications Humalog 100 unit/ML vial sliding scale AC (before meals) and HS (bedtime).
R104's Instant Care Plan dated 4/27/2024 type II, Dietary Mellitus.
R104's MAR for June 2024 documents, Humalog 100 unit/ML vial sliding scale AC and HS
R104's MAR for June 2024 documents, Humalog 7:30 AM, no amount of insulin units was documented for 16 of 18 doses. For the 11:30 AM, 15 out of 17 units doses were not documented, and for the 4:30 PM, dose 17 out of 17-unit doses were not documented.
On 6/18/2024 at 8:19 AM, V17, LPN stated, I gave insulin this morning to (R104). I normally take the blood sugar and record it in the book. I use each box for the blood glucose levels. There is not a spot for how many units were given. I don't think there is even a spot for it.
May 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to administer insulin timely as prescribed by physician for 1 of 3 res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to administer insulin timely as prescribed by physician for 1 of 3 residents (R2) reviewed for medications in the sample of 4.
Findings include:
R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including major depressive disorder with psychiatric symptoms, schizoaffective disorder, borderline personality disorder, and type 2 diabetes mellitus.
R2's Undated Minimum Data Set (MDS) printed 5/22/24 documented R2 was cognitively intact, had verbal behavioral symptoms directed at others every one to three days, and was independent with activities of daily living and ambulation.
R2's May 2024 Physician Orders document order for Basaglar 100 units/mL (milliliter) Kwikpen, inject 30 units subcutaneously twice per day.
R2's Medication Administration Record (MAR) for the month of February 2024 documents circled initials around the 8:00 PM dose of Basaglar 100 units/mL Kwikpen, inject 30 units subcutaneously twice per day, along with the documentation, MD (Medical Doctor) aware, no new orders.
R2's Progress Notes for the month of February 2024 do not contain documentation regarding any changes to R2's 8:00 PM Basaglar Kwikpen or whether it was given on 2/23/24.
On 5/22/24 at 1:21 PM, R2 stated a few months ago her insulin was not given for 24 hours and R2 was told the Facility did not have it in stock.
On 5/22/24 at 3:18 PM, V2, Director of Nursing (DON), stated R2 did miss the evening dose of insulin on 2/23/24 because it did not come in from the pharmacy in time. She stated the doctor said to give it when it came in, and they did.
On 5/23/24 at 9:25 AM, V12, Pharmacist, stated R2's Basaglar had to be ordered from another pharmacy, but it was received and sent out to the facility on 2/6/24. She stated the volume sent for R2 would have lasted until at least 2/29/24.
On 5/23/24 at 1:50 PM, V13, Licensed Practical Nurse (LPN), stated, (R2) gets her long acting insulin in the morning and at night. The pharmacy usually comes around 7:00-8:00 PM, and (R2) usually gets her medications around that time. That night (2/23/24), I checked (R2)'s blood sugar, and pharmacy had not come yet, so I documented we did not have it. The NP said to just monitor her blood sugar and give it to her when it came in. The medication came later that evening, probably around 8:30 PM at the latest. The medication was given but was not documented in (R2's) MAR (Medication Administration Record) or Progress Notes. I would sometimes document this in the Progress Notes, but often times I will just mention it (to the next nurse) in report.
On 5/23/24 at 2:10 PM, V2, DON, stated she would expect staff to document in the resident's medical chart to verify that a medication was given under these circumstances, but it may be written on the 24 Hour Nursing Report. She stated she was here on the evening of 2/23/24 and remembers R2 getting the Basaglar a little later after it came in from pharmacy.
The Facility's 2/23/24 24 Hour Nursing Report documents R2's insulin given when received approx (approximately) 9:45 PM.
R2's Progress Notes for the month of February 2024 do not document any physician communication regarding late administration of Basaglar Kwikpen on 2/23/24.
On 5/23/24 at 3:15 PM, V2, DON, stated she expects staff to follow the Facility's Medication Administration policy, but feels that order to resume insulin when received covers the administration time. She did not feel staff should have charted when the physician was contacted, whether the medication arrived, or whether the medication was administered.
The Facility's Undated Medication Administration - General Guidelines Policy documents, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications, and professional standards of practice. All current medications and dosage schedules are listed on the resident's medication administration record (MAR) or treatment record and administered timely according to facility policy. Medications are administered within one hour before and one hour after the scheduled time, except for orders relating to before, after, and during meal orders, which are administered as ordered. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g., resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR/TAR for that dosage administration is initialed and circled.
Oct 2023
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
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to prevent resident to resident sexual abuse for 2 of 8 residents (R3...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to prevent resident to resident sexual abuse for 2 of 8 residents (R3 and R4) reviewed for abuse in a sample of 22. This failure resulted in harm as a reasonable person would not engage in sexual encounters without the decisional capacity to do so.
Findings include:
R3's Face Sheet, print date of 10/02/23, documents R3 has diagnoses of cognitive communication deficit, altered mental status, and dementia.
R3's Minimum Data Status (MDS), dated [DATE], documents R3 is moderately cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. R3's MDS documents R3 requires extensive assistance of two plus person physical assist with bed mobility, transfer, and toilet use.
R4's Face sheet, with a print date of 10/02/23, documents R4 has diagnoses of personal history (Hx.) of traumatic brain injury, and Major depressive disorder.
R4's MDS dated [DATE], documents R4 is moderately cognitively impaired with a BIMS of 08 out of 15.
On 10/03/23 at 1:10 PM, V12, Housekeeping stated she was the one who found R3 and R4 in R4's room. She said the door was open but the curtain in the room was pulled so you couldn't see who was in the room until you entered. She said she knocked on the door and there was no response, so she entered the room. V12 stated when she went around the curtain, she observed R3 and R4 both had their genitals out and R4 performing oral sex on R3 while masturbating at the same time. V12 stated she asked them what they were doing and then she went directly to the nurse's station and informed the nurse what was happening in the room. V12 stated the nurse and CNA (Certified Nurse's Aide) went directly down to R4's room and removed R3 from R4's room. She said R3 was taken off the hallway for a couple of weeks and when they brought him back, he went into a room with his wife. V12 stated R4 doesn't know what is going on all the time.
The Illinois Department of Public Health Final investigation report completed on 9/15/2023, documents At approximately 1340 (1:40PM) on 9/10/2023 the north unit housekeeper knocked on the door to (R4's room). When no response was heard, the housekeeper proceeded to enter the room to complete her daily tasks. Upon entering the room (R3) (R3's room identified) was noted in the room of (R4) where the two were observed to be engaged in sexual activity towards one-another. Both residents were observed with their pants undone and sex organs exposed. (R4) was reportedly leaning forward into (R3's) lap attempting to perform oral sex. Upon observing the situation, the unit nurse was notified, and the residents were separated immediately followed by the completion of full body assessments on both residents with no issues noted. The facility Administrator, Director of Nursing Services, facility MD/Medical Director, and the POAs (Power of Attorneys) for both residents were notified of the occurrence. No concerns were voiced during notifications and agreement with the residents plans of care were expressed. (R3) was placed on 15 min (minute) checks and temporarily re-located to the TCU (Transitional Care Unit) unit in an attempt to ensure closer observation and discourage him from re-entering the room of (R4). A care plan meeting was set with (V13, R4's mother/POA) for 9/14/23 per her earliest convenience. Interviews and investigation were initiated per protocol and an initial report was forwarded to IDPH due to the low BIMS scores for both residents involved. Initial interviews with both residents were completed within 30 min of the event. At the time of the initial interviews, (R3) denied any sexual activity and reported he was in (R4's) room to assist him with his TV (television). (R4) reported no recollection of the event. The facility administrator along with the SSD (social service director) and DNS (director of nursing services) completed follow-up interviews with both residents on Monday 9/11/2023. During the follow-up interviews, (R4) continued to report no memory of the occurrence. (R3), reported that he is 'not gay or bi-sexual' but that he did allow (R4) to unzip his pants and allowed him access to his body. Continued SSD support and follow-up x72 hours remained in place for residents and no long-term negative psych-social issues were observed. The facility SSD completed interviews with multiple staff and residents to determine if there were any past observations of inappropriate sexual behavior with all responses indicating no concern.
On 10/03/23 at 12:20 PM, R4 was questioned about the incident that happened between himself and R3 and he stated he doesn't remember any incident between himself and R3.
On 10/03/23 at 12:50 PM, R3 was questioned about the incident that occurred between himself and R4. He stated something should be done about R4, he just likes to go up and grab people. He said R4 took his phone so he could call his mom and he was just chasing him down to get his phone back from him. He stated nothing inappropriate happened between R4 and himself. He said he didn't do anything to R4 and R4 didn't do anything to him.
On 10/12/23, at 10:09 AM, V13, R4's mother, stated this is very much out of character for R4. She said he would touch female's arms and she would have to remind R4 that he couldn't do that stuff. V13 stated she doesn't feel like R4 is capable of making decisions regarding sexual activity, she said he can barely walk let alone do anything else. She said he likes women and generally doesn't get along with men. She said it was totally shocking that this all happened. She said based on his past he would be more likely to be with a female than a male.
On 10/17/23 at 1:10 PM, V30, Medical Doctor when questioned by this surveyor if R3 and R4 who both are moderately cognitively impaired were able to make decisions when it comes to sexual activity and V30 stated no, they don't. He stated if they are impaired, they can't make a rightful decision. This surveyor repeated the question a second time and V30 stated if you are telling me they are cognitively impaired then they can't make a rightful decision.
The facility had no documented assessment regarding R3 and R4 decisional capacity to engage in sexual encounters.
The facility's abuse prevention policy, not dated, documents Policy: The facility is committed to protecting the residents form abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. It further documents c) Sexual Abuse: This includes, but is not limited to sexual harassment, sexual coercion or sexual assault, or non-consensual sexual contact of any type with a resident. It also documents Protection: 3. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed.
May 2023
7 deficiencies
3 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0602
(Tag F0602)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent misappropriation of resident property for 1 of 1 resident (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent misappropriation of resident property for 1 of 1 resident (R26) reviewed for misappropriation of property in a sample of 51. This failure resulted in R26 being upset and being a victim of theft of over $2000.00.
Findings Include:
On 5/3/2023 at 11:00 AM R26 was sitting up in her room in her chair. R26 stated she lived at the facility in the past and was discharged home then was recently readmitted to the facility. R26 stated she noted there were fraudulent charges on her bank card, but she didn't know what was going on because she had the bank card in her possession. R26 stated her family notified the local police regarding the fraudulent charges on her bank card. R26 stated the police told her and her family that a housekeeper that was employed at the facility took a picture of her bank card at the facility without her knowledge and made all purchases online. R26 stated she didn't know how someone had her bank card and she was told a housekeeper took a picture of her bank card and she spent over $2,000.00 at Amazon and Macy's among other stores. R26 didn't know what the housekeepers name was or if she ever met her. R26 stated she was very upset about the fraudulent charges. R26 stated This lady stole from me, and I don't have money like that.
The Facility's Undated Investigation, V1, Administrator documents, (R26) is a [AGE] year-old female who admitted to the facility on [DATE] and discharged on 12/21/2022. (R26) admitted with the following diagnoses: displaced intertotrochanic fracture of the left femur, spinal stenosis, heart disease, presence of a cardiac pacemaker, hypertension, hyperlipidemia, and major depression order. The resident is self-responsible and did sign her own paperwork upon admission to our facility. On 2/15/2023 at approximately 8:52 AM, I received a phone call from (V10), detective with local police department. (R26) had reported to her bank that there were charges on her bank card that she did not recognize. As the bank checked the charges, it was found that items purchased were shipped to the address of (V11, Housekeeping). (V10) asked this writer (V1) if I had a staff member by that name and I said that I did. (V11) was a housekeeping aide at the facility. (V10) asked me if she was here and I checked to see that she was clocked in. (V10) let me know the local police department would be coming to the facility to arrest (V11.) As I was on the phone with (V10), I had (V11)'s supervisor remove (V11) from the floor and placed her in the HK (housekeeping) supervisor's office. After hanging up, I waited on the police and directed them to the back of the building and (V11) was arrested on the charge of theft by the officers. They requested her purse and phone and the DON (Director of Nursing) retrieved both items. She was taken into custody without incident. The following was completed immediately: facility immediately removed (V11) from patient care area and sequestered her in office. Facility facilitated arrest of (V11.) IDPH (Illinois Department of Public Health) notified. Called (R26) and her family to give update, resident was readmitted to the facility on [DATE]. Communication between myself and (V10), detective. Administrator interviewed all housekeeping staff for information regarding this incident, with no findings. (V11) was subsequently booked into jail and charged with theft. The case number is 23-3411. I am awaiting information from the local police department about subpoenas of (V11's) of her phone to ensure that none of our other residents were affected by this employee. The staff member (V11) was hired on 6/1/2022. Upon hire, background check was initiated and there were no findings. Another background check was initiated subsequent to this offense, with no findings. The employee (V11) is obviously no longer an employee of this facility.
On 5/2/2023 at 4:15 PM V1, Administrator stated R26 was readmitted to the facility. V1 stated the police contacted V1 to ask if V11 worked at the facility and V1 stated V11 was a housekeeper. V1 stated it was determined that the local police investigated R26's card transactions and it was found that V11 had ordered Amazon items and had them sent to her home from R26's bank card. The police came to the facility and arrested V11 and she was terminated the same day. V1 stated staff were interviewed and no staff stated they had knowledge of what V11 was doing. V1 stated the police didn't tell her how much about what V11 spent on R26's bank card. The police had to get a subpoena for R11's cell phone to be unlocked because she wouldn't give them the code and it was told to V1 that there were 13 other card numbers saved in V11's phone when the police unlocked it, but the officer stated no other facility residents were involved that they were aware of. Residents and families of residents were also interviewed after both allegations and no other residents were affected by V11 and no other residents were missing money to the knowledge of V1.
V11's Employee File showed the facility did a criminal background check on her prior to hiring her and she documented she received/reviewed and signed the facility abuse policy that included misappropriation of resident funds.
The Facility's Abuse Prevention - Illinois Only, revised 10/22 documents The facility is committed to protecting the residents from abuse. Definitions: Misappropriation of Resident Property: the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Investigation: the facility will initiate at the time of any finding of abuse or neglect and injuries of unknown origin an investigation to determine cause and effect and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The administrator must immediately report any instance of misappropriation of resident property, as well as report any reasonable suspicion of crime to the Illinois Department of Public Health and in accordance with regulations of with section 1150B of the Social Security Act to the Department of Health as required. Protection: any allegation of misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the residents. All case of misappropriation of property must be thoroughly investigated, documented, and reported to the physician, families and/or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security Act's time limits for reporting a suspicion of crime. Reporting: the facility will report any knowledge of actions by a court of law against any employee, which would indicate unfitness for service as a nurse aide or other staff member to the state nurse's aide registry or licensing authorities. Alleged violations involving misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made. Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain timely emergency medical services for the treatment of a fra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain timely emergency medical services for the treatment of a fracture for one of one resident (R62) reviewed for quality of care in a sample of 51. This failure resulted in delay of treatment after R62 fell sustaining an acute and nondisplaced distal radial fracture as well as an acute fracture of the ulna styloid.
Findings include:
R62's Undated Face Sheet, documents she was admitted on [DATE].
R62's Quarterly Minimum Data Set (MDS) dated [DATE] documents R62 is severely cognitively impaired, supervision with walk in room and corridor, supervision with dressing, limited assistance with one-person physical assist for personal hygiene. R62's MDS documents steady always during balance during transitions and walking and uses mobility devices.
R62's Nurse's Note, dated 10/31/2022 no documentation of fall.
R62's Bath Skin assessment dated [DATE], V12, Licensed Practical Nurse (LPN) documents, No swelling, bruising or redness to right hand, fingers or wrist at time of fall.
R62's Pain Management Evaluation Tool, dated 10/31/2022, form was blank, no pain assessment documented.
R62's Nurse's Note, dated 11/1/2022 at 4:46 AM V38, LPN documents, Resident continues on incident follow up for fall, resident right 3rd digit bruised and edematous, right wrist edematous and bruised, call placed to FNP (family nurse practitioner), and order received for Xray to right hand and wrist.
R62's Nurse's Note, dated 11/1/2022 at 6:03 AM V38, LPN documents, Resident's family representative notified and Xray company notified of order for Xray to right hand and wrist. Xray will be out today.
R62's Patient Xray Report, dated 11/1/2023, documents Right hand, 2 views findings: acute and nondisplaced distal radial fracture as well as an acute fracture of the ulna styloid. Joint spaces preserved. Soft tissues are unremarkable. Impression: distal radial and ulnar styloid fractures. Right wrist 2 views findings: nondisplaced acute fracture of the distal radius as well as an acute ulnar styloid fracture. Joint spaces preserved. Soft tissues are unremarkable. This form was electronically signed by a physician on 11/1/2023 at 9:07 AM.
R62's Nurse's Note, dated 11/1/2022 at 11:42 AM V28, LPN documents, Resident had a fall evening shift 10/31/2022, the night nurse called Xray company as residents rt (right) wrist and hand was swollen and resident had a complaint of pain. Xray company called this nurse with results, stated that resident has a distal fracture of the radial and ulnar styloid physician notified, who evaluated resident as well stated to send to ER (emergency room) for evaluation and treatment. Physician ordered Tylenol 650 mg for pain. DON (Director of Nurses) and ED (Executive Director) notified.
R62's Nurse's Note, dated 11/1/2022 at 8:10 PM V12, LPN documents, 10/31/2022 2P-10P shift around 4 PM resident was sitting in common area by the dining room mingling with other residents. Resident attempted to assist another resident from one chair to another causing them both to fall to the floor. Resident was assisted off the floor. Pain/skin assessment, ROM (range of motion) and VS (vital signs) were done. Resident was able to move fingers and wrist but complained of some pain. Tylenol was given. Resident sat at dinner table for supper. After dinner resident went to room to prepare bed with no further complaints and rested quietly throughout rest of shift. Resident ambulates independently and had shoes on. The floor was dry. Resident toilets self.
R62's Medication Administration Record (MAR) dated 10/31/2022 documents no pain medication including Tylenol was administered on 10/31/2022 or 11/1/2022.
R62's Nurse's Note, dated 11/1/2022 at 8:57 PM V37, LPN documents, Resident sent to local ER via ambulance at 5:00 PM. Resident returned from ER at 8:00 PM with short arm OCL (splint.) Resident has fx (fracture) to radius and ulna styloid. It is recommended that resident follow up with physician in 2-3 weeks. FNP and family representative notified of dx (diagnosis) and return. Resident did have a moderate amount of swelling to hand and wrist before leaving unit. Swelling still present. Radial pulse present. Negative for heat to area. Resident currently in room resting with eyes closed.
R62's Local Hospital discharge instructions, dated [DATE] documents, Diagnosis pain in right wrist fracture of radius and ulna styloid.
On 5/4/2023 at 11:00 AM, V12 LPN stated she worked 8:00 AM to 4:00 PM day shift as the facility's Infection Control Preventionist (ICP.) V12 stated she worked as a nurse on the floor from time to time and on 10/31/2022 and was assigned to R62 evening shift. V12 recalled R62 fell on the evening shift, and she assessed R62 for injuries at that time and there were none. She reported to the night shift nurse that R62 fell.
On 5/4/2023 at 2:15 PM V28, LPN stated she worked 5:45 AM to 2:00 PM day shift on 11/1/2022 she received nurse report (unknown name) from the night shift nurse who reported R62 fell. V28 stated when she assessed R62's right arm that afternoon it was swollen and bruised and R62 complained of pain. V28 stated R62's physician, V29, was at the facility that morning and had assessed R62's right wrist and stated to send her to the ER. V28 stated she didn't recall if she called 911 or if she called for a non-emergency ambulance when V29 stated to send R62 to the ER. V28 stated If you don't call 911 it can take hours for the non-emergency ambulance to get to the facility. V28 could not recall if R62 was transferred to the ER prior to leaving the facility that day, if R62 was still at the facility she would have given the next shift nurse report regarding R62's fall and the need to go to the ER.
On 5/5/2023 at 1:10 PM, V2 Director of Nurses, DON, stated when a physician tells staff to send a resident to the emergency room, she expects staff to call 911/lights and sirens for a resident that a fall and Xray showed 2 fractures and is symptomatic meaning the resident has swelling, bruising and pain. V2 stated she was not aware of a resident that fell, had a complaint of pain with bruising and swelling and waited at the facility for an ambulance to take her to the emergency room for over 5 hours.
On 5/5/2023 at 8:54 AM V24, Nurse Practitioner stated she was the nurse practitioner for V29, Physician. V24 stated when a resident falls, she expects staff to document what occurred with the fall and if the resident sustained injuries from the fall in the resident's medical record the same day the fall occurred. V24 stated when V29 gave the physician's order to send R62 to the hospital after R62 fell, she would have expected staff to get R62 to the hospital pretty quickly within an hour, especially when the Xray report documents R62 had fractures from the fall. V24 stated she expected facility staff to follow physician's orders and facility policies and procedures.
The Facility's Notification of a Change in A Resident's Status revised 11/17, documents, Policy: the attending physician/physician extender (Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist) and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulation. Responsibility: All Licensed Nursing Personnel. Procedure: Guideline for notification of physician/responsible party (not all inclusive) any accident or incident (per Federal and State regulations.) Document in the Interdisciplinary Team (IDT) notes: resident change in condition, physician/physician extender notification and notification of responsible party.
SERIOUS
(G)
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** 3. R62's Undated Face Sheet, documents she was admitted on [DATE].
R62's Care Plan dated 2/16/2021 documents, Resident is at ri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R62's Undated Face Sheet, documents she was admitted on [DATE].
R62's Care Plan dated 2/16/2021 documents, Resident is at risk for falls psychoactive drug use, diuretic therapy and impaired cognitive skills. Diagnosis of hypertension and is being treated for this. Goal: falls/injuries minimized through the management of risk factors while maintaining maximum independence through the review date. Approaches: administer medications as ordered by MD (physician)/NP (nurse practitioner.) See POS (physician order sheet)/MAR (medication administration record.) Keep call light within reach when in room, ensure that she is wearing proper footwear when ambulating. She is able to transfer and ambulate independently. PT (physician therapy)/OT (occupational therapy) as ordered. Vital signs as ordered. Notify MD/NP of abnormal results. Perform a fall risk evaluation assessment on me quarterly and PRN (when needed.) 7/5/2022 fall without injury skin/pain evaluation PROM (passive range of motion) without issue, skilled therapy for evaluation for reacher. 8/12/2022 fall without injury approach added floor path clear from hazards footwear inspected proper footwear in place at all times. 9/25/2022 fall without injury approach added footwear inspected family representative to bring in proper fitting shoes. No progressive intervention was documented on R62's care plan after the 9/25/2022 fall.
R62's Fall Scale, dated 9/25/2022, documents total score 40 which was low to moderate risk action: implement standard fall prevention.
R62's Quarterly Minimum Data Set (MDS) dated [DATE] she is severely cognitively impaired, supervision with walk in room and corridor, supervision with dressing, limited assistance with one-person physical assist for personal hygiene. R62's MDS documents R62 is steady at all times during balance during transitions and walking and uses mobility devices.
R62's Nurse's Note, dated 10/31/2022 no documentation of fall.
R62's Nurse's Note, dated 11/1/2022 at 4:46 AM documents, Resident continues on incident follow up for fall, resident right 3rd digit bruised and edematous, right wrist edematous and bruised, call placed to FNP (family nurse practitioner), and order received for x ray to right hand and wrist.
R62's Nurse's Note, dated 11/1/2022 at 8:10 PM V12, LPN documents, 10/31/2022 2 P-10 P shift around 4 PM resident was sitting in common area by the dining room mingling with other residents. Resident attempted to assist another resident from one chair to another causing them both to fall to the floor. Resident was assisted off the floor. Pain/skin assessment, ROM (range of motion) and VS (vital signs) were done. Resident was able to move fingers and wrist but complained of some pain. Tylenol was given. Resident sat at dinner table for supper. After dinner resident went to room to prepare bed with no further complaints and rested quietly throughout rest of shift. Resident ambulates independently and had shoes on. The floor was dry. Resident toilets self.
R62's Care Plan was not updated after this fall with progressive interventions.
On 5/5/2023 at 1:10 PM, V2 Director of Nurses (DON) stated when a resident falls, she expects the nurse to immediately assess the resident and to ensure the resident is safe. If staff can pick the resident up off the floor safely, she expects them to. The charge nurse should assess the resident for injuries and pain and assess the root cause of why the resident fell. After each fall V2 expects staff do to document progressive interventions to prevent the resident from falling again. V1 expects the nurse to document the fall details in the resident's nurse's note in the electronic medical record.
On 5/5/2023 at 8:54 AM V24, Nurse Practitioner stated she was the nurse practitioner for V29, Physician. V24 stated when a resident falls, she expects staff to document what occurred with the fall and if the resident sustained injuries from the fall in the resident's medical record the same day the fall occurred. V24 stated she expected facility staff to follow physician's orders and facility policies and procedures.
The Facility's Accident & Incident Documentation & Investigation Resident Incident revised 7/2018, documents Policy: accidents and/or incidents involving resident care will be investigated and documented on the Resident Incident Report entry form in the LTC (long term care) system. An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accident and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents. The Policy documents The Licensed Nurse assigned at the time of the time of the resident care accident/incident is responsible for conducting an investigation of the circumstances surrounding the accident/incident, and for notifying the Supervisor, Director of Nursing, and/or the Executive Director as appropriate. The Licensed Nurse at the time of the incident is responsible for initiating/completing the Resident Incident Report, ensuring that all items identified on the form have been completed as applicable to the accident/incident. The Licensed Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record, in accordance with the guidelines below and set forth on the Resident Incident Report. The Policy documents The Nurse's Notes could contain the following documentation: date and time of incident: clear, objective facts of what occurred; the last time the resident was seen prior to the incident; An evaluation of the resident's condition at the time of the accident/incident could include a description of the resident, vital signs, and any other physical characteristics apparent as a result of the accident/incident; an treatment provided; any contacts made or attempted with the resident's physician, family, legal representative or any other health care professional or person involved with resident's care; The resident's outcome and any information concerning the incident and the Nurse's signature, date and time of the charting.
R47's Physician Order Sheet (POS) dated 09/10/21 documents weakness, Unsteadiness on feet, other abnormalities of gait and mobility, Alzheimer's disease with early onset.
R47's MDS dated [DATE], documents R47 has severely impaired cognition. The MDS also documents that R47 requires extensive assistance of two plus persons for locomotion on unit and locomotion off unit. The MDS documents R47 is not steady, only able to stabilize with staff assistance.
R47's Care Plan dated 07/27/22 documents (R47) is at risk for falls related to impaired thought processes. Diagnosis of epilepsy, unspecified dementia without disturbance, Alzheimer's disease, and CVA with left sided weakness, needs assistance with transfer, is impulsive, and is incontinent of bowels and bladder. The Care Plan documents R47 had falls on 11/21/21, 11/29/21, 10/11/22, 10/17/22, 12/09/22, and 01/09/23. R47's Care Plan Interventions dated: 11/21/21 documents bolster mattress to his bed. R47's Care Plan Intervention dated 11/29/21 documents Give frequent reminders to call for assistance with transfers. R47's Care Plan Intervention dated 10/11/22 documents remind to call assist with ADLs, transfers, mobility, toilet before each meal. R47's Care Plan Intervention dated 10/17/22 documents for therapy eval for transfer/gait imbalance. R47's Care Plan Intervention dated 12/09/22 documents to educate R47 on follow up importance of notifying for staff to assist him to bed. Refer to skilled therapy for balance and transfer. R47's Care Plan intervention dated 01/09/23 documents skilled therapy to evaluate for trunk strengthening/balance, abdominal assessment: urinary retention foley inserted.
R47's Fall Investigation dated 10/11/22 documents Resident had come back from the dining room before supper and attempted to put himself on the toilet in the North Hall shower room. I was at the nurses' station when I suddenly heard yelling coming from the shower room. When I approached the shower room resident was laying on his side. Resident stated he did not hit his head during the fall, explained to be that he was not hurt when asked and showed no sign of pain during ROM and no signs of physical injuries. Reminded to seek assist with ADLs toileting, and transfers. Toilet before meals.
R47's Nursing Note dated 10/12/22 at 8:59 PM documents Late entry 10/11/22 resident attempted to put himself on toilet in the shower room without help during supper time. Res (Resident) was found on the floor in the shower room on the floor laying on his side. When asked did he hurt anything or hit his head resident stated no. There were no physical injuries during head-to-toe assessment. No pain during ROM (range of motion). Resident was warned to not transfer himself to the toilet without staff assistance. Will continue to monitor.
R47's Nursing Note dated 10/17/22 at 1:33 PM documents resident was in the shower and was holding rail and CNA (Certified Nursing Assistant) was trying to have resident sit in shower chair and resident wouldn't let the handle go and was going to the ground and the CNA lowered him to the floor res has no injuries noted or c/o (complaint of ) pain noted at the time POA (Power of Attorney) notified and don (Director of Nursing) and NP (Nurse Practitioner) here and made aware.
R47's fall investigation dated 10/17/22 documents resident was in the shower and CNA was having resident stand up to get into the shower chair and was holding the rail to stand up and when the CNA got him to stand up, he wouldn't stay standing so the 2 CNAs lowered to the floor. Therapy to eval for transfers and gait imbalance.
R47's Nursing Note dated 12/09/22 at 8:02 PM documents Resident tried to transfer himself from his wheelchair to his bed and fell on the floor. The Note documented Resident stated he hit his head. Neuro checks in place. Brother (V34) called no answer message left. PCP (Primary Care Physician) aware. DON notified.
R47's fall investigation dated 12/09/23 documents Resident tried to transfer himself from his wheelchair to his bed and fell on the floor. Resident stated he hit his head. No injuries noted. Resident educated on the importance of waiting for staff to assist him to bed, refer to skilled therapy for balance and transfers.
R47's Nursing Note dated 01/09/23 at 2:03 PM documents T (temperature) 98 P (pulse) 96 R (respirations) 20 B/P (blood pressure) 156/90 at approx. 11 AM writer was called into room [ROOM NUMBER] by CNA staff. Writer entered room and found resident on floor besides his bed. Resident had cut above his right eye. Resident had c/o pain to his stomach. Resident stated that he was attempting to pull himself up with side rails and fell OOB. Resident was placed on neuro-checks that were WNL (within normal limits). Writer notified on call nursing supervisor and facility NP. Writer notified resident POA (V34). Resident received new order per (V24) FNP (Family Nurse Practitioner) to be sent to ER (Emergency Room) for evaluation. (Local Ambulance Service) arrived to facility at approx. 1:25 PM. Resident taken to (local hospital).
R47's fall investigation dated 01/09/23 documents At approx. 11 AM, writer was called into room [ROOM NUMBER] by CNA staff. Entered room and observed resident on floor besides his bed. Resident had a cut above his right eye. Resident had c/o pain to his stomach. Resident stated that he was attempting to pull himself up with side rails and fell OOB (out of bed). Resident was placed on neuro-checks that were WNL. Writer notified on call nursing supervisor and also facility NP. Writer notified resident POA (V34). Resident received new order per (V24) to be sent. Small superficial laceration to right eyelid. Skilled therapy to evaluate for trunk strengthening and balance, abnormal assessment: urinary retention observed, (indwelling) catheter inserted.
On 5/5/2023 at 1:10 PM, V2 Director of Nurses (DON) stated when a resident falls, she expects the nurse to immediately assess the resident and to ensure the resident is safe. If staff can pick the resident up off the floor safely, she expects them to. The charge nurse should assess the resident for injuries and pain and assess the root cause of why the resident fell. After each fall V2 expects staff do to document progressive interventions to prevent the resident from falling again. V2 stated she expects the nurse to document the fall details in the resident's nurse's note in the electronic medical record.
A. Based on interview and record review the Facility failed to provide supervision to prevent elopement for 1 of 1 resident (R65) from eloping in the sample of 51. This failure resulted in R65 being transferred to local hospital and treated for abrasions.
B. Based on interview, and record review, the facility failed to implement safe transfer techniques and implement progressive interventions to prevent falls and accidents for 4 of 4 residents (R59, R47, R62) reviewed for supervision to prevent accidents in the sample of 51.
Findings include:
A. R65's Face Sheet documents R65 was admitted to the facility 7/3/2021 with diagnoses of Dementia, Schizophrenia, Hyperlipidemia, and Major Depressive Disorder.
R65's Risk of Elopement Evaluation, dated 12/19/2022, documented R65 is alert and oriented has a history of leaving, increased risk, ambulates independently.
R65's Care Plan dated 7/3/2021 documents (R65) has a history of wandering and attempts to leave related to behavioral issues. The Care Plan documents she requires monitoring for safety. Interventions include Frequent monitoring for safety.
R65's Nurse's Notes dated 1/13/2023 at 8:36 PM document Resident was last seen in her room at about 4:05 PM, during the evening med pass. Once I made it halfway up the hall, I was approached by a CNA (Certified Nurse's Aide) who was taking a smoke break when she realized that the residents window shade had been kicked out and the resident was missing. Every staff member in the facility was notified and we began the search. DON (Director of Nursing), Admin (Administrator), family and doctor were notified, and patient was found in less than 5 min (minutes) a block over hiding behind a bush near the (local business). Res was aroused and aggressive with staff once she made it into the building and also refused body assessment and vitals. EMS (Emergency Medical Service) was called and when they arrived she allowed them to talk with her and take her vitals. Res is currently at (local hospital) in the behavior department.
R65's local hospital emergency department, ED, records, dated 1/13/2023 document R65 presented from the facility to ED complaining that R65 asked staff to open window and they would not. The ED Record documented R65 proceeded to kick out the window and was found walking down the street. The ED Record documented R65 being sent in for psych evaluation. The ED History and Physical documents R65 requested the window open but staff refused. The ED Record documented R65 kicked out window and was found wandering outside the nursing home. ED Record documented exam revealed R65 has an abrasion of 0.75cm on tip of the nose. No fractures to nose or facial bones. R65's discharge instructions document diagnosis of abrasion to nose.
R65's Nurse's Note, dated 1/17/23 at 10:06 AM, documented R65 had a Brief Interview of Mental Status (BIMS) score of 13 indicating she was cognitively intact.
R65's Nurse's Notes Addendum dated 1/18/2023 at 10:31AM documented a Note Clarification for 1/13/2023 5:50PM. The Note documented CNA came to this nurse to inform me that the window in one of the rooms looked to be kicked out. When she came in to check the room, the window was opened, and the resident assigned to the room was not present. I immediately went to look and (R65) was not in her room. This resident does not come out of room. I alerted all staff per facility policy by calling a Dr. Wander for elopement. Staff began searching the facility. I then notified ED (Executive Director) /DNS (Director of Nursing Service), Nurse Manager, and Hospice. The Note continued 6:01 PM, (R65) was located and returned to the facility by staff. Staff reported that they retrieved her from the business complex about 1 block from the facility. She was in front of the (local business) going behind the shrubbery. It seemed like she was attempting to hide. As (R65) was brought into the facility she was irate and yelling out. When I attempted to ask her why she left, she stated 'I', hungry. I want some real food and I'm not eating that s***.' She then requested heat because she was cold. I attempted to perform a skin and pain evaluation on her, but she refused. She was wearing a long-sleeved fleece sweater, long pants, socks, and rubber soled shoes. She also had a blanket wrapped around her shoulder. The temperature was 28 degrees, she was not appropriately dressed for the weather.
On 5/4/2023 at 3:45PM V1, Administrator stated R65 rarely comes out of her room. V1 stated R65 wants to be by herself. V1 stated she is in that room because she wants to be by herself and can't get along with any other roommates. V1 stated She is very picky about food, but never comes out of her room. Activities cannot get her out, nobody can. That's the only private room in the facility. The door next to it is an alarm door. (R65) knew what she was doing, she put on all these clothes. She didn't go out the door, she got dressed and put on the clothes and kicked out the window. V1 stated POA (Power of Attorney) declined R65 going to another facility. V1 stated R65 is not cognitively impaired. R65 very full well knew what she was doing, and she is here because she is schizophrenic. V1 stated R65's safety awareness is poor because she has a mental health condition. V1 stated it was a screen R65 kicked out to get out of window and all windows slide open.
On 5/4/23 at 3:31 PM, V2, Director of Nursing, DON, stated on [DATE], it was about 5-6PM, I got a phone call that said they couldn't find (R65). When I interviewed the staff, I was told (V31, Certified Nursing Assistant, CNA), went outside the North (100 hall) door to smoke and noticed there was some damage on the window. I was notified by (V32, Unit Manager), at the time. (V32) said they couldn't find her. (V31) came in to look at the room with the window damage. (V31) realized (R65) was not in the room and informed (R65's) nurse. (V13, Licensed Practical Nurse/LPN) did a 100% head count. We counted all the residents which took about 5 minutes max. I live about 30 minutes away, before I even made it more than a few minutes, they had already retrieved (R65). The reason we know how long it took is because (R43) was on the front porch. (R43) said he saw someone walking. She walked right by. It wasn't totally dark, but it was getting dark. V2 stated when the staff asked R43 if he had seen anyone, he pointed in the direction he thought R65 was going. V2 stated One of the nurses, (V33, LPN), and (V21, CNA), got in the car and drove in that direction. When they got over that way, they saw a small figure going behind a shrub at a business complex. (V21) got out and it was (R65). V2 stated R65 yelled a bit; they got R65 in the car and brought her back. V2 stated R65 had on terrycloth slippers with rubber soles, sweatpants, fleece, and blanket. V2 stated when they got R65 back, she yelled and screamed. R65 said she didn't want the food in the dining room and was going to look for food. R65 didn't go back to her room; we immediately sent her out just to be evaluated. V2 stated R65 had a tiny 0.5-centimeter (cm) abrasion on her nose, and they took her out to the hospital. V2 stated R65 was in room on the dementia unit. V2 stated R65 stood on her bed and kicked the screen out. V2 stated R65 was on the memory unit and was moved off for behaviors but didn't get along with anybody and was still high functioning at that time. V2 stated When I moved her off the hall (memory unit), I put her on the short hall, but she had a roommate, and they didn't get along. Another roommate on north hall, didn't get along. So, I had to get her a private room. V2 stated R65's safety awareness is poor because she has diagnosis of dementia and is also schizophrenic.
On 5/3/2023 at 2:00PM V12, LPN, stated (R65) didn't want to be here. She would say we couldn't make her be here. V12 stated R65 spoke this prior to the 1/2023 elopement.
On 5/3/2023 at 4:00 PM V13, LPN, stated I was working the day (R65) left the facility. I was passing meds and saw her in her room around 4pm. At closer to 5:00PM (V31, CNA) was out smoking and came in saying that (R65's) window was out. I ran to (R65's) room and saw she was gone. I alerted everyone in the building and called 911. I was running all over searching inside and outside. We found her in about 10 minutes. When (R65) came back, I saw she had an abrasion on her nose. She wouldn't let me touch her. She let EMS take her and I heard her say to EMS she wanted out of here. (R65) has a lot of behaviors. She cusses, kicks, and yells. She is in the same room she was in before.
On 5/5/2023 at 8:54 AM V24, Nurse Practitioner (NP) stated she was aware R65 eloped from the facility in January 2023. V24 stated R65 has multiple psychiatric diagnoses including schizophrenia and should not have been outside the facility by herself. V24 stated R65 does not have safety awareness, that is why she is in a nursing home, so they provide oversight. V24 stated R65 didn't have exit seeking behavior but exhibited agitated and aggressive behavior but not exit seeking. V24 expects the facility to provide protective oversight and keep all residents safe, she also expects staff to follow the facility's policies and procedures.
Facility elopement policy updated 5/2022 documents The Unit Charge Nurse is responsible for knowing the location of their residents. When residents are participating in various programs, such as physical therapy, recreational activities, dining, etc. The staff in these programs will be responsible for the locations of their participants. It is the responsibility of all personnel to report any resident attempting to leave the premises or suspected of being missing to the Charge Nurse as soon as practical.
B. R59's Face Sheet documents an admission date of 4/7/2021, with diagnoses of Hemiplegia following cardiac infarction affecting left nondominant side, Seizures, Unspecified Pain, and Major Depressive Disorder.
R59's Incident Report, dated 1/2/2023 at 3:10PM documents R59 was in the process of being transferred by 3 staff members with the mechanical lift when one of the straps broke from the mechanical lift pad causing her to fall back into her chair and she then slid to the floor. R59 had no injuries during fall and did not hit her head on the way down.
Facility's weight log documents on 1/9/2023 R59's weight was 364.2 pounds.
R59's Minimum Data Set, MDS, dated [DATE] documents R59 has no cognitive deficits and is totally dependent on staff for transfers.
R59's Care Plan with a signature date of 1/2/2023 documents R59 is at risk for falls related to needs mechanical lift assistance for transfers, is incontinent, seizures, slide when up in wheelchair at times, Cerebral Vascular Accident with hemiplegia affecting left non dominant side and receives psychoactive drugs. Diagnosis of hypertension and is being treated for this. Interventions include dycem in seat of wheelchair, use of reclining high back wheelchair when up, assist as needed to adjust body position when up, administer medications as ordered, keep call light in reach, assist of 2 to 3 staff with mechanical lift transfers. Skin/pain assessments, passive range of motion after issue, reevaluated weight capacity of mechanical lift, new slings ordered/received, increase staff presence during transfers.
R59's Nurse's Note, dated 1/2/2023 document R59 was being transferred by 3 CNAs when the mechanical lift pad strap broke while R59 was in the air hovering over her wheelchair. R59 then slid to the floor. The Note documented a full body assessment was completed and R59 did not complain of any pain or had any injuries. The Note documented R59 was then rolled back on to a mechanical pad where she was lowered to her bed and performed a safe transfer.
On 5/5/2023 at 9:00 AM V2, DON, stated, The CNAs were getting (R59) up in mechanical lift and one of the straps on the lift pad broke. (R59) landed on the bed or chair. She had no complaints of pain. I ordered more lift pads that are weight appropriate. My understanding is that the lift pad loops were frayed, but the pad was the appropriate weight. Laundry staff is now assessing the pads and loops. The pad that tore with (R59) on it shouldn't have been in circulation.
5/3/2023 at 4:00PM V13, Licensed Practical Nurse, LPN, stated I was working the day (R59) fell from the mechanical lift on 1/2/2023. I was working on the hall and 2 or 3 CNAs were putting (R59) in bed using the mechanical lift. (V12, LPN) came out of (R59's) room and said one of the lift's straps had snapped. (R59) must've been too heavy. (R59) was laying down and myself, (V12), and 3 CNAs transferred (R59) up in a new mechanical lift pad. (R59) had no complaints. The pad we were using was the biggest pad we have. The staff assisting to get her up were V12, V19, CNAs, and V16, CNA.
05/04/23 09:45 AM V16 stated I was in the room with 2 other staff, and we were transferring (R59) from the chair to the bed. During midair one of the strap's loops just broke. There are 4 straps and one of the loops just snapped. (R59)'s head hit another CNA, and then went to the floor gradually. We got other people to assist to get (R59) up off the floor. The nurse assessed (R59) and she didn't have any complaints. We have 2 mechanical lifts. One is a 450# max weight, and the other lift is 600# max. The lift pad we use for (R59) is larger and darker blue. We always use 3 people for transfer (R59). After this incident with (R59) we had a facility wide in-service on transfers. There is now a sheet in housekeeping that they have checked the straps. The pads are washed daily, so housekeeping checks the straps.
05/04/23 10:44 AM V19, CNA, stated I have worked here 3 years. In January I was in (R59)'s room with (V12), (V16) and (V21). (R59) was in her chair and we were putting her in her bed. We had (R59) hooked up to the mechanical lift and when she went up, one of the straps snapped. I stuck my leg out and she landed on my leg. (R59)'s head landed on my leg. We let her lay for a second and got her vitals. We got another lift pad under her. We got her in bed. She wasn't hurt at all. (R59)'s lift pads have numbers on them. They get washed every day. I check the loops. The loops looked warn and frayed, but they looked like they could hold her. We use mechanical lift (Brand name of Full Body Mechanical Lift.)
05/04/23 12:30 PM V25, Laundry, housekeeping, stated We wash the mechanical lift pads every time they are sent to us. I have a chart and inspect the pads monthly. I did not begin inspecting the lift pads until February.
Facility policy dated 8/2016 documents The (Brand Name Full Body Mechanical Lift) is to be used for total lifts to obtain a resident's weight from bed to chair, chair to bed, or from the floor (maximum lifting per manufacture's guideline). (Brand Name Full Body Mechanical Lift) capacity is less than 450#. (Brand Name Full Body Mechanical Lift) weight capacity is less than 600#.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to report an injury of unknown origin to the Illinois De...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to report an injury of unknown origin to the Illinois Department of Public Health (IDPH) for 1 of 3 residents (R29) reviewed for reporting of abuse allegations in the sample of 51.
Findings include:
R29's Face Sheet documents R29 was admitted to the facility on [DATE] and has diagnoses including hyperlipidemia, anemia, anxiety disorder due to known physiological condition, gastro-esophageal reflux disease without esophagitis, essential (primary) hypertension, insomnia, and major depressive disorder.
R29's Minimum Data Set (MDS) completed 3/16/23 documented R29 was severely cognitively impaired, required extensive one person assistance with bed mobility and transfer, and had no documented skin conditions.
R29's Care Plan, undated, does not address risk of abuse.
On 5/3/23 at 10:00 AM V8, R29's Family Representative, stated she is very involved with R29's care and visits her daily at the facility. V8 stated during her visit on 4/13/23, she observed bruising on the back of both R29's hands that was not present the day before.
V8, R29's Family Representative, provided (R29) Grievances Submitted to (Facility) Nursing Home 5/2/23 documenting, 4/13 Family noticed bruises on (R29's) hands. (V1, Administrator) directed (V2, Director of Nursing) to research and let family know.
Facility Grievance dated 4/20/23 documents, Summary Statement of Grievance for (R29): (V8) was not notified of bruises on both hands. No one can tell what happened with any of it. Immediate Response/Steps Taken to Investigate Grievance: (V2), Director of Nursing Services (DNS) talked w/ (with) aides (Certified Nursing Aides) and nurses on shift. Summary of Pertinent Findings or Conclusions did document any bruises or how they may have occurred. There was no Facility Grievance pertaining to 4/13/23 bruising reported by V8.
R29's Resident Incident Follow Up dated 4/19/23 documents, Narrative of incident: Bedtime ADL's (Activities of Daily Living) being completed. During transfer CNA assisted resident into a standing position by hold onto her hand that was covered by shirt sleeve. Sleeve twisted around causing friction to skin on hand resulting in a U shaped skin tear to top of left hand. 24 Hour Follow Up: bruising to hands noted. No documentation of assessment of bruising to hands or a description of how R29 sustained bruises to her right hand.
On 5/3/23 at 10:54 AM, V1, Administrator, stated R29 did have bruises on both hands, but the skin on her hands always looks a little purple. V2, Director of Nursing (DON) agreed with V1's statements.
On 5/4/2023 2:45 PM, V30, LPN (Licensed Practical Nurse/Wound Treatment Nurse), measured R29's right hand and stated the area was a dark purple bruise/discoloration that measured 8.0 centimeters (cm) x 2.5 cm. V30 stated she did not know how the bruise occurred and had only worked in the facility for a week.
On 5/5/23 at 10:00 AM, V2, Director of Nursing, stated, Per policy, if there is an injury of unknown origin, we do our best to figure out what happened. We investigate every incident and interview staff and residents. If it's reportable, we will report it to IDPH (Illinois Department of Public Health). I will look and see if I have an investigation or documentation regarding the bruises on (R29)'s hands.
As of 5/9/23 at 8:00 AM, no report regarding R29's bruising was received from the facility.
The Facility's Undated Abuse Prevention - Illinois Only Policy, documents, Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteer and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Identification: Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. The Administrator must be immediately notified of suspected abuse or incidents of abuse. The Administrator must immediately report any instances of abuse, neglect, or misappropriation of resident property and injuries of unknown origin, as well as, report any reasonable suspicion of crime to the Illinois Department of Public Health and in accordance with regulation of with Section 1150B of the Social Security Act to the Department of Health as required. Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency, APS, and local law enforcement as required). Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to investigate an injury of unknown origin for 1 of 3 re...
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 investigate an injury of unknown origin for 1 of 3 residents (R29) reviewed for investigation of abuse in the sample of 51.
Findings include:
R29's Face Sheet documents R29 was admitted to the facility on [DATE] and has diagnoses including hyperlipidemia, anemia, anxiety disorder due to known physiological condition, gastro-esophageal reflux disease without esophagitis, essential (primary) hypertension, insomnia, and major depressive disorder.
R29's Minimum Data Set (MDS) completed 3/16/23 documented R29 was severely cognitively impaired, required extensive one person assistance with bed mobility and transfer, and had no documented skin conditions.
R29's Care Plan, not dated, does not address risk of abuse.
On 5/3/23 at 10:00 AM V8, R29's Family Representative, stated she is very involved with (R29's) care and visits her daily at the facility. During her visit on 4/13/23, V8 stated she observed bruising on the back of R29's hands that was not present the day before. V8 stated she asked V1, Administrator, and V2, Director of Nursing (DON), what happened to cause the bruising and did not get an answer.
V8, R29's Family Representative, provided (R29) Grievances Submitted to (Facility) Nursing Home 5/2/23 documenting, 4/13 Family noticed bruises on (R29's) hands. (V1, Administrator) directed (V2, Director of Nursing) to research and let family know.
R29's Resident Incident Follow Up dated 4/19/23 documents, Narrative of incident: Bedtime ADL's (Activities of Daily Living) being completed. During transfer CNA assisted resident into a standing position by hold onto her hand that was covered by shirt sleeve. Sleeve twisted around causing friction to skin on hand resulting in a U shaped skin tear to top of left hand. 24 Hour Follow Up: bruising to hands noted. No documentation of assessment of bruising to hands.
Facility Grievance dated 4/20/23 documents, Summary Statement of Grievance for R29: (V8) was not notified of bruises on both hands. No one can tell what happened with any of it. Immediate Response/Steps Taken to Investigate Grievance: (V2), DNS (Director of Nursing Services) talked w/ (with) aides (CNAs) and nurses on shift. Summary of Pertinent Findings or Conclusions did not document any bruises or what may have caused bruising. There was no Facility Grievance regarding V8 report of bruising on 4/13/23.
On 5/3/23 at 10:54 AM, V2, Director of Nursing (DON), stated (R29) had a skin tear and a bruise on her left hand on 4/19/22 which were reported and investigated. V1, Administrator, stated (R29) had bruises to both hands, but the skin on her hands is always a little purple. V2, DON agreed with V1's statement.
On 5/3/23 at 1:05 PM, V15, Certified Nurse Assistant (CNA) stated she worked with (R29) during the month of April 2023 and did not observe any bruises on (R29's) hands.
On 5/4/23 at 9:15 AM, V16, CNA Supervisor, stated she heard R29 had a bruise on her hand (unknown whether left or right hand) because V8, (R29's Family Representative) called about it. V16 stated she did not know what happened to cause R29's bruising.
On 5/4/23 at 9:49 AM, V18, CNA, stated she works on R29's unit and has not observed any bruises on R29's hands.
The Facility's Resident Incident Report dated 4/19/23 documents, U shaped skin tear to top of left hand, 2 cm (centimeters). There was no documentation of any bruising to R29's hands.
R29's Weekly Skin Checks, dated 4/1/23, 4/6/23 and 4/10/23 document, No Skin Issues Present. No Weekly Skin Checks after 4/10/23 were provided.
R29's Bath Skin Assessments dated 4/4/23, 4/8/23, 4/21/23, and 4/22/23 do not document any bruising.
R29's Progress Notes for the month of April 2023 do not containing any documentation regarding bruising.
On 5/4/2023 2:45 PM, V30, LPN (Licensed Practical Nurse/Wound Treatment Nurse), measured R29's right hand and stated the area was a dark purple bruise/discoloration that measured 8.0 centimeters (cm) x 2.5 cm. V30 stated she did not know how the bruise occurred and has only worked in the facility for a week.
On 5/5/23 at 10:00 AM, V2, Director of Nursing, stated, Per policy, if there is an injury of unknown origin, we do our best to figure out what happened. We investigate every incident and interview staff and residents. If it's reportable, we will report it to IDPH (Illinois Department of Public Health). I will look and see if I have an investigation or documentation regarding the bruises on (R29)'s hands.
The Facility's Undated Abuse Prevention - Illinois Only Policy, documents, Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteer and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Identification: Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. The Administrator must be immediately notified of suspected abuse or incidents of abuse. The facility will initiate at the time of any finding of abuse or neglect and injuries of unknown origin an investigation to determine cause and effect and provide protection to any alleged victims to prevent harm during the continuance of the investigation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure medications were given as ordered. There were 27 opportunities with 2 errors resulting in a 7.41% medication error rate...
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Based on observation, interview and record review, the facility failed to ensure medications were given as ordered. There were 27 opportunities with 2 errors resulting in a 7.41% medication error rate. The errors involved 2 residents (R10, R51) in the sample of 51 out of 3 residents observed during medication administration.
Findings include:
1. On 5/3/2023 at 7:27 AM, V6 Licensed Practical Nurse (LPN), administered medications to R10. V6 administered D3-5 (vitamin D) 125 micrograms (mcg)/5,000 units (IU) to R10.
R7's Physician's Order Sheet (POS), dated 5/2023 documents the physician's orders to administer vitamin D 1,000-unit tablet 1 tablet once daily for vitamin deficiency.
On 5/3/2023 at 8:37 AM V6, Licensed Practical Nurse (LPN) looked at the D3-5 bottle that she administered to R10, and she stated it wasn't the correct dose because R10's MAR (Medication Administration Record) documents the D3 dose was 1,000 units. V6 went through the stock medication drawer and through several of the medication drawers on the cart and didn't find D3 1,000-unit bottle.
2. On 5/3/2023 at 7:45 AM, V7, LPN, administered medications to R51. V7 administered guaifenesin EX (extended release) 600 milligrams (mg) to R51.
R51's POS, dated 5/2023 documents the physician's orders to administer guaifenesin 400 mg twice a day (BID) for congestion.
On 5/3/2023 at 8:25 AM V7, LPN looked at the guaifenesin over the counter (OTC) card that he administered to R51 and stated the Medication Administration Record (MAR) documents 400 mg should have been administered. V7 stated he doesn't usually administer the guaifenesin from the OTC card, there is usually a bottle of it, but it wasn't on the medication cart this morning. At 8:40 AM V7 showed the IDPH surveyor a bottle of guaifenesin 400 mg and stated this is the correct dose of guaifenesin that R51 should have received.
On 5/3/2023 at 9:00 AM V2, Director of Nurses (DON) stated, I expect staff to administer medications per physician's orders. If nurses have questions or concerns regarding correct medication dosage during medication administration, I expect the nurse to ask me to ensure the correct dose is administrated.
The Facility's Medication Administration - General Guidelines dated 8/16, documents Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Medications are administered in according with written orders of attending physicians. All current medications and dosage schedules are listed on the resident's medication administration record eMAR (electronic MAR) and administered timely according to facility policy. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. Information on the medication should be checked against the MAR at least three times during the med preparation and administration process. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule prior to administering.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on interview and record review, the Facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resi...
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Based on interview and record review, the Facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 4 of 7 residents (R2, R28, R68 and R303) reviewed for antibiotic stewardship in the sample of 51.
Findings include:
1. The Facility's Infection Log documents No culture done as the pathogen causing R2's 12/7/22 urinary tract infection (UTI) to ensure medication prescribed was effective in treating R2's UTI.
R2's Physician Orders for the month of December 2022 documents order for 300 mg (milligram) Cefdinir capsule - give 1 cap PO (by mouth) BID (twice daily) for dx (diagnosis) of UTI (urinary tract infection) with start date of 12/7/22. The order documents, Need stop date.
R2's Medication Administration Record (MAR) for the month of December 2022 documents R2 received 15 doses of the antibiotic Cefdinir.
R2's Urine Culture and Sensitivity (C&S) was requested on 5/4/23 at 1:50 PM. On 5/9/23 at 8:00 AM, no C&S was provided to justify the R28's use of antibiotic Cefdinir.
2. The Facility's Infection Log documents No culture done as the pathogen causing R28's 2/7/23 urinary tract infection.
R28's Physician Orders for the month of February 2023 do not document any antibiotic orders.
R28's MAR for the month of February 2023 documents order for Cefdinir 300 mg capsule - 1 tab PO BID x 10 days for dx of UTI. R28's MAR documents R28 received six doses of Cefdinir.
R28's C&S was requested on 5/4/23 at 1:50 PM. On 5/9/23 at 8:00 AM, no C&S was provided to justify the use of antibiotic Cefdinir.
3. The Facility's Infection Log documents No culture done as the pathogen causing R68's 10/5/22 urinary tract infection.
R68's Physician Orders for the month of October 2022 do not document any antibiotic orders.
R68's MAR for the month of October 2022 documents order for 250 mg Zithromax PO daily x 5 days. No diagnosis or justification was provided with the antibiotic order. R68's October 2022 MAR documents R68 received four doses of the antibiotic Zithromax.
R68's C&S was requested on 5/4/23 at 1:50 PM. Facility provided a C&S that was faxed to facility from (Local) hospital on 5/4/23 at 4:32 PM and was not previously on file at the Facility.
4. The Facility's Infection Log documents No culture done as the pathogen causing R303's 11/12/22 urinary infection.
R303's Physician Orders for the month of November 2022 document order for 300 mg Cefdinir capsule - take 1 cap BID with start date of 11/11/22 and no end date.
R303's November 2022 MAR documents R303 received four doses of the antibiotic Cefdinir.
R303's C&S was requested on 5/4/23 at 1:50 PM. On 5/9/23 at 8:00 AM, no C&S was provided to justify the use of the antibiotic Cefdinir.
On 5/4/23 at 2:00 PM, V1, Administrator, stated the only time the Facility does not have cultures is when the residents come in on antibiotics. V1 added, The hospital does not usually send them to us.
On 5/5/23 at 7:50 AM, V2, Director of Nursing (DON) stated the hospital will send antibiotic orders back with residents and will let us know when residents need isolation. V2 stated she would not know if the hospital cultures were negative. If they start on antibiotic in hospital, they will come back with a certain number of days to complete.
On 5/9/23 at 7:58 AM, V1 stated it is the responsibility of every staff member to check when a resident is readmitted to make sure they have a culture to justify the antibiotic. She stated, If not, we stop it (antibiotic) until we receive the cultures.
The Facility's Antibiotic Stewardship Program revised 10/2022 documents, Goals: Set standards for antibiotic prescribing practices for all healthcare providers prescribing antibiotics. Review antibiotic use data to ensure best practices are followed. Infection Preventionist (IP) to track and trend all infections utilizing H.1a (Infection Log in AHT or Infection Control Surveillance Log) and H.1b (Healthcare-Associated Infection Report) monthly. The Policy documents Facility will collect reports summarizing the antibiotic susceptibility patterns. The policy documents Microbiology culture data will be used to assess and guide future antibiotic selection.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 10 harm violation(s), $213,909 in fines, Payment denial on record. Review inspection reports carefully.
- • 27 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $213,909 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Stearns Nursing & Rehab Center's CMS Rating?
CMS assigns STEARNS NURSING & REHAB CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Stearns Nursing & Rehab Center Staffed?
CMS rates STEARNS NURSING & REHAB CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 69%, which is 23 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 71%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Stearns Nursing & Rehab Center?
State health inspectors documented 27 deficiencies at STEARNS NURSING & REHAB CENTER during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 10 that caused actual resident harm, and 16 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 Stearns Nursing & Rehab Center?
STEARNS NURSING & REHAB CENTER 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 NORBERT BENNETT & DONALD DENZ, a chain that manages multiple nursing homes. With 109 certified beds and approximately 102 residents (about 94% occupancy), it is a mid-sized facility located in GRANITE CITY, Illinois.
How Does Stearns Nursing & Rehab Center Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, STEARNS NURSING & REHAB CENTER's overall rating (2 stars) is below the state average of 2.5, staff turnover (69%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Stearns Nursing & Rehab Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Stearns Nursing & Rehab Center Safe?
Based on CMS inspection data, STEARNS NURSING & REHAB CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Stearns Nursing & Rehab Center Stick Around?
Staff turnover at STEARNS NURSING & REHAB CENTER is high. At 69%, the facility is 23 percentage points above the Illinois average of 46%. Registered Nurse turnover is particularly concerning at 71%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Stearns Nursing & Rehab Center Ever Fined?
STEARNS NURSING & REHAB CENTER has been fined $213,909 across 3 penalty actions. This is 6.1x the Illinois average of $35,218. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Stearns Nursing & Rehab Center on Any Federal Watch List?
STEARNS NURSING & REHAB CENTER 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.